Discerning the Patterns

Only a week ago I was sitting on my patio in Champaign, Illinois, wrapped in a blanket against the cold, studying clue words in the final push before my board exam on Tuesday. Since then, I've been thinking about the take-home points from the past eight weeks and asking myself how they might apply to medical education at large. The trouble is, the PASS Program is so unique in its approach and effective in its delivery, an application of its principles might necessitate completely revamping the way we train medical students. Some would say that's an idea whose time has come. Rather than engage that debate, I'd like to simply allow the lessons I learned to speak for themselves.

One of the first things you discover upon arrival is, every staff person has either been a practicing physician or is applying for residency. This means they've had to sit for boards and thus, know what it's like to have been in shoes that pinch as tightly as yours. The element of personal experience creates fertile ground for establishing an empathic relationship that is instructive, encouraging, sometimes therapeutic, and very, very human. Some are graduates of the Program and know first-hand how to use its principles successfully. They're battle-hardened veterans, we're green recruits; they've been under fire and know how to survive; we do our best to pay close attention.

Now, despite having the initial four weeks of lecture feel like our first two years trimmed down to the essential of the essentials, the learning atmosphere at PASS is devoid of the competitiveness often associated with medical school. Partly, this is due to the fact that we've all completed our required courses and our common goal is to pass boards. But even in the classroom and small group sessions, if a student is stumped, the watchword is, "Can someone help so and so out?" No one tries to beat anyone else to the punch in the hope of gaining the instructor's recognition or approval. Support is taken seriously because so many have experienced failure and we're here to learn from and overcome our failures, not reenact them.

The material is the silent partner in the whole process. We've all been exposed to an overwhelming amount of information in medical school and I'm not sure a great deal can be done about that without doing damage to what we're about. However, the PASS Program focuses on what is truly high yield, for boards as well as rotations. And that's a surprise. Most of us thought we were going to address board exams exclusively; lo and behold, we're also being trained to be more effective in the clinical setting.

How the material is presented is as important as its content. Many, including yours truly, come to Champaign thinking their frustration with boards is due to a defect in memorization skills. We're informed on the first day that our problem stems from a basic misunderstanding of the nature of boards. They aren't intended to test what we know, but rather what we can use. Our mistake was in assuming memorization was the best way to prepare. It's far better to understand the material because then it becomes a tool for problem-solving rather than a reason to go hunting for Alka-Seltzer.

The metaphor that has stuck in my mind in this regard relates memory to enzyme functioning. Enzymes break big chemicals down into smaller ones so the body can use them for energy and to promote health and well-being. But every enzyme has a limit; it can only do so much work before it hits the wall. I can identify with that. So, once the enzyme is working at maximum capacity, the only way to get it to do more work is to increase what we call the substrate concentration. Basically, this means we add more chemical so that it competes for spots on the enzyme where it can be broken down.

How does this apply to memory? Well, it seems that short-term memory or RAM, to borrow from computer lingo, is like an enzyme: it has a maximum capacity. Once you've gotten it loaded down with facts, figures, statistics, and who knows what all, it's full. To remember more, you have to start forgetting a few things and that's what happens when a person prepares for a test. They've studied for days and they think they're ready at last when that pretty young medical student from Colorado (sorry, I have to give the honor to my home state) comes along and whoops! there goes a few hundred facts. Our guy asks her out after the test and there goes another few hundred. Next day he walks into the lecture hall and his mind is as blank as a slate and he wonders what happened.
The way to combat this normal state of affairs is by making connections, discerning the patterns and relying on useful and reliable concepts that provide the framework for learning. In this way, the instructors at PASS teach us how to reduce our obsessive reliance on rote memorization and replace it with understanding. In itself, this isn't revolutionary, but the way it is applied makes it feel that way.

You see, pattern recognition is one of the primary ways the brain processes and stores information. Take vasculitis (inflammation affecting the veins and arteries), for example. Once you've discerned the general pattern that characterizes this condition, the individual types of vasculitis can be identified by clue words specific to each. A memory tool? You could call it that but I'd say it's more like using an enzyme to break down a complicated system of disease categorization into a form that makes sense. Research scientists might cringe at the thought, but they don't have to take medical boards and neither do they have to stand at a patient's bedside. If all of this sounds simple, it is, and that's the beauty of it. "Simple" may be less impressive but if it renders a concept more accessible on an exam or in a clinical situation, isn't that the whole point?

Don't get me wrong, the Program isn't a Stupid's Guide to Medical Boards Exams. I came away with a notebook filled with notes and lecture material to the tune of some 500 pages. It's four solid weeks of eight hours a day worth of hard work. My classmates and I went home at night weary and bleary-eyed , as did our instructors who were on the job long after we were eating dinner. The additional four weeks I spent studying, trying to absorb and integrate what I'd learned, was invaluable and I feel safe in saying I'll still be doing that very thing for months to come.

There is another element in the PASS Program and it's not, strictly speaking, academic; it's pastoral. Failing to succeed at boards can shake a person's confidence and damage their self-esteem. You put your heart and soul into preparing for what you fear may be the exam of your life, you get your score report and it reads, "Sorry, Charlie, Starkist only wants the best tuna." Is there ever a time when a medical student feels lower? I doubt it. They know this at PASS, many of the faculty having had their own run-ins with failure and frustration, and so they place recovery of faith in yourself, your intelligence, and your ability to tackle boards and medical wards at the forefront. When you arrive, you feel battered, black, and blue. When you leave, the bruises have healed and you're ready to ask, what's next. Treating students like persons and whole ones at that, is the most osteopathic thing they do. And most of them are MDs.

How about that?!

(Photo of the PASS Program Center copyright 2010 by the author)