High Yield: High Stakes Testing and the Ambivalent Rigor of Medical Training

Michelle Munyikwa //

“This is floridly high yield, so be sure to keep it in the back of your mind.” The podcaster’s voice, now deeply familiar to me, floats into my awareness through my headphones. Poised at the ready, my pen scrawls the factoid he has advised me to etch into my mind. If I hope to not only pass this upcoming exam, but slay it, I will need to commit to memory many dozens of such “high yield” facts. Every day, I open my laptop to my to-do list, which details my review plan for the day. This plan was meticulously laid out months ago, when I first began preparing for the second stage of my board examinations, the USMLE Step 2 CK. Step 2 is the second in a series of exams that medical students who hope to practice in the United States must take in order to receive their medical licenses. A 9-hour examination covering everything from obstetrical complications to the treatment of infections, the exam is one of many hurdles students face in order to become physicians.

One phrase crops up again and again in my study materials: high yield. For those uninitiated into medical culture, the ubiquity of the phrase “high yield” may strike you as perplexing. What does it mean? How high yield can something be if everything is designated “high yield”? Can 5,000 facts, many selected precisely because they are hard to remember, all be “high yield”? High yield is one of many terms I have learned in developing my medical student lexicon, and it points to the sheer quantity of facts—some intuitive, some…less so—that we must memorize if we hope to be successful.

It is a curious time to be a medical student. On the one hand, present circumstances make medicine more essential than ever, as we battle an invisible but mighty foe. On the other, the radical transformation in our society has affected medical students as much as others; we, too, find ourselves sitting idly at home when we are not in the hospital or in class, plagued with uncertainty about our role in a rapidly-changing society. Now is also a time in which we are witnessing transformations in American medicine as an increasing number of practitioners strive for greater practice authority. During this time, one question comes up again and again: what makes a doctor different? What, if anything, makes our training special?

For many, the answer to that question is rigor. Measured in sleepless nights, caffeinated beverages, and too-long hours, the putative hallmark of medical education is, simply put, that it is hard. Perhaps that is why, despite nagging evidence that hours-long standardized multiple choice tests do not alone make a competent clinician, we remain attached to their existence. One of the most bewildering and pervasive aspects of medical education is how profoundly proud many of us are, ultimately, of the parts of our education that are the most rigorous—and, at times, toxic. We wear 30-hour shifts like a badge of honor. A badge of honor that we feel ambivalent about nonetheless. I think this ambivalence about rigor is a dominant affective orientation towards medical training—simultaneously proud and burnt out, many medical trainees are loath to let go of the challenging experiences that both run their lives and make them suffer.

I’ve often felt that rigor—that is, suffering—is as central to our profession as helping is. It strikes me as fascinating that at the same time as we push for much-needed changes in work hours and training culture, we cling to outdated standards and norms that justify such intensity in the name of necessary rigor. This ambivalence marks many conversations about what we should do about the standardized testing arms race—rising averages, even more intense stress—as students push for ever-higher scores in order to secure their futures. Making the exams pass/fail may alleviate this trouble, but not entirely. For many, the weight of these standardized examinations is a gift and a curse—for many students at less prestigious schools, they are perceived as an opportunity to prove themselves, allowing for admission to prestigious residency programs and competitive specialties. But concerns about the inequities baked into standardized testing are valid; who has the time and money for preparatory classes, review materials, and tutors? A complex problem, with even more complex solutions.

That said, as I study for this exam, I feel pulled in many directions: frustration at the fact that one exam has so much to do with the futures afforded to me, pride at how much I have learned and consolidated in just a few short weeks, and readiness to be done and on to the next hurdle. If this is a hazing ritual, I can only conclude that it’s partially working.

I am uncertain about what the future of medical training will be, but I suspect that high yield resources are here to stay.

Image credit: RyanJLane

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