Is Skipping Med School Lectures Making Inferior Doctors?

Education is a privilege many cannot afford. Given its increasing cost, the tendency for students of any discipline to skip the very classes they amass debt to attend is surprising. However, given the far heftier price tag of medical education, the tendency for medical students in particular to avoid the lectures designed to help them become quality doctors is inexplicable to some and alarming to others.



Medical school courses are taught by the experts in our field: researchers developing novelty drugs to target a new pathway, or physician-scientists who may be the first to discover a new treatment for a previously untreatable disease. They have illustrious careers to share with us, if we take the time to listen. However, medical students are increasingly not attending these lectures, never meeting those who have come prepared to share a lifetime's worth of wisdom with the amateurs who sit before them.

How does any of this make sense, given the vast amounts of money students are investing in their education, which overwhelmingly consists of the very lectures they no longer attend? More important, what does a classroom with empty seats mean for future doctors?

Skipping and Acing Classes

Recent research forces academic introspection: Undergraduate students who skip class tend to see a corresponding dip in their grades. Except, a recent study by a research team at the University of Central Florida College of Medicine, led by assistant professor of pediatrics Christine A. Kauffman, MD, found that lecture attendance during medical school is not as predictive of good grades as we'd like to think, given how much we pay for this seemingly invaluable resource.

Kauffman described the setting in which their research was conducted. "This is a second-year course—it's a preclinical course." The evaluation of students' performance consisted of a "single multiple-choice question exam based on medical knowledge." Of note, Kauffman explains, "The lecture-based materials, all of the materials, were available to the students online," Kauffman explained. "So whether or not they attended the in-person session, they had the materials available to them."

Kauffman's team also distributed the Motivated Strategies for Learning Questionnaire to these same students, which looks at multiple subscales of motivation and learning styles, and they compared this with the students' performance. Out of the 15 subscales examined, they were only able to connect one to performance: self-efficacy. "Those who were more confident seemed to perform better than those who were less confident."

Of note, "self-efficacy was negatively correlated with attendance," Kauffman explained. Basically, those who were more confident were less likely to attend classes. The opposite was also true, as Kauffman described, "Those who scored highly in peer-learning and help-seeking behaviors were students who were more likely to attend. Our assumption from that is that the social aspects of the learning environment were important to those students, and that's the reason they chose to attend."

This is a crucial point often underrepresented in many discussions about how lectures are "obsolete." Most medical students do not dispense with lecture altogether. This isn't about ignoring the information; it's about changing how the information is received and consumed.

The evolution of medical education is a restructuring and rebalancing. Some students feel more productive speeding through lectures at 1.5 times or twice their normal speed on video. This gives them the luxury to be creative with the rest of their day. They can watch videos on YouTube that complement their understanding and fill in gaps where multiple angles of attack may be useful. Other students dig through the overwhelmingly vast array of other options for review and practice. From First Aid to UWorld, Kaplan, Boards and Beyond, Lecturio, Board Vitals, and many more, the list seems endless compared with the amount of time allotted for this glut of resources.

Passive Learning and Misperceptions

Michael Lea, PhD, professor at Rutgers New Jersey Medical School in the Department of Biochemistry and Molecular Biology, is worried about what's lost by only listening to or watching lectures at home. He explained that without actually being present, "You may not get the facial expression or the subtle ways we communicate with each other."

Lea is also worried about things that won't show up on tests. "My concern is that the lack of attendance in-person will create more isolated individuals, and therefore we potentially lose some of those other things we're trying to teach, [such as] professional identity formation, the transfer to patient care, and the ability to communicate well with peers as well as patients."

Regardless of feelings on attendance, Lea admits that "traditional lecture is a very low-tech way of transmitting information, because everyone has to go at the same pace." Furthermore, Lea is worried that attending lectures moved from an active to a passive experience. As he described, "If not provided handouts of the material in any form, you had to listen very carefully and take notes—and that made learning very active." With lecture slides and handouts readily available online, Lea has observed an increased frequency of student "multitasking." He doesn't use the term to refer to additional simultaneous learning; "multitasking" is Lea's euphemism for students' tendency to tune into Facebook or Instagram during the lecture.


What can't be disputed is that the back-and-forth nature of discussions or questions asked in class is superior to corresponding via email. Instead of active participation, passive exchanges have become the norm. Beyond her role as a researcher, when considering the passive nature of lectures based on PowerPoint slides in her role as a professor, Kauffman asked, "Are we using our time as optimally as we could?"

Other things may be lost by not attending lectures as well. Kauffman identified the inability to recognize misconceptions as a potential danger. If two different students have wildly different interpretation of the facts, as Kauffman explained, "[t]hey may still be able to get the answer right on a multiple choice exam...but they wouldn't necessarily be able to do it on a different question...or they may not be able to transfer it to patient care because of that huge misconception." The worrying part is not the misinterpretation, as Kauffman clarified "We won't be able to [remediate] if there isn't some kind of person-to-person interaction."

Learning Is Changing, but What About the Outcomes?

If students are no longer learning in the same way, why are we being tested in the same way? Multiple-choice questions have never captured nuance, but without the same classroom interactions as before, are the gaps in assessment even more dangerous? "Our patients don't read the textbook," Kauffman explained. "They don't have the stereotypical presentation." With more passive learning and a failure to correct misperceptions, Kauffman stressed the importance of being able to "recognize the limitations of what we're assessing with those exams."

In a piece for the Washington Post , Brenda Sirovich, MD, professor of medicine at Dartmouth Geisel School of Medicine, argues that students are quick to figure out how to maximize test scores. She put out her frustrated take on her student's "to-do" lists:

1. Do not attend class, unless attendance is specifically required.
   
   
2. Complain about the (modest) number of class hours requiring attendance.
   
   
3. Resist discretionary learning opportunities, no matter how interesting.
   

Sirovich points out that this does often produce a good board score. However, is that score the sole desired outcome of medical education? Are professors increasingly "teaching to the test," toward the achievement of good board scores, the holy grail of medical education? Has the focus shifted from the outcome of students actually becoming good physicians?

Kauffman suggests that professors should consider their role in medical education beyond just imparting information. "Is that truly our most important role? Was it ever our most important role?" Board scores are essential, but so is the molding of students into mature physicians capable of the depth of insight complex patients require. Professors are our greatest asset, our guides toward adopting the doctorly demeanor. As Kauffman put it, "Do we need to consider that our more important role might be in the dimensions of professional identity formation; in the dimensions of clinical reasoning; in the dimensions of patient care, rather than just the ability to put information on a slide, or say the information out loud?"

Flexibility Is Also a Learned Skill

For medical students who are overwhelmed with over a dozen hours of lecture each week on top of our research activities, leadership roles, clubs, and community service, medical education is less about the language of learning and more about achieving a means to an end as efficiently as possible. Often, our primary goal is maintaining that glimmer of hope for some reincarnation of the former flexible lifestyles we once enjoyed.

The bottom line from the perspective of a medical student is that skipping class gives students much greater flexibility. This is especially true for nontraditional students and commuters, such as Robert, an M1 who had an almost 10-year career as a derivatives trader for various banks and clearinghouses before working in the pharmaceutical industry for 4 additional years. "I like podcasting because it gives me a lot of flexibility," he explained. Robert has a 15-month-old baby at home, who "likes reading books and chasing our cats," so recorded lectures are crucial because it helps him stay home more often. "I still haven't been able to help as much as I want to," he explained, "But definitely my wife appreciates that I'm home more than I would be."

Besides the convenience and support that recorded lectures provide to his wife and child, Robert explained the practical learning considerations that benefit not just parents of little ones, but also students who struggle with attention deficit, especially when having to absorb up to 5 hours of lecture in a sitting. "When I sit in lecture, if they move through a topic too quickly and I don't get it, it's over right there. And I might be lost for the rest of the lecture because [it's] contingent on understanding the first part. So I like podcasting because I can go at my own pace and really dig into [the material], and pause it when I need to."

Salma, an M1 who has dabbled in both recorded and in-person lecture-learning, agreed that the flexibility is key. "You can start the day how you want, not limited by time constraints, and according to your schedule." Despite having greater control over her day, she admitted that going to class is beneficial in forcing her to keep to a tight schedule. "I'm very regimented. I like having my time split into strict time slots." More important, she explained that attending lecture "forces me to understand everything in lecture, so I [don't] have to podcast or listen to it again. The classroom environment—I'm that front-seater—motivates me: being with people more educated than I am to feel inspired by them."

Salma savors the intangibles of attending lecture as well. "I care a lot about the history of medicine and what medicine means. I love talking to the professors after class, learning from them, being inspired by them." The times she has used recorded lectures, Salma feels like she's gained "information, but not the real-world application from talking to the professor after class."

Will You Regret Your Learning Method?

Yet, every benefit has its drawbacks. Medical students are known for our "A-type" personalities, yet the "A" for "ambition" may readily be replaced by "anxiety," as nervous chatter and one-upmanship are common classroom occurrences. "I always hear [classmates] freaking out about studying," Salma said, "I think, 'What was I doing last night?'" Being around that can make you feel "guilty for living your life," she explained.

Shabil, a urology resident who was a medical student when recorded lectures first arrived on the horizon years ago, says he spent 6 months of medical school skipping, and 18 months being physically present, in class. Reflecting on his experiences, Shabil says he never went to a single chemistry lecture during his undergraduate years, but still got an A+ in the class. "I prided myself on that," he said. "I thought that's who I was." Then, he got to medical school, where "lo and behold, that wasn't ideal," he says.

The takeaway: "Don't think you know yourself until you've really given each and every method an honest thought."

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