How much is too much?
Medical students can’t get through the assigned reading once.
In the 2009/10 academic pre-clinical year, faculty at Mercer University medical school assigned over 29,000 pages of reading (Klatt & Klatt, 2011). Two thirds of the students could read this material no faster than 100 words per minute. 500 pages per week at these low reading rates would require up to 40 hours weekly for reading alone, and that’s reading it only once (Klatt & Klatt, 2011). If untrained retention rates are usually less than 70% (Hahn & Bart, 2003), and if one assumes that the typical pre- clinical medical student actually reads for 40 hours a week to accomplish the assignment, then almost 9,000 pages of information is … gone.
Klatt & Klatt (2011) urge faculty to remember the complexity of the material and assign more reasonable reading assignments. So, by cutting this in half, there is still 20 hours of reading, at less than 70% retention. How much time do medical students actually have to read, outside of classes, and necessary personal time? During clinical (clerkship) training, medical students at Johns Hopkins had a median reading time of 10 hours weekly (ranging from 3-30 hours), and found reading around patient problems difficult (Leff & Harper, 2006).
“For medical schools,…content delivery can be compared with drinking from a fire hose” (Roberts & Klamen, 2010). Reading skills adequate for pre medical degrees may be inadequate for medicine (Roberts & Klamen, 2010). Numerous authors clamour for pre medical or early in medicine training in study and reading strategies (Roberts & Klamen, 2010; Amoriggi & Shaw, 2005/6; Gottesman & Hoskins, 2013; etc etc.).
Reading isn’t enough. Regurgitation of read material is inadequate. Making the transfer from basic science to clinical medicine application requires deep processing, the creation of links between multiple data trees (McNamara, 2010), and often a creative slant.
Medical students are now commonly challenged to complete portfolios of reflective exercises (Buckley, Coleman, Davison, Khan, Zamora, Malick, Morley, Pollard, Ashcroft, Popovic & Sayers, 2009), writings that challenge the student to think deeply about the patient, the clinical problem, the interpersonal dynamic. Clearly here is another literacy facet that the medical student must cover, and with which they often need faculty help and guidance (Dekker, Schönrock-Adema, Snoek, van der Molen & Cohen-Schotanus, 2013; and Aronson, Niehaus, Hill-Sakurai, Lai & O’Sullivan, 2012) but is beyond the scope of this paper.
Several faculty approaches can help students. An interesting position supporting the use of “cohesion gaps” in both lecture and text (McNamara, 2010) has been forwarded for consideration by medical faculty. High knowledge learners can proceed more quickly to deeper, more meaningful knowledge by forcing themselves to question, pull in information from other areas, and fill in those gaps actively. Unfortunately, these gaps in the presentation can completely lose those students with a lower knowledge base (McNamara, 2010). Students not attending lecture but using alternative materials were found to do just as well as those attending. Faculty has been urged to provide those alternate educational materials (Horton, Wiederman & Saint, 2012). Team based (Tan, Kandiah, Chan, Umapathi, Lee & Tan, 2011) or problem based group learning activity can be ideal for many students, many showing higher retention, and better grasp of material. Medical faculty often make the assumption that all students are accomplished learners, and have been reminded that basic problems such as dyslexia and dyscalculia exist in this environment (MacDougall, 2009). Availability of appropriate texts and materials for these students would be ideal. Medical students without defined learning disability diagnoses can still suffer from weak learning skills. Students that have repetitively failed USMLE (standard board licensing exams) have been shown to do well with a course of cognitive rehabilitation for accuracy and fluency in reading (Laatsch, 2009). This concept of spaced education is refreshing, the authors suggesting that interval emailing of clinical vignettes and associated questions to course graduates keeps retention levels and competence high (Kerfoot, Baker, Koch, Connelly, Joseph & Ritchey, 2007).
A number of authors argue for better training in accessing literature, suggesting pushing students to formally engage library faculty (Kleyman & Tabaei, 2012), improving online information literacy (Kingsley, Galbraith, Herring, Stowers, Stewart & Kingsley, 2011), maximizing opportunities to access such literature (Leff & Harper, 2006), and clear instruction in how to access Medline (Gruppen, Rana, & Arndt, 2005).
McNamara (2010) promotes direct teaching of better, deeper reading skills by the use of the iSTART tutoring system. This computerized system coaches students to think about the thinking process, to develop and improve “self explanations” of written material, line by line. McNamara (uofmemphisvideos, 2009) has actually helped develop almost a computer game complete with an interactive wizard that pushes readers to bridge, expand and predict, to break down presented information and actually understand it (uofmemphisvideos, 2009). Certainly, having access to such a gaming center in a medical school could help evolve deeper reading skills by students.
“Vocabulary instruction…is essential to content area learning” (Morrow & Gambrell, p.347). Is this a non issue in medical school? There is a relative dearth of literature on this topic. ESL (english as a second language) medical students show weakness in regular, non technical vocabulary; this has been shown to produce difficulties in understanding medical literature (Heming & Nandagopal, 2012). Medical students are challenged to read very widely (see above). Perhaps, as Anderson (Nagy, Herman & Anderson, 1985) has found, vocabulary is not explicitly taught as most words are learned indirectly through reading, through context; or perhaps verbally, in clinic.
The CREATE (Consider, Read, Elucidate hypotheses, Analyze and interpret data, Think of the next Experiment) strategy (Gottesman & Hoskins, 2013; Hoskins, Lopatto, & Stevens, 2011) is a teachable strategy that can help medical and science students make sense of scientific literature. Students are taught to take apart an experiment right down to specifics of n, control groups, hypotheses, sampling and so on before even looking at the collected data. This approach helps them to think as scientists. Students are asked to consider if the data could be synthesized differently, or if a follow up experiment would be useful (Gottesman & Hoskins, 2013). Certainly, this is not passive reading, but a style of actively challenging and picking apart the written material that would lead to deep understanding.
Similarly, an approach termed, “Figure Facts” teaches students to approach a scientific article targeted directly at the presented data, not text (Round & Campbell, 2013). Students are taught to use graphic organizers to analyze and categorize data presented in figures. The authors have found that students that are taught to analyze a journal article in such a way interpret new raw data sets more accurately, in essence making them better scientists (Round & Campbell, 2013).
Certain well defined critical reading techniques, such as the INSERT note making system (Morrow & Gambrell, 2011), or the TQM system (Hahn & Bart, 2003) developed from an industry model can give students strategies to actively read, instead of passively consume. To use the INSERT method, readers simply make small marks in the margin to designate material that is found to be interesting, objectionable, questionable, or noteworthy. The TQM method is more involved, in essence teaching the student a way to summarize and reword read material.
Simply taking a speed reading course, commercially available from many sources on the internet, for example, can help students (Amoriggi & Shaw, 2005/6). Techniques here are more than simply the cessation of sub vocalizing, learning to perceive more than one word at once, and keeping the eyes moving forward. Typical strategies taught include how to attack a text chapter. Merely learning to read the conclusion slowly first engenders subconscious, and conscious questions, turning the reading experience into a problem solving exercise. Reading subheadings, bolded text, and figures secondly simply leads to more heightened awareness, and a fine tuning of these questions. Forcing one’s self to read the first sentences of each paragraph next becomes the third time through the material, and is usually fairly quick. By the time the reader reads the article, she half understands it, and uses the exercise to fill in gaps, and further problem solve.
In conclusion, therefore, there are a plethora of techniques available to help that struggling student cope with mountains of reading material. It may be time, however, for faculty to take some responsibility in subsumption, or at least clearly teaching and emphasizing widely agreed upon fence posts. Let us start to teach the most important concepts, and allow our brilliant students the chance to actively use these gaps in “cohesion” to fill in the blanks, to cross bridge, to predict, to expand, to put up the fence rails themselves. Teaching less will help our students learn more, deeply.
Amoriggi, H. & Shaw, K. (2005/2006). Can SpeedReading / eSpeedReading skills training enhance the overall learning/ elearning productivity of 21st century medical students and surgical residents? International Journal of Learning. 12(12): 157-170.
Aronson, L., Niehaus, B., Hill-Sakurai, L., Lai, C. & O’Sullivan, P.S. (2012). A comparison of two methods of teaching reflective ability in Year 3 medical students. Med Educ. 46(8):807-14. doi: 10.1111/j.1365-2923.2012.04299.x.
Buckley, S., Coleman, J., Davison, I., Khan, K.S., Zamora, J., Malick, S., Morley, D., Pollard, D., Ashcroft, T., Popovic, C. & Sayers, J. (2009). The educational effects of portfolios on undergraduate student learning: a Best Evidence Education (BEME) systematic review. BEME Guide No. 11. Med Teach. 31(4): 282-98. doi:10.1080/01421590902889897.
Dekker, H., Schönrock-Adema, J., Snoek, J.W., van der Molen, T. & Cohen-Schotanus, J. (2013). Which characteristics of written feedback are perceived as stimulating students’ reflective competence: an exploratory study. BMC Med Educ. (13) 94: doi: 10.1186/1472-6920-13-94.
Gottesman, A.J., & Hoskins, S.G. (2013). CREATE cornerstone: introduction to scientific thinking, a new course for STEM-interested freshmen, demystifies scientific thinking through analysis of scientific literature. CBE Life Sci Educ. 12(1): 59-72. doi: 10.1187/cbe.12-11-0201.
Gruppen, L.D., Rana, G.K. & Arndt, T.S. (2005). A controlled comparison study of the efficacy of training medical students in evidence-based medicine literature searching skills. Acad Med. 80(10): 940-4.
Hahn, W.G. & Bart, B.D. (2003). Applying quality management process-improvement principles to learning in reading courses: an improved learning and retention method. Journal of Education for Business. (78) 4: 181-4
Heming, T.A. & Nandagopal, S. (2012). Comparative difficulties with non-scientific general vocabulary and scientific/ medical terminology in English as a Second Language (ESL) Medical Students. Sultan Qaboos Univ Med J. 12(4): 485-92.
Horton, D.M., Wiederman, S.D., & Saint, D.A. (2012). Assessment outcome is weakly correlated with lecture attendance: influence of learning style and use of alternative materials. Adv Physiol Educ. 36(2): 108-15. doi: 10.1152/advan.00111.2011.
Hoskins, S.G., Lopatto, D., & Stevens, L.M. (2011). The CREATE approach to primary literature shifts undergraduates’ self- assessed ability to read and analyze journal articles, attitudes about science, and epistemological beliefs. CBE Life Sci Educ. 10(4): 368-78. doi: 10.1187/cbe.11-03-0027
Kerfoot, B.P., Baker, H.E., Koch, M.O., Connelly, D., Joseph, D.B. & Ritchey, M.L. (2007). Randomized, controlled trial of spaced education to urology residents in the United States and Canada. J Urol. 177(4): 1481-7.
Kingsley, K., Galbraith, G.M., Herring, M., Stowers, E., Stewart, T. & Kingsley, K.V. (2011). Why not just Google it? An assessment of information literacy skills in a biomedical science curriculum. BMC Med Educ. 11(17): doi:10.1186/1472-6920-11-17.
Klatt, E.C. & Klatt, C.A. (2011). How much is too much reading for medical students? Assigned reading and reading rates at one medical school. Acad Med. 86(9): 1079-83. doi:10.1097/ACM.0b013e31822579fc.
Kleyman, E.Z. & Tabaei, S. (2012). Information literacy needs in graduate-level health sciences education. J Physician Assist Educ. 23(2):36-41.
Laatsch, L. (2009). Evaluation and treatment of students with difficulties passing the Step examinations. Acad Med. 84(5): 677-83. doi: 10.1097/ACM.0b013e31819faae1.
Leff, B. & Harper, G.M. (2006). The reading habits of medicine clerks at one medical school: frequency, usefulness, and difficulties. Acad Med. 81(5):489-94.
MacDougall, M. (2009). Dyscalculia, dyslexia, and medical students’ needs for learning and using statistics. Med Educ Online. 14(2). doi:10.3885/meo.2009.F0000213.
McNamara, D.S. (2010). Strategies to read and learn: overcoming learning by consumption. Med Educ. 44(4):340-6. doi:10.1111/j.1365-2923.2009.03550.x.
Morrow, L.M. & Gambrell, L.B. (2011). Best practices in literacy instruction, 4th ed. New York: The Guilford Press.
Nagy, W.E., Herman, P.A. & Anderson, R.C. (1985). Learning words from context. Reading research quarterly, p234-253.
Roberts, N.K. & Klamen, D.L. (2010). The case for teaching explicit reading strategies to medical students. Med Educ. 44(4): 328-9. doi: 10.1111/j.1365-2923.2009.03585.x.
Round, J.E., & Campbell, A.M. (2013). Figure facts: encouraging undergraduates to take a data-centered approach to reading primary literature. CBE Life Sci Educ. 12(1):39-46. doi: 10.1187/cbe.11-07-0057.
Tan, N.C., Kandiah, N., Chan, Y.H., Umapathi, T., Lee, S.H. & Tan, K. (2011). A controlled study of team- based learning for undergraduate clinical neurology education. BMC Med Educ. 11(91). doi:10.1186/1472-6920-11-91.
uofmemphisvideos. (2009).The university of Memphis’ institute for intelligent systems is developing “iStart”. [videofile] Retrieved from http://www.youtube.com/watch?v=G7oRUjGtRbQ