This is a terrific article that appeared on the New York Times blog.

Written by Abigail Zuger, M.D., it is titled “The Real World Is Not an Exam.”

Dr. Zuger explains what happens to the brilliant young doctors who aced every standardized test (there were so many of them!), but were flummoxed when it came time to diagnose a complicated real-life problem presented by a patient.

She gives examples of how these hotshots dealt with new situations: Badly.

They looked for the right answer, but there was none. What was needed was judgment and experience, and they didn’t have enough of either.

Dr. Zuger sees these young doctors as victims of linear thinking, a very bad habit caused by taking too many standardized tests with a single right answer.


She writes:



In 2009, a Supreme Court decision upheld the validity of multiple-choice testing for evaluating firefighters for promotion, prompting a heated nationwide discussion. Critics pointed out that test-taking savvy may have little to do with job performance.

Medical educators have been contemplating this possibility for years. But the problem particular to medicine may be the sheer volume of these tests, and the standard hysterical preparation they engender, which constitute a form of training in itself. Educators may not actually teach to the test, but students think to the test, in linear multiple choice.

They learn to recognize key phrases (neck pain) and stock situations (older woman), and they live in dread of unlikely worst-case scenarios. (Dies from heart attack while buying new pillow. You are sued.) Sometimes the actual, three-dimensional patient is not real enough to eradicate all her paper iterations.

Fear of uncertainty is expensive, and my young friend seemed poised to become single-handedly responsible for the high cost of health care in his ZIP code.

Like all victims of the single best answer syndrome, he ordered tests in wild profusion because, in his experience, every question had an answer and a test that would get you there. Options never included “You decide to keep an eye on it for a little while,” “You tell the patient to come back if it gets worse” or “You must make peace with the fact that you are never going to figure this one out.”

Some medical educators have tried to bend the linear algorithms of the multiple-choice experience to the nuances of the actual clinical world. One set, from the Mayo Clinic, specifically set out to teach against the test. Instead of the usual call-and-response questions, the educators took their students through complicated, contradictory cases for which there were no clear “best” strategies, but many reasonably acceptable ones.

Some students appreciated the point; others complained that all the ambiguity took up too much time. One bemoaned “cognitive overload,” and another wrote, “We know that there are many ‘correct’ ways to do things, but I prefer to be taught one way, rather than many.” (A linear thinker, that one, heading for an unhappy collision with the nonlinear world.)

My young friend never veered from his own well-honed habits. I could tell he thought I was remarkably ill trained, and I’d rather not imagine what he muttered about me to his peers. To my own, I muttered about his remarkable lack of sense and judgment until their eyes began to glaze.

From more than one, I got exactly the same response. “How bad could he be?” they said with finality. “He passed his boards, didn’t he?” Of course, that final hurdle in the path out of training consists of nailing a gigantic quantity of single best answer questions.