Mastering High-Stakes Exams: Strategies for Success in Medical Education and Beyond

Podcast Transcript

Dr. James K. Stoller:

Hello, and welcome to MedEd Thread, a Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise.

Dr. Tony Tizzano:

Hello. Welcome to today's episode of MedEd Thread, an education podcast to explore preparation for high-stakes exams. I'm your host, Dr. Tony Tizzano, Director of Student and Lerner Health here at Cleveland Clinic, in Cleveland, Ohio.

Today I'm very pleased to have Dr. Rahul Damania, Director of Academic Advising at Cleveland Clinic's Lerner College of Medicine, of Case Western Reserve University, here to join us. Rahul, welcome to the podcast.

Dr. Rahul Damania:

Thank you for having me, Tony.

Dr. Tony Tizzano:

Rahul, to get us started, can you please tell us a little bit about yourself? What brought you to Cleveland and your role here at Cleveland Clinic, as well as some of your educational background?

Dr. Rahul Damania:

I had a very unique path into medicine. I grew up in a family full of physicians, so I think it was great nurturing as I, I made my decision to pursue medicine. I did a accelerated combined BS/MD program at NEOMED, Northeast Ohio Medical University, and then subsequently did my categorical pediatrics residency at Rainbow Babies & Children's Hospital.

Afterwards, I transitioned to a little bit more warmer weather, and went to Emory for my pediatric critical care fellowship. And this is my first position out of fellowship, and it has been a whirlwind, but had been super exciting.

Within the medical education realm, at the medical school I am the director of Academic Advising, like you mentioned, and I focus a lot on learning science and helping students prepare for and excel on high-stakes exams, such as the USMLE. The USMLE, as we'll get into, has two parts... Step 1 and Step 2 CK, and I really made it my mission to create programming and integrations within the curriculum to help students reduce stress when it comes to these high-stakes exams.

Dr. Tony Tizzano:

Boy, I can remember those days. They, they were called something different, National Board of Medical Examiners, but where were you when I needed you?

Dr. Rahul Damania:

(laughs)

Dr. Tony Tizzano:

So in today's segment, we will explore a novel perspective and strategy for high-stakes exam preparation in medical education, healthcare... And really beyond, because there's lots of very difficult certification exams.

So Rahul, if you could help us frame this topic with our listeners so they have a sense of what is a high-stakes exam, and special considerations around preparing for them?

Dr. Rahul Damania:

So high-stakes exam preparation really refers to the process of studying and strategizing, specifically for important exams, where the results have significant consequences or even rewards related to professional licensing and entrance into educational programs. Some of the common examples are the USMLE, Step 1, in which medical students at the pre-clinical level are going to be reviewing the basic sciences... And m- are, are assessed on the Step 1, their mastery or proficiency regarding this topic. Step 2 CK, which is focused a lot more on clinical sciences that rising third or fourth-year medical students who have completed their clerkships typically go through.

And please note that these USMLE exams are international exams, in the sense that if you are a physician... Let's say in Pakistan, and you want to come here and practice medicine or get residency or graduate medical education training, you will have to appear for these summative exams... The USMLE, and take them as a part of your overall application.

We also note for high-stakes exam preparation, entrance exams, such as ACT... The SAT, which is at the high school level, and even the medical school admission test, which is commonly referred to as the MCAT. And I think that these exams have not only the preparation aspect of it, but primarily the content coupled with the strategies on how you can effectively excel on these exams, and I'm really looking forward to diving a little bit deeper into those.

Dr. Tony Tizzano:

Yeah. And so often, you know, we probably have not as had a holistic way of looking at applicants, but we look at these numbers, so in many cases, there's a cutoff. You've got to be above a certain level. And so, it has a lot of consequences.

So what sparked your interest in this area of endeavor, and what do you bring to the table for learners?

Dr. Rahul Damania:

I think as I have developed my passion... Initially, it was really focused on the content. I really wanted to make sure that students learned the content, knew what was high-yield, what came up on these exams, day in and day out. But now what has really fascinated me, are the psychological or performance aspects which go into preparing for these exams.

Now, USMLE, for example... Which is a high-stakes exam, is a summative exam, that really is going to be challenging because students prepare for it longitudinally throughout the year, and then they have this very intense six to eight-week dedicated study period in which they are committed to applying and learning th- the concepts that are going to be tested on that seven-hour exam.

And so really trying to make sure that we not only focus on content, but really emphasize the importance of s- staying psychologically safe throughout the experience... Is an area that really makes me very passionate, and something that I center myself on every day when I work with students.

Dr. Tony Tizzano:

Boy, point well taken. There is tremendous stress around these. So, you mentioned summative. What is the difference between formative versus summative assessment formats?

Dr. Rahul Damania:

This is a really important distinction. When we're thinking about formative assessments, these are going to be progress tests. Progress tests, you can think of it as like mini quizzes, to just make sure that you are on par with the level of knowledge that you have maybe accrued thus far. Formative assessments are really important in understanding small gaps in your knowledge, and what they can do, is they can serve as a way for you to review the content you may feel deficient or that the formative assessment really highlights as a opportunity for improvement.

The importance of formative assessments, is that they really help you understand, and memorize and learn the material for longterm, due to something known as the testing effect. We know that when we are put in a position that we have to apply our knowledge under... Let's say a time pressure, we're able to remember those experiences... Because not only do you have the sensory, but you have the emotion, and together they are going to couple to create good learning.

Now, summative assessments are the exact opposite. This is going to be, let's say, your final exams after a whole semester. Summative assessments are what high-stakes exams are, in which they are going to be not as frequent as formative assessments, but they cover a large breadth of topics... And these topics now are considered core topics. And if a student is going to be excelling on something like a summative assessment, then that may be an entry-level for a graduation or the next step in their education.

Dr. Tony Tizzano:

Yeah, those are the tough ones. Those are the ones that we sweat over, because there's such a long period of time that you're asked to bring information from your first year of college, all the way to your third year, and then spit it out in the MCAT, for example.

Dr. Rahul Damania:

Exactly and y- just one point regarding this. The summative assessments... You're absolutely correct, that they carry a lot of stress, but in the age of the next-gen learner, we have also started to see psychological stress surrounding formative assessments as well. And I'm really looking forward to diving into the non-content aspects of these different exam formats.

Dr. Tony Tizzano:

Well, tha- I'm glad you brought that up. So, let's dive into these psychological considerations around test-taking. Elaborate on that. What can we do? What are the problems, what can we do about them?

Dr. Rahul Damania:

One of the resonating problems that many medical students have at times is the notion that if we, for example, are going to not do as well on a formative assessment, that may translate to not doing well on a summative assessment. And I think this is an area of psychological tension, where sometimes students have trouble with being wrong and having that uncertainty.

In a age where there's so much data, when a student gets a low score... Let's say on a formative question block of USMLE-style questions, and they see a 36%, sometimes they extrapolate that and they say, "Well, I'm gonna get a 36% on the summative assessment." 

And breaking that stigma is really important, and so one of the practical solutions that I like to coach when I'm working with students, is to not be afraid to be wrong. Being wrong is an opportunity for you to lean into your deficiencies, and grow and perform, so that then you are that much stronger when you're walking into the Prometric exam center, which is where many of these summative assessments are held.

Dr. Tony Tizzano:

Of course. And perhaps even further, they don't do well, and all of a sudden they extend that to, "I'm not gonna be good at this. I'm not cut out for this," because they didn't do well. That whole idea of, uh, imposter phenomenon, do you wanna touch on that a little bit?

Dr. Rahul Damania:

Absolutely. I think that purpose and identity is something that many developing medical professionals deal with. I'm very young in my attending career, and I sometimes have this phenomena, where, "Do I fit in? Am I competent?" 

And I think that whenever we look at, let's say a medical student or a resident... When they are putting in so much effort, one of the identity components that they are looking for, is, "Are all of these efforts worth it?" And, "Am I part of a greater community, that I can share an identity with?"

And sometimes whenever there are shortcomings, that identity gets shattered, and that then ends up causing you to have, uh, imposter syndrome, in-

Dr. Tony Tizzano:

Yeah.

Dr. Rahul Damania:

... which you feel like you can't fit in.

Dr. Tony Tizzano:

In a couple of words, "Do I belong?"

Dr. Rahul Damania:

Exactly.

Dr. Tony Tizzano:

That belonging is such a key thing.

So when we think about these precepts more, how do they manifest in learners with respect to wellness and this psychological safety that you mentioned? What kinds of things might you see that we as educators should be on the lookout for?

Dr. Rahul Damania:

There was a really interesting study that was done at five different institutions, where they surveyed about 350 students that were going through the dedicated study preparation for the USMLE, which is that six to eight-week intense study period. 

What they noted when they gave standardized assessments of mental wellbeing, was that over 70% of students ended up having one or more depression or anxiety-related criteria during that dedicated time. And what was also interesting, are other components, such as many of these students are using third-party resources. 25% of them also felt financial pressures. And so this really kind of helps us conceptualize that it's not just the material itself, it may not even be the performance aspect of it, but it is all of these external factors that go into helping to support a student effectively.

Dr. Tony Tizzano:

Yeah. And that student won't sleep as well, that student won't spend time outside the classroom, engaging with friends as much. So, there is so much.

If we look at learning analytics to try to help us as educators identify students at-risk and learners to navigate the plethora of alternatives available to them, where do you begin?

Dr. Rahul Damania:

This has been something that I have been very grateful to be a part of here at Cleveland Clinic Lerner College of Medicine. And in particular, we have formed a team that dedicates themselves to making sure that we not only cover the curricula that students need to become effective bedside clinicians and researchers, but also to longitudinally prepare for these high-stakes exams. And I think the core of this committee, is to make sure that we have an equitable learning environment. 

I'll give you a really important example. There is a gold standard bank of questions, known as UWorld, and this bank of questions is used by m- over 95% of students who are preparing for the USMLE internationally. What we have done as a team, is take these USMLE board-style questions from UWorld, and we have leveraged the power of learning analytics to map each of these questions to their specific seminars.

And so now we not only have the traditional assessment model, which is in place, but we have the ability to meet students where they are at, because they are looking forward to preparing for this very high-stakes summative exam. And if we can do this throughout the whole year, while they are learning their organ systems, I think that we can really effectively reduce the stress during dedicated study.

Dr. Tony Tizzano:

So that brings up, what is our role then? What is our responsibility as educators, as an institution, to our students?

Dr. Rahul Damania:

I think it is definitely a balance, and I'm really happy that you bring in the institution's responsibility to help the students. Sometimes students feel that they are in a parallel curriculum. The school is doing one thing, but they, in order to succeed on, uh, tests like the USMLE, have to do something different.

And I think that first, bringing the institution's attention to this and addressing the elephant in the room... And mobilizing effective resources and time for this high-stakes exam, is the first step to lowering the barrier of entry and the barrier of stress. In my opinion, these exams have evolved so much, to not just now focus on minutia... Maybe that was the old model, but these are clinical reasoning-based assessments, that really can form the core of knowledge for practice for these medical students as they transition into clerkships and beyond.

Dr. Tony Tizzano:

Boy, that clinical reasoning, that is absolutely the key. I mean, that's what you need to survive when you finally step out of the ivory tower, and now you're in a small town in Western Pennsylvania and you're the only one in that specialty.

Dr. Rahul Damania:

Absolutely.

Dr. Tony Tizzano:

And there's no one standing behind you, as they have all the way through your training.

So you know, this is really interesting. I always got the feeling when I was in medical school that there was such a hierarchy, and I didn't feel it as much in undergraduate work, because I was an older undergraduate student and I had worked outside... From an industry standpoint, with some of the teachers. 

But you know, we have the sense in medical school that, "I'm the attending," or, "I'm the clerkship, organizer. I'm the boss and they're the students..." But without this medical school, we wouldn't have that job. You wouldn't be on faculty if there wasn't for a school. Who's working for who?

Dr. Rahul Damania:

Yeah.

Dr. Tony Tizzano:

Are we there for the students? Are the students there for us? You know, that, I think has to change a little bit. And I think it's easier in the first two years of training, but once you land in the clerkships... With very busy caregivers, t- c- having to carve out time and be teachers, how do you see this developing?

Dr. Rahul Damania:

This is an interesting paradigm, and I think that the problem itself is complex, and the solution is probably even more complex. 

I definitely agree with you that learning is a two-way street. The learner has to understand their role and responsibility, and the caregiver, or even the institution, has to recognize where the resources are going... And make sure that we can effectively diagnose, where are there poor learning experiences, and how we can mobilize resources to optimize those learning experiences?

And I think if we think about things as spectrums, where there might be some very poor learning experiences, those are the ones that we need to tackle first and resource allocate first, compared to those that are maybe a little bit lower stakes. I think that that could be at least w- a chip in the iceberg as we tackle this very unique problem that you brought up.

Dr. Tony Tizzano:

So, people are looking at you thus far. You've been here about a year. What's the feedback been like for you, from educators and from students?

Dr. Rahul Damania:

I've been very grateful to interact with not only the faculty, and gain great mentorship... And really meet some of the bigwigs, so to say, in our institution, from an educational lens... But I have been even more grateful to also be student-facing, and I have really centered myself on making sure that I meet students where they are, and also focus on a very active learning approach. 

I center myself a lot on active l- learning theory, and specifically adult learning theory, so that then I can make sure th- to not only just teach the student content, but coach them in areas that they feel that they are weak. And using that coaching framework, has been very fruitful and beneficial with these medical students.

Dr. Tony Tizzano:

Yeah. Well said.

Well, there is so much to think about with all of this. And I can't imagine that any student in any area of endeavor isn't listening to this and thinking, "How can I benefit by some of these principles?" What's next? What lies on the horizon? What would you like to see?

Dr. Rahul Damania:

One element of our conversation which I really am drawn to, is this aspect of clinical reasoning. And I think it's something that stumps many medical educators, is how can we effectively assess clinical reasoning?

And I think that now with the advent of artificial intelligence and large language models that can essentially be simulated patients and teach students diagnostic and management reasoning, I think that now we are going to be, be s- seeing a shift... Where traditional summative high-stakes exams are now going to be unique learner experiences, utilizing AI... In which the student comes into the testing facility, interacts with a certain set of AI models or interacts in a way that they can type or show their clinical reasoning, and then we are able to backmap and see what a learner's thought process is through a certain case. And I think that that's gonna be very fascinating, as that data is super rich as these students go from a testing center to the bedside.

Dr. Tony Tizzano:

Boy, I think you are spot-on, Rahul. I can think of times, as we had a whole new generation of physicians coming. It was... You know, we're talking 15, 20 years ago. And I was the old guy on the practice, and I'd, you know, be stumped on something, and I'd step out of the exam room and be heading over to the library... That we have, our little library in our office. 

And I'd see one of my colleagues, and I'd go, "Yeah, I gotta go look something..." And she'd pull out her phone, "T- t- da- da- da- da," and she'd show it to me. She goes, "I'll send it to your phone." She's on Medline or something, just like that. At my fingertips, the latest... And I'm thinking, "Wow." And then of course, she goes, "And if you want, you can just send that to the patient too. It's readable."

Dr. Rahul Damania:

Wow.

Dr. Tony Tizzano:

And what a tool. And, uh, it's incredible. And I think that students... Our new students, this generation of students, carry the torch in this area. This is second-nature to them. If I was any worse with this, I'd have a tail. So, I think it really makes a difference.

So, what have I missed? What are some questions or, I should've asked, and you'd like our audience to know?

Dr. Rahul Damania:

One aspect that I really want to highlight... And this may be a little bit of a conflicting statement, but I'd love to just put it out there... Is that in the realm of USMLE preparation and the exam itself, there's a lot of tension in the medical education realm about, "What is the role of this?" And, "Is this just another maybe money-making scheme, to just certify doctors?" And, "Why does our curricula even need to have these exams in there? Great bedside care is when students go and see patients."

And while I see the truth in that statement, I do feel like the foundation of knowledge can be very well-assessed when you have valid, reliable assessments, that are going to... Not only encompass basic sciences, for example, but systems-based practices... Things such as ethical scenarios, or biostatistics, things that really will empower a medical student to learn in a more controlled setting before they go out in the clinical environment. And they can engage with that material, be tested on that material, and show some element of competency.

And so one point that I really want to drive home, is that these are really tough exams, and I'm glad that they are really tough. The reason why they need to be tough, is because they form the core of medical knowledge.

I'll give you a really important example. I had a student who was rotating with me, and I asked them about a genetic syndrome. And you know what that student said? "Oh, man, this takes me back to when I was studying for the USMLE," and, "Oh, what was that gene?" And I was like, "Well, that's important for us to center ourselves on." That, this dedicated study period is when, for lack of a better term, a student learns the most. It is such a accelerated curve. 

And what I have found very fascinating and important, is that it ends up being a common thread. If I came to you, Tony, and I said, "Tell me about your USMLE experience," you and I can connect on it.

Dr. Tony Tizzano:

Yes.

Dr. Rahul Damania:

And that's what makes it so fascinating to me.

Dr. Tony Tizzano:

Yeah.

And you only have to look back historically to see what we used to do in the 19th century, and the folly of medical education early on, that... If you had money to go to Europe, you might've gotten a shot at it, but still, you were an apprentice. You didn't see patients. And if you did, you probably had to pay to do it. I mean, you just didn't do it. So, it's changed so much.

Well, thank you so much, Rahul. This has been a fascinating and insightful episode of MedEd Thread. 

To our listeners, if you'd like to suggest a medical education topic to us or comment on an episode, please email us at education@CCF.org.

Thank you very much for joining, and we look forward to seeing you on our next episode. Have a wonderful day.

Dr. James K. Stoller:

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, SoundCloud, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread, and please join us again soon.