We know a radiology resident who failed the American Board of Radiology’s core exam. In preparing for the exam the first time, he read textbooks, took cases at board review sessions, and worked through practice questions. The second time around, his fellow residents urged him to study only online question banks such as RadPrimer, Qevlar, Face the Core, Rock the Boards, and BoardVitals. So he shifted his attention accordingly—whenever he missed a question, he made a flashcard, and studied it over and over. This program of study occupied all his available time. He enlisted a faculty mentor to help in preparing to retake the exam, and spent most of his time attempting to analyze how he was “fooled” by questions he missed, attempting to enhance his “testmanship.”
The problem with this approach to learning radiology—or for that matter any subject—is this: it focuses most of the learner’s attention on the test, as opposed to the knowledge base and practice habits required for effective consultation and patient care. Over the years since the core exam was introduced, the interest of radiology residents in taking cases—an activity that closely simulates the work of radiologists in real practice—has given way to study focused on question banks. The stakes in passing the test are so high, and the structure of the exam is so grounded in multiple-choice questions, that residents seem to focus more than ever on encountering as many multiple-choice questions as possible.
This strategy may be likened to building a tree from the leaves down. If we conceptualize the knowledge, skills, and habits of expert radiologists as a tree, then the roots may be likened to the basic medical sciences—anatomy, physiology, pathology, and so on; the trunk to the pathophysiology of disease and its stereotypical imaging appearances; the branches to various disease categories—infectious, traumatic, neoplastic, and so on; the twigs to specific disease families such as bacterial infection or lymphoma; and the leaves to particular diseases and their characteristic radiological findings. For too many residents today, the study of radiology is focused on the leaves, with disappointingly little attention to how the tree’s different parts fit together and relate to each other.
A number of foundational studies of the differences between experts and novices conducted in the 1980s shed light on this problem ( ). One well-known series focused on the differences between experts and novices in the field of physics ( ). It turns out that when novices are confronted with a physics problem, they tend to rummage around in their mind for an equation that seems to fit the question. Their goal is to arrive at the correct answer, expressed as a physical quantity. By contrast, when experts are presented with problems, they do not focus on equations. Instead, they identify the category of problem they are dealing with, performing a qualitative search for the basic physical principle at stake. Equations and calculations are of secondary interest and not the real point.
Too many radiology residents are spending too much time studying radiology in a way that resembles the approach of a novice, short-circuiting the development of problem-solving abilities that characterize excellence. In radiology, experts are not defined by standardized exam scores. They are defined by their ability to consult with referring health professionals and contribute to the care of patients. Challenging cases require them to draw on their knowledge of the whole tree, extending all the way down through the trunk of pathophysiology to the roots of basic science. As a consultation on a difficult case evolves, two-way communication between radiologists and referring health professionals leads to the progressive refinement of hypotheses, as each asks and answers fruitful questions.
Our goal in educating radiologists should not be to entrench them ever more deeply in the habits of novices, but instead to help them lay foundations of expertise. Question banks and flash cards are like leaves on a tree, and for too many residents today, preparing for standardized tests closely resembles going out into the back yard and working their way one by one through pre-raked piles of leaves. We need a more organic approach that acknowledges that leaves grow from branches, branches from trunks, and trunks from roots—all bound together in the integrated form of a tree of knowledge. Compared to jumbles of facts, such coherent knowledge lasts longer, runs deeper, produces better results, contributes more to the advancement of medical science, and yields greater satisfaction in use.
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References
1. Larkin J., McDermott J., Simon D.P., et. al.: Expert and novice performance in solving physics problems. Science 1980; 208: pp. 1335-1342.
2. Chi M.T.H., Feltovich P.J., Glaser R.: Categorization and representation of physics problems by experts and novices. Cogn Sci 1981; 5: pp. 121-152.