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Are We Teaching Our Residents to Study to the Test? (Answer: "No")

There are those who wonder if our specialty's focus on testing in resident education is creating a generation of anesthesiologists who practice by rote. As a young physician and product of that education, I respectfully disagree. By James Lamberg, DO

I read with interest this ASA Monitor article, which describes an emergency situation requiring quick thinking and a rapid mental risk/benefit assessment while performing a task. Should you waste 15 seconds to scrub a hub before giving an epinephrine code dose? Probably not, the benefit of that does not outweigh the risk. Sure, this is a difficult thing to teach, but I don't think residency programs, the ABA, the ACGME, or anyone else is doing a disservice to residents. This clinical decision making comes with time, some call it wisdom, some call it experience, but really it is "synthesis."

I reject the idea that the ABA or the ACGME is focused on a "study to the test" approach. It would be easier to argue that specialties without oral boards are more focused on knowledge-based education. But even those specialties deal with urgent situations that require clinical acumen and fast thinking. The ABA has long had a written exam for knowledge and an oral exam for practical application. From a knowledge standpoint, anesthesiology may be the "most tested" specialty with two-part knowledge exams (BASIC, ADVANCED), annual in-training exams (ITE), and 3rd party exams (e.g. AKT).

Regarding the oral exam, knowledge deficit is a less common reason to fail, which highlights the ABA is focusing on other skills needed to become a capable anesthesiologist. Although the oral board exam was one of the most painful experiences I've ever had, it was immensely beneficial to my training. The ABA more recently has added a skills-based component to their exams to further evaluate physicians to ensure they are capable/well-rounded enough to practice. They have published research on the usefulness of their exams and continue to do research:

The ABA also requires anesthesiologists to have a minimum number of performed procedures or cases by the time of graduation. It is very interesting to look at this list then compare it to other specialties, especially not surgical specialties or non-physician provider requirements. If the focus was on knowledge-based learning, these requirements would not be as stringent.

The ACGME has a list of competencies required for all residents. Medical knowledge is only one of the competencies, with others including communication skills, professionalism, practice-based learning, patient care (practical/hands-on), and systems-based learning. Professionalism accounts for a large portion of cases involving loss of medical licensure, not lack of knowledge about a clinical situation. Programs should be teaching residents about all of these competencies and doing annual (or more) reviews to give feedback to residents and help them improve any deficiencies. I don't think we can blame the ABA or ACGME; I believe they provide sufficient groundwork.

There are many sources for this next information, but I would like to shout out to the ATLS Instructor Course through the American College of Surgeons. Their instructor course textbook has a great chapter on adult learning. Teaching involves three common learning domains: cognitive, psychomotor, and affective. The affective domain is probably the most important, which is attitudes towards learning and practice. Faculty can be role models for attitudes or examples of attitudes to avoid. Within attitudes are intrinsic motivation, such as the desire to learn, and extrinsic motivation, such as the desire to have a job. "Learning depends on motivation."

Within the cognitive domain, there are several levels or steps that start with knowledge. Then is comprehension (recall, discussion), application to a specific situation, analysis (dividing the problem into components), and synthesis. Synthesis is using the prior steps to solve a clinical problem.

Given the multiple knowledge exams during anesthesiology training, I can see why faculty would focus on this. I never felt during my training that the goal was just to get me to pass an exam. It is much more difficult to teach to the other domains and to create situations or scenarios where synthesis can be demonstrated. One very important thing faculty can do, in my opinion, is demonstrate these competencies themselves so that they serve as role models for residents. I'm forever grateful for the anesthesiologists who promoted positive attitudes during my training.

I believe the ABA is doing a great job with anesthesiology education and is, in fact, a leader amongst medical specialties.


1) ABA Staged Exams.

2) ACGME Information.

3) NEJM: "Exploring the ACGME Core Competencies".

4) Advanced Trauma Life Support, 10th Edition. Section 3: ATLS Instructor Training. Lesson 2: Adult Teaching and Learning.

James Lamberg, DO, is a physician anesthesiologist at Lancaster General Health in Lancaster, PA, where he serves in hospital leadership roles involving patient safety. His clinical practice areas include cardiothoracic surgery and complex anesthetics.


ASA Community Blog is published as a benefit for ASA members. The views expressed on this blog are those of the individual contributing writers only and do not necessarily represent the opinions of ASA.