Tuesday, May 11, 2021

Cheating in Medical School? A Personal Tale in the Wake of the Dartmouth Scandal

A recent NYT article about cheating at Dartmouth reminded me of some hermetic knowledge of cheating in medical school that I have kept mostly secret for almost a quarter century. Without commenting on the Dartmouth case, I will relate this tale to demonstrate that cheating in medical school is real, and my experience is the opposite that of Dartmouth - administrators turned a blind eye to cheating, denying its existence until confronted by direct evidence of it.

In 1996, the "final exam" after an 8-week internal medicine rotation was a so-called "shelf board" exam, which I have always understood as meaning a copy of some prior year's board examination, or a preparation test for it. In medical school in late August 1996, I had the top score on this examination during the first "rotation" of 8 blocks that we did during the third year. I was pleased by this and considered it vindication of my method of not "studying to the test" but instead reading Harrison's Principles of Internal Medicine (13th edition) cover to cover during the second and third years of medical school. I later noted that the top score crept up as the year went on, and I was bemused. Were others reading Harrison's Principles of Internal Medicine? Doubtful. There were rumors of a "question bank" that previous takers of the exam compiled as the year went on, and shared with one another. If the "shelf exam" was only changed each year this would make sense. Alternatively, the kids were just getting smarter as the year progressed.

My last 8-week rotation of third year was surgery. In addition to a written exam, there was an oral examination. To prepare for the oral examination, we were given a list of about 20 scenarios that we could be presented with by our examiner, a member of the surgical faculty. For example, one I remember was a kid gets hit up side the head with a baseball and later loses consciousness then regains it - something like that. I don't even remember the answer exactly, but this is the "lucid interval" and it points to epidural hematoma as the injury. During the course of studying that and the other 20-some questions at my favorite coffee shop haunt, a classmate - I forget who it was - made the mistake of asking me why I was studying all the questions. I was bewildered. "Because I don't know what one they're going to ask me!" I replied. She then asked who my assigned examiner was, and I told her the name of the neurosurgery attending. She replied that he always asks questions 8&9 on the list; the famed general surgeon always asked the question about appendicitis and sigmoid volvulus; Dr. so-and-so always askes questions 11 and 12; and so on. She said it was well known to "everyone." 

It had, until then, not been known to me. I had spent the first two years of medical school in the now defunct Independent Study Program. In that program we did not attend lectures but read study material and took tests independently, at our own pace. That allowed one gifted 15-year-old to do the first two years of medical school in only one year, and another chap, a slow learner, to extend the first two years into three. It also meant that I did not have a large social network, and was not privy to the kind of information that my classmate had enjoyed in the larger traditional lecture hall setting.

I don't recall my thought process about how to deal with this revelation, but I recall my action. I went to meet with the third year clerkship director (William A Wilmer) and told him what I had learned. He was resistant to hear it and denied that there was any cheating. I told him my suspicion that the scores on the shelf exams were increasing during the course of the year because of accumulating "question banks". He offered the alternative explanation that the kids were just getting smarter. (That taking a surgery or gynecology clerkship might lead to improved scores on an internal medicine shelf exam is reaching, I thought.) So I said something like "listen dude, here is what is being touted as the inside information about the surgery oral exam, here's who asks which questions. Call the examiners and ask them if I'm right." He never did acknowledge that my concerns were legitimate and I don't recall any other communication with him after that meeting.

On exam day, many students were shocked that the general surgery attending did not ask his usual questions, and nor did the other attendings. Furthermore, the shelf exam had been changed. Take a moment to guess whether the average score fell or not.

The average score on the written exam plummeted to that of the first rotation.

From this, one might surmise that cheating in the form or shared knowledge was rampant. This may be. Alternatively, students and their teachers were innocently "studying/teaching to the test", or it could all be noise. I only know for certain that a classmate told me that it was common knowledge that you could predict your surgery oral questions with high confidence based on your examiner and the prior known behavior of that examiner. And that it caused quite a stir when that prediction failed in the summer of 1997.

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