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Teaching To the Test

January 29, 2015

Last week my best friend took the re-certification exam in anesthesia, the so-called MOCA exam.  Like a good doobie, she paid her $2,100, paid her nanny extra so she could study, took a day off in which she missed the funeral of a friend’s husband, and took the test.  Wow, she must be, like, the most awesome, most well-read, most skilled, most enthusiastic anesthesiologist ever now!  Well, she always was, but the test didn’t make her that way.  In fact, there is a large body of evidence that suggests such testing requirements have the potential to reduce the quality of her work.

The American Board of Medical Specialties, in 2010, did a survey in which they found that 95% of the public rates participation by their physicians in Maintenance of Certification (MOC) as important. Doctors have derided the requirement of MOC as costly, irrelevant, and time-consuming, accusing professional boards of using such requirements as moneymaking ventures.  Plus the whole thing doesn’t make sense since doctors originally certified before 2000 or so don’t have to do it at all.  The public has said the doctors are whiny and just don’t want to keep up their skills and be accountable.  That doctors are, in effect, lazy.  Plus they have plenty of money, what do they care about fees?  We demand our high-quality healthcare goddamit!

In 1973 three guys named Lepper, Greene, and Nisbett did a study with a bunch of preschoolers (Journal of Personality and Social Psychology. 28(1), 129-137, 1973). They choose an activity that the kids all liked, drawing in this case, and tested whether kids were more or less interested in drawing when they were given a reward for doing so.  It is an If-Then scenario: if you do this, you will get that.  The kids who got rewarded showed much less interest in drawing two weeks later.  They had lost their motivation for drawing.  Studies like this were repeated many times in kids and adults, and in 1999 some researchers reanalyzed thirty years of such studies and found that “When institutions – families, schools, businesses, and athletic teams, for example – focus on the sort-term and opt for controlling people’s behavior, they do considerable long-term damage.”(Desi et al, Psychological Bulletin. 125(6): 659).

Daniel Pink, in his book Drive, points out these and many other examples of a solid literature suggesting that making people do things makes them less likely to want to.  Not only that, but Pink cites plenty of evidence that forcing people to do things reduces the quality of the work.  It is true of preschoolers, and it is true of adults.  The problem is the difference between External and Internal motivation.  My best friend has always kept up her knowledge and skills because of her internal drive to be the best she can be.  That drive can be diminished by randomly imposed requirements.

Extrinsic motivators narrow our focus and reduce the breadth and depth of our thinking.  If the extrinsic motivator is the most important or prominent motivator, the focus becomes pinpointed to the externally imposed goal.  This is certainly true for education.  One of the main problems with standardized testing is that students are extrinsically motivated by the imposition of a test.  The test becomes the most important motivator for studying.  The students’ focus narrows to the regurgitation of facts.  Extrinsic motivation is applied over and over in the case of students who do well on such tests.  The breadth and depth of knowledge is substantially reduced.  Plus, being made to take the tests has the effect of decreasing students’ intrinsic motivation, which is the kind of motivation that results in the best results over time.  The same sort of thinking explains why a kid who is interested in music will often lose motivation when external pressures to succeed are placed on him by parents and teachers.

And, dear reader, the exact same thing happens to doctors.  Doctors are no more noble or less human than the rest of us.  Being made to do things decreases our intrinsic motivation just a surely as making a kid practice diminishes his desire to make music.  The kid will push back.  Doctors do too.  Maintaining skills and knowing the latest research are important for doctors, just as they are for any profession.  We need to adjust the system in such a way that the intrinsic drive to be the best we can be is fostered.

Do you want a physician who loves his work, is internally motivated to read the literature because he is interested in the subject, one who has breadth and depth of thinking?  Or do you want a de-motivated, narrowly focused test-taking machine?


From → education, Healthcare

  1. thetinfoilhatsociety permalink

    I think it’s even worse than a “test taking machine” as you describe it. All of those tests, even the re certification one, are designed for a newbie with little experience. The tests actively select against real life experience in their design. Anyone who has worked in health care knows there is the test, and then there is real life. The two have very little in common. Personally I would rather have an old anesthesiologist than a certified one, for the simple reason that one has decades of experience and one has a certification. But that’s me, someone who has been in the medical field for most of my adult life. Trying to convince the public is something else entirely, I guess.

    I do completely agree that keeping up certifications is nothing more than revenue generation by the certifying agencies. Job security, that is. You should be able to submit CE’s in lieu of the test. In my opinion that’s much more valuable. But I’m a nobody 🙂

  2. Beautifully said. As we see in our own education system, teaching to pass tests and “certain preassigned markers” may make more good test scores, but it also makes for woefully unprepared people post-education. This is especially sad, not to mention potentially dangerous when it comes to doctors.

    We need doctors who have a connection with their work and their patients. A more holistic approach. We need more docs who not only are allowed to take their time, but are encouraged to do so as well. Make medicine personal again.

    I am in the process of applying for SSDI, and the IME I saw was AMAZING. He even had the old brown sachel with his named embossed on it, and even had all the mannerisms of an old country doctor.

    What made him especially great was how he went about his job. Yes, he is an IME, and as such his job is to give an impartial look at the conditions my others doc’s mentioned. Yet he not only took time to hear me out, he also made some key observations my own doctors (who my RN girlfriend and MD best friend both feel my docs are more focused on numbers than patients) missed. Even down to simple observations as swelling and neuropathy that I was unaware of. He even was able to give me advice based on seeing signs of irregular blood flow (I’ve been losing feeling and motor control of my right side, causing frequent falls).

    Although his assigned focus was narrow, he was a doctor first, and his professionalism, kindness and concern were the sort of medicine I needed.

    • Thanks for reading! I think the key words in your comments are “time” and “observation”. Close listening and great observational skills are two aspects of the doctor/patient relationship that make for great communication.

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