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30 Percent Bucket

“Chuvash polycythemia,” Sue declares. “That’s going in my 30 percent bucket.”

We are studying for our upcoming molecular mechanisms test, as part of the semester-long course intended to introduce us to the basic functions of molecules, cells and tissues. In this integrated curriculum, all the names have changed, and the organization of the material is promised to magically improve our comprehension and recollection of such details.

However, Sue and I have a sneaking suspicion that we are actually taking pathology! We are lectured at by pathologists, we have daily pathology lab and we are using a classic pathology textbook. I have yet to taste any samples, but if I did, I am sure they would taste like pathology.

“How full is your bucket?” I inquire. Sue clasps her fingers in the air, around an imaginary handle. She carefully weighs it.

“Feels like I’m at around 20 percent.”

“Excellent. Keep it in the bucket. Unless you are planning a trip to Chuvashia…”

As first-year medical students, we are undertaking a rite of passage, which we will one day fondly recall to our grandchildren. We are flooded with information — more than can be humanly absorbed — and then left to pick out what we think is important. On our exams, which are pass-fail, we are required to answer 70 percent of the questions correctly. Hence the imaginary bucket, into which we can safely discard up to 30 percent of everything we are taught.

While the selection process could be random (we could simply study material taught on Monday through Thursday and “bucket” Friday’s lecture), most students guide their selection by what it deemed to be “high yield.” Through an ever-evolving game of telephone, older students relay what is important to each individual professor.

As it turns out, Sue has to “unbucket” chuvash polycythemia, because professor B always asks a question about it. The man has an abiding concern for the Chuvashians. Yet no matter the process, we all live in fear of dumping out our buckets later, and finding something vital that we missed in the torrent.

As much as we are enjoying this ritual of the preclinical years, there is an equally satisfying, and even more ubiquitous tradition waiting for us on the other side of the USMLE Step 1: forgetting it all. In an informal, nonscientific survey conducted by the author this afternoon, 0 percent (+/- the hematologists) of hospital attendings can recall the molecular details of the coagulation cascade (n=10, including a few relatives). The following are a sample of responses:

“I do remember that it exists, and is important so that one doesn’t bleed to death!” -anonymous attending, fellowship director with over 25 years in practice

“Nope. Of course, I didn’t do so well on this exam in medical school…”         -anonymous department chair

“Wikipedia, dude.” -medical resident in need of a shower and shave

In summary, first- and second-year medical students are flooded with information that may or may not be important (see “chuvash polycythemia”), of which they learn approximately 70 percent, half of which they promptly forget, and replace with clinically relevant knowledge, such as how to access UpToDate.

The question we must ask ourselves is simple: is this the best way to educate doctors?

As a medical community, we should demand more than 70 percent acquisition of information that we believe could one day be lifesaving to our patients. Nobody wants a nuclear inspector who is 70 percent protecting us from disaster. Nobody wants to be taken care of by an intern that scraped by with a barely passing grade. As students, we cannot be reasonably expected to learn more, learn thoroughly, and retain it all. The solution, unfortunately, requires more than clever teaching devices like “flipped lessons” or an integrated curriculum (both excellent ideas, but not sufficient). Perhaps it is time to fundamentally refocus the medical school curriculum on the clinically relevant, reduce the amount of required information, and raise our standards for what constitutes mastery of the basics.

Joshua Stein Joshua Stein (1 Posts)

Contributing Writer

Columbia University College of Physicians and Surgeons

Joshua Stein is currently a Class of 2018 medical student at Columbia University in the city of New York. He graduated from Washington University in St. Louis with a bachelor's degree in neuroscience and subsequently earned a Master of Science in Teaching at Pace University. Prior to enrolling in medical school, he taught science for two years in the New York City public school system.

  • Sarab

    As a soon to graduate fourth year your words here describe well the conversations I’ve had with dozens of my peers about the randomness and the uselessness of the first two years of our education. It’s a hazing ritual, an annoyance and stupidity. I’d love for it to change but till it does, just push through. It gets better!