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By Associate Professor Richard B. Gunderman MD, PhD, MPH (auth.)

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Extra resources for Achieving Excellence in Medical Education

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Exams should not merely test the ability to recall specific facts, but to organize facts in larger contexts. As long as knowledge remains at the level of individual facts, it is inert. To bring it to life, we must invite learners to use that knowledge in solving problems. Suppose a patient presents with hematuria, blood in the urine. We should not merely ask for a laundry list of pathological processes that may cause hematuria. We should invite learners to begin developing ordered diagnostic hypotheses based on their understanding of pathophysiology and the facts of the particular case at hand.

Likewise, physicians may feel that we are not doing our best for our patients if we do not avail ourselves of medicine’s full diagnostic armamentarium. We need to understand more deeply what it means to be ill, and to clarify our vision of the state of health in which we seek to enable our patients to live. The World Health Organization’s Second International Classification of Functioning, Disability, and Health (ICIDH-2) provides a useful point of departure in this regard. As modified here, it approaches health and disease in terms of four levels or tiers: structure, function, activity, and participation.

The most primary of these is sensory memory. In sensory memory, information is available to us for a very short period of time after the stimuli have passed, perhaps but a split second. If we are to retain the information for a longer period of time, it must enter working memory. Short-term working memory is what we call consciousness. Once an event has passed, only certain features are accessible to short-term working memory. To an expert, those features are the most essential ones, such as the visual clues key to the diagnosis.

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