If you are a physician who has been in practice for over 20 years, you know from personal experience that medical knowledge has increased tremendously in recent times. More-experienced physicians have absorbed this knowledge organically — as new techniques, drugs, and test are developed, they are adopted by hospitals and practices. New guidelines come out every so often and are incorporated (or rejected). But now, doctors in training must learn all the new medical discoveries and science of the past half-century in a mere 4 years of study and 3 years of residency.
Nobody expects doctors to recall every symptom of every disease, nor every contraindication for every drug, so there are many pushing for a move to open-book exams.
Rote memorization in medical training is more than just facts, though. As one medical student writes on his personal blog:
I used to think I was good at rote memorization – then I came to medical school…
What we are memorizing now are things like this: T cells are a kind of lymphocyte. Immature T cells (and B cells, the other main lymphocyte) need the Rag1,2 genes to be able to mature/differentiate into the next stage of development. Immature T cells can go to CD4+ (helper T cells) or CD8+ (cytotoxic T cells) cells. CD4 and CD8 are specific receptors on the surface or T cells. Antigen-presenting cells (APCs) express MHC-I or MHC-II molecules, which help show off bits of pathogens to the lymphocytes. CD4+ T cells interact with MHC-II molecules on APCs and then further differentiate into Th1 or Th2 cells, depending on which signaling molecule gets secreted by the APC and acts on the CD4+ T cell. If it’s interleukin (IL) 12, then the CD4+ T cell differentiates into a Th1 cell. If it’s IL-4, it differentiates into a Th2 cell. Th1 cells secrete more IL-12 (to help other CD4+ cells differentiate into Th1 cells) and IFN-γ, which activates macrophages and CD8+ T cells. Macrophages then secrete TNF (tumor necrosis factor), which calls in monocytes to help chew up or sequester dead / infected / dysfunctional / foreign cells. Th2 cells secrete more IL-4 (which does double duty in helping CD4+ cells differentiate into more Th2 cells as well as helping naive B cells isotype switch into IgE-producing B cells) and IL-5 (which helps naive B cells isotype switch into IgA-producing B cells). Those immunoglobulins have different functions and act in different areas. For example, IgA is present in serosal and mucosal surfaces and acts to bind epithelium-binding receptors on the surface of bacterial pathogens so that they can’t bind to epithelial cells and get in through your nose skin. IgE plays important roles in cross-linking antigens on the surface of mast cells to activate them when an allergen is present, initiating histamine release and the reason why millions of people spray gallons of Nasonex up their noses every year.
What this student is expressing reflects what many others feel: It may be more important to know how to think through a problem than to memorize facts, but in order to get to the problem solving, you need to have a more-than-basic understanding of the facts, and knowing the facts well enough often means committing them to memory.
Why Do People Prefer Open-Book Exams?
Researchers have shown that most people find open-book tests less stressful than closed-book tests.
People assume that open-book questions will emphasize problem solving, creativity, or deep knowledge rather than a simple recall of facts. And this perception underlines people’s conviction that open-book exams reflect real life more accurately than closed-book exams.
Psychologist Afshin Gharib and his colleagues write that some researchers agree with students that open-book exams emphasize deep knowledge and mimic reality more closely than closed-book exams:
…Eilertsen and Valdermo (2000) argued that an open-book exam encourages greater engagement and improves understanding of course material. Feller (1994) further suggested that the open-book exam is superior to closed-book exams as it is more realistic—similar to problem-solving situations students are likely to face outside of academia. And of course, students prefer open-book to closed-book exams and find them less stressful (Philips, 2006).
Closed-Book Exams Actually Encourage Deeper Learning and Retention
Heijne-Penninga, Kuks, Hofman, and Cohen-Schotanus (2008) found that medical students who took a closed-book exam actually engaged more deeply with the course material than those who took an open-book exam. Although this conclusion seems counterintuitive, it is not an uncommon finding.
In recent studies, closed-book exams stimulated deep learning more than open-book exams.
In the article “Influence of open and closed-book tests on medical students’ learning approaches,” Dutch researcher M. Heijne-Penninga and colleagues write:
Three possible explanations are: deep learning is particularly necessary for remembering and recalling knowledge; students feel more confident when preparing for closed-book tests, and students are more motivated to study for closed-book tests.…
Perhaps students feel more confident when preparing for closed-book tests than they do for open-book tests. Preparing for open-book tests and using references during the tests seem to be difficult skills.
In our Q&A with psychologist Nate Kornell on learning and memory, he confirmed this view, saying:
Looking things up is great, but knowledge is always going to be important. If you are a physician, scientists, lawyer, etc., and you have to look things up every 5 minutes, you are not going to be very effective. In fact, when someone makes a discovery or reaches a deeper level of understanding, it is often because they are making connections between facts and concepts that they know. That does not happen if they don’t have the knowledge stored in their head. For example, I was planning a new study yesterday and realized that we should consider the implications of an older article that I read a few years ago. If I had not known about that article it would not have popped into my head and it never would have occurred to me to look it up, either.
As for the efficacy of open-book exams vs. closed-book exams for long-term retention, experts have found mixed results: Agarwal, Karpicke, Kang, Roediger, and McDermott (2008) found that students performed better on open-book tests, but their retention of this knowledge over the long-term was the same as that of the students who took closed-book tests.
Other studies have found that weaker students taking open-book exams rely more on their notes and texts than stronger students, and students who used their notes most ended up doing more poorly on the exam, suggesting that open-book exams may actually lead to lower scores.
The Future of Board Exams Is Uncertain
The ABIM 2020 group is exploring the possibility of an open-book exam, acknowledging that in practice, doctors have a lot memorized but often use UpToDate and other point-of-care sources for the situations that present in their offices.
It will be some time before we know whether or not the ABIM, ABFM, and other boards decide on the open-book vs. closed-book question.
Do you have experience with open-book and closed-book exams? Do you have a preference?