By Eric Brand

Many of my former acupuncture students took their CA board exams the other day, and I’d like to congratulate them on this important milestone. The exams are something of a completion ritual after a long haul, and I vividly remember the elated feeling of graduation and exam completion. That said, I feel that there is a tendency for some students and schools to place too much emphasis on the exam, and sometimes I wonder if this focus on exams serves us well from the clinical perspective.

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Examinations are a useful educational tool because humans tend to respond well to pressure. Having a test forces one to study, and developing the ability to test well is a useful skill. By nature humans must compete with one another for resources and we need to learn to relax and perform well in the face of adversity. Tests are a great learning tool for these reasons. Repeated tests help us to review the complex body of information that we learn and the tests show us where we are already strong and where we need to put in more effort. Learning to overcome test anxiety and prioritize one’s health, sleep, and spleen qi is a good exercise. Most importantly, we need to have professional standards that weed out truly incompetent or dangerous practitioners, so the need for a licensing exam is a given. All that said, there comes a point when focusing too much on the test can overshadow the more important aspect of focusing on the medicine itself, and sometimes I think our community needs to do some soul-searching to find the appropriate balance.

Test anxiety is a huge issue in our community, and anyone who remembers taking their boards can probably remember having some classmates who worked themselves up into a frenzy that was miles away from a holistic and healthy approach. Testing is a skill, and some students take their board exams after a constant stream of lifelong tests while others are taking major tests for the first time in decades. Testing is like public speaking, if you aren’t used to it, it can be incredibly stressful. There is a natural variance in testing experience amongst students, and high pass rates are a key goal for schools looking to survive in the competitive world of private acupuncture education. Consequently, schools often have annual major exams and mandatory board review classes (which are often more like hand-holding sessions of anxiety meltdowns).

We need to have tests and it is good to have high pass rates. Nonetheless, sometimes we focus too much attention on the exams. At the end of the day, the exams are not meant to be an end point, they are just a beginning. The exam is not a test of mastery or clinical skill; it is just a hoop to protect the public from grossly negligent practitioners. I understand that schools want high pass rates and students have anxiety about the test, but preparation for the exam should never come at the detriment of education for the sake of becoming a good clinician.

In addition to teaching consistently at one school, I’ve had the opportunity to provide guest lectures at many schools around the country. One of the things that I consistently see is that students have very little practical understanding of dosage. Classes that cover dosage on granules or prepared medicines are virtually unheard of, and very few students graduate with confidence in raw herb dose weight. The reason for this is simple- students are rarely tested on dosage. We need to memorize huge amounts of material so memorizing dosage easily falls by the wayside. Dosage is rarely a key issue on tests. Yet knowing dosage is of critical importance for the actual practice of medicine.

Memorizing dosage takes a tremendous investment of time but it yields few dividends on exams because at most there will be only a couple questions on dosage on any given test. For example, the California board exam only devotes 12% of questions to herbal medicine as a whole (with only 63 formulas). At most there will be 2-4 questions on the whole exam that relate to dosage, and it is simply easier to guess on those questions than it is to study the dose range of 300 herbs. From day one until graduation, there is rarely an occasion when it makes sense to invest the time to study dosage because its relative importance in testing makes study time a poor return on investment. Unless the student has a mentor or a truly active clinic instructor that teaches them proper dosage in real life, it is easy to become a licensed practitioner without ever learning much about things like dosage or Pao Zhi (when to use stir-fried Bai Zhu vs. raw Bai Zhu, etc).

I’m known some brilliant students who were fantastic in clinic but terrible at taking tests, and I truly believe that test-taking ability and clinical ability do not necessarily go hand-in-hand. I recognize that some students need more help with learning testing skills and it is good to have sequences of tests and courses that emphasize test-taking abilities. But I am always very disappointed when I hear about schools that require even their best students to take mandatory exam prep classes instead of using their tuition dollars to pursue an elective that will advance their real medical skills. If a student has no problem with tests, there is no reason for them to be required to take a class with students that are in an anxious frenzy. If a student was in the top third of their class and they studied continually for four years, chances are they will pass regardless of how they spend their final months before the big exam.

There is a vicious cycle at many schools wherein the students work themselves up into a huge frenzy and go on crazy, unhealthy study binges that further reinforce the test anxiety. Teachers cannot teach valuable clinical information because students only want to study what will be on the test. It is hard for teachers to use textbooks other than the books listed on the board exam because too many students are only focused on the test. In reality, any good books and teachers can give the student the tools they need for the test. Students try to memorize the idiosyncratic words of a few celebrity authors or cram by focusing exclusively on down and dirty charts for test prep; this is not how Chinese medicine is supposed to be learned. Chinese medicine is not a chart.

We go to school because we want to help people that are suffering from illness. We need holistic, healthy students that approach their lifetime of learning with passion and patience, this isn’t a simple career and passing the test is not a sign that we have achieved our goal of becoming a great doctor. The real test is our ability to impact the lives of our patients. Our time with our teachers in school is fleeting and precious, when we focus on the tests instead of the medicine we simply can’t see the forest for the trees.

Sorry about the rant!