Reducing Test Anxiety

by Jesse Foster, Pharm.D., PGY1 Pharmacy Practice Resident, Medstar Georgetown University Hospital

When I was a pharmacy student, I had a friend who seemed to understand the course content very well. When my friend took the final exam — an exam that weighed a lot toward our final grade — he failed the exam.  It was a classic case of test anxiety. Test anxiety can be a serious problem for some students.  An estimated 15-20% of students feel impaired by exam stress.²

The impact of test anxiety can lead to several negative outcomes.  Students with test anxiety can have a good understanding of the material but may be unable to recall what they know.  Anxiety can also impair problem solving and lead to poor decisions on exams. Some learners may develop avoidance behaviors and pass up learning opportunities. Avoidance behavior develops after past poor performance.  Understandably, students don't want to repeat the negative experience. ⁴  Further, test anxiety shifts the focus toward performance and outcomes rather than on learning the subject matter.  Lastly, poor performance due to test anxiety can lead to lost educational and job opportunities.²

At the heart of test anxiety is stress. In a study by Yusoff, the impact of stress on exam scores was examined in first year Malaysian medical students. This study looked at students' mental status immediately after taking a final exam. The results show that students with severe stress were 2.43 times more likely to fail the exam compared to students with normal to mild stress.⁵

Cognitive interference is a possible cause for exam anxiety. This model postulates that cognitive processes are occupied by negative and irrelevant thoughts resulting in poor exam performance.²  Test anxiety has been correlated to feelings of unpreparedness when students are unfamiliar with the exam style and content. Students can also feel unprepared when there is a large amount of content and limited amount of time to review what will be covered on the exam.⁵ Poor study habits add to test anxiety as well. Studies have shown that students with high test anxiety are more likely to procrastinate and use less effective studying strategies.¹

The perception by the student that the exam or assessment has significant implications can also increase anxiety and stress.  Students become overly concerned that poor performance on an exam will result in major negative consequences.  If a student has an unrealistic expectation that he/she will achieve a perfect score on an exam, then stress and anxiety can increase when he/she is unable to answer an exam question.⁶

To help with cognitive interference, cognitive behavioral therapy can be used to help reduce stress. Expressive writing is a technique to help with these disruptive thoughts. Using this technique, the student writes out his/her negative thoughts for 10 minutes before the exam. This allows the student to vent and express their concerns on paper before the exam. Expressing their concerns will clear their mind so they can better focus on the exam. Another approach to help reduce test anxiety is relaxation techniques. These techniques have the student focus on deep breathing along with muscle relaxation of the arms, legs and stomach. Similar to expressive writing, this helps the person clear their mind of negative thoughts and anxiety.⁴

Reducing the perceived significance of the exam can help to alleviate the stress and anxiety that a student may feel.  Both the learner and teacher can help minimize this type of stressor.  Its important not to overemphasize the importance of an exam and its potential impact. Multiple exams in a course can help reduce anxiety by minimizing the impact any one exam might have on the overall outcome.²

Providing more realistic expectations for the exam will help students who panic when they don’t know or understand questions. Answering questions where the answers are known and understood first can improve test anxiety. This helps to improve confidence and in turn, reduce anxiety during the exam as well as diminishes the sensation that time is running out.^{3, 4}

For students who feel unprepared, teachers can provide insight into the exam content and style to help reduce the fear of the unknown. Study habits can be improved by providing a clear, regimented course schedule. Study groups can also be beneficial by helping keep students focused. Having more frequent exams can also improve study habits since students will need to review material more frequently.^{1, 2}

Test anxiety is a major concern for some students. It can prevent students from advancing academically and professionally. Test anxiety also causes students to avoid other educational experiences and to focus more on passing exams instead of learning the content. However, test anxiety can be minimized if both the student and teacher employ some proven strategies.

References

1. Sansgiry SS, Sail K. Effect of Students’ Perceptions of Course Load on Test Anxiety. Am J Pharm Edu. 2006; 70(2): Article 26.

2. Neuderth S, Jabs B, Schmidtke A. Strategies for reducing test anxiety and optimizing exam preparation in German university students: a prevention-oriented pilot project of the University of Wurzburg. J Neural Transm. 2009; 116: 785–90.

3. Abolafia J, Lumpkins A, Malandro T. High Stakes Testing: Managing Test Anxiety. [Internet]. Accessed April 27, 2013.

4.  Paul A. Relax, It's Only A Test. Time 2013;181(5):42-5.

5. Yusof M, Associations of Pass-Fail Outcomes with Psychological Health of First-Year Medical Students in a Malaysian Medical School. Sultan Qaboos University Med. 2013; 13(1): 107-14.

6. Chinta R. Exam Anxiety Effect on Exam Performance: An Empirical Replication in the Middle East. Aryan Hellas Limited, IRBC Athens, 2005. Accessed 5 May 2013. 

Curving Exam Scores – Is it More Harm Than Good?

by Thanh-Van (Vicky) Nguyen, Pharm.D., PGY 1 Pharmacy Practice Resident, Kaiser Permanente Mid-Atlantic

When students hear the terms “curve” and “grades” used together in a sentence, they automatically assume that grades will be scaled upwards.  In fact, this is not always the case.  The act of scoring on a curve has been performed for years and is commonplace in higher education, particularly in science curricula.  However, grading on the curve has multiple meanings and, as with all other practices, there are pros and cons to grading on a curve.

Typically, curving an exam is achieved by adding points to everyone’s score in order to shift the average upward.  The score of the student(s) who performed the best on the exam is boosted to 100% and then the other exam scores are scaled up by a similar amount.  This consequently boosts all scores on the exam and often translates into higher grades for everyone.  If the procedure is rarely performed and students are not accustomed to curving, students wouldn’t anticipate receiving addition points and will likely put effort into studying.  But when curving becomes routine, potential pitfalls may occur.  Students may become less motivated to perform at their best if they know that they will automatically receive additional points.  The question then becomes whether or not curving grades accurately reflects knowledge and performance.  By curving grades, are we merely boosting students’ egos only to send them off into the world less prepared?  Does it create a false sense of security?

There are certain circumstances that may warrant curving exam scores.  For example, when creating exams, professors may misjudge the difficulty or clarity of their questions.  In these instances, it is simply unfair to punish students with point deductions due to poorly written questions.  In other situations, the subject matter may not have been taught well, resulting in poor student performance.  When the decision is made to curve scores for these reasons, its important to resolve the underlying problem.  This can be as simple as rewording future exam questions, modifying one’s teaching method, or providing additional instruction.  Unfortunately, some instructors move forward without conducting a root cause analysis or taking any corrective action.

Some proponents argue that curving can prevent grade inflation and ensures that grades are appropriately distributed among students.  In one form of curving, instructors assign grades based on a normal distribution.  The grades are distributed such that students who score near the average receive a high C or a low B.  Students above the mean would receive an A or B.  Students below the mean would receive a C or D.  Outliers are assigned an F.  This form of curving exists but it’s rarely used.  Assigning an “F” to someone who scored 82% on an exam where the class average was 93% would likely be met with outrage.  This method of curving penalizes students for not performing as well as their peers – even when they demonstrate reasonably good mastery of the material.

The procedures used to curve scores are not standardized and practices vary among professors and institutions.  Some professors review exam questions and curve based on the number of questions where a substantial portion of students got the answer incorrect.  Other professors simply bump the highest grade up to 100% and scale the rest by a similar amount.  Whether all scores should be curved across the board is another aspect to consider.  Curving can also be done selectively to help boost a few students’ scores or to reduce the number of students who fail.  This practice calls into questions fairness and smacks of favoritism.  Regardless, there is a lack of consensus regarding the best method of curving.  There comes a point when curving no longer accurately represents student learning but rather a manipulation of numbers.

There is a time and place when curving grades may be appropriate but the practice should not be commonplace.  When curving scores becomes a routine practice, it’s time to re-evaluate the teaching and evaluation methods.

References

1.  Kulick G, Wright R. The Impact of Grading on a Curve: A Simulation Analysis. International Journal for the Scholarship of Teaching and Learning. 2008;2(2):1-17. 

2.  Bradley B. To Curve or Not to Curve: Norm-referenced Grading vs. Criterion-referenced Grading. Focus on Faculty. 2005:3-4.

Motivating the Unmotivated

by Kristin Ho, Pharm.D., PGY1 Pharmacy Practice Resident, Walter Reed National Military Medical Center

Over the past year, I’ve served as a co-preceptor for students who are completing advanced pharmacy practice experiences.  I find it is much easier to interact with students who are motivated and want to complete the rotation at our institution.  It’s challenging when students lack motivation and my inexperience as a preceptor doesn’t make it any easier!  But I’m not alone.  According to a survey conducted at the University of California, San Francisco School of Pharmacy, many preceptors don’t feel very confidence in their ability to identify and manage the unmotivated student.  A majority of the survey respondents (61.5%) stated they had difficulty determining the reason why a student was unmotivated and 69.1% wanted more training on how to engage and motivate students.¹

What is motivation?

Motivation is "a student’s willingness, need, desire, and compulsion to participate in, and be successful in, the learning process."² There are two forms of motivation: intrinsic and extrinsic. Intrinsic motivation comes from an internal desire – formulated from both cognitive and emotional processes in the brain – to perform a task.  In other words, the student perceives the task to be "in and of itself" to be rewarding.  Extrinsic motivation is driven by external factors unrelated to the task.  Under these circumstances, the task is performed to gain some reward or avoid a punishment that is associated with, but not intrinsically a part of, the task.³ Intrinsically motivated students tend to do better because they are eager and willing to learn without inducement. Conversely, extrinsically motivated students must be encouraged, persuaded, cajoled, or, in extreme cases, coerced to perform the task.

Whether the lack of motivation is attributed to intrinsic or extrinsic factors, it is important to identify the reasons why students are unmotivated in order to appropriately address the problem.  Some reasons why students are not motivated and clues that can help you to identify students are: ⁴

Clues	Reasons
Student engages in negative self-talk about abilities and/or by makes faulty attributions to explain poor performance	Lack of confidence
Student procrastinates, verbal complains, frequent seeks teacher’s help, and other avoidant behaviors	Effort needed to complete work seems too much or unrealistic
Student requires praise or rewards as a ‘pay-off’ in order to apply greater effort	Fails to see a pay-off in doing the assigned work
Student display indifferent or hostile behavior toward instructor or preceptor	Negative relationship with instructor or preceptor

How to motivate unmotivated students?

If the students’ lack of motivation stems from fear of failure, preceptors should encourage students to focus on their improvements and help them evaluate their progress by encouraging them to critique their own work. This method, called attribution retraining, helps the student look for the explanations for their successes and failures. The goal of attribution retraining is assisting students in concentrating on the tasks rather than being distracted by their fear of failure.  Preceptors and instructors can help the student identify alternative methods or approaches to a problem instead of giving up; and attributing the student’s failures to ineffective strategies rather than a lack of ability.⁵  For example, a student may attribute poor clinical judgments to an inherent lack of ability. If the student believes he/she cannot succeed during the rotation, there is less motivation to strive for success. If a student perceives writing SOAP notes as being too difficult, the preceptor should use attribution retraining by encouraging the student to practice with hypothetical case studies so the task becomes easier when the student encounters real patients.

Positive or negative feedback influences motivation.  When a preceptor praises a student, this extrinsic motivator boosts self-confidence. Preceptors should acknowledge sincere efforts even when the student’s performance is less than stellar. If the student’s performance is weak, providing feedback for improvement as well as assure that he/she can improve and succeed over time. Before the preceptor provides feedback, ask the students to reflect on their perceived strengths and weaknesses to determine whether the students’ self-assessment is accurate. If the preceptor and student are in agreement, the preceptor can affirm the strengths and provide encouragement. This should be followed by a discussion of perceived weaknesses.  This will give the preceptor some insight into what the student identifies as areas that need improvement and facilitates goal setting for future performance.⁶

Most importantly, preceptors should display enthusiasm in teaching and a personal interest in the student to build a positive relationship. This can be achieved by tailoring the rotation to the student’s interest. Students are naturally more motivated to succeed when their interests are considered in the rotation plan. Therefore, constructing approaches to help the student realize how each learning activity relates to his or her personal and professional goals can improve motivation. For example, if a student has accepted a community pharmacy position and has no interest in acute care, it might be helpful to include more patient counseling during the rotation.  This learning activity would provide the student with more one-on-one patient interactions and boost confidence when speaking to patients.

Motivation is a powerful force. As preceptors and instructors, it can be challenging to motivate unmotivated students. However, identifying students who are unmotivated by paying attention to clues and addressing the problem with an appropriate method to encourage motivation is a valuable teaching tool. This resonates with me!  One of my preceptors reminds me that it’s easy to teach the intrinsically motivated students, but the truly great preceptor is one who can increase the unmotivated student’s desire to learn  … and achieve the intended learning outcomes.

References

1.  Mitra A, Robin CL, Peter AJ, et al. Development needs of volunteer pharmacy practice preceptors. Am J Pharm Educ 2011;75: Article 10.

2.  Bomia L, Beluzo L, Demeester D, et al. The impact of teaching strategies on intrinsic motivation. Educ Resour Inf Cent. 1997. ED418925

3.  Ryan RM, Deci EL. Intrinsic and Extrinsic Motivations:  Classic Definitions and New Directions.  Contemp Educ Psychol. 2000; 25 :54-67.

4. Wright, J. Six reasons why students are unmotivated (and what teachers can do). Intervention Central [Internet]. 2011. Accessed April 11, 2013.

5.  Lumsden LS. Student motivation to learn. Educ Resour Inf Cent. 1994. ED370200

6.  Orsmond P, Merry S, Reiling K. Biology students’ utilization of tutors’ formative feedback: a qualitative interview study. Assess Eval Higher Educ. 2005; 30:369-86.

Grades – How Important Are They?

by Justine Beck, Pharm.D., PGY1 Pharmacy Practice Resident, Walter Reed National Military Medical Center

The type of evaluation system used by an academic institution, pass/fail versus assignment of grades, has been a point of controversy for decades.  I hadn’t put much thought into this issue, since all of my education was completed at institutions that utilized a traditional grading system and where the overall performance was determined by calculating a grade point average (GPA).  However, this year I was no longer an applicant but rather a participant in the residency selection process.  When reviewing and compiling the information on the residency applications, I came across a few pharmacy schools that use a pass/fail evaluation system and, therefore, do not report a GPA.  At first I was taken aback, unsure how to compare the academic performance of the applicants from these schools to applicants who were graduating from more traditional programs.  My natural instinct was to question whether an applicant who ‘passed’ pharmacy school would perform the same in a residency program as an applicant who had a numeric GPA.

With an overwhelming number of applicants to pharmacy residency programs¹, an applicant from a program that uses the pass/fail grading system may be at a disadvantage when competing against applicants who have a GPA.  Admittedly, the most important criterion used when making selection decisions for residency programs is the personal interview.  However, there are several pre-screening hurdles that applicants must jump over before an interview is offered.

While there is a paucity of literature available specific to pharmacy regarding the impact of pass/fail grading, there is some data related to medical residency programs.  Dietrick et al. polled general surgery residency program directors to determine whether pass/fail versus competitive grading systems affected an applicant’s ability to compete for a residency training position.  The results demonstrated that 89% of program directors in general surgery preferred a transcript with grades over a pass/fail evaluation system. Also, 81% of the survey respondents thought that the medical students’ ability to compete for a residency position was adversely influenced by the pass/fail method of evaluation. Interestingly, 72% of the respondents stated letters of recommendation most frequently misled them in choosing a candidate for a residency position.²

Another survey conducted in Ontario found that 66% of program directors felt that students applying to their program from a school that used a pass/fail system would be disadvantaged.³   Moss et al. reported that the application performance index of residents from medical schools that reported grades performed significantly better than those from schools that used a pass/fail system.  Additionally, no residents from a school that used a pass/fail system ranked above the 87^th percentile, and 82% of those who ranked below the 15^th percentile came from pass/fail schools.⁴

Advocates for a pass/fail grading system reason that grades discourage collaboration and rely too heavily on external motivation.  Intrinsic motivation is learning prompted by true interest and enjoyment, whereas extrinsic motivation is based on external rewards, such as grades and honor society inductions.  Further, they argue, pass/fail grading systems improve student well-being by reducing stress, anxiety, and depression. Interestingly, over the years, many schools that adopted the pass/fail grading system have reverted back to multi-tiered grading systems (i.e. pass/fail/honors/high honors).⁵   Despite the potential benefits of pass/fail grading, it seems that the preference is an evaluation system that can differentiate students.

Inevitably, grades matter.  The much maligned GPA is the only way to sum up a student’s academic achievement in a quantifiable form.  Peter Filene wrote in The Joy of Teaching that, “grades can be used as a pedagogical whip to reinforce the mentality of working-to-get-a-grade, or they can be used in creative ways as carrots to encourage learning.” ⁶ I believe the real challenge is finding ways to use grades as a means to stimulate learning rather than a quantifiable measure of success or failure.  Students need feedback to help stimulate self-improvement.  Developing unique and creative ways to evaluate students would help achieve the dual aims of differentiating performance while cultivating intrinsic motivation to learn.

References

1. National Matching Services Inc. 2012. ASHP Resident Matching Program, Match Statistics. Accessed March 17, 2013.

2. Dietrick JA, Weaver MT, Merrick HW.  Pass/fail grading: a disadvantage for

students applying for residency. Am J Surg 1991;162(1):63-66.

3. Provan JL, Cuttress L. Preferences of programme directors for evaluation of candidates for postgraduate training. CMAJ 1995;153(7):919-923.

4. Moss TJ, Deland EC, Maloney JV Jr. Selection of medical students for graduate training: pass/fail versus grades. N Engl J Med 1978;299(1):25-7.

5. Spring L, Robillard D, Gehlbach L, Moores Simas TA. Impact of pass/fail grading on medical students’ well-being and academic outcomes. Med Educ 2011;45:867-877.

6. Filene P. The Joy of Teaching: A Practical Guide for New College Instructors. Chapel Hill: University of North Carolina Press, 2005. Chapter 8, Evaluating and grading; p.93-111.