Volume = Rate x Time

An equation about PA student education

I’ve sat through a lot of remediation talks and read even more advice threads, and they all say the same thing: break down the score, find the weak sections, assign more time there. Its not that this is wrong, but it is a narrow and superficial approach and it was stale a decade ago. The only thing that’s changed recently is that the advice now comes with AI bolted on. Across nearly every industry right now, we’re cosplaying innovation instead of doing it. Philosophy has a name for what’s actually going on underneath.

University of Utah philosopher, C. Thi Nguyen wrote an article called “Value Capture” in 2024 in which he describes the troubling chain of events that occur when someone enters into a pursuit for wonderfully complex reasons, be it an effort at improved fitness, or an academic challenge like a graduate degree. That complex journey is often measured through overly simplified metrics, like steps or test grades, resulting in a disproportionate effort being directed toward satisfying the metrics rather than being devoted to the complexity of the original pursuit. Nguyen calls this institutional value capture when it’s the system, not the person, that substitutes the score for the goal.

In the case of Physician Associate education, our goal is to produce competent clinicians, capable of safely diagnosing and treating their patients. Test scores serve as the proxy for that. Traditional remediation efforts tend to focus on these proxies and treat them as equivalent to achieving the goal. When a student performs poorly on an exam, we focus on the sections they scored the lowest on, get those scores up and close the case.

While this may get a student through a particularly tough exam, the cause of the deficiency remains intact. That deficiency has a name. It’s the same triage and prioritization gap I wrote about last week, and no amount of extra time on GI or Pharmacology touches it. The thing is that even students with poor study skills will learn, they just take longer to do so because the process is inefficient and shallow. It takes them much longer to retain adequate information and because the learning is shallow, they are often the students who second guess themselves or are tripped up by variations in question style. Most of the advice given to these students centers around spending more time with targeted topics. We are treating the symptom rather than addressing the skill deficit that produced it.

I think of studying as having a rate of retention, like “10 things per hour” and a destination for that information, like a waiting room, from where those things connect to other things and get filed deeper in the brain. When students have poor study habits two things happen: they are usually using a study method with a low rate of retention and those things get placed in the waiting area and have a very low rate of getting connected and filed deeper. These students are reaching into the waiting area too often when taking tests and this is why they so often can’t find the right answers and second guess the ones they do. As it turns out, this metaphor has an actual named function in cognitive psychology, called depth of processing, credited to Craik & Lockhart in 1972.

When we tell them to improve their scores by just studying the areas they were deficient in, this helps with the test in question for two reasons. They have more time to fill the waiting area, and they’re filling it with targeted information. More time compensates for the slow rate, and having a defined target means what does land is at least relevant, even if it’s not filed anywhere durable.

Unfortunately, if their study methods don’t improve, they’re likely to find themselves in the same situation again for the next test. These remediation efforts are value capture in action: they chase the score instead of the competency it’s supposed to represent, and in doing so they entrench shallow learning instead of correcting it. Our goal as a profession requires deep learning and I would argue that our remediation efforts should focus on this as well.

Remediation for these students needs to focus not just on the output of concern (a specific test score), but needs to also address the study skills upstream of this outcome. We should examine how these students are digesting the information they are given and how they decide what to learn (the first phase of learning described in my previous article). We should have them reflect on why they prioritize the information the way they do and examine whether they need to reevaluate their reasoning. We also need to have them examine the methods they are using to learn. They likely need to use study methods with a more effective rate of retention (Dunlosky et al., 2013). Effective studying demands more cognitive effort, and paradoxically, many students can be discouraged by this and wrongly assume these methods aren’t working (Deslauriers et al., 2019).

It is no wonder we chase test scores; they are the best measure we have of clinical competence. Even though this is institutional value capture, it’s not wrong, but we can do better. It makes sense that we use the score as a signal, but we should not treat moving it as the fix. If our job is to produce competent, caring humans who can safely diagnose and treat others, we should give them the learning tools to succeed in the long term, not just the next test.

This is a time-bound learning journey with consequences. There are only a handful of variables we can manipulate in a student’s studying: Volume of information that needs to be acquired, Rate of information acquisition, Time for acquisition. Volume = Rate x Time. Our job is to figure out how to help students balance this equation.