The word “pre-med” may recall an image of the constantly frazzled student with dark under-eye bags and a coffee cup in hand — at least at Yale College. But this image is far from accurate for some students who actually manage to complete the pre-med requirements — those at the University’s medical school.

With no grades — not even a pass/fail system — for the first two years, no mandatory homework or course attendance for all four years and no class ranking at all, the Yale School of Medicine’s educational system remains unique among the country’s medical schools for its academic flexibility and emphasis on student initiative. According to a survey conducted this year by medical school Admissions Director Richard Silverman, the “lax” Yale method of instruction was one of the most frequently cited reasons that students said they chose to come to Yale.

Medical school Dean Richard Alpern said the system, which has been in place at the school since 1931, is not intended to make medical school easier for students but instead, to simulate the conditions of the real world — where “you don’t get any grades.” He explained that all students must eventually undergo a transition from relying on grades and class ranking to inspire hard work during their school years, to working hard simply because they enjoy their course material and, eventually, their careers.

“When do you make the transition from the college pre-med mindset to the physician one? Most schools do it after medical school,” Alpern said. “We do it right after college.”

Alpern said that the infamous pre-med mentality — a label that has long described overtly grade-hungry and competitive students — is largely a function of the pressure-cooker system created by grades and ranks at the undergraduate level, rather than innate qualities pre-med students may possess.

“You’ll find that most pre-meds hate the pre-med experience,” he said. “They hate the tests and the grades and are grateful to climb out of them.”

Free from ‘binge and purge’

Instead of regularly scored tests that are counted towards a final grade, for their first two years, medical school students evaluate themselves through anonymous qualifying examinations. Instead of writing their names on exams, students identify themselves with a code that the teacher cannot trace back to them.

But this does not mean that there are no repercussions for failing.

The school’s honor code requires that students who do not pass an examination address their performance individually with the professor to determine how best to improve. In the case of successive failures, students cannot be promoted to the next year of study, Alpern said.

Alpern said the program was, until recently, even less evaluation-oriented. Tests were initiated only over the last decade or so as a compromise to other schools’ more evaluation-rigorous curricula, he said.

Teaching at the medical school occurs through optional lectures and small-group sessions, where faculty and students work on making sense of the material in an interactive manner by discussing optional homework assignments. In their third year — the year when medical students begin their clinical clerkships — a system of “Honors/Pass/Fail” is instituted, but Alpern said that system is not meant to be competitive and that roughly 70 percent of students end up receiving Honors.

Fitting with Yale’s emphasis on training broad-thinking physicians, the program requires students to complete a senior thesis during their final year based on independent research they conduct at the school. Students are also encouraged to finish their educational program at their own pace: While most complete it within the regular four years, a handful choose to stay on for an additional year.

The idea behind all of this, he emphasized, is that memorizing facts for grades is far less important that what lies at the heart of a good education — training students in methods of investigation and the scientific habit of mind.

And it works, students say.

The system effectively removes competition and external pressure from the medical school equation, medical students said, making their experiences arguably more enjoyable that they would have been at other peer schools.

“The style of things lends itself as well to the mastery and long term retention of material,” Emma Barber MED ’10 said. “For students who are good with doing a small amount everyday, it works beautifully.”

The system shifts the emphasis to learning for the future, freeing up students from the “cycle of binge and purge” that occurs when students cram for tests and forget the material shortly after, Barber said.

Yuen-Jong Liu MED ’09 said the philosophy is also extremely supportive of students’ outside interests, and enables them to lead an active life outside medical school.

Lieu, for example, said in addition to his coursework, he works with the Hungarian Children for Adoption and the New Haven Free Clinic, while also being a member of the Yale Ballroom Dance Team.

“In some ways, there are some people working less total hours that they would at other medical schools,” Benjamin Zabar MED ‘10 said. “But more importantly … I’m much less stressed here than [are] some of the people I know at other medical schools.”

Still an adjustment

But, Alpern said, Yale’s approach is not for everyone.

Some lower-ranked medical schools, he said, need to have ranking systems to ensure their top students get good residency placements. But at a place like Yale, where the calibre of students is high to begin with, distinguishing among them is not crucial for success after graduation.

The system’s danger, he said, is that it can foster perceptions that Yale’s program is not as rigorous as peer programs.

But Silverman said this has not been a problem for Yale’s students. “Just look at where our students end up,” he said enthusiastically.

Silverman said this year’s residency “match results” — which reflect whether graduating medical school students are accepted into their top choice residency programs — were 100 percent for the second year running. Conducted annually by the National Residency Matching Program, “matches” are produced by a computer algorithm that aligns the preferences of applicants to residency programs with the preferences of residency programs to fill the training slots at teaching hospitals around the country. Last year, only two medical schools, Yale and Stanford, achieved the 100 percent rate, Silverman said.

But the medical school system’s strength can also be its weakness — at least in terms of admissions.

Indeed, the system doesn’t work for everyone — especially those who are used to gauging their progress in a discrete, quantifiable way, Alpern said.

“There’s no system of short-term gratification,” he said. “Students who have been pre-med for four years and have gotten gratification every week of their years from doing well on tests and quizzes may feel empty and lost with the lack of reward.”

Zabar said, having come from Dartmouth’s structured undergraduate program, the transition required an initial adjustment. One of the challenges, he explained, was to understand how best he would learn material for the long run — whether by attending lecture, reading on his own or a mix of both strategies.

Considering the self-directed nature of the program, it is easy to abuse the system if students are not committed to taking advantage of the opportunity, Barber said, although she added that most do not because they are a self-selected group of self-motivated students.

“A trap that people get into is not looking far enough ahead,” she said. “Some people don’t do work unless its required, unless there’s a deadline looming. If that’s the case, you should not come to Yale.”

Empty seats and self-teaching

But, according to some professors, the medical school’s non-competitive atmosphere is often apparent — in the regularly empty seats in lectures and small-group sessions alike, for example.

Professors said, while they appreciate the system for the non-competitive atmosphere it promotes, it may exacerbate low class attendance and dampen the incentive to engage in voluntary activities like small-group sessions if students perceive no immediate gains.

During a small-group renal module workshop he recently headed, Peter Aronson, a professor of Internal Medicine and Cellular & Molecular Physiology said only about one-third of the students chose to complete the homework, while roughly half skipped the session altogether. Those who attended but had not completed the homework were less active in the discussion than those who had, he said, adding that students who completed the homework had a much better understanding of the material.

Indeed, students interviewed admitted that class attendance, even for some of the more popular lecture classes, is sporadic at best.

“There are people in my class I haven’t seen all year, because they just don’t go to lecture,” Barber said.

The challenge is thinking about how to improve the value of some of the medical school’s educational components, Aronson said.

“For the first two years, you can go through without ever really engaging the Yale faculty,” he said. “A large number [of students here] are very highly self motivated and use the system how it was designed, but there are many that get by doing less work than they would at any other medical school in the country.”

Aronson said he thinks requiring homework completion — but not grading it on a competitive basis — would be beneficial because it would increase the motivation for more students to “wrestle actively with difficult material.”

Marie Landry, professor of laboratory medicine, agreed, adding that low class attendance can also take a toll on professors’ morale and motivation to teach.

The trend away from class attendance may be a recent one: until about 2000, the medical school saw an average of a 90 percent attendance in lectures and laboratory sections, but there has been a sharp decline over the past decade, she said.

Part of the reason for this, Landry explained, is the increasing availability of accessible material online and the ”whole industry of concise review books” on medical topics — which has made the strategy of skipping lectures and self-studying more feasible. But this strategy also means that Yale students simply may not be taking advantage of Yale.

“To me, it creates a question,” she said. “Is the Yale system really becoming about students studying alone in the library and if so, is this the model of educational excellence we want to promote?”

But Alpern said the shift from learning through class attendance to self-teaching is one that is not unique to Yale, but common to medical schools around the country. Still, students said, Yale’s system may be at least partially responsible.

“Sometimes you have lectures by hundreds of different faculty members a year, and it’s difficult to make connections with all those one-time deals,” he said “It provides a challenge to the professors to give the lectures that are more valuable.”

To restructure or not?

Landry and Aronson said they are open to the idea that students learn differently, and many may learn more effectively on their own. Still, if this is the case, a dialogue needs to be initiated to restructure the current format of lecture classes, Aronson said.

One idea, he said, is to have them be more interactive and hold them in smaller rooms.

Another is to adopt the “problem-based learning strategy” common at Harvard Medical School where students are responsible for teaching each other course material, Landry said.

“You can give students a lot of responsibility and have them engage actively, without mandating lecture attendance,” she said.

But perhaps the issue is not one of educational restructuring, but instead stressing individual responsibility. Despite its controversies, students maintain that the Yale system works well if it is used as intended — like Barber does.

“I go to class every day and study just as much as I would if there were no grades,” Barber said. “The crux of the issue is that, its not whether things are graded that counts, but whether you have the skills and knowledge base to go and be a physician.”

Alpern said the system makes educational interaction more enjoyable. Having traveled to several medical schools around the country, he believes that many students lose sight of learning for learning’s own sake, but rather, obsess over getting ahead.

“A frequent question at the end of a typical medical school lecture is: ‘How much of what you’re saying do we need to know for the test?’ ” he said. “You never hear that at Yale!”