Behavioral Treatment of Debilitating Test Anxiety Among Medical Students

Douglas H. Powell
Harvard Medical School

This article presents and illustrates the behavioral treatment of medical students and physicians whose debilitating test anxiety was associated with their failure to pass the United States Medical Licensing Examination (USMLE) or a specialty board test. Seventy-two medical trainees were treated consecutively because of at least one failure to pass these professional examinations. Behavioral treatment focused on their anxiety, which resulted in the dual deficits of poor test preparation, poor test performance, or both. Treatment featured progressive muscle relaxation, systematic desensitization, the self-control triad, behavioral rehearsal, and a psychoeducational component. Ninety-three percent of the clients eventually passed the examination while in treatment. Pass rates for this group were substantially higher than the national average for repeat USMLE test takers. Limitations of this treatment method are that it seemed too elaborate for some medical trainees and was less effective with those who had difficulty evoking anxiety. 2004 Wiley Periodicals, Inc. J Clin Psychol/In Session 60: 853865, 2004. Keywords: test anxiety; medical students; USMLE; behavior therapy; systematic desensitization; self-control triad

Medical training creates high levels of stress. The average medical students anxiety level has been estimated to be at the 85th percentile compared to that of the general population (Vitaliano, Maiuro, Russo, & Mitchell, 1989). Among the negative effects of stress for a small group of otherwise capable medical students is performance anxiety so debilitating as to compromise their performance on professional licensing examinations. This problem is not specific to U.S. medical students; severe test anxiety has been reported for
The author is indebted to Christine Reiffenstuhl-Findl and Earl F. Bracker for their contributions to this article. Correspondence concerning this article should be addressed to: Douglas H. Powell, Ed.D., ABPP, Psychology Department, McLean Hospital, 115 Mill Street, Belmont, MA 02478; e-mail: douglas_powell@hms.harvard.edu.

JCLP/In Session, Vol. 60(8), 853865 (2004) 2004 Wiley Periodicals, Inc. Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20043

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medical trainees in many other countries, including Australia, China, England, Germany, India, Italy, the Netherlands, Pakistan, and Turkey. In the United States an aspiring physician must pass a series of professional licensing examinations in order to practice medicine. These include Step 1 of the United States Medical Licensing Examinations (USMLE), which covers basic science and usually is taken at the end of the second year in medical school. Step 2 of the USMLE focuses on clinical medicine and is usually given in the fourth year. A specialty board examination, such as that of the American Board of Internal Medicine, is required after the completion of residency training. The USMLEs are taken over a 2-day period. For more than two decades, the author has attempted to help young men and women who failed these licensing examinations because of debilitating test anxiety (DTA). On the basis of this clinical work, it is apparent that a subgroup of about 2% of a medical school class does not pass because of DTA. For those vulnerable to DTA, the anxiety aroused by the prospect of taking the USMLEs can create a dual deficit, which adversely affects test preparation, test performance, or both (Meichenbaum & Butler, 1980). A key feature of the first deficit is inadequate preparation for the examination. Avoidance and procrastination, often disguised as overinvolvement in other apparently useful activities, cause some individuals to postpone studying for the USMLE until the last moment. As a result, they do not spend enough time reviewing their notes and study guides. The second deficit is the inability to control anxiety during the test so that failure occurs. In these cases, there may have been thorough preparation for the USMLE, but the tension during the examination rises so steeply that worry and panic compromise attention and memory. Because test anxiety can adversely affect study habits as well as test performance, the most successful therapeutic interventions are likely to be those that improve test taking skills as well as moderating tension during the USMLE itself. In spite of the recognition that DTA can threaten the career of medical trainees and decades of research showing the positive effects of treatments for test anxiety, little has been reported about efforts to help these students. A Medline and PSYCINFO search found only three clinical reports of treatment of small numbers of medical students and residents who had conditions similar to DTA (Herbert, 1984; Shukla & Nigam, 1979; Stanton, 1993). The purpose of this article is to contribute to the small literature on this topic by presenting and illustrating the authors behavioral treatment of 67 medical students and five young physicians suffering from DTA. Debilitating Test Anxiety Most students who are apprehensive about tests do not suffer from DTA. In spite of the anxiety-arousing nature of the USMLE, well over 90% of medical students pass the first time they take Step 1 or Step 2. Even if they fail initially, most motivate themselves to work hard the next time, have a strong expectation of passing, and are successful (Brunstein & Gollwitzer, 1996). These individuals do not have DTA. DTA is an example of debilitating performance anxiety, which is defined in this issues introductory article by Powell. Several inclusionary and exclusionary criteria differentiate this condition from other subtypes of social phobia, as well as normal apprehension among medical students and physicians. These are as follows: 1. Severe anxiety symptoms occur in anticipation of and /or during professional licensing examinations, particularly those that contain test questions in a

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2.

3.

4.

5.

6.

7.

8.

9. 10.

multiple-choice format. These examinations produce disabling worry, emotionality, and autonomic hyperarousal (Bandura, 1997). Adverse cognitive impacts may include slowed mental processing speed; impaired attention, resulting in problems in focusing, overlooking of important details, and difficulty with retrieval of stored knowledge; reduced capacity to inhibit distracting inner or outer stimuli (Braunstein-Bercovitz, Dimentman-Ashkenazi, & Lubow, 2001); increased obsessional thinking that makes choosing among several possible answers difficult (Flett, Hewitt, Blankstein, Kirk, & Gray, 1998); constricted working memory so that the content of complex questions cannot be easily stored temporarily while potential answers are considered; reduced ability to break set; and problems with time management. These symptoms are not debilitating in other academic or professional work. Study habits are adversely affected by test anxiety; procrastination, disorganization, reduced effort, faulty study habits, and failure to monitor learning result (Smith, Arnkoff, & Wright, 1990). The individual has a history of similar reactions to, and performance on, other standardized multiple-choice tests, such as the Scholastic Aptitude Test / American College Test (SAT/ACT) and the Graduate Record Examination / Medical College Admission Test (GRE / MCAT). The person has a pattern of attaining scores on standardized multiple-choice tests that are significantly lower than other classroom performance, and the perception of the individuals ability of some faculty who have taught them. The person has failed on one or more occasions to pass professional licensing examinations such as the USMLE, despite sufficient energy and time spent in preparation. Often the person has a circumscribed sense of being bad at multiple-choice tests such as the USMLEs. Performing up to expectation on such tests does not build confidence for passing similar examinations at the next level. There is no evidence of health problems, learning disabilities, attention-deficit / hyperactivity disorder, other anxiety disorders, clinical depression, other Axis I or Axis II disorders, drug /alcohol abuse or dependency, secondary gain from test failure, or obvious external stresses that adversely affect cognitive functions. Except for performance on multiple-choice tests, there is a realistic sense of being competent in the classroom and other professional settings. Other demanding academic, extracurricular, and clinical activities are not impaired by anxiety.

It should be said that there is no one type of DTA that applies to everyone. Clients typically exhibit many, but not all, of these characteristics and experience them to varying degrees. The Medical Students and Physicians Seventy-two individuals who were seen consecutively by the author over a 16-year period are the basis of this report. Fifty-eight were students in medical school, who were treated at the universitys mental health clinic. Nine attended other medical schools and were seen privately in a nearby office. Each had failed the USMLE or its predecessor, the National Board of Medical Examiners (NBME), at least once. Fifty-five students failed

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Step 1, and 12 failed Step 2. Another five young physicians sought treatment because they failed a specialty board exam. The group consisted of 38 men and 34 women. Seventeen were members of underrepresented minority groups. The age range was 23 to 41, with most in the mid-20s. Among those for whom data were available, the undergraduate grade point averages ranged from 3.3 to 4.0 on a 4.0 grading scale. Their MCAT average was in the 62nd percentile. Academic performance in medical school varied, forming the shape of a wide normal distribution. One of the strongest students ranked second in his class and was headed for a prestigious residency, provided he passed Step 2. At the other end of the academic distribution were several students who had to repeat at least one medical school course. The majority of the medical students reluctantly entered treatment, many saying that they had been putting it off or had actively resisted the suggestion that they might need help. Several commented that they were ashamed to think that they needed professional assistance, and a few said they felt singled out and were angry. The initial interview determined whether DTA was the probable cause of failure, decided whether behavior therapy might benefit the student, and, if it might, devised a treatment plan. Nearly all reported a history of DTA on standardized multiple-choice tests, and all but a few were performing competently in classroom and clinical work. The interview also assessed whether and when the student had the available time, willingness, and energy to focus on overcoming the problem. Seven medical students were accepted for treatment though they did not meet the criteria for DTA of at least average grades in medical school and /or the absence of other psychiatric problems, such as depression or anxiety disorder. The treatment was seen as their last hope to remain in medical training. In addition to the 72 treated individuals, 12 medical students were interviewed during this period but did not enter therapy. Three thought the approach was too elaborate and discontinued treatment, and four did not return after the first visit. Five others were not accepted for treatment because they either were apprehensive but had no history of exam failure or had personal problems that interfered with adequate test preparation. They were referred to other clinicians. The Behavioral Treatment The treatment consisted of a broad spectrum of behavioral methods. These were made available to each student during the entire course of the treatment. 1. Progressive muscle relaxation (adapted from Goldfried & Davison, 1994): The clients were taught to tighten and relax nine major muscle groups. This technique was especially helpful to a small number of clients who could not easily put themselves into a relaxed state. The majority of individuals were able to follow suggestions to relax without the necessity of progressive muscle relaxation. 2. Systematic desensitization: An abbreviated version of systematic desensitization (Wolpe, 1958) taught the clients to remain calm while evoking the anxiety they could imagine during the days leading up to, and taking, the examination. As soon as systematic desensitization was mastered, the students were advised to practice it thrice daily. 3. Self-control triad: Systematic desensitization was not effective in lowering anxiety for several individuals when imagining being in the test situation or actually taking a comprehensive practice test. This failure led to the introduction of a modified version of the self-control triad (Cautela, 1983). This technique uses

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two forms of thought stopping (shouting subvocally to oneself, STOP and visualizing a stop sign) and two methods of covert reinforcement (a deep, relaxing breath and a pleasant scene). 4. Behavioral rehearsal: Behavioral rehearsal was always a part of the treatment, but its prominence grew over the years as the postexam debriefings pointed to its value. The goal of behavioral rehearsal was to reduce the potential distractions caused by anxiety that occurred on the day of the examination (Smith & Nye, 1989). Both covert and overt exposure techniques were used. Each student was asked to imagine the feelings that would be aroused on the day of the test from the moment of getting out of bed to actually taking the examination. Overt rehearsal entailed a practice run through all the steps that would be taken the day of the test. If possible, students were to wear the same clothes and travel the route they would take to the examination site. Then they were to sit in the actual room where the test would be given and take a practice examination, while trying to experience the stressful feelings this setting would evoke, and then apply anxiety control techniques. 5. Psychoeducational techniques: Inspired by Frierson (1987), the primary elements were pre- and posttesting while using the study guides, error analysis, and a discussion of tactics for answering multiple-choice examination questions. Specifically, when clients were using subject-related study guides (for example, anatomy), they were instructed to answer half the questions before studying and half afterward. If the pretest score was 30% correct and the posttest yielded 70% correct, the students would see clearly that their efforts were successful, because most of these licensing examinations require about 60% correct answers to pass. Error analysis helped the trainees identify areas of relative strength and weakness and was the basis for teaching them to create their own probability model for estimating their number of correct answers on a test. This technique was useful in creating an accurate self-assessment and building a sense of efficacy. Finally, a discussion of tactics for taking multiple-choice tests covered some of the ways well known to generations of medical students to maximize the probability of a correct answer. 6. Other interventions: Whereas the primary treatment was behavioral and psychoeducational, other interventions were sometimes employed. For instance, regular moderate exercise was recommended because it is known to correlate with lower anxiety, improved mood, and enhanced self-concept as well as quicker reaction time, better attention, and stronger reasoning skills. Cognitive techniques were occasionally used to help reduce negativism, self-criticism, helplessness, and distortions that interfere with test preparation and performance. From time to time, brief supportive psychotherapy was called for, usually in response to moments of experiencing overpowering feelings of despair, being overwhelmed by anxiety, or feeling that the test preparation was not working. The upsetting feelings almost always subsided after a session or two and /or phone call(s). Monitoring and modification of these six treatment methods were ongoing. Often the sequences or combinations of therapies had to be adjusted. Careful monitoring of these therapeutic methods was necessary because some are known to have a small but significant risk of adverse effects (Braith, McCullough, & Bush, 1988; Tarrier, 2001). After the initial interview the essentials of the treatment plan were explained and agreement on a period and sequence of preparation was reached. The ideal was about

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10 hours of work per week on exam preparation and practicing of these techniques for about 3 months before the USMLE. Most of this time was spent practicing systematic desensitization and study with pre- and posttesting using the study guides and error analysis. Many clients compressed their work into a 30-day period or even less. During this preparation period they were asked to report their progress or difficulties on a regular basis. Some did, but many avoided contact after learning the techniques unless they had severe problems. The number of face-to-face contacts with these clients after the initial interview varied from 2 to 16, with a mode of 6.

Treatment Results Follow-up of the treatment of the medical trainees found that 67 of the 72 individuals (93%) eventually were successful on their USMLE or specialty board. Forty-one (74%) passed Step 1 the next time they took it, and 10 passed Step 1 after one more failure. Of these, seven said they had not followed the suggested treatment approach and did not feel ready but took the test anyway. Two others failed twice during a 17-month span before passing. All continued with the preparation during this period. Immediate success was more common on Step 2 (10 of 12 passed) and the specialty board examinations (four of five passed). No gender differences were found among the 67 individuals who eventually passed their exam: Of the males 36 of 38 and of the females 31 of 34. Underrepresented minority students passed at the same rate as the others. Six of the seven students who did not meet the exclusionary criteria for DTA were successful. The passing grades were, on the whole, modest. Consider as an example Step 1 of the USMLE, which presently has a mean of 200 and a standard deviation of 20. A student usually needs as a minimum a score of about 176 (1.2 SD ) to pass. The average of the successfully treated students was 195.8 (about the 34th percentile) with a range of 176 to 230. Two medical students failed once and terminated their work with the author, and one of these later reported passing by using a different form of preparation. Three failed the next test and did not continue preparation. One student left medicine to pursue strong research interests, and another dropped out and lost contact. One of the physicians put her medical career on hold after the birth of twins.

Case Illustrations The following two cases illustrate how the characteristics of the DTA manifest themselves, the ways in which the behavioral treatment was adapted for each of them, and the outcome.

Student A Student A was a 25-year-old fourth-year medical school student who in mid-February asked for help because he had failed Step 2 of the USMLE the previous spring. He was the second-ranked student in his class, but unless he passed Step 2 he would not graduate. Student A said that he knew he should have begun sooner, but he had devoted the little spare time he had in the past year to conducting research at one of the hospitals. The research resulted in an article accepted for publication, which he was revising. Further

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eroding his time available to study was his concurrent interviewing for residency programs. All of this, plus his other clinical responsibilities, left little time to prepare for the USMLE. Further history found him to be a member of an affluent Philadelphia family. He attended a private day school, where he was a straight A student, and went on to achieve a 3.9 grade point average at an Ivy League college. In spite of his strong grades, Student A had always worried about multiple-choice examinations and performed well below expectations. He scored 1170 on the SATs, and his MCAT scores were slightly below average; both sets of scores had been achieved with considerable coaching. Student A said that he had barely scraped through Step 1 of the USMLE on the second try. Therefore, he was not surprised to fail Step 2. He said that he was always nervous before and during multiple-choice exams. He worried that his mind would go blank during the next Step 2, as it had previously. He did not know how he would face the embarrassment if he failed the USMLE and did not graduate on schedule. When asked about his preparation, Student A showed a study guide he had been working on in preparation for Step 2. Thumbing randomly through the study guide the author noticed that at least half of the lines on most of the pages had been highlighted. When asked why he had highlighted so much of the material, Student A replied that he was so nervous while studying he had trouble concentrating; therefore, he hoped that if he highlighted the material, the action would somehow transmit the material into his memory. Step 2 was scheduled for the end of April that year, approximately 2 months from the initial interview. It was agreed that he should have the journal manuscript and his residency interviews completed by the first of March so that he could begin to study for the USMLE. Meanwhile, it was suggested that he begin regular moderate exercise. From March 1 to April 20 he was seen four times. Initially, Student A rejected that psychological stuff, by which he meant relaxation training, systematic desensitization, and self-control triad techniques. He was interested only in learning how to study to prepare for Step 2. But in the third week of March, Student A became upset after he took a comprehensive practice test and obtained only 50% correct, a score well below the 60% correct needed to pass. During the practice test he felt apprehensive and worried about how he was doing. Afterward he recognized how much his anxiety impaired his test performance and realized he needed to control these emotions during the next USMLE. He then was taught to use systematic desensitization and the self-control triad. Student A found he could lower his exam anxiety by practicing systematic desensitization (five repetitions) once a day in the evening before going to bed. He also used systematic desensitization before sitting down to study and before taking a pre- or posttest, or at any time he felt anxious during a practice comprehensive examination. By the third session Student A had made considerable progress. He took another comprehensive test and found 71% of his answers correct. Using the error analysis strategy, he divided his pretest questions into those he was 90% sure of, those he was 50% certain, and those about which he had only 10% confidence in the correct answer. Of those about which he was 90% sure, Student A answered 98% correctly; when he was 50% certain, he answered two out of three correctly; and, when he thought that he had only a 10% probability, he was right 35% of the time. His scores were far better than chance. On the latter two types of questions he used the familiar tactic for multiplechoice tests of maximizing probability: He always chose the first of two answers when he could eliminate all but two possible choices. When he had no idea which of three or more answers was correct, he would use the letter of the day strategy (e.g., the answer to all questions is B.) Seeing these positive results seemed to build his confidence, causing him to study much harder than he had been.

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Two days before the exam Student A called to say that he was feeling confident. But on the night after the first day of the exam Student A phoned to say that he was in shock. When he found that he did not know the answer to several questions in a row he panicked. The worst part of that first day occurred when he lost track of time, looked at the clock, and discovered that with 10 minutes to go he still had 60 questions to answer. He then used the letter of the day test-taking tactic. Student A was understandably upset because he could not control his anxiety and was not able to do as well as he wanted to do. On closer questioning he admitted he had not used systematic desensitization on the day of the exam because he felt so confident. Then when he tried to apply it to stem his sharply rising anxiety, he could not make it work. After reassuring him, the author reviewed with him how he might manage his anxiety more effectively the next day. Then he was reminded that the self-control triad was designed for exactly the conditions he had faced that daynamely, overwhelming panic. He was urged to practice it before going to sleep and when he arrived in the room where the exam was given. The next evening Student A called. He felt much better. He used systematic desensitization before the USMLE and the self-control triad just before starting the exam. He completed the second half of the exam on time. Five weeks later, Student A called to say that he obtained the exact minimal passing score, had matched with a prestigious hospital for his residency, and would be giving one of the student speeches at graduation. Student B When Student B was first seen in October after her second year she already had failed Step 1 twice. Student B was not very happy about seeing a shrink. In fact, she had been referred the previous year after her first failure but did not consider herself a mental case. She was an above-average student, who had never failed a course. She was only now having treatment because she had been forced to take the year off to prepare for the USMLE the following June. Student B said that she had no idea why she had failed Step 1. During the exam she had not been particularly nervous, and she had studied hard for them, especially the second time, but still failed. Raised in a working-class family in a small Michigan town, Student B had been an honors student as well as an all-state high school basketball player. Her basketball was important because she obtained an athletic scholarship to a Big Ten university, where she pursued her lifelong dream of being a physician. In high school and in college, Student Bs grades averaged 3.5, with a stronger showing in the sciences. But her test scores were always far lower than class performance. Her ACT scores were only slightly above average and her MCAT scores were in the 27th percentile. She said that she hated doing poorly on these tests, in part because she felt she would surprise her teachers by her lower than expected standardized test results. Occasionally she felt that when her low test scores became known, she would feel a growing suspicion among some of the faculty that she might not be quite as talented as her record would otherwise suggest. Her fear made her even more anxious before these exams. In medical school Student Bs mind was set on becoming a surgeon. Early on she was influenced by a liver transplantation specialist. During the year off she worked as part of a medical team. Her job was, as she put it, to harvest livers from the recently deceased so they could be used in transplants. When it was stressed that she needed to set aside time to study for the USMLE several months before Step 1 because she had failed twice, Student B responded that she

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did not think the examination was going to be a problem for her. She was scheduled for another appointment in February before the June exam. But it was mid-April when Student B returned. The work with the liver transplant team had lasted longer than expected, she explained, and thus she was unable to find time to begin preparation for the USMLE two months later. At this meeting, it was stressed that time was becoming short and she needed to focus more on test preparation. She began by using the pre- and posttesting approach for those sections of the test in which her scores had been the lowest. She found herself disliking studying just to pass the damn test, which, in her mind, was not related to the kind of doctor she was going to be. Student B began to feel that she was just memorizing and learning tricks so that she could pass the USMLE. At this point, the author initiated a discussion, which featured an element of cognitive restructuring, about the fact that preparing for the exams was a different kind of intellectual undertaking from learning medicine. Basically, she needed to transform the knowledge that she had in her mind into a form that allowed her to answer multiplechoice questions correctly. Student B did not buy the idea. She decided that she would study independently. Only three more appointments occurred in April, May, and June, largely because of Student Bs reluctance to meet. It was impossible to monitor whether she was practicing the behavioral techniques or using the study guides as directed, yet she seemed confident. There was no word from her during or after the June USMLE, and she did not appear for a follow-up appointment. In July, Student B arrived unscheduled at the office. She was close to tears and at first had trouble talking. Finally she was able to say that she had just received the results of Step 1, taken 6 weeks earlier. Her score was in the 5th percentile, well below the 10th percentile threshold for passing. During a long discussion as to what might have contributed to her failing, Student B said she was surprised at how anxious she was immediately before the test. The first sign was a lump in her throat the day of the testing; it was followed by excessive perspiration. And during one entire section of the test she misaligned the questions and the answer sheet so that she answered 20% of the questions in the wrong space. Student B did not recognize her mistake until she was nearly finished. Because of her otherwise exemplary record, the medical school decided to give her one final chance to pass the examination in the fall, approximately 2 months from that day. A lengthy discussion ensued about what she might do to anticipate this sudden arousal of disabling anxiety to understand how it might affect her cognitive functions and then find ways to control it. Jointly we developed a strategy to encourage her to diagnose her own problems with test taking before deciding what would help her prepare for the board. She agreed to the suggestion that she take a comprehensive practice exam immediately and try to visualize it as the Step 1 she would take in September. Though she failed the first practice exam badly, Student B reported the following insights: First, she greatly resented having to take this exam, which sometimes made her so angry she could literally see red and had trouble concentrating on the questions. Second, when she felt rushed and when the problems were complicated, she hurried herself into making mistakes. Third, she felt no anxiety at all before taking the test, but then, just before she started answering the practice questions, had felt tightness in her throat followed by sweating, an accelerated heart rate, as well as worry that she would fail. We employed several techniques to minimize these problems. She was taught the self-control triad to control her anger, and it worked quite well. Next was the problem with time pressure. She had the idea of taking the next practice test with a chess timer, analyzing the type of questions that caused to her to rush into mistakes. Student B discovered that questions in two test sections (one of them behavioral sciences) were the most difficult

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for her. She recognized that she needed to study these two areas more intensively and then take practice tests on these two sections with her timer until she felt comfortable answering the questions in the time allocated. That left the problem of anxiety management when no obvious anxiety was present. She just could not discuss it. At one point Student B commented that it seemed to her a little crazy that she was being asked to feel nervous when all of her life she had been told, Dont think about it. The principles of systematic desensitization were again explained. She agreed that she should learn to do systematic desensitization anyway because anxiety was likely to make its presence known at some point before or during the USMLE. In its place, anger served as a proxy. Student B had no trouble becoming furious about the coming examination and resenting having her medical career dependent on a stupid test. So she desensitized those emotions. Student B began behavioral rehearsal about 10 days before the exam. The rehearsal entailed taking a series of practice exams while sitting in the room in which the USMLE was scheduled to be given, at the time of the day the test was scheduled to begin, dressed in the clothes she would wear, and trying to evoke the anxiety she knew that she might feel. The first faint signs of anxiety gradually appeared, again initially as tightness in the throat followed shortly by increasing perspiration and apprehension. Student B was able to use systematic desensitization to control its impact while taking practice tests twice during this brief period. And her scores were in the passing range. The night before the USMLE, Student B called to say that she was OK but jumpy, as she was before a basketball game. The night of the first day of the exam Student B phoned and said that she had been a little tense beforehand but calmed herself during the test by systematic desensitization and thought she did reasonably well. There had been no lump in her throat, only a little tightness. Also, she had no problems keeping her answers properly lined up with the questions on the answer sheet and finished the test on time. She did not call after the second day of testing and cancelled her follow-up appointment for the following week. Several weeks later, in a discussion with the medical school dean about how the students with whom the author had worked fared on their exams, the dean reported that Student B had passed Step 1 of the USMLE. Her score was in the 40th percentile. That was not the end of her story. Eight years later Student B phoned from a city nearly halfway across the country. By then she had completed her residency and was working as part of a liver transplantation team at a university hospital. However, she was still having trouble passing tests, this time the surgical specialty board. She knew that she should have called earlier, she said, but thought she could handle the exam on her own. But she had failed three times. She did not want to ask anyone there for help because she would be embarrassed. What could she do? When questioned Student B admitted that she probably failed the board because she had not prepared, just as in medical school. We briefly discussed how people retain vulnerability to debilitating test anxiety when facing multiple-choice tests for important exams and reviewed what had been effective for her in the past. We discussed again the behavioral techniques and the pretest- and posttest-taking approach to using the study guides. She called twice more to review her progress and had no trouble passing the specialty board the next time. Clinical Issues and Summary How might one judge the results of this behavioral treatment? One answer to this question is quantitative, the other qualitative. A quantitative response to the question might compare the pass rates achieved by the 72 treated individuals reported here with the national percentage of medical students and

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physicians who are successful on their next professional licensing examination. In 2002, more than 9 of 10 students at American medical schools passed on their initial attempt for both Step 1 (92%) and Step 2 (97%). Though there is interdisciplinary variation, in general the specialty boards set a higher passing threshold, which results in a success rate of about 80% among first-time test takers in internal medicine and pediatrics. These rates fall substantially for repeat test takers on all medical licensing examinations. The success rates for those who retake Step 1 and Step 2 drop to 59% and 70%, respectively. The pass rate for those who retake specialty board exams is also substantially lower and decreases with each subsequent failure. This group of medical students and physicians who received behavior therapy was more successful than repeat test takers nationally. Among these medical students repeating Step 1 for the first time, their overall success rate was substantially higher than average, 74% compared to 59% nationally. All of the 14 who failed the USMLE on the second try were successful, 12 of 14 on the next attempt, making the total pass rate for Part 1 91% for those who continued treatment. Of those facing Step 2, 10 of 12 scored above the threshold. Four of the five physicians passed their next specialty exam. Qualitatively, the author is certain that the behavioral treatment and psychoeducational instruction are powerful tools for helping students who have DTA. The primary reason for this belief is that the author learned these techniques in midcareer, having spent the previous two decades using a mix of psychotherapy and other forms of treatment with medical students and others who had DTA. Although psychotherapy seemed to reduce anxiety level, test performance often was unimproved, results consistent with the experience of others (Smith, Arnkoff, & Wright, 1990). After the author learned how to use these behavioral methods and psychoeducational strategies, and then applied them to those who had DTA, the results were far more impressive. Individual debriefings indicated that systematic desensitization, the self-control triad, and the pre- and posttesting approach to using the study guides played a central role in helping nearly all of the medical trainees overcome DTA and pass the professional licensing examinations. The reasons are that they engage the two greatest problems that people who have DTA confrontcontrolling their anxiety and learning the material in a form necessary to pass the test. An important bonus was that success in anxiety management and posttesting promoted a sense of internal efficacy (Bandura, 1997) that improved confidence and motivation. Other aspects of the treatment benefited a number of clients. Several, including a young physician who said she felt less guilty working out because it was now a prescribed activity, commented that regular exercise helped greatly. As Student B did, others found behavioral rehearsal especially helpful. One medical student reported that he discovered that his feet became distractingly warm when he sat in an examination room and imagined taking a USMLE. Wearing sandals kept his feet cool and his mind focused. Monitoring the students preparation was an essential part of this treatment. Though not officially acknowledged as therapy, this monitoring covered much of the same territory. Time was spent talking with the students, determining whether and how they were using the behavioral and psychoeducational methods, analyzing their effectiveness, and making changes as needed. These meetings provided an opportunity to review and clarify the reasons for using this or that technique, as when Student B initially did not want to use the pre- and posttesting approach with study guides because it seemed to her a trick that had nothing to do with learning medicine. These discussions provide a forum for the students to be active in their own improvement, as when Student B took a chess timer to her practice tests to improve her speed on more complex questions.

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Monitoring also provided an opportunity to make use of spontaneous insights that are often triggered by the use of behavior therapy (Powell, 1996). For example one medical student while practicing systematic desensitization began to recognize that he felt he was an impostor who did not deserve to be in medical school. In his mind, the only reason he had been accepted into medical school was that both of his parents were physicians. In spite of an outstanding record in college and medical school, he clung to the irrational conviction that he was not worthy of being a doctor and that the USMLE would reveal him as the phony he was sure he was. With the help of concurrent psychotherapy he was able to pass easily the next exam. Although this behavioral treatment of DTA is promising, there is reason for modesty as well as the recognition that improvements in this therapeutic model can be made. Seven of the medical students who had DTA did not enter this therapy. Of those treated, 10 failed again the next time they took the examination and 2 were unsuccessful twice before passing. Five others did not appear to benefit from this method. Of those who failed, six shared a common characteristic: As Student B had, they all had difficulty beforehand experiencing the high level of tension they would feel during the upcoming USMLE. All knew that they had been anxious in the past on tests and would be again but had a problem evoking these emotions in the clinicians office. Often, not until very close to the time of the test did the disruptive anxiety finally appear. Then they were suddenly overwhelmed by debilitating physical and psychological symptoms. People who control their feelings in this manner have been described as repressors (Shipley, Butt, Horowitz, & Fabry, 1978). Because they were not able to elicit anxiety, they could not practice the behavioral techniques, especially systematic desensitization and the self-control triad, effectively. Once this characteristic was appreciated by therapist and client alike, every effort was made to help them evoke these feelings so that they could learn to manage their anxiety before the USMLE. As Student Bs history illustrates, careful monitoring is required to detect early signs of this anxiety, in her case a lump in the throat that is precursor to the DTA, so that behavioral treatment can be applied. Her example illustrates, too, that if anxiety cannot be produced, another emotion (anger) can be used as a proxy in order to practice systematic desensitization and the self-control triad. But even when the student could evoke the anxiety and was able to demonstrate control of it, the therapist was often left wondering whether the stressful feelings were merely being suppressed rather than managed and would reappear during the examination. It is possible that advances in virtual reality therapy will be helpful for this vexing problem. As Student B had not, less than 50% of these medical students and young physicians informed the author when they passed the USMLE. As one student put it, I saw my relationship with you about the same way as with my dentist during a root canal. I was in a lot of pain, needed help, and felt close to the endodontist during the procedure. But afterward when my tooth wasnt causing pain anymore, I didnt even go in for a follow-up appointment. I was too busy. Clients who ignore follow-up meetings after successful treatment are familiar to experienced clinicians. Having no follow-up meeting after passing a crucial exam, however, puts clients who have DTA at a significant disadvantage with respect to future tests. They need to learn that many people who have DTA tend to retain their vulnerability to multiple-choice professional licensing examinations. Awareness of this vulnerability might have benefited Student B and prevented later specialty board failures. The behavioral intervention that was helpful in the past is usually equally as useful later. Medical trainees are not the only professionals afflicted with DTA; nor are they unique in their reluctance to seek help for this problem. A much larger proportion of

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people who have completed their studies in law, accounting, and other occupations fail their professional licensing examinations. It is likely that DTA played a role in the failure of a significant minority of these individuals. Unless individuals who have DTA are identified and treated, they may well continue to fail their licensing examinations and, as a result, be forced to leave their chosen field or work at a level well below their capabilities. One is struck by the economy of this behavioral treatment of DTA. Once the behavioral techniques and the pre- and posttesting have been taught, they are then selfadministered and can be practiced outside the therapists office. Therefore, the number of actual contacts with the medical students and young physicians was relatively small; the mode was 6. In a managed care environment, with its emphasis on short-term therapy, and in the lives of busy medical students, these interventions are economical and effective. Select References / Recommended Readings
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