Based on audits, year 1 medical student performance on exams has been dropping since before the time of Covid, when our exams went from short answer to single best answer (SBA) multiple choice format.  Restoring face-to-face classes has not returned student exam performance back to the levels of 5 years ago.  The cause of these low single best answer exam performances could be due to

(A) more demanding exam questions

(B) students who are less studious

(C) students who have weaker academic reserve

(D) weaker teaching that is unmatched to the exams, or

(E) an increase of taught material and a dearth of time on the exam.

Although option (E) is the most likely because we are aware of the creeping increase in material being taught, in this work we consider option (A), and show that the problematic SBA questions are often "vignette questions" that require problem solving in order to successfully answer them.  As our lecture-based course does not teach year 1 students problem solving per se, one possible cause of examination issues is problem solving in year 1.  In an audit of the previous year's performance, we find that purely factual exam questions are answered correctly, whereas a range of SBA questions requiring problem-solving have created difficulties for students.  We have attempted to address this by teaching problem-solving with lung function tests (LFTs).  Traditionally the problem-solving aspect of LFTs are taught by summarising with ATS/ERS flow charts, which most students find difficult to follow or memorise.  We taught this topic with a supplementary and optional hour-long problem-solving session working through each individual LFT case.  Although students (61 attendees in a cohort of 212) were very satisfied with the learning sessions (rating scale 1-5, 5 = excellent, mean ± SEM = 4.58 ± 0.08, N = 48 respondents) and they had little previous familiarity with the ATS/ERS diagram (2.33 ± 0.16), the students' self-rated understanding at the end of the problem-solving session was not great (3.86 ± 0.11), nor did they think that flow charts would "would help you personally to learn" the material (3.96 ± 0.14).  They were confident that with "time to study at home", that they could "now master the ideas behind the ATS/ERS diagram shown at the end" (4.42 ± 0.10). We conclude that optional problem-solving sessions are not particularly attractive to students, but those who do attend believe that their future learning of complex concepts like LFTs will be improved.