I recently came across the powerful concept of “hourglass learning” in this post by two professors who teach teachers and, not surprisingly, wondered how it might apply to teaching physicians and other healers.
That being said, if you love learning (or love someone who is trying to learn), these concepts can be applied at any age to anything – from bird watching to learning math!
Basic Sciences (Medicine taught in a classroom)
For basic sciences, the hourglass paradigm works well, but I added some practical points from the equally powerful SQR3 (Survey, Question, Read, Review, Repeat) system using a typical hour-long lecture and assigned reading as an example.
Survey (Establish a purpose).
It’s easy to forget that you don’t actually study medicine to pass a test… you are learning to heal, to serve those who need you. In that light, the first step – “establish a purpose” – can be thought of in two ways. The first is to set an intention, to remember why you are studying. And then, more specifically, to ask “What is the purpose of this lecture?” That’s where the tool of “surveying” comes in.
This is an exercise in curiosity not “studying”. Skim over everything to get the big picture. Look up words you don’t know (and their roots). Look at how the lecture is organized. Are there obvious sections? Are there lists that look like they will be important? Can you tell what the most important points will be?
Question (Extract evidence)
This is an interactive process that starts with your survey.
Before the lecture: As you are surveying make notes (on the slides, in the margin of the notes, or as a separate list) with what questions the lecture will and, more importantly, won’t answer about the topic.
During the lecture: Listen for and jot down the answers to the questions you wrote down the night before. If there are questions that aren’t answered in the lecture, ask the professor afterwards.
Read (Make sense)
After the lecture but on the same day (don’t wait!), add to your notes to make everything as clear and as organized as possible, look up anything that is missing, and then make a one page “30,000 foot” review of the lecture.
Review (Form meaning).
The 4th step is to return to the “why” by linking the lecture to how the information applies to actual human beings. Even though search engine AI may point you in the right direction, it should never be your sole source as a professional. (That’s in bold for a reason.) As a professional you need to make sure the information you have is vetted (i.e. peer reviewed).Start with PubMed or UpToDate to find a review article on the topic.
Repeat (Reproduce knowledge).
Real learning only happens with repetition, so setting up a schedule to review your notes with progressively longer gaps between reviews is the secret to success. This is where Anki or other similar systems can really help.
An important note on question banks… You can’t learn medicine from UWorld. (Again, in bold for a reason.) BUT, question banks are an awesome way to confirm you’ve learned the important stuff – and to identify where there might be some gaps. So please use them as an adjunct to, but not core of your studies.
Explain (Reproduce knowledge).
A great way to make sure you have “metabolized” what you are trying to learn is to share it with others. This is where study groups come in. They take as many forms as there are students, but in general, the most effective groups work as “out loud” reviews of the topics after everyone has spent time reading, reviewing, and repeating.
Teach (Share knowledge)
Teaching in the basic sciences is not as easy as in the clinics (other than “teaching” each other in study groups). But having a goal to to teach makes you organize your material in a way that insures you really understand it.
Rotations, Residency, Fellowship, and Practice (Medicine taught in clinic and hospitals)
The same “basic science” style of learning continues in clinical training, but there won’t (usually) be hour-long lectures or assigned reading. Instead, you’ll be seeing patients, attending conferences, and, yes, you will still be taking tests (shelf exams, in training exams, board exams, maintenance of certification tests, etc).
We want to and need to stay current in our field… but how? Here’s the best way I’ve found to do it, a practice that will serve you from starting rotations in medical school until you retire:
Find the most current and thorough textbook for your specialty
Make an Excel spreadsheet of every section/chapter
Set a goal (and make a plan) to cover the entire book in a year (which will look something like covering 12 sections/ week with weeks off for vacation and holidays)
Repeat every year! (It gets progressively easier after the 1st year since you are editing or adding to your notes)
Here’s the good news… Most of the 12 sections for the week (or whatever it works out to be for your textbook) will be chosen based on the patients you are seeing (It makes it a lot more fun…). The bad news is that all textbooks have really boring sections that still need to be learned, so spread them out over the year to make sure you cover them (but not all at once).
Repeat (Reproduce knowledge). Teaching and explaining on rounds is a built in way to make sure you understand enough to explain it to others. (Plus you look really good). This is where one page summaries and/or mindmaps really help since they make it easy to remember (and teach).
(Share knowledge) In clinical medicine, there are many opportunities to share … rounding, informal teaching for medical students on our rotations, formal lectures, presentations at conferences, handouts, etc, etc. Take advantage of this unique form of “group studying”!
“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” William Osler
Every year every resident in the United States takes an exam (called the In-Service or In-Training exam) that covers all of their specialty. It’s meant to be a formative exam for residents and their programs, which means it’s supposed to let everyone know which areas need more focus. Unfortunately, because there are numbers associated with this test it has become a higher stress exam than it should be, especially for residents who are applying to competitive sub-specialties.
First a word to Program Directors. When you think about this test there are only three categories for the results
1) Possibly at risk to pass the boards (< 10th% ile?)
2) Going to do fine (11-79th %ile)
3) Extraordinary test takers who really know the info (>80%ile)
This is a comprehensive (and long) exam that often has a VERY narrow bell-shaped curve. What that means is an incorrect answer on 2 questions (some years) can drop a resident up to 10%ile points. Doesn’t it seem silly to think that 70th%ile is somehow “better” than 60th% or 50th%ile? (I’m looking at you, subspecialty PDs)
Now for my colleagues in training. You stressed about this exam, you “crammed” (yes, we all did it – even those of us who know it’s stupid) and now you are breathing a sigh of relief that it’s over…
Take a good break from studying. For the next two weeks, use all the time you would have been using to study to binge watch something on Netflix, read a few novels you’ve been meaning to read, or do whatever gives you rest and joy. Then….
Put this in perspective. At the end of your residency, you will be launched into the wonderful, scary, amazing world of practice. You want to know that you know enough to do this, right? So back away from the idea of the In-Service exam as a pain in the gluteus, and see if you can think about it as a formative exam. Which leads me to…
Learn About Deliberate Practice. The best way I’ve found to think about deliberate practice is to understand how musicians practice. I wish I could remember where I read this so I could properly attribute it (please let me know if you know!), but here’s the best example I’ve found to understand deliberate practice – Serious amateur musicians and professional musicians practice a similar amount of time… say 2 hours a day (for the sake of this discussion). But how they practice differs. The amateur will play the piece from beginning to end multiple times, occasionally stopping to repeat the stanza that trips them up. The professional will play it once or twice, spend an hour on a stanza that trips them up, then start over. That’s deliberate practice. Taking the things that are hard (or you don’t like) and repeating them until they aren’t hard.
So, putting this all together, here is what I suggest you do to get ready for the In-Training Exam:
Step 1: Make notes.
Take one of the major textbooks in your field and make a spreadsheet of every chapter, topic, and subtopic in the book. Your goal is to make notes on every topic in the book from March 1st to December 1st. Start with some simple math… March 1st to December 1st is 39 weeks, so take the total number of topics in your text book and divide by 39 to set your weekly goal.
But you won’t start with page 1 and work sequentially to page 846. (Yes, for those not in medicine, the books are usually that long). When you are on call, and you admit a patient with pneumonia, read the chapter about pneumonia and make notes to store in Google Drive? EverNote? OneNote? It doesn’t matter as long as they are in the cloud and searchable. If you hand write notes that’s ok, too, just use an app like Scannable to turn them into PDFs and store them on the web (don’t forget the keywords and/or tags so you can search for them when you are reviewing). What should the notes look like? You graduated from college and medical school, so I’m betting you have a system that works for you. But, if you’ve never heard of it, take a look at the SQ3R system for studying. (Spoiler, it really works.)
A few other words of advice. It is VERY helpful to link your notes to a specific patient. You’ll remember everything much better; I promise. So, mention the patient with COVID pneumonia who always wore their yellow baseball hat… but don’t put any PHI in your notes so you don’t get in HIPPA trouble. Also, don’t limit yourself to notes from the textbook. This system allows you to make and store notes when you read an article, learn a pearl on rounds, create a mind map, use questions banks, or do a presentation…
Step 2: Deliberate practice. There will be sections of your textbook that thrill you. Parasites? For some reason we are all fascinated by them. Coagulation cascade? Not so much. Recognize that it will always be easier to learn about parasites than the intrinsic and extrinsic pathways. (Unless you are going into blood banking, in which case I apologize). Which means you need to spend more time on the coagulation cascade. Darn. #DeliberatePractice
The fundamental thing that differentiates learning (for your patients) from memorizing (for the test) is repetition. Your goal is to see everything you need to learn at least 5 times, spaced over at least 3 months. If it’s a topic that is difficult for you, it will probably be more times over a longer period of time. #DeliberatePractice
One of the best ways to learn specific pieces of information you need to know (like the coagulation cascade) is to use an app like Anki or other flashcard apps. The advantage of these apps is they force you into spaced repetition (remember the minimum of 5 times over 3 months?), but if you are more comfortable with the old-fashioned (but effective) analogue system of actual flash cards, go for it!
But – write this down and put it over your desk – You can’t learn to practice medicine from Anki. You may be able to learn the coagulation cascade and the ratios for Massive Transfusion Protocols… but you won’t learn how to care for a patient who is bleeding out. That’s why you read and that’s why you are in residency.
Another great way to learn something is to teach it. Put together a brief presentation and handout for your medical students on the coagulation cascade… and make notes about their questions, who was there (maybe even a team photo?) before storing your handout with your other notes.
Step 3: Review. This system builds in review of everything you learned over the year (by reviewing it at least 5 times over at least 3 months, remember?) but for next year’s In-Training Exam, plan to take a full month before the exam to stop making notes. Spend this month before the exam to go through question banks, review your notes, and memorize the coagulation cascade. 🙂
