Medical training is based on active learning – studying textbooks and articles, listening to experts, seeing patients, setting up procedures and then performing them, reading images, looking at slides. This kind of learning is straightforward – You do the task, get feedback (in a variety of ways), and then adjust to improve.
I’ve never really thought about passive learning in medicine … until I learned about this recent study from the Institute of Neuroscience at the University of Oregon that clearly showed that passive exposure improves active learning (at least in mice).
Based on my experience as a medical educator, that rings true for medical students and residents, too. Watching experts do a procedure over and over won’t ever replace learning to do the same procedure – but it does seem to be a habit embraced by superstar medical students and residents (in addition to their deliberate and very active learning).
“The core insight here is appealing precisely because it’s so easy to act on. Passive exposure costs almost nothing. No extra willpower, no additional scheduled practice time, no special equipment. You just need to put yourself in contact with the material you’re learning.”
How can you add a little passive learning to your day (in addition to rereading and highlighting notes or listening to a recorded lecture)?
Just listen. The ideal way to take advantage of the didactic courses in the first two years of medical school (and subsequently in clinical rotations and residency) is to engage actively with the material during the lecture. (Yes, I’m serious… and here is how to do it). But if you find yourself unable to really engage it turns out that “just listening” (i.e. being a passive learner) isn’t a complete waste of time. You can also attend departmental Grand Rounds or other interesting lectures as a first year medical student (Most of them are before your classes start or during lunch). You won’t understand much… until you do (which is always exciting!) . You can find a list of these lectures on every hospital and medical school website (Here’s an example from Baylor College of Medicine). These are public lectures so you won’t be out of place. If anything, they will be delighted there are basic science students interested enough to attend. (p.s. there is often food, too…)
Just watch. “Shadow” in the first two years of medical school…ask senior students or residents (who will ask their attendings) if you can watch surgery, follow someone in clinic, or go on rounds with a team. When you are on a rotation, “just watch” surgeries that you aren’t assigned to (which is a lot easier in minimally invasive procedures because you can watch it on a screen). The same goes for “just watching” a pathologist looking at slides, or a radiologist reading images, etc. You can also take advantage of YouTube to “just watch” videos of procedures, how to do a physical exam, etc, etc.
Passive exposure will never replace active learning (a really important point!) but just watching and just listening aren’t a waste of time… and may help make active learning a bit easier.
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
The definition of “knowledge” in English is pretty straightforward – To “know” something means being familiar and/or aware of it in a way that lets us understand. I find it fascinating that English has only one word for “knowledge”, where other languages use multiple words to reflect the depth and nuances of the concept. “Once widespread in Germanic, the verb [to know] is now retained there only in English, where it has widespread application, covering meanings that require two or more verbs in other languages (such as German wissen, kennen, erkennen and in part können; French connaître “perceive, understand, recognize,” savoir “have a knowledge of, know how;” etymonoline
How we understand “knowledge” affects how we teach, how we learn, and how we see the world.
The philosophers of Ancient Greece saw acquiring knowledge as an important part of the human quest for wisdom. Enter episteme, techne, phronesis, gnosis, and doxa. These nuanced ways to think about knowledge and wisdom have a lot to offer us as we navigate the misinformation and philosophical chaos of our time. For those in medicine, these nuanced definitions add beautiful complexity and understanding to our work, with special inspiration for those who teach the healing arts.
Techne refers to the technical skills of a profession – the grasp of grammar for a writer, pedagogical skills for a teacher, the ability to perform specific procedures for a surgeon.
I recently read this remarkable essay by Sami Sinada in which he states: “Medical school teaches episteme. Residency builds techne. But phronesis? We assume it appears through osmosis. It doesn’t.”
The entire essay is well worth your time to read, but Dr. Sinada makes an important point – Our medical school and residency curricula have gaps when it comes to teaching practical wisdom (which is the core of doctoring). He goes on to argue that we can close that gap with five important pedagogical choices:
What strikes me about doxa is that it has no moral weight associated with it. Doxa can refer to the deep orthodoxy of thousands of years of tradition in a culture … everything from how we greet each other to what we believe… as well as culturally accepted, politically motivated lies.
Gnosis is most often associated with gnosticism, a religious and philosophical movement in the 2nd century. But I wonder if the concept of a deep inner knowing (whether or not you view that as divine) isn’t worth refurbishing for our time as an important way to “know”. Contemplation, meditation, prayer can all open spaces that defy our intellectual understanding, leading to a way of “knowing” that, in some ways, we need now more than ever.
This week I told three separate friends about using their phones to create usable text from notes … and all three were astonished and then grateful. I’m sharing this in case this is something you need, too!
Hold the camera (like you are getting ready to take a photo) above any printed or handwritten text (notebook, article, book, screen etc) until you see yellow “corners” appear. In this example I’m using my phone’s camera to look at this CNBC post: Apple’s latest iPhone update lets you copy and paste text from photos — here’s how on my computer screen… which is a little meta.
Next step (after the corners appear) is to touch the icon in the lower right screen (the one with four corners and three lines), which starts the process of choosing your text.
Screenshot
You can use “copy all” or highlight the text you want to save.
You can do this “live” (like in my example) or from a photo you’ve taken and saved.
You’ve copied it to a clipboard on your phone. Open Notes, Google drive, Word… whatever you use on your phone and paste!
I often stumble onto ideas related to a project I’m working on (intentionally or by serendipity)… Other times I’m reading something and a really new idea pops into my head which could be a seed for a future project. You know as well as I that if we don’t jot down at least a couple of words those ideas are usually lost. To keep those notes from being lost in piles on our desks (or in our computers) it’s helpful to have a system.
Today I discovered a blog post called “On Rooted Productivity” and, since I’m working on a presentation on how to use a specific note taking system to increase productivity for a group of philosophers and ethicists, I knew this source might be helpful.
So, I decided to write this post on how I take a new idea and put it into a Zettelkasten AKA “slip card” system AKA “smart note” system for current and/or future projects.
Because I know a) I’m interested in this idea and b) therefore, I may use it in the future, I know I’ll need to be able to find the reference easily.
The first thing I do is create a reference in Zotero (which is an amazing, free reference manager. For articles and chapters that are in digital form, I make sure they are attached to the reference as a PDF (this is automatic most of the time in Zotero, but do it manually if Zotero doesn’t do it for you)
Step 2. Create the note.
There is a lot written about the Zettelkasten system, and I encourage you to read more about it from the many sources available (There’s a list of references at the end of the embedded presentation at the bottom of this post)
Here are a few core concepts about this system that are important:
You are making a “card” (if you have a physical system) or a Google doc (in my system) that is an “atomic” idea. It’s a single idea, one intellectual “lego brick”… that can be combined with or used to reflect on other ideas.
It is NOT just a bullet list or quotes from what you read. You need to take the idea and then describe – in your own words – why it’s important to you and where it led you in your thinking. The goal here is that you are creating the rough draft of a sentence or paragraph that can be copied and pasted into a future manuscript.
As a technical note… I start by putting a horizontal line in the document. Everything above it is my writing, everything below it is directly from the source or sources I’m using.
Step 3. Put it next to the card/Google document that is most like it.
This is the heart of this system. Unlike a filing system, the idea here is to find the single idea already in your system most “related” to your new idea. Which leads to some important questions…
What if there isn’t an obvious choice for the note “most like it” or, because you are just starting out, there are only a few (unrelated) notes in your file?
I have a really broad interests and I love how they often are connected in ways I don’t expect. When I started this process I realized I’d have to create a system for later notes.
There are many different ways to approach how to number your cards so they will be next to the card most like them. For more info, check out this post by Chris Aldrich)
I came up with a system that works for me by using Wikipedia’s Outline of Academic Disciplines. I created a spreadsheet to organize a 4 digit numbering system for those “first” notes.
Importantly, though, I only use this system if I’m not able to easily find a related note already in my file. Which leads to the next obvious question…
How do you find the note “most like” the note you are working on?
I start by using a set of keywords to search my notes, looking for the one that is most related.
If that fails, I find the topic that is closest to the note in my spreadsheet and create that “first” note.
For example, I used “productivity” and “meaningful work” as keywords to search for the note most like my note on “rooted productivity”.
After this search, the note I thought was most like it was this one…
To make sure these two notes end up next to each other, I changed the name of the note on Rooted Productivity to 2754/1a Rooted Productivity so it would be “filed” next to 2754/1 Meaningful work vs. productivity
Step 4. Create links between your new note and other notes in your drive.
This is not about “related” like the first connection you made. This step is about creative thinking and links that will lead you to connections that are not obvious.
(BTW… Make sure when you put the link in your new note that you make it a two way link. In other words, put links in both notes.)
Step 5. This is where it matters… using this system as a thinking and writing partner
I suspect you can see how this process helps with creative thinking, but this this quote from Soren Ahrens will help if you are confused: “Go through the notes you made …(ideally once a day and before you forget what you meant) and think about how they relate to what is relevant for your own research, thinking or interests. This can soon be done by looking into the slip-box – it only contains what interests you anyway. The idea is not to collect, but to develop ideas, arguments and discussions. Does the new information contradict, correct, support or add to what you already have (in the slip-box or on your mind)? Can you combine ideas to generate something new? What questions are triggered by them?” (Ahrens, 2017)
As for writing… I suspect you have a good idea how this system could help, but start by using it to link ideas and explore things that are important to you. When you get ready to write, I recommend one of these two books to help!
I don’t know many other professions that organize their teaching the way we do in medicine. In medical school, we start off with 18-24 months in a classroom and then send our students out on “rotations”, a month or so at a time in different medical specialties. The number of months (and years) is different, but the concept is the same for all professional medical training. In some ways it’s an old-fashioned apprenticeship – with all the good and bad parts that come with that kind of learning.
No matter how easy or hard your rotations might be, here are four important strategies to help you learn more and enjoy the process while you do it:
1. Be mindful, deliberate and excited about learning.
This is probably the most important piece of advice I can give. Clinical rotations are often a whirlwind of work and you can be swept away without realizing it. Residents can ignore you, people can be cranky, patients can be difficult… and in the midst of all this, you are expected to learn to be a doctor. You have to stay in charge of that mission, no matter what is happening around you.
Take a little time to reflect on why you are doing this and what kind of person/doctor you want to become. When times get tough (and they will) hold on to it. If it helps you, come up with a slogan to repeat. If needed, write it on a piece of paper to keep in your wallet or on your wrist.
Learn to practice mindfulness. Mindfulness will keep you grounded and decrease your (normal) anxiety. Mindfulness is not hard to learn, but it’s hard to master … which is the point of a “practice”. (e.g. the practice of medicine)
Learn to keep “beginner’s mind” (and write about it). The very first time you walk into an operating room it will seem like (almost) magic. It’s astounding, right? We have drugs to induce a painfree unconscious state… there are instruments that can delicately dissect out a nerve… I could go on, but you get the picture. When it’s new, it’s astounding. That sense of discovery can be nurtured even for things that have become more routine. This is a practice (yes, you have to practice this, too!) which will add joy to your learning… which, by the way, means you’ll learn more!
Get an app like Day One, a highly rated app for journaling. Use it for a brief notes to record “firsts” (first drainage of an abscess, first time you see a rare anomaly, etc). Take photos (HIPAA compliant!) to remember the places and events of your day. List at least one thing a day that delights you. (Trust me on this one… it helps!)
2. Understand what you are going to learn (the big picture)
On every rotation, you will be given a list of learning objectives. By all means, study the things listed and make sure you know them (they will be on the test). BUT… please realize that diseases don’t stay conveniently siloed in a single specialty so this is not learning “surgery”, it’s learning about how surgeons approach a specific disease you will see elsewhere, too. You also need to know that what is listed as learning objectives today may well be obsolete tomorrow (if they aren’t already).
You have chosen a career that ethically demands life-long learning. That means that one of the most important skills to learn is how to develop a system of learning that you can use in medical school, residency and later in practice.
Learning is iterative. You will learn broad concepts on each rotation along with a “fly over” of the entire terrain of the specialty You will need the information you learn on your surgery rotation on your medicine rotation when you are consulted on a patient with an ischemic leg who needs surgical treatment, or on your pediatrics rotation when your patient with a pneumonia develops an empyema. If you choose surgery at your career, you will read and learn the same topics throughout your residency (and after) but with increasing depth.
Pay attention to ergonomics, diet, exercise and sleep. Most importantly, take care of yourself emotionally and spiritually. You can’t learn or serve others if your tank is empty. Be intentional with this, too. If it helps, make a list every day of things you’ll plan to do, things that help you thrive. Review it before you go to bed. Celebrate the things you did and don’t be hard on yourself for the ones you didn’t get to.
If it gets too hard, seek help. It’s a sign of strength, not weakness, and most (if not all) of your fellow students, residents, and attendings have been there.
Being someone who goes to work every day to learn how to heal other people is one of the most amazing jobs on earth. When the administrative issues or political conflicts get to you (and they will), just remember – you are learning to take care of another human life with the goal of relieving their suffering. What could be more important than that?
It’s the beginning of the academic year in medical schools around the world, and that means there are thousands of students who feel they are suddenly being asked to drink from a fire hydrant. The information you are asked to learn in medical school is different in two really big ways – It’s voluminous and (unlike in undergraduate education) all of it is relevant (albeit to different degrees) to what you will be doing the rest of your life. Learning how to make the transition to this new kind of studying is one of the biggest tasks a new medical student has to accomplish.
The following is a guest post from Preston Tsang, a medical student at Tulane University School of Medicine. The main take home message?
You have to study how to study if you are going to succeed in medical school!
All of us arrive to medical school with a successful strategy for studying… which we then have to seriously revise. The incredible volume of material means you either rethink how to study, learn, and recall info from the beginning… or you are forced to do so when you stumble – after realizing the way you studied in college won’t cut it in medical school.
Every medical student quickly learns that standardized exams are a necessary objective measurement of how “well” you do in school … especially the mammoth exam called STEP 1. This exam (as you might guess) is the first of three “steps” to getting a license to practice medicine. But Step 1 in particular (and now Step 2) are also an important way residency programs assess the academic standing of students applying to their programs. #Pressure
Just like college, you need to study to pass the exams in each of your courses, but unlike college you need to prepare for Step 1 (which means everything you learn in basic sciences!). And BTW you also need to remember that you are not just studying to pass an exam or ace the Step exams. Learning (not just memorizing) this information is essential to being a good physician.
So how best approach this overwhelming task? Only one way – You need to study how to study if you want to succeed in medical school. Make some notes as you study how to study, create your own way… but to get you started, here are the key points I learned as I’ve gone through this process.
It’s all about active learning. Gone are the days of cramming, or just reading something three times to learn it. It’s all about active learning, and – fortunately – there are a lot of people who study this and have come up with methods to promote active learning. All of them involve taking notes to synthesize (not just list) the material and interacting with the material.1,2
Studying in groups helps! Asking each other questions and having to “teach” each other is a great example of active learning.1 Studies have shown being quizzed about material is superior to traditional learning and basically halves the time it takes to learn the material.5
Take notes, but not too many. Notes are key, but should reflect your synthesis of the information, not every detail. There are lots of studies (and stories) about people who spend hours and hours creating spectacular notes and then don’t have time to review them. Guess what… they don’t do that well.1 There’s lots of literature on note taking, with many different strategies. Add this to your “studying how to study” list!
Review, review, review. It seems obvious, but you don’t learn something on the first pass. There is science here, too! It’s takes 5-7 repetitions, spaced further and further apart, to really learn something. It doesn’t work as well if you review something 5 days in a row… it should be almost a logarithmic spacing to get best results.3,4,6
Flash cards (e.g. Anki) work great for details. Once you have the big picture summarized, go back and look for details that you need to know. Anki (and other similar apps) build in spaced repetition – they have you repeat things you don’t know well until you know them. Using this technique (i.e. using Anki) to learn a subject versus reviewing the material multiple times (i.e. re-reading notes) has been shown to improve learning.4
To enhance Anki flashcard learning even further, I discovered that there are certain structures to flashcards that make them more effective. In one study 80 students were randomized into two groups. One group used flash cards designed as a test (testcard) while the other half was randomized into flash cards using the more typical “studycard” format (see below). The group using the testcard format retained more of the information when tested. 7
UWorld has its place, but it’s not what you think. Despite what every upperclassman will tell you, your professors are right – you can’t learn medicine from multiple choice questions alone. But… once you have the concepts down, testing yourself and learning why you were right or wrong is a great form of active learning. More importantly, study questions are a great way to review (once you think you’ve learned the information) to find where you have gaps.
Don’t underestimate the power of mnemonics 2. Make them up and make them something you can’t repeat in public (a known strategy for successful mnemonics). Ask older students, residents, and even attendings for theirs.
So here is how to succeed at Step 1, based on what I’ve learned. When tackling a standardized exam with a vast amount of material, studies have proved the effectiveness of retesting, spaced repetition, and active learning. Start off with a solid base by learning initially from the notes you make in class and from class readings. Then, instead of just rereading the information, distill it down into summaries, draw diagrams, and create your own questions. On top of this find ways to promote active learning and retesting as you study like using practice questions or reviewing your Anki cards. This system of learning may not be best for every learner, but is a good place to start. Add to it with your own research into study techniques.
p.s. Don’t forget to build in (and schedule) time for self-care and sleep.1
1. Dattathreya P, Shillingford S. Identifying the Ineffective Study Strategies of First Year Medical School Students. MedSciEduc. 2017;27(2):295-307. doi:10.1007/s40670-017-0396-2
2. Roffler M, Sheehy R. Self-reported Learning and Study Strategies in First and Second Year Medical Students. MedSciEduc. 2022;32(2):329-335. doi:10.1007/s40670-022-01533-w
3. Ericsson KA, Chase WG, Faloon S. Acquisition of a Memory Skill. Science. 1980;208(4448):1181-1182. doi:10.1126/science.7375930
4. Larsen DP, Butler AC, Roediger HL. Repeated testing improves long-term retention relative to repeated study: a randomised controlled trial. Med Educ. 2009;43(12):1174-1181. doi:10.1111/j.1365-2923.2009.03518.x
5. Morris PE, Fritz CO, Jackson L, Nichol E, Roberts E. Strategies for learning proper names: expanding retrieval practice, meaning and imagery. Applied Cognitive Psychology. 2005;19(6):779-798. doi:10.1002/acp.1115
7. Schmidmaier R, Ebersbach R, Schiller M, Hege I, Holzer M, Fischer MR. Using electronic flashcards to promote learning in medical students: retesting versus restudying. Medical Education. 2011;45(11):1101-1110. doi:10.1111/j.1365-2923.2011.04043.x
And a few more things to help you on this journey!
What if I told you there’s a system that makes it easy to remember the things that you need to remember for exams, but also creates links that make it easy to study and understand the network of knowledge that you really need to learn to heal?
And what if you could start using this system beginning on the first day of medical school…or at the beginning of your PGY2 year… or wherever you are on this journey now?
Mine is labeled “card file”. You can always rename it. Maybe start with “My digital brain”?
If you just can’t stand it, you can create sub folders based on an anatomic filing system (e.g. Appendix, Colon, Heart, etc) but trust me – no sub-sub folders!
*I like Google Drive because it’s very flexible and you can access it from any computer and your phone. There are other ways to store digital data that can work as well, like Evernote, OneNote, etc.
Keep a notebook in your pocket, use paper out of the printer, use a white board, or dictate directly into Google drive… but just take notes!
This practice is a leap for most of us, but it not only leads to phenomenal learning, it fundamentally transforms how you interact with your day. There is power in a practice that makes you more present in your day. Every encounter, every lecture, every article you read becomes a potential adventure, a source for new insight and growth.
There are only two rules
Rule 1: One concept per note.
Rule 2: Write the note only one time – don’t rewrite or retype notes. (If its’ a paper note, take a photo, or create a pdf to file in your google drive.)
What kind of notes will go into this system?
Lectures. You know how to do this from other classes! Just because we call it “Grand Rounds” or “Path-Rad conference” doesn’t mean it’s not a class. Take notes!
SOP (Standard Operating Procedure). This one is key if you are in a procedural specialty. Keep a single “note” for each procedure and update it with new information as you scrub with new attendings. Put in links to good videos, photos from textbooks and anatomy books. Anything that will help you review what you know and have learned before you do the procedure again.
Milestones. The first time you….listened to a murmur, talked to a patient about their prognosis, did a Whipple.
Questions, thoughts… “Why isn’t there a way to diagnose malrotation that needs surgery (vs.nonrotation) with diagnostic imaging?”
What you learned from patients. Make it your goal to learn something from every patient you take care of. Write it down. Make sure it’s HIPAA compliant – no patient identifiers that someone else could decipher.
Sounds. Yes, you can digitally store recordings!
Summary Notes. One page summaries of complex ideas
Unanswered questions. Ideas for possible publications, future investigations, etc.
There are so many details in medicine that we often lose track of the big picture. That takes thinking, creating one page summaries of complex topics, and noticing connections.
Maybe it would be easier to show you rather than tell you. Let’s say you are in a lecture about how to read a chest x-ray. In your notebook (or on your computer) you are taking notes… lots of notes… how to tell what’s a pneumonia vs atelectasis, what different lung tumors look like, how to tell if the mediastinum is too wide. As a result, 2 years from now when you see a patient with a lung mass, you will be able to search your drive for “lung cancer” and these specific notes will come up.
But as you sit and think about this lecture, you’ll realize that in addition to the details, there were more general concepts that were important, too. For example, how important it is to systematically review every diagnostic image so you don’t miss the lytic lesion in the bone that was behind the big mass in the chest. (Link to my favorite study describing how this happens)
So you create a digital note that describes, in your words, how important it is to have a system to look at images. Which makes you remember that this is very similar to how we always follow a system to do a history and physical. So you search in your drive for the card you made about how to do an H&P and you link them, using the “insert link” command. And, as you look at your H&P card, you notice that you had already linked it to cards you made about Basic Life Support (BLS) and ACLS (Advanced Cardiac Life Support), two certificates you were required to obtain, both based on a system to not miss important steps in resuscitating patients. And suddenly you are interested in why systems like this make it so much easier, so you do a quick search and find a fascinating article on memory and learning (as opposed to memorizing).
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. 🙂
Yesterday was my first embryology lecture of the year to the new MS1s at Baylor College of Medicine, as well as the PA, DNP and Genetic Counseling students. For years, I’ve been including a few slides at the end of each lecture to help with the transition to medical school. Yesterday’s lecture ended with tips on how to study. I promised the students I’d share these slides in a written formate. I realized sharing them here might be the most appropriate way to do that!
Medical school (or any high volume graduate school) involves a dramatic change from what students have previously experienced. As you know, if you read this blog, I believe there are a lot of “tools” that can help students “thrive, not just survive”
The biggest change for many students is it really isn’t about the grades anymore. It’s about studying for the patients you will be caring for in the future. That means really learning the material, not just knowing it for a test.
Even though there is still a lot unknown about how the brain works to learn material, what is certain is that it is a physical process. You create new synapses when you experience or learn new things. As they are repeated, these synapses get stronger and stronger.
So, to organize the advice, I’ll share some basics, some specifics and then a little refinement.
Learning this volume of material at this level of complexity is about consistency. You can’t run a marathon by running 20 miles every weekend. This is no different. You need to study every day (except one). One of our great teachers at Baylor, Dr. Clay Goodman, tells our students that they have signed on for a 60 hour a week job. (which roughly means 1-2 hours of studying for every hour in the classroom). If you map out your week as a 60 hour job, it will work a lot better than ever trying to “catch up.”
The SQ3R system is the best system I know to learn what you need to know during the basic sciences. So, how do you translate the SQ3R system into practice?
The night before lectures, spend 30-40 minutes skimming the lectures. No “studying”. Be curious. What questions are going to be answered during the lecture? How is it organized? (BTW “Mike” is a fictitious patient with muscular dystrophy that Dr. Goodman uses in an introductory lecture to show how everything you learn in medical school matters – from the DNA to the psychosocial context of the family)
This 30-40 minutes is basically the “S” and “Q” of the SQR3 system.
SURVEY to get the big picture
QUESTION = what questions are going to be answered during the lecture? What else do you want to know to really understand this? (write them down!). Do not try to look up anything now.
During the lecture stay ACTIVE. Don’t sit in the back row and look at FaceBook – even if the professor is reading the slides.* You’ll need to take notes for this to be really active. Put the questions you want answered on an outline you prepare the night before lecture and fill it in during the lecture. Use mind maps or other powerful visual aids to learn. Click here to get to my post on taking notes during basic sciences.
*(If you are a lecturer who does this, stop it! – otherwise you are guilty of “death by PowerPoint.” Find someone who is a good lecturer and ask them to coach you.)
After the lecture, you move on to the 3Rs. Now you get down to the real studying. Read through the printed notes (or slides). Did everything get answered? MAKE NOTES that synthesize what you learned.
Review. Review. Review. Here’s the deal. Medical school is a lot like learning a new language. The first part of basic sciences (anatomy, physiology, embryology, etc) is learning the vocabulary. The second part of basic sciences (diseases, pharmacology, etc) is learning the grammar. When you get to the clinics, you are practicing the language until you are fluent. “Flash cards” such as Anki are great at learning “vocabulary”. They are terrible at synthesizing and learning connections and concepts. That’s why you need a single page summary of every lecture. The summary is the “forest”, your notes (plus or minus flash cards) are the “trees”. If you really want to succeed, you need both. BTW, I made the class repeat (out loud) after me (twice) – “You cannot learn medicine from Anki alone.” (It’s on tape. I really did this.)
Here’s an example of a single page summary of the embryology lecture I gave the class yesterday. I spent time to make this really look nice – more time than you will want to spend. It doesn’t need to be typed, it doesn’t need to be particularly legible to anyone but you, but take the time to do these summaries!
Did I already mention that you need to review?
This is probably the single most important slide I show when explaining how to best study in medical school. It’s the basis of many apps in medical learning, including the NEJM Knowledge+ courses. There are two really important points in this graph. First, it takes at least 5 repetitions to really learn something. Second, they have to be spread out in a logarithmic fashion over time.
Here’s how to do it. The first three repetitions should be same day, next day and 2-3 days later. The more times you review it, the better, but it should at least be 1 week later and 3 weeks later. More is better. Plan another review a month later and three months later, too. For the Type A folks in medical school (i.e. all of you), make a spread sheet!
Another thing about our brains and learning. Pushing through for hours without rest is as stupid as thinking you can build up your biceps by doing an hour of uninterrupted reps. Speaking of reps… use “study reps”. Get an app if you think it will help. 50 minutes of studying.
Stop studying for 10 minutes (no matter how engrossed you are) when the alarm goes. Repeat.
People sitting next to you in your study areas are going to look like they have it more together than you do. It might be true… but it probably isn’t. If someone has a study technique that looks like it will work for you, by all means try it! Just don’t change too often. I was a liberal arts major in college. If you come from a non-science background, the first 6 months are going to be a little tougher on you because you have more “vocabulary” to learn but don’t worry, after that you’ll be caught up,
Read this slide. Believe this slide. The most important point on this slide is the last line. You cannot make those physical synapses you need to really learn without 8 hours of sleep.
Keep notes about what works for you and what doesn’t. Everyone is a little different, but you will find a system that works best for you through conscious effort.
It’s like running. Some of this is just “time on feet”. Remember the 60 hours a week job concept and you’ll do fine.
I end with this slide to remind my students that there has to be balance for this to work. Most of what I tell my students about finding and keeping that balance is in this blog, so feel free to use the word cloud to the right or search for what you might need. Please contact me if you have a specific question I can answer or if you have an idea for a new blog post.
Welcome to the best career in the world! We are all happy you are here!
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