Studying In Medical School is Different!

Posted on September 5, 2023 by marylbrandt

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

References

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

6. Effect of uniform versus expanding retrieval practice on the recall of physiology information | Advances in Physiology Education. Accessed August 8, 2023. https://journals.physiology.org/doi/full/10.1152/advan.00090.2011?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org

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!

Study tips for first year medical students

It’s the first day of medical school… what should I do?

Learning medicine: #SmartNotes

Learning Medicine #SmartNotes

Posted on July 18, 2022 by marylbrandt

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?

Here’s how:

Step 1. Create a folder in Google Drive*

Step 2. Take notes. About everything.

Step 3. Put the notes in your digital folder, filed by date and time, identified by hashtags and keywords.

Step 4. Synthesize, summarize, and link.

Step 1: Create a folder in Google Drive*

Don’t panic. Yes… just one folder.

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.

Step 2: Take notes. About everything.

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!

Notes from Reading. Textbook chapters, articles, handouts…

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.

Step 3. Put the notes in your digital folder, filed by date and time, identified by hashtags and keywords.

File the notes by date and time + description e.g. 2022-07-18 1645 Creating a filing system for studying medicine.

Why?

Imagine… It’s the last year of your residency, it’s 2am, and you are admitting a patient with Hemophilia A who needs emergency surgery.

You open your phone, go to your folder and search for #Hemophilia… and you find these notes:

First year lecture on coagulation

Second year lecture on disorders of coagulation

Second year lecture on the pharmacology of factors given for the different types of hemophilia

Your summary notes on coagulation, coagulation disorders, and the meds used to treat them

Notes from a review article on caring for patients with hemophilia

Notes about that really cute 6 year old on your pediatric rotation who had hemarthrosis

Notes from Grand Rounds on your medicine rotation about disorders of coagulation

A lecture during your surgery rotation on pre-op preparation of patients with clotting disorders.

Notes from Sabiston’s Textbook of surgery on patients with Hemophilia

What you learned taking care of the diabetic hemophiliac who needed an amputation when you were an intern

Last years’ conference with the visiting professor who was an expert on Hemophilia B

Step 4. Synthesize, summarize, and link.

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).

This post represents a modification of the amazing Smart Notes system described by Sönke Ahrens in his book How to Take Smart Notes: One Simple Technique to Boost Writing, Learning and Thinking. I highly recommend it, especially if you are considering an academic career!

Other things I’ve written about studying in medical school and residency:

Studying for the In-Training Exam 2022-01-30

Study Tips for First Year Medical Students 2018-08-11

How to Succeed in Clinical Rotations (and residency, too) 2018-01-09

Top Ten Tips on Starting Medical School 2022-06-18

How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards 2017-04-14

Studying for the In-Training Exam

Posted on January 30, 2021 by marylbrandt

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 (< 10^th% ile?)

2) Going to do fine (11-79^th %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 70^th%ile is somehow “better” than 60^th% 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 1^st to December 1^st. 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.