The amount of information that must be learned in medical school is so much larger than in college that new study techniques may be required.
You didn't get into medical school by accident. If you’re here, it’s because you worked hard and dedicated your college years to study and discipline. But unfortunately (or fortunately, depending on how you look at it), being a medical student is very different from being an undergraduate student. The skills that got you to where you are now may not be the ones you need to succeed in this new stage of your life.
For example, like most students, you probably crammed the night before an exam, and you probably did well.
Unfortunately, cramming isn’t going to help you much in medical school. First, the volume of information that you need to take in and memorize in medical school is much greater than in college. Some students compare the flow of information coming at them to drinking out of a fire hose. To succeed, you’ll need not only more time but also better time management. Second, unlike college, where you often don't need to remember anything after the exam, the content in medical school is cumulative, that is, the information you learned in your first year remains relevant months and even years later. Third, not only do you need to remember the information, but you also need to constantly update it as new research (which you’ll also be expected to keep up with) makes some of the things you learned more relevant and makes others out of date.
Finally, the stakes in medical school are so much higher. Forgetting a critical piece of information won’t just result in a lower test score, it can seriously harm your patients.
There are 3 problems students face when trying to master large amounts of information:
- Rapid forgetting
- Passive studying
- Reversion to past behaviors
Thankfully, decades of evidence-based research has shown ways you can alter your behavior to avoid these problems and increase the likelihood you’ll remember and recall important information. We’ll highlight 5 of the most effective, neuroscience-backed study techniques (and the science behind them) that every clinical student should know:
- Spaced repetition
- Interleaved practice
- Testing effect
- Memory palace
- Fogg behavior model
Problem: Rapid Forgetting
- The large amount of information taught in medical school lends itself to rapid forgetting.
Solution: To combat the natural forgetting curve, apply strategies such as:
- Spaced repetition
- Interleaved practice
In a series of experiments in the 1880s, German psychologist Hermann Ebbinghaus found that if you plot retention, or how much you remember about a topic, vs. how much time has elapsed since studying it, it forms an exponential decay curve. So, if you learn something on day 0, and don’t review, your retention follows a “forgetting curve” similar to that shown in the figure below.
However, if you review (or better yet, actively retrieve) the material at increasingly spaced intervals after learning it, then the forgetting curve starts to flatten out, and you’ll experience much better longer-term retention. Thus, reviewing the material just once before an exam is not enough. To really learn it, you have to space out your learning and practice, which is a strategy known as spaced repetition.
You can also use interleaved practice, which is also called
- Varied practice
- Variable practice
- Mixed practice
This strategy involves mixing up the information you’re being tested on instead of breaking that information into chunks.
Together with spaced repetition, interleaved practice can lead to the most successful learning outcomes. These techniques fall under what UCLA psychology researcher Robert Bjork and his colleagues call "desirable difficulties," which are counter-intuitive strategies that may reduce short-term performance but improve long-term performance.
Spaced repetition is not only about revisiting the material more often, but also about reviewing it at the right time. It turns out that
- The best time to revisit information that you’re trying to learn is right around the time when you’d naturally forget it.
Because forgetting typically follows an exponential curve, the trick is to time your study sessions around the curve and revisit key points of information right when they’re about to fade from memory. The key concept is spacing your studying and self-testing over time, as opposed to massing, or "cramming," because this spacing helps to flatten your forgetting curve so you retain information longer.
Since your familiarity with different subjects can vary greatly, different bits of information have different forgetting curves. Studies show that you should have the following:
- For familiar material: More widely spaced intervals between study sessions
- For less familiar material: Shorter intervals between study sessions
While this strategy is effective for all fields of study, it’s especially important for students in the medical field, who have to retain key knowledge and skills in order to care for their patients. One study found that without spaced repetition, medical students forgot up to 33% of their basic science knowledge after one year, and more than 50% after 2 years. But when students and residents applied spaced repetition strategies in their studying, they significantly outperformed their counterparts, with some studies showing close to 40% greater learning retention.
Knowing all of this, why does cramming persist as a popular behavior? The truth is that cramming is often effective in the short term. Pulling an all-nighter can certainly help you pass tomorrow's exam, but 1 month later, you’ll have forgotten much of that information. Since you'll likely need that information for the rest of your career, it’s a good idea to space out your study sessions. And it's also important to note that spaced repetition doesn’t help just with knowledge retention; it also helps with skill retention, whether placing an IV or doing a lumbar puncture.
Applying spaced repetition is not always simple. Students—especially those in the health and medical fields—have to remember thousands of bits of knowledge. It can be incredibly hard to keep track of when it’s time to revisit each piece of information, especially since each bit of information follows its own forgetting curve. This is why researchers and software developers have created computer algorithms to help students optimize their studying.
These algorithms prioritize your studying based on what you do and don't recall. That is, if you get a question wrong, the algorithm automatically prioritizes that information for repetition and de-emphasizes the information in questions you answered correctly. Thus, these algorithms can actually reduce your overall study time by making sure you’re not wasting time studying information that you already reliably recall.
One of the best things about spaced repetition is that you gain a lot by studying smarter, not necessarily longer. With just a little more organization and forethought, you can achieve a whole lot more. However, spaced repetition may feel unnatural at first. You're not used to studying something that you feel is still sort of fresh in your memory. Also, when you take time to study something you learned just a few days ago, you might be concerned that you should be using that time to study something you learned today. But spaced repetition will leave you better off in the long run.
Let's say that you want to learn concepts A, B, and C.
The traditional model has you master each in turn through massed practice (block practice) which looks like this:
On the surface, this strategy makes sense. You practice a skill until you achieve proficiency and then (and only then) do you move on to the next one. However, this strategy often falls short:
- Topics rarely build on each other directly (that is, you can't learn B until you've mastered A).
- Learning new topics can help reinforce others.
That’s what interleaving does: it allows you to work on multiple skills at the same time by alternating between them, which looks like this:
Interleaving helps you figure out how concepts overlap and differ, which increases your retention overall. Interleaving also makes you do spaced repetition.
So, when you learn about the various diuretics, do not practice all the thiazides followed by all the loops; instead, interleave them, and mix up how you learn things!
Problem: Passive Studying
- Passive studying doesn’t lead to information retention.
Solution: Apply active learning techniques and memory association strategies such as:
- Testing effect
- Memory palace
Let’s say you have a big exam coming up and you need to review the material—what would be the best way for you to study? You might think that you should re-read the textbook or look over your notes, but as it turns out, one of the most effective ways to learn information is by studying actively, by testing yourself on the material, instead of passively. In other words, the mere act of answering questions will strengthen your memory. This phenomenon is called the testing effect or sometimes test-enhanced learning or retrieval practice.
Having said that, you can learn actively even while you read, as long as you make the effort to attach the information you’re reading to content that you already know. Studies show that the more associations you can draw between whatever you're trying to learn, the more likely you are to remember it in the future because there are more paths you can take to retrieve that information. One of the most successful memory association techniques you can use is called a memory palace, where you imagine a physical location (the palace) in which you place things that will help you remember more abstract information.
Having taken dozens of high-stakes tests, ranging from class finals to the MCAT, SAT, and ACT, you've probably come to associate tests with the end of a learning experience, rather than as part of it. But the truth is that low-stakes formative testing can play an integral role in the learning process. This phenomenon happens for a number of reasons. One is that
- Active learning is better than passive learning.
When you read a textbook chapter or re-read your notes, you're engaging with the material in a relatively passive way. We like to think that we’re information sponges—that we absorb knowledge as it passes across our eyes—but it turns out that real learning happens when we activelyengage with the material, like when we think about how it relates to other material we have learned or are learning.
Actively thinking about the material increases the likelihood that you'll recall the information when you need it later on, like during an exam. So active retrieval of information through testing strengthens the underlying knowledge. In other words, testing actually improves knowledge retention compared to less active forms of studying, such as rereading information or rewatching lectures.
In fact, the more actively you engage with the material, the better. Research has shown that you should take the time to test yourself in ways that force you to struggle with the material, rather than just focusing on plain recall. The benefits of testing are greatest when the questions are complex and you really need to push yourself to come up with the answer.
Another reason that testing is so effective has to do with the dynamics of recalling. In order to answer a question on a test, you have to search through your memory and retrieve the answer, right? Well, it turns out that—at least in one respect—your memory is more of a muscle than a filing cabinet.
When you first rode a bike, you probably fell over a lot, and your movements were rough and wobbly, but with practice, those movements became easier and smoother. Think of memory as working in the same way:
- The more you practice testing yourself and recalling the information, the easier it’ll be for you to recall it again later.
For example, one study compared medical residents who tested themselves vs. those who simply restudied information about two diseases. Every 2 weeks, one group did practice tests, while the other group simply re-read the information. Six months after they originally learned the material, those who had taken practice tests scored 13% higher than their counterparts, showing greater long-term retention.
Applying the testing effect
You can tap into this phenomenon by using any strategy that forces you to actively engage with the material, such as:
- Making flashcards
- Taking notes that put the information you need to learn in your own words
Studies show the testing effect is most effective when it takes place right after you first learned the material—so don’t wait! You should also make sure to complete any practice tests your professor gives you. If they don’t make any available, find some practice questions online that can automatically send you questions as you approach your exam.
Also, change your mindset about testing more generally. Don’t think of exams as only being about assessing your learning. Instead, see them for what they are—an important learning opportunity. Make sure you always review your exams and quizzes to see what you got wrong!
Let’s say you’re trying to remember the six drugs or drug classes that are known to cause pancreatitis, or inflammation of the pancreas. The list is:
- Valproic acid
Clinically, it’s really helpful to have these six drugs or drug classes in your working memory so that you can spot them on a medication list and think about them as a potential cause of pancreatitis.
Start with picking a place that you’re familiar with. This can be an actual place, such as your home, the gym, a store, or someplace you’ve seen on television, or a place you've imagined.
Next, you identify specific spots called “loci” in that place. It’s nice to pick really distinct spots, and in this case, we pick out six spots since there are six things to remember. Let’s use your bedroom as the palace and we'll pick:
- Ceiling light
Next, you have to create images for each term you’re trying to remember. You'll imagine an image on each spot. You use the images because it's comparatively easy to first remember a roomful of images—especially if they're attention-grabbing—and then remember the things you associated with each image. You can try a few approaches to come up with the images.
- “Sounds like”: For example, “papule” sounds like papa and mule, so you can imagine an excited new dad riding around on his baby mule.
- “Looks like”: For example, a parietal cell looks like a fried egg.
- "Seems like": For example, taking sedative medication and feeling drowsy seems like what a bear might feel while hibernating through the winter.
The more unique and descriptive the image, the better it will stick, because the mind loves to hang on to interesting visual images in familiar settings. But rather than trying to analyze which trick you’re using, you should simply use whatever image first springs to mind.
So in our pancreatitis example, you might imagine, for example:
- Someone urinating all over the sheets to help you think of diuretics on the bed
- A giant, angry body-builder on steroids smashing the window to think of corticosteroids and the window
- A drunk person missing the doorway and running straight into the wall for alcohol
- Aslan (the lion from Narnia) hiding in your dresser drawer for azathioprine
- Maybe, the Titanic sinking into the fuzzy rug for didanosine ("die ocean")
- Finally, a valiant professor (Indiana Jones!) swinging from the ceiling light for valproic acid
Picture in your mind all these things in your bedroom!
Of course you're not going to draw anything. You'll just imagine the memory palace and the things in it. However, you must pick the right material on which to apply this learning tool. Typically, the best material is very concrete, like the steps of a process or a list of some sort. Fortunately, that's just the kind of thing we have to learn a lot of in medicine.
The reason that memory palaces work so well is that our brains are better at remembering concrete images and locations, as opposed to abstract things like names and numbers. By using these images as a stand-in for abstract information, the memory palace provides a scaffold to help your brain organize and connect concepts. You learn faster while forgetting less, and creating the images themselves makes learning more enjoyable, adding a little flavor to the usual study routine. Although personalized images are the easiest to remember, if you belong to a study group, consider whether you can build a memory palace that will work for both you and others. Even thinking how you would build a memory palace relevant to others will increase your likelihood of recall.
Problem: Past Behaviors
- Continuing to use the behaviors that led you astray during your undergraduate studies
Solution: Change your mindset and implement behavioral changes that will allow you to become a better medical student.
Now that you know a few proven techniques to help you learn more efficiently and remember material for longer, how do you actually make a habit of them? The following techniques can transform your life (and help you counsel your future patients better, too!):
- Fogg behavior model
- Attaining a growth mindset
Fogg Behavior Model
Stanford behavioral scientist BJ Fogg reduces behavioral change to 3 variables:
If you think about any behavior—exercising, quitting smoking, or studying using the techniques described above—you need a certain level of motivation and ability, followed by a trigger to implement the behavior.
Let’s say you want to study new material and review past concepts on a daily basis. Your motivation is a desire to do well in classes and board exams and, more importantly, to be able to take good care of your patients.
- You can increase your motivation through engaging practices like gamified learning and social accountability (eg, study groups).
- You can increase your ability by using tools like mobile apps which make your study materials readily accessible wherever you are.
- Finally, you can trigger the behavior through reminder emails, text messages, and push notifications.
On this last point, the key is not to burn out on the triggers so that they lose their effectiveness. One way to decrease the likelihood of this happening is by making each trigger relevant by syncing it to your individual curriculum and schedule—so you practice answering questions on gram-positive bacteria when you’re actually learning about them in class or seeing patients with infections in clinic, rather than getting that information at random, less meaningful moments.
Stanford researcher Carol Dweck has found that when people are faced with challenges, they often develop different mindsets, or thought patterns, surrounding their problem and their ability to overcome it.
- Those with a fixed mindset believe that one is either born with a skill or without it, and that only so much can be done to change this initial ability.
- Those with a growth mindset believe that actions and hard work are more important than inborn biologic talent.
When students with these mindsets were given easy problems to work on (much like the problems you may have encountered as an undergraduate), both groups were successful. However, they responded quite differently when faced with a more challenging, difficult task.
- Those with a fixed mindset (such as a belief that intelligence is inborn and cannot change) were quick to give up on the task when it suddenly became difficult.
- Those with a growth mindset, however, were more likely to persevere and worked hard on the challenging problem until they found the solution.
When asked to choose between additional easy or difficult problem sets:
- Those with a fixed mindset were only interested in solving problems when they knew they would succeed.
- The students with a growth mindset expressed excitement about working on challenging problems
The most important part of this research was not defining these mindsets, but discovering how easily they could be overcome when students were made aware of them. In other words, lifelong mindsets about achievement and ability can hold us back, but they are not set in stone, and those who overcome them are more likely to succeed. Even if you are someone who breezed through your undergraduate years, you will undoubtedly face greater challenges in medical school. Remember that it is not natural for all topics to come easily to a person, and that you can move forward by working hard and applying yourself to the topics you struggle with the most.
With the start of each new school year, 25,000 incoming medical students in the United States—and hundreds of thousands around the world—will be faced with the challenges of intense coursework, board exams, and working in the clinic. Decades of neuroscience research have provided an entire toolkit of techniques that can guide you on your path to success, but you need to make the choice to use them. Pay attention to the suggestions listed in this study guide, and you’ll be well on your way to being a successful medical student!
- Osmosis, a learning platform that incorporates these learning techniques
- To learn more about the techniques in this study guide, we suggest you take a look at three books in particular: Make It Stick: The Science of Successful Learning, Moonwalking With Einstein: The Art and Science of Remembering Everything, and Learning Medicine: An Evidence-Based Guide.
Watch these videos to learn more about each topic:
- Memory Palace
- Testing Effect
- Spaced Repetition
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