By Peter Wei, MD, and Alex Chamessian
Medical school is known to test many things to the breaking point – relationships, sleep schedules, ability to handle stress. For us, though, what med school tested to the limit was how we learned – and like so many other students, we came out stronger for the experience.
Like most students, when studying in college and prepping for the MCAT, we tried a number of different approaches – outlines, notecards, cramming, the works. But when we reached medical school, with its famous “drink from a firehose” style of teaching, we realized that these approaches weren’t enough.
Worse yet, we found that with a pure cramming regimen, we’d start forgetting key concepts that we learned just a few weeks earlier. We heard well-meaning upperclassmen telling us, “Don’t worry – you’ll forget it all by second year and you’ll have to relearn it anyway.” What a depressing thought! We needed to find a better strategy if we were going to learn and keep on top of all this information. But as we dug into the literature on learning and memory, we found that they were right: Med students routinely need to re-learn massive amounts of forgotten information before taking their board exams, and residents eventually forget much of what they learned in medical school outside their specialty. All this translates into vast amounts of time wasted. One of the reasons med school felt so overwhelming was that not only did we have to learn new information, we had to fight a losing battle to remember the information we were forgetting every day. Our reading revealed that scientists had discovered this fact long ago – and had also come up with study techniques that would break this vicious cycle.
Over a hundred years ago, a German psychologist, Hermann Ebbinghaus, used careful experiments to determine how learning and forgetting works. From these experiments he described a “forgetting curve” in which “large amounts of forgetting occur quickly, followed by a more slow and steady decline in retention.” When you learn something, you start forgetting almost immediately. Within 20 minutes of learning some new information, you can only recall about 60 percent of the information you just learned. After nine hours, retention is less than 40 percent, and 20 percent after 10 days. These results led to another key observation: the temporal relationship of studying matters. “Learning events that are repeated over time result in more efficient learning and greater retention compared to exposure to a single bolus of material,” a psychological finding termed the “spacing effect.”
The solution was spaced repetition, a technique in which you review material according to a schedule determined by the spacing effect. At first, a newly learned fact is reviewed often; as time goes on, and the memory becomes deeply ingrained, it diminishes. In that way, you only have to study each fact exactly when the program predicts you’re likely to forget it – an enormous time savings. While cramming can buy you some short-term learning, if you want to retain information from medical school into clinical practice, spaced repetition is the way to go.
So, with this knowledge in hand, we and some of our classmates started using free, open-source flashcard apps, such as Anki and Mnemnosyne, which incorporate spaced repetition. Our understanding of the psychological literature also taught us the best practices for studying, and what sorts of resources to use for each course.
We talked with our classmates, who adopted parts of this methodology for themselves and offered useful suggestions to streamline it further. Pretty soon our class was teaching these techniques to the incoming first years, and a year later, that class started reaching out to the new incoming first years. And sure enough, many of us did very well on the USMLE step exams and found that had a firm grasp of clinical knowledge once we hit the wards; our studying yielded much better results than we could have expected otherwise.
It wasn’t perfect. After all, it took years for us to learn how to study the old-fashioned way, and we were trying to implement a new one in a few weeks. We made mistakes along the way, and as we kept talking to other students, we realized that many of them were running across similar stumbling blocks. We looked at the recurrent problems and figured out ways around them. Eventually we collected these experiences into a book – Learning Medicine, an Evidence-Based Guide – which encapsulates both the literature we drew from and our experiences putting these learning strategies into practice.
We wrote this book because we wanted to expand and improve on the community we’ve developed. We wanted to reach out to students across the country and the world and give them, in one piece, a system that they could quickly learn and hit the ground running in medical school and beyond. We wrote the book we wish we had had when we started our medical school journey.