In medical school, we talk in terms of “high yield” and “low yield”
information. Basically, everyone accepts that it is impossible to know
everything or even close to it, so medical school becomes an exercise in
figuring out what is most important. For every conversation about
memorizing, there are also a couple of self-deprecating quips about
forgetting. I’ve had times where I studied something, took a short
break, and then forgot what I was just reading. Is it sad? Yes.
Demoralizing? Can be. But unique? Talking to other medical students,
I’ve found the answer is a resounding no. The consensus on memorization
among my peers is comically
Lake Wobegon in reverse: here, everyone is convinced (s)he is below average.
Are we inherently bad at memorizing? Are we just not programmed to be
effective at learning everything the modern medical landscape demands
from us? I wondered about that. But more so, I wondered about solutions.
If we ask for help, most of us rely on casual tips from those who have
gone through the process before us, and we try to assemble diverse
anecdotes into a feasible personal plan. But research into the human
mind and its ability to remember is vast. And that knowledge says that
memorization is a skill that can be improved upon with strategy and
practice.
What of that knowledge can apply to medical training, specifically?
Which techniques can help information stick – in ways that are
meaningful, relevant, and ultimately useful for patient care?
***
Chunking. Our short-term memory can store and
retrieve a limited number of facts – and researchers have honed in that
number. In 1956, cognitive psychologist George Miller published a paper
providing evidence for
seven being the magic number,
plus or minus two. It was one of the most widely cited psychology
papers ever, and Miller’s figures are ones that many in modern
psychology circles still go by. What does that mean if you want to
remember more than seven items? The solution involves breaking down – or
“chunking” – larger sequences into smaller ones. For example, if you
want to remember the ten digit sequence 6256493174, you could instead
think of it as 6, 256, 493, 174. Or 62, 56, 49, 31, 74. Or some other
combination, as long as it’s in a retainable number of chunks.
Does it work? In medicine, we constantly need to remember
facts that relate to a particular umbrella subject. Chunking is useful
as a guide in keeping relevant concepts together, within a range that is
ideal for memorization. I know, for example, that if I am trying to
remember bacteria, it helps to classify them into groups – with each
group containing facts of nine or fewer items. In that sense, perhaps
chunking is little more than a fancy way of saying organizing – with the additional recommendation of what size you should organize subjects into to increase your chances of retaining.
One issue is that chunking refers to a technique for short-term
memory. In medical training, I care about knowing things for the long
term. Can chunking still help? Psychologist opinion seems to say yes:
chunking improves the transfer of short-term memory to long-term memory.
Some have used the example of
language
to make this point, in that we regularly use single words or phrases to
capture complex meaning and remember it in the long-term. Medicine uses
similar principles. That is, whenever we have a medical term for a
constellation of symptoms, a disease progression, or a type of
treatment, we are actually chunking multiple concepts into a single
phrase. Taken in reverse – a single medical term connotes multiple
ideas. Medical language enables us to memorize better by having us
memorize in chunks.
The bottom-line on the usefulness of chunking in medicine is that
it’s a way of thinking consciously about something we tend to do
naturally – organizing complex ideas into simpler ones. Having that
conscious awareness of why condensing works can make the number of facts
we are expected to learn in medicine less intimidating.
The memory palace. Picture some location you know
well, such as the rooms in your house or the streets in your
neighborhood. Now suppose you have to memorize a list of groceries.
Start at the beginning of your location and walk forward, placing items
at well-known landmarks as you go. Maybe you place a carton of milk at
the foot of your stairs, a dozen eggs at the top, and a pile of apples
next to the pillow on your couch. This technique is described well in
Moonwalking with Einstein: The Art and Science of Remembering Everything,
by Joshua Foer. The idea behind the memory palace is that we have an
innate knack for remembering spatial layouts – supported by brain scans
showing that spatial learning parts of the brain are used by people who
win memory contests.
Does it work? Since you’re walking along a path, the memory
palace works well for material that needs to be remembered in sequence.
What topics in medicine might apply? Stages in a disease progression do
the trick. The memory palace can also be useful in anatomy, a subject
filled with order: which blood vessels branch into which, how nerves
connect, and how layers of muscle and connective tissue lie – from top
to bottom, front to back, and left to right. Additionally, the memory
palace can be of use for lists where there is no order (such as the
groceries); I would simply create a different walk for each list. In
that way, any part of medicine I might “chunk” together, I could also
place within a memory palace.
There are a few drawbacks. One is that the images that do the most
for memory are ones that are most creative – or, as Foer puts it, most
ludicrous. Crafting ludicrous images might be fun, but it is also very
time consuming. Compounding the time investment is that many topics in
medicine are not prone to imagery the way groceries are. Imagine
biochemistry, for instance, where I am trying to remember the steps of
signal transduction: Ras activates RAF, which activates MEK, which
activates ERK. How can I place this alphabet soup of acronyms in my
house? Since Ras comes from “rat sarcoma,” I could imagine a rat with a
tumor somewhere in my house; maybe ERK reminds me of my friend Erik, so I
could picture him as the last step. It can be done, but it demands
imagination. As a result, I find the memory palace a good investment
only for very high yield information that I need to summon over and
over.
Mneumonics. Poems, acronyms, acrostics, and other
types of word play fall into this category. Mneumonics are extremely
common in medicine – so much so that they pepper every few pages of my
review books, and that there exist
entire websites devoted to them.
They work because they take things that lack any sort of transparent
meaning and package them in ways that resonate with subjects that are
familiar in our everyday lives (example: “Some Lovers Try Positions That
They Can’t Handle” resonates more than the arbitrary names of the hand
bones, Scaphoid, Lunate, Triquetrum, Pisiform, Trapezium, Trapezoid,
Capitate, and Hamate). Others are just catchy (to recall which nerves
innervate the diaphragm, I still say the rhyme, “C3, C4, and C5 keep the
diaphragm alive”). For topics where order matters, I also often find
verbal mneumonics simpler than coming up with ways to place the items in
the memory palace. For example, to remember the order of structures in
the femoral triangle region of the thigh – nerve, artery, vein, empty
space, and lymphatics – I find “NAVEL” easier to recall than attempting
to mentally place those body parts around my house.
The verdict is that this is a fantastic technique that I use
frequently in medical school. I will point out one downside, though,
which is that speed of retrieval does matter in medicine – so if your
mnemonics get too unwieldy, they are less useful. For example, imagine
being on rounds, and having your attending ask you a question about the
ninth cranial nerve. If you use
any of these mneumonics
to remember the twelve cranial nerves, and you need to go through them
all to get to number nine, your answer will be slow. And that won’t look
good. The consequences of slowness during actual patient care, of
course, can be more dire than a damaged ego.
Be emotional. For good or bad – we remember things that make us
feel.
In addition to personal anecdotes, there is much research supporting
the idea that emotional experiences are remembered more vividly that
less emotional experiences.
Brain scans,
for example, show that when people store and later recall vivid
memories, both the amygdala (a part of the brain involved in emotion)
and the hippocampus (a part involved in memory) are at work, and those
with
better recollection use the emotional parts of the brain more.
When
people encode vivid memories, the amygdala and hippocampus interact.
Emotional memories are retrieved better than neutral ones.
Does it work? That we remember better when emotions are
involved bodes well for medicine – a career in which we will be caring
for human lives and thus often immersed in emotional situations.
Already, I have experienced the impact of emotions on memory. I have
been more successful in remembering information about illness when a
patient was involved than when I was studying from a book. The details
stuck because they mattered. I am comforted by the idea that my
experiences with patients will be positive not only from a humanistic
standpoint of providing compassionate care, but will also aid in my
life-long learning to deliver quality care.
The downside is that during the first two years of medical school –
when we are supposed to be learning the basics of all of medicine – our
patient experiences are limited. During first year I saw patients once a
week; during second year, it will be twice a week. The vast majority of
my learning is from detached books. Still, we can do things to make our
emotional memories work for us; I find that placing information about
illness even in the context of a fictional patient is helpful. (I’ve
even tried fictionally afflicting myself with diseases I am learning
about – I’ve had some success there too, but to a lesser extent.)
Another downside of relying too much on emotional memory is that it
can open the door for biases. For example, doctors may be more likely to
diagnose a new patient with an illness they have seen recently, in a
situation that emotionally stuck in their minds, even when other options
they have not recently seen might be just as logical. I hope that
awareness of those potential limitations in our thinking can help me
work consciously and actively to avoid letting them bias my
decision-making.
Repetition. Every psychology text under the sun will tell you that
repeating things
will help with remembering them. The second exposure to facts is easier
than the first, and the third is easier than the second. While I find
this extremely true, the one caveat I would point out is that simply
repeating another’s words, without having an intuitive grasp of what you
are saying, is not the way to make this technique work. Medicine
involves a lot of rote memorization, certainly, but it also involves
conceptual understanding. Saying “increased afterload leads to decreased
stroke volume” over and over, without understanding the physiological
steps of
how and
why, does little for effective
memorization. More importantly, it does little for making connections
and applying, which is what we really care about in medicine.
The concept map. During first year, our physiology
professor drilled this one in our minds. A concept map involves writing
ideas in circles and connecting them by arrows. More than one arrow can
go to more than one circle, and they can represent relationships like
“contributes to” or “is caused by.” It works because it enables you to
piece information together in your own ways, seeing how parts of systems
work together without skipping steps or making leaps. We remember
things better when they make sense. And, just like I said in the
repetition section, the more important benefit is that it does wonders
for understanding and applying – the ultimate goal in medicine.
This one sounds obvious, but I’ll say it anyway: concept maps are useful only for conceptual
understanding. The memorization involved in medicine involves a blend
of conceptual understanding and rote memorization. Concept maps have
helped me make sense of how the human body acts and reacts, but
unfortunately does less for topics like drug names and anatomy.
Be healthy. Our bodies influence our brains. Though
not all mechanisms are understood, we remember better when certain
things are taken care of better: when we
eat well,
exercise, and
get enough sleep.
Unfortunately, I’d guess this is the one we are most likely to overlook
in medical school. But all of these tactics are pretty convenient, in
that these are things we should be striving to do anyway.
***
How much memorization should be required during medical
school? That is a question up for debate, with widely mixed opinions.
Some who have made it through to the other side argue that the modern
system emphasizes too much, for the reality of clinical care is that you
will always be looking up information. Critics also point out each of
us will go into a medical specialty; so knowing everything about
everything is less sensible than choosing a path earlier and focusing
our learning on what we will actually be practicing. There’s also the
consideration of motivation. A medical student who feels burnt out from
the first two years might become a less astute, less caring physician.
Others maintain that it is important to know a lot, because even if
you don’t remember everything (and you won’t), that first exposure is
critical in developing an understanding of the overall landscape and how
different pieces of medicine relate to one another. That is, even if
you don’t remember the exact details of what you learned, you will
remember that the information exists – so you will know what to look up, and how it’s relevant.
I am not nearly far along enough in my medical training to have a
strong leaning one way or another. I imagine things will become clearer
when I am caring for patients and can gauge what kinds of information I
use on a regular basis, what I use my memory for, and what I tend to
look up. There’s also the fact that the two lines of reasoning above are
two ends of a spectrum – and the answer may very well lie somewhere in
the middle.
When drowning in memorization, some perspective is valuable. In the
end, the most challenging parts of medicine are yet to come – and they
will not involve problems of memorization. The facts I am committing to
memory now will be the building blocks to solve complex patient cases
later. I will come across symptoms that will not fit into recognizable
molds. My future will involve piecing together clues, weighing relevant
and irrelevant information, proposing new ideas that are conceptually
viable, and evaluating outcomes. I will have to identify and confront my
own biases to try to hone in what is true, rather than what is easy,
convenient, or familiar. I will have to critically evaluate my own
skillsets and recognize when to ask for help, and from whom to get it. I
will have to do all of this within the framework of human interaction,
being constantly mindful of patients’ emotions, thoughts, and concerns. I
will be treating human beings, not diseases. And that is what I am
looking forward to.
In my first year physiology course, our professor gave us weekly
quizzes. Each quiz was open book and open notes. Our final exam was a
five-page case on a fictional patient, given to us two days in advance,
where we could work in groups consulting any and all resources we had.
That four-hour exam and the quizzes preceding it were the most
academically challenging of anything I took first year. Our professor
was preparing us, and I am grateful for the standards he held us to.
Because that’s medicine, he told us: “open book, but still hard.”
By Ilana Yurkiewic. Tomado de: http://blogs.scientificamerican.com/unofficial-prognosis/2012/07/26/drinking-from-a-firehose-can-research-into-the-human-mind-help-with-medial-school-memorization/
