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Study Skills & Exam Strategies

How to Drink From a Fire-Hose Without Drowning

Successful study strategies in medical and pharmacy school

April Apperson, UC San Diego SOM

Why should I change my study strategies?

The practice of medicine and pharmacy requires physicians and pharmacists to rapidly and accurately access a lot of information in their heads that is originally acquired from a great variety of sources.

Only change your strategies if you're NOT satisfied with your exam scores.

Material presented in medical or pharmacy school is not conceptually more difficult than many rigorous undergraduate courses, but the volume flow rate of information per hour and per day is much greater — it has frequently been described as "drinking from a fire-hose."

  • Everyone admitted to any medical or pharmacy school has developed study strategies successful for an undergraduate informational flow rate
  • Unfortunately, those developed by most undergraduate students are not efficient enough for the fire hose flow rate. (Virtually no one develops efficient study habits until their performance requires it.)

Efficient studying — the best use of your limited time — requires active learning, not passive.

If you are comfortable while you are studying, it almost certainly isn't active.

Active studying requires not knowing (uncomfortable), then working it out.

Passive studying is comfortable - just not efficient.

  • Active learning requires constantly making decisions about the material.
    • "Is this important?"
    • "How is this different from the other examples given for the same process?"
    • "Where does this fit into the 'big picture'?"
    • "What is the exact definition of this term?"
  • Passive reading of pages of text or "going over" notes (even with a highlighter) and "absorbing" the information is inefficient — if you have enough time, it will eventually work, but it usually isn't adequate for the fire hose.

Changing a habit that has worked for many years isn't easy, so don't be surprised if you need to hear the same things many times - and don't be afraid to ask to hear it again!

What are the fundamental processes in successful active studying?

  1. Identify the important information — answering the eternal question of "what's important here?"
  2. Organize the information — create chunks of information in patterns that facilitate memorization and emphasize the connections needed for application questions, e.g., for differential diagnosis.
  3. Memorize the information — this is an active process and not just reading it over enough times. Don't put this off because "I'll just forget it again". Memorize your chunks and patterns as soon as possible, then review the main points each time the topic appears again. It's annoying, but more efficient, and the information will get into long-term memory more effectively.
  4. Apply the information to more complex situations — practice this before the exam.

What are the goals of an active study plan?

  1. Create as quickly as possible the study sheets, aka study aids, that together contain the needed information organized into chunks and patterns that promote memorization and integration.
  2. Memorize and Synthesize that information by applying it in all available practice formats, e.g., practice questions, small group conference or problems sessions, quiz questions, etc.

What are the sugested steps of this plan?

  1. Before lecture, devote ≈ 10 minutes per lecture hour to identify and memorize the "big picture". These steps focus on lectures presented from powerpoint slides, but can be adapted for texts.
    • The goal of pre-lecture work is to have a basic roadmap of the lecture in your head - if you get lost during a complex part of lecture, you won't be lost for the rest of the lecture.
      • Use the outline to identify the key headings - then memorize the number of headings and then the actual headings (knowing the number helps!) to create your basic roadmap.
      • Use the remaining time to understand the basic logic behind the sequence of headings - this will also help you remember them.
  2. During lecture, take notes that emphasize connections and what the lecturer says is important.
    • If possible, take handwritten notes electronically (e.g., tablet) or on a slide printout - handwriting activates analytical centers that typing does not.
    • If practical, annotate power point slides or lecturer notes, rather than taking completely new notes; use abbreviations and symbols to increase what you can take down.
    • Add the "take-home message" for each graph or chart; clearly label the axes.
    • Note lecturer comments that identify or integrate key points, especially in the intro or summaries.
    • Always note information that helps you decide between options, e.g., circumstances that indicate when one reflex or response will outweigh another, or in what circumstances one DNA test is used rather than another, etc.
    • Let unimportant information go! Don't rewrite data already present; use a single slash across material the lecturer says is not key (you can still read it); leave out "color commentary" or "cool new stuff" that is outside the scope of the class.
  3. After lecture, on the same day (if feasible), edit your notes and begin organization.
    • Your lecture notes become the messy but complete back-up document - DON'T rewrite them.
    • Edit notes in a single pass by using the text (if needed) and learning objectives (if useful) to:
    • Identify/add any missing major headings or subheadings that reinforce your "road map".
    • Circle specific terms and definitions in a different color - these will be used both for reference and for keying memorization of the material.
    • Decide and identify what is needed for your study sheets and what can be left out.
      • Scan learning objectives (if specific enough to be useful) to help these decisions.
      • Don't get caught up working through non-relevant information on figures in slides taken from an article or text that include parts not needed for the key point.
      • If a key point or definition doesn't make sense, use the text or online references - but stay focused!
    • If a lecturer discusses something you remember from an earlier lecture, check it out! If it includes a different perspective or additional information, add the relevant information so your study aid will have all of it in one place.
    • For topics that lend themselves to reasonably simple organizations, e.g., flow diagrams, sketch out the organization.
  4. Within a few days, find time to complete your lists, charts, flow diagrams and pictures - these study aids form the "final draft" of your information that you will use to study for the exam (don't go back to your original notes!).
    • Memorize the organizations actively as you complete each one, and review them frequently to consolidate them in your memory (see Tips below).
    • Apply the information in practice and quiz questions well before the exam. Use them to work out a method for approaching complex problems that might appear on the exam.


Tips on Organizing, Memorizing, and Applying the Material

General Tips:

  • Design your study aids to illustrate a logical sequence within the material and emphasize connections or comparisons.
    • The analysis of the information needed for this is active studying! The resulting study aids work with known aspects of memory, which decreases the burden of "rote" memorizing.
    • People remember stories rather than unrelated facts. The order of headings in a chart or flow diagram, or the placement of the elements within a diagram should reflect a time-line or location or relationships in a logical order - this can act as the "story".
    • Studies show that the more connections within the information being organized or studied, the better and longer you will remember it. And virtually all people remember visual patterns better than paragraphs of text.
    • Flow diagrams or pictures or graphs are more effective that writing out a sequence of sentences or long descriptions.
    • For detailed material, start with a simpler, more memorizable overview that identifies each topic by a key word or phrase to establish the connections and the "story". Create further flow diagrams or organizations for each topic within the overview that needs more detail.
  • For lists, charts/tables and flow diagrams, use the "rule of 5": no more than five items under one heading. If you need more, then decide how the items are logically divided into subgroups and create subheadings.
  • Don't recreate the wheel. If you find a good chart in some text or other source, add it to your summaries. Customize it by crossing out non-core material and adding any needed material from lecture - use color to make changes stand out.

What organization should I use?


Some material lends itself to certain organizations, but much is just personal preference.

  • Deciding on the headings and subheadings in a list or table, or how the information is organized in a flow diagram, or where it is located in a picture or diagram, is the ACTIVE part of the process.
    • Sketch out different possibilities without adding the actual content, using the rule of 5 (or 6).
    • Try for one that flows logically and visually emphasizes distinguishing features between different examples or processes.
  • Different organizations have different strengths.
    • Tables clearly compare/contrast related processes or structures, but they invite simple transcription (passive!) and can be text-heavy and therefore harder to memorize.
    • Flow diagrams are very useful for organizing related topics and subtopics that have examples, but they can get too complex and hard to follow if the relationships aren't clear.
    • Graphs are very useful to present complex relationships in a simple visual pattern, but memorize the labels on the axes and not just the line shapes!
  • Finding connections between different topics aids memorization and application
    • Use equivalent headings or orders of headings for separate tables or flow diagrams on related topics - it both aids memorization and emphasizes connections within the material that help with application.
      • You can create and use a "default" heading sequence for some information:
      • For neurotransmitters, hormones, etc.: structure, synthesis, receptor and signaling, biological effect and regulation
      • For molecular processes: fundamentals, initiation, elongation, termination, processing.
    • Create "big picture" charts, flow diagrams or pictures that organize KEY related topics from multiple lectures - the topic charts from each lecture will provide the detail.
    • Don't hesitate to include key information on different summaries, especially if they are organizing the material from different points of view or at different levels of detail.
Memorize actively and use frequent short reviews.
  • Organized material is useless unless it is accessible within your memory - preferably long term.
    • Getting information into long-term memory requires multiple repetitions and active memorization - "going over" or "reading over" material is NOT efficient.
    • Cramming doesn't work in the long term! Courses build on each other and you need information from earlier courses to understand and apply material from later courses.
    • The most efficient memorization methods are also the LEAST painful.
  • Active memorization builds in steps: how many, then key words/phrases, then chunks.
  1. Memorize how many items (e.g., headings) there are so you know if you have them all.
  2. Memorize the headings in order - use biological logic, visualization, and/or mnemonics - before starting on the content.
  3. For the content, assign a key word or short phrase for each needed chunk of information, e.g., a cell in a table, or a piece of information in a flow diagram.
    • Memorize these for one row, column, or region, using the heading sequence or connections to reinforce the material.
    • Close your eyes and recite that piece - how many, headings, key words - until its clear.
  4. Add any needed further information to each key word/phrase and memorize that combination, and repeat two processes under step three.
  5. Continue until you think you have the full study aid memorized.
  • Self-test each full organization on paper or a whiteboard:
  • Cover the original and write it out on a blank paper/board (don't be pretty, but don't cheat).
  • Throw away or erase what you have just done (this is the tough part - get rid of it) and look at the original.
    • If you are confident that you wrote out all parts correctly, great1 (DON'T COMPARE)
    • If there is a part you're not sure about, DON'T COMPARE to what you wrote. Rememorize it and self-test again.
  • This method emphasizes what you don't know, while comparing old and new will just emphasize what you do know (more reassuring, but less effective!)
  • Actively review the key word/phrase version of a topic organization at every opportunity.
  • Every time an earlier topic or concept is mentioned in a lecture or practice question, close your eyes and quickly review the topic organization - how many, headings and key words/phrases.
  • Mentally review graphs or pictures or diagrams at other times, e.g., waiting for laundry to dry.
  • This sets the information in your memory and builds practice in the mental sequences you'll use answering questions under time pressure
  • When studying with others, quizzing each other can be helpful (and fun), but beware that you might be using subliminal cues to help answer questions without truly mastering the material. When studying along, explaining material out loud to yourself can also be helpful, but beware of the very common tendency to verbally "hand-wave" around areas you aren't actually clear on. Always check yourself with the active review described above.

Practice application early - do NOT wait until you believe you can get all the practice Qs right!

  • Practice questions are diagnostic tools best used to master the material BEFORE you know it.
    • Use the stems AND the answer choices (correct and incorrect) to help identify the level of detail you need to know, and how much integration and/or application is expected.
    • If you got a question CORRECT, identify exactly why each incorrect choice was wrong and why it was included as a potential choice for that question. Actively review your study organizations that include each incorrect choice. Predict a question stem that uses the incorrect choice as its focus.
    • If you got a question wrong, actively memorize the study aid that includes the question topic (and not just the part that applies directly to the correct answer).
      • Work out an approach or method for that type of question - "where do I start"?
      • If the material includes clinical cases or scenarios, predict application questions by asking: Given data (clinical or molecular), determine: i) the most likely cause of the symptoms or test results, ii) the best assay/technique to use, iii) the mutation that could cause the results, or iv) the calculation needed to determine the risk of having the disease, or to generate the pressure or flow asked about, etc.
  • Ungraded weekly quizzes are useful for gauging mastery of the material, but don't put them off beyond the correct weekend because it encourages falling even further behind; analyze the questions as described above to help mast the material.
  • Use practice or quiz questions more than once.
    • Retaking earlier quiz questions after a couple of weeks can point out content that was only in short-term memory. Actively rememorize it!
    • Even if you remember the correct answer, work through the approach or method for the question and use it to mentally review the relevant information. Use this to decrease the time needed to answer complex questions.
    • Change values or other features in the question to create a new version and work through it.
  • Where do I find time for all this?

    1. Successful high-volume studying relies on good investment strategies:
      1. Finding the "big picture" before lecture is easily put off, but it pays off by increasing learning during lecture and facilitating design of organizations after lecture.
      2. Focusing on key points and NOT getting caught up in unneeded detail on slides or in "color commentary" slides will provide more time.
      3. Creating study aids takes time, but you'll learn the material with connections and insight that will let you answer those application questions; study aids also pay off with more time during the inevitable finals crunch because you won't be leafing through endless pages of slides wondering where that information was (and what they all mean).
      4. Memorizing as you go and frequent review of earlier concepts as you study pays off immediately because you'll need less time to study for subsequent lectures. You'll be able to recognize connections and correlations that lead to more effective organizational aids, and you'll remember the material both more effectively and longer.
    2. There is more time available in a day than you think - don't let "studying all that" help you procrastinate.
      1. Divide your studying into a series of short tasks so you don't feel so overwhelmed, and so you don't feel the need to wait until you have 2 or 3 hours to study. Convincing yourself to start on one chart or diagram is much easier than finding a large block of time. And once you're started, it's easier to keep going.
      2. Use small bits of time while your clothes are drying or 1/2 of your lunch hour, or while the rice is cooking for dinner for active studying tasks.
      3. Use all the "extra" time you can in the first week to be caught up in lectures, because the courses (blocks) are short and there is much to cover.
      4. Be VERY careful about "robbing Peter to pay Paul". It's tempting to skip lecture or to put off viewing a recorded lecture to finish an upcoming project - but try to keep it to a minimum. These are typically bad investments because the lectures build on each other, so you'll probably need even more time to master the material

What are the most common problems MS1 and P2 students have ON exams

  1. Clarity and precision in definitions and concepts vs. approximate definitions derived from context.
    • Often, students generate their own general concepts or definitions from context (after all, that's how we learn to speak) - but this doesn't provide enough clarity to analyze and correctly answer the questions.
    • Medical terminology and equations are very precise - being "close enough" usually isn't sufficient.
  2. Familiarity with material vs. mastery of the material.
    • "Familiarity" refers to recognizing the logic provided by someone else - as when leaving a good lecture, you can say, "yeah, that made sense."
    • Mastery of the material requires integration and memorization of sufficient detail that the information can be successfully applied to a new situation.

More Study Tips

Frequently Asked Questions