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 as originally acquired from a great variety of sources.
Only change your strategies if you're NOT satisfied with your exam scores (and you don't need to score 90%!).
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 had 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 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?
- Identify the important information – answering the eternal question of "what's important here?"
- 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.
- 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.
- Apply the information to more complex situations – practice this before the exam.
WhAT ARE THE GOALS OF AN ACTIVE STUDY PLAN?
- 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.
- MEMORIZE and SYNTHESIZE that information so it can be applied to new situations and problems.
What are the SUGGESTED steps of this plan?
- Before lecture, devote ≈ 10 minutes per lecture hour to identify and memorize the "big picture".
During lecture, take notes that emphasize connections and what the lecturer says is important.
- 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.
- Identify the number of key heading from the outline/summary, then memorize the number and then the actual headings (knowing the number helps!)
- Reinforce the headings by reading the introduction and/or summary.
- If you still have time, scan the material for definitions, equations and/or diagrams that you'll need later.
- Preview materials from the lecturer if he or she provides them.
- From powerpoint: use the outline and summary slides – don't get caught up in the rest.
- From a text summary: use the major headings and subheadings.
- 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 axe
- 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.
After lecture, on the same day (if feasible), edit your notes and begin organization.
- 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.
- 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) while:
- Identifying/adding the major heading and subheadings into the notes (if not already there).
- Circling specific terms and definitions in a different color – these will be used both for reference and for keying memorization of the material.
- Deciding and identifying what is needed for your study sheets and what can be left out.
- Scan learning objective (if specific enough to be useful) to help this decision.
- 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!
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!).
- 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, sketch out the organization.
- 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 by doing practice questions or 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
What organization should I use?
- The most memorizable (and therefore useful) organizations reflect a logical sequence within the material and emphasize connections or comparisons, as well.
- People remember stories much better than dry facts, so the order of headings in a chart or flow diagram, or the placement of the elements within a diagram should reflect time-line or location or relationships in a logical order - a "story".
- Virtually all people remember visual patterns, e.g., flow diagrams or drawings or graphs, better than text.
- Studies show that the more connections within the information, the better and longer you will remember it.
- 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
Some material lends itself to certain organizations, but much is just personal preference.
Memorize actively using the "3 Ss" and frequent short reviews.
- 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.
- You can create and use a "default" heading or flow diagram 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.
- Different organizations have different strengths.
- Tables clearly compare/contrast related processes or structurs, 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 with some integrated material.
- 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.
- 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.
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
- Organized material is useless unless it is organized and accessible within your memory
- The material needs to be in long-term memory and accessible – which means organized in your memory.
- 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.
- Getting information into long-term memory requires multiple repetitions and active memorization – "going over" or "reading over" material is NOT efficient.
- Memorization is never fun, but the most efficient methods are also the LEAST painful.
- Active memorization with the "3 Ss": stories, steps and self-testing.
- The "story" is provided by your organization and is very helpful for memorization.
- Actively memorize with five steps:
- Memorize how many items (e.g., headings) there are so you know if you have them all.
- Memorize the headings in order - use biological logic, visualization, and/or mnemonics.
- Memorize the information for one row, column, or region using a sequence:
As you memorize the information for a row, column, or region, close your eyes and quiz yourself on just that piece until it's clear.Continue this process until you think you have the full study aid memorized.
- First assign a key word or short phrase and memorize it
- Then create an intermediate "chunk" with the key point and memorize it
- Finally memorize all the needed information
- Self-test 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) - now throw away or erase what you have just done (this is the tough part – get rid of it).
- Look at the original. If you are confident that you wrote out all parts correctly, great!. 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; comparing old and new will just emphasize what you do know (more fun, but less effective!)
- Self-test with a quick active mental review at every opportunity.
- Every time an earlier topic or concept is mentioned, stop and review the relevant summary list or flow diagram - how many, headings, key words, then the rest.
- Mentally review graphs or pictures or diagrams at other times, e.g., washing your hair.
- This sets the information in your memory and builds practices in the mental sequences you'll use answering questions under time pressure
- Quizzing each other is good motivation, but beware of subliminal cues used to help answer the questions without mastering the material. Explaining it out loud to yourself is a good start, but you can verbally "hand-wave" around areas you aren't clear on. Always check yourself as 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.
- 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. Predict a question stem that uses the incorrect choice as its focus.
- If you got a question wrong, go back to the study aids with the relevant information and rememorize them (not just the bits in the question).
- 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, or ii) the best
assay/technique to use, or 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.
- Weekly quizzes are useful for gauging mastery of the material, but don't put them off beyond the correct weekend and analyze their questions as described above.
- Use practice or quiz questions more than once, 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?
- Successful high-volume studying relies on good investment strategies:
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.
- Focusing on key points and NOT getting caught up in unneeded detail on slides or in "color commentary" slides will provide more time.
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).
- Memorizing as you
go and frequent review of earlier concepts as you study pay 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.
- There is more time available in a day than you think – don't let "studying all that" help you procrastinate.
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.
- 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.
- Use all the
"extra" time you can in the first week to be caught up in lectures,
because the blocks are short and there is much to cover.
- Be VERY
careful about "robbing Peter to pay Paul" – it's tempting to skip
lecture to finish an upcoming project, but try to keep it to a minimum.
Skipping class to study is usually a bad investment because you'll
probably need even more time to master the material from the skipped
What are the most common problems MS1 and P2 students have ON exams
- Clarity and precision in definitions and concepts vs. approximate definitions derived from contex
- 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.
Familiarity with material vs. mastery of the material.
- Medical terminology and equations are very precise – being "close enough" usually isn't sufficient.
- "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.
Frequently Asked Questions/Frequently Heard Comments (FAQ):
TOPIC: "How do I know what will be on the exam and practice for it?"
"How do I know what will be on the exam?" or "How do I know how much detail to learn?"
- How do I know how much detail to learn from lectures?
- If the learning objectives are "task-oriented" and specific, use them! Don't overthink the simpler objectives, and complete all of them using the lecture material, with the assigned text as a back-up. Task-oriented learning objectives focus on the level of material presented in lecture, so using outside Web sources often encourages students to go well beyond the lecture's intent, which wastes time.
- Check your lecture notes – they should emphasize the lecturer's context, which includes any comments by the lecturer on what is important.
- If the learning objectives are unfocused, seek help from the lecture outline, introductory and summary slides, and key point slides for "big picture" concepts should be important, then identify examples or conditions that support them. If the lecturer has provided any additional tables or charts, use them!!
- Other indications that information is important:
- If the concept is mentioned in more than one lecture, it's probably important – check your cross-referencing. The same topic may be addressed from different points of view in different lectures, but the exam question on the topic may integrate all those points of view.
- If a clinical example or disease is described or explained (not just referred to in passing), you may well need to know the molecular or biochemical or genetic abnormality and the biochemical or physiological consequences of the abnormality.
- If the instructor gives a sample calculation, and an accompanying table has more examples, fill it in.
- If the course includes conferences with assigned questions, be sure to analyze and answer all the questions that other students presented. There is a lot of difference between tracking logic outlined by the lecturer or text and applying principles in a way you have not seen before.
- Use any practice or sample problems to identify the level of "necessary detail" (see the question below); use quiz questions in the same way, then expand that to apply to all the topics not asked about.
- Assume that all lectures – including introductory lectures – will be asked about on the exam. In most cases, the questions on an exam are balanced to roughly proportionately to lecture hours per topic. Of course, it doesn't always work out that way, but it is a place to start.
"But I need to save the quizzes or practice questions to test myself after I know all the material."
Don't save practice questions to test yourself just before the exam – it is then too late to modify your studying!! You may do well and be complacent, or do poorly and be a nervous wreck – neither helps!
Practice exams or questions are a vital piece of the answer to the questions, "How much of detail do I need?" and "What kind of questions will they ask?"
Start using practice questions as you create the summary for a particular topic — after setting the headings in your summary, check over the practice questions on that topic to make sure you haven't missed anything.
You can use practice questions again – see the answer to the question below.
"How do I use quiz questions to help my studying?"
- Analyze each quiz question, don't just count up how many you got right. Whether or not you got the question right, analyze it thoroughly.
- Make sure you understand why EACH possible answer is right or wrong and how each wrong answer could be made correct and what topic it was referring to (why did they include it?).
- If you didn't get it right, go back and memorize the entire chart or summary that contained it.
- Ask yourself if there are any other examples that could easily be used with the same format. Make sure the information for each quiz question is somewhere in your summaries or charts (not just the original class notes) – if not, add it and any equivalent information to any related categories.
- Try writing a few possible questions yourself, then answering them (or trade with a friend). This is a very powerful technique because you have to analyze the material, know the big picture and know details.
"I need more practice questions to study from; where can I get them?"
Used properly, relatively few quiz and sample questions are plenty for preparation — see question above.
"I did well on the weekly quiz, but then I didn't do well on this exam."
It will be different questions and the predictive value of quizzes is lost if you do them "open book", so don't depend on your score on the quiz. Without the stress of the exam, you don't make as many mistakes and usually think more clearly. Thorough analysis of the quiz questions (see above), and predicting a few harder ones, will be much more effective preparation.
TOPIC: "I didn't do well on the exam – I need help with my test-taking strategies."
"I understood the material, but I had trouble answering the questions — my problem is test-taking."
Test-taking strategies can always be improved and can help the student display what he or she really does know, but usually most of the problem with less than stellar exam scores is passive studying strategies. Two common types of problems are listed below.
- Clarity of definitions or concepts vs. those derived from context.
Familiarity with material vs. mastery of the material.
- Students often generate their own general concepts or definitions from context (that is 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" often isn't sufficient.
- Knowing the exact definitions and equations very well also increases exam speed, allowing more time for analytical questions.
"I have trouble with those trick questions."
- "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 so that the information can be successfully applied to new situation.
- Knowing how much detail to learn is difficult, and varies with each class – see the first FAQ above.
Many "trick" questions aren't tricks at all — they just require careful reading (so will prescriptions, etc.) and care in answering. In general:
- Focus on the data in question by highlighting (exam software) relevant information in the stem.
- Jot down key information on the scratch paper in a quick organization if needed and do any needed calculations.
- Have a general idea of the possible answers before you read the answers, then find the most correct answer among them.
- Try to have a "back-up" alternative logic to verify your answer, other than that in the answer itself; emphasizing organization and connections during studying helps this technique this a lot.
Common specific problems that increase the chance of missing a question include:
- Choosing the first correct statement, even though it is not the best answer to the question.
Choosing a familiar association between two factors, even though that association does not work in the described scenario, or the factors are related inversely instead of directly.
- Be sure the statement answers the stem and is true under the conditions listed.
Reading the first half of an answer and choosing it, without reading the second half and realizing that it makes the answer false – make sure the 2nd half does not conflict with the 1st half.Trying to second-guess yourself or the exam-writer.
- Rely on clarity, not familiarity, and write out the appropriate equation or relationship.
Assuming that if you've never heard of an answer or a condition in a question, that it's a trick.
- If one answer is obvious to you, they aren't trying to trick you – it is almost always correct!
- The question is probably testing fundamental principles in a new application. Think basics! What situation that you've heard of might be analogous to this condition?
Unfocused questions ("Which of the following is true concerning _____?) require a different technique:
- A surprising number of students will skip over an answer they think is correct to choose one they have never heard of, assuming they must have missing something. Have faith! If you've never heard of it, the choice is probably wrong. Go with what you first thought was correct.
- Read each answer as a continuous statement with the stem or as an answer to the stem and decide if it is true or false; mark off incorrect answers and decide which of the remaining is most accurate.
"Except" or "which of the following is false" questions also require a different technique:
- Be sure to mark T or F next to the beginning of each answer in any "except" question – it is very easy to get distracted by your analysis of the question and just pick the next correct answer. Of course the question is asking you to choose the incorrect answer. If you see two Ts as you look at the next answer, you're more likely to remember you need to choose an incorrect "F" answer.
"I always get it down to 2 answers and the always choose the wrong one."
This is a very real problem for many students – it's not just a misperception. At least two different processes seem to contribute to consistently doing this.
- Students unconsciously equate effort with accuracy. So if it takes 3 minutes to justify one answer and only 30 seconds to justify another, the 3 minute answer is often chosen – after all, that effort must mean something (or you're just tired of trying to figure it out, so you pick the one you just spent a lot of effort working on). Of course this usually means that it took more assumptions and tortuous reasoning to justify the 3-minute answer, which makes it less likely to be true.
- Students also frequently give more validity to impressions of "what your body wants to do" or "what the cell wants to do" than to actual known relationships or equations that describe reality. Often, a student will say something like, "Well, I knew that stroke volume times heart rate equals cardiac output, and answer 'b' fit that equation, but I though that stroke volume should be really important in determining MV02 because the heart wants to move all that blood, so I chose answer 'c'." Notice the difference between "knew" and "should".
So try to avoid these traps by sticking with the answer that first that made sense – unless
you recognize a serious flaw in your logic or suddenly remember a fact or equation! If you're having this problem even with focused questions (the kind that you can guess at the answer by just reading the stem), sometimes it's worth considering each answer with a 5-part scoring system to help analyze the question.
When I change answers, I always seem to change them from right answers to wrong answers.
- Read the question stem once carefully and then begin reading each answer carefully – as you read each answer the first time, write its score (described below) just to the left of the answer.
It's important to assign a score on your first impression, since this is usually based on fundamentals and often correct – the more you analyze a question, the more likely you are to tangle up your analysis and end up choosing an incorrect answer.
- TT = definitely true – you are confident of the fact or can write out the equation or can visualize the information from your notes or summaries that support it.
- T = probably true – you aren't confident, but something tells you it's probably true.
- ? = no clue – don't be afraid to use this if you don't know!
- F = probably false – you aren't confident, but something tells you it's probably false.
- FF = definitely false – you are confident of the fact or can write out the equation or can visualize the information from your notes or summaries that support the fact this is false.
- Scan the answer scores for their pattern.
- If only one is TT or T and the others are ?, F or FF – no problem, pick the correct answer.
- If there are both TT and T or both T and ? (or both F and FF on an "EXCEPT" question), re-read the stem and the each answer as a single unit. Try to utilize biological or physiological mechanisms or equations in your analysis. Don't change a T into a TT, or a "?" into a T, or an F into an FF unless you can write the supporting evidence on your exam page. That rule will allow you to change answers when you need to and minimize answer changing for the wrong reasons.
If you don't have a good reason to change an answer, the first answer will most likely be correct. Your first answer choice is usually based (often subconsciously) on fundamentals – that's good. If you start thinking too much about the question, you're likely to mislead yourself by getting sidetracked into unlikely logic paths with more assumptions and tortuous reasoning. These are the same ones that take up a lot of time and make the answer less likely to be true. So:
- If you can write out the reason to change your answer, do so. This should take care of those times that you really recognized an error in your logic or in an equation, or a later question gave you some information you had forgotten.
- If you can't write out the reason, don't change the answer. This should minimize the problems explained in the first paragraph.
You may lose a question occasionally using this advice, but overall, you'll end up with better scores. (Several studies have concluded that changing answers on multiple choice answer exams is beneficial, but if you read the studies, these studies don't discriminate between changing answers for valid reasons versus not. This advice takes care of both issues.)