Study Skills and Exam Strategies


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 have quick access to a lot of information in a fashion that allows them to access it accurately and from a wide variety of different angles.

Only change your strategies if you're not satisfied with your exam scores (and you don't need to score 90%!).

The 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.

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

"Drinking from the fire hose" requires active studying – if you aren't making decisions about the material as you study, it isn't active.

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 hoping to absorb the information is very 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 concepts are fundamental to a successful active study pattern?

Four active processes will be used in the steps of any active study pattern, and any study time that does not involve one or more of these steps is almost certainly passive and inefficient!

  1. Identifying the important information – answering the eternal question of "what's important here?"
  2. Organizing the information – create a framework that facilitates memorization and emphasizes the connections within the material needed for application questions, e.g., for differential diagnosis. 
  3. Memorizing the information – do this in pieces along the way and review it in pieces – much easier! 
  4. Applying the information to more complex situations – practice this before the exam.

What are the steps of this plan?

  1. Before lecture, briefly preview for ≈ 10 minutes per lecture hour to identify the "big picture".
    1. If the lecturer provides learning objectives and/or a lecture outline– use it!  If not, skim the assigned reading for the headings and main points.
    2. Pre-lecture work has 2 goals: 
      1. Identify the number of major headings and subheadings and then memorize them (don't skip this part!); reinforce them by reading any introduction or summary.
      2. Scan the material to note any definitions, equations and diagrams that you'll need later.
  2. During lecture, take notes that emphasize the big picture and what the instructor thinks is important. 
    1. Annotate power point slides or lecturer notes, using the backs of the pages for your notes if needed.
    2. Focus on adding context from the lecturer – don't rewrite data already present in notes or slides.
      1. On a graph on a PowerPoint slide, note the "point" a graph or chart is making, or clearly label the axes.
      2. Emphasize any lecturer comments on key points or the "message", but don't worry about getting down all the historical detail or "color" commentary.
      3. 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 molecular technique is used rather than another, etc.
      4. Use abbreviations and symbols whenever possible to increase the information you can take down.
    3. After lecture, on the same day (if feasible), complete your lecture notes and design organizational headings.
      1. Complete the lecture notes by labeling, annotating and cross-referencing your notes all at the same time – this creates the messy but complete back-up document of information you might need.
        1. Add the major heading and subheadings for the lecture into the notes (if they aren't already present).
        2. Circle specific terms and definitions within the notes in a different color – these will be used both for reference and for keying memorization of the material.
        3. Use texts or online references to complete any missing definitions or fill in missing key information.
        4. Cross-reference! Each time the lecturer mentions something you remember being discussed in an earlier lecture, stop, find the pages in your earlier notes and list them in them in both places in the left margin; cross-referencing is much faster at this stage, not later.
      2. Use the learning objectives (if they are "task-oriented") or the headings or examples within the material to decide on simple lists, charts, flow diagrams, or pictures to organize the material.
        1. Sketch out headings for the charts or lists or flow diagram or picture – but don't fill in the details yet.
          1. If the lectures include "task-oriented" learning objectives – use them!!!!
          2. In each case, choose headings that distinguish between features or categories – the major headings and subheadings you memorized can be very helpful here
          3. Use a hierarchical approach for headings or spatial organization – no more than five major headings on a list or chart or six major sections on a diagram — if you need more headings or sections, decide how they are related and create subheadings.
          4. Make sure the order of your headings (charts/lists) or spatial organization (flow charts, diagrams) provide information due to their sequence or location; e.g., they reinforce the "big picture", or anatomy, or chronological sequence, or steps in a physiological or cellular or molecular process.
          5. Don't recreate the wheel. If you find a good chart in some text or other source, photocopy it and add it to your summaries.  Be sure to add any additional information to make it complete or more comprehensive — try a different color ink to make it stand out.
          6. This all requires analysis and integration of the material, which is active, and aids memorization, since there is a "reason" for the order or spatial organization.
        2. Limit the material covered in a single summary to an amount reasonable to memorize, then use multiple summaries to cover the material from different points of view.
        3. Use equivalent headings or orders of headings for related topics to emphasize connections within the material and facilitate memorization.
        4. Where possible, create "big picture" charts, diagrams or pictures that integrate material from multiple lectures.
        5. Don't hesitate to include the same information on different summaries, especially if each summary is organizing the material from a different point of view or at a different level of detail.
      3. Memorize the headings now – before you've filled in the details; this will help you memorize the rest of the information more efficiently later.
    4. Within a few days, find time to complete your lists, charts, flow diagrams and pictures – these summaries combine to form the "final draft" of your information that you will study for the exam.
      1. Finalize the organization of the headings for your list or chart, or the spatial organization for a flow chart or diagram before adding in any of the information.
      2. If you're not sure whether to include a specific detail, leave it out and just put in an asterisk in the appropriate spot with the page number from your lecture notes for quick reference.
      3. Use the lecturer's emphasis to help decide "what's important", and to look for missing information.
      4. Use texts or online references to fill in any portions of the organizations that weren't clear from the lecture notes but that you think might be needed to create effective summaries – use the index in the text to direct you to specific topics, so you don't get caught up passively reading large sections without actively pulling out the facts to incorporate into your organizations.
      5. See FAQ on "How do I know what will be on the exam?" or "How do I know how much detail to learn?" later in this summary.
    5. Continually review and apply.
      1. Actively memorize the material – don't just "go over" it.
        1. Memorize organizations rather than slides or paragraphs of text, because it is easier and most importantly, it will be more accessible for later use. Studies have shown that the more connections made between information, the better and longer you will remember it.
        2. Memorize the headings first – their order should contain useful information by themselves.
          1. First, memorize how many items (e.g., headings) there are – it's much easier to know if you've got them all memorized if you know how many you need.
          2. Second, memorize the headings themselves – using biological logic, visualization, or mnemonics.
          3. Third, memorize the information associated with each heading, starting with just a key word or short phrase, and finally adding the full item.
        3. When you think you have memorized any piece of the chart, etc.:
          1. Cover the original, and write out the material on a blank piece of paper (don't be pretty, but don't cheat!), then throw what you have just written away!!!
          2. Look at the original – if you're confident you got it all – great!  If there is any question, don't compare with what you should have thrown away – just memorize it again.
          3. This method emphasizes what you don't know; comparing the new with the old only confirms what you already knew, which can frequently mislead us into thinking we know more than we do.
        4. 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.
      2. Don't put off memorizing material!
        1. Of course you will forget much of it after the first time you memorize each piece — that's why you build repetitions into your study pattern so the information ends up in long-term memory in a framework usable for other classes and during your practice. If you cram it the night before, you won't remember it a week later, much less the next quarter or the next year.
        2. Memorize each "level" of material as that step comes up, which will make memorizing the next "level" easier and more effective – this is crucial to keeping up with the material
      3. Frequent review is relatively painless with organized material – and your most effective tool.
        1. Every time an earlier topic or concept is mentioned, stop and review to yourself the relevant summary list – start with how many, then the headings, then the key words, then the concepts or facts. This sets the information in your memory, and builds practice in the sequences you'll use to answer questions.
        2. This review actually decreases the time needed to master later lectures, since later material builds on earlier, and increases exam speed, since answering factual questions will be easier and faster
      4. Predict application questions by asking: "Given data (clinical or molecular)", determine the most likely cause of the symptoms or test results, or the best assay/technique to use, or the mutation that could cause the results, or the calculation needed to determine the risk of having the disease, etc.
      5. Use practice questions or quiz questions to work out methods for approaching complex or clinical applications well before the exam – and write some of your own! These are tools to learn from, so don't wait until you're pretty sure you'll know the answers. That's too late for the greatest benefit!

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.
    1. 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.
    2. Medical terminology and equations are very precise – being "close enough" often isn't sufficient.
  2. Familiarity with material vs. mastery of the material.
    1. "Familiarity" refers to recognizing the logic provided by someone else – as when leaving a good lecture, you can say, "yeah, that made sense."
    2. Mastery of the material requires integration and memorization of sufficient detail that the information can be successfully applied to a new situation.

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 shortening the time needed to create the rough draft.
    2. Creating summaries takes time, but you'll learn the material with connections and insight that will let you answer those application questions; and they 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).
    3. 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.
  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 a chart 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 (see below).
    3. 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 lots to cover.
    4. 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 class.

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?"

  1. How do I know how much detail to learn from lectures?
    1. 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.
    2. Check your lecture notes – they should emphasize the lecturer's context, which includes any comments by the lecturer on what is important.
    3. 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!!
    4. Other indications that information is important:
      1. 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.
      2. 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.
      3. If the instructor gives a sample calculation, and an accompanying table has more examples, fill it in.
      4. 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.
  2. 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.
  3. 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?"

  1. 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.
    1. 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?).
    2. If you didn't get it right, go back and memorize the entire chart or summary that contained it.
  2. 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.
  3. 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.
  1. Clarity of definitions or concepts vs. those derived from context.
    1. 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.
    2. Medical terminology and equations are very precise – being "close enough" often isn't sufficient.
    3. Knowing the exact definitions and equations very well also increases exam speed, allowing more time for analytical questions.
  2. Familiarity with material vs. mastery of the material.
    1. "Familiarity" refers to recognizing the logic provided by someone else – as when leaving a good lecture, you can say, "yeah, that made sense."
    2. Mastery of the material requires integration and memorization of sufficient detail so that the information can be successfully applied to new situation.
    3. Knowing how much detail to learn is difficult, and varies with each class – see the first FAQ above.
"I have trouble with those trick questions."
Many "trick" questions aren't tricks at all — they just require careful reading (so will prescriptions, etc.) and care in answering. In general:
  1. Focus on the data in question by underlining, boxing or circling relevant information in the stem.
  2. Jot down any useful equations or quick lists in the margin as a reminder – you may use them later, too.
  3. Have a general idea of the possible answers before you read the answers, then find the most correct answer among them.
  4. 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:
  1. Choosing the first correct statement, even though it is not the best answer to the question.
    1. Be sure the statement answers the stem and is true under the conditions listed.
  2. 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.
    1. Rely on clarity, not familiarity, and write out the appropriate equation or relationship.
  3. 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.
  4. Trying to second-guess yourself or the exam-writer.
    1. If one answer is obvious to you, they aren't trying to trick you – it is almost always correct!
  5. Assuming that if you've never heard of an answer or a condition in a question, that it's a trick.
    1. 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?
    2. 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.
Unfocused questions ("Which of the following is true concerning _____?) require a different technique:
  1. 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:
  1. 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.
  1. 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.
  2. 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.
  1. 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.
    1. 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.
    2. T = probably true – you aren't confident, but something tells you it's probably true.
    3. ? = no clue – don't be afraid to use this if you don't know!
    4. F = probably false – you aren't confident, but something tells you it's probably false.
    5. 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.
  2. Scan the answer scores for their pattern.
    1. If only one is TT or T and the others are ?, F or FF – no problem, pick the correct answer.
    2. 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.
When I change answers, I always seem to change them from right answers to wrong answers.
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:
  1. 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.
  2. 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.)