Do you know your phone number? What about your address? The complete lyrics to your favorite song? You do, yet you likely expended very little energy to learn these things. As cliché as it may sound, the human brain is fascinating and we are learning constantly, every hour of every day, even if we don't realize it. When it comes to things we enjoy, or things we do routinely, we usually learn seamlessly, without trying or even noticing that we are learning. One day you may struggle to write down a new phone number, and a couple of days later you effortlessly recall it without skipping a beat.
Sadly however, this all breaks down when we sit down to study. No matter how much we stare at the page, highlight or sketch things out, we often find that retaining factual information remains elusive. Some strategies help, such as teaching back or rationalizing mechanisms—but for pure memorization there are often few options that are both effective and sustainable.
This problem is particularly poignant in medical school and while studying for the USMLE, where although some concepts can be derived from basic principles through reasoning, a large portion of the material still seems like a laundry list of unrelated facts and figures. From receptors to muscles in the foot, medical students often find themselves drowning in memorization and often keep recurring to the same old tactics of college--pounding the books inefficiently.
While one would hope that reading and rereading a list of facts would help, even when it does, the time investment is disproportionate to the return, as over 90% of information that is read will be forgotten after 2 weeks. All in all, the disconnect between learning in our daily lives and learning for school comes down to the fact that our brains are just not designed to learn in the artificial environment of studying.
How do we learn?
Paradoxically, given how hard it is to memorize the brachial plexus, we never really “study” the things we know well. No one for example (or most people don’t anyways) sits down to memorize the lyrics of their favorite song. Instead, we sign along a couple of times, improving with each attempt. The first go-around might be atrocious, but we keep getting better and better. They key to efficient memorization is thus to unlock this method and apply it to medical facts.
Repetition emerges as a key tool, but an important distinction is clear. The repetition we typically use while studying tends to be forced and crammed, while the repetition in everyday life is more organic—it happens at different intervals, and we learn to correct the things we forget.
The theory to integrate these two concepts (repetition + spaced intervals) dates as far back as the 1930’s, and researchers through the years have validated its effectiveness. While fancy algorithms and papers exist describing it, at its core “spaced repetition” consists of seeing content at increasing time intervals, resetting the intervals for any forgotten material.
It sounds simple (and it is), but it a vital tool that has gotten me through medical school. It’s something that I continue to use, and something that I recommend all students incorporate from day one.
Putting it all together
Theory aside, what comes next? How do we integrate spaced repetition with the mountains of medical school material? Thankfully, there’s an app for that!
While alternatives exist, perhaps the most well-known and popular one is Anki. A web-based platform, it allows you to create “high tech” flashcards that incorporate spaced repetition algorithms to really hone the material. By integrating these into your studying, you can digest any source material into bite sized pieces that you can review conveniently and effectively.
Like any tool however, you only get what you put in, and several important considerations are vital for good cards:
Bite sized prompts
You want to go through cards quickly, with keywords and prompts that become solid associations in your head. This is not the time or lengthy clinical vignettes, but for short unmistakable questions. Think of prompts analogous to the rapid review section of First Aid.
One to one solutions
Just like prompts have to be short, solutions have to short, ideally with 1 or 2 concepts directly and unambiguously related to the prompt. Leave differentials out of these, answers should not be confusing.
Complementary explanations
While ideally each prompt will be answered with a single concept. Reviewing cards is also a prime opportunity to further explore concepts and be reminded of other details. As such, besides the answer/prompt pair, effective cards also include supplemental information to clarify concepts, either in the form of extra explanation or diagrams. These however, always remain clearly distinct from the answer, so as not to compromise points 1 and 2.
Finally, while many decks exist in the web of varying quality, the best advice I can give is to make your own cards. This will cut down on unnecessary cards of concepts you know well, and will reinforce concepts even more by forcing you to start by identifying the concepts that are important as you study.
Flashcards might seem old fashioned, but software such as Anki really brings them to the future, leveraging spaced repetition to make memorizing the bones of the hand almost as easy as learning a new catchy song. Studying for medical school or the USMLE will never be entirely painless, but you are far more likely to succeed if you employ an evidence-based technique, such as spaced repetition, when you study.
Emmanuel Carrodeguas is a 4th-year medical student at Harvard who scored a 257 on Step 1 and a 260 on Step 2 CK. He has matched at UCSF in Diagnostic Radiology and tutors for all subjects with USMLE Pro.
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