I wanted to do some blog posts on topics that have particularly begun to interest me recently - those around medical education. Over recent months, partly through my postgraduate medical education course, I have steadily realised that I have gone through well over a decade of higher education without ever being properly taught how to learn. This is quite a situation to be in with a training program as long as ours, and with a career of lifelong learning still to come. I therefore though I would start by looking at a topic that has really revolutionised my own learning over the past few months. The topic is that of ‘spaced repetition’ and I really don’t think I can understate the impact that it has had on my own retention of certain information.
Spaced Repetition
Now I will start by conceding that ‘learning’ as an entity is about much more than the declarative recall of facts (indeed this will be fascinating to explore further at some point). However, as someone who has been doing pretty much continuous examinations for about 20 years, I feel fairly confident in saying that much of our formal education system is still pretty keen on assessing learning by this approach. There is definitely a lot of workplace based assessment in clinical training, but even after medical school, the post graduate examinations involve a hefty dose of recall (I have only recently finished the Final FRCA examination process as an example of this). Now generally I have always found this quite a challenge. I am sure that many of you can relate to my feeling of perfect clarity of thought and vivid insight whilst studying a topic, but how, even by the next day, much of it has already blurred together into an indistinct mental mass. I personally seem to find that generalised concepts survive this decay much better (maybe that is why I like the interacting concepts of physiology) whilst things such as definitions, values or lists seem more slippery to hold on to. My default position since the start of my medical training has been to learn something, forget it, and then learn it again when I next need it (usually the next exam).
So now for the sale’s pitch, for just £9.99 a month, you can learn anything….just joking. As much as some of these benefits are impressive, I’m not quite peddling snake oil. The educational concepts behind spaced repetition are actually pretty ancient. The concept is this; when we learn something, it is surprisingly vulnerable to decay. Ebbinghaus famously described this effect by trying to remember random number, and the resulting graph bears his name (see below). The graph displays what happens to the knowledge that we have 'learned' during the period of time after initial learning.
So now for the sale’s pitch, for just £9.99 a month, you can learn anything….just joking. As much as some of these benefits are impressive, I’m not quite peddling snake oil. The educational concepts behind spaced repetition are actually pretty ancient. The concept is this; when we learn something, it is surprisingly vulnerable to decay. Ebbinghaus famously described this effect by trying to remember random number, and the resulting graph bears his name (see below). The graph displays what happens to the knowledge that we have 'learned' during the period of time after initial learning.
As we can see, the retention of knowledge displays a negative exponential curve. Pretty depressing! Now whilst we can probably appreciate this in many areas, I’m sure we can also recognise that this doesn’t appear to be the case for everything - some things actually hang about pretty effectively. Whilst there are different factors behind this observation in adult learning, the feature about this that we are interested in is the concept of repetition. As can perhaps be best demonstrated on this next graph, the act of repetition causes a renewal of the ‘knowledge level’ back to full. The big difference is that now this rate of decay is less severe.
The ‘spaced’ in ‘spaced repetition’ comes from the observation that the timing of this refresher session is important. Indeed, the optimal timing appears to be at the point of when you are just about to forget something. Here, the gains in knowledge consolidation are maximised if you revisit the information and refresh your understanding of it. This is a nice overview of the concept of spaced repetition from the team at Osmosis: https://www.youtube.com/watch?v=cVf38y07cfk
Now there is another additional aspect of this which I often group together with spaced repetition - the testing effect. This is the observation that if you test yourself on a concept, you will retain it better than if you simply revise it. This even includes if you get it wrong, as long as there is timely correction. The trick seems to be that it needs to require some effort to get the benefit. As with the spacing mentioned above, if it is just on the edge of being forgotten, more mental effort is needed, it’s harder to do, but the consolidation into long term memory will be stronger. This is another nice video from the Osmosis team about the testing effect: https://www.youtube.com/watch?v=_wqG7g1kZUo
Now there is another additional aspect of this which I often group together with spaced repetition - the testing effect. This is the observation that if you test yourself on a concept, you will retain it better than if you simply revise it. This even includes if you get it wrong, as long as there is timely correction. The trick seems to be that it needs to require some effort to get the benefit. As with the spacing mentioned above, if it is just on the edge of being forgotten, more mental effort is needed, it’s harder to do, but the consolidation into long term memory will be stronger. This is another nice video from the Osmosis team about the testing effect: https://www.youtube.com/watch?v=_wqG7g1kZUo
Putting it into Practice
What I do want to promote is Anki. This is one method for incorporating the aforementioned concepts into everyday learning. It is free software (also available in app form) that uses an algorithm to help you test yourself on knowledge, and to space this testing optimally. Think of it as a flashcard deck with an Ebbinghaus curve built in. You create (or can download) an electronic flashcard with a question on the front and the answer on the back, and it goes into your deck. When you open your deck next, you are presented with the questions you have written. Once you’ve answered it, you can click to see if you were right. If you were, you can tell the programme how easy you found it, and it will space the time until it is next presented appropriately, making the gap longer if it was easier (some of my cards have several months between testing now). If you were wrong, it goes back into the deck and will repeat in shortly. You are able to add images and sound as well as text which can be really helpful if you are learning diagrams or another language.
As noted by Chris Nickson in his excellent blogpost on the subject, there are clearly some topics that it will work well for, and others it really won’t. To me this seems to centre around the degree of simplicity: the smaller the package of information to be recalled, the more effective this system. As such, remembering the dose of dantrolene is well suited, whilst the steps involved in performing an awake fibreoptic intubation might be less so. In my most recent Final FRCA exam preparation, there were a few ways that I felt it worked well:
As noted by Chris Nickson in his excellent blogpost on the subject, there are clearly some topics that it will work well for, and others it really won’t. To me this seems to centre around the degree of simplicity: the smaller the package of information to be recalled, the more effective this system. As such, remembering the dose of dantrolene is well suited, whilst the steps involved in performing an awake fibreoptic intubation might be less so. In my most recent Final FRCA exam preparation, there were a few ways that I felt it worked well:
- Definitions
- Categories
- Equations
- Graphs
- (Simple) anatomy e.g. brachial plexus line drawing
Why Bother?
But I thought this was more just about passing exams? Well in some respects I think that this is one area where this approach really excels, but I think there is also a very 'real world’ applicability to it as well. There is no escaping the fact that medicine requires you to remember the odd detail or two to practice. It seems to me that many of the things that we deal with on a daily basis (the dose of propofol for instance) will have no relevance to this learning approach. We will simply have already been using repetition, spacing and even testing in our routine activities. It is more the information that is needed, but which will not be given the required consolidation that arises from routine employment of the information. Some examples I can immediately think of are uncommon drug doses and algorithms, or key physiological equations. I'm rarely going to need to bolus a splash of intralipid in my daily practice, but I'd like the have the dose in my mind for when my patient starts complaining that his lips are tingling and his ECG is looking a little odd. You could argue that this might be a rather extreme example of rarity, where the use of a written protocol or checklist is going to be invaluable, and I'd completely agree if there weren't some bad things that happen quite quickly in anaesthesia and ICM. A rare scenario warrants revising before you tackle it, but sometimes there really isn't time and it’s good to know some important details beforehand.
The other argument is one of volume - there is probably a bit too much of this knowledge to constantly be looking up. This is probably the more applicable point for most of us. There genuinely is a lot of this stuff that we learn in exam preparation that is very useful (no I’m not looking at you trimetaphan) but just doesn’t get used with quite enough frequency to know well enough. Examples that I have come across this week include the different lung segments (I’ve been back doing some bronchoscopy after quite a gap), the definitions and normal values of the lung volumes/capacities (revising preoperative assessment of respiratory function) and the normal values of a ROTEM (was performed on a patient in theatre). It is these things that I feel I should know, and will benefit from knowing, but which will not stick in my memory without some concerted effort. As such, nearly all my learning now includes identifying components that I think I will want to consolidate into my memory, and creating simple question and answer cards for my Anki deck.
The other argument is one of volume - there is probably a bit too much of this knowledge to constantly be looking up. This is probably the more applicable point for most of us. There genuinely is a lot of this stuff that we learn in exam preparation that is very useful (no I’m not looking at you trimetaphan) but just doesn’t get used with quite enough frequency to know well enough. Examples that I have come across this week include the different lung segments (I’ve been back doing some bronchoscopy after quite a gap), the definitions and normal values of the lung volumes/capacities (revising preoperative assessment of respiratory function) and the normal values of a ROTEM (was performed on a patient in theatre). It is these things that I feel I should know, and will benefit from knowing, but which will not stick in my memory without some concerted effort. As such, nearly all my learning now includes identifying components that I think I will want to consolidate into my memory, and creating simple question and answer cards for my Anki deck.
Does it Work?
Now this is a fair question, and always a challenge to get incontrovertible data in medical education. There is a degree of enthusiasm out there for this technique (as well as from myself), such as Gabriel from Fluent Forever, and Chris Nickson as previously mentioned. I think that the best summary of this (and several other key learning points) can be found in Make it Stick: The Science of Successful Learning, a book by Peter Brown, Henry Roediger III and Mark McDaniel. This summarises and brings together a huge amount of the work on this topic in a very accessible manner, and I know several #FOAMed guys have also promoted it (hence how I came across it). Over time I’m hoping to look into this and other topics in more detail, and will probably do my usual approach of posting my notes online, so keep an eye out on TheGasmanHandbook.co.uk for more. If I’ve managed to spark your interest on the topic I have included a few other links below which you might find useful for some more information on the topic.
Final Thoughts
Now, I don’t want to try and sound like this is the only thing you ever need to do to study medicine, especially given the great complexities of how we can apply this knowledge correctly into clinical practice. However, in the context of being a tool or a method that optimises long-term retention of large amounts of factual information, I have found both the personal experience of it and the literature around it very persuasive. I suppose the central crux of this post is this: effective learning is hard work. It requires repetition and a sense of mental effort to be most effective. Some of these idea that I have mentioned are just one perspective on this truth about learning, and I hope to explore some more soon. This approach isn’t a silver bullet - it still require the dedicated time of learning the topic and then the additional dedication to go through your flashcard deck each day. However, this sense of mental effort appears to be where the benefits lie, and I’ve been pretty impressed so far. As always, please add your own comments and observations about the topic and any other resources that you think would be useful.
BW
Tom
BW
Tom
Links & References
- Osmosis. Spaced repetition. 2016. https://www.youtube.com/watch?v=cVf38y07cfk
- Brown, P. Roediger III, H. McDaniel, M. Make it Stick: The Science of Successful Learning. 2014. The Belknap Press. Cambridge:Massachusetts.
- Nickson, C. Learning by spaced repetition. 2017. LITFL. https://lifeinthefastlane.com/learning-by-spaced-repetition/
- Anki. https://apps.ankiweb.net/
- Wyner, G. Fluent Forever. 2014. Harmony Books: New York.
- Schnapp, B. et al. Education theory made practical 2: Spaced repetition theory. ICE Blog. 2018. https://icenetblog.royalcollege.ca/2018/04/24/education-theory-made-practical-2-spaced-repetition-theory/
- Augustin, M. How to learn effectively at medical school: test yourself, learn actively, and repeat in intervals. Yale J Biol Med. 2014. 87(2):207-212. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4031794/
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