A couple of years ago I wrote a blog post looking at the technique of spaced repetition. With my (hopefully final) exams now completed I wanted to revisit the topic and add a few additional points that I think complement this approach to learning. These are ideas that I have come across over the intervening years of using spaced repetition, as well as from ongoing study around learning techniques. One of the most useful of these resources has been the free online course “Learning How to Learn” by Dr Barbara Oakley and colleagues on Coursera ( I believe I have read that this is the most popular course on Coursera). This course highlights some of the key evidence-based approaches to effective learning and I would strongly recommend the modest time investment involved in completing it. In addition, although I was still digesting it at the time of writing my initial blog post, I feel I have been able to absorb more of the concepts from the brilliant book ‘Make it Stick’. Although this is a more detailed dive into the evidence, this blog post from Eva Keiffenheim provides an excellent summary of some of the key themes which is well worth a look at. But now I’ll give a quick summary of some of my own learning points. These are all related to the optimal use of my flashcard deck using the Anki app, so some points may be more or less applicable to you depending on your own approach.
Note Making
This is a component of learning that I am sure is not new to most of you. However, I feel I have really increased the potency of my learning when combining effective note making with a spaced repetition technique. The educational theory that this is built on is all about constructivism; that is, we construct our knowledge, fitting it in with what we already know, rather than a simple copy and paste onto our harddrive. As such, taking the time to read, digest, then create your own understanding of a topic is a very powerful way for making sure it is retained. This is, therefore, actually quite a laborious process to do effectively, partly because of the time commitment, but also because of the cognitive effort involved in the full reconstruction of a topic in your own words. However, as is repeated through all of the sources, it is this sense of hard work that is part of the reason why it is effective learning. Learning requires the creation and reinforcement of new neurological connections and pathways, and this feels effortful. This does mean that I find that topics take longer for me to cover than previously, but I feel that the benefit is felt many months (maybe even years) later, when I still feel I have a strong grasp of the subject. Once I have put this effort into my notes, I feel I have a clear idea of which are the key nuggets of information that I want to add to my flashcard deck and work to commit to memory. I feel I then know the topic well and have created the global cognitive connections that have allowed me to ‘understand’ a topic. The role of the spaced repetition is then to help me remember the bits that I think will decay. This covers a huge range of things but will be clear to me once I have finished the topic. This process of creating my flashcards at the end of creating my notes also serves as a great revision session in itself, as I look through the topic once again to extract the key points. Indeed, I wonder if approaching a topic with this end in mind also helps me to engage with the source material more effectively, optimising the integration with my current learning because I am actively trying to construct my information.
Bearing all this in mind, I think I would summarise the key points to think about when making notes as such:
Bearing all this in mind, I think I would summarise the key points to think about when making notes as such:
- Using electronic notes is useful to allow repeated re-editing of your notes as your go (I use Google docs to allow me to edit documents wherever I am).
- Try and rephrase/reformat the source material as much as possible. I use some general structures for my notes that I fit the source information into e.g. definition, classification.
- Creating flashcards at the end of the note making process serves as a good revision process in itself, helping with the consolidation.
Flashcard Creation
Now there is a bit more technique in creating the optimal flashcards than I first appreciated. The goal is to create the optimal questions for improving your retention, but also for maintaining your habit (covered more below). Whilst you want there to be some effort in answering the cards, you don’t want to be demotivated because you are continually repeating cards that you get wrong. I have found that the key to this is to focus on making the answer component of the card as concise as possible. The smaller the information package in the answer, the easier it will be to answer in one go, without the problem of only half answering a question (and the subsequent issue of having to repeat it). I have found that this has helped me with answering the questions, improving my retention of the answers and also making it more pleasant to get through cards. This can be a bit of a challenge with some concepts e.g. treatment strategies, but just needs the focus on trying to keep the answer brief. In some cases, there has been a need to essentially turn a big answer into multiple smaller answers, although I think that some of the systematic approaches within medicine helps with this. For instance, instead of listing all the features of a disease, I might list the different systems involved as the answer to one question (respiratory, haematological, etc). I would then create a separate card about the specific systems e.g. list all the respiratory features of this condition. This can be done with examination findings, investigations (e.g. blood findings, ECG changes), and even management (medical options, surgical options). The more practice I have done the better I have got at this, but I can definitely tell that my newer cards are better than my old ones.
A final, albeit slightly separate, component of creating cards is about using pictures. I have not gone into detailed exploration of the theory beyond this (I am not sure how valid the VARK system is anymore) but I notice that some things are just better visually represented rather than in words. I think I have a preference for diagrams in my own learning, and so making sure that I could use these in this technique was important to me. I know I touched on this in the last article, but adding images to my card deck is very useful for a number of topics. What I have found to be helpful is to be sure that I have the facilities to draw and sketch when I am answering my cards. A piece of paper works well, but I have also downloaded a very basic drawing app on my phone that lets me simply sketch a simple diagram or equation if I need to. This additional engagement of drawing out an answer has helped make some of these topics much more ingrained than they otherwise might have been. Indeed, I find that writing out the written answers in some cases is also really helpful (e.g. lists or categories), but doing it for every question has always seemed a bit too laborious to work for me.
Key points:
A final, albeit slightly separate, component of creating cards is about using pictures. I have not gone into detailed exploration of the theory beyond this (I am not sure how valid the VARK system is anymore) but I notice that some things are just better visually represented rather than in words. I think I have a preference for diagrams in my own learning, and so making sure that I could use these in this technique was important to me. I know I touched on this in the last article, but adding images to my card deck is very useful for a number of topics. What I have found to be helpful is to be sure that I have the facilities to draw and sketch when I am answering my cards. A piece of paper works well, but I have also downloaded a very basic drawing app on my phone that lets me simply sketch a simple diagram or equation if I need to. This additional engagement of drawing out an answer has helped make some of these topics much more ingrained than they otherwise might have been. Indeed, I find that writing out the written answers in some cases is also really helpful (e.g. lists or categories), but doing it for every question has always seemed a bit too laborious to work for me.
Key points:
- Keep the answers short. More questions with shorter/smaller answers seems to work better for retention, as well as motivation for doing the cards.
- Break down larger answers into multiple small parts where possible
- Try adding in the facility to draw and sketch diagrams or equations for some topics
Forming the Habit
A key factor in deriving any benefit from this technique is actually answering the cards. I think this is even harder than it sounds and I recall the despair of missing a few days of questions and then finding 100 questions waiting for you when you next open the app. As well as being demoralising, I think this probably impacts on the efficacy of the spacing. The motivation of the exams was some help with this, but I have gone off the belief that willpower alone is an effective strategy here; it just seems too fickle and dependent on everything else that is going on in your life. I reviewed the excellent ‘Atomic Habits’ book here, and it is within these pages that I hope to have found the answers to this. I think turning it into a core habit is the best way to make sure you are getting effective utilisation of the learning. I would recommend that you go and read my post on the topic, or even better read the book, but will just focus on some key tips here. I have already touched on one, which was to make the answering of the questions as easy as possible (whilst still being effective). More cards with shorter answers is what I find suits me best, and creating more cards like this has made answering them less of a chore. There may be some personal preference here, but I would reflect on what you find is making it hard for you to answer your cards and try to combat it. As I note in my habit post, I use a habit tracker app to help me with this. This is simply a tick-box chart that lets you keep track of whether you have done that habit each day. The tick-box nature provides some form of incentive (the enjoyment of ticking things off a list) and identifies when you might be struggling. Again, you may have your own thoughts and preferences on this, but I would strongly encourage you to think about how you can ensure that the answering of all your cards is a daily practice.
- Create a habit of finishing your cards every day. I use a habit tracker app to help me with this
- Optimise your card writing to make them easier to do
Final Thoughts
With those three areas covered I think I will wrap things up. I hope these tips are ideas that may help you in your own learning practice and make learning easier, more effective, and hopefully maybe even more enjoyable for you. I will end with a confession: despite having finished all my exams I am still continuing with my flashcard deck! I know this is in the spirit of the lifelong learning that is part of medicine, but it is not something that I was sure I would have the desire or ability to do. A brief reflection on the reason why is that it is both enjoyable and pretty easy. Without adding loads of new cards each day (as during the peak of exam prep) the daily question load is pretty gentle. I find a modest degree of pleasure in a daily quiz on a few medical topics, and (I may be alone in this) find there is a little dopamine hit from getting answers right. Indeed, through my reading I am beginning to believe that there is something innately pleasurable in learning for us humans. It seems to have its own degree of reward, independent of any goal that it is directed to. And that is without even saying that being knowledgeable about things within your specialty is also quite a nice scenario for you to create for yourself. In addition, I feel I have spent too much effort in acquiring all this knowledge in the first place for me to simply let it decay. The cost seems small, and the benefit high, but we will have to see how these balance up in the long run. I hope that this may provide some further inspiration for you, and thank you again for reading.
BW
Tom
BW
Tom
- Heaton, T. Medical Education: Spaced Repetition. Rapid Sequence. 2019. http://www.rapidsequence.org.uk/blog/medical-education-spaced-repetition
- Oakley, B. et al. Learning how to learn. Coursera. https://www.coursera.org/learn/learning-how-to-learn
- Keiffenheim, E. How to remember everything you want from non fiction books. Medium. 2020. https://medium.com/better-humans/how-to-remember-everything-you-want-from-non-fiction-books-df17096d517f
- Brown, P. Roediger III, H. McDaniel, M. Make it Stick: The Science of Successful Learning. 2014. The Belknap Press. Cambridge:Massachusetts.
- Heaton, T. Atomic Habits. Rapid Sequence. 2020. http://www.rapidsequence.org.uk/blog/atomic-habits
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