Moving From Spaced Repetition to Spaced Learning

flying cadeuciiMedical education is dynamic and constantly adapting to the needs of society. With new technological advances, scientific discoveries, and healthcare policies arising each day, the amount of information medical students are required to learn increases exponentially. Many describe the early years of medical education as a vicious cycle of cramming and forgetting with block exams, shelf exams, and board exams. Long-term retention is rarely rewarded and the integration across topics is limited. On the contrary, medicine IS a life-long learning process that is heavily dependent on the ability to attain, integrate, and apply data.

Unfortunately, time is limited, and as a result, cramming often prevails as the method of choice for many students. As medical students, we constantly find ourselves re-learning large amounts of information time and time again, always preparing for the next exam or hurdle, rather than thinking years down the line when we will be taking care of patients. This is very inefficient.

In June, Duke medical students wrote an article entitled “Want to enhance medical education? Use Spaced Repetition”. This article proposed a strategy that revolves around the cognitive technique known as spaced repetition. Spaced repetition takes advantage of time and reinforces one’s knowledge the moment before one forgets it. This technique involves reviewing material according to a schedule determined by a temporal relationship known as the “spacing effect”.

Although beneficial, spaced repetition requires time and as a result, is not without its own limitations. Spaced repetition can help students remember what they learn, but it will not help students deepen their understanding or teach them things they don’t already know. After all, it is spaced repetition, not spaced learning. Overall, spaced repetition is a useful tool that can be further enhanced in combination with other cognitive techniques.

During my first two years of medical school, I constantly sought advice from upperclassmen and practicing physicians. Many, if not all, assured me that the majority of my long-term knowledge would be attained during my clinical rotation experiences. As a 3rd year now, I have come to understand why. I have learned that a large component of understanding, retention, and integration during one’s medical education is dependent on memory associations.

“Memory association” is a concept that has been studied for many years and in various contexts. The key is the associative design of the human brain. For example, compare the last name “Farmer” to the occupation of being a “farmer”. Farmer as a last name has very few associations whereas the occupation farmer has the ability to automatically activate a number of associations, such as farm animals, barns, “Old MacDonald”, etc. The more associations that exist with a word, the stronger the memory becomes. As fellow medical student and co-founder of Osmosis, Shiv Gaglani, described it in an article for Fast Company, “it’s like trying to catch a fish; the bigger the schema of associations, the bigger the net”.

These associations may be visual, auditory, or emotional and can come from music, art, literature, among other areas. This is why tools such as Picmonic are becoming more successful. They combine visual and auditory associations with a plethora of concepts that increase the number of associations. The majority of impactful associations for medical students come from patient interaction during their clinical wards.

Lets take the antibiotic vancomycin for example. Some important facts to remember about vancomycin are that it is given via the oral route in the setting of Clostridium difficile, via the IV route in settings such as MRSA bacteremia, and a commonly tested side effect of the medication is known as “Red Man Syndrome”. I am able to retain this information because the instant I hear vancomycin I think of the time my grandfather developed C. difficile and was treated with PO vancomycin. In addition, I had an 18-year-old patient who had developed MRSA bacteremia and endocarditis, and was treated with IV vancomycin. Lastly, vancomycin starts with “van”. My family used to own a red van, reminding me of the infamous Red Man Syndrome. Through my experiences, I have been able to build up my associations with vancomycin, and recalling and applying these facts have become much easier.

Another important factor is implementing active learning rather than passive learning. Reading a textbook or listening to a lecture is passive. Doing multiple choice questions and then the reviewing the answers is active. This is dependent on a concept known as the “actor-critic” model which entails a student taking an action and then critiquing that action. Interacting with experienced physicians, actual patients, and gaining real life experience, provides the highest-order of critique. Overall, if you want to make something memorable, you must first make it meaningful.

The early years of medical education are limited to the number of patient interactions and meaningful experiences in the context of healthcare. As a result, we must find other ways to strengthen our memories and build our associations. Combining spaced repetition with visual, auditory, and emotional associations is powerful and something that the medical education startup, Osmosis, strives to do. It formats and organizes information systematically and contextualizes it. More so, it combines powerful visual and auditory associations (Picmonic, YouTube videos, etc.) with other hooks such as mnemonics, flowcharts, and diagrams. By having meaningful context, the connections we have are solidified and strengthened more strongly than the weak associations created via rote memorization.  

Overall, we must continue to explore more efficient methods to better medical education in hopes of improving long term retention and understanding in hopes of creating the next generation of skillful physicians.

Ritesh Patel is a third year medical student at the University of Pennsylvania.

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