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YALE JournAL oF BioLoGY And MEdicinE 87 (2014), pp.207-212.

copyright 2014.

EducATionAL schoLArship

How to Learn Effectively in Medical School:


Test Yourself, Learn Actively, and Repeat in
Intervals

Marc Augustin
RWTH Aachen University, Germany

students in medical school often feel overwhelmed by the excessive amount of factual
knowledge they are obliged to learn. Although a large body of research on effective learn-
ing methods is published, scientifically based learning strategies are not a standard part of
the curriculum in medical school. students are largely unaware of how to learn successfully
and improve memory. This review outlines three fundamental methods that benefit learning:
the testing effect, active recall, and spaced repetition. The review summarizes practical
learning strategies to learn effectively and optimize long-term retention of factual knowl-
edge.

Learning in medical school can be di- knowledge covers what information,


vided into two forms of knowledge: factual whereas procedural knowledge covers
and procedural knowledge. Factual knowl- how and why information [1].
edge is the theoretical background of med- While the latter can be learned by
ical education, e.g., learning the adverse means of simulation and practice, factual
effects of beta-blockers, muscles of the knowledge is more difficult to obtain by
lower extremity, or the definition of the means of reading, summarizing, testing,
systemic inflammatory response syndrome. and restudying. The majority of time in
Procedural knowledge is the practical part medical school is spent on acquiring fac-
of medicine, e.g., how to perform the in- tual knowledge in the various specialties
sertion of a central line, draw blood, or con- that is subsequently tested in exams to
duct a clinical exam on a patient with acute prove that learning was successful. Usually,
respiratory distress. Factual or conceptual students feel overwhelmed and stressed by

To whom all correspondence should be addressed: Marc Augustin, Lousbergstrasse 19,


52072 Aachen, Germany; Tele: 0049 176 76 158 576; Email: marc.augustin@rwth-
aachen.de.

Keywords: learning, testing effect, active recall, spaced repetition, medical curriculum
207
208 Augustin: How to learn effectively in medical school

the sheer amount of facts that medical likewise. Thus, new factual knowledge that
school obliges them to learn [2]. Students we acquire is destined to be forgotten if it is
also experience that long-term retention of learned just once.
factual knowledge is mediocre at best and A different experiment revealed the im-
forgetting is the unpleasant side of learning pressive capacity of memory. The Swedish
something new [3]. psychologist K. Anders Ericsson and his
Surprisingly, scientific knowledge of team published a paper in Science in 1980
how to learn and acquire factual knowledge that describes an experiment involving an
is not a standard part of the curriculum in undergraduate with average intelligence and
medical school [4]. This article reviews memory abilities [6]. The student engaged
main scientific findings on how to success- in a task that involved recalling the sequence
fully learn and retain factual knowledge. of random digits that were read at the rate of
one digit per second. For more than 20
months, the student engaged in this activity
How CAn You IMpRovE
about 1 hour a day, 3 to 5 times per week.
LEARnIng In MEdICAL SCHooL?
Starting with a digit span of seven, the un-
How do students learn factual knowl- dergraduate reached a digit span of almost
edge? The process of learning can be exem- 80 after 20 months or 230 hours of practice.
plified by the above-mentioned adverse These results show that the memory skill
effects of beta-blockers. In pharmacology, can be improved by practice even with ab-
medical students learn about the different stract information.
substances in the group of beta-blockers, These two experiments show the effect
their indications, pharmacodynamics, ad- practice has on memory. Without practice,
verse effects, and conditions when not to learned information is quickly lost down the
prescribe them to patients. Adverse effects path of Ebbinghaus forgetting curve. With
of beta-blockers can be summarized to sev- practice, the memory can be trained compa-
eral facts such as bradycardia, bronchocon- rable to the training of a muscle. Yet which
striction, claudication, hyperlipidemia, and methods are the most suitable in order to
reduced sensitivity to hypoglycemia. These learn and practice what is learned based on
facts can be learned by means of reading, scientific findings? This section will cover
building mnemonics, or simple repetition. three topics of effective learning: the testing
Therefore, learning is successful when these effect, active recall, and spaced repetition.
five adverse effects can be named on free re-
call or by knowing that a patient with dia-
betes should not be treated with THE TESTIng EffECT
beta-blockers due to the adverse effect of re- The testing effect concerns a paradox in
duced sensitivity to hypoglycemia. In our the life of every student in medical school.
memory, we build links between the topic When learning pharmacology and the five
beta-blocker and these five adverse effects. main adverse effects of beta-blockers, stu-
Forgetting is the process of losing this dents read the facts, they summarize them,
information in memory or not being able to restudy, or memorize them for a consider-
retrieve it even though the information is able amount of time and are then tested once
still stored. The links between beta-blocker in a written or oral exam. Testing in the mind
and single adverse effects are missing. The of the average student is a means to assess
German psychologist Hermann Ebbinghaus knowledge and not part of learning.
hypothesized that the process of forgetting Testing as an active element of learning
follows a curve when experimenting with is more effective than studying the factual
the memorization of nonsense syllables and knowledge repeatedly [7]. A considerable
subsequent testing of the retention of these number of experiments were conducted to
syllables [5]. Ebbinghaus found that as time study this testing effect. One example cited
passed, his memory of these syllables faded in the aforementioned paper is a study by
Augustin: How to learn effectively in medical school 209

Hogan and Kintsch from 1971 [8]. One after the entire test. One week after the ini-
group of students studied a list of 40 words tial reading session, all four groups under-
four times with short breaks between the went a final test. The group that took no test
study time. A second group of students stud- showed 11 percent correct answers. Those
ied the list only once and took three free re- participants who were tested without feed-
call tests afterward. Two days later, both back presented 33 percent correct answers,
groups underwent a final test. The first immediate feedback resulted in 43 percent,
group that studied the list four times recalled and delayed feedback in 54 percent correct
about 15 percent of the words. The second answers. Therefore, testing even without
group, which studied once and then took feedback tripled the score in a test 1 week
three free recall tests, recalled about 20 per- after initial studying. Best results were ob-
cent of the words. Studying a list of words tained by delayed feedback, which hints at
just once and then testing yourself by free the positive contribution of spaced repre-
recall led to significantly better results than sentation of learning content that will be dis-
studying the identical content four times. cussed in one of the following sections.
A randomized controlled trial con- Despite the various studies that found
firmed these findings and discovered that re- retesting to be more effective than restudy-
peated testing resulted in significantly ing, students seem to be largely unaware of
higher long-term retention than repeated testing superiority in supporting short-term
studying [9]. This study involved a didactic retention [11]. When students use testing in
conference for pediatric and emergency a learning context, they apply it to assess
medicine residents. There were two coun- knowledge and do not see it as a technique
terbalanced groups. One group took tests on to intensify learning. In particular, students
the topic of status epilepticus and studied a do not seem to be aware of the superiority
review sheet on myasthenia gravis. The sec- of testing compared to studying.
ond group studied a review sheet on status
epilepticus and took tests on myasthenia
gravis. Testing and studying sessions were ACTIvE RECALL
held immediately after teaching and on two Whenever new information is repeated,
additional time intervals of about 2 weeks. an emphasis should be put on active meth-
Each time, feedback was given to the par- ods of repetition such as free recall. In the
ticipants. A final test after 6 months com- example of the adverse effects of beta-
pleted the study. Six months after the initial blockers, simple rereading or summarizing
teaching session, repeated testing resulted in of the facts is often applied. However, active
final test scores that were on average 13 per- recall (e.g., write down or name the five
cent higher than in the group of repeated main adverse effect of beta-blockers) is a
studying [9]. significantly more effective learning strat-
A significant contributor to the testing egy than passive restudying of the facts.
effect is initial feedback to teach the student Testing as described in the previous section
whether an answer was correct or incorrect. is a form of active recall. However, testing
Interestingly, feedback enhances learning, can also be performed by passive presenta-
but even testing without feedback is benefi- tion of information such as in multiple-
cial [10]. The study by Roediger et al. pres- choice tests. This section regards active
ents an experiment in which four groups of recall methods, meaning the effort to con-
students read a text passage. One group re- sciously reproduce information that was
mained passive after reading, and three learned before without using cues.
groups underwent a multiple-choice test. Of Active learning methods engage the
these three groups, one was tested without mind and do not necessarily need to be in-
feedback, another received immediate feed- stantly successful. It has been demonstrated
back after each question, and a third re- that even unsuccessful attempts to retrieve
ceived delayed feedback for all questions information from memory that were accom-
210 Augustin: How to learn effectively in medical school

panied by feedback enhanced learning [12], spaced repetition. Participants were asked to
and even quizzing about learning content try to recall the name of the person shortly
that was never presented before enhanced after they had just met him or her and then
learning of that very content. In a study by again after a longer interval [13]. Instead of
Kornell et al., two groups studied fictional trying to recall the name every 30 minutes,
history questions [12]. One group read the it is advisable to space out the repetition and
question for 8 seconds and was demanded to recall the name after 5 minutes, 30 minutes,
immediately type the answer. After 8 sec- and then after 2 hours.
onds, the answer was presented for 5 sec- In an experiment that tested steady
onds. The second group simply studied the against expanding retrieval practice, 250
question and answer together for 13 seconds students studied 30 immunology and repro-
without the instruction to give an answer. ductive physiology concepts [14]. The stu-
Although the second group had more than dents were divided into five groups. Two
double the time to study the fictional fact, groups recalled the concepts actively at a
both groups showed comparable results steady interval without (days 1, 10, 20) or
without significant difference. The attempt with a delay of 7 days (days 8, 15, 22). An-
to retrieve fictional information, which was other two groups recalled the concepts ac-
inevitably unsuccessful due to the fictional tively at expanding intervals again without
history facts presented, resulted in compara- (days 1, 6, 16) or with a delay, in this case of
ble learning success compared to a group 1 day (days 2, 7, 17). The fifth group served
that had more than double the time to study as a control group. All of the groups under-
the learning content. Therefore, quizzing is went a test at day 29 to assess the final score;
superior to learning because an equivalent consequently, the end point for all groups
learning success can be reached in less than was the same. It was found that expanding
half of the time. It is understandable that retrieval practice led to a significantly
challenging tests are thought of as discour- greater recall of facts at day 29 than recall-
aging for students. Yet the experiment con- ing at steady intervals [14]. Longer delay be-
ducted by Kornell et al. showed that difficult tween initial learning and recalling facts was
tests, which at first result in high error rates, associated with poorer retention rate. There-
actually stimulate subsequent learning. fore, the group that learned with expanding
Another experiment performed by Mor- retrieval practice and no delay preceding the
ris et al. demonstrated the superiority of ac- first assessment proved to have the best
tive retrieval practice compared to passive learning strategy.
representation of the content [13]. The exper- Generally, the four groups with retrieval
iment simulated a real-life experience of practice performed twice as well as the con-
learning names when meeting new people at a trol group did, thus emphasizing the positive
party. One group experienced representation effect of active retrieval practice independ-
of names, and another group applied retrieval ent of specific retrieval strategy. In compar-
practice. On average, the group experiencing ison, the two groups that applied expanding
representation of the name of a newly met per- retrieval performed significantly better than
son recalled 5.8 names at the final test. The re- the two groups that recalled the concepts at
trieval practice group recalled 11.5 names on steady intervals. The combined mean of the
average. Consequently, trying to remember first groups (42.57, SD 1.8) was signifi-
actively the name of a person you have just cantly higher than that of the two with
met is a more effective learning strategy than steady intervals (34.1, SD 1.36) [14]. In
merely hearing the persons name repeatedly. comparison to the control group (21.26, SD
1.4), there was a general beneficial effect of
retrieval independent, whether it was at
SpACEd REpETITIonS
steady or at expanding interval. Thus, two
The mentioned experiment by Morris et findings stand out: Retrieval practice after
al. also supported the positive effect of initial learning is a main contributor to suc-
Augustin: How to learn effectively in medical school 211

cessful learning, confirming the findings sures optimal long-term retention of factual
stated above about active recall and the test- knowledge. It has to be emphasized that de-
ing effect, and retrieval practice should be spite the obvious positive effects of these
performed on expanding intervals to further learning strategies on students performance,
enhance learning. learning how to learn is not a standard part
Additional insight into the benefit of ex- of the curriculum in medical school [4,16].
panding retrieval practice was presented in This lack is questionable.
another study [15]. The authors found that Obviously, medical knowledge is grow-
the positive impact of retrieval practice de- ing. Despite an increase in depth and com-
pends on the degree to which the to-be- plexity of medical knowledge in the past
learned information is vulnerable to decades, the length of medical education re-
forgetting. It is especially helpful when the mains constant. Time is scarce in the med-
learning content consists of several units that ical curriculum and never sufficient to teach
may interfere with each other. In one exper- the whole body of medical knowledge. Pro-
iment, 30 participants studied an educational viding time to teach medical students how
text about Antarctica. They were then in- to learn is difficult.
structed to free recall information about It is, however, even more difficult for
Antarctica at 4 time intervals of either 0, 3, students to provide time to learn in an inef-
7, and 18 or after 7, 7, 7, and 7 minutes. Be- fective way in medical school, to learn fac-
tween these intervals, the participants read tual knowledge, forget, and relearn it. It
text passages about 10 additional regions takes modest time for medical schools to
(e.g., Greenland, Africa) similar to the ini- teach the above-mentioned concepts that en-
tial Antarctica text. Consequently, this inter- able students to save time and effort. Even-
vening activity led to interference with the tually, students final scores and patient care
facts that were initially learned. may improve a result that satisfies med-
In a final test 1 week later, the group ical faculties and students equally.
that learned at expanding time intervals per- How should medical schools implement
formed significantly better than the group programs to convey these learning strate-
learning with steady intervals, outperform- gies? The author proposes that a program
ing the latter group by a 2-to-1 margin [15]. based on these concepts should be taught in
The authors conclude that expanding re- medical school at an early stage. The pro-
trieval practice is best used when the learn- gram should be based, obviously, on the
ing material is vulnerable to being forgotten. concepts it conveys. This means that the
In this case, expanding retrieval practice im- program should be taught actively by pos-
proves long term retention of correct infor- ing questions and quizzing students, provide
mation and prevents from learning incorrect tests to foster learning, and repeat the learn-
information. ing strategies in spaced intervals. A basis
module of this program may consist of sev-
eral hours to present the concepts and the
ConCLuSIonS
scientific background. Shorter modules
How do these studies impact learning in serving as repetition and application of the
medical school? Whenever students learn learning strategies should be taught in ex-
factual knowledge, they should test them- panding time intervals so that students learn
selves while learning, actively recall infor- the concepts at the start of the term and
mation, and retest the facts at expanding restudy them, e.g., 7, 15, 30, and 60 days
time intervals to make learning in medical later. Therefore, a basis module combined
school most effective. These learning strate- with several short follow-up modules would
gies help students learn the most in the least suffice to teach the basic scientific findings
amount of time. Studying according to sci- on effective learning strategies.
entific findings on the testing effect, active Additional scientific concepts apart
recall, and expanding repetition intervals as- from the three that were presented in this
212 Augustin: How to learn effectively in medical school

5. Ebbinghaus H. Ueber das Gedaechtnis.


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