To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all – William Osler

Medical School – One Last Exam

Fourth year is flying by fast and I’m in the final stretch before my licensing exams. It’s pretty neat to see how much medical knowledge you learn (and forget!) in just four years. While revisiting old notes, I’m surprised as to how much deeper I now understood and appreciate topics after some clinical experience. For example, long term management of diabetes can be quite boring in your first year but after you’ve seen many patients with it, learning becomes more meaningful. Even the weird and wonderful zebras become more fun to read about.

There is however one big regret I have about my learning during medical school.

I wish I had organized my “knowledge” better

Classroom Learning – A Flawed Approach

In the first two years of medical school, you spend a lot of time in the classroom. You listen to a lecturer speak, you go through the ppt slides and you try to summarize all the facts in a way you can understand. You cram all this knowledge in your head and regurgitate it for an exam.

This method works pretty well for passing your courses. It’s not a great approach for mastering clinical knowledge.

Classroom learning can be dangerous for several reasons. One is that your learning becomes centered around what teachers present to you, instead of on what you should and need to know. It’s easy to be complacent and have knowledge spoon fed for you. You start to memorize minutiae and trivia questions because that is often what they put on the test. You stop thinking and asking questions beyond the scope of the course, and instead focus on maximizing your grades. The classroom teaching often narrows the scope of your knowledge.

And the worst part is that the school system encourages this type of learning. You do well for being able to recite all the fine details that was taught in class. You get marks for remembering minutiae. You pass the exam, your marks are good, you feel reassured.

Learning Outside the Classroom

It’s not until your clinical years when you realize that learning from what they only give you can be a blunder. What you have learned in the classroom might not be relevant knowledge. On the wards, there is no longer someone telling you what you need to know to do your job well. You have to determine what knowledge you need to acquire to be a successful medical student.

You might still refer to your class notes initially but you soon begin searching for answers elsewhere. You start to learn from many different resources. When there was a topic I wanted to know more about I would consort more comprehensive textbooks, read journal articles and electronic references such as UpToDate.  I picked up clinical pearls from nurses, residents and staff doctors. I learned through experience and identified gaps in my knowledge that I could address.

My Dilemma – The Consolidation of Knowledge

The problem I face currently is consolidating all this knowledge. It can be quite tricky to put everything you learned into a system that works for you – one which you can translate into clinical knowledge. What I found in my clinical  years was that it was easy to study for each rotation by itself. You choose the right resources and you can focus your attention. The hard part is when you try to consolidate all these separate pieces of information together.

My Previous Solution: During third year, I separated each section of Toronto Notes as a basic study aid during my rotations. I would read around my cases and annotate any additional information in the margins of my notes. This turned out to be a sufficient method in creating a comprehensive guide to each specialty. I read every section of TO notes while marking it up with my own mnemonics and flow charts. I used a different approach to each rotation and it worked pretty well.

The Current Problem: What I face now is creating a consistent learning system that can capture information and turn it into knowledge. I have become adept at passing individual exams but I want to improve my learning to a point where I can be a master clinician.  Going into residency, I will have to start understanding each topic more in depth and be more evidence-based with my knowledge. It will require newer and better ways of learning.

Another issue is I am at a crossroad for is deciding on what medium to learn from. I enjoy studying from paper notes but find it lacks the flexibility of digital notes. I remember I had tried implementing Dr. Brandt’s strategy of index cards and her studying system but found that it wasn’t possible to keep up with the paperwork involved. I have tried digital strategies like OneNote but have found creating notes from scratch a time-consuming process.

An Ideal System

In a perfect world, I would remember everything I read, file it away in the right folder in my brain and have the ability to recall it whenever I wanted.

For those less than super-human, creating a study system is crucial to long-term learning. As I continue my medical training, my learning continues to evolve. What worked for me in the past might not be the best solution for my current studies.

My Goals, Strategies and Tools to Get There

My objectives are to have a deep and long term understanding of medical knowledge that I can apply clinically. I want to further develop a system of life-long learning and skills development. Passing my exams will be a measurement of my progress and not the end in itself.

Strategies I plan to use for residency include

• Reading around patient cases and related topics
• Aiming to learn something everyday – even if it’s on a topic I have gone over a dozen times
• Be inquisitive and come up with relevant clinical questions and find the answers to it
• Creating concise key summary notes that I can refer back to and update

Being more Evidence Based – Some tools I have started using to keep track of medical literature include Mendeley for keeping track of journal articles and Xmarks for organizing webpages. For keeping up to date with new medical literature I subscribe to the CMA’s Infopoems and the ACP Journalwise. I also subscribe to NEJM’s clinical cases and images via RSS.

Doing my Homework, Reading Textbooks – Next year, I’ll eventually purchase one of  “big texts” for internal medicine (deciding between Harrison’s or Cecil’s) and break it up into readable chunks. If I am motivated and lucky, I hope to get through it before my PGY3 year.

Notes, Notes, Notes – Finally, I have yet to determine if my notes will be paper, digital or some type of hybrid.

Experimenting – Just like how medical school was a new challenge, I’m sure residency will have its unique challenges. Being open and adaptable will be an important part on this new journey.

I guess you don’t really think about consolidating and organizing everything you have learned in medical school until a big exam like this forces you to do it. Just as we went from elementary school to high school, university to medical school, residency will require a new higher level of learning.

Would love to hear your opinion on what kind of a learning system you use? How do you collect your information and process it into knowledge? Are there any tools that you use to make learning more effective and efficient?