Most of us don't know how to learn.

At school, we learnt plenty, but we've never learnt how to study. We've been learning by 'what feels right', instead of 'what's right'.

When you enter medical school, there's tons of information to digest and memorise; it’s like drinking out of a fire hose. We need to learn how to study to live a happy and balanced life while still doing well in your studies.

Your IQ does not determine your success in medical school. How hard you grind for your exams doesn't matter either. What matters most is how you work.

Effective learning is difficult.

The most common myth about learning is that it’s easy. It's quite the opposite, and real learning should be challenging. Being effortful when learning changes your brain, makes new connections, builds mental models and increases your capability.

From my research and experience effective learning, the four most important principles of effective learning are understanding, testing, interleaving and spacing.

Understand

Understanding what you learn leads to a longer retention of knowledge. Memorising facts without knowing how to connect them causes it to leak out of your brain, while understanding gives you the context that enables retention over a more extended period. Once you have the big picture, it becomes easier to input facts into your memory.

If you don’t fully get it, it’s like a tree in your head with no trunk— and without a trunk, when you learn something new about the topic— a new branch or leaf of the tree— there’s nothing for it to hang onto, so it just falls away. By [developing understanding], I build a tree trunk in my head, and from then on, all new information can hold on, which makes that topic forever more interesting and productive to learn about.

Tim Urban

When I first started medical school, it feels like I don't have time to develop a real understanding of a topic, considering there's plenty to learn. They test in ways that optimise for recollections of facts instead of knowledge; MCQ's, SBA's and EMQ's, T/F questions. I found myself optimising and focusing on memorising as many points as possible to maximise my exam scores, but it backfired when I can't apply my knowledge by the bedside.

If you memorise instead of understanding, you won't be able to answer a question asked in a context different to the source material.  Exams in medical school often test your deeper conceptual understanding via tricky questions and clinical vignettes, instead of your ability to recall facts.

Even though developing your base by understanding requires more effort than memorising, it's more efficient to put in the effort as you retain the info over the long run. After all, the real aim of medical school is to make you a competent doctor, not to pass exams.

Conceptual knowledge gained through understanding also allows you to respond to novel scenarios and problems, something doctors face daily. No two patients are similar.

I'm not saying memorising facts are redundant. I'm saying getting the big picture and understanding is as important as committing facts to memory.

Realising this distinction changed how I viewed my exams - I started putting in more effort on understanding my basics well, instead of cramming and memorising random niche facts that would only serve me in my exams.

After all, exam grades don't define how good you are as a doctor. Knowing more doesn't lead to better action. Knowing that you shouldn't use NSAIDs in asthma because inhibiting COX enzymes causes increased leukotriene levels, exacerbating asthma is the same as knowing 'don't use NSAIDs in asthma' when it comes to treating patients.

If you want to learn to understand, don't skip the process of reading or listening to information within a context. Understand before burning these pure facts into your brain.

An excellent way to test your understanding is the Feynman method:

1. Select a concept
2. Try to explain it in a way that a 5-year-old would understand

• If yes, you've understood the material.
• If not, consider three things:

1. Which part don't you understand? Look at the gaps of your understanding fill it in.
2. Are there parts you don't remember? Try crafting an analogy that would make recall easier.
3. Are you having difficulty explaining it? Keep the concept as possible.

If you can't explain it to a six-year-old, you don't understand it yourself.

Albert Einstein

Another method of knowing whether you understand something is asking yourself 'Why?' 5 times

Spaced Repetition

Does this sound familiar to you? You attend a lecture with loads of information, only to forget everything the next day.

Don't beat yourself up, we forget at a fast rate.

In 1885, the German psychologist Hermann Ebbinghaus memorised thousands of nonsense words and recorded what he forgot over time. His experiment led him to discover the Forgetting Curve.

He found that you forget most of what you learn in the first 24 hours.

If you don't interrupt this curve by recalling what you've learnt, your remaining memory will continue to decay to zero.

To combat this decay, we need to space out our recall.

As you can see, the curve flattens out, making the rate of decay slower. It will take longer for you to forget something after a successful recall.

Spaced repetition means repeating what we learn with a gap or space of time between each recall.

Research has shown that spacing your study sessions over some time produces more solid and lasting memories compared to a repeated study in a short period.

With each repetition, your reinforce and make your memory permanent. On top of that, each subsequent review makes you understand more, and it will take you less time for each repetition.

Let's take a simple example:

If you've played the guitar before, you know that someone who plays the guitar for 10 minutes for one week will be a better player than someone who plays the guitar for 70 minutes in a day.

The same goes for learning. You'll get mastery if you repeat your studying over time rather than cramming it all into one session.

A common myth is that spending a set amount of time to repeat something over and over again; we can master something. We’ve never questioned this method because as we practice over and over, we see apparent improvements. What we fail to realise is that the gains that we made during this continuous repetition is only short term and will fade. Have you crammed for an exam before? You’ve repeated the materials enough times to recall the next day, but once a week passes, you've forgotten everything.

You can burn something into your memory forever by repetition, but you need to space out these repetitions.

Few people make time and effort to repeat what we learn. They don't bother to organise their time to repeat what they study. Taking the step to repeat what we learned, however, will lead to us forgetting less.

If you test yourself and space out your repetitions, you’ll forget a little since your last review. In result, you’ll have to put in more effort to recall what you’ve studied. This effort makes the ideas more permanent and allows you to connect previous knowledge and existing knowledge.

Spaced practice feels difficult because you’ve gotten rusty and the material is harder to recall. However, learning should be effortful. With every ounce of effort you put in to remember, you’re strengthening your memory and mastery of the topic. If you've tried going to the gym before, you should know that you can only be stronger if you’re putting in more effort when lifting weights.

You should increase the space between each subsequent repetition. When you learn something new, recall it from memory and review your notes after one hour, then one day, then one week, then one month, then six months and so on. There's no specific magic interval, but it's important to repeat to solidify your memory. You will forget what you learn over time, but spacing your repetitions will make your repetition and studying more effective.

Other methods of utilising Spaced Repetition is by using Anki, using a spaced repetition timetable and creating a Review System.

Test Yourself

The most counterintuitive way, yet effective study method is to test yourself. The process of forcing your brain to recall the information it has learned has a profound effect on memory and understanding. Testing yourself isn't for exams only; it should be a part of your learning process.

Research has shown that testing is more effective than re-reading for memory retention.

The arguments for testing yourself are logical - a simple analogy is: you can't learn how to bike by reading, you have to 'test yourself' and practice by cycling. You might make mistakes, but it's better to make mistakes when studying and learn from them rather than make mistakes during the exam. You'll never be able to learn how to cycle by reading. If your examinations require you to answer questions, why not practice for your exams by testing yourself and answering questions? ‘Answering questions' is equal to 'cycling' and 'reading passively' is 'reading how to cycle'. Reading is necessary for context and understanding, but testing yourself is the force that binds what you read to your memory.

When you quiz yourself, you can pinpoint your weak areas. Focus on these weak points instead of covering something you've mastered. Why would you want to test yourself on where is the capital of France if you know it by heart?

If all you do is make notes and read books, you'll never be able to gauge the information you retained. Testing yourself gives you feedback on what you know and what you don't, and you'll be able to track your progress over time.

When you read a book, pause now and then and ask yourself, without looking at the text: What are the key points? How do these points relate to what I know? What terms or ideas are new to me? How would I define them? You can also generate questions for yourself as you study and write down the answers. Many books also have problems at the end of the chapter. Answer these questions without looking at reference. Set a time every week to quiz yourself on what you've learnt that week and what you've learnt in prior weeks. Be sure to check your answers, so you know what you know and what you don't know.

The harder your effort to recall from memory, the better it is. Testing yourself and making errors are acceptable, as long as you check your answers and correct your mistakes. Self-quizzing is the space for you to prune out your mistakes.

What we often do is highlight text and slides, and re-read these over and over again until we're fluent in it. You should stop doing this, and throw away all your colourful highlighters and pens.

The familiarity and fluency that comes from rereading fools us into thinking we know the material. It creates the false impression that we've remembered the material.

Quizzing might not feel as productive as highlighting notes, but every time you work hard to recall something, you're strengthening it.

Interleave

You should structure your studies by interleaving the subjects that you studied.

What does this mean?

For example, if you're trying to study Anatomy, study more than one body part at a time, so that you're engaging your brain. Learning one topic at a time is more comfortable since there's context. Mixing up your studies makes your mind work harder to recall information.

In exams, you won't be answering questions in a single block. They will be at random, so why not practice the exam scenarios when studying?

How does mixing work?

Let's say you're studying Physiology. Once you understand the topic but haven't mastered it, learn something else. The case for interleaving is a simple analogy from sports: A baseball player who trains by batting different types of balls will perform better in practice. However, the player who asks for random pitches during training will learn how to analyse and respond to each pitch as it arrives and become a better hitter. The latter method is a better way to learn as it mimics a real game scenario.

What we often do is we focus on trying to master one topic, before moving on.

However, mixing up your studies teaches you to differentiate between different problems and identify the unique characteristics of each question.

Mastering all of one topic before moving on feels like progress while interrupting your study to practice a different type feels disruptive and counterproductive. However, interleaving your practice will provide you with success in later tests and real-world settings. As a doctor, you need to respond to the various types of scenarios, and interleaving your studies trains this spontaneity.

Use Mnemonics

Why us mnemonics?

Mnemonics make it easier for you to remember small details once you've understood the whole picture. There are various mnemonic techniques that you can use to aid your learning.

Imagery

Imagery involves visualising a memorable image. When you want to recall something, recall the image, and this triggers your recall. Resources such as SketchyMedical and Physeo are useful for this. For example, I find it easier to remember the side effects of a drug when I recall the image in a Sketchy Pharmacology video.

Logical associations

Whenever possible, try to create a mnemonic that relates to the subject you're studying. For example, you can remember the features of ulcerative colitis with the mnemonics ULCCCERS ( ulcers, large Intestine, continuous, colorectal carcinoma, crypt abscesses, extends proximally, red diarrhoea and sclerosing cholangitis)

Humour

Try to make your mnemonics as funny. The more absurd it is, the more likely you are to remember it. Your brain remembers events better when they evoke an emotion. Thinking of silly and ridiculous mnemonics makes it stick easier. For example, you can use FUCKING to memorise the management of diabetic ketoacidosis. (Fluids, Urea, Creatinine, K+, Insulin, Nasogastric tube, Glucose). It might be explicit, but it sticks with you and will come in handy for exams and clinical practice.

Use the 80/20 Rule

What is the 80/20 Rule?

The 80/20 rule, also known as the Pareto principles, states that 80% of the outcome comes from 20% of input. For example, 20% of the world's population owns 80% of the world's wealth, and so on.

This principle applies to medical school, as well. 80% of what comes out in your exam is 20% of your course syllabus. I'm sure you've had moments where you've studied so hard for an exam, only to find out specific select topics came out. The key is to figure out which 20% of your effort produces 80% of the results. You can achieve this by looking at past year questions and analysing the topics that usually come up.