“Medical students today face the unique challenge of having to learn an unprecedented amount of medical information in an increasingly limited amount of time. Medical texts and review books for high-stakes certification examinations increase in length every year. While this allows students to be more versed in all domains of medicine, it also increases the academic pressure to synthesize an overwhelmingly large amount of information. For us, this task became tangibly onerous when we were confronted with a preclinical curriculum of 25,000 slides that we had to cover in just a year and a half.”
So begins a recently-published paper co-authored by Osama Ahmed and Prerak Juthani, fourth-year medical students at Yale School of Medicine, under the mentorship of Michael Green, MD, professor of medicine (general medicine); director of student assessment, Teaching and Learning Center; and Jeremy Moeller, MD, MSc, associate professor; neurology residency program director. (Juthani is pursuing a joint degree at Yale School of Management.)
When they started medical school, Ahmed and Juthani employed the same learning strategy they had used in college: watching every lecture, taking meticulous notes, and reading and re-reading assigned texts in advance of exams. They soon realized this was not effective given the volume of information they had to absorb. “This approach led to cycles of ‘binging and purging’ information. Though we demonstrated a perceived understanding of the content in the short-term, this competence was an illusion due to poor long-term retention.”
Ahmed and Juthani responded proactively by investigating research learning strategies and successfully implementing a new approach. Moreover, they shared their experience and advocated for a change to medical education in Optimizing Preclinical Learning with Retrieval Practice: A Call to Action, published in Medical Teacher. Green says their paper “was accepted as is (no revisions) in a prestigious peer reviewed medical education journal. This happened to me once before in my career.”
In the paper, Ahmed and Juthani explain that although they were provided with many resources to help them navigate ‘what’ to learn, including dozens of video series and textbooks, they were not taught ‘how’ to learn so much content effectively.
When they asked for advice from faculty and older students, they were usually told that everyone learns in a unique way, and that they needed to figure out what worked best for them. However, as they explain in the article, “this advice ignores an established body of research on retrieval practice (RP) that emphasizes that certain approaches towards learning are more conducive to long term retention and transfer of clinically applicable knowledge.”
They explain that the underlying principle of RP is that deliberate, repeated efforts at retrieving knowledge, spread out over a period of time, yield greater long-term memory retention compared to passive studying over similar time intervals. Additionally, there is evidence that RP helps learners apply this information in another, unfamiliar context.
They provide a detailed explanation of why this occurs: “the science of RP is rooted in our understanding of memory, which involves the processes of encoding and consolidating information. ‘Encoding’ occurs when a representation of the memory is created in the brain, and ‘consolidation’ is the process by which that memory becomes enduring over the long term.”
After realizing their study methods were ineffective, Ahmed and Juthani began investigating the study techniques of other medical school students. In an AAMC questionnaire of second-year medical students in 2019, 48.9% of students responded they almost never or only occasionally attend lectures in person and were instead using self-study resources.
Ahmed and Juthani then looked at some of these online resources and saw that all of them employ RP, providing an overview of scientific concepts supplemented with flashcards and application questions, which are repeated over time and “help create a long-term cognitive schema that can integrate multiple concepts.”
Knowing many medical students find learning strategies on YouTube, they also searched YouTube for USMLE Step 1 board preparation guide videos. “We found that 70% of the videos, accounting for a total of 500,000 views, mentioned incorporating RP into their study plan.”
Ahmed and Juthani then tried using RP in their own daily learning. Rather than just reading notes and watching lectures, they made flashcards and did application questions over spaced repetition intervals, shifting from passive to active learning.
The difference in their knowledge and long-term retention was evident within the first few months. “Not only were we scoring better on our class qualifying exams, but we also found that the information we learned in one unit persisted even as we went into another unit. In fact, this long-term retention was synergistic because the information from one unit, such as nephrology, would enhance our understanding of other units such as cardiology.”
In their paper, Ahmed and Juthani argue that traditional lecture-based medical education is essentially passive learning that “relies on the false premise that concepts taught once will remain with students for the remainder of their careers,” which “stands in stark contrast to cognitive and neuroscience research on learning and memory.” For this reason, they argue that changes are needed in medical education.
“Firstly, medical schools should be teaching first-year students how to learn in addition to what to learn.” They specifically propose a one-week course, starting soon after school begins, on how to learn, which would outline the foundation of “Practice-Based Learning” by discussing “evidence-based skills that medical students can use throughout their careers to facilitate their own learning.”
They also propose that schools formally integrate RP into their curriculum, such as by incorporating new content with previously covered content in the form of regular formative quizzes. “This would encourage learners to repeatedly return to different areas of learning,” they maintain. Another integration strategy is for more advanced students to lead discussions with incoming students - educating others while enhancing their own retrieval capabilities.
Recognizing there are logistical challenges to their suggestions, especially given the space constraints in the curriculum, Ahmed and Juthani assert they nonetheless should be adopted. “In light of ever-increasing student disengagement with an outdated approach towards preclinical education, a paradigm shift is necessary to best prepare medical students to navigate the vastly expanding scope of modern medicine.”