Medical education is divided into Undergraduate Medical Education (UME), which includes coursework, supervised clinical rotations, and specialty electives, and Graduate Medical Education (GME) which is residency and like their entry level job. So, UME is graduate-level education (post-bachelors), but called Undergraduate, for reasons I’ve yet to discover. For the purposes of this blog, I’m focused on Phase 1 of UME – coursework. For most medical schools, preclinical coursework involves a series of short (4-8 weeks-ish) courses on foundational topics of anatomy and physiology and organ modules (e.g. cardiology, brain and behavior, hematology, etc.). UME students have an enormous amount of information to learn in each of these courses in an extremely short amount of time. Many medical schools have switched to a pass/fail curriculum such that the goal is not to master 100% of the content, but maybe 80% to stay safely above the passing threshold. At the end of their coursework, most students (this varies some by medical school) take their first Medical Licensing Examination (called Step 1). The exam is 8 hours long and tests their basic science knowledge through high working memory demand questions that ask them to apply their knowledge to a series of vignettes, usually requiring them to understand how information across systems are connected and problem-solving their way to an answer. Again, the goal is not 100% on this exam, but maybe 70% to be in very safe passing range.
The Problem
During a typical week of medical school, students have many required activities. These vary by school, but might include lectures, active learning sessions, simulations, etc. In addition, they have a long list of material that requires self-directed learning. There are simply not enough hours in the day for them to master the material. They need learning strategies that are not only effective, but efficient.
Effective but Inefficient
A lot of the strategies we discuss take time. It takes time (literally) to engage in quality spaced practice. It takes time to review and retrieve the same material multiple times. Creating effective visuals, organizers, writing quality questions for elaborative interrogation – these are all fantastic strategies for increasing understanding and retention (1), but it is impossible for students to engage in all of these strategies for the vast amount of new material presented to them daily.
Because of this challenge, students often turn to pre-created materials. These are some of the favorites among my students:
Anki (or Anking): Anki is a flashcard system that utilizes an algorithm to maximize retention using expanded spaced retrieval (2). When you get a card right, the space by which you will see it again increases. There are many existing card decks that are often even associated with other third-party materials, so students can unlock cards by topic, utilize cards from former students, and connect those cards with their current classes.
Pro: Anki is evidence-based. It is a retrieval practice tool and the algorithm used for spacing cards is based in the science of learning and can maximize retention of those cards.
Con: Anki is surface-level learning. It is a memorization tool that allows students to recall factual information at an item-specific level. That is helpful, but not sufficient. It can also take considerable time and cause considerable anxiety. One student I spoke with said that, on some days, it takes her 6-7 hours to get through all of her cards. There are some ways that you can adjust Anki to avoid that, but clearly novice users aren’t always aware or able to make those adjustments.
Boards and Beyond: This third-party program provides videos on common topics that are found in medical school curriculum and on Step 1. For my purposes, I’m going to put this as the example program, but the pros and cons below are true for most youtube videos (e.g. Dr. High Yield) and podcasts (e.g. Divine Intervention).
Pro: These videos tend to be more efficient than others. Only the most relevant information is included and the videos have high production value, reducing extraneous cognitive load (3).
Con: As they are videos, these involve what most medical students describe as “passive learning” (I don’t love this terminology). Without an effective note-taking strategy or other paired strategies, the videos themselves are not necessarily the most effective way to learn (4).
Amboss & UWorld: These third-party resources are essentially question banks. There are others, but these are the most frequently used by medical students. While each of them has other features, students are most often using them to answer questions that are very similar in style to the word-heavy, problem-solving questions that appear on Step 1.
Pro: There are a lot of pros here. These are retrieval practice tools and represent ideal transfer-appropriate processing (5) in that students are getting practice with the types of thinking that will be required on the actual big exams.
Con: Each of these has the option to be competed on tutor or timed mode. On tutor mode, students receive a question with immediate feedback. This feels like the most effective way to learn for most students, even though we know that delaying feedback (via timed mode) is more effective. Students can also choose to do a mixed block of questions (i.e. all topics included), a targeted block (e.g. just cardio questions), or they can create a custom bank (e.g. ischemic heart disease and arrhythmias only). Choosing the appropriate way to use these options requires metacognitive awareness and regulation, which may be challenging for students.
In addition to those above, I would love to talk about Sketchy and First Aid, but for the sake of brevity I’ll save those for a Part 2 perhaps.
