Rapid Learning

How To Study Neuroanatomy

The director of medical student cardiology training at the University of Miami once told me that cardiology was really not that difficult to learn, since it was based on a few general principles, but that neuroanatomy was difficult, since there were so many isolated facts that are difficult to digest.

I found this conversation interesting, since I had experienced just the opposite.  Cardiology to me was always nebulous; there were just too many facts to learn, especially drugs and their effects, and I always had difficulty with cardiology.  Neuroanatomy, though, seemed far simpler, since, to me, a few general principles conveyed the essence of the subject.  It occurred to me that the learning of a subject has a lot to do with the grasping of general principles.

For instance, there are some 100 billion neurons in the brain and in the range of a quadrillion synaptic connections (connection points between nerve cells).  This would surely be an overwhelming amount to learn.  However, it is interesting from a clinical standpoint that of all these synapses, there is only one that is of clinical significance to know about in evaluating a patient.  That is the synapse that separates an upper motor neuron from a lower motor neuron.  Where the synapse is located makes a big difference in the kind of paralysis that a patient experiences, whether of the upper motor neuron kind or the lower motor neuron kind (I won’t go into the details here).  Other than that synapse, it is the pathway along which information flows, rather than the number of synapses in that path that is important.  Whether or not the pathway has one synapse or many within it is unimportant in making a diagnosis as to where the problem lies. This simplifies the study of the subject.

As an example, the right side of the brain connects with the left environment of the body.  Thus, an injury to the right brain will result in sensory loss or weakness on the left side of the body.  It is not necessary to know where all the synapses lie along these pathways to know this.  Who would concern the physician more, a patient who complains of a right-sided headache and weakness and lack of sensation on the right side of the body, or a patient who complains of a right-sided headache and weakness and lack of sensation on the left side of the body?  It is the latter, because a problem with the right brain should not affect the right side of the body.  The location of the synapses is not so important in making this determination.

In learning neuroanatomy, then, it is more important, at least at first, to learn the general principles of pathway layout, rather than the location of synapses.  If you want to learn all about synapses too, it would be better to first understand the general principles of direction of flow of the pathways, then move on to greater detail.  This is the approach I have taken in Clinical Neuroanatomy Made Ridiculously Simple.

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Rapid Learning

How To Study Anatomy

In learning Anatomy, I think it is better to first learn through conceptual diagrams, rather than through photos of actual anatomy.  Photos of dissections, particularly those of formaldehyde-fixed specimens, contain fascia (connective tissue) and other features that obscure the conceptual picture of what connects with what.  In our medical school anatomy program, we had available a series of stereoscopic slides of actual dissections.  Few students used them.  During my ophthalmology residency, I also found relatively useless a book of photos of orbital dissections.  It is better to learn the anatomy conceptually, as through line drawings, and then fine tune this knowledge when learning surgery using unfixed tissue, having first learned the anatomy conceptually.

Anatomy is a very visual subject.  Here, a good way to learn the anatomy is to distort it into pictures that are common knowledge.  A typical vertebra, for instance, looks like a snowman, whose arms, legs, shoulders, and head resemble the actual vertebral anatomy (see below).  While learning other people’s mnemonics can be very helpful, they are often longer-lasting if they are your own.

From Clinical Anatomy Made Ridiculously Simple, by S. Goldberg, MedMaster

Ditties (e.g. “C3,4,5 keep the diaphragm alive”), acronymns (e.g. “SCALP” for layers of the scalp: Skin, Connective tissue, Aponeurotic layer, Loose connective tissue, Pericranium), and ridiculous associations (e.g. for cranial nerves 7 and 3, which open or close the eyes — see below) are also useful for learning anatomy.  A collection of such mnemonics may be found at medicalmnemonics.com.

CN7: A hook - closes eyes. CN3: 3 pillars - opens eyes. From Clinical Neuroanatomy Made Ridiculously Simple, by S. Goldberg, MedMaster.

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Which do you prefer, eBooks or print books?  Why?  Your opinion counts.

Medical School Curriculum

Should Lectures Be Eliminated in Medical School?

Lectures have always been a staple way of educating in medical school, particularly in the first two years.  But are they the most efficient way to learn?

PROS:

•  There are excellent lecturers, who can provide insights and important points not presented in other sources.

•  The lecturer, as a facilitator, is available to the student for clarification of ideas that are not clear.

•  Lectures provide a different avenue of learning that can add to the learning experience.

CONS:

•  You can’t just stop in the middle of a lecture to mull over the ideas, or go back, as you can with a book or an electronic presentation.  Key points may be missed, especially if you can’t write fast enough.

•  Students learn at different paces, and books and computer programs allow students to learn at their own speeds.  The quality of computer teaching programs is continually improving.

•  In cases where a lecturer speaks poorly, or does not teach with clinical relevance, would it not be better to use computers or clinically relevant texts to learn?

•  Some lecturers in the basic sciences may be excellent researchers who would make better use of their time in the research lab, where their talents and interests lie.  The department could also save money by hiring fewer lecturers.

•  Clinicians can be good sources of clinically relevant information, but are often too busy to put in a consistent teaching schedule.

Some students do not show up at lectures, and others do so because it is more likely that what a lecturer says will show up on an exam.  Others rely on note takers.

Should the emphasis on lectures be reduced?  Should more teaching shift to self-learning?  Would it be better to provide students with a list of clinically important concepts and points to learn in the basic sciences and then allow the students to learn them at their own pace?

What do you think?

Medical School Curriculum

Medical Curriculum In The First Two Years Of Med School

 Say you have a juggler who wants to be the best ever, to juggle 7 balls at the same time as balancing a stick on his head and twirling 3 hoops around his leg.  How would he go about learning this amazing stunt, which combines three skills?  You might say to start off practicing all of these skills together, since this is the final result the juggler wants to achieve.  However, the juggler is more likely to succeed by practicing one skill at a time, and then, after learning each of them, practicing them together.

 It is similar in working with patients.  In evaluating patients, it is important to incorporate the considerable information you have acquired in the basic sciences.  For that reason, medical school education in the past consisted of spending the first two years learning the individual basic sciences and then putting this information together when seeing patients.

More recently, however, the trend  in some schools is to start right from the beginning seeing patients, before there is a background in knowledge.  Is this the best way to learn medicine?  I suspect that a leading reason for the change to seeing patients  right away is the impatience at having to wait so long before entering the clinical world.  In particular, since the basic sciences are typically taught by non-clinicians, and much emphasis is on information that the student does not find relevant clinically, the student wants greater clinical exposure right from the start.

 It seems to me that the better way to approach medical education in the first two years is the old way of learning the basic sciences first, but with a strong clinical emphasis, minimizing information that does not have clinical relevance.  By cutting down on the more esoteric, clinically non-relevant information, there would be more time in the second year to  study for the USMLE Step 1 (an exam taken at the end of the second year), put the information together, and better prepare for seeing patients.

 You, as a student, may have little control over how your school arranges the curriculum, but should not feel as if something is wrong with you if you feel somewhat lost in evaluating patients before you are prepared.  Some schools may offer the student a choice of following the more traditional curriculum or following one that emphasizes early clinical exposure.  Personally, I would opt for the former, but use a text that emphasizes clinical relevance.

 What do you think?

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Rapid Learning

Studying In The Clinical Years

Hansel and Gretel luck out.

It is interesting that in medical school there is no course in medicine; you have to learn it through patient contact and deciding on your own what to read. It is a different kind of studying than in a course, where the instructor assigns a specific number of pages each day.

How should you study?

One way would be to set aside a certain amount to read each day in a large textbook, such as the excellent 4000 page reference book, Harrison’s Principles of Internal Medicine, reading it a little each day progressing from beginning to end.  Or you could read journal articles.  However, it can be  difficult, particularly when tired, to come home and focus attention when the literature does not pertain specifically to the patients you just saw.

It is more effective to prepare a number of questions each day that relate to the patients you encountered that day.  What is the differential diagnosis?  What are the diagnostic tests?  What are the treatment options?

There are a number of advantages to focusing study on the patients you encountered that day:

1.  You will be more attentive when looking up specific information that relates to the patients you have just seen than to read material that, however important, does not relate to the patient at hand.

2.  When presenting at rounds the next day, you want to appear sharp and informed.  You can do so by reading up on the patients who will be presented at rounds.

3.  Over the long run, by studying this way each day you will accumulate a knowledge of the most common presentations in the hospital.  You can’t know everything.  You can, however, know the most common situations.

In the old days, before computers and the Internet, one had to rely on reference texts, which could be out of date, and journals.  One could also go to the library and take out the voluminous Index Medicus and search out papers that pertained to your subject of interest.  Frankly, I was too tired to go to the library.

Now, with Internet access and medical search engines, it is relatively easy to quickly find the specific information that interests you.  Despite the explosion of new medical information, this is balanced by easier access to that information, and access continues to improve.

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eBooks vs Print Books

eBooks Versus Print Books: Pros and Cons

“It’s the most complete book for the Medical Boards. Unfortunately, no one can carry it out of the store.”

In addition to classical print books, there now is the growing option of reading eBooks, whether on reading devices (e.g. Kindle, iPad, Nook, Android), on the Internet (e.g. Google Books), or as downloads from the Internet to your computer.

As I see it, the pros and cons of eBooks versus print books in medical education are:

Pros:
•  eBooks avoid the space limitations of print books.  In small living quarters, it is space-saving to have books in electronic form.

•  It is easier to carry books in electronic format than heavy print books.

•  eBooks are generally less expensive than print books.

•  Ebooks have the potential for interactivity, including searching and hyperlinking to other sources of information, as well as audio and video enhancements.

•  Ebooks can be updated more frequently than print books.

Cons:
•  While there are provisions in some eBook reading devices and applications to underline, take notes, bookmark, and jump to different areas of the book, some people may find it less awkward to do this in an actual print book.

•  If books are read via the Internet, the ability to read would depend on whether or not there is an Internet connection at the time.  This problem does not exist in a printed book or when reading eBooks that are already downloaded to a reading device or eReader application on one’s computer.

•  Hand-held pocket sized devices may be convenient to carry around, but their small screens make them impractical for certain kinds of books, particularly those that have many illustrations and charts.

•  Many medical texts are in color.  This would render it impractical to read them on a device that uses electronic ink, such a black and white Kindle.

•  It can be fatiguing reading a screen for extended periods.

•  If the eReader device only allows reading one book at a time, this may be problematical for those who want to study from more than one book simultaneously.

When I was a medical student, the saying was that the highest grade would go to the student who could write the fastest, in view of the need to write down the lecture notes.  Today, students can take classroom notes on a computer.  A standard computer keyboard allows more rapid typing than on other devices, such as an iPad or hand-held device.  While one can purchase a wireless keyboard to type on an iPad, this is an extra device to carry around.

What is your preference – eBook or print book?  Do the needs of medical students differ from those of other readers?  What is your opinion about the future use of eBooks versus print books in medical education?

Rapid Learning

Memory Techniques for Med School #11 Hands-On

Centipede referral for hands-on approach

HANDS-ON
Despite the value of the 10 memory methods discussed in the preceding posts, perhaps the best teacher of all is the hands-on interaction with the patient. There is great truth to the patient being the best teacher. While we struggle with difficult hours and clinical situations on the wards and clinics during medical school, internship, and residency, it helps to bear in mind that the experience will be very valuable.  There arises a solid core of judgment and knowledge, ingrained in memory, from the experience of interacting with patients.

Which memory and learning techniques do you find most valuable in your medical studies?
What do you think of eBooks versus print books?

Rapid Learning

Memory Techniques for Med School #10 Acronyms

Placebos feel out of place in party with other kinds of pills

ACRONYMS
With acronyms, the first letters of the items in a list are put together to form a word.  For instance, the acronym SCALP is used to remember the layers of the scalp:

S = Skin
C = Connective tissue
A = Aponeurotic layer
L = Loose connective tissue
P = Pericranium

Related to the word-type acronym is one in which you remember a sentence in which the first letter of each word corresponds to an item on the list.  For instance, to remember the carpal bones:

Some Lovers Try Positions That They Cannot Handle”

S = Scaphoid
L = Lunate
T = Triquetrum
P = Pisiform
T = Trapezium
T = Trapezoid
C = Capitate
H = Hamate

These are effective mnemonics, since the letters all are nouns and refer to specific anatomical structures in the region.  There is little else that the letters could refer to.

It is difficult to find good acronymns, however.  In many, the letters are not necessarily nouns, and they could refer to so many things that they are hardly worth the effort to memorize, except perhaps for an exam the next day.  They are quickly forgotten.

You can find many lists of acronyms by googling “medical mnemonics.”

Which memory and learning techniques do you find most valuable in your medical studies?
What do you think of eBooks versus print books?

Rapid Learning

Memory Techniques for Med School #9 Chunking

Difficult directions — one of the major causes of poor patient compliance

CHUNKING
In chunking, you try to break up a large list of items into smaller chunks, each of which can be easier to memorize than the whole.  A classic example is the phone number, which, rather than a list of 10 successive digits, is broken up into a 3-digit area code, then a 3-digit number followed by a 4-digit number.

In medicine this can be done with lists of words or with pictures. For words, say you want to memorize a large list of antibiotics.  They are easier to learn by first grouping them into categories (antibacterial, antifungal, antiviral, antiparasitic).  Antibacterials can be  further reduced to the subchunks of penicillin family, anti-ribosomal, anti-tb and leprosy, and miscellaneous, etc.  If you can create subgroups of items in a large list (also aided by placing them in charts for cross-reference comparison), it becomes easier to keep them in mind.

Chunking can also be done with complex pictures.  For instance, the metabolic pathways in biochemistry form a large and complex map of associations.  Breaking them down into visual chunks eases the learning process:

Expanding on the chunks
Further chunk expansion (from Clinical Biochemistry Made Ridiculously Simple, MedMaster)

Which memory and learning techniques do you find most valuable in your medical studies?

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What do you think of eBooks versus print books?

Rapid Learning

Memory Techniques for Med School #8 Memory Palace

Surgical team and patient with "Hi, I'm...." social name stickers
Adding the human touch to the operating room

THE MEMORY PALACE
The Memory Palace (also called the method of loci, or mental walk)  is a terrific memory method that was used as far back as ancient Rome, but has been largely underused since the invention of  printed books.  Neuropsychologist A.R. Luria, in his book “The Mind of  a Mnemonist,” describes an amazing patient he followed for many years, who never forgot anything.  The patient used the Memory Palace method, which is also praised highly by Joshua Foer, who won the U.S. memory championship and describes the method in his best-selling book “Moonwalking with Einstein.”

In the Memory Palace you simply visualize a walk through a place that you know well.  For instance, it may be your home, in which you first encounter a large tree outside, then the front door, then the foyer, then the den on the right, then the kitchen, the bathroom, the bedroom, etc., in succession.  You know this sequential list well, simply by the familiarity that you have with your home.

You use this walking list of places to associate each stop along the walk with an item on the list you wish to memorize.

In the case of the 7 cancer signs:

1.  A change in bowel or bladder habits
2.  A sore that does not heal
3.  Unusual bleeding or discharge from any place
4.  A lump in the breast or other parts of the body
5.  Chronic indigestion or difficulty in swallowing
6.  Obvious changes in a wart or mole
7.  Persistent coughing or hoarseness

You might associate a cancerous tree, shaped like a “7,” that had a bowel and bladder exploding from its trunk.  Continuing the walk:

The fecal matter would land on the door, causing a large sore on the door.

The sore would erode through the door, causing a massive pool of blood and discharge in the foyer.

The den on the right would be filled to the ceiling with lumps.

etc.

The advantage of the Memory Palace over the Link and Peg methods is that you can have numerous memory palaces.  There then is no problem of confusing one item in a list with the same item in another list (such as a list of drug effects or symptoms of a disease).  Just use a different memory palace. Trained mnemonists use hundreds of Memory Palaces.  Moreover, you don’t have to memorize the number/letter combinations of the Peg method.  You already have ready made pegs through the places you have visited and know well.

Which memory and learning techniques do you find most valuable in your medical studies?
What do you think of eBooks versus print books?