LEARNING

MEDICINE
An Evidence-Based Guide
Peter Wei | Alexander Chamessian

Learning Medicine An Evidence-Based Guide

Copyright 2015 Peter Wei and Alexander Chamessian
All Rights Reserved. No part of this book may be reproduced by any means
whatsoever without the written permission of the authors.
Cover Design by ShanYi Zhao
Interior Layout by Steven W. Booth, www.GeniusBookServices.com
ISBN: 978-0-9961533-0-0

Table of Contents
Chapter 1 Introduction.............................................................. 1
Section I Brain Science............................................................... 7
Chapter 2 A Model of the Mind.................................................................................... 8
Chapter 3 Spacing and Testing...................................................................................20

Section II Spaced Repetition Software................................... 34

Chapter 4 Spaced Repetition Software: Supercharging Your Memory........35

Chapter 5 Getting Started with Anki........................................................................42
Chapter 6 Studying with Anki.....................................................................................58
Chapter 7 Other Spaced Repetition Programs......................................................67
Chapter 8 Your Other Peripheral Brain: Note-Taking Systems.........................71

Section III The Learning Method............................................. 73

Chapter 9 Overview........................................................................................................74
Chapter 10 Acquire...................................................................................................... 106
Chapter 11 Review....................................................................................................... 116
Chapter 12 Apply.......................................................................................................... 120
Chapter 13 Bringing It Together: Learning Method in Action...................... 128

Section IV Implementation................................................... 141

Chapter 14 Implementation An Overview....................................................... 142
Chapter 15 Anatomy.................................................................................................... 145
Chapter 16 Biochemistry............................................................................................ 154
Chapter 17 Physiology................................................................................................ 159
Chapter 18 Pharmacology......................................................................................... 163
Chapter 19 Pathology................................................................................................. 169
Chapter 20 Clinical Skills............................................................................................ 175
Chapter 21 Board Exams............................................................................................ 179
Chapter 22 On the Wards........................................................................................... 187

Epilogue The Future of Medicine.......................................... 194

Chapter 23 Becoming a 21st Century Physician................................................ 195

Acknowledgments
We gratefully acknowledge the assistance and encouragement of our classmates at Duke
and colleagues elsewhere. In particular, we are grateful for Allison Ta, Cristophe Hansen,
Curry Cheek, Danielle Sobol, Emily Ngan, Jeff Smith, Jessica Friedman, Nathan Brajer,
Rand Wilcox Vanden Berg, Rikesh Gandhi, Rui Dai, Sameer Hirji, and Toria Rendell,
and Ryan Muller, whose generous feedback helped make the book you see today.

Chapter 1:
Introduction
As a medical student, learning is your job. But while med school does a fine job of
transmitting knowledge, many schools do not teach students how to learn. That is what
we wanted to change with this book.
This book is going to show you a new system for learning. Were going to teach you
how to efficiently absorb and synthesize the material in your textbooks, even when the
material seems impenetrable at first glance. Well introduce software tools that will let you
memorize anything and everything you need to, and retain it for the long haul. Finally,
with these tools in place, well go through the major subjects youll learn in med school,
and show you how to put these principles into action, step by step.
What can you expect from these tools? First, they will help you excel on standardized
tests such as the USMLE Step 1, which is used as an important criterion for acceptance
into most residency programs. They will also help you perform well in school and on the
wards, by effectively retaining as much knowledge as possible so that you can apply it on
exams and during your patient care responsibilities. Most importantly, applying these
lessons to learn more effectively will help you become a better doctor, better informed by
your training, more able to stay on top of developments in your field. And also, by the
same token, being more effective in your learning will free up time to connect with your
patients and think more humanistically about the practice of medicine.

2 Learning Medicine An Evidence-Based Guide

At a Glance What This Book Will Do For You
Give you a basic understanding of how learning and memory work
Provide you with powerful learning practices and the evidence that supports
them
Develop a complete learning methodology that you can apply throughout
your career in medicine
Help you to identify and employ useful digital tools for medicine
Help you perform at a high level academically
Equip you to become the best doctor you can be

Our story
Alex and Peter, your humble co-authors, met as medical students at Duke. Alex is an
MD/PhD student interested in pain medicine. Peter is an MD starting his training in
radiology. Above all, were passionate about medicine and effective learning.
Like most of you, when studying in college and prepping for the MCAT, we tried a
number of different approaches outlines, notecards, cramming, the works. But when
we reached medical school, we were overwhelmed by the volume of information. We realized that these approaches werent enough. Brute force would let us learn most of what
we needed and pass the tests, but good enough wasnt enough for us.
Worse yet, with a pure cramming regimen, wed start forgetting key concepts that we
learned just a few weeks earlier. We heard well-meaning upperclassmen telling us Dont
worry youll forget it all by second year and youll have to relearn it anyway. What a
depressing thought! We needed to find a better strategy if we were going to learn and keep
on top of all this information.
So we went to the literature on learning and memory, and sought out what science
had to say about optimal ways to study. With some theory under our belts, we were better
able to experiment and develop unconventional study strategies that far outperformed
what we had been doing before. We talked with our classmates, who adopted parts of this
methodology for themselves and offered useful suggestions to streamline it further.
It wasnt perfect. After all, it took years for us to learn how to study the old-fashioned
way, and we were trying to implement a new one in just a few weeks. We made mistakes
along the way, and as we kept talking to other students, we realized that many of them

Chapter 1: Introduction
were running across similar stumbling blocks. We looked at the recurrent problems and
figured out ways around them.
Pretty soon our class was teaching these techniques to the incoming first years, and
a year later, that class started reaching out to the new incoming first years. And sure
enough, many of us did very well on the USMLE step exams and found that we had a
firm grasp of preclinical knowledge once we hit the wards our studying yielded much
better results than we could have otherwise expected.
We wrote this book because we wanted to both expand and improve on the methodology weve developed. We wanted to reach out to students beyond Duke to present
them with a fully developed system so that they could hit the ground running in medical
school and beyond. We wanted to write the book we wish had existed when we started
our medical school journey.

Who is this book for?

Our background is in medicine, and so we wrote this book with incoming first-year
medical students in mind. We chose our examples and tailored our implementation to
specifically help you navigate and get the absolute most out of medical school.
Theres value here for grizzled med school veterans as well. If youre in your preclinical
years, we can help you retain and systematize your learning in medical school. (We ourselves hadnt fleshed out our system completely until well into our preclinical education.)
If youre on rotations, our system can help you make sense of the often haphazard clinical
learning that comes at you on the wards. And for residents and beyond, lifelong learning
is a way of life in medicine. As you deepen your knowledge of your specialty and stay
abreast of the latest research, we want to equip you to be the best practitioner you can be.
That said, the principles we present are universal, and extend well beyond learning
medicine. With a few tweaks you could use the same principles to learn any subject.
Despite our title, we believe that the systematic approach to learning we advocate can
be valuable for everyone. Other health professions students can find value here, adjusting implementation based on their own in-depth knowledge of how nursing school or
physician assistant school is structured. Furthermore, what were offering is a general,
evidence-based approach to learning and retaining knowledge. And thats a tool that can
help anyone, of any age, who approaches any body of knowledge as a student.

4 Learning Medicine An Evidence-Based Guide

How this book is organized

This book is organized to take the reader from theory to practice. The first section,
Brain Science, explains the fundamental psychological principles of learning. Part II talks
about spaced repetition software, the backbone of our learning method. It walks you
through how to set up Anki, our preferred spaced repetition system, and explains how
to use it to get the maximum benefit. Part III, The Learning Method, is a step-by-step
description of how to study anything in medical school, whether from books, videos, or
lectures. Part IV, Implementation, gives specific tips, tools, and frameworks to help you
approach the diverse subjects you learn in medical school, from anatomy to pharmacology. Finally, in the final section, The Future of Medicine, we consider what skills a 21st
century doctor might need beyond whats taught in medical school and suggest how you
might teach yourself those skills.

Our philosophy
When trying to decide how to learn, everyone comes at the problem with their own
perspective, and we are no different. Since we in medicine believe in informed consent,
lets lay out the three major principles that inform our approach in thinking about how
to study for medical school.

1. Evidence-based learning
One dominant theme in modern medicine is the idea that the practice of medicine
should be grounded in solid empirical evidence, whenever it is available. It even has a
trendy name: Evidence-Based Medicine or EBM. You will hear this term throughout
your medical career and for good reason: if we want to achieve predictable and optimal
outcomes, then we should look to the evidence to see what actually works. With something as serious as medicine, it sensible to insist on evidence-based methods.
But it also makes sense for any other endeavor in life where we want to achieve the
best, most consistent results. As medical students, our job is to learn medicine, and we
spend a tremendous amount of time, money and effort in doing that job. Shouldnt we
strive to apply best practices to what we do? Shouldnt we make use of the available evidence about learning to guide our studies rather than just doing what seems right?

Chapter 1: Introduction
We certainly think so. Learning medicine is serious business, and it deserves to be
treated that way. So weve gone to the literature on learning, memory, and psychology,
and weve written the recommendations in this book based on the best available science.
But there are still many things we dont know about learning and memory, especially in
applying these findings to learning medicine. In those cases, we appeal to our experiences
and those of other successful medical students. This, too, is analogous to the way doctors
practice EBM. When solid evidence is lacking, they must integrate what they know with
their expert experience and judgment.

2. Learning comes first

We all have our reasons for why we wanted to become doctors. Maybe we wanted
to learn all about the amazing complexity of the human body. Maybe we wanted to do
cutting-edge research to cure diseases. Or maybe we wanted a chance to show compassion
and personally ease the suffering of our patients. Medicine can be all of these things, but
it comes with something more a deep responsibility for the well-being of our patients.
Lets run some numbers. Lets say youll be practicing for 30 years although many
physicians practice well into their 70s and beyond. And lets give you a leisurely clinic
schedule of 10 patients a day. This means that youll have 75,000 patient visits over the
course of your career. Many of them will be sniffles and scrapes common problems that
anyone with the right training can manage. But some of them will be more challenging,
testing the limits of your diagnostic and management skills. This is where the depth of
your knowledge will make a difference.
Lets say that one in 50 patients 2% of them have an unusual presentation or
require unconventional treatment. Theyre the rare zebras, the patients where you have
to go above and beyond cookbook medicine. Over the course of your career, the number
of such patients you will encounter is 1500. Let that sink in for a minute. Throughout
medical school, residency, and the lifelong learning beyond, how well you learn your craft
will determine whether these patients will get better or get worse. You will have a massive
impact on 1500 lives.
That is why we aimed this book at helping you learn in medical school, rather than
helping you ace medical school. Of course we want to help you succeed at all the steps
along the way med school grades, boards scores, and residency applications. And we
think we can do a pretty good job. But at the end of the day, our responsibility is to our

6 Learning Medicine An Evidence-Based Guide

future patients, not to the testing agencies. Keeping an eye on this goal can help us stay
focused on whats important, as well as motivate us and insulate us from burnout as we
go through the challenges of medical school.
In this book, youll see that we advocate some unconventional methods. Well show
you how to study in a new way. Well encourage you to test out not going to lectures.
Well have you do additional reviews beyond what you need to ace your school exams. If
we cared only about short-term goals weekly quiz grades, giving the appearance of being a good student these may not be the very best methods. But in our minds, helping
to take better care of those 1500 patients is far more important than doing things by the
book. If you apply our lessons, theres no reason you wont be very competitive, both in
class and on the boards. But our ultimate goal, and hopefully your goal too, is to be the
best doctor you can be. Thats why we wrote this book. Thats what we want to help you
strive passionately towards.

3. Use of technology
Med school today looks a lot different than it did even a decade ago. In many schools,
lectures are streamed online for students to watch at their own pace. New books and online resources have sprung up and become overnight classics. The computational power
at our fingertips and in our pockets opens up entirely new ways of studying that were
impossible in our professors generations.
Were enthusiastic fans of using technology to augment our learning. Well be practicing in a world where genomically targeted cancer therapy and robot-assisted surgery are
commonplace. Theres no reason that our studying should be any less high-tech. Books
and lectures have an important place in our system, but well also be introducing you to
online resources and computer-based tools that your professors may not be familiar with
but that we think can supercharge your learning.