Hello beautiful people, I am back with a post on how I applied active recall and spaced repetition in my learning and revision for my third year exams. If you are short on time, and you are here for the key message I have to share, here it is-
Stop making copious amounts of notes and start actively and consistently testing yourself the material, spaced out over time.
If you have five (maybe ten) minutes to spare, read on to find out why this method worked for me, and how it helped me score an A in the 3rd-year systems exam.
Let me take you back to the beginning.
In first and second year, I often got asked by classmates about how I make notes, to which I would show them my 50-page word documents for each body system. What I used to do was to have the learning outcomes provided by the medical school transferred to a word doc, and those served as an outline to guide my note-taking. This prevented me from going completely off tangent and copying information that was beyond what was expected from us.
However, this process of note-taking was still very time consuming, and due to my tendency to space out during lectures, I ended up spending my breaks in the library trying to catch up on my notes. I probably spent an average of five hours outside of lectures to complete my notes for the day. I was barely keeping up with the pace at which the material was being taught to us. It felt like I was drowning.
I always knew something was highly inefficient about the way I studied, but I was trapped in old habits and was unable to break the cycle. Back in A Levels, and even IGCSE before that, we had tons of past year papers to test ourselves with before the actual exam. However, in medical school, we do not get past year papers so I did not have a clue as to whether I was studying in the correct direction, or whether I actually understood what I was learning. My foundation felt shaky, and it seemed like I was constantly grasping at straws. I stopped enjoying what I was learning because none of it made sense to me, and none of the dots connected.
During the first year formatives, I did well on the multiple choice questions (MCQ), and flunked the short answer questions (SAQ). The SAQs were based on case scenarios and went along the lines of "name two investigations which are most appropriate for this presentation" and "what is the most likely diagnosis". I found these super challenging because never had I asked myself these questions whilst revising. I was too busy trying to memorise the epidemiology, pathophysiology, clinical presentation, investigation, and treatment of each medical condition that when the questions were posed in a manner that truly tested my basic understanding, I faltered. My brain could not compute.
I was incredibly frustrated. It felt like I was putting in the hours to make notes that amounted to very little yield in the end.
Despite all this, I scored reasonably well for my first year exams. Obviously, that was a relief, but deep down, I knew that my performance was in spite of the way I studied, not because of it.
In second year, when the number of systems taught increased from two to eight, that was when I truly started to lose my mind. I was still making large quantities of notes, without adequate time to test myself on the material until the prospects of 2nd-year finals loomed before me.
In my hearts of hearts, I knew I was a goner for the exams. I had already forgotten most of what I had learned at the start of the year, and with a one-month study break to study ten systems, I could not fathom how I was going to be able to cover hundreds of pages of notes and test myself sufficiently.
Then, the pandemic happened, and 2nd-year exams were cancelled. When university closure was announced, exams were not cancelled right away. During that one month before my exam dates, I was in Malaysia, waiting with bated breath like everyone else in my year to see how things would unfold with regards to our exams. I was still revising to the best of my abilities, but no matter what I did, it just did not feel enough. I was reading through my notes, closing them and attempting to regurgitate them back up by reciting out loud and scribbling furiously on a whiteboard. It felt at the time like I knew my stuff, but the feeling was fleeting. After five days, when I took another look at the same topic, I could not recall the material the same way I could five days ago.
I resigned myself to the fact that if exams were going to go on as usual, I would just have to bite the bullet.
After the momentary euphoria due to exams being cancelled and replaced with online formatives, I sobered up really quickly. I knew that even though I was given a free pass into third year, I had not truly progressed. I could only kick the can down the road for so long. Eventually, come third year, with 20 systems to be tested, I would finally succumb to the brutal inefficiency of the way I had been studying.
With that uplifting thought, I started my third-year blocks weeks later. MSK was as awful as my seniors had told me. Nothing made sense. I made notes as usual, feeling like I was just going through the motion for the sake of it. Why did we have to know what external fixators were? What was traction? What were seronegative arthritides? Why did they all sound more or less similar? Anatomy was bleak as well. Without cadaveric specimens, I resorted to websites like Teach Me Anatomy and the ones subscribed by the medical school, like Acland's. Trying to remember the name, attachment, function and innervation of every muscle of the body was difficult when all I had were two-dimensional images on a textbook. I cannot say I was enjoying myself, mostly because I was wandering without direction, confused by the wealth of information around me. This sense of impending doom was growing within me. I feared I would not truly grasp how to study medicine until it was too late.
Having said so, I did find a way to dramatically improve my anatomy learning using this app called Complete Anatomy. I write more on another post about how I used this app to hugely supplement my learning, especially when it was all online.
In October 2020, I was then finishing up the reproductive block, preparing to start the medical humanities' block. I was looking forward to creative writing, which was what I had chosen to study during those six weeks of medical humanities. Primarily, it was because I enjoy writing, but I also learned from seniors that it was a very chill course, which would free up a lot of time for me to catch up with notes.
That was around the time I stumbled across Ali Abdaal's youtube videos on active recall and spaced repetition. Essentially, he talked about how we as (medical) students have been so accustomed to making notes by copy-pasting from lecture slides, which is time consuming and passive. It is undeniably easy to transcribe what the lecturers say onto a blank piece of paper, even if it is arduous. However, we waste so much time passively learning that we do not test ourselves often enough to maintain that knowledge. It is so bad to the point that when we finally get around to revising, it might seem like we are looking at material like it is the very first time, when we should already have built up a reasonable level of understanding.
The act of testing oneself is coined the term "active recall". My understanding of this technique is that no matter how you learn or revise, it has to be an active process that exhausts your mind. We are all familiar with the difference between active and passive transport. Learning is not passive, and it is wishful thinking to expect that the knowledge will diffuse into our minds by highlighting it with pretty colours or staring at it long enough to burn a hole through. You need to make it difficult to retrieve the information. You need to sit there and make yourself explain a concept to the point that a five-year old can understand. That is when you know you truly understand the material. You need to be asking yourself "Why?" to the point that you are satisfied that you are not merely memorising for the sake of it.
So how did I incorporate "active recall" into my learning?
I started making questions. I used this app, Notion, which is a free note-taking app recommended by Ali Abdaal and one I would also highly recommend after having used it for nearly a year now. It is free to begin with, and if you are a full-time student, I believe you can get the upgraded version for free too.
Now, I cannot say I have fully utilised all the features on Notion, but one of the main features I like the most is the toggle option. This toggle button allowed me to make questions and have the answers hidden under them. I made a page of questions for each block, divided into "physiology", "pathology", "anatomy" and "OSCE".
This method is somewhat similar to making flashcards using Anki. Though I have never really gotten into the world of Anki, the underlying principles are the same. To come up with good quality questions from each lecture, I was training my mind to be a lot more discerning, like I was the examiner setting the questions. I would look at the information, scan through it and ask myself: What kind of questions can they ask about this? To what extent do I need to know this?
A problem I had while making notes was that I always had this fear that I would miss out on key information that may be tested on in the exam. Hence, I ended up just copy-pasting most of the information onto a word doc, which made revision miserable. Once I started making questions, my note-taking became a lot more succinct, and I only transcribed information that was the answers to the questions I had come up with.
My theory was that if I could answer those questions I had made for myself on Notion, it meant I understood the material enough that no matter what sort of questions were thrown at me, I could handle them.
After implementing this method, I ended up with hundreds of questions for each system, which sounds like a lot. So how is this more efficient than note-taking?
This is where the concept of spaced repetition becomes relevant.
Spaced repetition is a technique built upon an irrefutable truth that is the forgetting curve. When we study something, unless we are consistently applying it and actively remembering it, we will eventually forget it. It is a completely normal phenomena because our long term memories are formed through the reverberating circuit, which just means that we have to hammer the same information into our head, ACTIVELY and CONSISTENTLY over a period of time.
So, how did I apply spaced repetition?
Every day, I went through at least 50 of those questions I had made for myself. I used the term "Active Recall Questions" or "ARQs". Before testing myself, I would not look at my notes and would just dive right into the questions. It was brutal. I could not answer most of the questions, save and except the easier ones like "What hormones are produced by the ovaries". However, this was completely normal. Even though I could not answer the questions straight away, I did not immediately reveal the answers, instead making myself ponder for at least a minute or two and really digging through my long term memory to try and come up with an answer. I would talk myself through what I do know and try and make an educated guess as to what the answer was. Basically, after I had satisfied myself that I genuinely had no clue as to what the model answer was, I would then reveal the answer by pressing the toggle button on Notion. To remind myself that I was unable to answer this question, I would then highlight this question yellow. Those that I could answer I would leave un-highlighted. That way, when I came back the second time to revise the same question, I would know that I had difficulty answering this question and should pay a bit more attention to this particular area during my revision.
Each time I revised the same set of questions, if I still could not answer the question on the subsequent round, I would highlight the question a different colour. For example, during the first round of revision, I highlighted the questions I could not answer yellow. During the second round, I highlighted the questions I still could not answer orange. During the final round, red.
Wait for it, there is logic in this madness.
On the day before my exams, with literally hours to spare, instead of even bothering to read notes, I would go straight to the questions that were highlighted and test myself with them. This saved time going over material that I was already familiar with and ensured that I went into the exam having reminded myself of the mistakes I had made.
Also, every time I revised these questions, if I could answer the ones I previously could not, I would un-highlight them because it meant that I had finally gotten the hang of that particular medical condition.
Did it work?
It sure did! I went into the two systems' exams confident and assured as I had managed to cover all the questions I had made at least twice, even having the time to do the formative quizes on our student portal to warm up.
If you are worried as to how you will be able to cover twenty systems in the one-month study break leading up to the exams, coupled with having to revise anatomy and OSCEs, I will be writing about how I micro-managed my time during that month. I will share what I studied first, and why I chose to study that, and how my timetable looked. If you are thinking that it is impossible, I would almost agree. When we finished paediatrics, we had exactly one month to revise everything from 1st to 3rd year. Actually, we were already handed the longer end of the stick as compared to my seniors who only got two weeks. Blimey, now that is impossible! One month is still pretty damn difficult, but it is doable, provided that you practice active recall and spaced repetition as often as you can throughout the year.
I narrowly managed to complete my revision in time for the exams. Bear in mind that I had only started applying active recall and spaced repetition in 3rd year and only completed my ARQs towards the end of 3rd year due to concurrent teaching. When I started my intense military-style revision at the end of February, I was going over ARQs like it was my first time and it was brutal. More about that in a separate post.
Right, I will end this post with the key message from the beginning- If you are still making lots of notes by copy-pasting information from your lectures, and you find that you are hard-pressed for time every day, you are doing something wrong. I had been doing it wrong for three years, rather, my whole life! I just never realised until then.
The silver lining is that it is never too late. I challenge you to re-evaluate the way you study and ask yourself if it is an active process. Whatever method you use, whether it is making questions like I did, or doing spider diagrams from memory, or teaching your flatmates all about the endocrine system, it has to be actively stimulating your memory. It has to be exhausting. It has to make you think and scratch your head in frustration. Otherwise, it is passive and will NOT help you learn efficiently.
Also, remember that spaced repetition is all about going over the same material time and time again, spaced out over a period of time. I can testify to the effectiveness of this method. After going over my MSK ARQs for the 5th time before my exams, I had less than 10 highlighted ARQs within the pool of hundreds of ARQs. It was a major confidence booster, and I thoroughly enjoyed the systems' exams, to the point that I was smiling to myself at one point. I was just so happy that my hard work had paid off, and that I had finally found a solution to this enigma that is how to study medicine.
OKAY, this post has gotten out of hand in terms of verbosity, but if you have any questions or thoughts, leave them in the comments! Thanks for reading and I hope this inspires someone out there today!
Cheers,
Jie Fei