Accelerated Learning in Healthcare
The following was contributed by James Mathison, bio below.
Do you find it odd that we’re never encouraged to learn how to learn? To study studying? To practice practising?
What if you could double how much information you retain from a given amount of study time? I believe we can do far more than that. Today I’m happy to contribute to the Medics.Academy blog on one of my favourite subjects – meta-learning!
Table of Contents
Why spend time on learning techniques?
Learning with poor technique is like swimming with your clothes on. It’s possible, but it’s slow and exhausting. Why not switch the jeans for a swimsuit, don a pair of flippers, and dive as deep as you like in every topic your career demands of you?
Put these meta-learning techniques into practice as soon as you can
The first insight I’ll share is that using what you learn right away sticks it in your mind. Why? Beyond the obvious, that practice makes perfect, it engages far more parts of your mind, creating a stronger web of connections. Your goal-oriention wakes up now that you have something to do. Your ego stirs and nags you to do the technique well. Your neurons and muscles go through the actual motions of whatever you’ve learned. What started as an abstraction is now cemented in a time and a place, with all the sights, sounds, and feelings associated with it.
Why not practice learning techniques with a bit of ophthalmology?
Next week we’re announcing a great new deal on a bundle of courses for junior doctors. We selected most of the courses in this bundle to be ideal for preparing yourself to be a junior doctor. We also included a course of pure clinical information, Ophthalmology for the Non-Ophthalmologist. When you watch it, try out the techniques in this article on the information presented by Dr Muhammed Jawad.
Let’s start with a technique that will make your flash-cards much more valuable. Spaced repetition.
Spaced Repetition: revolutionise rote memorisation
If you have ever used flash-cards to learn facts and you repeated the same cards every day for a while, you wasted time.
Your memory of a fact is strengthened most when you recall it just before it’s forgotten. Every time it’s recalled, it will take longer to forget. That’s crucial to why this technique is so efficient.
At first the forgetting curve is very steep. The next time you recall it, the connection is stronger, and the curve begins to level out. By the fifth well-timed recall, it may take months to forget. If you were revising it every day for a month, the memory wouldn’t be much stronger. Think about how much time that saves!
Dive into spaced repetition further with this interactive comic, which teaches you how to set up a simple system with physical flash-cards.
Alternatively, you can use spaced repetition software. The one I use is Anki. It’s free, has a huge community, and you can add pictures, sounds, even video to your cards to make them all the more memorable.
You’ll find many examples online of people using spaced repetition to blow up their rate of learning many things, from foreign languages to coding to, of course, medical knowledge.
Structured Study: select, chunk, connect
Truly skillful learning is about much more than abstract facts.
Real learning is about meaningful connections.
That’s why, if a flashcard is refusing to stick, make several flashcards that use different angles or a different context.
It still took me a moment to remember it, I admit. I thought, “What’s the name of that thing I remember taking from the tiny lab stockroom in Perpignan?” For some reason, that memory was the connection I used to access the object, but I could have used dozens of others. That’s why it’s never going away.
Take this concept and apply it to your learning. Things you actually use in your day-to-day life are no longer mere words or pictures or concepts. They are enmeshed in your reality. We don’t need to worry about them.
What we need to consciously think about “enmeshing” in our minds is important knowledge that you won’t need regularly, and particularly that you can’t predict when you’ll need it. A doctor’s mind should be chock-a-block with such information because you can’t predict what problems you’ll come across each day.
How to structure your studies
The internet is full of methods of structuring your learning (go to the bottom for my recommendations). It’s more important that you have a structure than what structure you have.
At minimum, a good structure includes
Selecting a measurable goal
Giving yourself a timeline and deadline
Blocking out time to focus 100%
Selecting the highest-impact material
Putting everything into practice as fast as you can
The goal is important for focus and motivation. Without a learning goal, I find myself going off on tangents. Thinking about the word “pipette” made me curious about what the Latin root of the prefix “pip” is. See what I mean? A goal will stop you spiralling off into an etymology deep-dive. An exception would be if you’re using knowledge of word roots to give yourself another connection on an important word, such as a rare disease or treatment.
The timeline serves a similar purpose to the goal. Estimate how much time you need and periodically measure your progress toward your goal.
Blocking out time is good for virtually every area of life. From surgery to family-time, distraction leads to waste. Also, note that your timeline can be shorter if you space out your study blocks. Good sleep is essential for settling information into long-term memory.
High-impact material is that which maximises your time-to-proficiency by affecting other aspects of the skill or knowledge base. For example, in many languages you can express yourself with “I need/want/must/should” plus the infinitive of any other verb. Thus, you only need to learn the conjugations for a handful of verbs to speak at a conversational level. What is that for you or the specialty you’re going into? What handful of things would confer a “ripple effect” of benefit to other areas?
Put it into practice immediately. Sometimes you can’t, understandably, such as when you’re using a spare five minutes to watch a video. Regardless, understand that the ideal learning session is not passive absorption. You don’t need much. If you’re learning a suturing technique you could practice on a sheet of paper. Paper is far from an accurate model of human tissue. That’s irrelevant. The important thing is to get your hands moving and mimicking the technique.
If you’re learning something purely didactic, “putting it into practice” can look like either active reading or teaching it to someone else. Active reading is taking each concept or fact and making note of it in various contexts. Think of angles, think of situations, think of diverse connections.
Don’t just read. Think.
The Memory Palace
Humans have such a good memory for a handful of things, it would appear to be savant-level genius if it wasn’t so common.
Our memories are built for:
Iconic symbols such as animals or objects that have strong meaning or are visually vivid
You are able to memorise a huge string of 50 random numbers using the above. You would only need to read it once to commit it to memory. I don’t care how bad you think your memory is, you are able to do this.
Follow along with me. Take out your debit card and look at the number on the front. In two minutes you’ll have that memorised.
Look at the key-table to the right. Each number is encoded into an animal or object. I prefer to use an archer’s arrow for number one and an elephant for six, but to each their own.
In your mind, place yourself in your bedroom.
Take the first four numbers and come up with a wild, dramatic story that makes the order of the numbers obvious. If it were 6834, let’s say you take a golf club, swing it through a snowman, knocking out its heart which goes through the window and sinks a ship that’s passing outside.
Imagine walking out of your bedroom and to whichever room you normally first go in the morning.
Make up another story for the next set of numbers.
And so on.
(If possible, I recommend you not read on until you’ve done this. It’s worth it.)
Once you’re done, put your card away, and see if you can recite the numbers, using the key above to help. If you’ve done it right, you’ll be able to recall your bizarre story easily, and then it’s just a case of decoding the characters and objects. With a few revisions, you’ll never forget it. Keep it going with different rooms and locations for the account number, sort code, and the CVV, and you’ll never have to pull out your card out to fill in an online form again.
To apply this method to healthcare, think of any information that you don’t want to look up in the moment. Example: a “standard operating procedure” with a long list of steps which must be done in order to avoid risk to patient safety. Any codes or passwords that you could shave seconds off by not looking them up.
The best in the world of any skill tend to practice in a specific way. The rest of us tend toward the exact opposite habits.
They focus relentlessly on their weakest points.
Most people focus on where they’re strong because it’s more fun. It’s egotistically gratifying to play the sections of a sonata you have already mastered and just struggle through where you still have some work to do.
I used to practice like that when I played piano in my spare time. I was good enough that I would still master the whole thing, but it took much more time than necessary.
Recently, I’ve started applying deliberate practice to my piano playing. Even though I have much less free time, I can learn music even faster than I used to. If I stumble over some notes, they now become my sole target until they’re fixed. I might play only two chords at half-speed, over and over and over until it’s wired in. Then I’ll add the notes just before, then those just after. Then I’ll change the key and mess with the rhythm. In a few minutes it’s completely mastered, inside and out.
How to apply deliberate practice to healthcare
If we apply deliberate practice to surgery, for example, things start getting exciting.
Surgical skill can be broken down into a myriad of components. Refer to the Journal of Thoracic and Cardiovascular Surgery and their article, The role of imaging, deliberate practice, structure, and improvisation in approaching surgical perfection. It takes the example of using a needle in coronary artery bypass grafting. To perfect this skill, you can take a stick of butter, cooled to a temperature where it mimics flesh, and passing a needle through. Since you’re using a curved needle, the trick to a perfect pass is to keep true to the curve as you move it, to know exactly where it will exit, and to follow through and reload with swift dexterity.
The key is, once you’ve mastered one tiny thing, make it harder. Cool the butter until it’s harder than flesh. Put it in a box to simulate a chest cavity slightly deeper than any you’ll actually be working on. Think of creative ways to push yourself until merely “good enough” is far behind you.
Then, move on to the next tiny aspect of the procedure that you need the most work on. Soon you’ll be unstoppable.
When Medics.Academy began, we focused on one specific surgical procedure – perineal repair. We created both the course and in-person practice training to be deployed at Barts Hospital in London. The purpose was to arm the nursing staff with the skill of perineal repair. For surgery, perineal repair is simple and safe but very common. Teaching the nursing staff to carry it out immediately freed up a lot of time for the obstetricians on the ward.
In this video, you can see how to practice perineal repair using a just a chunk of pork.
You can simulate many surgical skills without spending a lot of money. And for things that you can’t, 3D printing technology is closing that gap. In this section of the article mentioned above, the author gives the example of mitral valve repair. Each patient could have anatomical peculiarities that make them very different from the last. Practising on animal models has limited value because the challenging abnormalities (e.g. hypertrophic cardiomyopathy), while common in MV patients, are rare in the general population of pigs.
Thankfully, technology is catching up. We can now print heart models with perfect tissue density, simulating any abnormality we choose. When 3D printing technology gets better and cheaper, more of us will be able to apply hours of deliberate practice to procedures that, historically, we had to content ourselves with years of close observation in the theatre and the practice of generic skills.
We’ll give the last word on practice to Professor Auer, who said, “It really doesn’t matter how long [you practice for]. If you practice with your fingers, no amount is enough. If you practice with your head, two hours is plenty.”
Conclusion & Further Study
Meta-learning is a fascinating topic. It could be the most transferable set of skills in existence.
However, if you want to get further into the world of accelerated learning, I would recommend Tim Ferriss above all. I love his book, The Four Hour Chef, in which he uses his experience learning how to cook to demonstrate everything he’s learned about skill acquisition.
Scott Young has kept a blog on learning for a very long time. He focuses more on the fundamentals of learning and demonstrating how to design intense, immersive study programmes for yourself.
Finally, Josh Kaufman is another good resource. His book, 20 Hours to Learn Anything, is a great entry-level work into meta-learning and skill acquisition.