How do you keep effectively adding new information to your brain throughout your life as an adult learner? Dr. Young, the Madigan Army Medical Center Residency Program Director, shares the latest science on what makes effective learning for adult learners, so you can maximize your efforts to get smarter every day.
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All right. Hey everybody. My name is Scott Young. And if you can't tell from all the cheesy branding going on all around me, I am from Madigan Army Medical Center, I am the outgoing residency program director. And I like you all, I am a lifelong learner. I successfully navigated College, medical school residency, and even fellowship, I passed the 10 year research exam. And you would think that would mean that I'm pretty smart, right? Or at least able to get through a couple of standardized tests. That list of quote unquote accolades would imply that I have mastered learning. But the truth is, I don't think I have, I've been really frustrated by you know, coming across an interesting bit of information or a journal article or a podcast or learning something from a resident or a colleague on shift, and then not being able to recall that stuff later on, not like 20 minutes later, or two days later, or when it really matters, you know, maybe a couple of weeks later in the emergency department, especially sometimes when it's really important. And this fact has really frustrated me to no end. And so I started doing some looking into learning and how we can learn more effectively. And that's what I'd like to share with you today. There's a couple parts of this lecture that the first 10 minutes or so we'll be talking about some education concepts in learning. And then the second part will be some thoughts on how we can implement that into some of the things that we already know in love journals and podcasts and things like that. So of course, as a disclaimer, these are my views and not the Department of Defense's. So starting with education theory, man, everybody's favorite, right? Well, we're just going to discuss four concepts today. And that is the ideas of retrieval, spaced repetition, elaboration, and interleaving. When most of us started learning in high school, in college and medical school, we did a lot of reading. And then we did a lot of rereading, right, you go through, you'd read, you would highlight sections, and then you go back through and reread your highlights a few times, and hopefully that would get you through the exam. But educational research has shown that this is not the most effective way to learn, and it definitely doesn't make things stick for the long term. So if we shouldn't be rereading, what should we be doing? Well, as it turns out, we should be asking a lot of questions to ourselves, as opposed to rereading using that retrieval mechanism that forces us to recall the information. Now, this image comes from an article on a website called Teach Like a Champion, and it just discusses the importance of retrieval. retrieving information, rather than Rereading is hard, right, which is why a lot of us don't like to do it. But it does provide the greatest amount of strengthening of neural pathways to solidify information in our memory. I'm gonna show you a graph here that kind of represents a lot of the education literature out there. And this is from a study that was published back in 2006. But when you look at this graph, there's three groups, the four SS group, those individuals were exposed to some data, which they were allowed to read four separate times. And then they were tested at five minutes, and then tested again, at one week, the second group three S's and one T, they read that information or that piece of data, three separate times. And then the fourth time, they were just asked to recall as many pieces of the data as they could. And then the third group, one s, and three teas, were only allowed to read the data once. And then they had to recall the information on three separate occasions, or three separate intervals times. And then they were all tested again at five minutes in one week. And as you can see from the graph, the people that read the information, just reread it several times the four S's in that black bar there on the left, obviously, they had the best recall of five minutes, but their recall at one week was terrible. Now, as you can see from the other two bars in the graph, the individuals that just read through the information once and then had to recall the information on three separate occasions had the best recall at one week, even though they had the worst recall at five minutes. And everybody's going to lose some recall, as one would expect over that period of time. So in the interest of the idea of retrieval, what is the most effective method to review information for long term retention? Let's retrieval right, as we just talked about. Now, we know that asking questions and forcing retrieval is the most effective means of learning. What is the next step in that process? Well, it turns out asking those questions repeatedly, over a space period of time. I love this quote that came out of a great book called Make It Stick. It certainly would recommend to anybody that's interested in education. Your brain is like a forest, the memory is in there somewhere. The more times you make a path to that memory, the better the path is, and how often How frequently do we need to space out? The more times right that we make the path to that memory and that's what we're talking about here is spaced repetition. So there's a couple little ways to go about doing this one, you could do it in an expanding manner where you learn the information, and then you retrieve it one day later, and then three days later, and then five days later, sort of an expanding format, you could do an equal spacing, so every five days, you just re retrieve that information. Or you could do it in a retry contracting manner, where you retrieve the information at seven days. And then again, that three days after that, and then again, one day after that, so they looked at this. And the bottom line up front is, it doesn't really matter, you can see, especially from these, the three clusters of bars to the right of the graph, the short, medium, and long. Each bar represents a different type of spaced repetition, expanding equal and contracting. And you can see that the recall the recall, or the proportion recall, there's really not that much different amongst the each of those different techniques. So the bottom line is, it doesn't really matter how you space it out, you just have to do some sort of spaced repetition. So we talked about retrieval, and how we need to retrieve information through questions rather than than just rereading it, we talked about spaced repetition, and how you need to obviously see that information more than once in some sport, sort of spaced manner. And it doesn't matter how you do that spacing. The next concept we're going to talk about is elaboration. So another great quote, learning should not be an accumulation of knowledge, but rather a construction of lattice work that interlaces newly acquired information with previously learned knowledge. So the idea is that you want to click that new piece of information into all the things that you already know. And sort of update your knowledge rather than trying to just learn something new that's sitting out in space on its own. And that's what the idea of elaboration is. So it's taking that new piece of information, and then somehow integrating it into what you already know. And there are probably a lot of ways to go about this. And because we're in the military, somebody says there's got to be a five W's in there somewhere, right? So that's how we're going to talk about doing elaboration. And it's a little cheesy, but bear with me here. The who is who taught this information to me before again, I get it, it's a little cheesy, but what did you know, before on this topic, before you got to this new piece of information? What is the actual piece of information that you're trying to learn or concept or whatever, you know, what is it that you're actually trying to learn here? When When are you going to use this information, what patient population, what setting etc. Where this is a prompt, to encourage you to perform maybe some visualization, actually see yourself in the setting that you would be using this new piece of information, whether it's a drug dosage, or, you know, a way to evaluate pulmonary embolism or whatever. Where is that specific setting, that you're going to use this piece of information, and he actually see yourself in your mind through visualization, using this piece of information in the way that you would want to do that. And then of course, why there's got to be a why behind it, there's no reason to learn, maybe it's just for the test. Or maybe it's for something that you think would be really important, clinically down the road at some point. So let's touch on the last of the concepts here. We talked about retrieval, and spaced repetition. And we touched a little bit on elaboration using the five W's. So we're going to talk briefly about interleaving. Now interleaving is basically mixing up subjects. Like, rather than doing a bunch of cardiology questions, you're mixing up cardiology, and endocrine and you whatever other subjects you might be studying. They've looked at this both in the education literature and, you know, sort of, again, a little bit cheesy, and I'm not a huge sports fan, but bear with me on this one, you know, pitchers is a great way to talk about this concept of blocking versus mixing. If you have a pitcher who throws a bunch of fast balls, until they really feel comfortable with fast balls, and then they throw a bunch of curveballs until they really feel comfortable with curveballs and so on and so forth. You know, they perform pretty well, as you can see in the graph on the left, let her be the blockers, those are the ones that are blocking all their practice for each type of pitch at the same time. Right. They perform pretty well when they practice until they're really comfortable with it. We're the people who the pitchers in this particular example who throw a couple fastballs and then a couple sliders and then a couple curveballs, you know, their accuracy or their performance is maybe not quite as good when they're going through practice. But then when it comes to testing, the people that mix up those pitches, the mixers, right, they actually going to perform better than the blockers because the blockers in the performance phase are actually going to have to mix that stuff. Mix up those pitches, right, kind of like we do in the emergency department. We obviously You're going from room one, it might have a chest pain or to room two, that's a pediatric fever to room three, that's a DKA, or whatever. So you don't want to necessary study by reading a bunch of cardiology questions or, you know, spending a lot of time reading through a bunch of cardiology articles, and then moving on to the next topic. So the bottom line is that interleaving mixing things up a little bit is going to increase your tension, your retention, even though it probably doesn't feel as effective. But it certainly represents more what we do in the emergency department. So those four learning techniques one more time retrieval, spaced repetition, elaboration, and interleaving. Alright, so I'm sure you guys love education theory as much as I do. But let's move on to some practical application here. This is where I think a lot of us get our EM knowledge from right it's podcasts like em rapper em cases. It's great blog posts like rebel em, it's journals such as Annals of Emergency Medicine. It of course, there's a whole lot more out there. How do we consume this information? Well, we often do it while we're driving, or while we're exercising, or maybe a journal club or a board round, something comes up. And how can we use these four techniques that we've talked about, to learn this information in a way that it is more retrievable at one week, one month, or one year, and is there when you really need it in the emergency department when providing patient care. So starting with the first concept of retrieval? Well, of course, there's an app for that. And there's a lot of different options out there. These are just a couple of examples. The one on the far left is Anki, a and k i and many of you have probably used this before, it's kind of a flashcard type app, the one in the middle is neuro cash. And then of course, if you don't want to pay for an app, you can always just use the notes function on your device, whether it's, you know, an eye device, or Android or whatever, I'm sure they all have note functions, where you can basically create a question off of something that you want to learn so that you can quiz yourself in the future. Now, I like the Anki. And they don't pay me any money. And I certainly paid for it myself. I'm just biased, because that's the one that I use, right. So this is an example of my desktop version of Anki. And basically, as you can see, it comes up there, there's a front in the back of the flashcard. And you can organize them by subject as necessary. But this particular flashcard actually came off a journal feed article where just thought thought was an interesting piece of information about using the IRS criteria, but then modifying your high D dimer value to age adjusted rather than just the 1000. And what's important about this, I know that there's a lot of Anki flashcard decks that are floating around out there, and my residents trade them around all the time. But I don't think it's the same when you didn't create the flashcard yourself. So I think it's important that you ask the question in a way that's meaningful to you. And the answer is also written in a way that's meaningful to you. So that's what I've done here. I created the question, and then the answer on the back. And then for those that haven't seen Anki, before, this is how the question comes up, at least on my desktop, my phone versions a little bit different. And then, you know, when you click Show, answer just shows you the back of it. And I always put a reference on the bottom in case I can't figure out what the hell I was talking about, I can always click the referencing, and go sort that out. So that's the retrieval part of this process. Right. So now, I've created a question and forced myself to retrieve the information rather than just rereading it over and over again. So the next step in this process is spaced repetition. We talked already about how frequently this should be, and it really doesn't matter as long as you're reviewing it in a spaced manner. And again, these apps are great, you know, Anki, and neuro cash, especially will already do the spacing for you, you don't have to determine it yourself. At the Notes app, you might have to set a reminder for five days from now or however long you want that spacing to be. But they'll do these, you know, expanding and contracting. It's mostly expanding, I think, at least with Anki. But it gives you that spaced repetition that you're looking for. Alright, so that gives us the retrieval and the spaced repetition. And then the next thing is elaboration. So I want to give me an example of this collaboration thing. I love journal feed. I think journal feed is great, great piece of information in my inbox every day. By problem a journal feed is it's like a, you know, they give you this fun fact in a little bit of background based on the journal article, but it's usually sort of this fun fact, that's kind of hovering out without any real connection. So for me when I read something on journal feed that I find interesting. I run through again, the five W's for as cheesy as they are. So who taught me about this particular topic before? What did I know before coming across this new piece of information going back to the years thing, right, what did I know about using the D dimer to evaluate pulmonary embolism before? And then what did I just learned about it? How did I learn? Or excuse me, what did I learn about that? years criteria and the age adjusted D dimer that is going to impact the way that I used to evaluate these. And when am I going to use this? What setting what patient population? Am I talking about? Specifically? What situations you know, what WELS risk level am I going to be thinking about before I consider using these different age adjusted D dimers. And then where, and this is where I will literally just think to myself, Okay, I'm in bed, you know, for Charlie, the Madigan emergency department, and I'm talking to this patient who is a low risk by wells for pulmonary embolism. And I'm an order d dimer. And what you know, value I just visualized myself going through this process. And it really just kind of just kind of helps solidify the information and helps it stick better. And then why do I care? Well, obviously, because I want to do less CTS if I can. But I also don't want to miss any pulmonary embolisms. And I think this is a great piece of information, it was worth adding to what I already knew on the topic. So after elaboration comes interleaving, and some of this comes naturally, right, we already do this with Rush review. Pier nine, a lot of these question banks are already mixed up for you. And again, as I said before, it really matches what we already do in the emergency department. You know, we're we're seeing patients have different you know, complaints, chest pain, and peds fever, and they're all mixed up. And that's how we have we pretty much work anyways, those apps also fortunately, will mix up the questions that you put into them as well. So it automatically does the interleaving for you, which is helpful. If you're using the Notes app, you might have to mix them up yourself a little bit. So now I know you're thinking, I'm going to create these flashcards about when exactly am I going to go through all these flashcards, it's just not something you know, that's not in my process, not on my daily process? What am I really going to go through that I'm not a resident anymore, even though I realize some of you probably are. So I think this cartoon really tells it well, Someday, you'll be able to hold one of these in the palm of your hand while you poop, then all I have to say is that you'll have time to go through these flashcards if you really want to, and we'll leave it at that. So I know what you're thinking, do I really have to go through all these steps and I really get into the five W's every time I learned something that's interesting to me, you know, it seems pretty onerous. And the answer is, you know, not necessarily, you don't actually have to do all this retrieval and create a flashcard and spaced repetition every single time. But I do think that it is worth stopping a podcast or whatever you're reading, when you come across something that's important to you, and going through some of this elaboration, right. And if you don't like the whole five W's thing, then figure out what it is that helps it helps you to insert that new piece of information to what you already knew before about it. I mean, essentially, you're just making learning a more active process, right? And that is going to increase your long term retention, and hopefully make that information available to you when you really need it at the bedside. So, in summary, good learning is hard. Retrieving is much more challenging than rereading stuff over and over and frankly, doing a bunch of multiple choice questions, which is what we often do, it's going to feel like you're not making progress, but the evidence shows that you are right short questions as you come across new information. And force yourself to retrieve that information rather than just rereading it or going through multiple choice questions where you get prompts, spaced repetition, take those questions that you wrote, you wrote, and just review them a few times, over a few weeks, the spacing doesn't matter. Just reexpose yourself to that information in a retrieval fashion, using spaced repetition. I've shown you some electronic resources, I'm sure there are plenty of others out there that I haven't talked about. And I'm certainly not biased. Anyone in particular elaboration, think about this new information that you came across? How does it fit into what you already know? And how would you explain it to someone else? And your words, right? Not in the speaker, if it's a podcast or the author, or if it's a blog post or journal article here reading. And when you're building a bank of questions, just make sure you're mixing them up. That way, you're more likely to remember them in a mixed up manner, which is how we practice because that's what we do in emergency medicine. So from my experience with this, I've definitely found it to be helpful in retaining some knowledge that I don't think I would have otherwise. And honestly, if nothing else, it just feels like I'm doing something right when I'm trying to learn something new. I feel like I'm not wasting my time or spinning my wheels. I read something over and over and spent two hours trying to remember it and then one week later, I can't even remember, right, at least this way, it's a structured process that is reproducible. And you know, I have those flashcards and I can go through them whenever I want and rehash some of that information. So with that, I appreciate your attention and opportunity to speak to you today. I certainly would love to hear your questions about these topics that I've, or these concepts, I guess, that I've been talking about. But I also would love to hear your take on the best ways to learn this information and remember it so that we can, you know, so it'll be there when we need it at the bedside. Thank you very much.