HOW TO DRINK FROM A FIRE-HOSE WITHOUT DROWNING

Successful study strategies in medical school courses

April Apperson, UCSD SOM

Why should I change my study strategies?
If you're not happy with your performance, the most likely culprit is your study strategies. The
material presented in medical school is not conceptually more difficult than many rigorous
undergraduate courses, but the volume flow rate of information per hour and per day is much
greater it has frequently been described as drinking from a fire-hose.

Everyone admitted to a medical school has study strategies successful for an

undergraduate informational flow rate unfortunately, those developed by most pre-meds are
not efficient enough for the fire hose approach of medical school.

The most fundamental principle of efficient studying the best use of your limited time
requires active, not passive learning.
o
Active learning requires making decisions about the material Is this important?,
How is this part organized?, Where does this fit into the big picture?, What is the precise
definition of this term?,Where have I seen this in an earlier lecture?
o
Passive reading of pages of text or going over notes (even with a highlighter) and
hoping to absorb the information is very inefficient if you have enough time, it will work and
probably did in undergraduate classes, but it usually isnt adequate for the fire hose.

Changing a habit isnt easy, so dont be surprised if you need to hear or review active
strategies multiple times it takes time to change.
What are the fundamentals of active studying?
Four active processes will be used in the steps of any active study pattern and any study time that
does not involve one or more of these steps is almost certainly passive and inefficient!
1. Identifying the important information answering the eternal question of whats important
here?
2. Organizing the information start with the big picture to create a framework that facilitates
memorization and access appropriate for differential diagnosis.
3. Memorizing the information this requires frequent review to keep it available for use!
4. Applying the information to more complex situations practice questions, quiz questions,
clinical applications, etc.
Everyone will develop their own high volume study methods eventually, but the majority of
medical students benefit from a starting strategy and one generally successful starting point uses
five basic steps:
1. Finding the "big picture" by skimming the information before lecture identifying and
memorizing the four or five major topics will keep you on track during lecture.
2. Creating a complete rough draft of the material by annotating the lecturer's slides notes
emphasizing the lecturer's context are supplemented as needed from other reading
materials. Don't rewrite this!
3. Creating summary charts, lists or diagrams that organize the needed material to emphasize
patterns that facilitate memorization.
4. Actively memorizing the charts, etc., as they are created, then incorporating quick and
frequent review during later study to nail the information down you'll still need the
fundamentals after finals are over.
5. Practicing application using practice or quiz questions during the study process and not to
test yourself just before the exam.

Why find the "big picture" before lecture?

Many students find they lose sight of the forest as they focus on the leaves, much less the trees. If
you notice you are getting lost during lecture, finding the "big picture" before lecture provides a
road map through the forest that will increase active learning during lecture.
Pre-lecture work should take no more than 10 minutes/hour lecture and has 2 goals:
1. The road map. Scan the material to identify the number of major headings and the major
subheadings each has, then take just a couple of minutes to memorize those (don't skip
this part!). Read the introduction and summary, which emphasize those points.
2. The vocabulary. Scan the material again to note any definitions or equations. Exact
definitions are crucial and equations help relate many different factors correctly.
If the lecturer provides a syllabus prior to the lecture use it! If not, you can benefit from skimming
theassigned reading.
How do I generate my "rough draft" of all this information?
Take lecture notes that emphasize context the big picture and what the instructor thinks is
important.
1. Much of the factual information is typically provided in a syllabus or a handout of a
lecturers Power Point slides, so just annotate these dont forget you can use the backs of
pages for your notes.
o
Focus on adding context from the lecturer this requires decision-making and so is
active.
o
On a power point graph, note the point a graph or chart is making, or clearly label
the axes.
o
Emphasize any comments of the lecturer on what is important information vs. what
is just color.
o
Always note circumstances that indicate when one reflex or response will outweigh
another!
2. Number the pages of lecture notes for each subject so that you can easily identify them.
You will need those specific page numbers for cross-indexing your notes and references
from your summaries.
3. Use abbreviations and develop your own shorthand from them. Never write out the entire
name of a macromolecule, gene, etc. after the first time. Use symbols for words whenever
possible and be creative. Keep a list of them for the first quarter or two and be consistent.
As they become habit, your speed will improve a lot.
Create the rough draft by labeling, annotating and cross-referencing your lecture notes as you read
through them the first time this is the messy but complete document youll use as source material
for more concise summaries.
1. Impose the big picture on your notes.
o
Add major headings and subheadings within the notes and in the left margin in a
different color ink this reinforces the organization of the lecture. The lecture outline will
frequently provide headings if they aren't apparent from the lecture slides.
o
Label each topic in the left margin and circle specific definitions within the notes in a
different color these will be used both for reference and for keying memorization of the
material.
o
These processes force you to analyze the material and begin to actually learn it (not
just track it); this will speed up integrative summary design, also.
2. Supplement your notes with any additional information from other readings that will be
needed to create effective summaries.
o
Use your notes about the lecturers emphasis to help decide whats important, and
to look for missing information if the lecturer discussed three abnormal conditions and
provided causes for only two, maybe you missed the third.
o
Use the index in the text to direct you to specific topics don't get caught up
passively reading large sections without actively pulling out the facts to incorporate into
rough draft.

3. Cross-index your notes between lectures you won't remember which lecture contained
each experiment the weekend before the final.
o
Each time the lecturer mentions something you remember being discussed in an
earlier lecture, stop, find the pages in your earlier notes and add the page numbers in
both places.
o
This makes it much easier to create summaries that contain the from multiple
lectures which are the most useful summaries!
Your rough draft is the single reference document you will refer to incase you need to add detail
later to summaries or check on somethingyou originally didn't think was important.
How do I create organized summaries from my rough draft?
Organizing necessary detail into integrative summaries facilitates both memorization and
application and these summaries combine to form the final draft of your information that you will
use to study for the final.
1. What is "necessary" detail? See FAQ on "How do I know what will be on the exam?" or
How do I know how much detail to learn?
2. Different material lends itself to different types of summaries simple lists, charts, flow
diagrams, or pictures use whatever combination you prefer.
3. In each case, organize the material to emphasize connections and facilitate memorization.
o
Where possible, create "big picture" organizations that integrate material from
multiple lectures.
o
If you're not sure whether to include a specific detail, leave it out and just put in an
asterisk in the appropriate spot with the page number from your rough draft for quick
reference.
o
Don't recreate the wheel. If you find a good chart in some text orother source,
photocopy it and add it to your summaries. Be sure to add any additional information to
make it complete or more comprehensive try a different color ink to make it stand out.
4. Create and organize the headings before you spend any time filling in the actual
information.
o
The headings or location within a diagram should reinforce the big picture or
anatomy or chronological sequence or steps in a physiological process or someaspect of
the process.

Finalize the organization of the headings for your list or chart, or the spatial
organization for a flow chart or diagram before adding in any of the information (this
uses up a lot of scrap paper).

This requires analysis and integration of the material, which isactive, and
aids memorization, since there is a "reason" for the orderor spatial organization.
o
Use a hierarchical approach for headings or spatial organization no more than five
major headings on a list or chart or six major sections on a diagram more is too hard to
remember.
o
If you need more headings or sections, decide how they are related and create
subheadings.
o
The same numerical limits apply to subheading if necessary, go to the next level
of subheadings.
o
Make sure your headings (charts/lists) or spatial organization (flow charts,
diagrams) provide information due to their sequence or location.
5. Multiple summaries or diagrams are better than one big one.
o
Simple outlines in a syllabus provide a great source for topics that your summaries
should cover.
o
Limit the material covered in a single summary to an amount reasonable to
memorize, then use multiple summaries to cover the material from different points of
view.
o
For complex material, the organization of the headings may not be enough to
establish the "big picture"; in these cases, some summaries just focus on the big picture.

Don't hesitate to include the same information on different summaries,especially if

they are organizing the material from different points ofview or at different levels of detail.

How can I memorize actively and be sure I know the material?

1. Don't put off memorizing material until just before the exam.
o
Of course you will forget much of it after the first time that's why you need to build
repetitions into your study pattern. But if you memorized it actively (see above), you
forget the "address" of the information much more than the actual information. So review
will move it into long term memory. If you cram it the night before, you won't remember it
a week later, much less the next quarter or the next year.
o
So save the picky (but necessary) details for the night before, but memorize all the
concepts and the first couple of levels of detail as you go and review them as you study
later material.
2. Memorize the headings first their order should reinforce useful information like anatomy,
time course, etc.
o
First, memorize how many items (e.g., headings) there are
o
Second, memorize the headings themselves using biological logic, visualization,
or mnemonics.
o
Third, memorize the information associated with each heading, starting with just a
key word or short phrase, and finally adding the full item.
3. When you think you have memorized any piece of the chart, etc.:
o
Cover the original, and write out the material on a blank piece of paper (dont be
pretty, but dont cheat!), then throw what you have just written away!!!
o
Look at the original if you are confident you got it all great! If there is any
question, dont compare with what you should have thrown away just memorize it
again.
o
This method emphasizes what you dont know; comparing the new with the old only
confirms what you already knew, which misleads us into thinking we know more than we
do.
4. Quizzing each other is good motivation, but beware of subliminal cues used to help answer
the questions without mastering the material. Explaining it out loud to yourself is a good
start, but you can verbally "hand-wave" around areas you aren't clear on. Always check
yourself as above.
5. Frequent review is relatively painless with organized material and extremely helpful.
o
When an earlier topic or concept is mentioned, stop and review to yourself the
relevant summary list start with how many, then the headings, then the key words, then
the concepts or facts.
o
This review actually decreases the time needed to master later lectures, since later
material builds on earlier; this also increases exam speed, since answering factual
questions will be easier and faster.
How do I prepare for exam questions?
What are the most common problems medical students have with exams?
1. Clarity of definitions or concepts vs. those derived from context.
o
Students often generate their own general concepts or definitions from context
after all, thats how we learn to speak but this doesnt provide enough clarity to analyze
and correctly answer the questions.
o
Medical terminology and equations are very precise being close enough often
isnt sufficient.
2. Familiarity with material vs. mastery of the material.
o
Familiarity refers to recognizing the logic provided by someone else as when
leaving a good lecture, you can say, yeah, that made sense.
o
Mastery of the material requires integration and memorization of sufficient detail that
the information can be successfully applied to new situation.

Good test questions discriminate between the two!

3. Not having enough time to answer the more difficult applications questions involving
multiple steps in feedback loops or multiple related equations.
o
You need a method to approach complex question before you get to the exam.
o
Use examples given in lecture, quiz questions, or other practice questions while you
are studying to work out approaches for such questions ahead of time.
Where do I find time for all this?
o

1. Successful high-volume studying relies on good investment strategies:

o
Finding the big picture before lecture is easily put off, but it usually
saves more time during creation of the rough draft.
o
Creating summaries takes a lot of time, but it provides the "final draft" from which
you study for the final you won't have time to go back through the origninal notes!
2. There is more time available in a day than you think use it all.
o
Divide your studying into a series of short tasks don't wait until you have 2 or 3
hours to study. Use small bits of time while your clothes are drying or while the rice is
cooking for dinner for a single task.
o
Use all the "extra" time you can in the early weeks to be caught up in lectures and
ahead on papers so there is some slop when it gets really intense.
o
Be VERY careful about "robbing Peter to pay Paul" it's inevitable, but try to keep it
to a minimum. Its tempting to completely quit keeping up with other classes to study for
the upcoming exam, but this is a major trap that class has a final, too. Usually, skipping
class to do a paper or study for an exam ends up costing significantly more time in makeup time in the missed subject.
Frequently Asked Questions / Frequently Heard Comments
Topic: "It takes too long to do this active studying thing."

"I need to go over my notes at least twice before the final so I don't have time for all those
other steps."
Active studying must replace passive studying, not add to it. Analyze what you are doing
and delete all the passive steps. Replace passively "going over your notes" the first time
with labeling and supplementing your notes as you review them - yes, this is more work and
takes longer, but it saves time in the end. It is much more effecient to review your
summaries, rather than working through all your original notes!

"It takes too long to make those summaries."

Basically, if your studying isn't giving you the results you want, there is a very good chance
you need to integrate the material and memorize it better. Identifying the "necessary"
information and organizing it in summaries, diagrams and chartis is the best way to do this!
They do take time to create, but your time investment pays off when you are studying for
the final! Be sure you aren't recreating the wheel by copying over perfectly good(but not too
pretty) charts or by recopying perfectly good charts fromthe text or syllabus. Photocopies
work well and let you modify them asyou need, using a different color of ink to highlight
important modifications. When creating your own, use bits of time (15 to 30 minutes) during
the day and the time you previously used for passive studying.

"I don't have time to pre-read."

The active process is an integrated pattern that emphasizes overall efficiency, but each
step depends on having performed the earlier steps. If you decide you don't have time to
pre-read, your notes will be poor and you won't track much of the lecture. You just lost one
iteration of the details (you'll need to make that up later) and you will need more time to fix
your notes. Skipping a 15-minute process which then requires 30 minutes or more to make
up for is a bad investment. If you've had a good course as an undergraduate, your prereading can probably be limited to memorizing the course outline.
Topic: "I still need to go over my notes and/or recopy them."

"I need to go over my notes and/or the reading a couple of times to get familiar with it
before I can make charts."

Students usually feel this way if they didn't have grasp of the "big picture" during lecture.
Pre-lecture skimming and memorizing the major headings and subheadings eliminate this
problem. Reading the introduction and summary in the text reinforces this. As you read
through your notes the first time, create your rough draft with the course outline/syllabus
and text at hand to help you inserting the organizational headings into the notes. It is more
comfortable to go over your notes first, but it isn't time-efficient.

"I need to recopy my notes."

Your notes are the complete rough draft of the information. Your summaries are the final
draft with the "necessary" information organized for integration and easy memorization.
Don't worry about your notes being pretty, just well labeled and cross-indexed. Use your
time to create summaries instead.
Topic: "I don't want to go to lecture."

"I never went to lecture as an undergraduate and did just fine. Why start now?"
I don't recommend skipping lecture, since you are then missing the first chance to hear all
of the details (if you don't get lost - and pre-lecture skimming can solve that problem) and
review the big picture. Lecture is also the best place to find out what is likely to be on the
exam (see FAQ below), which depends a lot on context and emphasis often is not available
if you just study from the posted slides, even if you do listen to the podcast. The
information flow rate in medical and pharmacy school is a lot higher, and the analysis by the
lecturer is a valuable tool you should use, not ignore.

"I have an exam coming up, so I don't have time to go to lecture."

The above answer applies here, too. If you do skip lecture for whatever reason, don't forget
you need to replace both the analysis and review the lecture provides and the further
studying you need to organize and memorize the material.

"I don't like the lecturer and don't learn anything from him/her."
Different lecture styles work better for different people, but the bottom line is that lecture is
still the best place to find out what the professor thinks is important. If you aren't learning
anything in lecture, pre-read more rigorously and memorize the headings and subheadings
well enough that you won't get lost if the lecturer rearranges the order somewhat.

"My note-taking is so bad that it is a waste of time to go to lecture."

Annotate the power-point slides rather than taking completely fresh notes. You still lose the
experience of hearing the emphasis and extra explanation. And the only way to improve
your note-taking is practice. As a physician, you will be continuing your education (and note
taking) the rest of your life, so now is a good time to get better. Re-read the section on note
taking for specific suggestions on how to improve it.
Topic: "How do I know what will be on the exam and practice for it?"

"How do I know what will be on the exam?"

1. Find out whether the exam is multiple choice, short answer, essay or problems it
does affect your studying. The types of summaries and charts described above work
well for both types.
2. How many questions will each topic get? Theoretically, the questions on an exam
should be balanced to roughly parallel the proportion of lecture hours per topic. Of
course, it doesn't always work out that way, but it is a place to start. Some topics are
covered in multiple hours of lecture, so use the lecture schedule to estimate how
many questions each topic will receive.
3. How do I get practice on the kinds of questions that will be on the exam?

If one example is given in class or in a handout to illustrate an equation or

principle or graph, assume that any others are good subjects for exam questions.
Look them up in your notes or text and work them out ahead of time!

If the instructor gives a sample calculation, and the accompanying table has
more examples, fill it in.

Use practice problems or quiz questions as you study! They are one of your
best guids to "what is important" and "how do I need to think about this
information". Think about them as a guide, not as a test!

If the course includes conferences with assigned questions, be sure to

analyze and answer all the questions that other students presented. There is a lot

of difference between tracking logic outlined by the lecturer or text and applying
principles in a way you have not seen before.
"But I need to save the quiz or practice questions to test myself at the end."
Don't save quiz questions or practice questions to test yourself just before the exam!!! It
is then too late to modify your studying. You may do well and be complacent, or do poorly
and be a nervous wreck. So what? Practice/quiz questions are a guide for studying and the
same question can be used multiple times. It's not about knowing the answer - it's about
knowing how to analyze the material! Not sure what to know from a lecture after you have
created your "rough draft" - look at the practice questions from that lecture. Don't worry
about answering them, just think about how what type of material you need to know and
how questions might be asked. As soon as you have created the summary for a particular
topic before you have done the active memorization look at the questions on that topic
again. Do you have the information needed to answer them (and any variations you could
imagine from the "wrong" answers") in your charts? If not, modify your chart. If you want, try
answering them after you have memorized the material in the chart, but do so thoroughly
(see question below). Having it all memorized may only happen the night before the exam,
and that is too late to be of use.
"I need more questions to study from; where can I get them?"
Used properly, the quizzes and practice questions provided in each course are plenty for
preparation see question below. Also, many of the core textbooks and additional
readings recommended by the faculty have end-of-chapter practice questions.
"What is the best way to use quiz or practice questions?"
As described above in 'But I need to save...', don't save them to test yourself!! Efficient use
of quiz or practice questions requires analysis, not just finding the right answer!
1. Analyze exam question, don't just count up how many you got right. Whether or not
you got the question right, analyze it thoroughly.

Make sure you understand why EACH possible answer is right or wrong and
how each wrong answer could be made correct and what topic it was referring to.

If you didn't get it right, go back and memorize the entire chart or summary
that contained it.

Ask yourself if there are any other examples that could easily be used with
the same format.
2. Make sure the information for each question is somewhere in your summaries or
charts (not just your rough draft) if not, add it and any equivalent information to
any related categories.
3. Try writing a few possible questions yourself, then answering them (or trade with a
friend). This is a very powerful technique to having to analyze the material, know the
big picture and know details.
"I used the quizzes and practice questions and did well, but then I didn't do well on this
exam."
For a variety of reasons, "taking" a practice exam is always easier than taking a real exam which is yet another reason not to save the quiz and practice questions to test yourself. The
actual exam will be a different exam and the time pressure and stress will always make the
predictive value of quiz and practice questions marginal. Using quiz and practice questions
as described above will be much more effective preparation.
Topic: "I need help with my test-taking strategies."
"I understood the material, but I had trouble answering the questions. I have a problem with
test-taking."
Test-taking strategies can always be improved and can help the student display what he or
she really does know, but usually most of the problem is due to passive studying strategies.
1. In many cases, the student understood general concepts but did not memorize
enough facts clearly enough to analyze and answer the questions. Medical and
pharmacy school requires a much greater level of clarity of information than
undergraduate classes. Definitions must be precise and equations must be correct.
Knowing how much detail to learn is difficult, and varies with each class; quiz and
practice questions can be helpful (another reason to use them early) as well as

listening to the professor's emphasis during lecture (this often takes attention and
practice, since each lecturer's style differs).
2. In many cases, the student doesn't realize the difference between "familiarity" with
the logic provided by someone else and synthesizing the material well enough
to apply it to new situations. "Going over notes" only helps with "familiarity".
Organizing the material in charts or diagrams requires synthesis and integration and
helps identify connections in the material that will allow you to quickly and
accurately eliminate incorrect answers or identify the correct answer.
3. More difficult exam questions often require working through multiple equations or
multiple steps in a complex pathway. This type of analysis is difficult to do rapidly for
the first time, especially under the pressure of an exam. Quiz and practice questions
can provide examples, and should be used to work out methodical approaches that
allow you to answer that style of question. Such methodic approaches need to be
worked out ahead! Yet another reason to use quiz and practice questions during
studying, not saving them for the night before the exam.
"I always get it down to 2 answers and the always choose the wrong one."
This is a real phenomenon, and not just your imagination. At least two different processes
seem to contribute to consistently doing this:
1. People, including students, unconsciously equate effort with accuracy. So if it takes
3 minutes to justify one answer and only 30 seconds to justify another, the 3 minute
answer is often picked. Of course this usually means that it took more assumptions
and tortuous reasoning to justify the 3 minute answer, which makes it less likely to
be true. (Perhaps part of the reason for picking the more tortuous answer is fear one
won't be able to recreate the logic again!)
2. Students also frequently give more validity to impressions of "what your body wants
to do" or "what the cell wants to do" than to actual known relationships or equations
that describe reality. Often, a student will say something like, "Well, I knew that
stroke volume times heart rate equals cardiac output, and answer 'b' fit that
equation, but I though that stroke volume should be really important in determining
cardiac oxygen consumption because the heart wants to move all that blood, so I
chose answer 'c'." Notice the difference between "knew" and "should".
How can I keep from doing this? Few, if any, of us can prevent this entirely, but
you can decrease the frequency by actually writing a "truth score" next to the letter
of the answer. Have faith in your score - if you've never heard of it, don't assume it's
right (because you're sure you miss things) and don't assume it's wrong.
Use a 5-point scoring system (e.g. "++, +, +/-, -, --" or TT, T, ?, F, FF) to assign a
"truth" value to each answer as you first read it before you agonize over any of
them. For example:

TT is definitely true (you can write an equation or fact that demonstrates it).

T is probably true (you can't think of a definite proof, but you have a hunch).

? is one you are really not sure of (don't assume it's true or false if you just
don't know)

F is probably false.

FF is definitely false.
Think about each answer you aren't sure of, but don't change the original "truth"
value unless you have a revelation of an equation or relationship you can actually
write out.

If the one you are agonizing over gets a +/- or ?, but the original has a + or T, go
with the original.
"I have trouble with those trick questions."
Most "trick" questions aren't. Well-written multiple choice questions (MCQ) ask for
discrimination between similar conditions or possibilities (as will differential diagnosis) and
definitely require careful reading. This is why those precise definitions are important, and
where compare-contrast charts between topics or conditions are so useful. This isn't to say
that differential diagnosis requires discrimination between molecular processes, of course,

but the thinking needed to eliminate or include answers in well-written molecular or detailed
MCQ and on clinical MCQ is very similar.
Common problems in this category include:
1. Choosing the first correct statement, even though it is not the best answer to the
question.
2. Choosing a familiar association between two factors, even though that association
does not work in the described scenario or the factors are related inversely instead
of directly.
3. Choosing an answer based on an imprecise definition of a critical word in the
question.
4. Reading the first half of an answer and choosing it, without reading the second half
and realizing that the second half makes the answer false.
Techniques that can help reduce mistakes made during the exam:
5. For each answer, read the stem and that answer as one continuous statement.

Make sure the statement answers the question asked and is true under the
conditions listed.

While reading each answer, make sure the entire statement is correct, not
just half.
6. Slow yourself down by underlining, boxing or circling relevant information in the
question and jot down any useful equations or quick lists in the margin as a
reminder.

Try to have a "back-up" alternative logic to verify your answer; emphasizing

organization and connections during studying helps this technique this a lot.