Episode Transcript
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Scott Young (00:00):
All right. Hey
everybody. My name is Scott
Young. And if you can't tellfrom all the cheesy branding
going on all around me, I amfrom Madigan Army Medical
Center, I am the outgoingresidency program director.
And I like you all, I am alifelong learner. I successfully
navigated College, medicalschool residency, and even
fellowship, I passed the 10 yearresearch exam. And you would
(00:23):
think that would mean that I'mpretty smart, right? Or at least
able to get through a couple ofstandardized tests. That list of
quote unquote accolades wouldimply that I have mastered
learning. But the truth is, Idon't think I have, I've been
really frustrated by you know,coming across an interesting bit
of information or a journalarticle or a podcast or learning
(00:44):
something from a resident or acolleague on shift, and then not
being able to recall that stufflater on, not like 20 minutes
later, or two days later, orwhen it really matters, you
know, maybe a couple of weekslater in the emergency
department, especially sometimeswhen it's really important. And
this fact has really frustratedme to no end. And so I started
doing some looking into learningand how we can learn more
(01:06):
effectively. And that's what I'dlike to share with you today.
There's a couple parts of thislecture that the first 10
minutes or so we'll be talkingabout some education concepts in
learning. And then the secondpart will be some thoughts on
how we can implement that intosome of the things that we
already know in love journalsand podcasts and things like
that. So of course, as adisclaimer, these are my views
(01:26):
and not the Department ofDefense's. So starting with
education theory, man,everybody's favorite, right?
Well, we're just going todiscuss four concepts today. And
that is the ideas of retrieval,spaced repetition, elaboration,
and interleaving. When most ofus started learning in high
school, in college and medicalschool, we did a lot of reading.
(01:48):
And then we did a lot ofrereading, right, you go
through, you'd read, you wouldhighlight sections, and then you
go back through and reread yourhighlights a few times, and
hopefully that would get youthrough the exam. But
educational research has shownthat this is not the most
effective way to learn, and itdefinitely doesn't make things
stick for the long term. So ifwe shouldn't be rereading, what
(02:10):
should we be doing? Well, as itturns out, we should be asking a
lot of questions to ourselves,as opposed to rereading using
that retrieval mechanism thatforces us to recall the
information. Now, this imagecomes from an article on a
website called Teach Like aChampion, and it just discusses
the importance of retrieval.
retrieving information, ratherthan Rereading is hard, right,
(02:30):
which is why a lot of us don'tlike to do it. But it does
provide the greatest amount ofstrengthening of neural pathways
to solidify information in ourmemory. I'm gonna show you a
graph here that kind ofrepresents a lot of the
education literature out there.
And this is from a study thatwas published back in 2006. But
(02:52):
when you look at this graph,there's three groups, the four
SS group, those individuals wereexposed to some data, which they
were allowed to read fourseparate times. And then they
were tested at five minutes, andthen tested again, at one week,
the second group three S's andone T, they read that
information or that piece ofdata, three separate times. And
(03:12):
then the fourth time, they werejust asked to recall as many
pieces of the data as theycould. And then the third group,
one s, and three teas, were onlyallowed to read the data once.
And then they had to recall theinformation on three separate
occasions, or three separateintervals times. And then they
were all tested again at fiveminutes in one week. And as you
can see from the graph, thepeople that read the
(03:34):
information, just reread itseveral times the four S's in
that black bar there on theleft, obviously, they had the
best recall of five minutes, buttheir recall at one week was
terrible. Now, as you can seefrom the other two bars in the
graph, the individuals that justread through the information
once and then had to recall theinformation on three separate
(03:55):
occasions had the best recall atone week, even though they had
the worst recall at fiveminutes. And everybody's going
to lose some recall, as onewould expect over that period of
time. So in the interest of theidea of retrieval, what is the
most effective method to reviewinformation for long term
retention? Let's retrievalright, as we just talked about.
(04:19):
Now, we know that askingquestions and forcing retrieval
is the most effective means oflearning. What is the next step
in that process? Well, it turnsout asking those questions
repeatedly, over a space periodof time. I love this quote that
came out of a great book calledMake It Stick. It certainly
would recommend to anybodythat's interested in education.
(04:39):
Your brain is like a forest, thememory is in there somewhere.
The more times you make a pathto that memory, the better the
path is, and how often Howfrequently do we need to space
out?
The more times right that wemake the path to that memory and
that's what we're talking abouthere is spaced repetition. So
there's a couple little ways togo about doing this one, you
(05:01):
could do it in an expandingmanner where you learn the
information, and then youretrieve it one day later, and
then three days later, and thenfive days later, sort of an
expanding format, you could doan equal spacing, so every five
days, you just re retrieve thatinformation. Or you could do it
in a retry contracting manner,where you retrieve the
information at seven days. Andthen again, that three days
(05:23):
after that, and then again, oneday after that, so they looked
at this. And the bottom line upfront is, it doesn't really
matter, you can see, especiallyfrom these, the three clusters
of bars to the right of thegraph, the short, medium, and
long. Each bar represents adifferent type of spaced
(05:44):
repetition, expanding equal andcontracting. And you can see
that the recall the recall, orthe proportion recall, there's
really not that much differentamongst the each of those
different techniques. So thebottom line is, it doesn't
really matter how you space itout, you just have to do some
sort of spaced repetition. So wetalked about retrieval, and how
(06:05):
we need to retrieve informationthrough questions rather than
than just rereading it, wetalked about spaced repetition,
and how you need to obviouslysee that information more than
once in some sport, sort ofspaced manner. And it doesn't
matter how you do that spacing.
The next concept we're going totalk about is elaboration. So
another great quote, learningshould not be an accumulation of
(06:27):
knowledge, but rather aconstruction of lattice work
that interlaces newly acquiredinformation with previously
learned knowledge. So the ideais that you want to click that
new piece of information intoall the things that you already
know. And sort of update yourknowledge rather than trying to
just learn something new that'ssitting out in space on its own.
And that's what the idea ofelaboration is. So it's taking
(06:49):
that new piece of information,and then somehow integrating it
into what you already know. Andthere are probably a lot of ways
to go about this. And becausewe're in the military, somebody
says there's got to be a fiveW's in there somewhere, right?
So that's how we're going totalk about doing elaboration.
And it's a little cheesy, butbear with me here. The who is
who taught this information tome before again, I get it, it's
(07:12):
a little cheesy, but what didyou know, before on this topic,
before you got to this new pieceof information? What is the
actual piece of information thatyou're trying to learn or
concept or whatever, you know,what is it that you're actually
trying to learn here? When Whenare you going to use this
information, what patientpopulation, what setting etc.
Where this is a prompt, toencourage you to perform maybe
(07:37):
some visualization, actually seeyourself in the setting that you
would be using this new piece ofinformation, whether it's a drug
dosage, or, you know, a way toevaluate pulmonary embolism or
whatever. Where is that specificsetting, 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
(08:01):
in the way that you would wantto do that. And then of course,
why there's got to be a whybehind it, there's no reason to
learn, maybe it's just for thetest. Or maybe it's for
something that you think wouldbe really important, clinically
down the road at some point. Solet's touch on the last of the
concepts here. We talked aboutretrieval, and spaced
(08:22):
repetition. And we touched alittle bit on elaboration using
the five W's. So we're going totalk briefly about interleaving.
Now interleaving is basicallymixing up subjects. Like, rather
than doing a bunch of cardiologyquestions, you're mixing up
cardiology, and endocrine andyou whatever other subjects you
might be studying. They'velooked at this both in the
(08:47):
education literature and, youknow, sort of, again, a little
bit cheesy, and I'm not a hugesports fan, but bear with me on
this one, you know, pitchers isa great way to talk about this
concept of blocking versusmixing. If you have a pitcher
who throws a bunch of fastballs, until they really feel
comfortable with fast balls, andthen they throw a bunch of
curveballs until they reallyfeel comfortable with curveballs
(09:08):
and so on and so forth. Youknow, they perform pretty well,
as you can see in the graph onthe left, let her be the
blockers, those are the onesthat are blocking all their
practice for each type of pitchat the same time. Right. They
perform pretty well when theypractice until they're really
comfortable with it. We're thepeople who the pitchers in this
particular example who throw acouple fastballs and then a
(09:31):
couple sliders and then a couplecurveballs, you know, their
accuracy or their performance ismaybe not quite as good when
they're going through practice.
But then when it comes totesting, the people that mix up
those pitches, the mixers,right, they actually going to
perform better than the blockersbecause the blockers in the
(09:52):
performance phase are actuallygoing to have to mix that stuff.
Mix up those pitches, right,kind of like we do in the
emergency department. Weobviously You're going from room
one, it might have a chest painor to room two, that's a
pediatric fever to room three,that's a DKA, or whatever. So
you don't want to necessarystudy by reading a bunch of
cardiology questions or, youknow, spending a lot of time
reading through a bunch ofcardiology articles, and then
(10:14):
moving on to the next topic. Sothe bottom line is that
interleaving mixing things up alittle bit is going to increase
your tension, your retention,even though it probably doesn't
feel as effective. But itcertainly represents more what
we do in the emergencydepartment. So those four
learning techniques one moretime retrieval, spaced
repetition, elaboration, andinterleaving. Alright, so I'm
(10:40):
sure you guys love educationtheory as much as I do. But
let's move on to some practicalapplication here. This is where
I think a lot of us get our EMknowledge from right it's
podcasts like em rapper emcases. It's great blog posts
like rebel em, it's journalssuch as Annals of Emergency
Medicine. It of course, there'sa whole lot more out there. How
(11:00):
do we consume this information?
Well, we often do it while we'redriving, or while we're
exercising, or maybe a journalclub or a board round, something
comes up. And how can we usethese four techniques that we've
talked about, to learn thisinformation in a way that it is
more retrievable at one week,one month, or one year, and is
there when you really need it inthe emergency department when
providing patient care. Sostarting with the first concept
(11:23):
of retrieval? Well, of course,there's an app for that. And
there's a lot of differentoptions out there. These are
just a couple of examples. Theone on the far left is Anki, a
and k i and many of you haveprobably used this before, it's
kind of a flashcard type app,the one in the middle is neuro
cash. And then of course, if youdon't want to pay for an app,
(11:43):
you can always just use thenotes function on your device,
whether it's, you know, an eyedevice, or Android or whatever,
I'm sure they all have notefunctions, where you can
basically create a question offof something that you want to
learn so that you can quizyourself in the future. Now, I
like the Anki. And they don'tpay me any money. And I
certainly paid for it myself.
(12:06):
I'm just biased, because that'sthe one that I use, right. So
this is an example of my desktopversion of Anki. And basically,
as you can see, it comes upthere, there's a front in the
back of the flashcard. And youcan organize them by subject as
necessary. But this particularflashcard actually came off a
journal feed article where justthought thought was an
interesting piece of informationabout using the IRS criteria,
(12:29):
but then modifying your high Ddimer value to age adjusted
rather than just the 1000. Andwhat's important about this, I
know that there's a lot of Ankiflashcard decks that are
floating around out there, andmy residents trade them around
all the time. But I don't thinkit's the same when you didn't
create the flashcard yourself.
So I think it's important thatyou ask the question in a way
that's meaningful to you. Andthe answer is also written in a
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way that's meaningful to you. Sothat's what I've done here. I
created the question, and thenthe answer on the back. And then
for those that haven't seenAnki, before, this is how the
question comes up, at least onmy desktop, my phone versions a
little bit different. And then,you know, when you click Show,
answer just shows you the backof it. And I always put a
reference on the bottom in caseI can't figure out what the hell
(13:13):
I was talking about, I canalways click the referencing,
and go sort that out. So that'sthe retrieval part of this
process. Right. So now, I'vecreated a question and forced
myself to retrieve theinformation rather than just
rereading it over and overagain. So the next step in this
process is spaced repetition. Wetalked already about how
(13:34):
frequently this should be, andit really doesn't matter as long
as you're reviewing it in aspaced 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, youmight have to set a reminder for
five days from now or howeverlong you want that spacing to
be. But they'll do these, youknow, expanding and contracting.
(13:57):
It's mostly expanding, I think,at least with Anki. But it gives
you that spaced repetition thatyou're looking for. Alright, so
that gives us the retrieval andthe spaced repetition. And then
the next thing is elaboration.
So I want to give me an exampleof this collaboration thing. I
love journal feed. I thinkjournal feed is great, great
(14:17):
piece of information in my inboxevery 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 basedon the journal article, but it's
usually sort of this fun fact,that's kind of hovering out
without any real connection. Sofor me when I read something on
journal feed that I findinteresting.
I run through again, the fiveW's for as cheesy as they are.
(14:40):
So who taught me about thisparticular topic before? What
did I know before coming acrossthis new piece of information
going back to the years thing,right, what did I know about
using the D dimer to evaluatepulmonary embolism before? And
then what did I just learnedabout it? How did I learn? Or
excuse me, what did I learnabout that? years criteria and
(15:01):
the age adjusted D dimer that isgoing to impact the way that I
used to evaluate these. And whenam I going to use this? What
setting what patient population?
Am I talking about?
Specifically? What situationsyou know, what WELS risk level
am I going to be thinking aboutbefore I consider using these
different age adjusted D dimers.
And then where, and this iswhere I will literally just
(15:23):
think to myself, Okay, I'm inbed, you know, for Charlie, the
Madigan emergency department,and I'm talking to this patient
who is a low risk by wells forpulmonary embolism. And I'm an
order d dimer. And what youknow, value I just visualized
myself going through thisprocess. And it really just kind
of just kind of helps solidifythe information and helps it
(15:45):
stick better. And then why do Icare? Well, obviously, because I
want to do less CTS if I can.
But I also don't want to missany pulmonary embolisms. And I
think this is a great piece ofinformation, it was worth adding
to what I already knew on thetopic. So after elaboration
comes interleaving, and some ofthis comes naturally, right, we
already do this with Rushreview. Pier nine, a lot of
(16:08):
these question banks are alreadymixed up for you. And again, as
I said before, it really matcheswhat 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'show we have we pretty much work
anyways, those apps alsofortunately, will mix up the
(16:30):
questions that you put into themas well. So it automatically
does the interleaving for you,which is helpful. If you're
using the Notes app, you mighthave to mix them up yourself a
little bit. So now I know you'rethinking, I'm going to create
these flashcards about whenexactly am I going to go through
all these flashcards, it's justnot something you know, that's
(16:51):
not in my process, not on mydaily process? What am I really
going to go through that I'm nota resident anymore, even though
I realize some of you probablyare. So I think this cartoon
really tells it well, Someday,you'll be able to hold one of
these in the palm of your handwhile you poop, then all I have
to say is that you'll have timeto go through these flashcards
if you really want to, and we'llleave it at that. So I know what
(17:14):
you're thinking, do I reallyhave to go through all these
steps and I really get into thefive W's every time I learned
something that's interesting tome, you know, it seems pretty
onerous. And the answer is, youknow, not necessarily, you don't
actually have to do all thisretrieval and create a flashcard
and spaced repetition everysingle time. But I do think that
it is worth stopping a podcastor whatever you're reading, when
(17:36):
you come across something that'simportant to you, and going
through some of thiselaboration, right. And if you
don't like the whole five W'sthing, then figure out what it
is that helps it helps you toinsert that new piece of
information to what you alreadyknew before about it. I mean,
essentially, you're just makinglearning a more active process,
right? And that is going toincrease your long term
(17:58):
retention, and hopefully makethat information available to
you when you really need it atthe bedside. So, in summary,
good learning is hard.
Retrieving is much morechallenging than rereading stuff
over and over and frankly, doinga bunch of multiple choice
(18:18):
questions, which is what weoften do, it's going to feel
like you're not making progress,but the evidence shows that you
are right short questions as youcome across new information. And
force yourself to retrieve thatinformation rather than just
rereading it or going throughmultiple choice questions where
you get prompts, spacedrepetition, take those questions
that you wrote, you wrote, andjust review them a few times,
(18:39):
over a few weeks, the spacingdoesn't matter. Just reexpose
yourself to that information ina retrieval fashion, using
spaced repetition. I've shownyou some electronic resources,
I'm sure there are plenty ofothers out there that I haven't
talked about. And I'm certainlynot biased. Anyone in particular
elaboration, think about thisnew information that you came
(18:59):
across? How does it fit intowhat you already know? And how
would you explain it to someoneelse? And your words, right? Not
in the speaker, if it's apodcast or the author, or if
it's a blog post or journalarticle here reading. And when
you're building a bank ofquestions, just make sure you're
mixing them up.
That way, you're more likely toremember them in a mixed up
(19:22):
manner, which is how we practicebecause that's what we do in
emergency medicine. So from myexperience with this, I've
definitely found it to behelpful in retaining some
knowledge that I don't think Iwould have otherwise. And
honestly, if nothing else, itjust feels like I'm doing
something right when I'm tryingto learn something new. I feel
like I'm not wasting my time orspinning my wheels. I read
something over and over andspent two hours trying to
(19:45):
remember it and then one weeklater, I can't even remember,
right, at least this way, it's astructured process that is
reproducible. And you know, Ihave those flashcards and I can
go through them whenever I wantand rehash some of that
information. So with that, Iappreciate your attention and
opportunity to speak to youtoday. I certainly would love to
(20:07):
hear your questions about thesetopics that I've, or these
concepts, I guess, that I'vebeen talking about. But I also
would love to hear your take onthe best ways to learn this
information and remember it sothat we can, you know, so it'll
be there when we need it at thebedside. Thank you very much.