- Do you feel like you get plenty of clinical experience but don’t get any learning from it?
- Would you like to get more knowledge out of your daily clinical practice?
- Do you want to practice evidence based learning just like you practice evidence based medicine?
Yes? Well then, this post was written for you.
Learning is an essential part of our progress as clinicians. Taking on board new information and remembering it is key to our development but does it just happen by chance, by hard work or just by osmosis as we spend more and more of our time with patients? Well there is actually a lot of evidence behind ‘learning science’ and over the years a number of strategies have been firmly established as the best ways to learn. For a great explanation of each of these strategies you could head over to The Learning Scientists website where they have blog articles, a podcast series and downloadable materials that cover these together with the science that backs them up. If you prefer to curl up with a good book, ‘Make it Stick’ is an easy read which also touches on some of these principles and uses real life examples to demonstrate their power.
Below is a very briefly summary of those evidence based strategies and then my suggestion of how we can apply them to our busy, everyday clinical practice in a way that I hope is quick, easy and practical. This is not meant as a substitute for quality time spent with an experienced educator but it is something we can do for ourselves to help compliment and consolidate any formal learning that we receive.
The principle here is that the real tool for learning is the act of remembering. Trying to recall information you have learnt is far more likely to make it something you remember than the act of reading or hearing about it in the first place. Rereading text books or relistening to podcasts isn’t productive learning, writing down what you think you are about to read or listen to and then checking if you are right, is what the smart people do.
What we learn is slowly forgotten but the principle of retrieval forces us to try and recall it. Spaced practice leaves greater and greater time between those attempts at recall, making retrieval increasingly difficult whilst also making the memory more solid. Ideally new material should be reviewed after 24 hours, then after about a week and then after longer periods of time depending upon the success of recall efforts.
Whilst it might seem easier to concentrate on learning one topic until you know it really well, the evidence is that this is a poor strategy. Interleaving means mixing up the subjects you are learning which, whilst more difficult, is actually a far more effective strategy because future recall of information is rarely required in blocks, it is random, so you are practicing how you will actually perform. It also allows you to make useful links between the different subjects you are studying which is part of another learning process called elaboration.
Learning sticks better if we can link it to information we already know and elaboration is the act of doing this. Comparing and contrasting new information with old and asking ourselves questions like ‘Why is this true?’, ‘What does this mean?’ or ‘How does that work?’ (Elaborative Interrogation) are two really good ways of elaborating during learning. Another great way of practicing elaboration is to try explaining what you have learned to someone else as it forces you to recall the information and use details about the subject to get your point across.
We are creatures with a huge visual input so it shouldn’t be surprising that adding (relevant) images to our learning helps make it more memorable. It is the principle of dual coding which helps explain the current rise of the infographic but it is also why we find diagrams in text books so useful or even the doodles in the margin of a note book. You don’t need to be a great artist to use this tool, creating simple stick drawings, word clouds and mind maps are all using dual coding to help you learn. Apart from images, other stimuli such as smell, taste and touch may also link to new learning and help with the process of information recall.
When we are trying to remember particularly unusual or abstract ideas or information, having a concrete example to link it to is helpful. To prevent us focusing on the wrong aspect of an individual example it is even better is to have multiple illustrations which then allow us to compare and contrast issues around the specific, central topic we are learning.
Application of these tools is perhaps more obvious when it comes to personal study at home or in groups. Making flash cards for retrieval and spaced practice, varying topics for interleaving, drawing mind maps for dual coding and the conversations of study groups which draw upon elaboration and concrete examples. These are all great ways of integrating our strategies in to learning in these circumstances but what about when we are in clinical practice: at the bedside of a patient, on a ward round, in a clinic… even in the operating theatre? Can we possibly leverage these tools in the clinical setting to help our learning then?
Let us consider the clinician going about their daily work. Our interactions with patients require us to recall information (retrieval) which has usually been learnt some time previously (spaced practice). Each patient is a living… or dying… embodiment of their condition, management and outcome (concrete example) and has visual stimuli associated with them in charts and medical imaging as well as other sensory input such as smells, touch and sounds (dual coding). Each patient, even if they are in a specialty clinic, will be different from the previous one and require accessing a variety of previously stored learning on different topics (interleaving). Finally we spend time critically evaluating the various aspects of the case, constructing a diagnosis and then explaining it to a colleague or to the patient (elaboration). It turns out that these six learning strategies are essentially hardwired in to our daily routine. Clinical practice is essentially a powerful engine for learning and instinctively we know this from our own careers as few of us would deny the learning gained ‘on the shop floor’. So, if this is happening anyway is there really anything we need to do or can we just get on with our work and let it happen? I would suggest that to really harness this learning environment we need to be more deliberate in using the opportunities available, actively choosing to use them rather than being subject to them passively. To that end, here is my proposed two minute exercise to carry out after seeing a patient that makes use of the power of learning science. I call it TakeTwo4U.
After seeing a patient, choose one of the actions below and spend two minutes on it. You can consider the whole case or concentrate on just one aspect ie the history or examination, the anatomy or physiology, the pharmacology or the sociology
- How is this similar or different to a case you saw last week?
- Presentation, Clinical Findings, Drugs Used, Imaging Results
- What is this patient’s case a great example of and why?
- Symptom, Side Effect, Pathology, Treatment
- Make a list or word cloud of everything you know about one aspect of this case.
- Pathology, Pharmacology, Symptoms, Microbiology
- Draw a picture to explain some part of the case.
- Physiology, Anatomy, Psychology, Imaging
Ideally, keep the pieces of paper with the written exercises on and review them for a few minutes at the end of the day and/or at the beginning of the next day. If you keep them in a pocket notebook you can look at them later in the week for added spaced practice.
Clinical practice is a brilliant learning environment and with a little effort we can make it even better. We are all busy and under time pressure but why don’t we just take two minutes for ourselves five times a day and really supercharge that learning opportunity. Surely nobody could object to that?*
Go on TakeTwo4U!
*If somebody does object to you taking 10 minutes a day to become a better clinician, just ignore them… they’re not worth bothering with.