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Memory Techniques for Med School #11 Hands-On

Centipede referral for hands-on approach

HANDS-ON
Despite the value of the 10 memory methods discussed in the preceding posts, perhaps the best teacher of all is the hands-on interaction with the patient. There is great truth to the patient being the best teacher. While we struggle with difficult hours and clinical situations on the wards and clinics during medical school, internship, and residency, it helps to bear in mind that the experience will be very valuable.  There arises a solid core of judgment and knowledge, ingrained in memory, from the experience of interacting with patients.

Which memory and learning techniques do you find most valuable in your medical studies?
What do you think of eBooks versus print books?

Memory Techniques for Med School #10 Acronyms

Placebos feel out of place in party with other kinds of pills

ACRONYMS
With acronyms, the first letters of the items in a list are put together to form a word.  For instance, the acronym SCALP is used to remember the layers of the scalp:

S = Skin
C = Connective tissue
A = Aponeurotic layer
L = Loose connective tissue
P = Pericranium

Related to the word-type acronym is one in which you remember a sentence in which the first letter of each word corresponds to an item on the list.  For instance, to remember the carpal bones:

Some Lovers Try Positions That They Cannot Handle”

S = Scaphoid
L = Lunate
T = Triquetrum
P = Pisiform
T = Trapezium
T = Trapezoid
C = Capitate
H = Hamate

These are effective mnemonics, since the letters all are nouns and refer to specific anatomical structures in the region.  There is little else that the letters could refer to.

It is difficult to find good acronymns, however.  In many, the letters are not necessarily nouns, and they could refer to so many things that they are hardly worth the effort to memorize, except perhaps for an exam the next day.  They are quickly forgotten.

You can find many lists of acronyms by googling “medical mnemonics.”

Which memory and learning techniques do you find most valuable in your medical studies?
What do you think of eBooks versus print books?

Memory Techniques for Med School #9 Chunking

Difficult directions — one of the major causes of poor patient compliance

CHUNKING
In chunking, you try to break up a large list of items into smaller chunks, each of which can be easier to memorize than the whole.  A classic example is the phone number, which, rather than a list of 10 successive digits, is broken up into a 3-digit area code, then a 3-digit number followed by a 4-digit number.

In medicine this can be done with lists of words or with pictures. For words, say you want to memorize a large list of antibiotics.  They are easier to learn by first grouping them into categories (antibacterial, antifungal, antiviral, antiparasitic).  Antibacterials can be  further reduced to the subchunks of penicillin family, anti-ribosomal, anti-tb and leprosy, and miscellaneous, etc.  If you can create subgroups of items in a large list (also aided by placing them in charts for cross-reference comparison), it becomes easier to keep them in mind.

Chunking can also be done with complex pictures.  For instance, the metabolic pathways in biochemistry form a large and complex map of associations.  Breaking them down into visual chunks eases the learning process:

Expanding on the chunks

Further chunk expansion (from Clinical Biochemistry Made Ridiculously Simple, MedMaster)

Which memory and learning techniques do you find most valuable in your medical studies?

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What do you think of eBooks versus print books?

Memory Techniques for Med School #8 Memory Palace

Surgical team and patient with "Hi, I'm...." social name stickers

Adding the human touch to the operating room

THE MEMORY PALACE
The Memory Palace (also called the method of loci, or mental walk)  is a terrific memory method that was used as far back as ancient Rome, but has been largely underused since the invention of  printed books.  Neuropsychologist A.R. Luria, in his book “The Mind of  a Mnemonist,” describes an amazing patient he followed for many years, who never forgot anything.  The patient used the Memory Palace method, which is also praised highly by Joshua Foer, who won the U.S. memory championship and describes the method in his best-selling book “Moonwalking with Einstein.”

In the Memory Palace you simply visualize a walk through a place that you know well.  For instance, it may be your home, in which you first encounter a large tree outside, then the front door, then the foyer, then the den on the right, then the kitchen, the bathroom, the bedroom, etc., in succession.  You know this sequential list well, simply by the familiarity that you have with your home.

You use this walking list of places to associate each stop along the walk with an item on the list you wish to memorize.

In the case of the 7 cancer signs:

1.  A change in bowel or bladder habits
2.  A sore that does not heal
3.  Unusual bleeding or discharge from any place
4.  A lump in the breast or other parts of the body
5.  Chronic indigestion or difficulty in swallowing
6.  Obvious changes in a wart or mole
7.  Persistent coughing or hoarseness

You might associate a cancerous tree, shaped like a “7,” that had a bowel and bladder exploding from its trunk.  Continuing the walk:

The fecal matter would land on the door, causing a large sore on the door.

The sore would erode through the door, causing a massive pool of blood and discharge in the foyer.

The den on the right would be filled to the ceiling with lumps.

etc.

The advantage of the Memory Palace over the Link and Peg methods is that you can have numerous memory palaces.  There then is no problem of confusing one item in a list with the same item in another list (such as a list of drug effects or symptoms of a disease).  Just use a different memory palace. Trained mnemonists use hundreds of Memory Palaces.  Moreover, you don’t have to memorize the number/letter combinations of the Peg method.  You already have ready made pegs through the places you have visited and know well.

Which memory and learning techniques do you find most valuable in your medical studies?
What do you think of eBooks versus print books?

Memory Techniques for Med School #7 Lists (Peg Method)

King Kong helicoptered into hospital.  Nurses complaining about heavy patient.

THE PEG METHOD
 The Peg method is used to remember the specific numbered items in a list. Thus, if someone were to give you a list of 100 words or ideas to remember and then asked you “What was number 37?” you would be able to recall this immediately. There are different variations on the  Peg method.  Here’s one that I like:  You must remember in advance the following consonants that correspond with the numbers 0-9:

0.  S or Z
1.  T (or D) (has 1 vertical line).  Think of the word “Tea”
2.  N (has 2 vertical lines) Think of the word “Noah”
3.  M (touches the base in 3 spots) Think of the word “May” or “Ma”
4.  R (last letter in fouR) Think of the word “Ray” or “Rye”
5.  L  (Roman numeral for 50) Think of the word “Law”
6.  J (or SH, CH, or soft G) (J looks like a backwards 6)  Think of the word “Jay” or “Shoe”
7.  K (or hard C, hard G) (two sevens together can make a “K”)  Think of the word “Key” or “Cow”
8.  F (or V or PH) (a handwritten “F” has two loops, like an “8”)  “Think of the word “Fee”
9.  P (B) (P looks like a backwards 9)  Think of the word “Pea” or “Bee”

Numbers beyond 9 are simply the combination of the single digit numbers and letters.  Thus:

10. TS would be Toes
11.  TT could be “Tot”
12.  TN could be “Tin”

You can add any vowel sounds you want to the letters. It takes a little effort to learn the letters corresponding to 0-9, but with this knowledge, you can remember large lists and numbers.  For instance to remember the 12 cranial nerves (1 = olfactory, 2 = optic, 3 = oculomotor, 4 = trochlear, 5 = trigeminal, 6 = abducens, 7 = facial, 8 = vestibulocochlear/auditory, 9 = glossopharyngeal, 10 = vagus, 11 = spinal accessory, 12 = hypoglossal):

1.  T (tea):  Imagine a tea cup in which is an old factory (olfactory)
2.  N (Noah): Imagine Noah in the ark with giant 30 foot binoculars (optic) looking for land
3.  M (May): Imagine a Maypole piercing a car’s motor that looks like an eyeball (oculomotor)
4.  R (Ray): Imagine a ray of light so strong that it melts a toy “truck” (trochlear)
5.  L (Law): Imagine a law book that is kept open with 3 gems (trigeminal)
6.  J (Jay):  Imagine a blue jay abducting (abducens) an elephant
7.  K (Key): Image a key twisting itself through someone’s face
8.  F (Fee): Imagine a fee being charged to sew on an extra 12 foot ear (vestibulocochlear/auditory)
9.  P (Pea): Imagine a pea flying through the air and  smashing a one hundred foot high glass (glossopharyngeal)
10.  TS (Toes): Imagine a set of toes being used in the roulette wheel at Las Vegas (vagus)
11.  TT (Tot): Imagine a tot being an accessory (accessory) to mass murder
12.  TN (Tin): Imagine a tin piercing a hypodermic (hypoglossal) needle

Now if someone were to ask, what was number 5, you would recall trigeminal, because 5 is the law book being held open by 3 gems.  These particular examples are rather far-fetched.  Personally, I don’t think this method is that valuable for memorizing lists in medicine.  There are too many lists; words in one list could be confused with those in another; it may be more effort than it’s worth to create the mnemonic.  It’s a good parlor trick for recalling 100 numbered items, but probably not that helpful clinically.  It’s not that good for long term retention.

The Peg technique, however, can help recall numbers.  Thus, to remember a drug dosage of 20mg for Lexapro, you might remember a Lexus with a big nose (20 = NS = nose) for a front hood.

The number/letter combinations are like “pegs” on which you hang the words or ideas you want to remember as a list.

Apart from the linking and peg methods, there are two others, the Memory Palace (outstanding) and Acronyms for remembering lists.  These will be discussed in the next two blogs.

Memory Techniques for Med School #6 Lists (Linking Method)

Cat on cardiac monitor that indicates "3 lives left"

LINKING
There are a number of methods for memorizing lists:  The Link method, the Peg method, the Memory Palace, and Acronyms.

The Link method involves memorizing a list by creating a ridiculous association between one word or idea and the one that follows on the list.  For instance, the American Cancer Society lists 7 symptoms that could be a sign of cancer:

1.  A change in bowel or bladder habits
2.  A sore that does not heal
3.  Unusual bleeding or discharge from any place
4.  A lump in the breast or other parts of the body
5.  Chronic indigestion or difficulty in swallowing
6.  Obvious changes in a wart or mole
7.  Persistent coughing or hoarseness

To remember these, you might want to:

1.   Start with a bowel and bladder which are normal but then erupt suddenly into explosive diarrhea and peeing all over. (Change in bowel or bladder habits)
2.  The fecal matter lands on someone, producing a huge 12 inch sore on the person’s face that persists forever.  (Sore that does not heal)
(The purpose here, of course, is not to make fun of cancer, but to create a vivid link between one item on the list an the next.  Making the sore huge adds to the memorability.)
3.  The sore erodes through the body, causing unusual bleeding and discharges everywhere. (Unusual bleeding or discharge from any place)
4.  Some of the bleeding remains under the skin causing lumps in the breast and elsewhere. (Lump in breast or elsewhere)
5.  The patient eats those lumps and gets chronic indigestion and difficulty in swallowing due to one of the lumps getting stuck in the patient’s throat. (Chronic indigestion or difficulty in swallowing)
6.  The patient enlists the help of a mutant wart hog and a mole to try to remove the stuck lumps.  (Obvious changes in a wart or mole)
7.  That doesn’t go over well, and the patient ends up with an injured lung and trachea. (Persistent coughing or hoarseness)

Of course, the above mnemonic is crude, repulsive, unprofessional, and puerile, which are good features.  The drama facilitates the remembering of  important clinical signs.  You could probably do better creating your own mnemonic.  What is important is that the associative links are striking and memorable.  It also helps to review them to fix them even more solidly in memory.  After a while, with repetition, a remembered list will not require the ridiculous association for recall; it is just remembered.

Memory Techniques for Med School #5 Ditties

Successful cardiac resuscitation at the George Gershwin Memorial Hospital

Successful cardiac resuscitation at the George Gershwin Memorial Hospital

DITTIES
 Our memories are stronger for words set to to music or rhythm, a reason for the effectiveness of advertising jingles.  For instance, in remembering the cervical nerves that elevate the diaphragm, the ditty is  “C3,4,5 keep the diaphragm alive.”

And, in recognition of “poor dendal” (pudendal nerve) from the previous blog: “S,2,3,4 keeps the penis off the floor.”

There is not enough space on this blog to list all the excellent ditties and other mnemonics in medicine, but you can find an extensive list by googling “medical mnemonics.”

Memory Techniques for Med School #4 Substitute Words and Pictures

Pathologist explaining the differential diagnosis of a road kill

The fine art of pathological diagnosis

SUBSTITUTE WORDS AND PICTURES
One of the hurdles of medical school is learning a new vocabulary and new images, such as those in anatomy.  Try to distort the difficult word or picture into something familiar.  For instance, to remember the anatomy of a typical vertebra, you might visualize it as a snowman petting a moose.  The  moose (rib), snowman’s head (spinous process),  arms (transverse process) breasts (superior articular processes), and pockets and petting site (facets) are part of the vertebral/rib anatomy and are easier to remember when changed into something you already know and can easily visualize. You don’t have to learn what a snowman is.  You already know that.  You can use what you already know to pose or distort  it in a ridiculous manner that helps you remember an important anatomical structure.

Vertebra and rib seen as a snowman petting a moose

Of course, before setting out to remember a picture, it helps to ask whether it is worth remembering the picture to begin with.  Someone once presented a distorted picture of the penicillin molecule as a way to  remember its structure.  But is the structure worth learning?  That is something that might be easier to just look up rather than remembering.

Apart from pictures, distorting  difficult vocabulary words helps memory.  For instance, back in medical school one of my classmates casually remarked that he remembered the function of the pudendal nerve as “poor dendal.”  The pudendal nerve innervates the genitalia, and poor dendal’s pudendal nerve was severed and could no longer function as he wished.

The next blog post will discuss ditties as a memory aid.

Please feel free to comment on any of these posts.

Memory Techniques for Med School #3 Ridiculous Associations

Tired doctor fantasizing about how nice it would be to be in bed all day as a patient

“These lucky patients, sleeping all day.”

RIDICULOUS ASSOCIATIONS
 Although you are serious about medicine, do not dismiss the value of  using ridiculous associations as an important memory tool.  We remember things better when they are very unusual, vivid, very enlarged, humorous, sexual, or just plain ridiculous.  The more ridiculous and exaggerated, the better the retention. While a rhinocerus, a bottle of Corona beer and a bottle of Nyquil, when considered individually, are hardly unusual,  if you saw a sniffling rhinocerus holding a bottle of Corona beer in one hand and a bottle of Nyquil in the other, an overall ridiculous association among the three, you would be unlikely to forget that the rhinovirus and coronaviridae cause the common cold.

Causes of common cold remembered as rhinocerus (Rhinovirus) holding a bottle of Corona beer (Coronavirus) in one hand and a bottle of Nyquil (common cold) in the other

Imagine three pillars (Roman numeral III) inside one eye, keeping the eyelids apart, and the number “7” acting as a hook to pull down the upper lid of the other eye.  This helps to remember that cranial nerve III opens the eyelids, while cranial nerve 7 closes the eyelids.  Here we combine visualization with ridiculous associations.

Function of cranial nerve 7 as a hook pulling down eyelid.  Function of cranial nerve III as 3 pillars holding eyelids open

While you can always use other people’s mnemonics, it may stick best when you invent your own; let your imagination run wild; medical students are very creative.  While it may take a little extra time to invent the association, it pays off in retention.

Memory Techniques for Med School #2 Visualization

Anatomy Dissection Lab - Cadaver thinking

VISUALIZATION
People remember better when they visualize.  Forgot where you left your glasses?  If you make a point of visualizing them when you put them down, you are more likely to remember where you left them.  It is similar with learning anatomy.  Try to spend a few more seconds visualizing, fixing in your head, the anatomy, or for that matter any other picture, before going on.

It is easier to first learn anatomy through conceptual line drawings than through photographs of dissected specimens, with all that fascia to muddy the conceptual view.  When I was an ophthalmology resident, I found books that showed photos of actual ocular anatomy dissections relatively useless compared with books that showed conceptual pictures, particularly line drawings.  We are very visual learners, and it helps when we can visualize things as a whole.

Memory Techniques for Med School #1 Understanding

Many years ago, before the print era, people used memory techniques extensively, because there were no books.  Now, with books and Internet searches, it seems memory methods are less in favor, since we rely on the information in print, as extensions of our brains.  However, there still is much basic material that needs to be memorized.

Eleven memory methods useful in medical study:

  1. Understanding
  2. Visualization
  3. Ridiculous associations
  4. Substitute words and pictures
  5. Ditties
  6. Linking
  7. Peg method
  8. Memory Palace
  9. Chunking
  10. Acronyms
  11. Hands on

UNDERSTANDING

Understanding should not be underrated as a memory method.  Why go to the trouble of trying to memorize isolated facts when the facts could easily be deduced from a simple rule or understanding of the issue?  For instance, muscles generally connect one bone to another across a joint.  Why memorize which muscles in a region lie more deeply when one can apply the simple logic that the shorter muscles lie deeper.  Thus the muscles that span 1 vertebra lie more deeply than those that span 2-4 vertebrae, which lie more deeply than those that span 5 or more.

The neuroanatomic pathways are remembered more easily with the simple rule that the first part of the name generally indicates where the pathway comes from, while the last part of name indicates where the path is going.  Thus, the corticospinal path travels from the cerebral cortex to the spinal cord;  the spinothalamic tract travels from the spinal cord to the thalamus; the spinocerebellar tract travels from the spinal cord to the cerebellum, etc.  Understanding principles and rules reduces the need for rote memorization.

A valuable way to learn a wealth of new medical terms is to recognize their Latin and Greek roots.

I remember the case of a nurse who had chronic uveitis (an inflammation of the middle layer of the eyeball), who was admitted with the inability to void.  She had been taking atropine eye drops, a parasympathetic inhibitor to keep the iris open, so that it would not stick to the lens.  Understanding that atropine eye drops can also enter the circulation systemically, where it could act on the bladder to impede bladder contraction, enabled the ophthalmologist to understand the cause of the inability to void and to correct the matter with an alternative approach to the uveitis.  It was an understanding of the drug’s potential effect, rather than a nonexistent caution in a drug reference that it may paralyze the bladder, that was helpful in resolving the issue.

In pharmacology, it can be cumbersome trying to learn one drug after another.  After a while they all tend to meld into one another as a confusing jumble.  However, there are principles that govern the effects of each class of drugs.  If you know the principles, there is no need to memorize the individual effects of each drug.  Each drug in the class will have effects that resemble those of the other drugs.  It may be better to learn the general principles and focus on those effects that distinguish one drug in the class from another, if we deem those effects important to memorize.

In memorizing the manifestations of a disease, it may help to emphasize any quality that is pathognomonic, namely that is specific to that disease.  For instance, neurologic weakness in a limb generally is either the type where there are overactive reflexes and no muscle atrophy, or the type that has underactive reflexes and significant muscle atrophy.  There is one disease, amyotrophic lateral sclerosis (Lou Gehrig’s Disease), where there is a combination of overactive reflexes and profound atrophy in the same muscles.  If you see that, you have virtually made the diagnosis of ALS.  Remembering a pathognomonic feature, a feature that distinguishes a condition from all others, can enable the clinician to quickly arrive at the diagnosis.  Similarly, remembering the specific effect of a drug that distinguishes it from others can help in choosing it as a drug of choice.

Other memory techniques will be discussed in the next posts.