How Do You Handle Pre-examination Stress

How Do You Handle Pre-examination Stress



I often panic before an exam because I am so worried about my performance. This makes it even harder to do well. What should I do?

Response from Sohil H. Patel, MD

There is an obvious answer to this question: prepare well for the examination. But of course, it is hard to find anyone who would actually claim to be well prepared in the days before an exam. This is particularly true for exams that encompass a vast amount of information. No student knows every detail about the topic being tested. That is why it may always seem like you need more time to study, and why you never feel fully prepared.

The examinations themselves can generate anxiety as well, whether because of the time limits for finishing or perhaps because of an oral performance component. Of course, no two people handle stress in the same way, but here are some things that helped me.

The first step in destressing involves gaining some perspective. Having been in the clinical setting for a few years now, I have been exposed to life and death situations that legitimately stress people out. Given those experiences, I now find it hard to believe that I ever stressed out over my medical school examinations to the extent that I did. In fact, I remember developing a different (and more healthy) attitude toward studying and exams after I started my clinical rotations, which made me realize just how insulating the pre-clinical years can be. So, if you are a first- or second-year medical student, shadowing a physician in the hospital might help put your exams in proper perspective.

Another way to gain perspective is to remember why you chose to attend medical school (hopefully, doing well on medical school examinations was not the reason). Studying really should be viewed as a means to a much larger goal than just passing a test. Exams should never be treated as ends in themselves. They are really just little check marks of approval on your way to becoming a physician -- nothing more.

Certain study techniques may also be effective in reducing your stress level. Cramming facts into your brain at random is not effective; if your mind goes blank during an exam, you won't have any broader framework on which to anchor your thoughts. Before memorizing details, I always tried to build a framework. Take pulmonology, for example. Instead of learning pulmonary diseases at random, learn the basic categories of disease (eg, obstructive, restrictive), then learn the common features within each category, and finally, fill in the categories with particular diseases. This way, if the answer to an examination question is not immediately obvious, you have a systematic way of proceeding and narrowing your choices.

Another helpful method, particularly for oral exams involving standardized patients, is to develop routine practices. Before the exam, run through common scenarios or complaints you might encounter and think of the basic steps you should always take in those scenarios. Do this a few times so that, if a similar situation is encountered in the exam, your brain can run on auto-pilot as you follow through with your prepared steps.

Of course, there are many ways to address the stress itself, and what works for one person may not work for another. For me, it seemed to help if I stuck with my workout schedule regardless of how close I was to an examination; this helped me set aside some time when I was not thinking about the exam. I also had the peculiar habit of taking a shower if I thought I was getting overly stressed out and I needed a break. But these methods vary for everyone. In general, it is probably a good policy to keep your life as close to normal as possible before an exam. This avoids giving the examination undue significance.

Finally, it is important to be confident. Medicine is not the single most complicated field of study, and most minds are similarly suited to learning it (unlike, perhaps, philosophy or some other fields that some people seem more inherently suited for than others). It means that there is a good correlation between how much effort a person puts into learning medicine and how well that person masters the subject. It is less a matter of "getting it" and more a matter of "knowing it," and almost anyone can learn the material with a certain amount of effort. So, work hard and take confidence that your honest effort will pay off!

Test Taking Tips

When you take a test, you are demonstrating your ability to understand course material or perform certain tasks. Successful test taking avoids carelessness.

Examples of objective tests are true-false, multiple choice, fill-in-the-blank.

Examples of subjective texts are short answer, essay, or oral exams

NB: If you have any doubts about the fairness of tests, or of the ability of tests to measure your performance, please see your academic counseling service.

These suggestions may help you avoid careless errors!

Prepare

• Analyze your past test results. Each test can further prepare you for the next test. Use your tests to review when studying for final exams.


• Arrive early for tests. Bring all the materials you will need such as pencils and pens, a calculator, a dictionary, and a watch. This helps you focus on the task at hand.


• Be comfortable but alert. Choose a good spot and make sure you have enough room to work, maintain comfortable posture but don't "slouch."


• Stay relaxed and confident. Remind yourself that you are well-prepared and are going to do well. If you find yourself anxious, take several slow, deep breaths to relax. Don't talk about the test to other students just before it; anxiety is contagious.

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  Test Taking

  
  
  
  
  • Read the directions carefully. This may be obvious, but it will help you avoid careless errors.
  
  
  • If there is time, quickly look through the test for an overview. Note key terms, jot down brief notes.
  
  
  • Answer questions in a strategic order:
    
    
    
    1. First easy questions. To build confidence, score points, and mentally orient yourself to vocabulary, concepts, and your studies (it may help you make associations with more difficult questions)
    
    
    2. Then difficult questions or those with the mot point value. With objective tests, first eliminate those answers you know to be wrong, or are likely to be wrong, don't seem to fit, or where two options are so similar as to be both incorrect. With essay/subjective questions, broadly outline your answer and sequence the order of your points.
    
    
    
    
  
  
  
  

  Review

  
  
  
  
  • Resist the urge to leave as soon as you have completed all the items.
  
  
  • Review your test to make sure that you have answered all questions, not mis-marked the answer sheet, or made some other simple mistake.
  
  
  • Proofread your writing for spelling, grammar, punctuation, decimal points, etc.
  
  
  • Change answers to questions if you originally misread them or if you have encountered information elsewhere in the test that indicates that your first choice is incorrect.
  
  
  • Decide on and adopt study strategies that worked best for you.
  
  
  • Identify those that didn't work well and replace them.
  
  
  
  

Test Anxiety

What Causes Test Anxiety

Lack of preparation as indicated by:

• cramming the night before the exam.


• poor time management.


• failure to organize text information.


• poor study habits.

Worrying about the following:

• past performance on exams.


• how friends and other students are doing.


• the negative consequences of failure.

Physical Signs of Test Anxiety

During an exam, as in any stressful situations, a student may experience any of the following bodily changes:

• perspiration


• sweaty palms


• headache


• upset stomach


• rapid heart beat


• tense muscles

Effects of Test Anxiety

Nervousness

• Having difficulty reading and understanding the questions on the exam paper.


• Having difficulty organizing your thoughts.


• Having difficulty retrieving key words and concepts when answering essay questions.


• Doing poorly on an exam even though you know the material.

Mental Blocking

• Going blank on questions.


• Remembering the correct answers as soon as the exam is over.

How to Reduce Test Anxiety

• Study and know the material well enough so that you can recall it even if you are under stress.


• Learn and practice good time management and avoid:
  
  
  
  • laziness
  
  
  • procrastination
  
  
  • day dreaming
  
  
  
  

• Build confidence by studying throughout the semester and avoid cramming the night before the exam.


• Learn to concentrate on the material you are studying by:
  
  
  
  • generating questions from your textbooks and lecture notes.
  
  
  • focusing on key words, concepts and examples in your textbooks and lecture notes.
  
  
  • making charts and outlines which organize the information in your notes and textbooks.
  
  
  
  

• Use relaxation techniques, for example, taking long deep breaths to relax the body and reduce stress.

Preparing for or Anticipating Test Anxiety

• What is it you have to do? Focus on dealing with it.


• Just take one step at a time.


• Think about what you can do about it. That's better than getting anxious.


• No negative or panicky self-statements; just think rationally.


• Don't worry; worrying won't help anything.

Confronting and Handling Test Anxiety

• Don't think about fear; just think about what you have to do.


• Stay relevant.


• Relax; you're in control. Take a slow, deep breath.


• You should expect some anxiety; it's a reminder not to panic and to relax and cope steadily with the situation.


• Tenseness can be an ally, a friend; it's a cue to cope.

Coping with the Feeling of Being Overwhelmed

• When the fear comes, just pause.


• Keep the focus on the present; what is it you have to do?


• You should expect your fear to rise some.


• Don't try to eliminate fear totally; just keep it manageable.


• You can convince yourself to do it. You can reason your fear away.


• It's not the worst thing that can happen.


• Do something that will prevent you from thinking about fear.


• Describe what is around you. That way you won't think about worrying.

Common "Worries" that Increase Test Anxiety

• Worry About Performance


• Worry About Bodily Reactions


• Worry About How Others Are Doing


• Worry About Possible Negative Consequences

Reinforcing Self-Statements

• It worked! You did it!


• It wasn't as bad as you expected.


• You made more out of the fear than it was worth.


• You're getting better. You're learning to cope more smoothly.


• You can be pleased with your progress.


• You like how you handled it. You can be proud of it.

Goal Setting

• Be sure your goals are your own. It's your life. Do what means most to you. Self-set goals are better motivators than those imposed by others.


• Put goals in writing. This will lessen the odds of losing sight of your goals in the shuffle of daily activity. Writing goals also increases your commitment.


• Make your goals challenging but attainable. Good goals are neither too easy nor impossible. They should cause you to stretch and grow. A challenging, attainable goal will hold your interest and keep you motivated.


• Goals should be as specific and measurable as possible. Don't say, "I want a better job." Ask yourself: What kind of job? Making how much money? In what industry? Living where? Requiring what kind of skill? By when? Specify clearly what you want and you will save an enormous amount of time and effort.


• Every goal should have a target date. Never think of a goal as a goal until you set a deadline for accomplishment.


• Check your major goals for compatibility. Don't fall into the trap of setting major goals where the achievement of one will prevent the attainment of another.


• Frequently revise and update your goals. As a growing person your needs will change over time, and this means goals will have to be modified, discarded and added from time to time. Plan flexibly. Don't think of your goals as carved in stone.

Relaxation Techniques

This is a series of relaxation techniques that you can do almost any where and any time. They do not take very long to do. Do not force yourself to relax - just let it happen.

Breathing

2-Step breath - Fill the bottom of your lungs first, then add the top as you breathe through your nose. Breathe out slowly. Feel the tension flowing out.

Tense-Relax Muscles

Tighten the muscle that you want to relax. Focus on and feel the tension where you have tighten. Now let the muscle become loose and limp. Feel the relaxation flow into the muscle.

Body Scan

With your mind briefly scan every muscle in your body from the tips of your toes to the top of your head. If you sense a tight muscle, just let it become limp and relaxed.

Limp Rag Doll

1. Do the 2-step breath two times.


2. With your mind imagine that you are a limp rag doll. Feel your mind and body become limp and relaxed.

*** You may use whatever image you like best **

Mind Quieting

In order to quiet your mind first, focus on your breathing. As you breathe in say slowly to yourself "I am" and as you breathe out, say slowly to yourself "calm". When your mind feels calm, focus only on your breathing with no other thoughts.

Shoulders, Arms and Hands Heavy and Warm

Put your mind into your shoulders, arms and hands - imagine and experience them becoming heavy, relaxed and warm.

Multiple Choice Exams

Multiple choice questions usually include a phrase or stem followed by three to five options.

Test Strategies

• Read the directions carefully


• Know if each question has one or more correct option


• Know if you are penalized for guessing


• Know how much time is allowed (this governs your strategy)


• Preview the test


• Read through the test quickly and answer the easiest questions first


• Mark those you think you know in some way that is appropriate


• Read through the test a second time and answer more difficult questions


• You may pick up cues for answers from the first reading, or become more comfortable in the testing situation


• If time allows, review both questions and answers


• It is possible you mis-read questions the first time

Answering Options

• Improve your odds, think critically


• Cover the options, read the stem, and try to answer. Select the option that most closely matches your answer.


• Read the stem with each option. Treat each option as a true-false question, and choose the "most true"

Strategies to Answer Difficult Questions

• Eliminate options you know to be incorrect. If allowed, mark words or alternatives in questions that eliminate the option.


• Give each option of a question the "true-false test:" This may reduce your selection to the best answer.


• Question options that grammatically don't fit with the stem.


• Question options that are totally unfamiliar to you.


• Question options that contain negative or absolute words. Try substituting a qualified term for the absolute one, like frequently for always; or typical for every to see if you can eliminate it.


• "All of the above:" If you know two of three options seem correct, "all of the above" is a strong possibility.


• Number answers: toss out the high and low and consider the middle range numbers.


• "Look alike options" probably one is correct; choose the best but eliminate choices that mean basically the same thing, and thus cancel each other out.


• Double negatives: Create the equivalent positive statement and consider.


• Echo options: If two options are opposite each other, chances are one of them is correct .


• Favor options that contain qualifiers. The result is longer, more inclusive items that better fill the role of the answer.


• If two alternatives seem correct, compare them for differences, then refer to the stem to find your best answer.

Guessing

• Always guess when there is no penalty for guessing or you can eliminate options.


• Don't guess if you are penalized for guessing and if you have no basis for your choice .


• Use hints from questions you know to answer questions you do not.


• Change your first answers when you are sure of the correction, or other cues in the test cue you to change.

Remember that you are looking for the best answer, not only a correct one, and not one which must be true all of the time, in all cases, and without exception.

Effective Reading Techniques

Improvement of Reading Rate

It is safe to say that almost anyone can double his speed of reading while maintaining equal or even higher comprehension. In other words, anyone can improve the speed with which he gets what he wants from his reading.

The average college student reads between 250 and 350 words per minute on fiction and non-technical materials. A "good" reading speed is around 500 to 700 words per minute, but some people can read a thousand words per minute or even faster on these materials. What makes the difference? There are three main factors involved in improving reading speed: (1) the desire to improve, (2) the willingness to try new techniques and (3) the motivation to practice.

Learning to read rapidly and well presupposes that you have the necessary vocabulary and comprehension skills. When you have advanced on the reading comprehension materials to a level at which you can understand college-level materials, you will be ready to speed reading practice in earnest.

The Role of Speed in the Reading Process

Understanding the role of speed in the reading process is essential. Research has shown a close relation between speed and understanding. For example, in checking progress charts of thousands of individuals taking reading training, it has been found in most cases that an increase in rate has been paralleled by an increase in comprehension, and that where rate has gone down, comprehension has also decreased. Although there is at present little statistical evidence, it seems that plodding word-by-word analysis (or word reading) inhibits understanding. There is some reason to believe that the factors producing slow reading are also involved in lowered comprehension. Most adults are able to increase their rate of reading considerably and rather quickly without lowering comprehension. These same individuals seldom show an increase in comprehension when they reduce their rate. In other cases, comprehension is actually better at higher rates of speed. Such results, of course, are heavily dependent upon the method used to gain the increased rate. Simply reading more rapidly without actual improvement in basic reading habits usually results in lowered comprehension.

Factors that Reduce Reading Rate

Some of the facts which reduce reading rate: (a) limited perceptual span i.e., word-by-word reading; (b) slow perceptual reaction time, i.e., slowness of recognition and response to the material; (c) vocalization, including the need to vocalize in order to achieve comprehension; (d) faulty eye movements, including inaccuracy in placement of the page, in return sweep, in rhythm and regularity of movement, etc.; (e) regression, both habitual and as associated with habits of concentration; (f) faulty habits of attention and concentration, beginning with simple inattention during the reading act and faulty processes of retention; (g) lack of practice in reading, due simply to the fact that the person has read very little and has limited reading interests so that very little reading is practiced in the daily or weekly schedule; (h) fear of losing comprehension, causing the person to suppress his rate deliberately in the firm belief that comprehension is improved if he spends more time on the individual words; (i) habitual slow reading, in which the person cannot read faster because he has always read slowly, (j) poor evaluation of which aspects are important and which are unimportant; and (k) the effort to remember everything rather than to remember selectively.

Since these conditions act also to reduce comprehension increasing the reading rate through eliminating them is likely to result in increased comprehension as well. This is an entirely different matter from simply speeding up the rate of reading without reference to the conditions responsible for the slow rate. In fact, simply speeding the rate especially through forced acceleration, may actually result, and often does, in making the real reading problem more severe. In addition, forced acceleration may even destroy confidence in ability to read. The obvious solution, then is to increase rate as a part of a total improvement of the whole reading process. This is a function of special training programs in reading.

Basic Conditions for Increased Reading Rate

A well planned program prepares for maximum increase in rate by establishing the necessary conditions. Four basic conditions include:

1. Have your eyes checked. Before embarking on a speed reading program, make sure that any correctable eye defects you may have are taken care of by checking with your eye doctor. Often, very slow reading is related to uncorrected eye defects.


2. Eliminate the habit of pronouncing words as you read. If you sound out words in your throat or whisper them, you can read slightly only as fast as you can read aloud. You should be able to read most materials at least two or three times faster silently than orally. If you are aware of sounding or "hearing" words as you read, try to concentrate on key words and meaningful ideas as you force yourself to read faster.


3. Avoid regressing (rereading). The average student reading at 250 words per minute regresses or rereads about 20 times per page. Rereading words and phrases is a habit which will slow your reading speed down to a snail's pace. Usually, it is unnecessary to reread words, for the ideas you want are explained and elaborated more fully in later contexts. Furthermore, the slowest reader usually regresses most frequently. Because he reads slowly, his mind has time to wander and his rereading reflects both his inability to concentrate and his lack of confidence in his comprehension skills.


4. Develop a wider eye-span. This will help you read more than one word at a glance. Since written material is less meaningful if read word by word, this will help you learn to read by phrases or thought units.

Rate Adjustment

Poor results are inevitable if the reader attempts to use the same rate indiscriminately for a-1 types of material and for all reading purposes. He must learn to adjust his rate to his purpose in reading and to the difficulty of the material he is reading. This ranges from a maximum rate on easy, familiar, interesting material or in reading to gather information on a particular point, to minimal rate on material which is unfamiliar in content and language structure or which must be thoroughly digested. The effective reader adjusts his rate; the ineffective reader uses the same rate for all types of material.

Rate adjustment may be overall adjustment to the article as a whole, or internal adjustment within the article. Overall adjustment establishes the basic rate at which the total article is read; internal adjustment involves the necessary variations in rate for each varied part of the material. As an analogy, you plan to take a 100-mile mountain trip. Since this will be a relatively hard drive with hills, curves, and a mountain pass, you decide to take three hours for the total trip, averaging about 35 miles an hour. This is your overall rate adjustment. However, in actual driving you may slow down to no more than 15 miles per hour on some curves and hills, while speeding up to 50 miles per hour or more on relatively straight and level sections. This is your internal rate adjustment. There is no set rate, therefore, which the good reader follows inflexibly in reading a particular selection, even though he has set himself an overall rate for the total job.

Overall rate adjustment should be based on your reading plan, your reading purpose, and the nature and difficulty of the material. The reading plan itself should specify the general rate to be used. This is based on the total "size up". It may be helpful to consider examples of how purpose can act to help determine the rate to be used. To understand information, skim or scan at a rapid rate. To determine value of material or to read for enjoyment, read rapidly or slowly according to you feeling. To read analytically, read at a moderate pace to permit interrelating ideas. The nature and difficulty of the material requires an adjustment in rate in conformity with your ability to handle that type of material. Obviously, level of difficulty is highly relative to the particular reader. While Einstein's theories may be extremely difficult to most laymen, they may be very simple and clear to a professor of physics. Hence, the layman and the physics professor must make a different rate adjustment in reading the same material. Generally, difficult material will entail a slower rate; simpler material will permit a faster rate.

Internal rate adjustment involves selecting differing rates for parts of a given article. In general, decrease speed when you find the following (1) unfamiliar terminology not clear in context. Try to understand it in context at that point; otherwise, read on and return to it later; (2) difficult sentence and paragraph structure; slow down enough to enable you to untangle them and get accurate context for the passage; (3) unfamiliar or abstract concepts. Look for applications or examples of you own as well as studying those of the writer. Take enough time to get them clearly in mind; (4) detailed, technical material. This includes complicated directions, statements of difficult principles, materials on which you have scant background; (5) material on which you want detailed retention. In general, increase speed when you meet the following: (a) simple material with few ideas which are new to you; move rapidly over the familiar ones; spend most of your time on the unfamiliar ideas; (b) unnecessary examples and illustrations. Since these are included to clarify ideas, move over them rapidly when they are not needed; (c) detailed explanation and idea elaboration which you do not need, (d) broad, generalized ideas and ideas which are restatements of previous ones. These can be readily grasped, even with scan techniques.

In keeping your reading attack flexible, adjust your rate sensitivity from article to article. It is equally important to adjust you rate within a given article. Practice these techniques until a flexible reading rate becomes second nature to you.

Summary

In summary, evidence has been cited which seems to indicate a need for and value of a rapid rate of reading, while at the same time indicating the dangers of speed in reading, as such. We have attempted to point out the relationship between rate of reading and extent of comprehension, as well as the necessity for adjustment of reading rate, along with whole reading attack, to the type of material and the purposes of the reader. Finally, the factors which reduce rate were surveyed as a basis for pointing out that increase in rate should come in conjunction with the elimination of these retarding aspects of the reading process and as a part of an overall reading training program where increase in rate is carefully prepared for in the training sequence.

Learning Styles

What are Learning Styles?

Each individual person has their own set of ways with which they learn best. Some students find they learn best from a lecture when the professor presents key points in a visual manner-either on the board, on an overhead, or with a handout. Others find they have a much easier time hearing someone talk about a subject rather than reading the same ideas on paper. These two examples present the two key learning styles: Visual and Auditory. But learning styles are not limited to the senses of hearing and sight; there are as many different ways of learning as there are learners.

While learning styles are varied, there are some specific categories which people fall into, and there are some specific hints for each category on how to learn more effectively.

The Barsch Learning Style Inventory

To gain a better understanding of yourself as a learner, it is useful to identify the way you prefer to learn. Learning is easier when study skills match your preferred learning style. The Barsch Learning Style Inventory is a short diagnostic test to assess your learning style. You will discover if you learn best through seeing things (visual), hearing them (auditory), or through the sense of touch or body movement (tactile/kinesthetic).

What do the scores mean?

When you have identified your style, what do you do with that information? You need to build on your strengths and address your weaknesses. Most students have one dominant learning style. If you have scores that are close or tied, you can use either learning style equally well. Those who learn to adapt study skills to incorporate all 3 learning styles learn faster and remember longer.

The Visual or Auditory style, whichever scores the highest, is considered the primary preferred learning style. The Tactile/Kinesthetic is considered secondary, even if the score is higher than the other two. This is because we do most of our learning through our eyes and ears, and use the senses of touch, feeling and motion to enhance our primary learning.

What should I do now?

To be flexible to meet any academic situation, you need to use your strengths but also try to build up your weaknesses. Capitalize on your learning strengths because it's like money in the bank you can draw from. Try to convert study materials to the sensory format of your preference. But why should you focus on things you're not good at?

• Not every learning situation gives you a choice.


• Teachers with a learning style different from yours give assignments they find naturally appealing.


• Flexibility = Freedom. The more ways you can learn, the more options and power you will have over your life.


• It's not clear whether learning styles are inborn or the result of experience. Constant deliberate effort can often change your style. But it will take repeated practice and may even be a little painful at first (like working out at a gym.)

Learners taking written tests are expected to retrieve the information in the VISUAL learning style. All students must learn how to strengthen their visual skills if they are to succeed in college because nearly all college testing is conducted in the visual or written mode. If you do not naturally learn in the visual style, you can get the most help by developing some of the visual learners' techniques.

Study Skills

Seven study skills/learning tactics to apply to medical school learning opportunities

Surveying Techniques

Surveying is a skill that can be applied to a wide range of learning opportunities. Surveying a block of subject material (an instructor's handout, a section of a course syllabus, a chapter in a textbook, a patient's chart) is carried out by skimming the material to be studied. Read major topics and subheading and the first sentence of paragraphs. Look quickly at charts and diagrams and read the captions. Textbooks usually have a summary at the end of each chapter that will provide an overview. Surveying carries out the following important functions:

• Overcomes student inertia. Surveying is an excellent way to start to study.


• Provides advance organizers. Advance organizers serve as topics or categories around which facts and details may be organized and subsequently learned. Advance organizers have been shown to be very important in helping students learn, remember, and interrelate material they have studied.


• Builds a foundation: A preview of the material to be studied and learned forms a broad framework of prior knowledge upon which new knowledge and understanding can be built.

Organizational Techniques

Information can be organized is many different ways. Understanding the pattern of organization of information is an important guide to learning the information. Common patterns of organization are given below.

Sequencing

Information may be sequenced by:

• events in time; example = events in a normal menstrual cycle.


• stages leading to an end point; example = stages of a disease.


• position in space or location; example = structures arranged in sequence from the dorsal surface to the ventral surface of the chest cavity.


• importance; example = from most to least important symptoms of a disease process.

Listing

A common pattern of organization when items of information are all related to a common topic.

Definition

Provides meaning and identity to general classifications and gives distinguishing characteristics.

Classification

Organizes according to categories or characteristics.

Cause and Effect

Organization pattern present when events are causally related.

Compare and contrast

Organizes by comparing similarities and/or contrasting differences.

Concept Mapping Technique

Humans learn new information best by integrating the new information into an existing knowledge base. Concept mapping utilizes this knowledge about learning by providing a technique by which interrelationships can be mapped or charted. It taps into a learner's cognitive structure and externalizes what the learner already knows while depicting relevant concepts and relationships the learner is currently learning. A meaningful map will integrate the new knowledge with the previous knowledge.

Highlighting and Attaching Questions

Many students use highlighting or underlining techniques to emphasize information that they believe to be important. A process for increasing the efficacy of highlighting as a study skill/learning tactic is to attach questions to the highlighted text material. When a passage of text is highlighted, ask what question does the highlighted text answer, and write that question in the margin of you notes or textbook. Connect the question to the highlighted text and double check the question-answer relationship. What, why, when, where, which, how, and who questions tend to interrelate information and make a handy hook on which to hang information. The technique is a memory directed tactic, and is particularly useful in preparing for multiple choice examinations.

Imaging Techniques

Imaging skills are perhaps one of the more important skills/learning tactics that you can develop in medical school. Imaging skills will involve the right hemisphere in the learning process. The right hemisphere tends to process separate elements into a holistic view of the information being learned. If you depend only on words and language for learning information, you are neglecting one of the most powerful ways of learning. By learning to convert written and/or spoken language into images you enter into "whole brain learning". The skill is really the reverse of seeing something and then describing what you see in descriptive language. In imaging, the more senses you can employ, the more effective the image will be for remembering information. Clinicians use the same skill when they palpate an abdomen. Many will shut their eyes and try to visualize what they are palpating with their fingers. This is an example of the first medical imaging machine.

Reinforcement Techniques

These are study skills designed to facilitate learning and to store the learned material in long term memory banks. Frequent repetition is an example of a reinforcement technique. Other examples are using new information to solve problems or to answer questions, and the "see one, do one, teach one" technique used to teach clinical skills. In the basic sciences frequent repetition and using the information to solve problems or to answer questions are the most effective techniques. A sequence of reinforcement might look like this:

• The evening before a class survey the subject material to be covered the next day. Skim the text or syllabus. Major topics, subheadings, and the first sentence of paragraphs might be read. Charts and graphs are quickly scanned and the captions are read. Major topics and concepts are quickly listed in the notebook used for lecture notes. The skimming and major topics list should be done in 30 minutes. The list will form "advance organizers" that will serve as categories or concepts around which other information can be learned and organized. Also take about 15 minutes to look back over the work that you did after the preceding class session.


• Attend to the lecture next day by adding information as subtopics under the list of advance organizers. The structure of each of the major concepts will begin to form as you carry out this task. Do not try to write down every thing. Most faculty present a syllabus, handout, or reading assignment that will contain the details needed to understand the topic under discussion. Take 3-4 minutes to read through your notes immediately after the lecture.


• That evening read your notes again and either begin to work out the content of the instructor's learning objectives or write out three or four questions that you will answer during that evenings study period. Again, move quickly, using the objectives or questions to guide your study. Return to step 1 the evening prior to the next scheduled class in each subject.


• The weekend will play an important role in this reinforcement scheme. Study time during the weekend might be used to go back over the weeks work, tie up loose ends, and to organize the weeks work so that it can be easily reviewed prior to an examination.

Taking notes from Lectures

It is very helpful to "skim" the material to be covered before the lecture, and to provide a list of advance organizers so that you can relate what the lecturer says to what you already know. Active listening is an important skill that will help you get maximum learning gain from a lecture. To listen actively, listen for the signals the lecturer uses to stress important information. There are seven common signals used by most lecturers to signal important information:

• Introduction of a topic: For example "next, I am going to discuss..."


• Words that stress importance: For example "It is important to know that ...", "You should remember that ...", "The next exam will cover ...".


• Definitions: "The term adductor means ...", "Atrophy is a process that ...".


• Identification of a list or series of steps: "The stages in the process of wound healing are ...", "Damage to the ulnar nerve will cause the following list of problems...".


• Writing on the blackboard, speaking slowly and louder, body language.


• Showing a graphic or drawing on the blackboard.


• Summarizing or restating important points.

The second portion of taking notes concerns organization of the subject material in some sort of descending order of detail. The list of advance organizers that you prepared by previewing the subject matter to be covered in class could form the major headings in an outline, or the first step in the development of a "concept map". The outline would develop the subject material from more general to specific details. A concept map will interconnect the elements in the outline and demonstrate visually how they are related.

Group Study or Peer Teaching

One of the most powerful ways to learn is to teach other students about a subject. One of the most efficient ways of completing the work of the medical curriculum is to organize a committed group of three or four students that will study, teach, and learn together. Preparation and presentation of subject material is a reinforcement exercise that increases the learning of each "student teacher". Group discussion afterwards moves the learning from rote memorization into a conceptual understanding of the subject.

Concentration and Retention

How We Remember

1. Memory itself probably cannot be developed; however, improvement in remembering comes from correcting certain habits or thoughts so that we use our memory to its fullest potential. Remembering is like seeing; improvement in either function does not depend upon how much we use it but, rather, how we use it.


2. The first and most important rule for remembering is: cultivate the habit of close attention to the thing you wish to remember. Be sure you have a clear, sharp impression of the face, name, date, or facts, which you will need to know at a future time. If you wish to remember a fact, make it meaningful to you.


3. When we are learning, we should try not only to get a strong impression but also to obtain as many different kinds of impressions as possible. Some people can remember colors distinctly, but have a poor memory for shapes. But anyone, by putting together and using all of the impressions our sense organs bring us about a thing, can remember it much more clearly than if we rely on sight or sound alone. For example, try reading your lesson aloud. In doing this, your eye takes in the appearance of the printed word, your ear passes the sound of the words to your brain, and even the tension of the muscle of your throat add their bit to the total impression which your mind is expected to store away.


4. Try to visualize it. Either remember a diagram or a picture of the material to be remembered, or take short notes about it, which you can visualize.


5. Intend to remember. The mere intention to remember puts the mind in a condition to remember, and if you will make use of this fact in studying you will be able to recall between 20 and 60 percent more of what you read and hear than you would if you were not actively trying to remember.


6. Think about it. A fact doesn't belong to you until you have used it. In making use of this principle, plan to spend not more than one-half of your study period in reading your lesson. Use the other half in doing something with what you learn. Think about what you have studied, write down notes on it, and explain it to somebody else.


7. Logical memory. One of the most important of all aids to the remembering process is the habit of associating a new idea immediately with facts or ideas that are already firmly lodged in the mind. This association revives and strengthens the old memories and prevents the new one form slipping away by anchoring it to the well-established framework of your mental world.


8. Remembering by brute force. We will forget more, on the average, during the first hour after learning that during the next 24 hours; and we will forget more, on the average, during the first day than we will during the next thirty days. Whatever is left after thirty days time, we will probably be able to hold on to without much further loss for years to come.


9. Reviewing is much more effective if carried out before memories have entirely escaped than it is after considerable time has elapsed. Repetitions should be strung out over as long a time as is available. We remember better if we pause a little between periods of study.


10. How much study? You should study more than enough to learn your assignment. Experiments have proven that 50% more resulted in 50% better retention. After a week had passed, it was found that extra work had salvaged six times as much of the material as in the case when it was barely learned.

Improving Memory

If you review research on memory and learning, you will find that there exist a vast amount of information on the subject. But in learning to become more personally and academically effective, you are probably most interested in seeing how this knowledge can be put into practice. In other words, how can it help you improve your memory. Thus, we focus on memory techniques and strategies.

Pulling it all Together

Organizing and ordering information can significantly improve memory. Imagine, for example, how difficult it would be to remember a random list of 62 letters. On the other hand, it would not be difficult to memorize the first sentence in this paragraph (consisting of 62 letters). Similarly, learning a large amount of unconnected and unorganized information from various classes can be very challenging. By organizing and adding meaning to the material prior to learning it, you can facilitate both storage and retrieval. In other words, you can learn it better and recall it easier. The following concepts can help you pull various information together in order to increase understanding and organization. This can mean organizing material on paper, such as when you make an outline or idea web, or simply organizing material in your memory, such as learning it in a particular order or making intentional associations between ideas.

The Funnel Approach

This means learning general concepts before moving on to specific details. When you study in this manner, you focus on getting a general framework, or overview, before filling in the details. When you understand the general concepts first, the details make more sense. Rather than disconnected bits of information to memorize, such as history dates, the material fits together within the overall framework. Seeing how the smaller details relate to one another, you process the information more deeply (which helps you store, and later retrieve, it from memory). This idea is probably familiar--there are many learning strategies based on the funnel approach. For example, the approach is used in previewing a chapter for the major ideas as a way to enhance your comprehension of details contained in the chapter. You may also notice that many textbook chapters are organized in a "general to specific" format. Finally, you probably use this type of approach when studying from an outline, matrix, or concept map. Because of their organization, these tools are particularly well-suited for learning general to specific.

Organizing Through Meaning and Association

Earlier, we discussed the concept of making intentional associations in order to improve learning retention. What do we mean by "intentional associations"? When learning, a person continually makes associations. We make associations between what we are learning and the environment we are in, between the information and our mental states, and between the information and our stream of thoughts. When things are associated in memory, thinking of one helps bring the other to mind. Have you ever actually retraced your path when you have forgotten where you put an object such as your keys? Often, as you approach the place where you put them, you are suddenly able to remember the act of laying them down on the table or putting them in your gym bag. This is association. The memory of putting the keys down was associated with your memory of things in the environment. You can make associations work for you by making them intentional. When you are having difficulty recalling new material, you can help bring it to mind by thinking about what you have associated it with. In other words--retrace your mental path. We will return to this idea later when we discuss specific strategies.

• Deep processing--relating the material to yourself. One way to process information more deeply, and also to create meaningful associations, is to think about how the information can be personally meaningful. You might think about how the new material relates to your life, your experience, or your goals. If you can link new information to memories already stored ("mental hooks"), you'll have more cues to recall the new material.


• Grouping. You can organize material by grouping similar concepts, or related ideas, together. Arranging the material into related groups helps your memory by organizing the information.. When you are trying to remember lists for a test, the concepts and words may or may not have a natural organization. Therefore, you may need to be creative when making associations. Finally, the process of organizing a list into groups can often help you to understand the relationship between the concepts better.

Vivid Associations

We have already discussed the idea of associations: aiding storage and retrieval of new information by intentionally pairing it with something familiar. When learning something new and unfamiliar, try pairing it with something you know very well, such as images, puns, music, whatever. The association does not have to make logical sense. Often times it is associations that are particularly vivid humorous, or silly that stay in your mind. Some people remember names this way. For example, they may remember the name "Robert Green" by picturing Robert playing golf (on the green), wearing green clothes, or covered in green paint. Or suppose for your anatomy course you have to recall names of the veins in the human body, and the first one on the list is "pancreatic" followed by "right gastroepipeloic" and "left gastroepipeloic" and so on. You can picture a frying pan being creative--maybe painting a picture with bright paints and bold strokes. If the frying pan is working in a studio, picture gas pipes with little padlocks on them (gastroepipeloic) in the left and right studio corners...

Active Learning

You will notice that the term "active learning" has come up frequently. Active learning facilitates your memory by helping you attend to and process information. All of the memory techniques we have discussed require active learning. Even if you attend every lecture and read every assignment, there is no guarantee that you will learn and remember the information. Although you may passively absorb some material, to ensure that you remember important information requires being active and involved, that is attending to and thinking about what you are learning.

Visual Memory

Some people remember information best when it is encoded visually; if that is the case for you, then code information in this manner. But even if you do not consider yourself specifically "a visual learner," you may find that including visual memory can still help. After all, it is one more way of encoding and storing information--and one more way of retrieving it for a test.

There are many ways of visually encoding and retrieving information. We have already mentioned the strategy of associating concepts with visual images. But other aids to visual memory include diagrams, tables, outlines, etc. Often these are provided in texts, so take advantage of pictures, cartoons, charts, graphs, or any other visual material. You can also draw many of these things yourself. For example, try to visualize how the ideas relate to each other and draw a graph, chart, picture, or some other representation of the material. You may even want to make it a habit to convert difficult material into actual pictures or diagrams in your notes, or to convert words into mental images on the blackboard of your mind.

Finally, using your visual memory can be as simple as writing out vocabulary words, theories, or algebraic formulas. This allows you to not only practice (repeat) the information but also to see the way it looks on the page (developing a visual memory that you may be able to retrieve later). Another advantage is that it helps you take an active role in learning the material. When you draw your ideas on paper or write down things you are trying to remember, you have the opportunity to think about the information more deeply.

Talk it Out

When trying to memorize something, it can help to actually recite the information aloud. You might repeat ideas verbatim (when you need to do rote memorization), or you can repeat ideas in your own words (and thus ensure that you have a true understanding of the information). Repeating information aloud can help you encode the information (auditory encoding) and identify how well you have learned it. Some students have told us that they know the test information and are surprised when they "freeze" and cannot give adequate responses. For some students, this "freezing" may be a result of test anxiety. For others, however, it may be a result of overestimating how well they know the material. If you recite the information aloud from memory (answering questions, defining words, or using flash cards), it is often quite clear how well you know it. If you stumble in your responses, have to look up answers, or can only give a vague response, then you know that you need to study more.

Although reciting aloud can be a helpful memory technique, some people avoid it out of fear of appearing foolish ("what if someone sees me talking to myself?"). If this applies to you, work with a friend or study group. Another advantage of working with someone else is that they can inform you when you are missing important concepts or misunderstanding an idea. Keep in mind, however, that studying with others does not work for everyone. For example, some students may become anxious or intimidated in study groups and would be more comfortable studying alone.

Visialize Yourself Teaching the Material

An effective way to enhance recall and understanding of dense material is to teach it to an imaginary audience. By doing so, you are forced to organize the material in a way that makes sense to you and to anticipate potential questions that may be asked by your students. Moreover, by articulating your lecture aloud, you will uncover gaps in your comprehension (and recall) of the material. (Far better to discover those "weak" areas before a test than during it.) After you have mastered a particular section from your textbook, try delivering an organized lecture on any topic from that section. Then check for accuracy. Don't forget to anticipate questions that students might ask about the material as a way of anticipating potential test questions.