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HowtoSucceed atMedicalSchool

Anessentialguidetolearning

Dedication

ToGeertandJerry,fortheirsupportandpatience,without whichthisbookwouldneverhavebeenwritten.

Howto Succeedat Medical School

Anessentialguideto learning

SECONDEDITION

DasonEvans MBBS,MHPE,FHEA

SeniorLecturerinMedicalEducation

HeadofClinicalSkills

BartsandtheLondonSchoolofMedicineandDentistry

QueenMary,UniversityofLondon, London,UK

JoBrown EdD,MSc,BSc(Hons),PgCAP,SFHEA

ReaderinMedicalEducation

HeadofClinicalCommunication

AcademicDirectoroftheStudentExperience

CentreforClinicalEducation

StGeorge’s,UniversityofLondon London,UK

BMJBooksisanimprintofBMJPublishingGroupLimited,usedunderlicencebyJohnWiley&Sons.

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JohnWiley&SonsLtd,TheAtrium,SouthernGate,Chichester,WestSussex,PO198SQ,UK

EditorialOffices

350MainStreet,Malden,MA02148-5020,USA

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Fordetailsofourglobaleditorialoffices,forcustomerservices,andforinformationabouthowtoapply forpermissiontoreusethecopyrightmaterialinthisbookpleaseseeourwebsiteat www.wiley.com/wiley-blackwell.

TherightofDasonEvansandJoBrowntobeidentifiedastheauthorsofthisworkhasbeenassertedin accordancewiththeUKCopyright,DesignsandPatentsAct1988.

Allrightsreserved.Nopartofthispublicationmaybereproduced,storedinaretrievalsystem,or transmitted,inanyformorbyanymeans,electronic,mechanical,photocopying,recordingor otherwise,exceptaspermittedbytheUKCopyright,DesignsandPatentsAct1988,withouttheprior permissionofthepublisher.

Wileyalsopublishesitsbooksinavarietyofelectronicformats.Somecontentthatappearsinprintmay notbeavailableinelectronicbooks.

Designationsusedbycompaniestodistinguishtheirproductsareoftenclaimedastrademarks.All brandnamesandproductnamesusedinthisbookaretradenames,servicemarks,trademarksor registeredtrademarksoftheirrespectiveowners.Thepublisherisnotassociatedwithanyproductor vendormentionedinthisbook.

LimitofLiability/DisclaimerofWarranty:Whilethepublisherandauthor(s)haveusedtheirbest effortsinpreparingthisbook,theymakenorepresentationsorwarrantieswithrespecttotheaccuracy orcompletenessofthecontentsofthisbookandspecificallydisclaimanyimpliedwarrantiesof merchantabilityorfitnessforaparticularpurpose.Itissoldontheunderstandingthatthepublisheris notengagedinrenderingprofessionalservicesandneitherthepublishernortheauthorshallbeliable fordamagesarisingherefrom.Ifprofessionaladviceorotherexpertassistanceisrequired,theservices ofacompetentprofessionalshouldbesought.

LibraryofCongressCataloging-in-PublicationData

Evans,Dason,author.

Howtosucceedatmedicalschool:anessentialguidetolearning/DasonEvans,JoBrown.–Second edition. p.;cm.

Includesbibliographicalreferencesandindex.

ISBN978-1-118-70341-0(pbk.) I.Brown,Jo,1957-,author.II.Title.

[DNLM:1.Education,Medical–methods.2.Learning.W18] R737

610.71′ 1–dc23

2014049428

AcataloguerecordforthisbookisavailablefromtheBritishLibrary.

Typesetin9.5/12ptMinionProbySPiGlobal,Chennai,India 12015

Abouttheauthorsvii

Forewordtothefirsteditionix Introduction1

Chapter1 Whatkindoflearnerareyou?5

Chapter2 Learningknowledge19

Chapter3 Learningclinicalskills47

Chapter4 Learningclinicalcommunicationskills68

Chapter5 Workinginagroup100

Chapter6 Developingyouracademicwritingskills117

Chapter7 Portfoliosandreﬂection125

Chapter8 Life–workbalance138

Chapter9 Revision151

Chapter10 Examtechnique:generalrules162

Chapter11 Examtechnique:speciﬁcexamples174

Chapter12 Teaching,mentoringandcoaching:helpingothers tolearnanddevelop203

Chapter13 Professionalism:notasstraightforwardasyouthink224

Chapter14 Thinkingahead:student-selectedcomponents, careersandelectives242

Index253

Abouttheauthors

DasonEvans and JoBrown haveworkedtogetheronandoffsince2000, initiallyatBart’sandtheLondonSchoolofMedicineandDentistrywhere theywereawardedtheDrapersPrize‘inrecognitionoftheexemplary practiceandinnovationforenhancingthequalityoflearningandteaching’, andsubsequentlyatStGeorge’s,UniversityofLondon,wheretheywere appointedjointChiefExaminersforOSCEs.Theyhaveaninternational reputationfortheirworksupportingstudentsinacademicdifficultyand thisexpertisebringsinsightstothisbook,whichwillbenefitallstudents. Theyarerecognisedfortheirstudent-centredapproachtolearningandtheir passionateadvocacyfortheneedtoempowerstudentstomakethebestuse ofthelearningopportunitiesopentothem.

DrDasonEvans isaSeniorLecturerinMedicalEducationandHeadof ClinicalSkillsatBart’sandtheLondonSchoolofMedicineandDentistry, QueenMary,UniversityofLondon.Heisfollowingacareerinmedicaleducationandworksclinicallyinsexualhealth.Hehasbeenworkingformally inmedicaleducationsince1999andteachingandsupportingstudentssince 1995.DrEvanshasstronginterestsinclinicalskillslearning,teachingand assessmentandlearningwithintheclinicalenvironment.ThroughhisfellowshipoftheHigherEducationAcademy(HEA),andactivecontributionto theAssociationfortheStudyofMedicalEducation(ASME),theAssociation forMedicalEducationinEurope(AMEE)andexternalexaminingduties,he hasaclearunderstandingofthecurrentcultureinhealthprofessionaleducation.Hisresearchinterestsincludeclinicalskills,preparationforpractice, studentsinacademicdifficultyandeducationaroundsexualhealth.Hehas alsoco-authoredabookonlearningintheclinicalenvironmentand,withJo Brown,abookchapteronacademicsupport.

DrJoBrown isReaderinMedicalEducationandHeadofClinical CommunicationatStGeorge’s,UniversityofLondonaswellasbeing AcademicDirectoroftheStudentExperience.Shebeganhercareerin nursingandmanagementandhasbeenteachingsince1992.Shehas specialisedinClinicalCommunicationsince1998andherpassionforthe

subjectisinfectious.In2012,shewonaprestigiousNationalTeaching FellowshipawardfromtheHigherEducationAcademy.Shehasaparticular interestinprovidingacademicsupportforstudentswhostruggleorfail whileatmedicalschool.Sheisacurriculumdesigner,examinerandan externalexaminer,andhasspent2yearsvisitingmedicalschoolsinThe NetherlandsandCanadatoexploredifferentconceptualisationsofmedical education.Sheisanexperiencedmentorofteachersinhighereducation andrunscoursesonteachingandlearningtechniques.Shehasdeveloped anddeliverspostgraduatecoursesforseniordoctorsontheuseofadvanced clinicalcommunicationineverydayclinicalpractice.Sheisamemberofthe AssociationfortheStudyofMedicalEducationandisaSeniorFellowofthe HigherEducationAcademy.Herresearchinterestscentreonthemovement oflearningfromclassroomtoclinicalenvironmentandthechallengesto learningintheclinicalworkplace.

Forewordtotheﬁrstedition

Throughouttheworkingcareerofadoctor,keepinguptodateisamajor factorinprovidinggoodcaretopatients.Thisbookaimstohelpundergraduateslearnsomeofthehugenumberofdifferentskillsrequiredtodistilnew factsandnewknowledgeinordertokeepaheadwiththeirlearningforthe restoftheirprofessionallife.Itisamostunusualbookinthatitiswrittento helpstudentsdeveloptheirownskillsandawarenessaroundlearning.Itdoes notcontainfactualknowledgebutisabouttheskillsrequiredtocopewith medicalschool.Itcoversaspectsoflearningsuchascognitiveskills,motivation,self-regulationofstudyskillsandtheactual‘concept’oflearningrather thanthecontentforknowledge.Ithelpsaidstudentstolearneffectivelyand efficientlyandeventellsyouhowyouwillknowwhenyouknowenough! Itdoesthisinsectionsaboutknowledge,learningclinicalandcommunicationskills,learninghowtoworkinasmallgroupand,lastly,iteven giveshelpfuladviceon‘examinationtechnique’!Therearehelpfulsuggestionsaboutreflectingonthetypeoflearnerthestudentisandhowtorevise forexaminations.Aboveall,itdiscussesthebroaderissuesabout‘living’and howtoachieveagoodlife–workbalance.Italsohelpswiththeaspirations ofstudentsandguidesthemtothinkaboutthefutureandthetypeofcareer theymightlike.

Althoughtheauthorssaythattheyhavewrittenthisbookforstudents abouttoembarkonamedicalcourseandyoungermedicalstudents,this bookwouldalsohelpthoseinvolvedin‘teaching’health-careprofessionals. Itcertainlywouldhavesavedmealotoftimelearninghowtogetthrougha medicalcourse.

x Forewordtotheﬁrstedition

Theauthorsbothhaveavastexperienceinthisareaandmuchoftheirbook hasbeengleanedfromfirst-handexperience.Icertainlyenjoyedreadingit andwouldrecommendittoallstudentsandteachers.

ParveenKumar ProfessorofMedicineandEducation, Bart’sandtheLondonSchoolofMedicineandDentistry, QueenMaryCollege,

UniversityofLondon

Introduction

Whoisthisbookfor?

Youmaybereadingthisbookbecauseyouarethinkingofjoiningamedical courseorbecauseyouareinthefirstfewyearsoftraining.Inthiscase,you willfindthisbookparticularlyusefulinhelpingyoumanagethetransitionto newwaysoflearning.Moreover,thisbookwillbeofinteresttomoresenior studentsandmaybeofinterestandrelevancetostudentsofotherhealth professionsandacademicsinvolvedintheirlearning.

Whatisthisbookfor?

Learninghowtolearneffectivelyandefﬁciently

Duringyouryearsatmedicalschoolyouwillbuyplentyofbooks.Almostall thesebookswillcover what youneedtoknow.Thisbookisdifferent,itconcentrateson howtolearneffectivelyandefficiently whileatmedicalschooland beyond.Thereisgoodevidencethathelpingstudentsdeveloptheirawareness ofhowtolearnandhelpingthemdevelopavarietyoflearningtechniques resultsinlargeimprovementsinperformance.

Medicalschoolisdifferent

Thelearningenvironmentatmedicalschoolisfundamentallydifferentto secondaryschoolorotheruniversitycourses.Youareexpectedtolearna hugeamountofdiverseinformation,rangingfromAnatomytoEthics,to becomeproficientinmanynewskills,rangingfromtakingbloodtobreaking badnews,andtobeabletointegrateskillswithknowledgeinordertowork withapatienttomakeadiagnosisandmanagementplan.Youareexpected tolearnmuchofthiswithoutbeingspecificallytaughtit.Youareexpectedto beabletofindoutwhatyouneedtoknowandtolearnittoanappropriate level,oftenwithlittlesupport.

Howwillthisbookhelpyou?

Thisbookworksontwolevels.Onthefirstlevel,itoffersadviceonhow tolearnmostefficiently(studyskills).Thisisdividedupintofoursections: LearningKnowledge, LearningClinicalandCommunicationSkills, Workingin aGroup and ExamTechnique.Onthesecondlevel,itaimstogetyouthinking abouthowyoulearnandwhenitmightbebesttousewhichstudyskills.This isembeddedwithinthesefoursectionsandcoveredinmoredepthinfour othersections: WhatKindofLearnerAreYou?,Life-WorkBalance,Revision andThinkingAhead.Byreadingandworkingthroughthisbookyouwill gainnotonlyawiderrangeofstudyskills,butalsoanawarenessofwhento usetheminyourlearning.

Whatisinit?

Anoverviewofthesections

Thebookstartswithachaptercalled WhatKindofLearnerareYou?, which introducesasimpleoverviewoflearningstyle,helpsyoutothinkaboutwhat yourpreferredlearningstyleisandhowthismightinfluenceyourlearning. Forexample,youmaybeaperfectionist,wantingtounderstandthedeepest nuancesofeverythingthatyoulearn–ifthisisthecase,youmayhavetrouble knowingatwhichpointwhatyouhavelearnedisgoodenoughandwhento moveontothenextthingtolearn.Bycontrast,youmightbeacrammer,great atfillingyourheadwithfactsforafewweeksbeforeyourexams,readytoforgetshortlyafter–ifthisisthecase,thevolumeofstudymaywelloverwhelm you,howevergoodyourshort-termmemory.

Thechapteron LearningKnowledge covershowtomakethemostoflectures,includingtakinglecturenotes;whatsortofbookstouseandhowto learnfromthem,througheffectivenotetaking,reviewingyourlearningand testingyourself,howtosiftouttherubbishfromtheInternetandsearcheffectivelyusingIT,makingthemostofthelibraryandhowtofindappropriate reviewarticlesfromjournalsthatgivethemostuptodateview.

Inthechapterson LearningClinicalSkills and ClinicalCommunication Skills,weofferguidanceonhowtobeself-directedinlearningtheseskills, howtomakethemostoutofsimulationandhowtocapitaliseontherichness thatlearningwithpatientsoffers.Wespecificallycovertheclinicallearning environment,asmanystudentsfindtheclinicalsetting(hospitalwards, generalpractice)averydifferentandunstructuredenvironmenttolearnin, wediscusshowtogetthemostfromyourclinicaltutorsandwheresome ofthehiddenlearningopportunitiesare.Thewardroundasalearning opportunitygetsaspecialmention.Withrespecttoclinicalcommunication skills,wepresentanevidence-basedapproachandadviceonlearningboth insimulationandintheclinicalenvironment:learningbothbydoing andalsobywatchingothers.Newinthesecondedition,wehighlightthe

roleofempathyandthewaysinwhichdiversityaffectsourpracticeand includeanewsectiononhowtogiveinformationeffectively.Wediscuss theessentialnatureoffeedback,bothhowtogiveeffectivefeedbackand alsohowtoreceiveit,andhowtoactonit.Finally,wecoverthepatient presentation,acommoncauseofanxietyamongbothmedicalstudents andtheirsupervisors.Throughoutbothchapters,wemakenoapologiesfor repeatedlystressingtheprimacyofpatientcare.

MuchofthelearninginmedicalschoolsintheUnitedKingdomis through WorkinginaGroup.Workingandlearninginagroupisinescapable inmedicineandthissectionstartswithadiscussionontheprosandcons ofgroupworkandhowtogetthebestfromit.Itspecificallydiscusses Problem-BasedLearning(PBL)anditsvariants,informallearninggroups andhowtomakeinterprofessionallearningwork.

Studentsatmedicalschooloftenstrugglewithdevelopingan Academic Writing style,referencingappropriatelyandconceptsofplagiarism.Wegive anintroductiontotheseareasinadedicatedchapter,whichwehopewillstart youoffwithsafefoundations.

PortfoliosandReflection areinescapableinundergraduateandpostgraduatemedicaleducation,andthechapteronthesubjectprovidesapragmatic overviewonwhatportfoliosare,howtomakethemworkforyouanddemystifiessomeoftheconceptsofreflection.

Fortherestofyourlife,therewillbetoomuchtodoatworkandtoo muchtodoathome.Balancingsocialandprofessionallivesformsarecurringthemeinresearchaboutstressindoctors.Thechapteron Life–Work Balance providessomeguidanceintohowtomanagebothahealthysocial lifeandahealthystudylifeand,mostimportantly,willhelpyougetintogood habitsrightatthestartofyourprofessionalcareer.Bothtimemanagement andstressmanagementarecoveredhere.

Thechapteron Revision buildsonandsummarisestheprinciplesfrom thepreviousones,discussinghowtomanagethelearningenvironment, prioritising,planningandtimetablingandmanagingstress.Thischapter, aboveallothers,offerswholesome,sensibleadviceonhowtomanagethe limitedtimerunninguptoexams.

Thechapterson ExamTechnique covergenericadviceabouthowto approachexams,liststhedifferentkindsofassessmentsthatyoumightfaceat medicalschoolandthenoffersspecificadviceonhowtomakethemostfrom eachofthese.Itincludeshowtodoyourbestinmultiple-choice,extended matchingquestionexams,datainterpretationquestionsandhowtosurvive theOSCEorclinicalskillsexam.Wediscusscopingmechanismsthatdo notwork,alongsidethosethatdoandadviceonhowtomanageexamstress. Newinthiseditionisspecificadviceonthelatesttrendinassessment–the dreaded‘SituationalJudgementTest’(SJT)–whichshouldhelpyouprepare effectivelyandrecognisewhatthequestionsareactuallylookingfor.

Increasingly,medicalstudentsareinvolvedinformalandinformal teachingofothers.Thenewchapteron Teaching,MentoringandCoaching helpsguideyouthroughthis,linkingclearlyfromthechaptersonhow studentslearn,inordertoexplainhowyoucanhelpotherslearn.

Inthissecondedition,weprovideanewchapteron Professionalism Professionalismistheveryfoundationofmedicalpracticeandthisismirroredthroughoutthisbook.Professionalismisnotseparate,butintegrated withineachchapter.Whetheritbelearningeffectively,encouraginglife-long learning,conceptsofreferencingandplagiarismorastrongemphasison learninginordertoprovideexcellentcareforpatients,ratherthantopass exams,youwillfindlittleinthisbookthatwillnotcounttowardsyour developingprofessionalism.Whatthischapterspecificallycoversishowto learnprofessionalism,howitisassessedandsomeofthedilemmasaround professionalism,particularlythequagmirethatisdigitalprofessionalism. Wehopethatthischapterwillhelpyoutoreviewandactivelymanageyour ‘digitalfootprint’.Inaddition,itmaystimulateyoutobecomeinvolvedwith thisemerging,rapidlychangingfield.

Finally,thechapteron ThinkingAhead:SelectedStudyComponents, CareersandElectives offerssomethoughtsaboutlongertermplanningof learning–includingwhichoptionalcomponentsofyourcoursetochoose, whichelectivestogoonandsomediscussiononhowtocheckoutwhich careerinmedicinemightberightforyou.

Howtousethisbook

Thisbookhasbeenwrittentoprovideawholeview,buteachchapterhas beendesignedtostandalone,withconsiderablecrossreferencing.Whether youprefertostartatthebeginningandreadstarttofinishordipinandout, bothapproacheswillwork.Wehighlyrecommendthatyoureadwithsome roughpaperhandyand activelyengage withthefewexercisesthatyouwill findinmostchapters–itwillbeeasytoskipthem,butyourunderstanding andlearningwillnotbeasdeepifyoudo.Teachingonlearningstyles(what kindoflearnerareyou)andonlife–workbalanceisoftenunappealing.We haveworkedhardtomakethesechaptersrelevant,interestingandpractical; theyarefundamentalandwewouldstronglyencourageyoutogivethemago.

Summary

Thisbookwillnotteachyouwhatyouneedtoknowtobeadoctor.However, byusingthisbookactivelyyou will learnhowtostudymoreeffectivelyand efficientlyatmedicalschool,howtobalancestudyingwithanenjoyablesocial lifeandhowtoshowyourbestabilitiesintheexams.Inotherwords,thisbook willshowyounotonlyhowtosurvivebutalsohowto thrive atmedicalschool andhowtoenjoylearningfortherestofyourlife.

Chapter1 Whatkindoflearnerareyou?

OVERVIEW

Thischapterformsafoundationfortherestofthisbook.Itwillhelpyou becomeawareofyourlearningpreferencesandthefactorsthattendtoaffect yourlearning.Thisawarenessitselfwillbeusefultoyou,bothwithrespect toplanningyourlearningandwithrespecttohighlightingwhichchaptersof thebookyouarelikelytoﬁndparticularlyimportant.Wehavetriedtogive abriefoverviewofthemostimportantfactorsandhavetriedtoencourage youtomakesomejudgements.Youmightwanttorevisitthischapterwhen youhaveﬁnishedthebooktoseeifyourimpressionshavechanged.

Introduction

Thischaptermightbequitetoughtoworkthrough.Itasksyoutotaketime awayfromreadingtothinkaboutthethingsthataffectyourlearning.The temptationwillbejusttoreadon;however,youwillbenefitconsiderablyfrom havingafewsheetsofpaperhandyandtryingtoanswereachquestion.Concentrateoneachbriefexerciseandansweritasbestyoucan,itwillmake theinformationsinkinmuchbetter.Attheendofthechapter,wehaveput asummarydiagram,whichwehopewillhighlightwhereyouhaveassessed yourstrengthsandweaknesses.

Wewillcoverthefollowingaspectsoflearning:

• cognitiveaspects(how deep isyourlearning?)

• motivation(what drives youtolearn?)

• self-regulationofstudyskills(areyou aware ofhowyoulearn?)

• howdoyouknowwhenyouknowenough?

• conceptionoflearning(whatyouthinklearningisfor?)

• learningingroups(loveitorhateit)

• moodandlearning(ahelporahindrance)

• VARK(yourpreferencesinusingyoursensesinlearning).

Youmaywanttohaveabriefbreakaftereachsection,asthereisquiteabit tothinkabout.

Aspectsoflearning

Youmayhavealreadycompletedlearningstyleinventoriesorpsychometricteststotryanddefinewhatsortoflearneryouare.Thereareallsortsof differentlearningstylesandeachtendstolookatslightlydifferentaspects oflearning.Theauthorsofthelearningstylesinventoriesclaimthatgreatnesscanbereachedbyunderstandinghowyouthinkandlearn,usingtheir learningstyleinventoryofcourse.Ouraimismoremodest–wehopethat bythinkingabouthowyoulearn,youwillbecomeawareofwhataspectsof learningyouwillfindeasierandwherethechallengesmightlieaheadforyou.

Fillinginalearningstylequestionnairewasfantastic,ithelpedmerealise thekindoflearnerIamandbuildonmynaturalstyle.

Jo,first-yeargraduateentrystudent.

Cognitiveaspects

Thisreferstothewaythatyougoaboutbuildingnewinformationinto memories–howmuchdoyouskimoverthesurfaceorhowmuchdoyou struggletoreallyunderstand?Howwellcanyouremembersomethingthat youhavelearned?Forhowlong?

EXERCISE

Thinkaboutatopicthatyoulearntreallywell.How‘deep’wasyourlearning? Howmuchdidyouthinkabouthowyournewlearninglinkedintowhatyou knewalready?Didyoulearntounderstandordidyoulearntomemorise? Whichdoyouﬁndeasier?

Makeajudgementcall,onthelinebelow.Wherewouldyouputyourself?

I tend to try and memorise facts, and try not to expend too much information on thinking about the application or understanding of what I‘m learning.

I prefer to learn to understand, I link new knowledge to old knowledge, I think I‘m a deep learner.

Ifyouhaveapreferenceformemorisation(theleft-handendoftheline), thenyouwilldoverywellwithsomethings–drugnames,anatomy,teststhat askyoutoregurgitatefacts–butyouarelikelytostrugglemoreonthosetasks thatrequireadeepunderstandingorapplicationofthefacts;unfortunately, agoodamountofresearchindicatesthatstudentsscoringtowardstheright tendtodobetteratmedicalschool.Youmightthinkaboutsomestrategiesto encourageyoutoshiftmoretotheright,andinChapter2(LearningKnowledge),wewillgothroughsomeofthese.Ifyoutendtomemoriseasmany factsaspossibleshortlybeforeexams,forgettingthemshortlyafterandhave aneasytimetherestoftheyear,thenyouwillrunintotroublewiththevolumeofworkinmedicineandwillneedtostartworkingregularly;thismight beachallengeforyou.

WegivemoretipsonencouragingdeeplearninginChapter2,andadvice ontimetablingandregularstudyinChapter8.

Motivation

Whatmakesyoulearn?Doyoulearnforinterest,orperhapstopassexam oreventopleaseothers?Somemedicalstudentslearnbestbecausetheyare fascinatedbythescienceofmedicine,otherslearnbestwhentheycanseethe practicalapplicationoftheirlearningandafewlearnbestwhensomeoneis standingoverthempressurisingthem.

EXERCISE

Spendaminutethinkingaboutwhatmotivatesyourlearning.Youmight wanttospendsometimetalkingwithyourfriendsaboutthis,behonestwith yourself.Asyoucometoadecision,thinkabouthowyoumightmakeuseof thisinsight.

Iammostmotivatedtolearnby:

• Ifyouﬁndthe sciencefascinating,spendacoupleofhourseachweekin thelibrarylookingatthejournals– Nature,The Lancet.Whenlearningabout diabetes,youwillwanttoreadaboutinsulinreceptors,aboutthepathology, abouttheunderlyingmechanismsbywhichdiabetescausesincreasedcardiovascularrisk,inadditiontothecoreareasthatyou need tolearn.Thecommonestpitfallifyouarethiskindoflearneristhatyoumighthavesometroublewithknowingwhentostopreadingandwhenenoughisenough–you cannothaveaPhDlevelofknowledgeoneverythinginmedicine;wediscuss tacticstomanagethisinChapter2.

• Ifitispatientsandthe practicalapplicationofknowledge thatdoesit foryou,youmightﬁndsomeofthebookworkinmedicineratherdulland difﬁculttodigest.Spendtimethinkingaboutpracticalapplications.Ifyou arelearningaboutdrybiochemicalpathways,readalsoaboutclinicalpresentationsofpatientswithproblemsinthosepathways.Youcanlookforcase studiesorevenpatientvideosonlinethatarerelevanttoyourlearning.You willwanttobuysomeclinicaltextbooksearly,sothatyoucanreadaround clinicalfeaturesofdiseases.Whenlearningaboutthepathologyofthecervix, haveareadaboutcervicalsmears,aboutthediagnosisandtreatmentofcervicalcancer,thinkabouthowwhatyouarelearningwillaffectthecareyou givetopatients.Youmightaskafriendlygynaecologistifyoucansitinon theircolposcopyclinic.Seeasmanypatientsaspossibleandreadaboutthe conditionsthatyouhaveseen–youwillrememberinformationmuchmore clearlyifyoucanlinkitinyourmemorytoapatientyouhaveseen.

• Manystudentsaremosthighly motivatedbyexams.Ifthisisyou,then lookuptheexamstructureearlyintheyear–lookattheobjectives,plan howyouwillcoverthem.Usepastquestionstostructureyourlearningand totestyourself,writeyourown,learninagroupandwritetestsforeach other.Therevisionsectionofthisbookwillappealtoyou(Chapter9)and alsosomeofthestudystrategiesinChapter2.

• Does ‘knowingthatyou’vedoneagoodjob’ motivateyoutolearn more?Formanyofus,praiseandrewardareimportant.Ifitisamajordriver foryou,youmightwanttobepragmaticinsomeofyourlearning.Ifyou aresittinginanasthmaclinicnextThursday,thenlearnaboutthemanagementofasthmabeforethen.Youwillfeellikeyouunderstandwhatis goingon,youwillasksensiblequestionsandtheclinicianinclinicislikelyto beimpressed–thiswillmotivateyoutostudymore.Thissimpletechnique worksexceptionallywell!

• Thereareafewstudentswhothriveon externalpressure.Theyloveteacherswhointimidatestudents,whereasmostoftheirpeerstendtohidein threateningenvironments,theythriveinthem.Ifthisisyou,thenyoumight wanttotryandcreatesituationsthatwilldriveyoutolearn.Agreedeadlines withtutorsoryourpeers,agreetoteachstudentsinyouryearortheyear below;encouragethemtotryandcatchyouout,sothatyouknowthatyou willhavetolearnyourtopicwell.

Ofcourse,youwillnotfitsinglyintoanyoneofthesefivevignettes,but youwillknowwhichonesapplymosttoyou.Youarealsolikelytofindthat differenttopicsmighthavedifferentmotivationsforyou.Clearly,therewill notbeasinglestrategythatappliestoyou.Youcannotonlyreadaboutthe conditionsthatyouhaveseenpatientswithoryouwillneverlearnaboutthe rareones.Similarly,ifyouare100%examinationfocused,youmightmissout onthethingsthatareimportantbutnotexamined.However,knowingand manipulatingwhatmotivatesyouinordertomaximiseyourstudyisakey skill.Itmightevenbeworthpinninganoteuponthewallaboveyourdesk, remindingyouofwhatmotivatesyou.

Self-regulationofstudyskills

Studentswhoareawareofhowtheyarelearning(thisiscalledmetacognition) tendtoperformmuchbetterthanthosewhodonot.Thisbookislargelyabout helpingyoudevelopeffectivestudyskillsandanawarenessofwhenandhow tousewhichones.Howawareofyourlearningareyou?Howconsciously doyoumakechoicesinhowyoulearn?Didyouusedifferentmethodsto learndifferenttopicsatschool?Ifnot,whynot?Themoreyoucanlearnto thinkabout how youarelearning,themoreyouwilldevelopasaneffective learner.

EXERCISE

Thinkaboutthefollowingtasks.Spend2minutesoneachtaskthinkingabout howyouwouldgoaboutit.Timeyourself;itwillbetimewellspent.

• Youhavealistofcomplicationsofdiabetestolearn.

• Youhavetomemorisealistofdrugnamesfortreatinghighbloodpressure; thenamesallsoundratherforeigntoyou.

• Youhavetolearnthesurfacemarkingsofthevariouslobesofthelungsso thatyouknowwhichoneiswherewhenyouareexaminingapatient.

• Youhavetolearnhowtotakeblood.

Howeasywasittoplanhowyouwouldgoabouteachtask?Wasyourplan foreachtaskdifferentorthesame?Didyouhaveseveraloptionsforeachtask orjustone?Themoreoptionsandthemoreactiveyourdecisions,theeasier youwillfindlearning.Ifyoutendedtothinkofjustonemethodoflearning (‘IwouldjustkeeprepeatingituntilIremembered’or‘Iwouldjustlearnit’), thenyouarelikelytobenefitfromspendingextratimeonChapter2andit mightbeworthwhilefindingoutiftherearesomestudyskillsworkshopsrun byyouruniversity.Improvinginyourstudyskillsisaninvestmentthatwill reallypayoff.

LearninghowtolearnwasthemostimportantthingIgotfrommedical school,unfortunatelyIdidn’trealisethisuntilthesecondyear!

Rebecca,finalist.

Howdoyouknowthatyouknowenough?

TheA-levelsyllabusthatyoustudiedwaswelldefined,intermsofboth breadthoftopicsanddepththatyouneedtogotoineachtopic.Thisisnot sotrueatmedicalschooland,aswehavealreadymentioned,knowingwhen tostopcanbeachallenge.Somestudentsareexcellentatmonitoringtheir progressandusethesortoftricksthatwediscussinthechapteronlearning knowledge(Chapter2),butotherseithertendtolearnfartoomuch(and runoutoftime)orlearnfartoolittle.

EXERCISE

Thinkforaminutehowyouknowwhenyouhavelearntenoughonatopic. Whatevidencedoyouusethatyouknowsomething?

Thisevidencethatyourelyontoknowthatyouknowenoughonatopic maybeobjective,subjectiveor‘non-evidence’. Objectivemeasures might includetestingyourselffromabookofpastquestions,orwritingquestions beforeyoustartlearningfromthecourseobjectivesandseeingifyoucan answerthemwhenyouthinkthatyouhavefinishedlearning;perhapsyou tryandexplainittosomeoneelseandseeifyoucanansweralltheirquestions.More subjectiveevidence willincludeotherstellingyouthatyouare knowledgeableorperhapsyoumakeajudgementthatyoucannowunderstandsomethingthatpreviouslyyoufoundrathercomplex,perhapsyoulook atthelearningobjectivesandmakeajudgementonwhetheryouhavecoveredthem. Non-evidence tendstobeprettyuseless,itincludesjudgements suchasjudgingthenumberofhoursthatyouhavelookedatapage,orhow manybooksyouhaveonthesubjectorhowtidyyournoteslookassome ‘guesstimate’ofhowmuchyouhavelearnt.

Youarelikelytouseablendofthesethreeapproaches,andstudentswho tendtocross-referenceobjectiveandsubjectivemeasuresarelikelytohavea farmoreaccurateideaofwheretheyareuptointheirlearning.Studentswho usenon-evidencetendtoberathersurprisedwhentheyfailexams–‘butI spenthourslookingatthebooks’or‘butmynotesarealwayssoperfect’.

Conceptionoflearning

Whatislearningfor?Whatislearningabout?Doyouseelearningasapassive increaseinknowledgeorperhapsasmemorisationoffacts;perhapsyousee learningasawayofgaininginformationthatyoucanapplyinpracticeor perhapsyoulearninordertotryandmakesenseoftheworldaroundyou. Studentswhotendtotryandmakepersonalmeaningoutofwhattheylearn seemtobemoremotivatedandachievedeeperlearning.

Youmighthaveleftsecondaryschoolthinkingthatlearningwasaboutgettingfactsintoyourhead.Ifso,youshouldbeawareofthetransitioninhigher education,whereyouwillbeexpectedtoquestion,debateandweighupdifferent,conflictingevidenceinordertotryandmakesomesortofsenseof theinformationinfrontofyouandhowitrelatestotheworldaroundyou. Youcanspeedthattransitionbyquestioningyourself:asking‘Whatif … ?’or ‘Why ?’and‘Whatuseisthisinformation?’.

Asanexample,whenyouarelearningaboutdiabetes,youmightaskyourself‘whatifdiabeteswasnotadiseasethateitheryouhadoryoudidnothave, butacontinuumbetweennormalbloodsugaranddamaginglyhighblood sugar?’Perhapsyouwillask‘whyisthethresholdfordiagnosingdiabetesa fastingsugarof7.0mmol/Landnot7.4mmol/L?’Ifyouhaveaveryconcrete ideaoffacts,validquestionslikethesemightbeuncomfortable.Itisbetterto havethisdiscomfortandlearntomanageitearlyon,ratherthanlaterinyour career.Youmighthavetotrustusonthisone!

Learningingroups

Collaborativelearninghasitsprosandcons.Somestudentsfeelthattheycan onlyreallylearnthroughdiscussionanddebatewithothersandtheytendto struggletofindpeoplewithwhomyoucandiscusseverythingthatyouhave learnt.Ifthisisyou,youwillbenefitfromreadingthechaptersonstudyskills (Chapter2)andrevision(Chapter9).Incontrast,somestudentsfindthatthey hatetostudywithothers.Thesestudentstendtostruggletoknowwhether theyarelearningtotherightdepthandtheyreallystrugglewithclinicaland communicationskillslearning,asfeedbackfrompeersandpeerpracticeis crucial.Ifyoufitintothisgroup,thechaptersonclinicalandcommunication skillslearning(Chapters3and4)andworkinginagroup(Chapter5)willbe particularlyrelevanttoyou.

Mood

Moodaffectslearning.Haveyoueverbeensoangryorfrustratedthatyou wereunabletostudy?Orsopassionateaboutasubjectthateverything youreadseemedtomakesense?‘Feeling’canbeintimatelyinvolvedwith ‘thinking’?

EXERCISE

Markonthelinewhereyouimagineyouliebetweenthetwoextremes.

‘Logic’

‘Emotion’

Aretherethingsthatparticularlyswingyouonewayoranotheralongthis line?Somepeoplefindcertaintriggersthrowthemintoemotionalresponses; guilt,forexample,drivessometostudybuthandicapsothers.Howaboutanxiety?Doyouspendtoomuchtimeworryingaboutthethingsyouhavenot doneratherthangettingonanddoingthem?

Whatifyouareontheotherendofthescale,emotionneveraffectsyour thinkingandlearning,wouldyoubemissingoutonthepassion,thebuzzof knowingthatyouare‘onaroll’?Howwillyoudevelopempathyifyoucannot seehowemotionaffectspeople’sdecisions(logically,surelyeveryoneshould agreetotakepartinmedicalresearch)?Whataboutteamworkskills–how willyourelatetoothersifyoucannotseetheemotionalcontextsinwhich theyexist?

Thinkaboutwhereyouareonthelineandconsideratwhatpointonthat lineyoumightbemoreproductive.Spendsometimeconsideringhowyou

canactivelymanagethetriggersandswingstobealittlemoreproductive alittlemoreofthetime.Wehaveworkedwithmanystudentsandthesimpleststrategiesareusuallythebest–ayoungwomanwhosestudyingused tobedistractedbyregularfamilycrisesmovedoutofhome.Whenphone callsreplacedknocksonherbedroomdoor,shediscoveredthatshecould switchoffherphonewhileshewasstudyingandshecouldstudywithaclear head.

Sometimesemotionclouds all yourthoughts,andthatisatimetogethelp. Indeed,everyonewillstrugglewiththewaythattheyarefeelingandtheway thataffectstheirworkatonetimeoranotherintheircareers.InChapter8, wetalkaboutavenuestoensurethatyougainsupportwhenyouneedit.

VARK:usingyoursenses

Thinkaboutincense.Whatcomesimmediatelytomind?Forsomepeople theywillseesomethingrelatingtoincense–perhapsthesmokecurlingup fromaburningpot.Otherswillhearsomething–perhapstheringingnoise thatanincenseburnerinchurchmakeswhenitisswungorthewordincense beingsaid.Othersmightseethewordasitiswritten,perhapsthinkaboutthe differentmeaningsoftheword:‘piecesoffragrantsubstance’or‘toinfuriate’. Finally,youmightthinkaboutthemovementsthatyouwouldmaketolight ortoswingtheincensearound.

Itseemsthatsomepeoplehavea visualpreference,othersanauditoryor auralpreference.Somepreferto readorwritethingstolearnthemandothers haveastrong kinaestheticpreference–thatisphysicallytodothings.The VARKlearningstylehascomeupforcriticism,butithassomeuses.Lookat thefollowingdescriptionsandthinkofhowmuchtheyeachapplytoyou.

Visualpeople willliketousecolourandshapes,andtheydrawflowcharts andliketohaveeverythinginsightinfrontofthem.Theylikebooksthatare visuallyappealing,withsmallblocksoftext,plentyoftablesanddiagrams. Theymightfindlearningvisualtopicslikeanatomymucheasierthanmemorisinglistsofwords.

Auralpeople liketolisten,theythinkthatlecturesarebetterthanbooks andlikeitwhensomeoneexplainsthingstotheminwordsortheyexplainto others.Theyremembertheanecdotesfromthelecture,orwhatthatpatient saidandsometimestheyforgettowritethingsdownastheyaretoobusy listening.Theyarenotfondofbooksandtendtoreadbooksbyformingthe wordsintheirheads.Sometimestheirlipsmovewhentheyarereading.

Thosewitha read/writepreference tendtolikebooksandtextsandlists. Theymightcopyoutchunksoftextfromthebooktoformtheirnotes,which areoftenquitelengthyandquitedry.Theyaregoodatspellingandcan

rememberlistsofwords.Theymightlookataforeignwordandworkout whatitmeansfromsimilarwordsthattheyknow.

Kinaestheticlearners liketolearnbydoing.Theylikepractical applications–‘thisgoesthere’.Real-lifeexamplesaregreatandlearningbytrialanderrorreallyconsolidatestheirlearning.Abstractthingsare moredifficultforthemandtheystrivetothinkofapplicationsforwhatthey arelearning.

EXERCISE

Foreachofthesepreferences,ratewhetheryouthinkthatyouarestrong(you oftenthinkandlearninthisway),average(yousometimesthinkandlearnin thisway)orweak(yourarelythinkorlearninthisway)

Visuallearning

Aural/auditorylearning

Read/writelearning

Kinaestheticlearning

Mostpeoplehaveapreference:somehavestrongpreferences,othershave amoreevenspread.

Thinkaboutyourpreferences,yourstrengths.Thiswillgivesomeindicationofthesortsoftasksandsubjectsthatyouwillfindeasiest.Thinkabout howyoucancapitaliseonyourstrengths:

• Ifyouareavisualperson,areyoumakingbestuseofcolourandpictures? WouldyoubebettermakingyournotesonapadofA3ratherthanA4 sothatyoucanseemoreinoneglance?Doyoutakeoneofthose4-or 10-colourpensintolectureswithyou?Ifnot,whynot?Doyoutryand convertdifficultconceptsintoflowchartsorcartoons?Youwilllikethe sectiononconceptmappinginChapter2.

• Ifyouareanauditoryperson,thendoyoumakethebestuseoflectures, sittingnearthefront,awayfromdistractions?Haveyoutriedusingtapes orreadingyournotesoutloud?Doyoueverputdifficultfactstomusicto helpyouremember?Youwillfindteachingandexplainingtoothersreally useful.Howaboutstartingastudygrouporadebatingsociety?

• Ifyoulikethewrittenword,youcanwritebriefdescriptionsofdiagrams orflowcharts.Youcanchangethewordsthatyournotesarewrittenin, choosingyourownwords,sothatyouaresurethatyouareprocessing theinformation.Youcanwritedownpatientstories,makelistsandwrite essays.Youmightwelllikestudyinginlibraries.Perhapsyoucouldstart anonlinegroupwithothersfromyourmedicalschoolorothermedical schoolswhereyouexplainthingstoeachotheronamessageboardorwiki.

• Ifyouhaveakinaestheticapproach,youwillwanttofindpracticalapplicationsforwhatyouarelearning.Getoutthereanddothings–ifyouhave seenapatientwithadiabeticfootulceryouwillfinditmucheasiertoread aboutit.Applywhatyouhavelearnedwheneveryoucan,searchforrelevance.Useyourimaginationandimaginethingshappeningwhenyouread aboutthem.

Thinkalsoaboutyourweaknessesandhowyoucanaddressthem.There aretwomainapproacheshere.Firstyoucantryandredesignthetasktoplay toyourpreferences.Ifyouhavetomemorisealistofdrugnamesandyou areterribleat‘read/write’butstrongonauditorymemory,makeupasong orapoemandsingitoutloud.Ifyouhaveapreferenceforvisualthings, turnthewordsintopictures:thedrugzopiclonemightbecomeanumberof identical(clones)Z-shapedfloppyaliens(zoppy),allsleepyinbed(zopiclone isasleepingpill).

Thesecondwaythatyoumightaddressyourweaknessesistotrainyourself tobestrongerintheseareas.Timetableextratimeforthetasksthatyoumight findchallenging,andaskyourpeerswhattrickstheyuse.Youcanfindothers withsimilarpreferencestoyou(theincenseexerciseisagoodone,although lotsofpeoplesay‘thesmell’,whichdoesnotfitwellintoVARK,butisdiscussedmoreinChapter9)andfindouthowtheylearn.If,asagroup,youall hatelearningvocabularythenatleastyoucanempathisewhenyouaretesting eachotherondrugnames–youwillmostlikelylearnatasimilarrate.

YoucanfindoutmoreaboutVARKatwww.vark-learn.comorbytyping VARKintoyourfavouriteInternetsearchengine.Thereisnotahugeamount ofevidenceforVARKoveranyoftheotherdimensionsoflearninglisted abovebut,liketheothers,itisusefultohelpyouthinkaboutwhereyour strengthsandweaknesseslie,howyoucancapitaliseonyourstrengthsand activelymanageyourweaknesses.

Learningstyles

Aswementionedatthestartofthischapter,differentlearningstyleinventoriestendtomeasuredifferentcombinationsoftheaspectsoflearning

Deep learning (learning for understanding)

Intrinsic motivation (learning for interest)

Self-regulation (awareness of how you learn)

Conception of learning (learning for wisdom)

Mood (emotions help learning)

Visual (visual things are easy to learn)

Learning in groups (you beneﬁt from learning in groups, but can also manage without)

Knowing when you know enough (you use accurate measures)

Kinaesthetic (you like to learn practical things)

Read/write (you like words)

Auditory (you remember what you hear)

Figure1.1 Summary.

thatwehavelisted.Ifyourmedicalschoolhasaprogressivecurriculum, youmightwellfilloutaquestionnaireonyourlearningstyleandevenget somenumbersoragraphthatwillsummariseyourpreferences.Wewould recommendthatyoulookthroughthischapteracoupleoftimesandactually dotheexercisesandanswerthequestions.Writesomenotesonwhereyou identifyyourstrengthsandweaknesses,triggersthatupsetyourlearning andtipsthatmaximiseyourlearning.

Summary

Thischapterhasaskedyoutomakemultiplejudgementsaboutfactorsthat affectyourlearning,whichisnotsomethingyoumighthavedonebefore. Yourjudgementsmightnothavebeenterriblyaccurateandwewouldrecommendthatyourevisitthischapteragainwhenyouhavereadtheremainderof thebookandhadachancetothinkinmoredepthaboutwhatfactorsaffect yourlearning.

Themultipleaspectswithinthischapterhavemadeitrathercomplex.You mightfindFigure1.1usefulinsummarisingthechapter–youcanmarkon eachaxiswhereyouthinkyourstrengthsare(perhapsyoudecide10relates to“strength”or“noproblem”).

Referencesandfurtherreading

Coffield,F.(2004a). LearningStylesandPedagogyinPost-16Learning:ASystematic andCriticalReview.London,LearningandSkillsResearchCentre. Coffield,F.(2004b). ShouldWebeUsingLearningStyles?:WhatResearchhastoSayto Practice.London,LearningandSkillsResearchCentre.

Questionsandanswers

Q:IhavedoneanonlinetestforVARKandmykinaestheticscoreislow–willI havetroublelearningclinicalskills?

A:Thepredictivevalidityofthesedifferenttestsisnotgreat.Somestudies havesuggestedthatstudentswitheitherdeep(learntorememberandunderstand)orpragmatic(learntopassexamseffectively)learningstylesdobetter inmedicalschoolexamsthanthosewithsuperﬁcialstyles(cramfactsforthe exams,skimoverthetop),butthisreallyisnotrocketsciencetounderstand. Theusefulnessintheseinventoriesisthattheyencourageyoutothinkabout yourpreferencesandthewaythatyoutendtolearn–doyouthinkthatthis judgementistrueforyou?Ifyoutendtoavoidpractisingwhenlearningaskill, howareyougoingtomakesurethatyoupractiseyourclinicalskillsagreat

dealwhenyouarelearningthem?SeeChapter3foranin-depthdescription ofeffectiveclinicalskillslearning.

Q:Mymedicalschoolnotonlymakesmedolearningstyleinventories,butalso inventoriesonhowIworkinateam–itdrivesmemad!

A:Thereareinventoriesforalmosteverythingyoucanimagine,asasignificantproportionoftheworldismadeupofpeoplewholiketomeasure things,everything;infacttheyevenmakeupnewthingsinordertomeasure them.Asyoumightguessfromthischapter,ouremphasisislessonformal, accurate,statisticallysignificantmeasurement,butmuchmoreonusingthese toolspragmaticallyinordertodevelopyourself-awareness.Weknowthatstudentswhodevelopself-awarenesswithrespecttolearningoutperformtheir peers,soseewhatyoucantakeoutfromtheexercises.Perhapsyouwantto findProfessorCoffield’spapers(Whichcritiques,andcriticises,learningstyles inventoriesindepth)andengageinadiscussionwithyourcourseconvenor.

Chapter2 Learningknowledge

OVERVIEW

Thischapterintroducessomeofthekeyissuesandstrategiesforlearning knowledge.Wediscussthedifferenttypesofknowledgeandtipsfor improvingyourlearningbasedonwhatweknowabouthowmemoryworks. Finally,wediscussdifferentlearningenvironmentsandhowtomakebest useofthem.

Introduction

Thereisonethingthatwecanbeprettysureabout–thatyouareintelligent. Youdidwellatschool(youmightevenhavebeennearthetopoftheclass)and someofyouwillhavereliedonagoodmemory,butnotagreatdealofstudy,to passyourexams.Unfortunately,medicalschoolisnotlikesecondaryschool, collegeorsixthform.ThecurriculumisnotasclearlysetasforA-levels,and ithasatendencytochangealittlewhileyouarestilltryingtofollowit.The volumeofworkishuge,toobigforeventhebestmindstoholdwithouteffort andtoomuchinformationtocramintoyourheadtheweekbeforetheexam. Thesourceofknowledgemightbedifferenttoo:youmighthavebeentold whattolearnatschool–learntheclassesanddothesethomeworkandyou willdowellatmostsecondaryschools.Inmedicine,youwillnotgettaught everythingthatyouneedtoknow,andyetyouwillstillbeexpectedtolearn it–toworkoutwhatyouneedtolearn,toworkoutwaysoflearningit,to workoutwaysofknowingwhenyouhavelearntitandtogetonandlearnit.

Thisdrasticchangeofemphasiscomesasacultureshocktomany.This chapterhighlightssomeoftheissueswithlearninginmedicalschooland lookstoestablishedtheoriesfromeducationalpsychologyandestablished