This is the second post in a three-part refashioning of my talk on being a better learner from The Teaching Course in New York. Find part one – Physician, Know Thyself – here.
PHYSICIAN, TEACH THYSELF
Neurobiology of learning and memory
First off, it can be helpful to understand a little bit about how memory works.
In very general, simplistic terms there are two kinds of memory. Transient working memory is an evolving concept of very short term storage of information. It has both a limited capacity and time frame and is a component of recognition, comprehension and processing.
We also have a long-lasting stable memory; under the right conditions, learning is moved there for future access and development. Memories here are not static nor stable constructs but dynamic and available for modulation or alteration, invested in context and emotion, stress and affected by subsequent events.
Memory is the ability to remember specific experiences, whereas learning can be defined as a process that will modify subsequent behaviour. Memories can be important components of learning because they have a strong influence over how we make decisions, both now and in the future.
We learn in two key ways; implicit and explicit learning.
Implicit learning is a passive process by which you acquire new knowledge through exposure to a new stimulus. You may even lack awareness that learning has taken place.
Here are some examples of implicit learning in medicine which come from this paper:
- Non-associative (link between stimuli e.g. patterns of disease manifestation which does not require a consistent temporal sequence or positive/negative reinforcement – whole picture interpretation)
- Associative (connection between two stimuli by operant or classical conditioning e.g. tachycardia indicating poorer clinical status in a sick child)
- Perceptual (pattern recognition and association of meaning e.g. normal/abnormal breath sounds)
- Motor (procedural skill)
Explicit learning is an active process whereby you actively seek out new information having created a hypothesis to test. This might include things like deliberately learning facts (stored concepts e.g. drug doses) or recalling experiences (e.g. illness scripts, memory of an event, activity or skills “this makes me think of…”).
You may have heard educators talk about learning styles but they probably don’t exist in the way that popular media would have us think (link added post-publication: thanks @ffolliet!). It’s more likely that the learning preferences we think we have actually represent areas of weakness and strength. There’s also no good evidence for right or left brain learners or gender differences in learning when it comes to neurobiology – no good quality studies demonstrate a consistent effect size. These concepts likely carry an illusory legitimacy because you may have better expression verbally vs visual-spatially – but this does not equate to learning ability (think about people who can write fantastic papers but struggle to give a compelling lecture). Also some subjects lend themselves to some methods and vice versa. Combining forms is probably the way forward.
The importance of crossing domains
Lessons hard learned – they’re the ones that stick. Learning is stronger when it matters. Learning in context helps us to make it real. Owning a toolbox does not make you a master mechanic. You need to know what you have and how to use it to apply it in new situations.
We can make learning stronger when we reframe it to cross Bloom’s domains (find more about Bloom’s taxonomy here). Revisiting concepts and information through multimedia/sensory processes – using different techniques and approaches to learn and understand the same thing – is more powerful and memorable.
Think about learning to ride a bike. Can you remember not being able to?
Close your eyes and think for 10 seconds about how to ride a bike.
Welcome back. Did you move while you were recalling the tasks involved? If you challenge people to describe the steps involved in a task they will often reflexively involve echoes of the movements required, which brings us nicely onto…
Simulation and visualisation
Mental rehearsal is an important biological process in activating neuronal circuitry in an associated pattern, combining sensory, motor, executive and decision-making pathways in the brain. Reflection and simulation supplement this.
There’s evidence that visualising techniques – so without actually undertaking the motor aspects of a procedure for example – is very effective in formalising and strengthening neuronal pathways.
In terms of being a better clinician, it’s essential that you stretch yourself – many life threatening emergencies are rare and we need to both practice and simulate otherwise skills and knowledge will fade, making them unavailable when we need them most.
Learning is strongest when we are actively involved in it – doing is learning. This is where sim comes in! Success builds confidence as well as learning, so positive sim experiences are just as valuable as the reflection opportunities. Here at St Emlyn’s we’ve found that you can learn from participating in sim as a clinician, as a patient, as a peer observer…
One of the greatest tools of engaging in sim is learning how to formulate and share your mental model.
Take Control of Learning
Be passionate about being better
Adult learning is a choice; it requires a state of readiness and willingness, accepting responsibility and creating goals for ourselves. This is my call to you to take control of your learning. Your passion is infectious and you’ll find that you’ll get a greater return from your teachers and mentors if your enthusiasm is apparent.
Be positive – positive attitudes help fix learning in your brain. Reward and reinforcement can be helpful too. Delivering rewards and promoting the joy of learning increases the capacity of the brain to strengthen learning.
If you’re struggling to be passionate about learning tougher topics the Pomodoro technique may be helpful – divide your learning into timed 25min chunks followed by a 5min reward. This can help your sense of achievement (an intrinsic reward) and maintain attention. You might also be someone who responds well to extrinsic rewards, like doing better in tests and winning competitions. That’s ok, as long as you recognise that about yourself 🙂 Some of us at St Emlyn’s are self-confessed badge collectors too.
Recognise opportunities for learning and improvement – and say yes!
As we mentioned in the sim and visualisation section, active engagement and passion utilises neuronal circuitry.
If we commit to recognising opportunities for learning this can help us to develop and change our mindset, feeding our passion. Commit to saying yes when learning opportunities present themselves to you – for example when a senior doctor or colleague offers to teach you how to do something.
Having a positive attitude helps to frame subsequent learning experiences (and you’re likely to find people are more willing to offer future opportunities to you too).
Spaced repetition utilises the psychological spacing effect to aid recall. It’s good for learning facts and works well with flashcards. The intervals between testing are gradually increased to halt degradation of memory. There are software programmes that can help you to memorise in this way, including ones which treat correct and incorrect answers differently, increasing frequency of exposure to the difficult material and reducing exposure to the easier stuff.
In my mind this is one of the key strengths of twitter as a learning tool – social media helps as common topics occur frequently and are often reframed, combining spaced repetition while engaging higher processing by presenting the same material in different ways.
Deeper knowledge and key themes
Teaching increases learning. It highlights our own areas of unconscious incompetence and we benefit from the teacher-learner duality – teaching is intrinsically linked to learning, to self-explanation of the topic you’re going to teach (which helps you detect and repair any defective mental models when you prepare answers to anticipated questions), we can undertake deliberate practice with feedback, and we have to engage both metacognition and self awareness (planning teaching involves reflecting on previous methods and successes, identifying our own learning points, and engaging in adaptation of our original plan).
Teaching stimulates learning due to this interplay of metacognitive awareness, deliberate practice with feedback and self-explanation – so in teaching we become more engaged in our own learning both on the topic we are teaching and in general. Studies support this – medical students and residents who teach demonstrate better knowledge acquisition than self-study or attending lectures.
One of the key techniques in planning a teaching session, particularly on a clinical topic, is anticipating the kind of questions your audience may ask you and preparing answers. This is a great example of transfer of learning; using existing knowledge to solve unfamiliar problems, acting effectively beyond past experience and learning as we discussed in the first blog post.
Reflecting on teaching
You will be a lifelong teacher as well as learner and reflecting on your teaching sessions is key to improving both your teaching skills and your learning skills too.
Teaching also builds your communication skills, between clinicians and with patients – teaching and provision of feedback are effectively components of a medical consultation. As a teacher you can develop these skills and understand the importance of shifting the focus away from yourself to the learner/patient because after all the ED consultation is more than information transmission.
So that’s how I think you and I, as learners, can get better at learning by thinking about teaching. Next up: Enjoy Thyself!
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