September 8th, 2011

Finding the Learning Sweet Spot

Dr. Bergman LewisDr. Bergman Lewis is a senior resident in Pediatrics at Seattle Children’s Hospital. By way of introduction, I am finishing my pediatric residency at Seattle Children’s Hospital, have enjoyed being a resident editor of Journal Watch Pediatrics and Adolescent Medicine for the past 3 years, and will write as an interim blogger for the next month or so. Greg left big shoes to fill but I’ll do my best to pave the way for the next resident blogger.

I am in the agitating phase of studying for a test — I am loosely aware of what looms ahead but have not strategically plunged into studying. The General Pediatrics Boards are about 5 weeks away. Similar to my view of all standardized tests, I’ve dreaded this test since the first time I heard about it. I have been trying — with varying levels of success — to adapt the “right” attitude: Focus more on learning material that I think a “good pediatrician” should know and less on being bitter about how much it costs. (The worst part about failing is that I’d have to pay again next year!) 

On a good day, the prospect of studying for boards serves as an appropriate wrap-up to 4 years of medical school and 3 years of residency. On a bad day, it’s another painful hoop to jump through. But the test must be taken, so I’ve sucked it up and bought a book. I ended up buying First Aid for the Pediatric Boards, which was a steal at $53 compared with Laughing Your Way to Passing  the Pediatric Boards ($97!). Maybe I’m wrong, but I do not anticipate laughing will be an integral part of my studying. 

Given my imminent trip back to the books, I have been reflecting on how learning happens in medical school and residency. Before I entered medical school, I was involved in launching a middle school where I taught sixth grade for 2 years. At the Seattle Girls’ School, we taught an integrated curriculum. For example, the first trimester’s theme was inventions, and core subjects like reading and math were taught under this umbrella theme. We explained to parents that by mirroring how we learn naturally, neural connections are made, and students stay passionate about learning. 

When I entered medical school, I experienced an environment that was quite far from facilitating natural learning. In fact, the first year of medical school took the most natural “integrated curriculum,” — the human body — and artificially broke it down into histology, pathology, anatomy, and biochemistry. Without a strong science background or honed study skills, I struggled and barely eked by in my classes. It was not until clinical clerkships that I started to believe I might be smart enough to be a doctor. As I began caring for patients, the connections I couldn’t make from a PowerPoint presentation began to appear. I often wish I could go back to the first 2 years of medical school now that I have a scaffolding of patient encounters on which to hang my knowledge. 

Learning in residency looks different than it did in medical school. For those like me who learn from hands-on patient interactions, there is endless material, but little time to process it. Although it may feel more comfortable to learn from a prepared noon conference lecture, do you learn more from the patient care call that causes you to leave the lecture? The answer to where this sweet spot of learning and hands-on experience lies is a moving target, and different for all of us. 

The intensity at which our highest quality of learning occurs is another variable. Some of us may absorb information best when presenting a patient on rounds, voicing a plan despite being less experienced than anyone in the audience. For others, being in the hot seat short circuits all neural connections. During residency, I experienced some of my best learning when I was post-call on rounds but had gotten at least 30 minutes of sleep (this has interesting implications for new work hour restrictions that may take people off post-call rounds). 

The fact is, we all learn differently and most of us spend much time worrying about if we are learning enough. If only we’d give ourselves a collective break. We are all naturally curious people who want to be the best doctors we can be. We cannot help but learn. We should have a bit more faith in the process and trust that when we’re spit out the other end of residency, we will have acquired enough knowledge to be good doctors. 

Of course, our formal training represents the tip of the iceberg of what we will eventually learn. It does seem like developing good learning habits from the get-go is important. For this reason, in residency we should be paying as much attention to how we learn as what we learn. For what it’s worth, here’s some advice for learning that I wish I’d been given: 

  • Set up habits that encourage, and don’t squash, your natural curiosity: Look up answers to your questions, not just subjects you are instructed to read about.
  • Break learning down into small nuggets. Small nuggets of learning add up and the more you crack open the book or open the online journal, the more habitual and less cumbersome this process will feel.
  • Pay attention to what learning medium works for you. Do you prefer print or online material? Are lectures more helpful? When possible, study material in the right medium for you.
  • Select one patient per rotation and write down what they taught you.
  • Start some sort of filing system for helpful articles or handouts — even if it’s just Google Docs or a box.
  • Register for free e-mail alerts from Journal Watch. Read the rest of the relevant Journal Watch publications when you can — the format is perfect for residents and provides brief summaries of relevant studies and take-home messages provided by well-respected clinicians.
  • Convert the time you use asking yourself if you are learning to try some of the above suggestions. And by the way, the answer is yes, you are learning a lot…enough.

As residents, one thing we do is try hard. So, we will try hard to keep learning and trust that we are learning while caring for patients. Speaking of trying, I need to face the music and set up a study schedule for Boards so I can get it over with. I will try and stay focused with the right attitude and view studying as a last episode of a sitcom when I will revisit the patients I have encountered in training. Now, if I can just figure out the right soundtrack. . .

11 Responses to “Finding the Learning Sweet Spot”

  1. David Lewis says:

    Sarah, a very helpful essay which I will certainly show my students (1st clinical year – Y3).

    I have always found it challenging to keep up to date and as time goes by am less certain what ‘up to date’ means.

    It is certainly worthwhile finding a way to save nuggets of information in whatever form they come to you. I have found Evernote is my method of choice now after trying several others. Finding an easy way to retrieve the information is also needed.

    However, our patients provide all the learning we really need (at least, those of us who see patients all the time).

    David Lewis
    UK GP

    • Sarah Bergman Lewis says:

      David-
      Thanks for the comment. I have not tried Evernote but will have to check it out.
      I agree that patients are our guide.
      Best,
      Sarah

  2. Ann Weissman says:

    I am a now retired general internist. I could not help but respond to your outstanding article. How often during my years of practice did I wish I could return to the classroom portion of medical school, now that I had patients to connect the facts to. Each of us learns differently, but I still remember individual patients I saw thirty years ago and what I learned from them. The art of medicine, I think, is the ability to connect the general and the particular.

    • Sarah Bergman Lewis says:

      I have not heard that before– “the ability to connect the general and the particular”– very relevant as I head out to the daunting, but bright, world of primary care. Thank you!

  3. Wayne Wheeler says:

    After 30 years in Emergency Medicine and a senior attending at a small residency program, I tell residents that 50% of what I believe to be true is wrong — either from senility or change in what we believe to be true. It is their assignment to learn which is which and tell me. I learn more from them than they do from me. I encouraged Carol Rivers MD (now unfortunately deceased) to use positive imaging and trust the experience. We will find out this next year if that works.

    • Sarah Bergman Lewis says:

      Sounds like you have a quality learning environment going with your residents– lucky for them. What do you mean by using positive imaging? I’m intrigued.

  4. Robyn Butler-Hall says:

    As a therapist and former school psychologist, with doctors in generations above and below me, I am delighted to see this article. Someone trained in education who is thinking about HOW–not just WHAT– she is learning? Metacognition! The degrees we achieve are in part, the permission slip to go out and do what we are called to do…and THERE, we REALLY start to learn! As a pediatrician, especially, this orientation will be invaluable as you work with your patients and their families. Congrats on joining the medical field. You’re going to be great addition!

  5. Sarah Bergman Lewis says:

    Thanks– I tell people that going from a middle school for five years to pediatrics is actually not a leep but instead coming full circle. There is so much teaching and learning in medicine- and now I basically have parent-teacher conferences all day.
    Thanks for your kind words!

  6. Louiselle LeBlanc says:

    Sarah, thank you for your post. I have recently gone through much of the same thoughts as you. I did my Canadian boards 6 years ago, and have been practising since as a clinician and teacher, and I just recently did the ABIM this year. What struck me the most during my review is how things I remember struggling with before were now just falling in place and all of a sudden seemed so obvious (even in areas of internal medicine that I don’t practise) – I was dumbfounded by how many links there were that my brain had just never made before. It made me realize that our brain simply can’t process everything and make all links at once, no matter how hard we try and study as a student. I guess I am referring to your nuggets, but more specifically, even within a topic.

    My point is that levels of learning will naturally change with time and experience, and that’s good to keep that in mind when we get frustrated for not remembering something we just read last month – maybe the second or third time our brain will be able to process it better and it will finally sink in. Also a good lesson for those of us who teach and sometimes find ourselves frustrated because of having to repeat the same thing over and over again.

  7. Ben Hagopian says:

    Good insights! Just started as an intern and trying to discern how best to fit in personal learning with learning in the hospital… very helpful tips, thanks!

  8. Mark Learned says:

    Sarah, I am a third year resident in internal medicine at the University of Colorado. I was also your tenant in Seattle for a year. 🙂 Great article. I am headed for a year as chief resident and then I too will join the ranks with a primary care job. I hope to use your observations and pass them on – I love the parent-teacher conference image, I have child-teacher conferences about their parents. Congrats on getting through and on your beautiful daughter. Tell Steve hi from us (Cheryl and Jason say hi and are doing great too)!!

Resident Bloggers

2018-2019 Chief Resident Panel

Justin Davis, MBBS
Cassandra Fritz, MD
Scott Hippe, MD
Ashley McMullen, MD
Ellen Poulose-Redger, MD

Resident chiefs in hospital, internal, and family medicine

Learn more about Insights on Residency Training.