SHOOT YOUR NOTES IN MEDICINE

Why you fail and how to shine again

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MODULE 1 . MENTALITY CHANGE
Lesson 1. Why do you study the way you study? When did your way of studying appear?
Lesson 2. Worksheet: analysis of your way of studying in Medicine
Lesson 3. What is an exam for you?
Lesson 4. How to introduce new study methods

1. Why do you study the way you study?

Stop for a moment and write in the box below what reason came to mind in response
to this question.

If you can't think of anything, I'll give you as an example what I told myself the first
semester of Medicine:

“That's how everyone studies”

Your answer:

Although your way of studying seems identical to that of other people, because you all
do the same thing (read several times, underline, make an outline when the topic is complex,
etc.), in reality there are differences in the way you process information through of these
methods, and these differences explain why the results in the exams are very variable.

When did your way of studying appear?

I started taking written exams when I was 8 years old and was in the 2nd year of Basic
General Education (EGB).

The previous year I had memorized the multiplication table, and my teacher would line
us up next to her table and make us recite the table in question, one after the other. Listening
to the child in front, I managed to memorize in extremis some number that I didn't remember
from the most difficult tables (those with high numbers).

When did you start taking written exams?

How were you studying at home the day before? (reciting out loud, silently reading the text
over and over again, etc.)

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Your way of learning to study and review for small exams or “controls” at school explains
many things about your current way of studying as an adult .
Before I was 10 years old I was a disaster. I remember a specific day with the Calculus
book, I was reading the definition of “inclined plane” and I was extremely bored. He must have
been about 8 years old. I started playing and the book stayed open on the bed until night.
When I saw it again, I got really scared and ran to close it.
I also remember when I was 8 years old an exam full of divisions; I had to mark which
ones were “exact” and which ones were “whole.” I remember looking at the classroom window
and then back at the exam sheet and having no idea what they were asking me for. And answer
at random, purely at random. You know, a 50% chance of getting each question right. It wasn't
bad for me...
At 9 years old, my handwriting was a mess and my homework arrived incomplete to
the teacher, who sent a notice to my mother and asked her to supervise me more in the
afternoons. So my mother started chasing me to finish all the homework before I could go
outside. I heard the happy voices of children playing and I had to do grammar exercises or read
about the parts of a flower, things that did not interest me at all. What I liked was playing and
reading adventure books.
At the age of 10, in the 5th year of EGB, everything changed: I made some very
studious friends who competed with each other to see who could get the best grade. I liked the
challenge and I became interested in studying. It was like the perfect action movie. A “bad
guy”, the teacher. A terrifying challenge, the weekly exam. Perfect competitors, my friends.
Methods of deception? Pretend that you had studied little. Strategies for success: increasingly
better schemes. The ending of the film: grade delivery day. It could end well if you scored a few
tenths more than the rest; or bad, if you got less. Pure adrenaline!
The first diagrams I learned to make were synoptic tables, also called “keys”, like this
example:

Anther
Stamen
Filament
Stigma Style
Pistil
Ovary
Parts of the Ovum
flower

Petal
Sepal

When your grades improve, your parents congratulate you. With the desire to please
them, you study more and more and start with more time. Therefore, I took a liking to
studying, my pens, notebooks, the smell of a new book, I began to be really interested in
Science, Language, Physics, Chemistry... even sharing with others and helping them study.

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 I became a brilliant student and got very good grades that allowed me to enter
Medicine, my dream since I was 15 years old.

Then came the medical exams.

What do you feel right now when you think about yourself as a student?

When you arrive at the race and face the first exams, everything is new. You have had
several teachers in each subject. The medical vocabulary is new and it is estimated that in the
first two years of Medicine the student must learn 10,000 new terms.

The amount of material you must study for each exam increases greatly compared to
Secondary School. If exams normally cause us nervousness and fear, in the first medical exams
the anxiety multiplies.

If you get a bad grade, negative thoughts about yourself may arise. When these
thoughts cause excessive anxiety, it may be too late. YOU ALREADY BELIEVE THEM. You think
you are clumsy, or lazy, or unstudy, or worse: “I'm the worst,” “I'm not good for this,” “I'm a
fraud.”

What phrases do you say to yourself when you do poorly on an exam?

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Worksheet: analysis of your way of studying in Medicine

CLASSES
Do you attend classes?
Yeah
oo No

PERSONAL STUDY
What material do you use?
or My notes
o Class slides
o Commissions/notes from other colleagues
or Books

How do you work with the study material?

o Underlined only
o Schemes of everything
o Summaries of everything
o Complete slides/notes

REVIEW FOR EXAMS

How far in advance do you start?
either Since the beginning of the semester
either several weeks before
either several days before

Main review technique

either Reread original text
either Reread outlines/summaries
either
Do you use flashcards?
or if
or No/what is that?

Do you use mnemonics by system?

or if
or not

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3. What is an exam for you?

Write down below what emotions and sensations appear when you think about exams
in general or about the closest exam you have on the horizon. Give it a value between 1 and 10.

Fear 1 2 3 4 5 6 7 8 9 10
Anxiety 1 2 3 4 5 6 7 8 9 10

Rage/anger 1 2 3 4 5 6 7 8 9 10

Delusion 1 2 3 4 5 6 7 8 9 10

Interest 1 2 3 4 5 6 7 8 9 10
Fun 1 2 3 4 5 6 7 8 9 10

Exams as a training control tool

The first written records of medical education date back to the time of Hippocrates.
Back then, you learned by observing a teacher and there was no teaching structure or
predetermined curriculum.

Imagine that you learn to practice medicine in this way, accompanying a doctor in his
daily work and gradually receiving more important assignments until you could become
independent. It is easy to imagine that it was a reliable and accessible method for that time, given
the existing medical technology, but we would train very few doctors each year with this system.

The ancient Chinese are to blame!

As the story goes, the Chinese invented exams in the 7th century BC Students were
locked in small cells with a mattress and a urinal, and spent several days answering a written
exam. They were very competitive, since there is evidence of some exams with 450,000
applicants for only 600 diplomas. They say that some candidates died and then they wrapped
them in mats and threw them to the other side of the walls of the exam complex (
http://www.semana.com/educacion/articulo/historia-de-los-exanoes-por-que
-se-done/482393 ).

What have regulated exams allowed for centuries, and also at the present time? Train
thousands of doctors every year with the minimum knowledge required for those who will have
the responsibility and privilege of caring for the sick and seeking the recovery of their health.

That is, it is a cheap and massive tool that allows controlling the knowledge acquired by
dozens, hundreds or even thousands of students in a few days and with limited resources.
Therefore, they will continue to exist for a long time, especially in their “test type” or multiple
response selection version, with a response template that can be automatically corrected by
computer systems.

Despite being a cheap and “scalable” tool (that is, applicable to 10 students, 100 or
10,000 with the same effort), it does not mean that it is perfect, or even the most appropriate for
measuring certain medical knowledge. But this discussion goes beyond what this course attempts
to cover.

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 Written exams will always be with us, and I only hope that you understand how they
work and how they influence our mood , so that you develop your maximum capacity when
facing them.

Let's remember again what you noted in the following question:

What phrases do you say to yourself when you do poorly on an exam?

This is how they influence your mood.

Conditioning from Primary

When we are children, an exam is almost the only external stimulus that pushes us to
study about issues that matter little or nothing to us. Divisions with decimals, geometric figures,
celestial bodies or the Roman Empire, none of this is too attractive next to television, Netflix,
tablet games, dolls, bicycles, skates or swimming pools in summer.

Therefore, the exam is that threat that your teachers invoke, and that your parents
second, when you are at 10 years old in your room, sitting at the table with the book open and
without studying, distracted by colored pencils or a fly. flying.

There have been many years of hearing “You're going to fail the exam! Study now!”,
along with the angry face of your parents. You soon associate the exam with faces of discomfort,
worry, and threats of punishment.

Some time later, when you are already a good student, exams continue to make you
afraid and afraid of failing, even though you have already become an expert in preparing for and
passing them. You have your study methods, refined during years of school and institute, and you
blindly trust them. In fact, they lead you to get into the Faculty of Medicine.

That is, for you at this moment, exams are something very negatively conditioned in your
brain, and from a very young age. That is why the first reaction to them is often primary and
visceral, with discomfort, cold sweats, chills, etc. Next comes rationalization, which can be as
varied as the student's different personalities and life circumstances.

From the following, select which phrases you have come to think of in relation to the exams
⃝ “I will never be able to pass”
⃝ “I will never be able to get a good grade”
⃝ “With such bad teachers, it is impossible for me to do well”
⃝ “With colleagues who are so nerdy and so selfish, who do not share, it is impossible
get the grade I deserve”
⃝ “I should think in change my career, I can't do medicine”
⃝ “I'm not worth itdoctor"
⃝ ………………..

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⃝ ………………..

The chosen phrases and the new ones you have captured in the table above represent
your way of rationalizing your exam experiences.

That rationalization is simply your interpretation of the facts . As an interpretation , it is

imperfect, and the bad thing comes when you take that interpretation of the facts as absolute
truth.

Do you want me to tell you what interpretation I give, as a professor of Medicine, to your
results in an exam?

Your exam score represents how many questions you were able to answer about a given
subject on a given day in a given context. Full stop .

That is, your grade is not your person. Your grade is not an indicator of your discipline. It
is not an indicator of your definitive interest in my subject. It's not my opinion of you as a
student. It is not the Professor's opinion about you as a person. It is not an indicator of what your
future career will be like. It also doesn't indicate how good a doctor you will be.

Equating low grades to your entire person or your entire future is a cognitive error .

Imagine that great tennis players like Rafael Nadal, Novac Djokovic or Roger Federer
collapsed when they lost a match or a grand slam title eluded them. That they would say to
themselves “I'm useless” “I'm not going anywhere like this” “I'm going to quit tennis, I'm not
good for this”.

What do these great athletes say when they leave the court after losing? “My opponent
has maintained a high level throughout the match” “I have not been able to break his serve
today” “The injury has prevented me from being quick in the decisive points” “We have to slowly
analyze how the match has gone” “My injury It is no excuse, my rival has read the ball exchanges
very well”, etc etc etc…

That is, they are clear that “that” match has gone badly for “certain” reasons and they
express the need to “analyze” the causes and correct the errors for the next tournament.
However, a defeat does not change the fact that they are tennis players, they love their sport and
will continue to practice it until the end.

The same applies to you as a medical student. You can analyze where your preparation
and execution errors are, and a failure does not kill your passion for Medicine nor will it prevent
you from becoming a doctor, if that is your dream.

Most common negative beliefs of medical students

These beliefs are what I have found in my case and in my experience with students. In my
opinion, they appear as a consequence of the fear we develop of exams, comparison with peers
and the social pressure that exists in this area.

1- “To achieve something worthwhile you have to suffer.” – False. It is a mythical legend
spread by Hollywood movies, and especially by those marine movies in which the

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 protagonist has to shave his hair or suffer immense lacerations, or allow himself to be
beaten over and over again by the bad sergeant on duty, until in the end of the 100
minutes of film to emerge victorious…

It is also a legend spread by the protagonists of Grey's Anatomy, crying all day on the
corners because the boss won't let them help in heart surgery... There is no need to
suffer. “Suffering” implies negative and false emotions and thoughts most of the time.
We have to work hard". Some have a special facility for achieving their goals, I agree. But
most of the winners have had to work hard, and that's what you have to do in Medicine.
“Trying hard” means sitting down to study when you don't feel like it; spend more time
studying when the exam approaches; delay the time to watch your favorite series
because you have to present a job. Making an effort is investing time and dedication for
the sake of a superior benefit that will allow you to continue advancing on the path to
becoming a doctor.

“Suffering” brings up negative emotions and thoughts and has these unfavorable
consequences:
• May it be difficult for you to sit down to study with enough advance notice.
Sitting down to study is associated with those negative ideas, and naturally you
want to avoid it. Therefore, do not sit down to study until the exam date is so
close that the fear of failure outweighs the fear of sitting down to study.

• The closer the exam gets, the more anxiety you feel and the more time you have
to spend calming down (snacking between meals, getting up to chat with your
roommate or brother), and the less time you have to review
• You are afraid to try new techniques even if experts or other students speak
highly of them
2- “If I get fewer grades than my classmates it is because I am less intelligent than them”

Getting fewer grades than your friends is painful because we all need to feel the
best, at least from time to time. It is a survival mechanism and we experience it since we
were children. Remember when you play with a 4 or 5 year old child and how tantrums
he gets when you don't let him win at anything: Parcheesi, soccer, a race...
Speaking with a Professor of the Psychology Degree at the UAM a few years ago,
he made it very clear to me: with the grades required to enter Medicine, no one who
manages to enter is lacking intelligence. At most it lacks adequate methods and
motivation.
A specific grade means what proportion of questions you managed to get right
on a given day in a given subject. Nothing else.
Getting a lower grade than your friends on an exam means that, on that exam,
you got fewer questions right and/or missed more questions than them that day. Which
in turn means that, in preparing for that exam, you used less efficient time and/or
methods than them.

3- “If I get bad grades it means I will be a bad doctor.” - It is also a mistaken belief.

A good doctor is that person who, after working with a patient, manages to
correctly diagnose and treat said patient; manages to communicate well so that the
patient feels well cared for and comforted; and who knows how to ask other colleagues
for help when he detects that he is not being able to help the patient on his own.

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 I assure you that none of my most grateful patients have asked me about the
number of A's I got in college.
Tests, as we have said before, are imperfect and incomplete quality control tools.

What really are exams? Exams as a training tool

Exams are a great learning tool. Thats the reality. Well-written exams, without twisted
questions, allow us to realize whether we have correctly understood a concept. On other
occasions, they reveal to us that we have misunderstood some detail. In many multiple choice
exams throughout my degree, I was able to clarify small doubts that I had from studying my
notes.

*Unfortunately, almost no department allowed us to take the exam home to finish

correcting it and learn from its content. I think that, in this sense, little has changed since I
studied the degree.

Have you ever felt like you left the exam knowing a little more than before you went in, but not
enough to pass?

This happens precisely because exams are a typical trial and error activity that has the
effect of allowing us to learn.

How did you learn to ride a bicycle? Did you memorize the parts of the bike, how it was
assembled and how it was driven...

…or rather did you try to imitate the older children by getting on your bike as soon as
possible and trying to pedal?

First you get on and keep one foot on the ground. You feel the saddle, you notice if it is
high or low. When it is at your height, you put your feet on the pedals and try to pedal.

First you do it too slowly because you're afraid of falling, and it turns out that the bike doesn't
gain momentum, and you fall to the side. You try again and hit it harder, and then your foot gets
caught in the chain, the bike stops and you fall.

In short, trials and failures; trials and failures; and you repeat this loop until you get used
to the weight of the bicycle, the position of the saddle, the hardness of the pedals, the sensations
in your arms and legs, and you finally roll away.

Preparing for a College exam should be similar to this, but we don't prepare the same
way, right? The exam consists of a series of questions that must be answered by choosing the
best option (test type), or by writing an answer by hand, sometimes a word or a phrase (short
questions), and sometimes an essay (long or development questions). .

The most active and specific way to prepare for an exam is to do at your study table the
same thing that they will ask of you at the Faculty desk. Answer questions, reflect on difficult
questions and try to find the best answer.

When you try to answer exam questions is when you realize if you really know that topic
or not. You realize that you THOUGHT you had memorized that treatment algorithm, but you
failed to memorize part of it and you can't answer a question. Or you had misunderstood a
concept, and reading a question about that concept you realize this and can correct the error.

If you have exams from previous years from your Faculty , you have a true treasure that
you should use from the beginning to guide your study. You can also take advantage of the

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collections of questions created by students when leaving the exam, and you should make your
own too. Later (module 3) I will show you how.

When do you review exams from previous years?

⃝ One or two days before the exam, when I have already studied everything
⃝ When I start preparing for the exam
⃝ As soon as I get them!

I would be surprised if you answered the last option, but if so, congratulations. In module
3 I will explain how to use exams from other years to create your review flashcards.

Why do we tend to look late at other years' exams? Because we are negatively
conditioned. We associate reading exam questions with unpleasant visceral sensations and
negative thoughts. Therefore, we are afraid, and we put it off until it is inevitable.

If we compare him with a tennis player, it is as if Rafael Nadal, before a tournament on

grass (Wimbledon, for example), continued training on clay (his favorite surface and the most
common in his country), practicing strokes with his coach and without Watch videos of your
competitors, to avoid feeling afraid. Two days before the start of the tournament he travels to
Wimbledon and the day before the first match he plays for a while on a grass court. The ball
makes strange movements, different from what it does on land, but it is too late. The next day he
plays against a total stranger whom he only knows by name.

It sounds absurd, right?

Conclusions about the exams

• They are an excellent tool to practice and train for the final real test, the written exam.

• We never have enough exams to cover all the subject matter we have to take the exams
for. That is why we need to “make” our own training questions, the flashcards.

• The current medical training system forces us to train in the special skill of passing
written exams in order to reach the final goal. This skill can be improved through
techniques aimed at that specific type of test.

• High grades make it easier to obtain scholarships, rotations in certain hospitals or

Services, and produce a lot of personal satisfaction. However, low grades do not
necessarily represent a bad professional future, nor do they mean that you cannot learn
more about that subject in the future.

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 • How to compensate for low grades with parallel medical and/or academic activities:
through volunteering in health associations, NGOs, vacation work, collaborating in
Faculty research groups (it does not have to be the most cutting-edge group, since you
can learn from any junior researcher), collaborating in scientific publications, etc.

• In the future, your patients will appreciate you if you know how to listen to them,
communicate your medical impressions, and give them the feeling that you care about
their case. Your colleagues will appreciate you as a colleague if you are hardworking, if
they can count on your help (in the ward, office or emergency room) and if you are open
to learning from them. All of these interpersonal skills are ultimately what determine
whether you get hired at a medical center or whether more patients visit you in your
private practice.
4. How to introduce new study methods

Respect your usual methods

They have brought you to where you are now, which is no small thing. They have allowed
you to pass Primary and Secondary education, and reach the university level. This indicates that
they have great power.

To gain efficiency in running, you don't have to reinvent the wheel. You just have to
improve the efficiency of the methods you already use, and acquire new methods that are proven
effective.

If you have been studying in a specific way all your life, you cannot suddenly give it all up
on the first day. If you do, in a few days you will start to feel overwhelmed and insecure and you
will end up leaving everything new behind and going back to the same old thing.

Since childhood you have been studying and passing exams. At the same time, your
parents praise your good grades, give you shelter and food and money for leisure and vacations.

Somehow, your brain identifies “survival” with “study.” Your way of studying is your way
of surviving. You can't change it all at once. Surely you've tried it before, and what happens? The
alarms go off and after a few days you return to your usual study habits. They may be
unproductive and you want to learn something new, but they are YOUR study methods and they
have brought you where you are now.

Introduce new methods with strategy

In a podcast by Sergio Fernández that I listened to a while ago, they talked about how to
replace old habits with new ones. To be successful, those new habits should take up no more
than 20-25% of your total time.

This makes perfect sense and is practiced in many professional environments when it
comes to innovating procedures or processes. For example, if a car manufacturing plant needs to
introduce new software that will speed up manufacturing times for a particular part, it will not
install it on all of its computer equipment at once. You will choose a few computers on which to
run the new program, detect any problems that arise, correct them and in this way transfer the
new software to the rest of the computers. This way they make sure they don't accidentally

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interrupt daily production, which won't be optimal, but it works.

Translated to studies, this means that if you have 3 or 4 hour blocks of time each day to
study, you should not dedicate more than 45 minutes or 1 hour to new study techniques. If you
spend more time, alarms will soon go off and you will feel insecure.

YOU HAVE REACHED THE END OF MODULE 1

CONGRATULATIONS!

YOU HAVE UNDERSTANDED THAT YOU CAN IMPROVE YOUR STUDY PROCESSES
THROUGH A RELIEF ANALYSIS OF WHAT THEY ARE AND WHAT RESULTS YOU OBTAIN WITH THEM.

In this you have learned to imitate the great elite athletes and their way of analyzing their
performance after a demanding competition.

You have also realized that you can continue improving as a person and student for the
rest of your life.

In MODULE 2 you will learn the basics of planning and organizing the study, and we will
analyze the most popular study techniques and how we can improve them

YOU ARE THE GREATEST EXPERT ON YOUR OWN MIND AND YOUR WAY OF STUDY, SO IT
IS ESSENTIAL THAT YOU NOTE BELOW YOUR FIRST DIAGNOSIS OF THE CURRENT SITUATION

WHAT HAVE YOU DISCOVERED THAT YOU CAN IMPROVE FROM TODAY AFTER HAVING READ THIS
MODULE?

⃝ Feel brave when facing an exam?

⃝ understand your current way of studying?

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MODULE 2 ORGANIZATION AND PLANNING

Lesson 1. Phases of study at the Faculty of Medicine

Lesson 2. Your star techniques and their weak points

Lesson 3. Energy management

Lesson 4. Optimize time

Lesson 1. Phases of study at the Faculty of Medicine

It is important that you realize the difference that exists between studying what you
want, and studying to pass exams. In the future, when you are a doctor, your way of studying
will be different.

Studying to work When we are practicing doctors, it is necessary to study often to stay up to
date in our profession. The purpose of our study hours is to understand new concepts, theories
or action protocols in our patients (both diagnostic and therapeutic protocols, whether medical
or new surgical approaches).

Luckily, we study about topics that we are passionate about (because we dedicate
ourselves to them), and we can choose the time of day, shift, or subway trip to read an article
or a review in our field of hyperspecialization.

We focus on understanding to know how to apply new developments in our daily work.
But we don't need to memorize every last word of a clinical practice guideline, just understand
how it is organized. Because? Because during the consultation or the floor visit it is enough for
me to know where to consult the guides when I need them. This way I make sure I am applying
them correctly in each case; The patient does not perceive anything strange, but feels equally
well treated.

Studying to pass exams However, you have the obligation to demonstrate that you have
understood a significant part of the subject, and that you know how to apply it (at least, in a
written context). You have to prove it on the date decided by each Department or Professor.
And they force you to study for days and days on that subject, whether you feel like it or not,
whether you like it or not, whether you are more or less tired, with the flu or bored.

These time and space obligations make studying for exams much more effort than
studying to learn more once you are a doctor. It is more than justified that you often feel
unmotivated, bored and even fed up with studying Medicine.

I already explained to you in module 1 that exams are the cheapest and most scalable
procedure that we can apply to future professionals currently in training. Incomplete,
imperfect, and forever. Luckily, you won't have to deal with them forever. For many years you
will enjoy studying at your pace, to your liking and about your main interests. Once you finish
your degree and pass the admission tests for specialized training (MIR, ENARM, UMSLE, etc.),
your study will take on a very different nuance.

But at the moment you have exams to pass. So you must organize your daily work to
be able to arrive at each exam in the best conditions to be able to answer from memory a
good handful of questions about the corresponding subject on a given day.

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 Do you know the good thing about all this? If you do it well, you will remember a lot of
Medicine for your practices and for the future.

Phases of study aimed at passing exams

These phases are what we go through throughout a semester or academic quarter. At

the beginning of these time units you find yourself in a learning state

Keep in mind that you are a novice or novice in each subject, that is, you are facing
each subject practically for the first time in your life. This contrasts with the knowledge of the
teachers, who are experts in the subject. As such, they can be victims of “expert bias,” which
consists of losing the perspective of the novice, and therefore making leaps of reasoning when
presenting the subject, leaps of reasoning that the novice is not able to follow. You therefore
need to review the material on your own to cover those logical leaps.

Phase 1. Initial contact

In this phase you come into contact for the first time in your life with the new subjects
and the topics that make up each subject. It is much harder the first two years, since thousands
of new terms are learned from Anatomy, Histology, Physiology, Biochemistry, Microbiology,
etc.

In the clinical years (in Spain from 3rd and 4th Grade), we study diseases of the
different organs and systems of the human body, applying for the most part the words that we
have already learned in the first courses.

This means that for 1st and 2nd year students, initial contact involves greater cognitive
effort. In an ideal world, each and every university professor who teaches basic subjects should
be able to facilitate that initial contact, making the subject more understandable. In the real
world, some teachers may have great research talent, and less talent for explaining these dry
subjects in class.

In clinical courses, the difficulty of the subjects lies in understanding all the different
ways in which an organ or system can become ill. This illness is influenced by the circumstances
of the patient and the causal agent of the disease. From there arise the different symptoms, the
great similarity between different diseases, how to differentiate them and what tests and
treatments are indicated. These are the years in which we begin the skill of diagnosing, which is
very costly at first.

How is the initial contact made?

• Option A: in master classes

• Option B: through individual study
In some faculties class attendance is mandatory. In many others it is optional. It can be
difficult to decide what is best for you in your particular case.

In general terms, I recommend attending class in these circumstances :

• If you are in initial courses, because the new vocabulary is very broad and it may be
easier for you to know the subject if it is explained to you in more or less colloquial
language in a master class
• If you are clear that you learn more easily when you hear an oral presentation on a
topic before studying it on your own

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It may be more advantageous for you to miss class if these conditions are met :
• You assimilate a topic or a series of concepts better when you read about them in a
book or a notes committee
• Your most productive hours of individual study coincide with the hours in which your
classes are scheduled
Careful! Some students stop attending class, not because they are clear that it does not
help them, but because they lose the habit of getting up early, or of sitting and concentrating
for 1 hour straight. If throughout the same day, or that week, they do not study those classes
on their own, they will soon fall behind. If you delay the initial contact with the subject, you will
have to take it close to the exam, which will make it difficult to memorize everything you need
to pass.

The initial contact phase is essential to begin to understand the subject. If you discover
that you are falling behind in your initial contact due to laziness or fear of a subject that is
difficult for you, remedy it as soon as possible (by recovering the habit of getting up early and
going to class, or establishing the habit of always reading on your own the topics taught that
day).

Phase 2. Comprehension

It is what occurs while we work individually on the subject. It involves reading the
reference text (generally notes) several times (as necessary).

In this phase, the favorite study techniques of any student on this planet are almost
universally used: underlining, rereading and outlining (1). With these techniques we understand
differences and similarities between metabolic processes, or between biological cycles (p. e.g.
mitosis and meiosis), diseases of varied pathophysiology, etc.

In easy topics, understanding can occur from the first reading, or in the master class.
Then all you have to do is prepare the reference material that you will consult to prepare for
the exam: bound commissions, numbered sheets, completed slides, etc.

In difficult topics, you will need to work more time on the concepts and their
interrelationships. For example, cardiac arrhythmias, cardiovascular drugs or audiological tests
are examples of complex topics that require more hours of rereading and reflection until they
are well understood.

When you have comprehensively understood a series of interrelated concepts, you will
probably remember a part of them forever. Q. e.g. When you understand how cardiac preload
and afterload relate to each other, for a long time you will be able to reproduce its physiology
and how the heart muscle becomes sick. In this phase of understanding, therefore,
memorization can already occur. In fact, it occurs almost involuntarily.

From the moment of understanding, the only way to keep all the concepts fresh in your
memory will be to review them with the appropriate frequency for the exam. Once you have
passed the exam, you will have to review them periodically to keep them active. If you're lucky,
you'll be able to retain important concepts if you do regular, good-quality clinical practice.

Phase 3. Memorization

This phase is usually concentrated in the weeks/days leading up to the exam. It

involves rereading each topic several times to ensure that we remember most of the concepts.

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The way to check it usually consists of mentally reciting the concept, with its variants of reciting
it out loud (until your vocal cords are exhausted) or reproducing it in writing, through scribbled
words or drawings and diagrams.

When you lack time to review, we usually resort to "mental recitation." We reread
each paragraph and look away to reflect and check if we could reproduce it from memory. This
process is repeated in a loop throughout the hours of study, and has a weak point, the "illusion
of competence."

The illusion of competence consists of believing that you correctly remember a series
of concepts, simply because they seem familiar to you when you reread them. But if you do not
check that you are able to reproduce it without help, you may find that you do not remember it
completely, and often too late, in the exam itself.

What does it depend on to get a good grade on an exam, that set of questions about
a specific subject? Experts talk about two factors:

1. The solidity of the memory , which in turn depends on having reviewed that concept
the necessary times
2. Retrieval speed , which is the time it takes to bring a concept to your consciousness
when asked about it

Has it not happened to you many times that, during an exam, you have been asked
about a concept and you have felt that you knew it, that you had read about it and made the
effort to understand its implications, but you were not able to remember it immediately
because you had you reviewed it too long ago?

If you are lucky, as you continue answering the exam questions, at some point the light
bulb will go on in your mind, you will remember the answer and mark the correct option.

If you're unlucky, you'll remember the answer... hours after leaving the exam, at home,
or about to fall asleep.

Well, there is a way to expressly train both factors , both the strength of your memory
and the speed with which you recover the data in your consciousness. This technique also
allows you to reliably control that you really remember that concept, and not fall into the
illusion of competence. It's called "spaced active review" and we'll talk about it in Module 3
(and final) of this course.

Lesson 2. Your star techniques and their weak points

It is not that these techniques "fail." To be more precise, it would have to be said that
they are insufficient in Medicine, and in general, in many careers that have a large theoretical
or technical load.

I want to explain to you why they have worked for you all your student life, since your
first Primary exams, and why they are not enough in Medicine. These are three:

1-Reread

2-Underlined

3-Make summaries and/or diagrams

Star technique 1. Massive rereading

Rereading is one of the most popular techniques on the entire planet and in all medical
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schools. According to experts (1), it is popular because it requires little effort and offers an
immediate sense of familiarity with the text.

I have observed in my nephews that it is the only technique we know how to use
when we start taking exams at age 8 . Put yourself in a situation, you are in your room the
afternoon before the exam…

1. You read the topic

2. You try to repeat it out loud in front of the adult who is helping you study

3. If you get stuck, they let you read the sentence again

4. You continue reciting the text. You stumble to the end and then start again

And so on until you are able to recite it without looking.

In later years we read faster and faster. Little by little we learn to underline, and from
the age of 10 we are taught to make summaries and diagrams (generally synoptic tables and
tables).

In Medicine we started by using this same system, but we applied it to amounts of

material 20 times greater than the Primary topics, 5-10 times greater than what we had to
study for a Baccalaureate exam. Then it happens that it becomes insufficient, because it takes
us a long time to complete a first round. And when the 2nd round comes, so much time has
passed that we have forgotten much of it. According to science, if we do not review the
concepts within a certain period of time, after a week we will remember only about 15% (see
the physiology of memory and forgetting, lesson 1 of module 3).

Normally we do an intensive rereading , that is, initially we have read the subject day
by day or week by week, depending on how we received the classes. But, finally we
concentrated several rereadings in a few days before the exam. It is when we lock ourselves at
home or in the library to study the same subject all day. This massive and intensive study helps
us because we gain a lot of familiarity with the subject in just a few days.

Therefore, the risks of rereading are the following :

1. Between the first and second in-depth reading of a topic, an excessive amount of time
passes, which encourages forgetting the concepts learned in the first round.

2. Illusion of competence.- When you read the text for the second time, it begins to feel
familiar. This table is placed at the top right of this sheet; That diagram is at the bottom
of the next page. The danger of it being familiar is that you may come to believe that
you already know it , and that is not always the case.

3. Dedicate equal time to what you know and what you don't.- When you reread, you
review everything equally. Apparently it is worth it because it is fast and requires little
effort. But inevitably you will end up reading everything equally, what you have already
memorized (and therefore does not need review), and what is not yet memorized
(which needs more review).

This wouldn't be a problem if you had 30 sheets of notes for the exam (like in
Secondary School). But it is a problem if the amount is 10 times higher, because then those
extra minutes that you dedicate to what you ALREADY know begin to accumulate.

Even if it is little effort on each topic, after hours and days it accumulates and tires you.

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Star technique 2. Underlined

At first it is our teachers who help us highlight the book in Primary. Some main phrases,
like “At the center of the solar system is the sun , which is a star .” The solar system is made up
of 8 planets .”

We use graphite pencil when we are very small, but as we get older, an explosion of
colors and textures occurs. Colored pencils, fluorescent markers, gold and silver ink pens, an
orgy of stationery that delights us.

Do you remember the exercise analyzing your way of studying from module 1? How many
colors do you use and what brands with each color?

[color] … Headers
[color] … Important words

Experts recommend limiting underlining to one word per sentence and a maximum of
one sentence per paragraph (1). I confess that I have not yet been able to give up underlining
articles and books, but I encourage you to consider some of their risks:

1. Illusion of competence.- Again, it may happen that you underline a topic and believe that
you already know it, “because you have underlined it.” But how many times have you done that
automatically due to tiredness or boredom?

In this case, you stop assimilating concepts, but you keep going because you mistakenly
believe that you are learning something. But underlining is not always synonymous with
understanding or memorizing .

When you notice that you are mechanically underlining, I recommend that you stop
and take a break . Make sure your underlines are always active , because otherwise they will
be of no use.

Risk 2. Waste of time.- It happens when you use many colors to underline. Pick up a marker,
drop it, choose another, and so on. Handling so many markers takes time that seems ridiculous,
but... do the sum at the end of the week.

Risk 3. Loss of isolation effect. -With many colors, we end up having a page full of phrases and
words marked with different colors, to the point that you may not understand why you
underlined this and not that unless you read the text carefully. At that point, the mission of the
underline, to isolate important meaning, is diluted.

I'm going to go a little ahead of lesson 4 (Optimize time) and take advantage of the fact that
you just reviewed how you underline to suggest ways to make your underlining more
effective:

Use 1 color . What would happen if you just used a pencil? You can vary the stroke

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between a continuous line, a dotted line, a wavy line. You can mark important words by
surrounding them with an oval; mark paragraphs with a margin sign (an exclamation, an
asterisk). Try it and enjoy the agility that working with a single instrument gives you.

Structural underlining vs meaningful underlining.- In 99% of cases we use colors to mark

concepts and data in a superfluous way. Let me explain: we underline the titles with a color; the
beginnings of the section with another; what we want to memorize, with another; the fact that
stands out, of everything we want to memorize, with another color.

If you think about it, the YA titles stand out from the rest of the text, the beginnings of
the section, too. They have a different font, bold, italics... a paragraph separated from the
other, some indentation. You don't need to further mark those divisions because they ALREADY
exist.

Therefore, it would be enough to use a single color to mark what you want to study.
Wait, wait, I know you're going to protest. If you have summarized notes, you end up
underlining almost everything and with the same color you don't get anything in particular to
stand out. I agree, but...

...I encourage you to consider this idea: the underline can mean something in itself. You
can code colors or shapes that already indicate, without having to read the text, a concept or
meaning. I give you examples:
• Anatomy, muscles of the forearm: some will be innervated by the median nerve, others
by the radial, and others by the ulnar. You can mark each of these nerves with a
different color, and use that color code in the drawings in your notes and in the tables.

• Pharmacology and the hell of antibiotics. You can mark penicillins in blue, and different
shades according to subgroups; aminoglycosides in yellow; rifampicin in orange or red
(depending on the color of the urine); etc

• Clinical subjects: If you developed a color code for antibiotics, each time you study the
infectious pathology of a system, the corresponding color can illustrate each treatment.
Thus, at a glance you will know that penicillins or quinolones are of choice for the
treatment of certain pneumonias, or musculoskeletal infections, etc.
Star technique 3. Summaries

What is the purpose of summarizing? Summarizing is a very powerful technique to

ensure that we have understood a subject. It is when synthesizing what we have read that we
realize whether we have understood correctly or not.

Throughout Primary and Secondary School, the preparation of summaries is

encouraged as an ideal study method for children, since a summary indicates whether the child
has done a good enough reading comprehension. Parents can easily check whether their child
has worked on the subject, and the teacher can also see before the exam whether the student
has understood the concepts, and propose solutions before it is too late.

But let me tell you that summaries are a death trap in Medicine .

If you participate in a Notes Commission, perhaps you will understand why I tell you
this. Isn't it true that it takes you a long time to prepare notes from class notes, slides, and with
the help of books?

When you finish your songs, you understand them perfectly. But there are many topics
to memorize.

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 Don't get me wrong, I'm not telling you that summaries are bad in and of themselves.
Quite the opposite. I'm simply telling you that they are a method of very limited effectiveness
compared to others . Because?

Because the volume of each subject is enormous, they require a lot of time, and when
you have finished summarizing the subject, so much time has passed since you summarized the
first topic that you have forgotten many concepts, and you have to make the effort to
memorize them again .

You are an adult learner and you surely understand most of the topics when they are
explained to you in class, or with the first reading you do alone. You don't need to make sure
you understand them by creating summaries of everything .

A hint on when to make summaries :

• With the topics that are really difficult to understand, and using the most abbreviated
format possible, such as mind maps and tables.

• When you study concepts with great similarities to each other, but that require
thoroughness to understand the differences, since that will be the difficulty in the
exam. Q. e.g., cardiac arrhythmias; antihypertensive drugs; forearm muscles (you can
see that it was difficult for me to study them, I use them as an example a lot), etc.
Lesson 3. Energy management
Here I use the word "energy" to refer to that perception we have of the state of our
body and mind that tells us what effort we can undertake in the following minutes or hours of
the day.

Thus, after spending the morning in master classes and practices, when you return
home you may realize that you have spent a lot of "energy", and that you need to eat and rest
to fill your reserves again. We can make it equivalent to the cell phone battery, in a way.

After spending an entire Saturday locked in your room studying for exams, you are very
aware that, as the hours go by, you are losing energy and you know that you have less and less
"battery" left to continue studying. My maximum when I was in college and when I was
preparing for the MIR was 10 hours a day. Obviously, performance could vary greatly over
those hours.

What does the "energy" we have to study at any given moment depend on? From
many factors. I'm going to list a few:

1. We are biological entities , not robots. Therefore, our energy depends on the
availability of nutrients, our level of hydration, and the degree of tiredness and sleep
that we have accumulated at each moment
2. We are beings with emotions , so our energy can vary depending on the events in our
life or depending on the subject we have to study. A boring subject saps our energy.
Having low expectations about our ability in a difficult subject also saps our energy. On
the contrary, a subject that we enjoy, or in which we have obtained good results in a
previous exam, excites us and makes it easier for us to sit down and study it. We can
also suffer a loss of study "energy" if we have a personal problem (argument with a
friend, fight with a partner, illness of a parent or grandparent).
3. We are beings with an internal clock and a chronotype that varies depending on our
physiology, determined by genes. The term "chronotype" refers to each person's
preferred sleep schedules. Science shows that being up at 6 a.m. is a matter of

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 discipline (and a bomb-proof alarm clock). But being completely clear and at 100% of
our cognitive performance precisely at the time when classes start at our Faculty
depends largely on our genes . This explains why there are "larks", people who get up
early, and "owls", people who enjoy nightlife easily. Furthermore, it is scientifically
proven that adolescents and young adults tend to have later chronotypes due to the
very nature of their hormonal states and physiological evolution (2).

Surely you can identify specific circumstances that influence your particular energy levels.

What events or circumstances influence your energy levels when studying? Write them down
in this table

INCREASE MY ENERGY THEY REDUCE MY ENERGY

My favorite subject / going for a run Family feud/recent suspense

What does this all mean? Normally I don't just talk about time management (that too), but also
about energy management.

Managing time correctly means knowing your exam and assignment delivery schedule
in advance. This is simple and we all know how to do it with the typical digital or paper calendar
that we have on the table or on the wall of our desk.

Managing time correctly also means knowing yourself to manage your energy and
knowing what task to undertake at any given moment. It means that you know when it is time
to enter phase 1 of study, that of initial contact, and when you should undertake phase 2
(understanding), which generally requires more effort. It requires more effort because you
need to consult notes, computer files, atlases, that is, you have to be sitting at the table,
upright in your chair, and prepared to move sheets and books from one place to another.

Regarding phase 3 of memorization, depending on your exam calendar, you can

undertake it in the days before the exam (if there are enough days), or as I always recommend,
you can distribute it appropriately throughout the entire semester to get to the exam. in the
best possible conditions (and raise your grades). We are not used to doing this and no one has
taught us how to do it, but you will learn how to do it successfully in this course.

Another interesting thing: using digital applications of active spaced review (we will see
this in module 3), you will be able to review when you encounter suboptimal energy levels.
Resting on the couch to relieve your back, recovering from the flu in bed, or at a relative's
house waiting for New Year's Eve dinner to be served.

Organizing and planning correctly means that you know how to raise your energy levels,
and understand why at a specific moment, a certain afternoon, you are not able to perform at
your best level and you should look for activities that also help you progress in your work tasks.
the Faculty or the hospital in the short or medium term. Because those who barely pass, and
those who always get A's or honors, have the same number of hours each day. Where is the

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difference? It is not in intelligence. The difference lies in how each person uses their hours and
days .

We finish this third lesson of module 2 with a few ideas on how to raise our energy levels in
the most basic aspects.

Nutrition and hydration

Studying is a cognitive activity that consumes large amounts of energy. Glucose is the
main fuel, and the organ where this cognitive activity occurs (the brain) can be considered as a
gelatinous mass composed of proteins, lipids...and a lot of water.

Reading occurs through our eyeballs, which must make a gentle but sustained effort to
accommodate our lens to the sheets of notes and books placed on the table.

It is common to study for hours without hardly realizing that time is passing, only to
suddenly feel a physical and mental decline that can force us to stop for a long time. When I
was in college, I often confused that depression with major problems... was I studying the right
career? Was I using the correct technique? Was I right to continue taking music classes, or
should I focus exclusively on Medicine? My goodness, how many hours wasted philosophizing...

You would be surprised to know how much of this decline or "slump" can be due to
reasons as prosaic as lack of hydration, lower availability of nutrients, a sleepy physiology from
having been immobile for a long time, or sore eyes from looking closely for too long. .

Make sure it doesn't happen to you like it did to me, and anticipate physiological
decline:
• Eat complete, regular and balanced meals . Neither scarce nor too abundant. A scant
meal makes you feel hungry before you know it. A large meal promotes postprandial
drowsiness. If you have to study in depth, find a middle ground in your diet. Add a meal
in the middle of the morning or afternoon, even if you are not hungry, so that there is
no extreme hunger attack that forces you to leave the library early. Quickly absorbed
carbohydrates give you a boost of energy that can be very stimulating, but can be
followed by ravenous attacks of hunger that force you to get up from the table, with
the risk of losing concentration. Your Endocrinology professors or your family doctor
will surely give you good advice on the type of food that promotes stable glucose
availability.
• Drink plenty . Water, juices and infusions keep you hydrated, and force you to get up
regularly to the bathroom, which promotes body movement, reactivation of your blood
circulation and rest for your eyes. When you return to the table you will feel more vital.
• Manage your caffeine doses wisely . When you have been consuming caffeine for a
long time, tolerance to it develops, which means that it loses its stimulating effect and
you need more quantities to achieve the same effect. That tolerance disappears if you
stop consuming caffeine for a while. You can do caffeine “fasts” on weekends or on
vacation, in order to recover that advantageous effect for times of need, such as exams.
You will have to accept that the first few days you do not consume caffeine you will be
sleepy or tired, but it is not too serious if you can just laze around the house or lie next
to a pool.
Dream
Individuals have different sleep schedules, or chronotypes. The chronotype of each
individual governs not only sleep, but dominates all bodily functions, from the expression of

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various genes, changes in body temperature, secretion of hormones, to cognitive functions.

Conversely, chronotype is conditioned by our genes, by the activation and deactivation of

multiple genes and fluctuations in the cocktail of hormones and transmitters that bathe all our
tissues. That is, it is not a question of personal discipline.

The prestige of the “larks” comes from a rural era in which early risers took great
advantage of getting up early: they had an advantage when picking fruits, mushrooms and
other vegetables that grew freely; They undertook the hardest agricultural work in the coolest
hours; They took advantage of those hours to travel to other towns to trade their products, etc.

It has been shown that the sleep schedule is physiologically delayed in adolescents, which
explains why at those ages and during university it is so difficult to get up early to adapt to
socially acceptable schedules. This represents discrimination for late chronotypes (2).

When I studied the MIR I realized that I performed better if I respected my chronotype. The
first few months I insisted on getting up at 8 and starting studying at 9. It was difficult for me to
reach maximum concentration and after eating I got sleepy. I didn't want to take a nap out of
pure prejudice, and I spent the afternoon at half throttle. At night, however, I went to bed at 11
p.m., but I was nervous and had trouble sleeping. Things changed when one day I decided to
take a break and watch television with my family. I went to bed at 1.30 am and I fell asleep
easily. I woke up at 10 am without needing an alarm, and I performed perfectly working in 3
periods: from 10:30 a.m. to 2:30 p.m., from 4:30 p.m. to 8:30 p.m. (goodbye, nap!), and from
10 p.m. to 1 a.m. The performance remained high the rest of the weeks until the MIR.

Once we understand why it is difficult for many of us to get up early, we move on to the
next point. How to overcome drowsiness during study sessions and how to take advantage of
our biological rhythms.

Do the heaviest or most demanding tasks during peak hours . To do this you will have to
observe how you feel throughout the day. You probably already know yourself well and know
when your mind works best by studying. It can be in the morning, shortly after you wake up, in
the afternoon or at night. You may perform evenly throughout the day. It does not matter! The
point is to know it and adapt to your natural schedules, especially when you don't have to get
up early to go to class. Spend your best hours on that heavy or difficult or boring subject to
make sure you get your work done with it. In less awake periods of the day you will not have as
much problem studying your favorite subjects.

How to beat drowsiness during study session . It is common to feel drowsy during a long study
session. John Medina, an American neuroscientist, became popular for writing a popular book
about some aspects of our brain (3). He explained that we can find ourselves at a conference
listening to the best speaker in the world, hearing about the topic that interests us most on the
face of the earth. After about 15 or 20 minutes, various physiological variables experience a
change towards decline , towards values typical of rest and sleep. Blood pressure drops, heart
rate is reduced, skin conductance changes. That is, we prepare to sleep.

Why is this? It surely has to do with our adaptation to living in wild environments,
where we must quickly flee from any danger and take advantage of calm periods to rest and
regain strength.

Imagine what happens when you have been sitting for half an hour, in silence, studying
a topic that does not particularly attract you, beyond the abstract interest that you will need to
know about it for a future written exam.

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 Accept your physiology and turn it around! Some days you will not need special stimuli
to study frequently and clearly. Other days you will feel clumsy, sleepy or very unmotivated.
In that case I encourage you to try the Pomodoros (4). They are periods of intense work of 25
minutes followed by 5 minutes of rest. In those minutes of rest, it is a good idea to do
something active, such as doing sit-ups, snacking on an ounce of chocolate, or dancing to your
favorite song. Get up from your chair and take a quick walk out of the library. This bodily
activation will result in cognitive activation, and you will positively condition yourself to
continue studying if in those 5 minutes you do something that you really like.

If you are active and enjoy sports a lot, you will especially enjoy dedicating your breaks
to exercising. HIIT routines will help you wake up and you will have visible physical results in a
few weeks.

If you are an owl, you had to get up early and after eating you feel sleepy, try sleeping on a “
power nap ” . This power nap thing is what the Anglo-Saxons have called the traditional Spanish
nap, about which everyone makes jokes but the Japanese know how to appreciate it for what
it's worth. In fact, they invented rented sleeping cubicles (which Japanese office workers seem
to really appreciate).

The division between the sleeping and waking periods is relatively artificial. We are
physiologically more willing to sleep while there is no sunlight, but throughout the day sleep
impulses can also arise that are necessary to resume activities with more energy. The student's
great fear is taking too long a nap, from which he wakes up too late and too groggy to study
effectively.

The reason that sleeping more than 20-25 minutes makes us groggy lies in the fact that,
after that time, we descend into deeper levels of sleep, even REM phases. If we limit the
duration of the nap to less than half an hour, we will not go beyond phase I of sleep and we will
wake up more agile, yet more rested. But some of us find it very difficult to get up in half an
hour. What can you do? In my case I use a free application called Alarmy (sleep if u can). I set it
so that it sounds very loud and doesn't stop until I take a photo of a particularly difficult corner
of my kitchen... I assure you it's not easy. I get up grunting and cursing, and by the time I get the
damn thing to shut up, I'm already on my feet and it's much easier for me to stay up.

Another fun option are those clocks with wheels that run around the room while we
chase them to turn them off. I can assure you that it works. And if not, try the old analog
resource... having your brother or a roommate come into your room, banging on a saucepan
until you get up.

Lesson 4. Optimize time

After the last lesson, in which we reviewed how our body works and we have learned
tricks to get it going, in this last lesson of the module I want to review some psychological
aspects, and less obvious, but equally useful, tricks to take advantage of your time and plan.
better.

Misguided all-or-nothing belief and the planning fallacy

It is common among medical students that we are perfectionists. We schedule many

tasks to do each afternoon, and almost always more than we really have time to do.

We also think in absolute terms of “all or nothing,” black or white. If we plan to read 4
topics in one afternoon, and we have given time to 2 and a half topics, what do we think?
"What a mess…"

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 Mistake 1: Scheduling too many tasks to do in a single afternoon or day. Surely you
resort to your memory of how long it took you to study each topic last semester. But it is
proven that after the fact we remember how much time and effort it took us. And we also do
not take into account that emergencies and setbacks can get in our way, such as a cold, a
breakdown at home, or a grandparent's unforeseen hospitalization (and I give this example
because, as a university student, you are at that time of life in that grandparents are already old
and get sick easily).

Error 2: not valuing what we have been able to do in its proper measure . Let's go
back to the example. You planned to read 3 topics this afternoon. Maybe because in previous
days you didn't sit down to study and you want to recover. You feel a little afraid, and it calmed
you to think that this afternoon you would get ahead with work. But it could not be! You left
that seminar late. Or you were more tired than expected. You have sat down to study with your
batteries at 50% and you have barely read 1 topic, and you are unfocused. Or maybe not,
maybe you have read those 3 topics, but... (there is always a but) you haven't had time to
underline. Or they have not been very clear to you. “What a disaster…” you think again. This
way you are not going to improve this semester, it will be as disgusting as the last one.

Stop! Whatever you've done, you've done something . You have come into initial
contact with those topics (phase 1 completed). You have understood some concepts that you
did not understand 3 hours before (phase 2 completed). If your final exam was the Camino de
Santiago, you may not have walked 30 km towards your destination, but you have advanced 5
km... You are 5 km closer to your goal.

Those few advanced kilometers are worth a lot. Because human beings tend to
overestimate what they are capable of doing today (concrete concept), but underestimate
how much they can advance after a few weeks (abstract concept) if they do a little work each
day . That's how we are, what is far away in time is abstract, it does not exist. That's why it's so
hard to sit down and study in time for exams.

In module 3 I will explain how by reviewing a little each day with flashcards you can
advance further and with more time for the final exams.

Do what you have to do at every moment. Study in weekly blocks

At the beginning of the semester, we have a conflict between what we want to do (play
sports, go to the movies, rest after class, watch series) and what it is convenient for us to do
(study).

The conflict appears when the exams, the great external motivator for studying, are far
away. After the last final exams we have associated studying for hours with negative emotions:
boredom; fear; burden; regrets; sadness (did I leave something out?).

The result is that we have conditioned ourselves (like Paulov's dog) to feel unpleasant
emotions when we sit down to study at the beginning of the course. Until the exam is close
enough, the fear of failing it does not overcome the discomfort of studying.

But you're in luck. A study showed that those visceral reactions that we suffer when
sitting down to study last a few minutes, and then they disappear (5). This, together with the
fact that you are going to learn to review in time for the exams, and with an active and
entertaining method, is going to be your salvation. You are going to sit down to study in time.

How to do it if you are not used to it ? It is likely that you study hard, that you only sit
down when the exam approaches. How to plan studying from the beginning of the semester if

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you have never done it, or if you have never been comfortable doing it?

I propose planning by weekly blocks. Each week has 7 days, of which you should
allocate one to rest. Yes, to rest. If you don't rest periodically, you will soon slack off. The
semester is a marathon.

Of those 6 days you have to study, see when you will have your long study blocks .
These are those afternoons (or mornings, if your classes are in the afternoon) when you have 3-
4 hours straight to work at your desk.

Make a list of your subjects for the semester. You probably have between 5 and 7
subjects. Assign a “fat” subject (the important ones) to each of those blocks. In that block you
will study that subject in depth, including your brand new study habit on the go, flashcards.

You can allocate a block to recoveries. For those subjects that in the end you have not
been able to watch on the planned day because an unforeseen event has arisen. Or for that
other subject that is more difficult than the others and you need to dedicate more time to it.

By working in weekly blocks you ensure that you touch on each subject at least once
a week . This frequency will make the material familiar to you and after a couple of weeks it will
be easier for you to sit down and study.

If you have midterms in your calendar, schedule a few monographic review afternoons
the days before, as you always do to prepare for exams. Once the midterm has passed, resume
your weekly schedule.

How to decide what to study in each block, and how to study throughout the block?
Decide based on your energy and the difficulty of the subject. If Saturday morning is a very
productive day for you, use it for that difficult subject (Microbiology, Pharmacology...). If you're
clumsier at the beginning of the afternoon (because it's right after a nap), start with something
active (a summary or reviewing your flashcards) or less demanding (like watching a class video).

As entrepreneurs and corporate workers in general say, “ Eat the frog first .” Eat the
toad first! We already know that we don't feel like it, but the more rested we are, the more
willpower, and the more ability to do “what needs to be done.” If you are strong at the
beginning of the week, on Monday or Tuesday, use those days for the bone subject. Use the
hardest hours of your study block for the hardest stuff, even if you don't feel like it. And of
course, give yourself a treat on those days, you deserve it (your favorite series after dinner, or
whatever).

Don't study more hours... make better use of your hours

As you will see in the next module, it is not about dedicating more hours to studying.
This course is not about infusing you with such strong willpower that you start studying 8 hours
every day from the first day of the semester. No, that doesn't work... We are human. We like to
rest. We need to sleep well to strengthen our memory (6). We can fall ill. We can get an
opportunity to take a wonderful weekend trip at any time... and we should take advantage of it,
especially if we haven't seen those friends or family in a while...

Nothing of that. It's about making better use of the hours that you are already up and
alert. When you are at the Faculty or in the hospital, but your internship tutor has not yet
arrived. When a class has been suspended and you have 1 hour free, too little to sit with books
in the library. Waiting for the bus that takes you to the hospital. Those loose moments in which
you can't rest, but you also can't study as you understand what studying is, sitting at the table

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with your notes and laptop.

Pay attention to module 3, because there you will discover a highly effective technique
according to learning experts, but that can be put into practice in almost any context, and with
energy levels lower than ideal...

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 YOU HAVE REACHED THE END OF MODULE 2

CONGRATULATIONS!
YOU ARE THE GREATEST EXPERT IN YOUR OWN MIND AND YOUR WAY OF STUDY, SO IT IS
ESSENTIAL THAT YOU NOTE YOUR DIAGNOSIS BELOW ON THE TEMPLATE AND ANALYZE HOW
MUCH TIME YOU INVEST IN EACH STEP OF THE STUDY, AND THEREFORE, WHERE YOU CAN
INTRODUCE A TIME SAVING

In what steps of your study can you save time after reading this module?

STEP YOU CAN IMPROVE ACTION YOU WILL TAKE

Underlined Reduce colors
Summaries Only on difficult topics

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REFERENCES
1. Dunlosky J, Rawson KA, Marsh EJ, Nathan MJ, Willingham DT. Improving Students' Learning
With Effective Learning Techniques: Promising Directions From Cognitive and Educational
Psychology. Psychol Sci Public Interest 2013;14(1):4-58. doi: 10.1177/1529100612453266.

2. Till Roenneberg. Internal Time: Chronotypes, Social Jet Lag, and Why You're So Tired.
Harvard University Press 2012

3. John Medina. Express your neurons: 12 basic rules to exercise your mind. Grupo Planeta
Spain, 2011

4. https://dominalamedicina.com/2015/01/05/tecnica-pomodoro/

5. Lyons IM, Beilock SL. When math hurts: math anxiety predicts pain network activation in
anticipation of doing math. PLoS One 2012;7(10):e48076. doi: 10.1371/journal.pone.0048076.

6. Yang G, Lai CS, Cichon J, Ma L, Li W, Gan WB. Sleep promotes branch-specific formation of
dendritic spines after learning. Science 2014;344(6188):1173-8. doi: 10.1126/science.1249098.

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 SHOOT YOUR NOTES IN MEDICINE
Why you fail and how to shine again

MODULE 3 TRAIN FOR THE REAL EXAMS

Lesson 1. Highly effective review techniques
Lesson 2. Long-term remembering with Active Spaced Review and flashcards
Lesson 3. How to write good flashcards
Lesson 4. Anki. How to get started and learning plan

Lesson 1. Highly effective review techniques

In an in-depth and very complete review published in 2013 (1), widely used techniques
such as rereading and underlining received low ratings. In module 2 I explained to you what the
risks were, among others, the illusion of competence, spending equal time rereading what you
know and what you don't, etc.
What the authors of the review indicate, and I have confirmed in real life with my
students, is that these popular techniques (rereading and underlining) are not useless, far from
it. Underlining, making summaries and diagrams, and reading the topic several times are
techniques that we learn as children and perfect year after year, and they are very useful at
those ages, and have allowed you to reach university, which has a lot of merit.
It is simply that the techniques classified as “very useful” such as self-examination or studying
slowly, win by a landslide for the same amount of time invested. That is, if you spend 30
minutes reading a topic, and another 30 minutes rereading it, you will achieve worse results
than if you spend 30 minutes reading it and another 30 minutes examining yourself on this
topic. It's that simple.
The highly effective techniques according to experts are self-examination and spaced practice
1. Self-examination.- It consists of answering questions about the topic you have just
read/worked on, in various ways:
• Flashcards (generating the answer yourself)

• Answering questions included at the end of each chapter (available in some books)

• Practicing with multiple choice questions from exams from other years (which involves
recognizing the correct answer).
That is, examining yourself in these ways is a type of exercise that makes it clear to you
whether you know the answer or not. It is much more solid than finishing reading a topic and
trying to remember it mentally and literally, just as you have read it in the book or the notes.
Recalling mentally or reciting out loud can predispose you to fatigue and the illusion of
competence, that is, ending the review believing that you know everything, when you don't
(the content is simply familiar to you).
As I explained to you in module 1, exams are something viscerally unpleasant for all of
us, because we have always used them as evaluation tools that were administered to us on the
date and in the manner decided by the teacher, and that could bring bad results (bad grades). ).
This may explain why you do not want/can believe this statement made in Dunlosky's review

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(1) and in hundreds of works published on the subject . Interestingly, even the students
themselves who have gone through such an experiment doubt the effectiveness of the method
(2).
Moral? Don't trust your feelings here. Trust the science. Start self-examining to prepare
for your exams.
What type of self-examination seems most effective? According to several works
reviewed by Dunlosky (1), freely generating the answer is more effective than generating it
following clues, or recognizing the correct answer among several options. That is to say, the
review work that flashcards force you to do is more effective.
2. Spaced practice.- It consists of distributing the study and memorization work over a certain
period of time. This spacing improves long-term memory. It means that you will remember a
text studied over 5 hours spread over several days (for example, 1 hour each day) for longer
than the same text studied over 5 hours in a row.
This effect also occurs with longer terms. If you review every few days or weeks, over
several months, you strengthen your memory of what you studied and you will be able to
remember it for much longer (long term).
Someone will say “What difference does it make to remember in the short or long
term? The important thing is to pass the exam .” If what you want is to simply pass an exam and
get rid of that subject forever, that's fine. It is enough to study that subject all day for a
sufficient number of days before the exam (this is called “massed practice”).
But if you want to remember what you studied for longer, you will need to review
periodically. The small forgetting of data that occurs between one review and another forces
more effort to remember, but it is precisely that effort that reinforces memory (3).
As a medical student, it is not always enough to remember the subject in the short
term through massive practice (the classic intensive study for final exams):
• For it to work with all exams, you need to have a minimum number of days between
one exam and another. With the volumes of material handled in Medicine, this requires
4-5 days at least. And you won't always have them.
• When it comes to clinical subjects, you will need to remember them after the exam in
order to apply your knowledge in internships and rotations, in internship, in residency...
in short, in your work as a student and as a doctor
Now you will say, “It's okay, as soon as I need something, I'll go over it and remember it
quickly.” Yes, it's true, when you review something that you already worked on in depth and
massively for an exam, you spend less time remembering it. But the problem in Medicine is that
we have too many tasks and little time to study.
Therefore, THE MOST EFFICIENT THING IS TO AVOID FORGETTING IMPORTANT CONCEPTS.
Think how wonderful it would be to be able to remember most of the concepts that you learn
every day in classes, practices or rotations. Don't forget what you understood that day, and
keep it fresh in your memory for the time of the final exams.
IT IS POSSIBLE TO REMEMBER LONG TERM if you understand the physiology of memory
and forgetting. It is possible to avoid forgetting if you understand why it happens, and how to
prevent forgetting important concepts for your exams. That way you will no longer be afraid of
having exams on consecutive days.

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why do we forget
The brain is extremely efficient in its use of resources. You will easily remember
important data and concepts for survival and daily life. You will easily forget data that is not
relevant or is not reviewed frequently. “Use it or lose it.”
If you were once afraid , for example, if you were bitten by a snake while walking in the
countryside, your brain will solidly encode that danger (thanks to the negative emotion
associated with the event), and will cause future encounters with anything that seems a snake,
be alert quickly.
It will also make it easier to remember data that you use very often , although it is not
vital to remember them, since you could keep them written down. For example, the landline
number of your home, your best friend's cell phone number, or anyone you call often, will
remain engraved in your memory.
On the contrary, the brain makes it easier to forget data that is not important for daily
life or that is not used often. It is a question of economy and energy efficiency, since the brain
uses a large part of the calories we eat daily.
What happens with the dozens of new facts that we are taught every day at the Faculty or in
the hospital? That they lack intense emotional meaning, or you do not confront that new
concept again for several weeks, even months. Therefore, spontaneous long-term
memorization does not occur . Maybe it does happen with some concepts that catch your
attention; but, in general, you will have to work on each topic personally to be able to
understand it well and then memorize it.
If some concepts are repeated in several subjects, then you will come into contact with
them more often and remember them more easily (physical signs of heart failure, laboratory
values, etc.). But let's be honest, I have also been a student: every day of class we are
presented with SO many new concepts that they quickly lose interest or their ability to stand
out among the multitude of details provided daily by teachers, internship tutors or classmates.
What you memorize today may soon be forgotten if you don't review it. This physiology
of memory and forgetting has been known for a long time. The first author to publish on this
was Ebbinghaus, a German psychologist, in 1885 (4).
Ebbinghaus did experiments to find out how long it took to forget newly memorized
concepts. After him, many scientists have obtained similar results, with slight variations
depending on the material used and the learning conditions. So that you understand it easily:
on day 0 of the experiment you study a series of concepts until you can reproduce 100%. If you
don't go over it again, each day that passes you will forget a certain percentage until, after a
week, you don't remember more than 10-

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20%. This decay of the percentage of memorized data is represented in a curve of this style:

% memory

This curve represents the painful fact that you experience after each exam: we forget
much of what we studied very quickly.
Lesson 2. Long-term remembering with Active Spaced Rehearsal (flashcards)
In my mentoring I emphasize putting into practice active study techniques as soon as
possible . Underlining and rereading are very useful for phase 2 of the study, “processing” or
understanding the subject. The underline is active at the time you are doing it (if you don't do it
automatically). But as soon as the rereading is repeated more than 2 times, it becomes a very
passive study technique, especially if we are tired (as I explained in previous modules).
Once you understand the content of a topic, it is time to memorize and consolidate
your memory with a view to the exam and practices. Here the highly effective techniques that
we have seen in lesson 1 of this module come into play, and which result in Controlled Spaced
Active Review .
How do we implement Controlled Spaced Active Review ? Through an excellent active
memorization tool that is flashcards, also called memory cards in our language.
What is a flashcard
Initially they were made on paper or cardboard cards. A question is written on the front
of the card, and the answer on the back. For example, if we are reviewing German vocabulary,
on the front we can write “Gebäude”, and on the back “Building”.
When dozens or hundreds of cards were accumulated, they were kept in small
cardboard boxes (like book cards in a library), or bound with rings for easier transport.
Today we have digital applications that work in a similar way, with the advantage that
they do not take up space apart from the device with which we access the cards, which can be
a computer, a tablet or the smartphone itself.
Features that define Controlled Spaced Active Review and therefore make digital
flashcards so powerful:
1. Review
It involves reviewing each concept the number of times necessary to solidify it in
memory.
A very common review system in the race is “laps”. You start with the first topic and
advance to the last one. Once here, you start again on a 2nd lap. This will be faster than the
first. I used this system and the ideal for me was to go through the syllabus 3 times, which
meant going through each concept 3 times. If a group of concepts, or a topic, were more
difficult, I would spend longer.

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 However, the flashcard system involves reviewing some concepts 3 times, others 7,
others 2. It depends on how easy each concept is for your particular memory. This way, you
spend more time doing what needs more time.
2. Asset
It means that you have to generate the answer after each question, not simply
recognize it from a series of options (as in a multiple choice exam). This gives more power to
the workout (like training for a race while wearing ankle weights).
Thinking about the question, locating the answer, and bringing it back to working
memory can be difficult, but that difficulty makes memorization more solid, and makes it last
longer (3).
3. Spacing
In general terms, there is scientific evidence that it is advisable to space out the review
of each concept by 10-20% of the total time that you need to prolong the memory. That is, if
you are studying for 10 days, you should review approximately every 2 days.
This is easy to program if you are short on material. But when you take several subjects
at the same time, and the topics accumulate, it is very difficult to keep track.
Digital applications solve this problem. Every time you open the flashcards app, the
software selects the questions you need to review. This depends on when you last reviewed
them, and how difficult they were then.
How does the app know how difficult each question is? The flashcard program asks you
to rate each flashcard once the answer is opened. Easy to remember, difficult... It collects your
successes and errors from each day of review, and will re-present each flashcard to you in the
optimal period chosen by its internal algorithm (determined by the forgetting curve and by how
easy or difficult it is for you each card).
4. Checked
You maintain control of what you study for several reasons:
• Because you must answer every question they present to you.
• Because you have to rate how easy or difficult it was for you.
• Because the application records in its memory how many times you have studied each
card and with what degree of success. This provides you with statistics from your
master's degree on the content of your “decks” of flashcards.
Common student complaints when first encouraged to use flashcards
“I would have to do a lot and I don't have time”
It is true that you need many hours of work to put all your subjects, with all the details
that may fall into the exam, into a flashcard system.
However, the system also works even if you do not enter all your subjects, and even if
you do not enter absolutely all the details. Starting to review the top 5-10 concepts of each
topic, day after day, week after week, will begin to make a very positive difference in your
preparation.
In countries where flashcards are more popular, such as the US, some publishers sell
flashcards along with medical textbooks. In Spanish we do not yet have this service, but there
are English-speaking medical students who sell their personal flashcards for a small price.

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 Another solution for the lack of time would be to organize a study group of 3-4 people
in total, in which you would distribute the topics to prepare the flashcards. Because the power
of flashcards is not in making them, but in reviewing them .
“ It will take away my time to study like I always do”
Once you master the system, you will be happy to spend much of your time on
flashcards. But when they start, students feel insecure about spending time on flashcards and
not rereading or underlining as usual.
The key is to start things off gradually. This way it will only take away a small
percentage of your time. If you follow my advice, you will initially invest a maximum of half an
hour a day, which is perfectly affordable for anyone. In lesson 4 and the last of this module you
have the step-by-step system to begin implementing your flashcard system and progress
appropriately in its use.
“This technique will work for the most intelligent, but it doesn't work for me.”
Remember what I told you in module 1. Everyone who has managed to enter Medicine
has enough intelligence to pass these studies.
Its effectiveness has been proven at different ages (primary school, secondary school,
university) and with all types of students, including medical students. Regarding medical
students, there are multiple studies that show that self-examination with flashcards about what
has been studied provides better results than re-studying, both in theoretical exams (5) and in
practical skills (6).

There are many different applications. Which is more recommended?

There are many flashcard review applications with varying percentages of market
penetration, such as Anki, Brainscape, StudyBlue, Cram, Quizlet, etc.
The one I usually recommend is Anki, for several reasons:
• It is open source, which means that many users help in its continuous improvement
and renewal
• It has had millions of users for several years, and some have designed fantastic add-ons
for the application (such as the text reader, which allows you to work with headphones
and thus rest your eyes, or the cards with image occlusion)
• Anki is only paid for the iOS system, in a price range between €24.99 and €29.99. For
the features it provides, it is economical compared to other applications. For that
amount, Anki allows you to export cards in various formats, print in Excel table format,
import cards from other people and have a large number of decks (some apps in their
free version do not allow you more than 2 decks).
• And finally, it is the system that I know best as a teacher, and in which I trust the most
because some students at my Faculty have personally informed me that, indeed, their
review algorithm WORKS
Lesson 3. How to write good flashcards

When we start writing flashcards, one thing happens: in view of all the content in each
topic, we are tempted to write long flashcards that have a lot of content. This is a mistake for
three reasons:

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 • Extend the time you spend reviewing the flashcard
• You will know parts of the answers well and other parts you won't, but when it comes
to grading the flashcard, you won't know whether to mark it as difficult or easy.
• You run the risk of the illusion of competence: believing that you have mastered the
entire flashcard, when in reality there is some part that you don't remember. That is
fatal for the exam
How to make good flashcards according to scientific evidence?
1. Concise questions, concise answers
Trivial style. The answer must be short, quick, or at least reduced to the minimum unit
of knowledge. A real example of the first cards of a Neuroanatomy student:

What characteristics are characteristic of slowly and rapidly adapting cutaneous

mechanoreceptors?
a) They are active while the stimulus lasts
b) They include Meissner and Paccini corpuscles, and hair follicle receptors.
c) Response changes at the beginning or end of the stimulus
d) They include Merkel cells, Ruffini complexes, and hair follicle receptors.
e) They indicate the presence of a new stimulus
f) They encode the characteristics of the stimulus

***
g) Slow adaptation: a), d), f)
h) Quick adaptation: b), c), e)

This card is an example of the temptations that attack us when we begin. Many
concepts have been included in a single card, it will take a long time to read and the answer can
be difficult to evaluate.
We are going to reduce this card to minimum units of knowledge, so we will get several
cards. They will be much more concise and easier to review in less than 1 minute each. Here are
some examples:

What structures include slowly adapting mechanoreceptors? (3)

***
Merkel
Ruffini
R for hair follicles
What structures include mechanoreceptors?
quick adaptation? (3)
***
Meissner corpuscles Paccini R corpuscles of sharp follicles

Are hair follicle R's slow or fast adaptation?

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 ***
Both

What type of cutaneous mechanoreceptors encode

the characteristics of the stimulus?
***
Slow adaptation

2. Use images to reinforce memory

In this way we are taking advantage of the extensive visual and special representation
that exists in our cerebral cortex. This is crucial in subjects such as Anatomy, Histology,
Pathological Anatomy, etc.
Images can be included in both the question and the answer area. In the previous
example, for example, graphics can be included that represent the cellular structures studied.
3. When studying lists, use the “fill in the blanks” option
This is called cloze deletion in English and that is what they are called in Anki. It allows
you to obtain several flashcards with the effort of writing one. They would be questions like
this: “Donald ［…］ was the elected president of ［…］ in 2017.”
Experts advise against memorizing lists of words or concepts. But that was because
they did not study Medicine in our faculties... If necessary, they recommend the cloze deletion
format to work with the lists (see point 5).

4. When studying Anatomy, use the “graphics occlusion” option (image occlusion enhanced
in Anki)
In this type of flashcard, we put complex anatomical images in the question area, with
the name of some structure hidden. Your job on these types of cards is to name the structure in
question.

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By checking “show answer”, the marked name appears and thus we check our success or error.

By checking “show answer”, the marked name appears and thus we check our success or error.

5. Search for meaning within the lists

Q. Wozniac, a neuroscientist who pioneered spaced active review systems,
recommended avoiding lists at all costs. Curiously, in Medicine we have no choice but to
memorize lists everywhere. Lists of antihypertensive drugs, lists of differential diagnoses, lists
of effects caused by an interleukin...
One way to make memorizing lists easier is to always do them in the same order. For
this, different tricks can be used:
• Sort by alphabetical order. For example, to memorize the bends of the cerebellum in
chronological order, they coincidentally coincide with the alphabetical order: cervical,
mesencephalic and pontine
• Create sub-lists, easier to memorize, following criteria that may arise in each of these
lists. For example, to memorize the orbital structures that pass through Zinn's ring, we
can specify that there are 4 nerves and 1 artery (ophthalmic), and within the list of
nerves, arrange them in alphabetical order: Abducens, Nasociliary branch, Oculomotor ,
Optician.
Wozniac's top tip for reviewing lists is to use cards that allow “blank spaces” or cloze
deletion . Following the previous example, the question “What nerves pass through the ring

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 of Zinn?” will appear on the front of the card. And then the answer, in which one of the
options will appear blank: ［…］, Nasociliary, Oculomotor, Optic branch. You have more
details about this type of card in Lesson 4, Step 5.

6. Ask very specific questions with very clear answers

When you have spent 1 hour reading about a topic, you may write questions that, out
of context, are not at all clear. After a few days or weeks, when that question arises mixed with
questions about other topics, you will need to know specifically what you are asking.
An example of an ambiguous Pharmacology question:

What diuretics eliminate Na Cl K Ca Mg HCO3?

***
Those with high efficiency

This question is ambiguous because it actually asks about the specific category of
diuretics that eliminate these molecules. After time you might think that they ask for the
specific name of all the diuretic drugs included in that category.
Therefore, to get that answer, the question should be: “Which category of diuretics
eliminate Na Cl K Ca Mg HCO3?”

7. Specify (in the question) the number of elements that make up the answer
This does not represent any false clue that weakens the memorization of the flashcard.
On the contrary, it can be an advantage especially if you are going to face short answer
questions in the exam.
For example:

List 2 types of facilitators of glucose uptake by tissues

***
Biguanides
Thiazolidinediones

This question allows you to remember both categories of drugs, and also remember
that there are 2 categories. In this way you strengthen your memory, whether it is recognizing
the correct answer in a test type, or writing it in your own handwriting in an exam with short
answer questions.
8. Shorten the text as much as you can
Real example of a student starting out with flashcards:

List the nuclei of the medial group of the thalamus. (2)

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 ***
Dorsomedial nucleus
Midline nuclei

It is not necessary to head each answer with the word “core”, since it is already deduced from
the question. Although it may seem like a small thing, it speeds up reading.

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Lesson 4. Anki. How to get started and learning plan
In this section we are going to see step by step the steps you must follow to introduce
Anki smoothly into your daily work and without trauma.
The flashcard method needs to be introduced gradually because it requires a learning
curve . But the most common mistake of the beginner is to start using it without a time limit
(“They say it works, so I'm going to use it thoroughly from now on.”)
If you introduce it intensively, it will be too expensive and difficult a learning curve. It's
similar to being a sedentary person and considering running a 10 km competition in 4 months:
you can't start your training by trying to run for 1 hour straight on the first day. You will burn out
before the deadline and risk injury and giving up on your goal.
Similarly, making flashcards at first costs time and effort. There is no point in making 30
or 40 flashcards of the first topic, because it will take hours and will be very tiring. In 2 or 3 days,
when you realize that you are not dedicating study time to other subjects, you would feel
insecure and would run the risk of giving up too soon, long before having experienced the first
benefits of working with this method.
It is also not advisable to review more than half an hour a day at first: although it may
seem simple, it is tiring for the mind. It is much better to review for a short time, but daily, to
build experience little by little.
That is why I suggest that you follow these steps that I explain here, which I have used
with more than 50 mentoring students and have progressively refined based on the results they
have obtained.

ANKI LEARNING PHASES

1. Initial or basic phase : includes 4 steps (installation of the software, choosing a subject,
first flashcards and first reviews) that can be carried out in about 2 weeks, at the end
of which you will begin to notice better control of the subject
2. Advanced phase , which begins after the 3rd week of use and reaches its peak in about
2-3 months. In this phase you will become increasingly faster at creating cards, and
you will be able to increase the review time you dedicate each day, according to the
needs of your semester. Includes 4 steps (new types of flashcards, add subjects,
configure reviews and read the manual to advance your knowledge of the tool)

INITIAL PHASE in 4 steps

STEP 1. Facility
1st.- Access the website ( https://ankiweb.net/about ) and create a username and password with
one of your emails (click on “Sign up”)
2nd.- Download the desktop application and install it on your computer from this address:
https://apps.ankiweb.net/
• The desktop application is essential because it is the only one that has all the
functionalities, such as installing add-ons, exporting decks and making all types of cards

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 • Plus, it's easier to type cards from a computer
3rd.- Download the smartphone application
• For Android: https://play.google.com/store/apps/details?id=com.ichi2.anki
• For iOS: https://itunes.apple.com/es/app/ankimobile-flashcards/id373493387?mt=8
STEP 2. Choose a subject to start with
The first cards will be the most difficult and the ones that will take you the most time.
But as a reward, you will start reviewing them sooner and those concepts will stick well. Taking
this into account, I propose several criteria so that you can choose the best subject to start with:
• A subject whose exam will be held shortly after another exam (1-2 days later): the
flashcard method will allow you to arrive at that second exam in better conditions (this is
the real experience of one of my students)
• A subject that is especially difficult for you. Working with flashcards will force you to
carry out a deeper cognitive processing of that subject and thus you will be able to
compensate for the initial difficulty
• Avoid subjects that involve learning to use very complex cards from the beginning, e.g.
e.g. Anatomy. This may enter your system a little later.
Once you have chosen your subject, create a deck with its name.

STEP 3. Start making your first flashcards

1 Enter the deck 2 Click on “Add”. By default it will be a “basic” card, which consists of a field for
the question (front) and another for the answer (back).

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 You can add images in the answer field to help you better consolidate your memory of
the concept you are reviewing with that card. Q. e.g. If you ask to list the nuclei of the
cerebellum, it is advisable to add a diagram in the response area, so that you memorize not only
verbally, but also supported by images.
Do you have to make cards about EVERYTHING? This is the big question for anyone
starting out. My answer is always NO. No, because it will take too much time and there are many
topics to advance. At the beginning we must limit it to 10 cards per topic (the topic being
understood as the content that a teacher gives in 1 hour of class).
"It's very little! ", my students always answer. Yes, it is not enough if what you want is to
put all the material on flashcards. You will achieve this later, when you have gone from beginner
to expert (about 2-3 months). But it is more than enough if you want this technique to thrive in
your daily life. If you put more cards per topic, it will take too much time. Be patient. You can't
imagine how powerful it is to periodically review 10 concepts of each topic , one topic after
another, the first 2-3 weeks that you start working with this method.
Choose the 10 most complex or difficult concepts to memorize for each topic. You will
leave a few out, but that's okay; You will review them later, when you reread the entire topics a
few days before the exam. By rereading the topics you will recover the global vision of each
topic, and what you have spent days or weeks memorizing will easily fall into place.
Finally: this limit is maintained during the initial phase of learning the flashcard method,
which will last about 2-3 weeks. When you gain more agility, you can increase the number of
cards.
STEP 4. Review every day
Basics of daily review.- This is the most important step of all, and the one that is most difficult to
perform. Even more than inserting cards. After all, making cards is similar to making summaries
or outlines of a topic, a method that you have used for years in high school and perhaps also in
college.
Why is it difficult to review daily? There are many reasons:

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 • Mainly, because we are not used to reviewing daily on topics or subjects whose exam is
far away. We are also not in the habit of reviewing subjects shortly after having studied
them, since it gives the impression that you are wasting your time by not studying the
following topics.
• Because it is a new technique, and no matter how much scientific evidence tells you that
it is very effective, you have not yet experienced its benefits personally.
• Therefore, while you are reviewing, alarm bells begin to go off inside you telling you “ I
am wasting my time ”, “ I am stopping studying things that are necessary ”, etc.
The key to reviewing every day is to do it at first for a limited time, about 15 minutes
(maximum 30 minutes) , with the following conditions:
• It should be the first thing you do every day. You will be tempted to leave it until the end
of the study, or after dinner. Nothing of that! By then you will feel too tired, and your
willpower will be low. Remember what I told you in Module 2: Eat the frog first! With
the difference that reviewing flashcards will become the most dynamic and almost fun
moment of the day.
• Look for spare moments of time. On the blog I once spoke about how great people take
advantage of any lost time of the day to advance in notes for books or in conference
outlines ( https://dominalamedicina.com/2014/11/19/aprovechar-el-tiempo/ ) . In your
case, those free moments may appear in the time it takes to get to the Faculty or the
hospital, waiting for transportation, or getting on the bus or subway. Also between
classes, or if a practice starts unexpectedly late.
• Those spare moments of time away from home are not useful for other things. They are
not useful for studying a new topic (there is no time or space to take out the book), they
are not useful for resting on the couch, or for sleeping... Maybe they are useful for
listening to music or looking at Facebook, that way you look at Facebook without much
effort. interest, just to kill time. Therefore, replacing these activities with a review will
provide you with great added value.
• If your cards are concise and well written, it will take you between 30 seconds and 1
minute to go through each one. That makes it worth taking advantage of any free time,
even 5 minutes.
• Remember to review for 15-30 minutes a day. Count how much time you have reviewed
in the spare moments that have arisen during the day. When you sit down to study at
your table, complete those 30 minutes and move on.
How to review with Anki.- Open the deck you want to review and click on the “Start studying”
box.

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 During review, each time Anki shows you an answer, it will ask you to rate the card as
“Again,” “Good,” and “Easy.” A tip from my own students: never rate flashcards as easy , as then
Anki's internal algorithm will tend to schedule them for review too soon.

KNOWLEDGE WITHOUT ACTION IS OF NO USE

Stop reading the module right now, install Anki and start working with the program and
inserting your first cards. Do not enter more than 10 flashcards per topic in this first phase .
The first few days it will be very easy for you to go through practically all the cards in less than
half an hour, since you will have a small number.

ANKI ADVANCED PHASE, STEPS 5 to 8

STEP 5. Introduce new types of cards
Cloze cards. It is a card template that is included by default in Anki. These cards are shown, when
studying, as the typical sentence in which you have to remember which word or phrase
corresponds to the blank space. In lesson 3 of this module, in point 3, I gave you the following
example: “Donald ［…］ was the elected president of the United States in 2017.” In other

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card, you may get a different blank term, for example: “Donald Trump was the elected
president of ［…］ in 2017.”
This type of card is recommended when you need to memorize lists, which are very
common in Medicine. They can be lists of interchangeable elements (e.g. e.g., differential
diagnoses), or steps within a process, which will therefore have a specific order. Experts
recommend that these lists always be memorized in the same order, and with this type of card.
To select this type of card, click on the "Basic" box, and look for the word “cloze” or
“hole” in the drop-down menu.

Let's see how the gaps in the general sentence are marked. The spaces correspond to
the elements that we want to memorize. Let's see an example with a Musculoskeletal Anatomy
question in which we want to review which muscles of the forearm are innervated by the
median nerve. We write down the complete phrase and select the elements that will appear
'blank'.

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 As seen in the image above, we select the element (in this case “pronator teres”) and
click on the icon above that marks the arrow, ［…］. We do the same with the following
elements, “palmar major” and “common flexor digitorum superficialis”. This is what they look
like in the card design window:

We finish by clicking on “Add”. When we review, Anki will have automatically

generated as many cards as there are elements we have defined as “blank”, and they will look
like this:

In this way, Anki allows us to review our list of elements several times, each time

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hiding a different element. With this resource you will save a lot of work time.

"Image occlusion" cards.- Useful for memorizing anatomical structures, parts of a biochemical
cycle, algorithms and tables. This type of card does not exist by default in the application. It is
an Add-on and is installed using a code that you must download from the descriptive page of
each plugin. The current code for this type of card is 1111933094
In this link ( http://www.ankitips.com/2016/08/04/anki-medical-school-using-image-
occlusion-study-anatomy/ ) you have a good tutorial (in English) to learn how to install and
use this type of card.
It can also be used for tables and algorithms, and thus allows us to recover the global
vision of a broad topic. For example, burn treatment algorithms, differential diagnosis
algorithms or statistical test tables. An interesting option is to place this type of "overview"
card in a subdeck within the main deck of each subject. For MIR opponents it is a good idea to
place all the image occlusion cards in a separate deck that they can review every 2-3 weeks, in
addition to the rest of the cards.

STEP 6. Enter more subjects

Once you have been practicing making and reviewing cards from a single deck (a
single subject) for about 2 weeks, it is time to create as many other decks as there are subjects
you need to review for your exams.
Any subject lends itself to being "dissected" in the form of flashcards, even if the exam
consists of questions to be developed ("essay" questions). In this case, you can make cards
where you outline the steps and sections of possible long questions.
Avoid creating too many decks , as you run the risk of 'corrupting' the database. It happened
to me when I had more than 20 accumulated decks from my different students. Therefore, my
advice is that you create 1 deck for each subject.

STEP 7. Set up daily reviews to review multiple decks

When you have 2 or more decks, you need to learn how to set up review with Anki ,
which means scheduling how many cards you want to review per day for each deck. This is
very well explained in the introductory video on the Anki manual website (
https://youtu.be/QS2G-k2hQyg ) , and I encourage you to watch it right now before
continuing any further. Before minute 1:56 they explain how to get public decks (decks shared
by other people). However, I do not advise you to use public decks for medical subjects, since I
have found that their quality is very debatable and tends to be very low.

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 To open the review configuration box, the first thing is to click at the bottom of this
window, on "Options":

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 In the options window, you can choose how many new cards to study each day, and
how many to review. Choose a number such that, adding all the decks, it does not force you to
review for an excessive amount of time, especially at the beginning. As you will not be
accustomed to it, I recommend not exceeding 45 minutes of daily review in this phase, with a
maximum of 2 cards per minute.
It is very important that each day you study all the new cards added the previous day,
so make sure you set a sufficient daily limit. If you normally make between 5 and 20 new cards
(depending on the day), set a limit of 20. This way you comply with one of the principles
identified by Ebbinghaus, which was to review what you studied before 12-24 hours had
passed.
In the next tab, you will be able to determine how many cards to review each day.

Frequently asked questions

1. " I'm wasting my time . " - The most common thing is that you feel insecure when you start
spending time on Anki, even if it's only half an hour a day. Something in your mind will say " I'm
wasting my time ", " I should be reading the next topic now, not reviewing the one I read
yesterday ".
IGNORE THOSE MESSAGES! The reason you feel restless is that your brain has not yet felt the
beneficial effect of remembering the topics read several days ago, but you will soon notice. The
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solution to insecurity is to be clear about the maximum amount of time you are going to review
each day, and how many maximum cards you will prepare per topic.
2. " Limiting myself to 10 cards per topic is too little . " - Certainly, each topic usually contains
several dozen concepts. But if you try to make cards of all of them, it will take too much time
and you will feel even worse, more insecure. Stick to this limit, vary it as needed (if your topics
are very long, raise the limit to 15 or 20), but wait 2 or 3 weeks to gain practice and speed with
Anki before increasing the number of cards per topic.
What concepts to choose when you have a limit? Those who have failed in other exams or who
you think will take longer to memorize.
3. “ I find it difficult to review cards from days gone by . ” It may happen that you have
forgotten them, and being forced to review them makes you realize this, which is
uncomfortable. The solution is simple: keep reviewing. If you don't remember an answer, rate
it as "soon."
Experts know that alternating review of different subjects on the same day (" interleaving ") is
more difficult than dedicating the entire day to the same subject (" massive practice "). In the
case of "mass" practice, you have a lot of familiarity with the subject. When you interleave,
your brain has to make an effort to rescue the concepts from memory. But it is precisely that
effort that consolidates the memory and makes it easier to recover it on the day of the exam
(3). The advantage of interspersing subjects is as beneficial as interspersing plays in football,
baseball or hockey, since it makes the brain develop new keys and free associations to recover
the memory of each concept (or play), and allows for a much more fluid execution. exam (or
match) day.
STEP 8. Read Anki manual thoroughly
The Anki manual is available in English ( https://apps.ankiweb.net/docs/manual.html ) and in a
Spanish/Castilian translation ( https://apps.ankiweb.net/docs/manual.es. html ) made by
volunteers. It is worth spending 2-3 hours reading it in its entirety to familiarize yourself with
Anki's own terms. This way, if you have any questions about how to review or modify the
configuration, you can easily search the various forums that exist on the Internet, such as the
Anki forums ( https://apps.ankiweb.net/docs/help .html ), reddit (
https://www.reddit.com/r/Anki/ ) and some YouTube tutorials.

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 COURSE EPILOGUE

This will be the outline of your study flow in the near future. Starting with the Initial Contact,
applied to each new topic, your work process will become a more dynamic, active, and in the
words of some student... even fun routine. Much more interesting than rereading the notes,
slides or books over and over again. An intelligent work and study flow that will allow you to
prepare for exams like elite athletes prepare for their competitions... in a specific, active,
focused on what is still lacking, and dynamic way.

Contact
initial Grasp

Add
Review cards

I wish you much success, and above all, that you enjoy studying.
REFERENCES
1. Dunlosky J, Rawson KA, Marsh EJ, Nathan MJ, Willingham DT. Improving Students'
Learning With Effective Learning Techniques: Promising Directions From Cognitive and
Educational Psychology. Psychol Sci Public Interest 2013;14(1):4-58. doi:
10.1177/1529100612453266.
2. 2. Karpicke JD, Roediger HL III. The critical importance of retrieval for learning. Science
2008;319:966–8
3. Peter C. Brown, Henry L. Roediger III, Mark A. McDaniel. Make It Stick. The Science of
Successful Learning. Belknap Press, 2014
4. Hermann Ebbinghaus (1885). Über das Gedächtnis (about memory). Leipzig, Verlag von
Duncker & Humblot
( https://archive.org/stream/berdasgedchtnis01ebbigoog#page/n7/mode/2up )
5. Schmidmaier R, Ebersbach R, Schiller M, Hege I, Holzer M, Fischer MR. Using electronic
flashcards to promote learning in medical students: retesting versus restudying. Med
Educ 2011;45(11):1101-10
6. Kromann CB, Jensen ML, Ringsted C. The effect of testing on skills learning. Medical
Education 2009;43:21–27

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