Mastering the Secrets of Study Productivity

Whether your undertaking a course or degree, at some stage they may find themselves overwhelmed with the amount of knowledge they need to learn. Most of us have worked out what works for them, however you always wonder whether there is a better way. In today's episode of Aussie Med Ed, I interview a specialist in surgical education and ask her about what techniques she is aware of that can lead to more efficient use of a person's study time. G'day and welcome to Aussie Med Ed, the Australian medical education podcast. A program born during COVID times to emulate the general chit chat and banter around the hospital with the idea of educating the medical student and GP alike. I'm Gavin Nimon, an orthopaedic surgeon based in Adelaide, and it's my pleasure to bring Aussie Med Ed to you. And in this episode of Aussie Med Ed, we interview Lisa Hadfield-Law a surgical educationalist years of experience teaching surgeons in over 68 different countries. She's going to talk to us about the various techniques of studying and learning. And how she would approach the study of medicine in current day. I'd like to start by acknowledging the traditional owners of the land on which this podcast has been produced, the Kaurna people, and pay my respects to the elders both past, present and emerging. Well, it's my pleasure now to introduce Lisa Hadfield Lore. She's a specialist surgical educator and she works for the British Orthopaedic Association, as well as the Royal College of Surgeons of Edinburgh. With 20 years of experience, she knows how to study and learn and how to teach. She's going to talk to us about her approach. If she was learning a new course, how she would address the huge amount of information that you need to learn and what techniques she is aware of to study in an effective way. Welcome

Lisa Hello, good morning. So, that's a really interesting question because, of course, the way I would approach things now, in my 60s, is very different from the way I approach things in my 20s or 30s. Partly because we didn't have access to the internet, and I can't believe... We managed anything, uh, before that time. So, with the benefit of hindsight, and understanding what I do now about how brains work, and how brains help us to learn, I would, number one, really get to grips with any curricula that was available to me. Now, when it comes to medical practice in the UK, there are very, very clearly laid down curricula. Because that's what's required by the General Medical Council. But all over the world, with all kinds of programs, there would usually be some kind of curriculum. A good idea of what people are expected to know, and a good idea how that would be assessed. So, That's where I would start really getting to grips with what is expected of me. And I've learned now not to arrogantly assume that I know better than somebody whose job it is to decide what I need to know as a general practitioner, as a physician, as a neurophysiologist, whatever it is. Somebody has taken some time and trouble to clearly define that to start with. So that's where I would start first off. Okay,

basically you'd look at the curriculum or the syllabus and try and analyse it. Would you make notes of it and try and work out what were the important aspects and what were the less important ones? How would you come to terms with what are the important aspects to do in that scenario?

So, I would chunk things up and I would really try to boil whatever the subject is down to seven points. So, seven simple chunks and use that as a sort of framework for then going after what I need. So, say I was needing to learn about... the reason somebody would turn up to an outpatients clinic with a set of symptoms. I would start with that in the middle, the group of patients or the topic I'm looking at, and then I would look for seven areas. That I would need to then flesh out to really understand a subject. That's where I'd start if it were completely new to me. Now, if the topic wasn't completely new and I knew a bit about it, then again, I would take the topic, write it in the, in the middle of a, a piece of paper, and then I would try and put everything I know down. about that particular topic before I start anything. So, just get everything down and start to look for some links and then either go online and look at videos or journals or books to work out which bits were right. And which bits weren't, where the holes are in my knowledge and then how I might go about filling those. That's sometimes called the Feynman technique and that's really useful if you know a little bit about something, which a lot of the topics that your listeners will be addressing will

know a little bit about. Excellent. I certainly know that when I was looking at trying to study, I would try and keep it simple and try not to expand it too much. There's a tendency to try and read as much as you possibly can about a certain subject and then get bogged down by the little nitpicks of knowledge about that. What is your approach? Do you think it's important to try and remember everything or try and get the basics first up?

Well, that's a little bit like trying to drink out of a fire hose. And we can sometimes be seduced, and I certainly have been seduced, into sitting down with a book or some stuff and then ploughing my way through it. Reading it, highlighting, underlining, and then feeling very proud of myself at the end of a very long session because I've done a lot of work. But that is really just reading, trying to remember, and then trying to regurgitate. And what most of your listeners are wanting to do is to learn stuff that is going to last, and learn stuff that is going to last to get through exams. but also to be accessible in real life practice with patients. We don't need to know everything anymore. You, people are not walking around with a great big formulary in their pocket anymore. Stuff is accessible, but we need to know where to access it, how to access it, and what we're looking for. So, Making structures, filing systems if you like, about what we need to know, how we access it, to then use that to make decisions and to recognise patterns. That's what we're after. We're not needing to remember and regurgitate stuff anymore. That happened quite a lot with my generation and I have loads of stuff in my head. That is no use to man the beast. So I can draw out the carpal bones beautifully for you But I wouldn't be able to recognize those on an x ray and that so therefore that's that's not really any use to anybody Certainly not me

So really keeping it simple and trying to know approach to where to go for to expand your knowledge when you need to is The way to go almost like A lot of the open book exams that some of the courses offer as well, where it's not about actually remembering the individual information, it's actually about an approach to actually addressing the answers.

Exactly right. And that's why these sort of, these filing systems in your mind are so very important. And that's why I start with topic 7 issues, major points around that topic and then fleshing those out. Another really important thing for clinicians to remember is If we go back to that carpal bones example, the reason that isn't any use to me is it's not linked to anything. The way clinicians hold things in their head and make them accessible is around what educators sometimes call illness scripts, and what you and your listeners would call patient scenarios. So, in our minds, we will have a whole load of patients we've heard about or experienced and stuck to those patients will be lots of theories, lots of differential diagnoses, lots of investigations, that kind of thing. So, if I give you an example, I've been out of clinical practice for 20 years now. But having come across an accident the summer before last, as I was running towards the person lying in the middle of the road who'd been hit by a lorry, I, I wasn't thinking, ooh, what are the list of things it could possibly be? As I was running towards her, There were all kinds of patients I've looked after in the past that we've talked about, I've read about in journals, I've heard about on ATLS programs, and looking for matches. What, how was she moving? What was she sounding like? What did the environment look like? And it was all like a really quick match with lots of pictures and images in my mind. So we know that that's how people hold stuff. In their long-term memory that will then be accessible when we need it in practice, in outpatients, in the ed, in general practice rooms. And that really

reinforces the whole approach of actually the more you see, the more it makes it easier to learn things. Exposing the students to the clinics and the theaters helps them remember information.

Yeah, so what, what happens is we've got in our long term memory all these illness scripts, all this stuff that's connected together amazingly, and when we are seeing something in theatre or in clinic or on ward rounds, The relevant stuff is pulled back into our working memory, and new things added to it, things changed, and then put back. So it's that retrieval and putting back that is crucial in practice, but also what is required when you are revising. So, really good revision is about retrieving stuff back into our working memory, adding new stuff, changing and putting it back. It's that ability to pull out what's in our long term memory. And so, Really good revision shouldn't feel comfortable because it needs to be about sort of half forgetting stuff and bringing it back out and it's not comfy. If you're sitting revising, reading things and underlining and feeling very proud of yourself, if it's feeling lovely and comfy, it's, it's probably not working. Certainly,

I know the Feynman technique involves this as actually questioning what you're reading and simplifying it to help you remember things.

Yeah, absolutely. So if you're learning about something, reading about something, or you're in a lecture, or you're listening to a podcast like this, being able to listen, then stop, look away. Um, try to explain what you've heard in your own words is a fantastic way of revising. And another technique is something called the Leitner system. And I thought this was really excellent. So essentially, you have either physical boxes, five Physical boxes or online boxes. And so, as you're practicing that retrieval of concepts, information, combinations of information, as you're practicing retrieval, once you, you have your five boxes, one of them you review daily. Another, the next one, number two, every other day. The next one, number three, every four days. The next one, number four, every nine days. And the final one, the fifth box, is every two weeks. So every time you manage to retrieve or explain or you're confident that you know something, you move that topic, that bit, up a box.

Yes, that system is certainly a good way of providing repetition and also questioning as well at the same time.

Yeah, it's that retrieval. It's that retrieval. It's a little bit like treading a pathway into your long term memory and treading it back again. The more you tread it, the more you'll be able to find it when you really need it.

What about the technique or concern that you often get of actually trying to buy more and more information or look for more information? That golden... book that will help you remember everything perfectly. Is that a good technique or is it better to stick with one text or one or one or two texts that help you learn things and focus on that, which covers most of what you need to know?

It's so interesting, isn't it? Because my sister and I always laugh about that. When we want to learn something, we buy the most expensive book we can find and then assume that that's going to do it. Of course, if it's left on your desk and just looking at you, it acts actually a little bit like a guilt bomb, because of course it doesn't work. Also, because of my generation, we, we loved books because that's all, all we had. But of course now, Things date so quickly. And if you think about how long it takes to turn a book around and the process of publishing it, by the time it comes onto the market, often it's already out of date. So I tend not to use Many books now. And I will use journals, I will use podcasts like this, and I will use sources from the internet. But again, it's difficult, isn't it? Because there's so much stuff, how do we know it's reliable? Well, that, I think, again, uh, uh, being an older learner now, and, and I have got some areas of expertise. I'm able to be a bit more discerning and work out what are, what's, what are reliable sources and what kind of information I can trust and what I can't. But if we go back, Gavin, to the curriculum, oftentimes with a lot of our curricula, there are recommended resources. And again, go, go back to, who are you working with? who is an expert and who can recommend some really useful resources. That's what I do now. If I'm new to something, if there's an area that I'm really not confident that I understand the landscape, I will find somebody who does, who understands the landscape and also my needs in terms of being a learner.

Once you've got this information, what's the approach to actually trying to retain it? We know we talked about the repetitive nature and the questioning nature. What about actually the actual process of actually sitting down and studying? You know, there's a tendency to have the music in the background or do it in front of a TV or do it when you're rushing late at night. What are the best approaches to try and retain this information?

Okay, so the really, there are some important principles here. We've said that retrieval practice is crucial. That's what learning stuff is about. Treading the pathway into your long term memory, retrieving, half forgetting and retrieving again. is something very important about spaced out practice of that retrieval. So that, if we go back to the Leitner system of daily, every other four days, nine days, that spaced practice of retrieving stuff and not cramming is really important. My generation loved a good cram. They loved the good squeezing a load of stuff in the night before. We understand much more though now about the role of sleep. Sleep when it comes to learning it, it's a little bit like when you go to sleep. Your, your mind is, is all tied it up and, and it's like sorting out the hard drive of your mind and duplications wiped out connections that you weren't aware of. Start it, it, it binds and it strengthens and it reinforces the connections. So not enough sleep is an absolute disaster. So my generation who would sleep for two or three hours, That was a real mistake because it's not enough time to solidify knowing all that stuff. So, sleep is crucial. There's an interesting thing here. There's something about learning something just before you go to sleep. That is very powerful. So, I, for a long time, thought relax back, do something different. No, it looks like having a good review of some important stuff just before you go to bed might really work well. So, space learning, getting enough sleep, time. Now, probably no more than 90 minutes before you stop. and do something else. So you're not crowding that pathway into your long term memory and back out again. So 90 minutes. One technique, the Pomodoro technique, and it's only called that because the person who invented it had got one of those plastic tomato cooking timers and would set it to 25 minutes. No phones, no distractions, no TV, nothing. No music, just really hyper focused for 25 minutes, and then go and do something completely different and active for 5 minutes. Then back for 25 minutes, really hyper focused, do do do do do, and then go away for another 5 minutes, um, and do something completely different. That's called the Pomodoro Technique, and that has got some really, really good results. The distractions thing is an interesting one. So clearly, you've reduced as many distractions as you possibly can. So you go somewhere where there isn't going to be loads of stuff going on all around you that will distract you. Get your phone out of the way. Because actually nobody can multitask no matter what they say. The music thing is interesting because lots of people really enjoy music and really like it and want to have it in the background. But the bottom line is, we know it is distracting, no matter what kind of music it is, whether it's... Classical, whether it's rock. You may like it, and as long as you're doing something where you're on automatic pilot, you're fine. But if you're trying to learn something, it will get in the way. We know it dilutes the content. The distractions

point is a really important thing. I recall while studying, the number of times I actually thought of jobs that I suddenly would want to do. Where normally I would never wanna do them was really quite annoying to yourself. And I would find by having a break and getting those little jobs outta the way would actually take that off those off of your mind. And so you get back on with the study.

Yeah, that's, that is a good way. And then you feel as though you've got to the end of the day really productive.

Yeah. For a long time I've actually noticed the benefits of studying the night before or actually reading what I've already read during the day, the last minute, just before I go to sleep to help consolidate my knowledge. And I still use that technique while operating. If I have a difficult operation coming up, I'll be reading through those notes in advance, looking at the patient's notes and looking at my resources, just before I go to sleep. And I'll wake up feeling like I've done the operation three times in my head. When I go into surgery, I feel so much more confident in doing that.

Oh, that's really, that's really interesting. And I wonder, Gavin, whether when it comes to doing your complex or high performance surgeries, It might be worth you thinking about doing some cognitive simulation, which is not just sort of thinking about it and thinking about the steps, it's recreating using all your senses. the night before and going through the operation as though you are doing it in your mind's eye. There's some amazing results from that as well. So that's, that's worth thinking about when you're doing something practical, whether it's a very complex procedure that you're doing or for our medical students or GPs, some of the practical procedures that are just new and difficult. While you're, you're learning how to make them, just part of

what you think it explains to the listener how you might use this technique for practicing, say, the shoulder examination? Could they use this technique going to an OSCE, they might get a shoulder examination as a case? They could use cognitive simulation as a way of... Being aware of it prior, in the weeks leading up to it. How would you do that if you were going to that sort of approach?

So the trick here is it's multisensory. So it's using all your centers. You are going into a patient in your mind's eye. You are seeing, you are hearing, you are feeling what, what you're feeling at the end of. fingers and also where you're standing in relation to the patient. Sometimes even smelling familiar scents in the, for example, the outpatients department or in your GP surgery room. It is recreating it and going through it as though you're actually doing it. And the, the results from that Significantly impact what happens when you go into a real patient. It's as, as you said, Gavin, it's as though you've done it before, because you have. It's just in your mind.

Exactly. I think it's a great way of actually practicing this technique. Being prepared mentally is a key. I'd like to let you know that Aussie Med Ed is supported by Healthshare. Healthshare is a digital health company that provides solutions for patients, GPs and specialists across Australia. Two of Healthshare's core products are Better Consult, a pre consultation questionnaire that allows GPs to know a patient's agenda before the consult begins, with the aim to reduce admin and free up time during a consult, and Healthshare's Specialist Referral Directory. A specialist and allied health directory integrate into GP practice management software, helping GPs find the right specialist. You can find out more from healthshare. com. au

I mean, the bottom line is when it comes to not just knowing stuff, but doing things, again, it is deliberate practice that is the key here. It's not just doing something a lot of times. It's doing it with real purpose, really thinking about what you're doing, really pushing right to the edge of your comfort zone. So again, practice. It's not just feeling lovely and having a great time, that's just doing something without any purpose. And that does feel very nice. Really good practice is hard work.

What other things do you need to take into account when you're trying to study? We've talked about obviously getting a good night's sleep and studying at the end of the day as well to help consolidate your knowledge. But what about the use of caffeine and coffee to help you remember things, or also sugary drinks to help keep you motivated and fired up? Do those things actually help you, or are they actually more of a hindrance? So

interesting. The latest feeling is that looking at really healthy, nutritious... Snacks is much better than those sugar spikes and the caffeine spikes. The next generation is so much better than us at really being aware of eating and drinking healthily. One really interesting tip that I learned from a student and I laughed at when I first heard, he said chewing gum whilst you're studying has had some really good results and so I laughed and thought he was joking. He came in the next day with some really interesting evidence. It looks like it might be increasing blood flow in the head. Who knows? But it seems that chewing gum whilst you're studying can have a positive impact on how much you retain from what you're studying.

And also exercise is supposed to be excellent for remembering things. Whether it's the break to give you a chance to consolidate your knowledge. Yeah. Also the process of actually going for a walk or when you're swimming. Just thinking about what you've learnt.

Or reflecting, yeah, because if you think about it, reflecting, that again the next generation are so much better at, that is a form of retrieval practice. Looking at the role of exercise in learning, obviously we now know that it will, exercise increases mood and reduces stress, and stress and emotions rushing around is very distracting, but what exercise does. Is it produces something called BDNF in the brain and that's a bit like fertilizer for the dendrites and so that really results in growing dendrites and making connections between. So that's the theory but it looks like exercise can have a really positive impact. So maybe we can think about how that might fit in with the Pomodoro technique and it might be that going for a brisk walk. every 25 minutes or every 90 minutes. Combinations of all these things can really make a difference because Learners come in and it's a little bit like all of our listeners here come in with different experiences, different bits of knowledge, lots of straggly weeds that need connecting. And whatever you can do to make those connections, build those links and patterns as a learner will help you retain what you need, whether it's for exams or for managing real life practice.

Well that brings me to one of my questions I had jotted down to ask you is about study groups. And I suspect you've probably answered it in the sense that a study group is not much use if you're sitting there passively, but if you're actively involved in questioning and thinking about it, while you're involved in reviewing information you've already read about, it actually strongly reinforces your memory on that scenario. Is that correct?

Yes, there's also that feeling of connection. I think while people are studying for exams, I think it can be so isolating and things get way out of proportion and it isn't a very healthy state for a lot of people. So, having those study groups where people come together. Compare notes, share ideas, test each other. And that testing each other can be incredibly powerful because as we've said, retrieving stuff from a long term memory, adding new stuff to it and putting it back is really what revision is about. So, if you have People who come together and challenge each other, that can be incredibly powerful and reduce that sense of isolation, particularly prevalent during the exam period.

And everything you've said seems to go against what I initially tried when I first started at school, which is reading a textbook, noting it and not even thinking about it, writing it down and making a new textbook in your own handwriting, and having music in the background, all those things. probably are against what we've talked about already and it's why, you know, that technique doesn't work that well. And

it's so interesting, the more we know... the more things change. And it's the same with loads of aspects of medicine. If I think back to how gastric ulcers were managed 40 years ago when I started, we did the best with what we knew at the time, but we know better now. So I do look back sometimes and think, goodness, I could have, what I could have done if I'd have known how my mind works when it comes to learning. But we didn't. We did our best at the time, but we know better now. And we need to be careful not to fall back in to old habits because it's what's familiar. There is something about making handwritten notes that can't be replaced by making notes on a keyboard. There's something about the pace and the shape of writing notes that really helps in a way that making notes on a phone or a laptop doesn't. So it's worth thinking about that. But in, instead of the rote learning that you and I did, now really good establishment of knowledge foundations boils down to good project management. So setting easy, accomplishable goals with a clear plan of where we're going, not the timetables that we spend days creating when we were revising and then actually didn't get down to doing any work, but really thinking of going back to that. What's the topic? Let's make it simple in seven parts and then really going for retrieval practice. And there's a really useful quote for me. He or she who sweats more in training Bleeds less in wool.

That's excellent. Well thinking about the different things we've talked about today. I've actually been making some notes myself And whilst I hate acronyms, coming up with a little acronym myself is like PETTASK, PREPAREDNESS, EFFICIENCY, REDUCING DISTRACTIONS, TIME, DON'T OVERLOAD YOURSELF, REPEAT, DO IT AT THE END OF THE DAY, TECHNIQUE, ANALYSE, SIMPLIFY, and then communicate it back to yourself with my little acronym as I've been raking notes as we've been speaking. I don't know if that's of any use to people, but what are your thoughts on that one, Lisa?

I'm going to write that down. Any of these acronyms that... Again, it goes back to that structure, doesn't it? Gavin, let me ask you, how do you remember the colours of the rainbow? Visualising the

colour, the rainbow, but particularly by the acronym ROYGBIV is how I remember them colours, so. So

that's interesting. I remember it like this. Red and orange and green and blue. So I can't recall without singing that song to myself. So whatever it is, whether it's a song, whether it's a rhyme, whether it's an acronym, a mnemonic. Whatever helps you and gives you a bit of structure that you can retrieve in practice or for an exam can work brilliantly.

That's brilliant. Yeah, and I certainly did, you remember, destroy my textbook or notes by putting colours all over it, like almost like a mini mind map over my notes to try and help me remember things.

Actually, that's just reminded me about how I manage books now because I still fall into the trap of, oh, if I don't know something, I'm going to buy a book about it. But now what I do is I will get a book, look at the contents, go straight to the conclusion and then decide what I need to know. to get to that conclusion. And I write all over, I'm writing in the margins, I'm writing in the fly leaves. My books have all got loads of stuff written all over them. And for me, that's what makes a really

great book. Exactly. I think it also helps your picture or reminds you of the different parts in it. If it's all just black and white and in columns, it's hard to remember it. But if there's a bit of information written on the side, it helps you remember that little. And again, it's probably doing what you were talking about right at the start, which is reinforcing and questioning what we're, what you're reading. Look, that's excellent. I think we've covered a fair bit today and I really appreciate your time. Lisa, have you got any closing thoughts on this subject? Just

remember. We are learning to last. And the techniques that were used in the 80s, 90s, early noughties, we know better now. So, think about planning, project planning your learning and you will get so much more out of the time you spend learning. So, you're not just doing more and more and more. There's a great story about a woodcutter. Going into the woods because he's been asked to chop down as many trees as he can, and he rushes in with his lovely sharp axe, cuts down on the first day 10 trees, the second day four trees, the third day one tree, and then was discovered sobbing because he hadn't. sharpened his axe between he hadn't planned how he was going to sharpen the axe, how often he was going to sharp the axe. And the result was by the third day, he wasn't getting anywhere. So work out what your plan is and how you're going to keep your axe sharp. Excellent.

Well, thank you very much once again, Lisa. Lisa Hadfield Law, it's great having you on board on Aussie Med Ed. Really appreciate your time on this really important subject.

No problem. Good luck everybody.

Thanks again. I'd like to thank you very much for listening to our podcast. I'd like to remind you that the information provided today is just for general medical advice and does not pertain to one particular medical condition or one way of treating a particular condition. If you have any concerns about the information raised today, please do not hesitate to contact your general practitioner for further information. We hope you've enjoyed the podcast. And please don't hesitate to give us a review or tell your friends about it. We look forward to presenting another podcast to you in the near future on a different topic. Until then, stay safe. Thank you very much.