17 PowerPoint decks, 942 slides, and 39,273 words. That was the amount of content I was responsible for yesterday morning for my second exam of my final semester of didactic year of physician assistant school. It was an absolute monster of an exam, on the entirety of orthopedics and dermatology, including pathophysiology and pharmacology.
It got me thinking… how many words exactly is 39,273? Considering the content I was faced with, I thought it had to be at least the entire length of a Harry Potter book. But when I did the math, it was only 51% of the entirety of the shortest book, The Sorcerer’s Stone, right about at the part where Harry learns how to fly a broomstick for the first time. Especially as an adult reader, half of that book—isn’t really that much information. You could read half of that book in a day and I could ask you questions and you’d probably get most of the questions right without having to study. So why is learning the same amount of words, provided on PowerPoint slides, so much more difficult? Well, because a story is memorable, right? A story has a setting, and a plot, and characters, and humor. It has themes that connect to your life and is relatable, even if it’s a fantasy. The study of medicine often doesn’t have any of those things.
But what if it did? What if Multiple Myeloma, a Lisfranc joint injury, Paget’s Disease, and Dyshidrotic Eczema were as memorable as a fantasy novel? And what if you could be the author?
The Problem With Memorization
We’ll talk about storytelling in a second, but first we have to talk about memorization.
The problem with memorization is that we don’t talk about it enough. We don’t acknowledge that a strong memory is one of the most powerful skills during didactic year of PA school.
There’s a science to medicine and we spend our time in PA school focused on understanding pathophysiology, medication indications and side effects, but we don’t spend any time on how to tackle or retain that information. There’s a science to learning and I think we really overlook it.
I think we have to be comfortable with the fact that memorization is a big requirement for PA school, as well as many other disciplines. But that’s okay—memorizing is still a form of learning. And there are simply better ways to remember things. We shouldn’t be annoyed when we’re met with a list to memorize; actually we should celebrate because it’s a lot easier to memorize a list than most people realize.
There are many things that memorization doesn’t work great for, like complex pathologies, how osmolality works, the Renin–angiotensin system, how to read an EKG, etc. But the problem we students face is we can’t give those processes the time they require because we’re inundated with material that needs to be memorized. The best strategy is to fast-track what needs to be memorized so you can spend your time truly understanding those other processes.
I think there’s a misunderstanding that to memorize something, you just have to repeat it over and over again until it sticks. That works well for shooting three-pointers and hitting a fast ball, but PA school is a different ballgame. You don’t need muscle memory, you need memory… with muscle.
You can brute force rote memorize anything—but that takes a lot of time, and you’ll likely forget it in 24 hours. So why do it? And the bigger issue with rote memory techniques like flashcards is that they don’t battle interference. Sure you can recite that triad, but do you remember what disease process it belongs to? You know what Auspitz’s Sign is—but do you remember what skin condition you see it in?
The Memory Experts
Listen, in any other part of your life, who do you look to for advice? The experts. You’d go to a personal trainer for fitness advice, or a pro athlete to learn how to throw a football. But who are the experts of succeeding in PA School? There is no olympics of learning—or is there? To me, it’s critical to break down what the actual constituent parts of academic success are.
What is succeeding? Passing, graduating. Okay, so interview the top students in the class and those that graduated before you and see how they studied. You could do that, but class intelligence and performance are spread across a bell curve. Some students are just more gifted than others; some can read through a slide deck right before a test and do just fine. I’m not one of those people so it doesn’t make sense to compare myself and you shouldn’t either. So now what? Well what do you have to do to pass? Score well on an exam. And how do you score well on an exam? You have to remember the content from the lectures. Well how do you do that? You have to study that material. Well how do you study? Maybe you look at a flashcard and try to remember what’s on the other side. Well, how do you know if you studied effectively? Well, if you remember what you studied when you’re taking the exam. If what you studied… stuck. If Topic A doesn’t interfere with Topic C. If you remembered what belonged where.
And there it is. The core skill to passing an exam isn’t how you studied, or how long you studied, it’s simply what you remember.
And who knows the most about remembering—who are the experts of memory? They’re not medical students or law students; they’re not students at all actually. They’re the folks who who practice memory on a professional level at the USA Memory Championship. And yes, that’s a real thing. Things that we devote hours of our time studying, like a list of 16 diseases that cause rashes on the palms and soles, memory athletes can memorize in seconds, and they do it for fun.
And what strategy does every single memory champion use? It’s called the Memory Palace / Method of Loci / Roman Room and it entails harnessing spatial memory of locations you’re familiar with and mentally placing pieces of information in those locations. It’s easy to learn and will change your academic life. It’s certainly changed mine.
And no, the memory athletes aren’t savants; they actually all have average memories (as do I). I just finished reading a book called Moonwalking With Einstein, where a journalist who was writing an article on the USA Memory Championship learns the techniques and then wins the competition the following year. And I want to give you an idea of what this competition is like. One of the events is called Speed Cards. You’re given a full deck of 52 randomly shuffled cards. You have as much time as you’d like to memorize it, in order. When you’re done, hit your buzzer and then you have 2 minutes to put another deck of cards in that same exact order without looking at the first one. How long would it take you to memorize the sequential order of 52 cards? An hour? A day? Do you want to know what the world record is?
Under 14 seconds.
Do I have your attention? The Method of Loci is that powerful. And I now almost exclusively study using this method, replacing rewatching lectures, taking extensive notes in class, and using flashcards.
And it’s been an absolute game changer for me. It’s allowed me to maintain a consistent sleep schedule now for 10 months and I’ve yet to miss a single hour of sleep. It’s been a breath of fresh air and I truly think it can change the way we think about PA and medical school and academics in general. It’s by far the most powerful, efficient, and longest-lasting study technique I’ve ever encountered, and it’s not even close. And I think more people should consider using it.
Storytelling: My Current Study Process
I’ll walk you through exactly how I study and use this technique and narrate how and why this works.
The first step is to look at each slide deck and figure out who the players are. How many distinct “characters” or disease processes are here, especially those with distinct treatments? And also, how much weight, or how many slides does that process have? And that looks like this:
I try to put everything into groups, or families. It’s a simple outline—nothing groundbreaking. Then I put each “family” into a matrix, or table, that looks like this:
Then I fill the table in with all of the details I think are important. I usually do this in class, in real time. Sometimes I fall behind, which is fine. But I’ll sort of passively listen to my instructor and pick up on hints; sometimes they allude to important topics, or even more valuable, tell us which slides are just “fun facts.” If they say “You definitely need to know this” it goes in my chart. I use a combination of what they’re saying, and my own judgment for what I think is important, unique, or testable. I ask myself, “If I was writing this exam, what would I ask?” I leave a lot behind; most topics require less than 5 things to memorize. Oh this condition warrants a CMP and this one needs a BMP? This one has fatigue and dizziness, and this one just has fatigue? Is that important in practice? Maybe. But I’m not there yet. I’m just trying to pass an exam. Even if it’s tested on, it’s one question, so it’s not worth my time to memorize the labs and generic symptoms for 150 diseases to score .8 points higher on an exam. PA School is about playing the numbers and you have to be comfortable leaving things behind. Shoot for 90s, not 100s.
Anyway, sorry for the rant. You’ll notice I use numbers instead of bullet points in the table. I try to make every thing very singular: Concept 1, Concept 2, etc. These are the 7 things I want to remember? Perfect.
Once I repeat the above process for the entire content for the exam, I build a dashboard that looks like this:
Then I write a story, preferably using a real location, as all of the Memory Champions do. For the above, I used my school library. Each row, each unique disease process, gets a scene and it looks like this:
It’s silly, entertaining, and a tad crude, and that’s precisely the point, because that all makes this information infinitely more memorable. Forever, dyshidrotic eczema will be synonymous with my school library elevator and I wrote the scene you see above sitting right in front of it. I wrote 60 scenes for Dermatology, and 55 for Orthopedics. Some of them just have a couple of points to remember, others have 10. I don’t always go to the location in which I’m referring to; I use a lot of locations from my past like hospitals I used to work at.
So I write the scene, encoding each bullet from my table into it, then immediately look away from my computer and recite the entire thing back. Then I set a timer for 1 hour, and repeat it the scene again from memory, and then once more the following morning, after a full night’s sleep. That’s an important part of this. The science says that memory is improved by quality sleep, so it’s critical that you stick to your sleep schedule above all else. You’ll see those 1 hour and 1 day milestones in the dashboard; I use that to battle the forgetting curve; it’s simple spaced repetition. I audit what I remember each time to make sure I didn’t forget anything. And every now and then, I do. But I’d say I remember 95%+ of what I encode in a scene as long as I stick to my schedule. And after that third repetition the following morning, not only do I remember nearly all of the information word for word, I remember it for weeks to months after. Just today I was asked what the treatment was for Tinea Versicolor. I wrote a scene for it for my Infectious Disease exam 81 days ago using a park behind my apartment building. So all I did was think of that location and I saw my old neighbor Celine standing there who I wrote into the scene to help me remember the treatment: Selenium.
And I know what you’re thinking, “Oh I don’t have time for all that.” I would argue that, per minute of time, this is the most efficient way to study. Does this process take time? Of course. But it’s extremely time efficient because it encodes new information into the already existing long-term memory of locations. With a dashboard, you can statistically give each concept equal time and repeat it at spaced intervals. Every minute of studying becomes incredibly purposeful and, more importantly, trackable.
Here’s why this works. Think about your childhood home. Will you ever forget the exact layout and every piece of furniture there? Never. Spatial memory and those neurons that hold that information are incredibly long-lasting. A Memory Palace works by taking new information and just placing it next to rock-solid long term neurons that already exist rather than painstakingly try and build new ones. Imagine a bunch of “full” storage boxes in a closet. And you have five new items you need to store. Sure, you could purchase or put together a new box, place those five items in and then put the entire box in the closet, taking up a box-worth’s amount of space even though that box isn’t completely full. Or you could sift through your already existing boxes and find little cracks and crevices to store your new five items, using the boxes that have been inside for months or years. That’s the idea here.
I encoded all of the different types of eczema in one section of the library near the elevator. Then I moved to the back and encoded all of psoriasis in an area around a giant statue that looked like a dragon scale. Distinguishing buzzwords between the two, like “Silver Scale” or “Tapioca” became effortless because I’d never confuse an elevator in the middle of a library for a sculpture in the back of the library. The plague of interference, which can mean disaster on an exam, is eradicated.
This also works because I’m not studying just words on a page anymore. I’m making Bullous Pemphigoid and Ewing Sarcoma come to life. And I use cartoon characters, family members, Pokemon, and everything in between to make things stick. I convert medications and numbers to objects and people and just place them along the path of these memory palaces. It’s engaging, allows me to be creative, and makes me laugh. I’m making studying as close as possible to a fantasy novel—and it’s pretty magical.
Onward
At the end of the day, PA School of course isn’t just about memory. Like I mentioned before, there are tons of things that require you to understand them from the inside out, and memorization can’t help you there. But when you’re tasked with memorizing a list of 50 pediatric milestones, or the side effects of countless medications, or the DSM-5-TR criteria, those are tall orders and can take up an inordinate amount of your time. And I’m here to tell you I think there’s a way to get some of that time back.
I don’t memory palace everything. It works best when you’re flooded with either long lists or a lot of “buckets” of things you need to distinguish amongst. I’ll still use Anki for one-off concepts, definitions, and things like that.
After being at this for 10 months now, I think the ultimate triad of learning is:
The Method of Loci / The Memory Palace
Free Recall
Spaced Repetition
The process I use hits all three and I would simply never study in any other way. So if you’re looking to raise your GPA, study less, get more sleep, or are just looking for a new way to study, reach out. I’d be happy to teach this process to anybody.
I’ll see you in the next one.