Disrupting The DSM-5 & How to Memorize Numbers

For someone who blogs a lot about memory, a post on the DSM-5-TR was inevitable. For the uninitiated, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) is a 1050-page guide published by the American Psychiatric Association outlining the criteria for around 300 psychiatric diagnoses.

Part of the PA school curriculum in my final semester of didactic year is to memorize the criteria for each disorder, little by little, week by week.

Here’s an example of one:

Now, we don’t technically need to memorize it word for word, but anything there is fair game to test on. We’ve been responsible for anywhere from 3-10 of these a week for the past three months.

With a healthy mix of distinguishing features, time frames, age-ranges, and number of criteria needed, the DSM-5 is the purest test of raw memory that I’ve encountered so far in PA School. And without a solid memory strategy, it can become a grueling slog of time-consuming repetition.

And this challenge is largely because it involves the memorization of a lot of numbers. It’s tough to keep each disorder separate. “Oh, did this one need three criteria or two criteria, and was it 3 months, 6 months, twice weekly, or no time frame at all?”

And I firmly believe that numbers are the most abstract and arguably the most difficult thing to remember, ever. There are countless posts and tricks online to help memorize numbers. I talked about this problem back in January when I trialed the Major System (which didn’t end up working out because that’s better suited for long strings of numbers). Think about how hard it is to remember a simple phone number. Before smart phones and when you were without a pen it was always: “Okay you memorize the first three digits, I’ll take the middle three, you take the last four.”

Try to remember these three words:

• Adam Sandler

• Billiard Ball

• Cat

Now try to remember these three numbers:

• 3

• 8

• 9

Words are much easier to remember, yea? You can picture them. You can come up with similarities or make up a story: “Adam Sandler playing pool with a cat.”

But what does the number 3 look like? What does it sound like? What does 3 make you think of? Well if you’re normal, probably nothing… it’s just a number. Unless it’s your favorite number or if you have it tattooed on your hand, it’s just not memorable. And what do 3, 8, and 9 have in common? I have no idea. Numbers are pretty arbitrary and it’s difficult to make connections amongst them.

But what if numbers… weren’t numbers?

If numbers are objectively hard to memorize, and the DSM-5 requires the memorization of a lot of numbers, I’m making the argument that you should… stop memorizing numbers.

Let me explain.

In one of my very first blogs I came across this post on a forum called “The Art of Memory” where a user said they had converted every number from 1-100 to an object or a person. I laughed a bit at that idea… until I tried it for the numbers 1-10. I stopped laughing. It works insanely well.

So here’s the trick: You should convert the numbers 1-10 (and beyond) to literally anything else: people, shapes, objects, foods, family members, celebrities, whatever. The more ridiculous, the better.

The number 1 for me is anything Pixar related (My #1 favorite movie studio): the Pixar Luxo Lamp, Woody, Steve Jobs (he was a founder), etc. Two is any set of twins: Olsen, Lindsay Lohan from The Parent Trap, real sets of twins that I’ve encountered in life, etc. Three at first for me was just Adam Sandler (I don’t have a clear reason for that one; it just stuck) but the number 3 comes up so often in the DSM, that I expanded to Drew Barrymore (his co-star in 50 First Dates), Happy Gilmore, etc. Eight is a billiard ball or a pool table. And 9 is a cat, Cat Woman, Anne Hathaway (played Cat Woman), just to name a few.

The absurd picture of a horse (my number 5 because 5 kind of looks like a seahorse) riding a cat (9) helped me remember that the age peak for Specific Phobia was 5-9.

The slight learning curve of remembering who or what signifies what numbers takes a fraction of time compared to how much time I’ve saved by using this strategy. The incidence of interference with the DSM is insane. Was it two criteria or three criteria? I would never confuse the Olsen Twins for Happy Gilmore. 

The other thing you can do is convert time periods. For me, 1 year is Santa or a Christmas Tree. So Happy Gilmore (3) attacking Santa (12 months) with a hockey stick (a physical act of explosive anger) is 3 criteria in 12 months, part of the criteria for Intermittent Explosive Disorder.

Six months is Fifty Cent (half of a year) or any rapper. So suddenly Snoop Dogg (6 months) underneath the Pixar Lamp (1), is 1 criteria in 6 months, for Specific Learning Disorder.

One week for me is a margarita (like at a happy hour at the end of a long week), so suddenly two twins (2) making a toast with margs (1 week) while a limo pulls up with a small rapper like Little Bow Wow (3 months) is: 2 events, weekly, in 3 months, the exact criteria for the other part of Intermittent Explosive Disorder.

Yes, I actually study like this. No, it did not take long to memorize who or what represents each number or time frame. If it took longer than 2 hours to memorize the entirety of 12 DSM-5 criteria, I’d be lying. I run through it once (combining this strategy with a memory palace), once again an hour later, and then once more the following morning, and I know I have it committed to memory. There’s little reason for me to have to review the information again before the quiz. It’s impossible to forget an image of Snoop Dogg under a Luxo Lamp, or Adam Sandler fighting Santa. Scenes like this that you can combine in any way you want are infinitely more memorable than just abstract numbers and has made tackling the DSM a breeze.

The magic of this is that you can scale this as high as you want. 18 for me is Ulysses S. Grant or the Civil War (he was the 18th president). So suddenly a Civil War battle with each side throwing eggs (my code for 6) at each other are the ages of 6-18 for Disruptive Mood Dysregulation Disorder.

As a side note, converting numbers to their respective presidents was extremely valuable for me for Women’s Health. I always have trouble remembering milestones for the weeks of pregnancy. Suddenly a cannon (15 for James Buchanan) being operated by Cleveland from Family Guy (in Grover Cleveland’s first presidency he was the 22nd) was the time-frame for a Quad Screen. A landslide (for Landslide Lyndon B. Johnson) for 36 helped me remember when to test for Group B Strep.

I know it sounds insane, but it’s been the most effective way for me to remember numbers, which have been the bane of my existence since the start of PA School. Blood pressure thresholds especially… for strokes, pre-eclampsia, grades of hypertension, etc. Those are tough to remember. But suddenly Abe Lincoln’s hat (16) with polka dots (James K. Polk = 11) gives me the severe threshold for preeclampsia of 160/110.

Obviously some knowledge of the presidents was necessary here (I only knew a handful), but I just looked up who went with which number and it stuck.

The biggest barrier to strategies like these that I’ve heard is “I don’t have time to come up with stories or convert numbers.” I’d argue this strategy affords you extra time. Ask yourself how many times you have to repeat a flashcard, or look over a DSM Criteria for it to stick and even with that, just to stick long enough to survive through the quiz until your forget it entirely. How much time are you actually spending when you really add it all up? And then how often do you have to revisit that same information again before the exam?

Behavioral Health in PA School deserves to be an event at the USA Memory Championship. And I treated it as such the entire summer and it’s been one of my strongest (and most enjoyable) classes all year.

And I believe this class has become this big reason the summer semester can appear so brutal because memorization takes time. But it doesn’t have to. If you spend your time hammering in nails with a rock, it’s always worth it to take a day to put down the rock and build a hammer out of steel. Do you lose an entire day’s worth of progress? Sure, but you’ll save weeks to months of time in the long run. It’s about memorizing information in a way that makes it stick so you don’t have to keep returning to it.

And maybe I was the only one who had issues memorizing numbers. But after 11 months, I’ve finally found my solution.

Three weeks and I’ll be a P2. I’ll see you then.

Summer Semester, The Problem With Memorization, and What PA Students Can Learn From Memory Athletes

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:

1. The Method of Loci / The Memory Palace

2. Free Recall

3. 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.