Almost every medical student must be familiar with the overwhelming feeling of sitting in front of a large pathology textbook filled with pages and pages of small print. Each piece of information seems highly significant and impossible to exclude; after all, pathology is the foundational branch of medicine. All medical students want to understand and retain information, but numerous approaches are applied to reach that common goal. As a medical student starting my clinical years at the University of Zagreb School of Medicine, Croatia, I’d like to share my approach to learning pathology – while studying for board exams as well as for the USMLE Step 1 exam.
The four processes
The model that describes my style of studying pathology comprises four processes that overlap: understanding, problem-solving, active recall, and spaced repetition. I have used an example of studying the pathology of brain tumors, which encompasses patient profile, epidemiology, pathogenesis, histopathology, and clinical presentation of each tumor. When seeing the information for the first time (through a textbook or video lecture), asking questions such as “Why is this feature specific to this tumor?” helps me gain a better understanding. For example, while reading about glioblastoma multiforme, I may ask myself: “Why does glioblastoma cross corpus callosum and why is it called a ‘butterfly tumor?’’’ Links and connections make the information easier to encode and remember, compared with a random fact. After gaining a general understanding of a topic, problem-solving in the form of questions presenting real-life medical cases is the next step to deepen the understanding and apply the learned information (1).
Repetition, repetition
Nevertheless, each piece of information from a textbook, a video lecture, or a question has a “forgetting curve.” In other words, if the information is not recalled after a certain amount of time, it will be forgotten. From my experience, the flashcard application Anki is ideal for retaining this valuable knowledge, especially knowledge extracted while problem-solving. The two already well-known tools for long-term retention of information that drive the fundamental features of Anki are i) active recall and ii) spaced repetition. Compared with passively rereading or reviewing information, the active recall of information imposed by Anki (in the form of a flashcard question) is a much more effective method in the long term (2). Moreover, Anki’s algorithm uses spaced repetition as a means of scheduling a review of each flashcard, “tricking” the forgetting curve by increasing intervals (for example: one day, three days, seven days, 20 days) right before the information is forgotten (3). Each time a flashcard is reviewed, the forgetting curve attains a gentler slope (more time must pass before the information is forgotten). Regarding the interval of flashcard review, I suggest experimenting with the settings in different situations – there is a great deal of variability in the difficulty of pathology chapters as well as personal differences when it comes to information retention!
Flashcard formulas
With an example question about brain tumors (see Figure 1), I have attempted to communicate my approach to making flashcards in a simplified manner. After answering the question, understanding explanations for correct and wrong answers is crucial, as each concept that is significant or hard to remember can be converted into a flashcard. For example, as the explanation section focuses on different brain tumor histology, a flashcard questioning the recognition of glioblastoma can be made (see Figure 2). Furthermore, flashcards about the histology of other types of brain tumors can also be created.
Solving questions and going through scheduled Anki flashcards every day are two habits I acquired during my third-year pathology course – and I am retaining (!) those good habits in my clinical years. The results of this approach were most noticeable before my large end-year pathology exam, when I needed a few days to refresh my mind skimming through the textbook; Anki helped keep all the essential concepts in my long-term memory. Experimenting with Anki and finding the perfect settings that suit you – in combination with habit formation – may be the most challenging part of it all. Yet, when the ball starts rolling, sit back, enjoy the ride, and let Anki do all the planning and work for you!
Figure 1. Example question
A 64-year-old male is brought to the emergency department after a seizure. The patient had multiple seizures in the past week, and progressively worsening headaches in the past year. An intracranial mass is shown on imaging traversing the corpus callosum, and pathohistological analysis is shown below. What is the most likely diagnosis:
- A) Meningioma
- B) Ependymoma
- C) Oligodendroglioma
- D) Glioblastoma
Explanations
Answer: D) Pathohistological analysis shows pseudo palisading and the tumor crosses the corpus callosum (butterfly glioma)
Other answer explanations
A) Meningioma typically show elongated cells in whirls pattern that may calcify into round structures (Psammoma bodies) on histology
B) Ependymomas typically show pseudo vascular rosettes on histology
C) Oligodendrogliomas typically show cells with a ‘fried egg appearance’ (round nuclei surrounded by a halo of clear cytoplasm) on histology
Figure 2. Example flashcard
What brain tumor is shown on histology?
Glioblastoma multiforme
-Pseudopalisading
-Necrosis
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References
- A Dasgupta, “Problem based learning: its application in Medical Education,” J West Bengal Univ Health Sci, 1, 11 (2020).
- BW Yang et al., “Using testing as a learning tool,” Am J Pharm Educ, 83, 7324 (2019). PMID: 31871352.
- KA Rawson et al., “When is practice testing most effective for improving the durability and efficiency of student learning?” Educ Psychol Rev, 24, 419 (2012).
