By Althea Need Kaminske

Cover image by Pexels from Pixabay

One of the most common metaphors to describe what the first few years of medical school is like is that it is like drinking water from a fire hose. There is an overwhelming amount of information that students need to learn, and need to learn fast. One of the areas that I help medical students with is in improving their notetaking to help them manage the “fire hose” of information. 

The way I define notetaking here is probably a little different than how most people think of notetaking. In this context I think of notes as any record of learning that is formatted to improve understanding and long-term retention of material. Ideally this record should be continually updated so that it is a living document of progress towards learning goals. This means that notes could include: handwritten flashcards, typed out charts and tables, annotated diagrams, sketches of flowcharts and mind maps, etc. 

What makes notes good or effective depends on the goals you have for the notes. For example, a common question is whether it matters if you take notes by hand or typed out on a device. Generally, I would argue that the format doesn’t matter so much as the cognitive processes that you engage in while making the notes (see this post by Megan explaining more). Notes taken by hand tend to be better because it’s harder to take notes by hand - forcing you to be selective about what you write down and to paraphrase things into your own words (1). It’s the selectivity and paraphrasing that’s helpful for memory and understanding, not the physical movement of your hands. Once you know about this, it’s easy to apply the same principles to typed notes. However, if your goals for notetaking are to provide some sort of transcription of the event, then, yes, typing notes will most likely be faster and easier for that goal. 

Effective note-taking in medical school needs to achieve several goals. First, notes need to be formatted to aid subsequent retention (i.e. spaced retrieval practice). Second, they need to condense the fire hose of information into something more manageable. Third, they need to be done in a way that builds understanding of the material. And finally, they should be a record of learning to help track and monitor learning - a living document that reflects current understanding. Good notes are notes that are:

1. Formatted for spaced retrieval practice

2. Condensing large amounts of information

3. Building understanding

4. Recording and monitoring understanding

In the book Study Without Stress by Eugenia G. Kelman and Kathleen Straker (2), the authors cover five different note formats that meet those goals. They cover flashcards, diagrams, flowcharts, charts and tables, and combinations. 

Flashcards

Flashcards refer to any method where you use a cue to help you recall simple target information. For example you could write Five Note Formats on one side of an index card, and then list the five (flashcards, diagrams, flowcharts, tables, combined) on the other side. You can also use any number of apps, programs, or websites to make “decks” of digital flashcards to study with.

Flashcards are excellent for terms, definitions, and lists. They are very easy to sort and practice spaced retrieval with. Finally, they are very easy to score, making it easy to monitor your learning (e.g. you know if you are able to recall 80% of a deck or 20%). However, flashcards are not as useful for placing information in context, understanding more complex relationships, and labeling locations.

One of the common questions I get is whether students should use digital flashcards like Anki. Regardless of whether you go digital or pen and paper, I strongly recommend making your own decks of cards. First, this ensures that you’re building the flashcard deck that is most useful for you. Second, this means that you are being selective about what you make flashcards out of. 

When you practice using flashcards it is important to accurately assess whether you correctly recalled the target information or not (3). Additionally, make sure that you are spacing out your practice (4). Generally, an expanding schedule of practice where you increase the spacing between each subsequent practice session is better for long-term retention (5). In addition, when thinking about spacing your practice also note that sleep has many positive effects on consolidation, attention, and later retrieval of information (6, 7). For example, you might practice a set of material on Monday, Wednesday, the following Wednesday, then again two weeks after that for a spacing of 2, 7, and 14 days between practice.

There are a lot of factors that influence how quickly we forget (and therefore how quickly we learn) information. This is perhaps where digital flashcards and apps shine - many of them will track your data and design schedules of practice for you. However, the effects of retrieval practice and spaced practice are so robust that I am confident that completely optimizing your practice is not necessarily worth it. You can achieve durable, long-term learning by following a few basic practices. First, in a single study session I suggest selecting your deck(s) and going through them in successive passes. On the first pass, sort them into piles based on your ability to correctly retrieve the information. Set aside the pile that you got right, shuffle the pile you got wrong and go through it. Again, sort it into piles based on whether you got it right or wrong. Shuffle the “wrong” pile and do it again. Repeat this until there are no more cards in the “wrong” pile. Shuffle the whole deck together again and go through it once more. Note how well you did on that deck and set it aside to practice again on another day. This uses retrieval practice, spaced practice, and if you’re shuffling the deck, interleaved practice (8). Additionally, focusing on the “wrong” pile means you’re practicing with the items that you need the most practice with, optimizing your time. Going through the final deck at the end makes sure that you’re spacing practice with items that you got correct on the first pass, and hopefully also noting improvement from the first pass.

Flowcharts

Flowcharts, or mind maps, refer to a boxes-and-arrows type of display where sequence, order, and relationships can be conveyed. For example, in an Intro Psych class you might be asked to describe the flow of information in a neuron: dendrites → soma → axon → terminal buttons.

Flowcharts are useful for depicting processes and sequence-based information. Additionally, they require you to break down a process into components and place those components into a larger context (2). They also are easy to practice retrieval with - simply cover up the boxes, or the arrows, or recreate the boxes and the arrows. Your success at recreating the flow chart is somewhat easy to score since you’ve broken it down into its component parts, making it easier to monitor your learning. All of the same principles of spaced practice from practicing with flashcards can apply here as well. 

While flowcharts are incredibly effective for the information they are designed for, they are less effective for other types of information like location and labeling, spaced practice of details, and certain types of relational information. It may take some practice with the material to get a sense for whether something is best depicted in flowchart, a list, or even a diagram.

Similar to advice above, the value of flow charts lies in both making the flowchart yourself and in practicing retrieval with it. For example, when students are asked to create a concept map from memory they recall much more than when they are asked to simply study the concept map (9). 

Diagrams

Diagrams refer to images that convey information about location and labeling. For example, an image showing the inner and outer layers of a cell.

Diagrams are useful for location and labeling and most obviously useful for studying anatomy. Depending on the type of diagram, or the perspective in the diagram, they give a lot of contextual information. Diagrams clearly take advantage of dual coding (10). Additionally, you can practice retrieval by simply covering up the labels (and potentially re-drawing the diagram but that depends on the level of complexity of the diagram and your own artistic abilities).

Similar to other formats, diagrams are very good for the information they are designed for but less effective for other types of information. Another challenge to be aware of is that it can also be difficult to accurately reproduce a diagram if you are drawing it by hand. 

If the diagram is simple, or if you can simplify the important information, then I would recommend reproducing it by hand to the best of your ability. However, if a high level of detail is important, then printing out a picture or copying and pasting a picture will do. Just make sure that you are able to label it, or that any existing labels are easy to cover up and practice retrieval with.

Charts and Tables

Charts and tables organize information into columns and rows, allowing for side by side comparisons of different factors and dimensions. For example, I have made an example chart of note-taking formats below. 

Charts and tables are very effective for condensing large amounts of information that is highly structured or related (see this guest post by Ratika Deshpande explaining the use of tables, i.e. matrices, and other graphic organizers). Organizing information into a chart has a few key advantages. Deciding what goes into a chart, and how to best organize your chart, requires a lot of detailed, item-specific processing and relational processing (11). Finally, once the information is formatted in a chart it is very easy to practice and assess retrieval practice. You know you’ve recalled 100% of the information if the chart is complete (2)! However, it does take some skill and practice to decide what information can or should be in a chart.

If you notice that information often comes in a repeated structure (e.g. you realize that you’ve listed the location, function, and structural characteristics of several different types of neurons), then you may need to create a category chart instead of several different lists.

Combinations

While each of these formats can be used alone, it is also possible to combine formats. For example, you could create a flowchart by laying out flashcards in a sequence. You can put diagrams in charts to help understand the structure, function, and location of different structures. A flowchart could be combined with a diagram to show the flow of information in a neuron. You might decide to make this image instead of the flowchart above if you are less familiar with the structures and need to learn how to identify those as well as understanding the relationship between those structures. Note that you could make a chart of this information as well.

As with any of the formats above, the key to making combination notes is recognizing what type of information needs to be recorded/learned and choosing the appropriate format, while making sure it’s in a format that you can practice spaced retrieval with. 

Final Thoughts

I really like using these different formats because they are already set up to practice spaced retrieval with, they condense large amounts of information, and by selecting how the information is organized they help learners build their understanding of the material. An additional tip that I give students is to create a cover sheet, or a tracking sheet, to help track and monitor their progress on the material. This could also be achieved by a header at the top of the page of notes that logs previous practice attempts with this set of material (e.g. “11/5 40%”, “11/6 70%”, “11/7 100%”, “11/15 95%”, “11/30 100%”). Recording progress can help you to identify which material you still need to work on, which material you have a good handle on and can set aside for now, and which material you may need to revisit for some spaced practice. 

References

(1) Mueller, P. A., & Oppenheimer, D. M. (2014). The pen is mightier than the keyboard: Advantages of longhand over laptop note taking. Psychological Science, 25, 1159-1168.

 (2) Kelman, E. G., & Straker, K. C. (2000). Study Without Stress: Mastering Medical Sciences. Sage Publications.

(3) Rivers, M. L. (2021). Metacognition about practice testing: a Review of learners’ beliefs, monitoring, and control of test-enhanced learning. Educational Psychology Review, 33, 823-862. https://doi.org/10.1007/s10648-020-09578-2 

(4) Ebbinghaus, H. (1885). Über das Gedächtnis: Untersuchungen zur experimentellen Psychologie. Dunker & Humbolt.

(5) Küpper-Tetzel, C. E., Kaper, I. V., & Wiseheart, M. (2014). Contracting, equal, and expanding learning schedules: The optimal distribution of learning sessions depends on retention interval. Memory & Cognition, 42(5), 729-741. https://doi.org/10.3758/s13421-014-03941 

(6) Gerbier, E. Toppino, T. C., & Koenig, O. (2015). Optimising retention through multiple study opportunities over days: The benefit of an expanding schedule of repetitions. Memory, 23(6), 943-954. https://doi.org/10.1080/09658211.2014.944916 

(7) Maquet, P. (2001). The role of sleep in learning and memory. Science, 294(5544), 1048-1052. https://doi.org/10.1126/science.1062856 

(8) Pan, S. C. (2015). The interleaving effect: Mixing it up boosts learning. Scientific American, 313(2). www.scientificamerican.com/article/the-interleaving-effect-mixing-it-up-boosts-learning/ 

(9) Blunt, J. R., & Karpicke, J. D. (2014). Learning with retrieval-based concept mapping. Journal of Educational Psychology, 106(3), 849–858. https://doi.org/10.1037/a0035934 

(10) Clark, J. M., & Paivio, A. (1991). Dual coding theory and education. Educational Psychology Review, 3(3), 149-210. www.jstor.org/stable/23359208 

(11) Meyers-Levy, J. (1991). Elaborating on elaboration: The distinction between relational and item-specific elaboration. Journal of Consumer Research, 18, 358-367.