#6: Prioritizing Concepts

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In this episode I’ll share a story from the ICU, and a lesson that it reminded me of, about concepts and memorization.  I hope you can take this lesson, incorporate it into your study strategy, and use it to reduce volume.

When I first recorded this episode, it was much too long.  I guess I went overboard with the examples.  So I’ve cut it down and put all the extra examples into a downloadable PDF.  It  summarizes this episode, and exactly how you can use this information to reduce the volume of material you are faced with in the first two years.

So let’s talk about concepts.  I feel like a broken record sometimes, but I always say that memorization is not enough.  Every medical student in America can memorize vast quantities of information very quickly.  The student who can integrate that information and apply it to a new situation is the one who will end up ahead, both in terms of board scores and also patient outcomes.

Now, I always say that…but it’s only half the story.  The other half is that you need to be able to prioritize concepts.  Let me give you a real-life example from my time in the ICU.  On the first day, my attending asked me what would happen to the stroke volume of a young, healthy person if you flooded them with IV fluids.  I responded that stroke volume would increase, and he said “Right, because they operate on the steep part of the Starling curve.”  Wow, that took me back.  I haven’t thought about the Starling curve in years.  And here’s why: cardiovascular mechanics actually bore me to tears.  I got an “A” in that class because I had a memory palace for all of the murmurs, cardiac drugs, and endocarditis.  But if you want me to explain the Starling curve or the effect of cardiac tamponade on a Swan-Ganz catheter reading, I’ll look at you with Orphan Annie eyes.  But what I want to share with you is that I discovered I could get many Step 1 questions right with a pretty basic understanding of cardiovascular mechanics.  

And this is what I mean when I say “not all concepts are created equal.”  I classify the concepts on Step 1 into three categories. Each has a different strategy and should be given a different priority level when you are studying.  This is all summarized in a PDF that accompanies this episode, so make sure to grab that at sholamd.com/6download.

Category I: Single concept, pure memorization

The first category is info that can be memorized without much comprehension.  Usually there is a single concept that unifies all of the facts, but it is a straightforward concept.  This is like the antibodies associated with different forms of rheumatic disease.  You need to understand that the different rheumatologic conditions are associated with different antibody profiles on a laboratory workup, and in general this reflects an understanding of how autoantibodies work.  After that, you need to memorize a long list of facts.  Anti-Ro and Anti-La antibodies are buzz words for Sjogren’s, anti-double-stranded DNA and anti-Smith are associated with lupus.  Some other examples:

  • Multiple endocrine neoplasia (MEN) Syndromes.  Concept = different gene mutations cause different combinations of tumor locations.  Memorize: MEN1 is the diamond, MEN2A is the square, MEN2B is the triangle.
  • GI Hormones. Concept = GI secretory hormones are each responsible for different physiologic responses.  Memorize: Hormone source, action, regulatory pathway, and associated disease states.
  • Modes of Inheritance.  Concepts: Deciphering patterns of disease expression in a family can be a clue on Step 1.  Memorize: Autosomal vs x-linked, dominant vs recessive diseases.  Rarely, such as with trinucleotide repeat diseases like Huntington’s and Fragile X, do you need to understand more of the genetics behind a disease.
  • This category is low priority, because you can memorize it before your school’s exam, forget it, and then memorize it again right before Step 1.  This kind of information can exist in your short-term memory study system, like flash cards.


Category II: Combination of concepts and memorization

The second category is info that needs to be memorized with concepts.  An example is the characteristics of various heart murmurs.  You can memorize that a widened pulse pressure is associated with aortic insufficiency, but you also need to understand why: increased end-diastolic volume in the left atrium from the leaky valve increases stroke volume by the Frank-Starling mechanism, which increases systolic pressure in the aorta.  Meanwhile, diastolic pressure goes down because of the blood leaking back into the ventricle. In my palace, I had a bobble-head in the location of aortic insufficiency because head bobbing is the pathognomonic clinical finding – but it’s important to understand the physiology behind that head bobbing, which is the widened pulse pressure that I just explained. And that’s the key to Step 1: understanding those concepts that they can ask a tricky question about.  Some other examples:

  • Effects of strokes.  These are very easy syndromes for Step 1 to ask about, and I definitely had questions on my exam about this.  Memory palace: Stroke locations and associated clinical picture.  An MCA (middle cerebral artery) stroke classically causes contralateral arm and face paralysis and loss of sensation, often also loss of speech or hemi-neglect.  Concept: Blood supply to the brain and anatomic location of neurologic functions.  An MCA stroke impacts the contralateral arm and not the leg because of the topographical mapping of the motor and sensory areas of the cerebral cortex, which is the homunculus you’ve seen with the hands and face on the lateral sides and the feet on the medial side.  If Step 1 throws a scenario at you where a patient with MCA stroke also has loss of sensation in the contralateral foot, it’s not enough to have a list of syndromes memorized; you need to be able to think through the possible explanations.
  • Nephrotic vs Nephritic renal syndromes.  Memory palace: Which diseases are classified as nephrotic, nephritic, or both.  Concept: Nephrotic syndromes happen due to damage to the glomerular capillary wall, which causes it to be leaky – thus the proteins and clotting factors in the blood can leak into the urine and be excreted, giving you the clinical picture of edema, hypoalbuminemia, and increased infections from lost immunoglobulin.  Nephritic syndromes, on the other hand, are from inflammation, and the glomeruli get damaged and you’ll see blood in the urine and RBC casts.  Again, if Step 1 throws a new scenario at you, like where one thing doesn’t seem to fit the overall picture, you need to be able to critically think about what’s going on in the kidneys and what are the possible explanations.  Pure memorization won’t help you accomplish that.
  • Hypersensitivity types.  Memory palace: Cells responsible and example disorders for each of the four types of hypersensitivity reactions.  Concept: The four types of hypersensitivity reactions differ in fundamental ways, and the cells involved explain the natural course of the reaction.  Type 1, for example, involves IgE degranulation of mast cells, which is why it happens quickly, as in anaphylaxis or angioedema.  Type 4, on the other hand, doesn’t involve antibodies at all, but rather T lymphocytes, which is important when you think about Graft-versus-Host Disease (very high-yield for Step 1).

This category is high priority, because it is easy for the Step 1 writers to make questions around the concepts that require memorization of the associated facts.  In addition, you will encounter this information in various organ blocks – for example, you will come across hypersensitivity reactions during renal, dermatology, immunology, pulmonology, and more.  The strategy here is to learn the concept when you first encounter it, and reinforce the memorization every time you encounter it – for me, that was adding things to my memory palace and reinforcing the images.  It’s not enough to understand the concept alone, or to cram this into your short-term memory.  This needs to be understood and also exist in your long-term memory system.

Category III: Concepts alone

The third and final category is items that you can’t just memorize, you need to understand the concept purely.  This is like the Starling curve that my attending asked me about. This is the idea that as end-diastolic volume goes up in the heart, stroke volume will go up, as a result of the way the cardiac muscle fibers work when they are stretched.  How can you make a mnemonic for that, or put it into a memory palace?  Impossible.  You need to understand what is being shown in the graph of the Frank-Starling Curve and why the cardiovascular system works that way.  This is when a study group is most effective.  Pick a few topics and go around the table and try to explain the physiology from the beginning.  In hindsight, I wish I had done this more.  You get used to speaking the lingo of medicine, and also talking through a concept helps solidify it in your mind.  I also wish that I hadn’t stopped at trying to explain concepts using proper medical terms, but had gone on to explain the same concept again using simple language, because that’s a skill that I’ve needed as an intern and don’t feel I practiced enough as a medical student.  I think if you can explain a concept to a layperson in regular language, you truly have a grasp on it.  Here are some ideas of concepts to talk through in your study group:

  • Lung volumes.  Do not memorize: equations for lung volumes, like VC = TV + IRV + ERV.  Concept to understand: On the graph of lung volumes, what do the horizontal lines represent?  Can you illustrate this using your own breathing?  How would you explain this to someone with COPD?
  • Cancer grading and staging.  Do not memorize: staging criteria for all the different forms of cancer.  Concept to understand: how cancer arises and progresses; that grading is based on cellular differentiation while staging is based on localization and spread; and that staging has more prognostic value.
  • Muscle functions.  Do not memorize: each muscle’s action.  Concept to understand: the point of insertion and origin, and the direction of the muscle fibers, will dictate the action of the muscle. Trying to put all of this in a palace would be unwieldy.

This category is medium priority, because it is difficult for test writers to make questions that most students won’t guess correctly, even if they don’t truly understand the concepts.  But understanding the concepts might gain you an extra question or two on Step 1, and it will definitely help you as you get on the wards and into residency.  The strategy here is to talk these concepts through with your study group so that they feel like common sense to you – then it will never be an issue of “remembering” as much as an issue of critical thinking.

So to summarize, there are different kinds of information that you need to learn in medical school, and each has its own priority level and an appropriate strategy.  If you think about what you are learning in this way, as you prepare for needing to know it for Step 1, you can save yourself a lot of extra work and essentially reduce the volume of material that you need to manage at one time.

Ok, thank you for being with me again today.  I hope this podcast gave you a way of prioritizing concepts so that you can categorize the material, stay organized, and ultimately reduce volume.

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