Incremental versus Insight Learning

Steven R. Daugherty, Ph.D.
Director, Education and Testing
Kaplan Medical

Why is it that some people seem to get so much more out of their USMLE* study time than others? Why is it that although two students spend the same amount of time preparing for the USMLE, one gets a top score while the other barely passes? Students often tell me how hard they try as they prepare for the USMLE. I've seen their preparation and know what they're saying is true. Yet, some students do not seem to get the improvement one would expect from the time and effort that they put in. Why does effort sometimes not equal success?

The short answer is what matters most is not the time you put in, but what you do with that time. No one gives you credit for effort. No one cares about your struggles. All that anyone will care about is the score you get. Stop focusing on working hard and focus on getting results. Hard work without results means nothing.

You reap the benefits of your efforts by using your study time to gain the level of insight that the USMLE requires. This process is often very different from the one needed for your exams in medical school. USMLE learning is different than medical school learning.

Learning takes place by two distinct processes: the accumulation of details and the organization of those details into a systematic whole. The accumulation of details is incremental. Piece by piece, step by step, you commit the essentials to memory. Brick by brick you collect the critical pieces out of which you will build your intellectual home. But just having the bricks is not enough. At some point you must actually build the house. Accumulation of the parts means little unless they are assembled into a coherent whole.

The organization of knowledge requires a different process than the accumulation of the pieces. No longer are you engaged in a search for the pieces of the puzzle. Now you must fit them all together into a systematic whole. This process is not one of incremental accumulation, but of insight, punctuated by the flash of the emotional "Aha!" Insight forms the pieces into patterns. And the pattern, once understood, gives a context by which all of the pieces are seen in a new light. The difference here is gathering information vs actually getting the point.

You have all had this experience at some point. Think about the time you struggled with your study material, trying to remember the details. And then, suddenly, it all made sense. The details all link up and everything comes into focus. No longer where you concerned about remembering the individual details, because the pattern, once recognized, holds the details in place for you. Once you get it at this level, you "have" it. And the knowledge stays with you even with the passage of time.

The USMLE is not testing whether you have gathered in the necessary knowledge, but whether you have achieved the requisite level of insight so that it all makes sense. USMLE questions are problems that need solutions, not questions in need of remembered answers. Insight allows problem-solving. Without it, you are merely guessing.

All of this means that the study methods that may have served you in medical school may not get you to the level required by the USMLE. Medical school exams are about demonstrating that you have accumulated the bits and pieces of knowledge the professor wants you to master. Multiple-choice exams in medical school expect you to recognize the correct facts on a presented response set. As you study you memorize the required content, bit by bit until you have a storehouse of the things your faculty wants you to learn. You answer their questions by searching that storehouse and finding just the fact needed to answer each question.

Success in medical school depends primarily on the incremental accumulation of knowledge. Success on the USMLE grows out of the insightful assembly of these bits of knowledge into a lucid whole. Learning is not nearly as hard as unlearning. The real struggle in getting ready for the USMLE is not learning the knowledge you need, but learning to use that knowledge, to think about that knowledge differently that you did in medical school. The hardest part of your preparation is learning to leave your old habits of incremental accumulation behind and take on the new processes of insight.

Why do some people get more out of their study time? The long answer is those who gain the needed insight walk away with the information in a mental form that sticks with them, while those who are locked in the incremental accumulation of facts are vainly trying to hold on to the individual pieces that keep slipping away.

Students learn facts for exams. Doctors have that knowledge organized in a way that allows insight to solve clinical problems. Strive for insight. Spend study time not just reading, but thinking about what you have read. Take time to talk to yourself and others about the core concepts and ideas. Your self-confidence will soar and you will achieve a USMLE score that demonstrates that your study time has been well spent.

Can You Name It?

Mechanism of Action:

• This agent is delivered in an enteric-coated delivery system that is able to resist gastric inactivation and deliver enzymes into the duodenum. Once delivered to the duodenum and when the duodenal pH reaches approximately 5.5, the enteric coating begins to dissolve and release of the enzymes is initiated. These enzymes act locally in the gastrointestinal tract and catalyze the hydrolysis of fats into glycerol and fatty acids, protein into proteoses and derived substances, and starch into dextrins and sugars. Once their digestive function has been completed, the constituents may be partially absorbed and subsequently excreted in the urine. Undigested enzymes are excreted in the feces.

Indications:

• This agent is indicated for the treatment of steatorrhea secondary to pancreatic insufficiency such as cystic fibrosis or chronic alcoholic pancreatitis.

Route of Administration:

• Oral capsules: 4,000 units; 10,000 units; 16,000 units; and 20,000 units

Selected Adverse Effects:

• General: diarrhea, abdominal pain, intestinal obstruction, vomiting, intestinal stenosis, and constipation.
• Other: dermatitis, hyperuricemia, hyperuricosuria and fibrosing colonopathy primarily in cystic fibrosis patients.

Selected Drug-Drug Interactions (Drug + Other medication =):

• + indomethacin or ibuprofen = intestinal and liver lesions in animal studies

Special Considerations:

• Contraindications: Hypersensitivity to pork protein or any other component of this product.
• Warnings/Precautions: Cases of fibrotic strictures in the colon have been reported primarily in cystic fibrosis patients with the use of this product; any change in drug therapy should be made cautiously and only under medical supervision; pregnancy category B

Drug of the Month: pancrelipase (Pancrease MT ®)



Diagnostic Dilemma

A 34-year-old male body builder collapses during a particularly strenuous workout. His trainer accompanies him to the emergency department and is able to provide information regarding the patient. He denies any significant past medical history except for a torn biceps tendon 2 years previously. The trainer, however, appears hesitant when asked about illicit drug use. Physical examination reveals a hypotensive, tachycardic patient in moderate distress. Radiologic examination reveals a subcapsular mass within the liver and a large amount of blood within the abdomen. The patient is taken to the operating room in which a 14 cm subcapsular solid yellow mass is removed. Which of the following is the most likely diagnosis?

(A) Focal nodular hyperplasia
(B) Hepatic adenoma
(C) Hepatic cyst
(D) Hepatic hemangioma
(E) Hepatocellular carcinoma

The correct answer to the question above is: B.

1. Focal nodular hyperplasia leads to well-circumscribed liver nodules, classically with a central scar. The nodule is made up of disorganized liver parenchyma. It is important to note that all components of the liver parenchyma are present, albeit disorganized. These are usually discovered incidentally and are not prone to hemorrhage.
2. CORRECT: Hepatic adenomas are commonly seen in young female patients taking oral contraceptives and in those patients that are taking anabolic steroids. Although these are benign tumors, they can rarely undergo malignant transformation. The greatest risk, however, is not in terms of their neoplastic activity, but in the risk for subcapsular lesions to rupture with resultant hemorrhage. This may present with right upper quadrant pain, but if severe enough, it can lead to hemorrhagic shock (as in this patient). Histology reveals a solid yellow nodule with hepatocytes. Other hepatic components (Kupffer cells, bile ducts) are not present.
3. Hepatic cysts are cystic rather than solid, and not a likely source of hemorrhage.
4. Hepatic hemangiomas are the most common benign hepatic tumor. The size and clinical presentation is highly variable, with the most common being asymptomatic. These lesions can rupture with significant blood loss; however, the histology would demonstrated large vascular channels.
5. Hepatocellular carcinoma usually appears in the cirrhotic patient after many years. Although they may bleed, it is an unlikely diagnosis in this case.