Handwritten Notes Lead to Better Learning

In response to the trend to abolish teaching of cursive in schools, about a year ago I posted an article on what I thought were the developmental benefits of handwriting (http://www.psychologytoday.com/blog/memory-medic/201303/why-writing-hand-could-make-you-smarter). That post has generated over 230 comments.

Now there is evidence that handwriting of lecture notes, compared to typing on a laptop, improves learning by college students. Following up on prior studies that indicated relative ineffectiveness of taking notes by laptop, researchers Pam Meuller and Daniel Oppenheimer provide clear evidence that handwritten note-taking produces better learning in college students.

They reported three experiments that compared the efficacy of college students taking notes by handwriting or with a lap top. Those who used handwritten notes that they studied later scored significantly higher than students using laptops, including fleet typists who took vastly more copious notes. Handwriters took fewer notes overall with less verbatim recording. There are many possible explanations, beginning with the "less is more" idea in which too much information produces cognitive overload. Notably, when the typing students were told to avoid verbatim notes, they still did it. This suggests that there is something about typing that leads to mindless processing.  Handwritten notes involve more thought, re-framing, and re-organization, all of which promote better understanding and retention. The manual act of handwriting requires more engagement with the subject matter. Finally, handwritten notes capitalize on the use of drawings and of personalized spatial layout of the notes. Memorization involves not only what the information is, but where it is spatially located.

Added note: Readers interested in education are invited to join our Neuro-education group on Linkedin (https://www.linkedin.com/groups?home=&gid=4883556&trk=my_groups-tile-grp)

Mueller, P. A., and Oppenheimer, D. M. (2014). The pen is mightier than the keyboard: advantages of longhand over laptop note taking. Psychological Science. 23 April. DOI: 10.1177/0956797614524581. http://pss.sagepub.com/content/early/2014/04/22/0956797614524581

In U.S. and U.K., statin debate goes on

As previewed in a previous blog post, the August 15th issue of American Family Physician features a concise summary of the American College of Cardiology / American Heart Association updated cholesterol treatment guideline. Key points include an expansion of the role of statins in the primary prevention of atherosclerotic cardiovascular disease (ASCVD); elimination of specific low-density lipoprotein cholesterol (LDL-C) target levels; and a new tool for assessing of 10-year and lifetime risk for ASCVD. An accompanying POEM notes that full implementation of the new guideline would increase the number of U.S. adults eligible to take statins by nearly 13 million, with the percentage of adults 60 to 75 years of age for whom statins are recommended rising from 47.8% to 77.3%.

Two editorials in the same issue further explore the implications of the new guideline. Writing for the members of the guideline panel, Dr. Patrick McBride and colleagues emphasize that the recommendations are largely based on high-quality evidence from randomized controlled trials that measured patient-oriented outcomes. They argue that "these changes should simplify the approach to clinical practice by reducing titration of medication, the addition of other medications, and the frequency of follow-up laboratory testing." In a second editorial, Dr. Rodney Hayward concurs with the panel's decision to abandon LDL-C targets, but disagrees with setting a universal 10-year ASCVD risk threshold of 7.5% for treatment with a statin:

My biggest criticism of the new guideline is that it does not acknowledge a specific gray zone—a range in which the potential benefits and harms of a statin make the “right decision” predominantly a matter of individual patient circumstances and preferences. It may be reasonable to set 7.5% as a starting point for discussion (e.g., for every 33 patients treated for 10 years, roughly one heart attack will be prevented [i.e., number needed to treat = 33]). But these risks and benefits are estimates with a nontrivial margin of error. The guideline does note that shared decision making should be used, but it provides no clear direction on when statins should be recommended rather than just discussed.

A similar debate is taking place in the United Kingdom, where its National Institute for Health and Care Excellence (NICE) recently recommended offering a statin to all persons with a 10-year cardiovascular event risk of 10% or more. An editorial in BMJ observed that doctors need better shared decision making tools to help patients understand the tradeoffs involved in taking medications that have potentially large population health benefits but are unlikely to prevent a bad outcome in an individual patient:

Doctors are unlikely to start giving patients clear numerical information simply because they are told to do so. They might do so if NICE can recommend information tools with the same force as when it recommends drugs, and if it becomes as easy to give contextual numerical advice as it is to print a prescription. ... We will need better data, from bigger trials, and better risk communication than for conventional medical treatment. ... Without such innovation in the use of medical data, we can say only that statins are—broadly speaking—likely to do more good than harm. That is not good enough.

If you are a clinician reading this, have you already integrated the ACC/AHA or NICE cholesterol guideline into your practice? If so, how do you decide whether to "recommend" versus "discuss" statins with patients? If not, what reservations or workflow issues have stopped you from transitioning to the new guidelines?

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This post first appeared on the AFP Community Blog.

Stay focus and full attention while studying

You need to be able to focus well and put your full attention on what you are learning.  If you are distracted, information may not be encoded into short-term memory – making later study useless.

Attention is the first step in getting information into memory. If you are distracted while studying, you won’t be able to devote your full attention to the information you are trying to learn.

Set all other considerations aside for the time being. Be fully present in each moment, instead of letting your mind jump about to thoughts of the feature or the past.

Find a quiet place so you can concentrate on what you are reading, learning, or observing.

Don’t try studying while lying on your bed because the next thing you known, you’ll be asleep.
Stay focus and full attention while studying 

Memory Athlete Gimmicks for Memory Wimps. Tip 3: SVO

"Moon Walking with Einstein" is the title of a recent memory improvement book written by Joshua Foer, a reporter of memory championships. Foer became so entranced by watching astonishing memory feats in the contests that he decided to learn the secrets. After talking to memory athletes, he started practicing the techniques and within a few years became a memory champion himself.  You could do that too!

Memory athletes are those seeming freaks of nature who enter contests to see how fast they can memorize the sequence of four shuffled decks of cards or how long a string of digits they can memorize. But memory athletes are not freaks. They are ordinary people like Foer, you, and me who have learned some gimmicks that make possible the seemingly impossible.

Here, I will describe the simplest and easiest gimmick to use. I call it SVO, which stands for SUBJECT (or actor or agent), VERB, and OBJECT. This is the intuitive way we think with our language. Usually the subject is a person, which is why others call this technique POA for person, object, action). But animals or inanimate things can do things too. The trick is to visualize, using lots of imagination, an actor doing something relating to an object … as in moon walking with Einstein. Memorization is made easy because the images are so bizarre and vivid. 

I will illustrate the principles with Foer's method for memorizing the sequence of a deck of cards. He didn’t explain his method completely, deliberately I think, because he probably did not want to be “drummed out” of the elite memory athlete club to which he had been initiated. Not knowing his particular scheme, I will conjure an illustration of how all cards can be visualized. For example, the suits might be as follows:

·         Spades: Batman (black, darkness)

·         Clubs: Tiger Woods (re: golf clubs)

·         Diamonds: Diamond Jim Brady (diamond tie stud) or Za Za Gabor (who famously said, “Daaahling, always wear your diamonds, even to the grocery store. You never know who you will run into”).

·         Hearts: Somebody you love

Then, to associate the card number with the suit, you could use the number code, which is another tip that I will explain later. But as an illustration, the number four is coded as “rye,” which can be a picture of a field of grain or a bottle of rye whisky, whichever you prefer. Thus, for example, the four of clubs would be visualized as Tiger Woods (SUBJECT) teeing off (VERB) on a bottle or rye whisky (OBJECT), instead of a golf ball. What does one do with the face cards? They can be converted to numbers too, Jack = 11, Queen = 12, King = 13, Ace = 1 (Or 14; the number code for one is “tie” and you don’t want to get confused if you are using Diamond Jim Brady as your code for diamonds.

Finally, Foer did mention that he clusters three sequential cards into one image, so that he only has to memorize 17 items, with one item left over, instead of 52.

Well most of us aren’t going to enter memory contests or card-count in Vegas (they catch on to you pretty quick). So, how do we apply this to everyday life? You could use this SOV approach to play a better game of bridge. But many events in daily life are better remembered this way.

First, a simple illustration:

·         Capital of Arkansas (Little Rock): most people know Bill Clinton was Governor of Arkansas. Visualize Clinton (SUBJECT) throwing (VERB) a little rock(OBJECT) at Noah's ark (…ansas)

Now, here is a more complex example where you can string together multiple items to be remembered:

·        Harvey’s discovery of the circulatory system: Everybody knows that the heart is key, because it pumps blood. See the heart (SUBJECT) as pumping (VERB) blood (OBJECT) out on to the main traffic artery, like a freeway. Imagine you as an image of Harvey (like Harvey the rabbit in the movie) riding in a boat in the blood river. See the boat slow down and start to back up as it leaves on the off ramp. Maybe you want think of the boat going through a hole (“ole” for arteriole) to get to the off ramp. Then see the boat stop at the stop light (covered with baseball caps … capillary). Then, on green the boat goes back up on the access road (because Harvey had gotten off too soon, in vain (vein). This schema also helps as a metaphor for associating function at the various locations.

While all this seems bizarre, it works with great power. Facts and concepts memorized this way are robustly encoded and readily consolidated into lasting memory because humans are visual animals. We have far more brain area devoted to vision than we do any other sense.

Another way to make the point is with the age-old phenomenon of fairy tales. Fairy tales often carry a moral that we want our children to remember. A few fairy tales are even for adults, with the political protest embedded as a metaphor. In any case, a fairy tale is easy to remember because it is visually vivid, with people acting on or with things.

SVO is perhaps the most flexible memory device. Use it for simple memory tasks or for truly demanding memory challenges.

The publisher of Dr. Klemm's "Memory Power 101" book has now made it available as an audio book at Amazon. Also, you can read multiple reviews at http://03908f9.netsolhost.com/thinkbrain/book-reviews-of-memory-power-101/ 

The problem of pain

My patients lie to me every day. Some tell me that they have been taking their medications regularly when they haven't. Some say that they have been eating a healthy diet and exercising for at least 30 minutes every day and don't know where the extra pounds are coming from. Some lie that they are using condoms every time they have sex, that they have quit smoking, and if they drink alcohol at all, it's only a single glass of wine with dinner. They bend the truth for many reasons: because they want to please their doctor, because they don't like to admit lapses of willpower, or because they are embarrassed to tell me that they can't afford to pay for their medications. I forgive them; it's part of my job to understand that patients (and health professionals) are only human. The only lies that I find hard to forgive are the lies about pain.

Like many doctors, I have complicated feelings about prescribing for chronic pain. On one hand, I recognize that relieving headaches, backaches, arthritis and nerve pain has been a core responsibility of the medical profession for ages. On the other hand, deaths and emergency room visits from overdoses of prescription painkillers have skyrocketed over the past 25 years, and I have inherited many patients with narcotic addictions that resulted from a prior physician's well-intentioned generosity with his prescription pad.

Even worse, I've had patients I trusted turn out to be junkies in need of a fix. An earnest, well-dressed young man once came to my office complaining of a common chronic condition that, he said, had not been relieved by high doses of over-the-counter painkillers. He convinced me to to prescribe him narcotic pills, and didn't bat an eye when I asked him to sign a pain contract that required him to return every month for refills and only receive prescriptions from me in person. For the better part of a year, he never missed an appointment, and seemed genuinely receptive to unrelated preventive care that I recommended based on his age and risk factors. His deceit was exposed only after he stumbled, intoxicated, into an acute care facility staffed by a doctor who knew me and requested an early refill of a prescription for a different brand of painkillers prescribed by a third doctor for another imaginary condition. My colleague told him the gig was up, and I've never seen him again.

I believe that drug addiction is a disease. So why do I find this patient's lies (and those from others like him) so hard to forgive? Because they have consequences for people who are truly in pain. For patients' convenience, I transmit virtually all prescriptions electronically to the pharmacy, but I'm not allowed to do this with "controlled substances" such as painkillers. Wary of encouraging drug abuse, some insurers impose arbitrary limits on the number of pills a patient may be prescribed in one month, which I can only override by spending hours on the phone or not at all. One chain pharmacy recently started demanding signed copies of chart notes that included the pain-causing diagnosis before they would dispense painkillers (a practice that I believe to be an illegal invasion of privacy, but they didn't budge an inch when I told them so). And worst of all, doctors like me who have been burned before are that much more likely to view our patients with suspicion.

In the July issue of Health Affairs, Janice Schuster described a health odyssey that began with a seemingly minor surgical procedure and ended with her becoming "one of the estimated 100 million American adults who live with chronic pain" - in this case neuropathic pain, or pain from nerve damage that in my experience can be the most difficult type to treat. She wrote about how health system restrictions designed to discourage abuse created obstacles to her obtaining adequate pain relief, and about a lack of compassion from her primary care physician (who "dismissed my symptoms") and her surgeon (who "said again and again that he had not heard of a patient experiencing such pain"). As the author of a popular self-help book for persons facing serious illness, Schuster understood better than most the public health crisis posed by prescription painkillers, but that understanding offered little consolation as she navigated "the maze of pain management" that has evolved to deal with it:

Pain patients like me often feel trapped between the clinical need to treat and manage pain and the social imperative to restrict access to such drugs and promote public safety. ... When I am not overwhelmed by pain, or depressed by it, I am furious at the attitudes I encounter, especially among physicians and pharmacists. It has been stigmatizing and humiliating. ... Surely, we can find better ways to ease the suffering and devise treatments and strategies that do more good than harm and that do not shame and stigmatize those who suffer.

A few of my colleagues have become so disillusioned with the dilemmas of pain management that they have sworn off prescribing narcotic painkillers entirely. As often as I've been tempted to take that path, I won't abandon patients in pain, for whom the services of caring and competent family physicians are needed now more than ever.

Misconceptions about palliative care are common

In inpatient settings, family physicians frequently care for patients with progressive, incurable conditions that cause severe pain. Interventions aimed at slowing the progress of a disease often add to patients' physical distress; therefore, pharmacologic management of pain is a key component of end-of-life care, as outlined in an article in the July 1st issue of American Family Physician. However, as Drs. Timothy Daaleman and Margaret Helton discuss in an accompanying editorial, providing analgesia is only the starting point for effective palliative care:

Palliative care generally begins with diagnosis of a life-limiting disease and initiation of an ongoing conversation on the goals of care and treatment. This often begins in patient-centered medical homes, continues through acute hospitalizations, and may conclude in long-term care facilities. At each point, family physicians may be called on to provide primary palliative care and can expect to encounter nonpharmacologic challenges in managing pain.

Misconceptions about palliative care are common. For example, many believe that palliative care, like hospice care, cannot be offered to patients who are still pursuing "aggressive" treatments such as chemotherapy for cancer. On the contrary, one of the American Academy of Hospice and Palliative Medicine's Choosing Wisely recommendations states, "Don’t delay palliative care for a patient with serious illness who has physical, psychological, social or spiritual distress because they are pursuing disease-directed treatment." Palliative care does not necessarily increase patient comfort at the cost of shortening life; in a randomized trial of patients with metastatic non-small-cell lung cancer, patients assigned to early palliative care not only experienced better quality of life and fewer symptoms of depression than patients receiving standard care, they actually lived more than two months longer.

The recent announcement by a large health insurance company in the Pacific Northwest that it will prioritize palliative care by training physicians and caregivers about having appropriate end-of-life conversations; and pay for previously unreimbursed home health services and counseling about advanced directive planning suggests that policymakers are finally recognizing the value of improving the availability of palliative care to appropriate patients. What have been your experiences with connecting patients or loved ones to palliative care services?

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The above post originally appeared on the AFP Community Blog.