Optimal Spacing for Study, What's this?

We have all been told by teachers that learning occurs best when we spread it out over time, rather than trying to cram everything into our memory banks at one time. But what is the optimal spacing? There is no general consensus.

However we do know that immediately after a learning experience the memory of the event is extremely volatile and easily lost. It's like looking up a number in the phone book: if you think about something else at the same time you may have to look the number up again before you can dial it. School settings commonly create this problem. One learning object may be immediately followed by another, and the succession of such new information tends to erase the memory of the preceding ones.

Memory researchers have known for a long time that repeated retrieval enhances long-term retention. This happens because each time we retrieve a memory, it has to be reconsolidated and each such reconsolidation strengthens the memory. Though optimal spacing intervals have not been identified, research confirms the importance of spaced retrieval. No doubt, the nature of the information, the effectiveness of initial encoding, competing experiences, and individual variability affect the optimal interval for spaced learning.

One study revealed that repeated retrieval of learned information (100 Swahili–English word pairs) with long intervals produced a 200% improvement in long-term retention relative to repeated retrieval with no spacing between tests. Investigators compared different-length intervals of 15, 30, or 90 minute spacing that expanded (for example, 15-30-45 min), stayed the same (30-30-30 min) or contracted (45-30-15 min) revealed that no one relative spacing interval pattern was superior to any other.

Another study has revealed that the optimally efficient gap between study sessions depends on when the information will be tested in the future. A very comprehensive study of this matter in 1,350 individuals involved teaching them a set of facts and then testing them for long-term retention after 3.5 months. A final test was given at a further delay of up to one year. At any test delay, increasing the inter-study gap between the first learning and a study of that material at first increased and then gradually reduced final test performance. Expressed as a ratio, the optimal gap equaled 10-20% of the test delay. That is, for example, a one-day gap was best for a test to be given seven days later, while a 21-day gap was best for a test 70 days later. Few of any teachers or students know this, and their study times are rarely scheduled in any systematic way, typically being driven by test schedules for other subjects, convenience, or even the teacher's whim.

The bottom line: the optimal time to review a newly learned experience is just before you are about to forget it. Obviously, we usually don't know when this occurs, but in general the vast bulk of forgetting occurs within the first day after learning. As a rule of thumb, you can suspect that a few repetitions early on should be helpful in fully encoding the information and initiating a robust consolidation process. So, for example, after each class a student should quickly remind herself what was just learned—then that evening do another quick review. Before the next class on that subject, the student should review again. Teachers help this process by linking the next lesson to the preceding one.

Certain practices will reduce the amount of time needed for study and the degree of long-term memory formation. These include:

• Don't procrastinate. Do it now!

• Organize the information in ways that make sense (outlines, concept maps)

• Identify what needs to be memorized and what does not.

• Focus. Do not multi-task. No music, cell phones, TV or radio, or distractions of any kind.

• Association the new with things you already know.

• Associate words with mental images and link images to locations, or in story chains

• Think hard about the information, in different contexts

• Study small chunks of material, in short intervals. Then take a mental break.

• Say out loud what you are trying to remember.

• Practice soon after learning and frequently thereafter at spaced intervals.

• Explain what you are learning to somebody else. Work with study groups later.

• Self-test. Don't just "look over" the material. Truly engage with it.

• Never, never, ever CRAM!

The vital role of guideline narratives

A few weeks ago, I presented Family Medicine Grand Rounds at Georgetown University School of Medicine on resolving conflicts between screening guidelines. During the question and answer session, Department Chair James Welsh, MD asked how evidence from carefully conducted clinical trials can possibly overcome powerful emotional stories of "saved lives." I answered that evidence-based medicine's supporters must fight anecdotes with anecdotes. For every person who believes his or her life was extended by a PSA test or a mammogram, statistics show that many more are temporarily or permanently injured as a result - and their stories matter too. As blogger Kevin Pho, MD wrote about the USPSTF's recent prostate cancer guideline, "Task Force advocates will need to put a human face on the complications stemming from prostate cancer screening" in order to convince physicians and patients that it's okay to stop. Indeed, news stories about PSA test-related complications such as this one by Associated Press writer Marilynn Marchione will go a long way in balancing the scales.

An insightful commentary published in JAMA last month took this point one step further by asserting that narratives deployed to support evidence-based guidelines should include not only patients' stories, but the story of the guideline developers themselves:

Typically, experts present a “clean” version of their findings without any narrative about how they made sense of the data. This fulfills the scientific virtues of objectivity, coherence, and synthesis. When the USPSTF released its report on screening mammography to much controversy, it included no narrative about the process. Only later was the story of the task force deliberations revealed. This narrative, with multiple characters operating within the context of historical precedents, timing mandates, and a messy political milieu, created a substantially more compelling perspective. But the account came too late to engage a confused and angry public with the task force's conclusions.

Guideline developers could include as part of their reports the narrative of their internal workings: We started with what we knew, we looked at the evidence, we revisited our hypotheses, we argued about the findings, and ultimately we acted here and now because it was prudent, but there are more data to come, and here is what we plan to do as we learn more. Such stories could increase trust and therefore improve the translation of evidence for individual use and public policies.

I attended both of the Task Force's 2008 meetings when screening mammography was debated, and the difference between them spoke volumes. During the first meeting, the panel deadlocked multiple times over whether to recommend for ("B") or recommend against routinely ("C") mammograms for women in their 40s. Both sides made impassioned arguments in favor of their points of view, and after running hours beyond the time allotted for discussion, they finally admitted that they were unable to reach a consensus. In contrast, at the second meeting when the results of a new decision analysis were presented, there was - to everyone's great relief - near-unanimity that the benefits and harms of screening were closely balanced in this age group. (Incidentally, the Canadian Task Force on Preventive Health Care recently concurred with the USPSTF's 2009 recommendations.)

Given the potential for narratives to humanize guidelines for the public, it was disappointing that the USPSTF's first Report to Congress offered a thoroughly sanitized description of the lengthy and challenging process by which it identified and prioritized research gaps in clinical preventive services. This process, which I participated in as a medical officer, consisted of a series of spirited debates over more than two years about thorny questions such as: 1) Is there an objective, defensible way to prioritize certain preventive services more than others? 2) Is it more important to support research on services with insufficient evidence that are already in widespread practice (e.g., PSA tests), or less commonly provided services with potentially large benefits (e.g., CT scans for lung cancer)? Unfortunately, the Report doesn't even begin to hint at how we grappled with these and other contentious issues, much less the multiple impasses that were reached and eventually overcome.

Consequently, I couldn't agree more with the elegantly stated conclusion of JAMA commentators Drs. Zachary Meisel and Jason Karlawish:

Stories help the public make sense of population-based evidence. Guideline developers and regulatory scientists must recognize, adapt, and deploy narrative to explain the science of guidelines to patients and families, health care professionals, and policy makers to promote their optimal understanding, uptake, and use.

Excuse-making by School Children

My last column on "Blaming the Victim" was a departure from my usual emphasis on improving learning and memory. But it did set the stage for this current post on the crippling effect of allowing children to make excuses for underperformance in school.

Most of us know how common it is for kids to make excuses ("the dog ate my homework" syndrome). When we adults were young, we also probably made excuses, blaming the textbook, the teacher, the school, and whatever else could serve to avoid facing the real causes of the problems.

Why do kids do that? The main reason is their fragile egos. Confronting personal weakness is especially hard for kids when they are embedded in an adult culture that inevitably reminds them that they are relatively powerless kids.

I remember a recent dinner-table conversation with my competitive 6th grade granddaughter, who was complaining about a test in which some of the questions were not aligned well with the instruction, which itself was deemed confusing. I said, "I understand that others did do better than you on the test. Wasn't everybody facing the same handicap?" No answer. Then I added, "It doesn't matter who the teacher is or what instruction you get. If you are not first in the class, it is your fault." Again, no response.

One approach that parents and teachers use is to bolster children's egos by praising them richly and often. Too much of a good thing is a bad thing. Too much praise makes kids narcissistic. Anybody who is not aware of the raging narcissism in today's youngsters must not be around young people very much. The most obvious sign is the compulsive checking of e-mail and texting, all in an effort by a child to be at the center of attention.

I and other professors notice narcissism in college students. In a selective college, most students think they are "A" students, and because of low standards in secondary school and grade inflation they are actually told they are A students. If they don't make As in college, it is somebody else's fault (usually the professor).

Scholars are beginning to address this growing narcissism. Eddie Brummelman at the University of Amsterdam in the Netherlands and his colleagues studied 565 children between the ages of 7 to 12. They picked this age group because most other such studies have been in adults, and they believed that early adolescence is when children develop narcissistic traits such as selfishness, self-centeredness and vanity.

Over 18 months, the children and their parents were given several detailed questionnaires that were designed to measure narcissistic traits and parental behavior. There was a small but significant link at each stage between how much parents praised their children and how narcissistic the children were six months later. Because the effect was only small, it suggests that other things also make people selfish and self-centered. I suspect the effect is larger in the U.S.

Maybe school culture is part of the problem. As in Lake Woebegon, "all kids are above average." For brighter students, the instructional rigor is so low that these kids get a false sense of how smart they are and how easy it is to be an "A" student.

I suspect that another factor is that students are not taught enough about how to be realistically self-aware. They may not even know when they are making excuses unless adults call them on it. Too often, parents side with the student in criticizing a teacher when the real problem is with the child.

Some of the blame shifting comes from biology. It is in human nature to claim ownership of things we do that turn out well, but disown actions that yield negative consequences. Experiments support this conclusion. The most recent experiments had a primary focus on our sense of time in association with voluntary actions. The experimental design was based on prior evidence that the perceived estimate of time lag between when we do something and when we think we did it is an implicit index of our sense of ownership. Investigators asked people to press a key, which was followed a quarter of a second later by negative sounds of fear or disgust, positive sounds of achievement or amusement, or neutral sounds. The subjects were then asked to estimate when they had made the action and when they heard the sound. Timing estimation errors were easily measured by computer. Subjects sensed a longer time lag between their actions and the consequences when the outcome (the sound) was negative than when it was positive.

Teaching Kids to Deal with Failure

There is a common denominator to most self-limiting styles of living. It is a fear of failure. Children express this fear by making excuses, which has the unintended effect of blocking the path to success. Excuses may provide immediate relief of anxiety, but it creates a self-limiting learning style that assures continued underachievement.

Whatever one’s station in life, one axiom is paramount: for things to get better for you, you have to get better. This point is well illustrated in an inspiring rags-to-riches success book by A. J. Williams. He points out that a main reason that people do not make the changes they need to is that they are afraid of failure. But, paradoxically, learning from failure is how many people turn their lives around and become happier. Children, I have noticed, are highly resistant to personal change, maybe more so than adults. I am dismayed at how often I show children how to memorize more effectively and they just can't bring themselves to study in a different way. It is as if they don't believe me enough to even try new approaches. Or maybe they have convinced themselves they are mediocre and need the shield of excuses to keep others from detecting their weaknesses.

Louis Armstrong, the famous trumpeter, told an instructive story about fear when he was a boy. One day when his mother asked him to go down to the levee to fetch a pail of drinking water, he came back home with an empty pail. Upon noticing the empty pail, his mother said, “I told you to bring back a pail of water for us to drink. How come your pail is empty?” Louis replied, “There’s an alligator there, and I was scared to death.” His mother then said, “You shouldn’t be afraid. That gator is as afraid of you as you are of him.” To which Louis answered, “If that’s the case, then that water ain’t fit to drink.”

If there is an alligator keeping you away from what you need to do, have faith you will prevail over your demons. But as long as a child lets fear get in the way, her pail will stay empty.

Other kinds of fear are also self-limiting. Many children fear commitment to learning. Commitment exacts an emotional price requiring dedication, passion, and self-discipline. Children fear confusion and difficulty. They fear disapproval.

Kids need to put their under-performance in perspective. Failure and under-achievement are not permanent. They are not pervasive reflections of inadequacy. Children can acquire learning skills that lead to success. Unfortunately, schools don't teach much about learning skills, being focused on teaching to high-stakes tests.

Kids need to recognize their weakness and strive to fix them. But to bolster their motivation and general attitude about school, they need to recognize what they have done well and strive to do even more of that. Dwelling on under-performance is counter-productive.

The Most Important Thing Kids Need to Learn

Excuse-making prevents a child from developing the attitude that will best serve them throughout life: a sense of personal efficacy, a state of perceived control over one's life. I explain this more thoroughly in my book, "Blame Game, How to Win It." But a summary here will have to suffice.

How children perceive their personal power determines how much effort they will expend to control their lives. If they lack a genuine sense of power, excuse-making applies salve to their wounded egos. Self-efficacy is not the same as self-esteem. Psychologist, Albert Bandura, puts it this way: “Perceived self-efficacy is concerned with judgments of personal capability, whereas self-esteem is concerned with judgments of self-worth.” Both are important for happiness, but it is perceived self-efficacy that drives academic achievement. One practical application where this distinction is apparently not recognized is with school teachers who think the cure for low achievement in school is to foster self-esteem. Teachers should emphasize self-efficacy. Children learn self-efficacy from teachers and parents who enable them to master their environment. Students who are filled with self-doubt do not put much effort into school work. They make excuses. As kids are progressively given the skills to achieve, they develop a sense of confidence in their ability to succeed, which will motivate them to strive for more achievement. When I was a kid, I only became a good student when I discovered, more or less by accident, that I could make good grades. Discovering that I could make good grades if I tried motivated me to do just that. This sense has to be earned. It does not come from excuses.

Physical exercise to improve memory

A great way to improve memory is a physical exercise. It is an exceptional way to increase memory.  Exercises can reverse changes in the brain that cause cognitive decline.

Exercise increases blood flow and oxygen to the brain and stimulates nervous system. This releases endorphins onto the blood stream that creates that overall feeling of well-being.

Exercise can help us to get back our memory where it should be. We can take a walk and free ourself from any frustration that we may be experiencing.

By increasing the supply of oxygen to the brain, exercise helps reducing risk for disease and disorders that eventually lead to memory loss.

According to studies, high levels of physical activity could be more protective against cognitive decline than lower levels (Scarmeas, Luchsinger & Schupf, 2009; Taaffe 2008; Weuve, 2004).

When we’re not exercising, our brain is not receiving much blood. Blood needs to flow to the brain so we can think straight.  We have to move around and not be stagnant. Researchers from the Netherlands’ found that physical fitness could improve memory by boosting blood flow to the rain and increasing brain volume.
Physical exercise to improve memory

Managing symptoms in end-of-life care

Family physicians who care for terminally ill patients must manage a wide range of bothersome symptoms, including pain, fatigue, dyspnea, delirium, and constipation. According to a Cochrane for Clinicians article in the December 1st issue of American Family Physician, constipation affects up to half of all patients receiving palliative care and nearly 9 in 10 palliative care patients who use opioid medications for pain. Unfortunately, a Cochrane systematic review found limited evidence on the effectiveness of laxatives in these patients, as Dr. William Cayley Jr. comments:

For patients with constipation, especially those with opioid-induced constipation, there is insufficient evidence to recommend one laxative over another. The choice of laxatives should be based on past patient experience, tolerability, and adverse effects. Methylnaltrexone is a newer agent that may be useful especially for patients with opioid-induced constipation that has not responded to standard laxatives, but there is limited evidence of potential adverse effects. Therefore, judicious use preceded by a discussion with patients about known risks and benefits is warranted.

The Cochrane Library recently discussed this review in its Journal Club feature, which includes open access to the full text of the review, a podcast by the authors, discussion points, and a Powerpoint slide presentation of the review's main findings.

Additional resources for physicians and patients on advanced directives, hospice care, and ethical issues are available in the AFP By Topic collection on End-of-Life Care.

Counterintuitive answers on quality inducements and persistent satisfaction

They've been repeated so often that many health care quality gurus take them for granted: 1) paying physicians for performance will improve quality of care; 2) increasing patient satisfaction will reduce care costs and improve outcomes.

Not necessarily, two recent studies suggest.

A Cochrane for Clinicians piece on financial incentives for improving the quality of care in the April 1st issue of American Family Physician concludes that despite their increasing popularity, there is actually "limited evidence" that pay-for-performance models are successful in primary care practice. When positive effects were seen in the studies examined in the Cochrane review, they were disappointingly modest. Further, writes commentator Elizabeth Salisbury-Afshar, MD, MPH, "In addition to costs, potential harms must be considered. For example, if financial incentives are provided only for certain health indicators, physicians may spend more time focusing on meeting those indicators while paying less attention to other important components of care." This commentary elicited several online comments from readers, ranging from a defense of the "tried and true" fee-for-service model to requests for better tools and systems to allow physicians to improve care quality without making unsustainable demands on their time.

In a similar vein, a study published in the Archives of Internal Medicine found that although higher patient satisfaction was associated with lower rates of emergency department use, it also was linked to several less desirable outcomes, including higher odds of any inpatient admission, greater total and prescription drug costs, and higher mortality. Is it possible, questions Dr. Brenda Sirovich an accompanying editorial, that patient satisfaction is driven by receiving more care, but not better care? She goes on to observe:

Practicing physicians have learned ... that they will be rewarded for excess and penalized if they risk not doing enough. More aggressive practice, therefore, improves not only patients' perceived outcomes, but also those of physicians (reimbursement, performance ratings, protection against lawsuits), and the positive feedback loop of health care utilization is fueled at two ends. ... A positive feedback system is not in fact positive (ie, favorable)—it represents an unstable system, one that cannot control its own growth, or demise. We, as a profession and as a society, can take responsibility for controlling this unrestrained system only if we commit to overcoming the widespread misconception that more care is necessarily better care, and to realigning the incentives that help nurture this belief.

How much does it cost to have an appendectomy?

A few years ago, a good friend of mine who holds bachelor's and law degrees from Ivy League schools lost his job and became one of the estimated 50 million medically uninsured persons in the U.S. Over the course of several days, he developed increasingly severe abdominal pain, fever, and vomiting. Though reluctant to seek medical attention, he finally was persuaded to visit his local hospital's emergency department, where he was diagnosed with acute appendicitis. Despite his critical condition and the need for immediate surgery, he refused treatment until the hospital's billing department gave him an estimate of how much an emergency appendectomy would cost. Then, as he was being prepared for the operating room, he somehow managed to bargain with the surgeon to reduce his customary fees.

Sharing this harrowing story weeks later, my friend, until then a strong believer in the power of the market to control rising health care costs, was justifiably proud that his negotiating skills had prevented the hospital bill from completely depleting his savings. On the other hand, he recognized the insanity inherent in trying to practice "consumer driven health care" during a medical emergency, especially given the lack of information about the pricing of health care services. I've written before about how difficult it was for my wife and I to estimate how much it would cost to have a baby (our son, incidentally, is now two months old and doing well). It turns out that variations in pricing for the diagnosis and treatment of acute appendicitis are even larger and less explicable.

A study published yesterday in the Archives of Internal Medicine reported that the hospital charges for patients hospitalized in California for acute uncomplicated appendicitis ranged from $1529 to $182,955, with a median charge of $33,611. Patient age, insurance type, and geographical location explained only about 2/3rds of the observed variations. My friend's experience in a different state confirmed what the authors of this study observed:

A patient with severe abdominal pain is in a poor position to determine whether his or her physician is ordering the appropriate blood work, imaging, or surgical procedure. Price shopping is improbable, if not impossible, because the services are complex, urgently needed, and no definitive diagnosis has yet been made. In our study, even if patients did have the luxury of time and clinical knowledge to "shop around," we found that California hospitals charge patients inconsistently for what should be similar services as defined by our relatively strict definition of uncomplicated appendicitis.

Given better transparency about pricing, perhaps there is a role for comparison shopping for predictable health care expenses, such as elective surgery or labor and delivery. But huge variations in pricing for emergency care illustrate how badly the consumer health care model fails. There are many flaws in the Affordable Care Act that Congress passed in 2010, but extending insurance to millions of currently uninsured Americans is not one of them. As this example shows, it is our country's broken health system, not the health law, that requires urgent repeal and replacement.