Introduction: The Need for Better Learning Strategies
Two recent articles published in the American Journal of Pharmaceutical Education provide meaningful insight into the daunting academic challenges facing the typical pharmacy student.1,2 Persky et al suggested that some pharmacy students need to improve their learning startegies because they often rely on ones that are either ineffective or inefficient.1 Zorek et al introduced the term “bulimic learning” as a descriptor for the binge-purge pattern of intensely cramming as much information as possible into one’s short-term memory immediately prior to an exam, followed by the regurgitation of that knowledge during the exam.2

The result is an endless cycle of frenetic, late-night studying that produces much stress and not much long-term learning. The authors pointed out that the vast amount of information that pharmacy students are expected to learn pushes many of them into bingeing and purging from exam to exam. It’s a valid observation, one that pharmacy faculty need to carefully consider when developing courses and designing curricula. Zorek et al suggested that bulimic learning is an unhealthy educational practice that undermines a student’s professional growth.2 There has to be a better way.

This article is written for students of higher education, whether undergraduate, graduate, or professional. Although it is slanted toward prepharmacy and pharmacy students, the principles can be applied to students of any discipline. It is not designed to be an exhaustive treatise on educational theory or cognitive psychology, but the content is based on validated, empiric studies that have been reported in 4 well-researched books on the dynamics of learning, all of which were published since 2010.3-6 The intent is to distill the information into concise explanations that are simple, straightforward, and easily applied. But before delving into specific learning strategies, one must first understand a few fundamental concepts about learning.

Learning is an active process of construction that results from the formation and reinforcement of neuronal connections in the brain. It is predicated on thinking. No one can transmit or transfer knowledge into your brain. As you learn, the brain searches its neural networks to relate what is being learned to that which has already been learned, thus integrating the old and the new. The more extensive and integrated the neural pathways are, the easier it is to recall information and utilize it in the future.

Learning occurs at multiple levels of cognition, the most basic being to remember facts. Knowledge isn’t of much value if you can’t recall the information, but you also need a functional understanding of what it means. Interestingly, studies have shown that having a good understanding of a concept makes it easier to recall. If you understand the mechanisms by which angiotensin-converting enzyme (ACE) inhibitors cause side effects, for example, you will find it easier to remember those side effects.

Pharmacy students are exposed to a wide variety of teaching styles, course designs, curricular programs, and instructor personalities. It is up to you to learn as much as you can, regardless of the academic circumstances. Be careful not to blame faculty for your academic shortcomings. They are responsible for their teaching. You are responsible for your learning.

The rapidly expanding fields of pharmacy and medicine necessitate that pharmacists continue learning for as long as they remain in practice, lest they gradually become incompetent practitioners. Upon graduation, you will be on your own, fully dependent on the learning skills that you are establishing as a student. Now is a good time to sharpen those skills and become a master learner. The following 10 strategies are designed to enhance the effectiveness and efficiency with which you learn. They apply equally well in academic and nonacademic settings, providing skills sufficient to support a lifetime of learning.

1. Commit to Improving as a Learner
People are capable of improving how well they learn. The ability to learn is not a fixed trait that you inherit at birth and are stuck with for the rest of your life. Learning skills can be cultivated. Carol S. Dweck, a leading researcher in the field of developmental psychology, has conducted fascinating research into the effect of mind-set on how one approaches learning. According to Dweck, some people have a fixed mind-set, meaning that they think their ability to learn is rigid, while others have a growth mind-set, based on the belief that learning is a process that can be improved.

The impact of mind-set on learning habits is profound. Some fixed-mind -set people perceive that their capacity to learn is limited, believing that they are simply not “smart enough” to understand certain concepts. They tend to become overwhelmed with feelings of helplessness when faced with difficult academic challenges, and give up. Others with a fixed mind-set consider themselves to be advanced learners who are smart enough to master anything. They tend to blame others when their academic performance falls short of expectations. Either type of fixed mind-set leads to a pervasive attitude that there is no point in working harder or trying something different.

In contrast, growth mind-set people see their learning capacity as an ongoing work in progress. They believe that with sufficient effort and the right strategy, they can learn almost anything. Attitude matters. Set your mind firmly on a path of growth. Think of learning as a skill that can be developed, not a fixed trait. Take responsibility for how well you learn, and if there is room for improvement do something about it. (For further explanation, see Ambrose 200-201; Bain 101-111; Brown 92, 179-183.)

2. Strive for Deeper Learning
Learning that results in a superficial understanding of concepts and the transient, short-term memorization of facts has been described as surface learning. Even if sufficient to pass an exam, surface learning is not likely to result in long-term retention or the ability to relate concepts to a variety of situations. In other words, it is of little educational or professional value. Deep learning involves greater depth of understanding and results from advanced levels of cognition, such as applying, analyzing, evaluating, and creating. Surface learning enables you to recognize dots; deep learning enables you to connect the dots.

The depth of learning is dependent on the extent of critical thinking that goes into it. Deep learners don’t limit themselves to memorizing facts about drugs and diseases; they seek to understand the mechanisms behind the facts. For example, knowing that “guidelines” recommend ACE inhibitors for the treatment of diabetes with hypertension is surface learning. Deep learners go on to ask why, how, and what if. Why do the guidelines make that recommendation? How does the pathophysiology of diabetes and hypertension match up with the pharmacology of ACE inhibitors? How do ACE inhibitors compare with other antihypertensive drugs? What if a patient has renal failure; does that matter? Don’t just memorize treatment guidelines! Seek to understand the evidence and rationale upon which the guidelines are based. Gourmet chefs do not rely on cookbooks.

Surface learning might be sufficient to get by academically, but deep learning is transformational and life-changing. Take advantage of opportunities to deepen your learning by engaging in hands-on activities. Don’t just go through the motions to complete assignments or projects that are intended to stimulate you to think critically. Critical thinking involves carefully examining the information you have to work with, evaluating that information to determine how relevant and valid it is, and then forming conclusions or making decisions based on that information. Health care practitioners must think critically as they make clinical decisions on behalf of a patient. It is a vital skill that every good pharmacist should have and every pharmacy student should develop. (For further explanation, see Ambrose 118-119; Bain 155-157.)

3. Identify What You Need to Learn
Stephen R. Covey’s best-selling book, The 7 Habits of Highly Effective People, includes the sage advice, “Begin with the end in mind.”7 In other words, to achieve a goal, you must first understand what the goal is, establishing a target. In education, goals that define what students should learn are termed “learning outcomes.” Learning outcomes (sometimes designated learning objectives) define exactly what students should be able to do as a result of the learning that is expected. They generally begin with an action verb followed by conditions and qualifiers, such as, “Calculate the creatinine clearance of an adult patient using the Cockcroft-Gault equation.” Instructors should provide a set of broad, course-level learning outcomes, as well as more detailed learning outcomes specific to each lesson.

Carefully review the learning outcomes that are made available to you from an instructor. You can also gain perspective on learning “targets” by analyzing assignment instructions, criteria in grading rubrics, study guides, exam reviews, or any other sources that provide insight into the instructor’s expectations. For further clarification, ask for some guidance from the instructor about what to focus on in your studying. If all else fails, try to set learning priorities of your own. Don’t set out on a journey of learning until you have a reasonably clear picture of the destination. If you know where you are going, your brain will function like a GPS device to keep you on track. (For further explanation, see Nilson 17-18.)

4. Stop Cramming! Spread Out and Mix Up Your Studying
The typical pattern of intense, condensed cramming of material shortly before an exam is unequivocally the most detrimental study pattern plaguing pharmacy students today. If this applies to you, take heed—there is nothing you can do to enhance your learning more dramatically than breaking the bulimic pattern of cramming for exams. Cramming not only restricts you to surface learning, but it generates undue stress—the last thing a pharmacy student needs. Studying is more effective, more efficient, and less stressful when it involves learning smaller chunks of material over longer periods of time. It might feel as though you are learning more when you study material at one time en masse, but evidence suggests that digesting it in smaller bites is better.

Researchers have also found that learning is enhanced when you mix up and alternate study topics. It is better to study 1 subject for a while, switch to another, and then go back to the original topic, than to study the same material the entire time. The learning capacity of the brain improves when the focus of attention switches from time to time. It requires greater effort to spread out and vary studying, but the effort is worth it. Remember—learning is a complex process of construction that depends on repetition and reinforcement. (For further explanation, see Bain 243-245; Brown 31-32, 46-52, 203-207.)

5. Read for Understanding, Not for Speed
Reading to learn is distinctly different from reading a novel or a newspaper. Reading to learn requires a strategy that incorporates thinking about what you are reading as you read it. One method is SQ3R: Survey, Question, Read, Recite, and Review. Before you start reading, survey the material by flipping through the pages. Make note of the introduction, conclusion, headings, tables, and figures, just to get a feel for the content. As you survey the material, question what you should be learning from each section of the reading. This provides an idea of what to look for. As you read, search for the take-home points. Avoid reading too rapidly. Be methodical and take your time. Stop periodically to recite (or write) the highlights of what you’ve read in your own words. Don’t just repeat or copy verbatim from the text. Lastly, try to review (recall) the key points without referring to the text. Studies have shown that reading followed by rereading produces less learning than stopping periodically as you read to paraphrase and recall key points. Reading to learn has elements of effective studying deeply ingrained in the process. That’s why it works. (For further explanation, see Ambrose 128; Bain 232-241; Brown 201-203; Nilson 30-31.)

6. Write What You Learn in Your Own Words
Writing is a potent catalyst of learning, probably because it is not possible to write coherent sentences without thinking, and for sentences to convey a meaningful message, one must have a reasonable understanding of the topic. Paraphrasing lecture notes, handouts, textbook readings, or other materials facilitates learning and identifies gaps in knowledge and understanding. A pharmacy student at the Lloyd L. Gregory School of Pharmacy shared an illustrative story a few years ago. She had been struggling in therapeutics courses throughout her second professional year, barely getting by with grades of C. At the start of her third year, she instituted the practice of rewriting lecture notes and reading assignments in her own words. Her learning improved dramatically as evidenced by exam results. More importantly, she sensed that she was learning at a much deeper level and gained increased confidence about her upcoming advanced pharmacy practice experience rotations.

Research confirms that students who write what they are learning in their own words perform about a half letter grade higher than students who don’t. Better yet, the learning difference is still evident months later. Any practice so effective at getting you to think is bound to help you learn. (For further explanation, see Bain 249-251; Brown 89-90; Nilson 26-28.)

7. Practice Retrieving and Explaining as You Study
Many students have mastered the art of skimming over their notes to remind themselves of key points. It’s a comfortable process that seems to solidify knowledge. Studies, however, have shown that greater learning is achieved by practicing retrieval rather than rereading or highlighting notes. Retrieval is a process of self-quizzing. It involves pausing after each section to recall the key points and trying to explain the concepts, similar to the SQ3R reading method. Repetitive self-quizzing stimulates the brain to search its neuron networks for information, strengthening the associative connections that make it easier to remember what is being learned and relate it to new situations. The result is deeper learning.

Retrieval practice works best when a spaced-out study pattern is used, so there is sufficient time to forget some of the material and then relearn it. Ironically, research suggests that practicing retrieval before you’ve spent much time studying, such that your recall is limited, still produces tangible learning. The study method of scanning over materials to “refresh your memory” before an exam tends to create a false sense of security, based on the assumption that if the material seems familiar, it has been learned. Self-quizzing produces a more realistic assessment of learning and is better suited to expose gaps in knowledge.

It is prudent to build self-quizzing into your experiential training, as well as your didactic coursework. You should engage in retrieval practice at every opportunity, constantly asking yourself about drugs you encounter. Try to recall the pharmacologic class, mechanisms of action, therapeutic indications, standard dosing, major adverse reactions, etc. For disease states, quiz yourself about the etiology, pathophysiology, and therapeutic options. Turn experiential training into a 24/7 self-administered quiz. When you can’t recall an answer, jot down the topic and look it up later. Quizzes are more tolerable when you are able to administer them (and grade them) yourself. Build self-quizzing into every pharmacy experience. (For further explanation, see Ambrose 192-193; Bain 246-247; Brown 43-45, 76-79, 201-203; Nilson 31.)

8. Reflect on How Well You Are Learning
The term “metacognition” refers to thinking about your thinking, or in this case, reflecting about your learning. Such self-reflection provides insight into how you are learning and how you might be able to do it better. Are you effectively quizzing yourself? Are you striving to achieve deep learning? Are you allocating enough time to study, spreading topics out, and paraphrasing what you learn? Are you able to apply what you learn to a variety of situations?

To help students reflect on their learning and optimize their learning practices, several learning style inventories have been developed. One of the more popular of these is VARK (Visual, Auditory, Read/Write, Kinesthetic). Students can complete a VARK online survey to identify their predominant learning style among the 4 categories (www.vark-learn.com).

One drawback of the survey is that it measures preferences, not abilities. Students might mistakenly assume a certain learning style works best for them because it feels comfortable, although they might be better off utilizing a different learning modality. In reality, studies to validate the accuracy and reliability of learning style measurement tools are lacking. This is not to suggest that VARK is of no value. On the contrary, it provides a useful model of how people receive information. It behooves students to explore study options that correspond to each of the 4 categories (although the “Read” and “Write” should probably be separate).

You are capable of learning in many ways. Why label yourself as a certain type of learner and thus limit your learning possibilities? There are many portals by which information can gain access to your brain. It would be better to adapt your choice of learning style to what you are trying to learn at the time, rather than restrict yourself to one preferred method. The best strategy is to have a variety of learning styles ready to use in your learning toolbox, and to know how and when to use each one. (For further explanation, see Ambrose 190-200; Bain 24; Brown 88-89, 131-146 and 209.)

9. Approach Mistakes as Learning Opportunities
Learning is a messy process. It involves making mistakes, identifying deficiencies, and adjusting strategies as warranted. That is what growth is all about—a continual series of course corrections. People who possess a growth mind-set appreciate the role that mistakes play in learning. They understand that failure can be a precursor to success. When faced with a setback, they welcome the opportunity to learn from it. The results of studies show that by applying sensible learning strategies, a disappointing performance can become a stepping stone to improvement. Failure is only final when you stop trying to succeed.

Evidence also suggests that a wrong answer during self-quizzing benefits learning more in the long run than a correct answer does. It gets your attention. When taking a graded exam, there is no point in being discouraged about a poor performance. The best approach is to scrutinize the exam, try to identify what went wrong, learn from it, and strive to do better next time. Even when you earn a passing grade, analyze each incorrect answer to ascertain why you got it wrong. This will improve your understanding of the material covered on that exam and provide additional insight into how to better prepare for future exams. (For further explanation, see Bain 99-120; Brown 90–94, and 180-182.)

10. Help Others Learn
Neil Markham, a professor of biology at the University of Wisconsin-Whitewater in the 1970s, once commented to me, “You’ll never really understand anything until you teach it to someone else.” I’ve found that adage to be true on numerous occasions. The process of explaining a complex concept to someone else deepens your own knowledge and expands your understanding. An explanation that makes perfect sense in your mind can have its inaccuracies and uncertainties brought to light when struggling to articulate it in a manner that makes sense to another person.

This final strategy is designed to take advantage of the learning synergy that results from collaborating with peers. Self-quizzing is effective; peer-quizzing is even better. Some students shy away from participating in study groups because they perceive it to be too time-consuming or they are concerned about a mismatch of academic abilities within the group.

In practice, most students benefit from the academic interactions and interpersonal dynamics of group study, regardless of the make-up of the group, provided that the members are committed to learn. Group study has been shown to broaden students’ perspectives on a topic, expose students to other learning methods, instill a sense of mutual accountability, and foster a supportive motivation to learn.8,9

Find some like-minded classmates who desire to learn more deeply, and form a study group. Quiz each other, explain concepts to each other, challenge each other, and encourage each other.

Think of your study group as a learning team—a cognitive co-op. As the saying goes, “Together Everyone Accomplishes More.” (For further explanation, see Sibly 50-56; Hendry.)

Putting Strategies into Action
Make no mistake—it takes careful planning and the skillful use of time to successfully navigate the intense demands of pharmacy school. A comprehensive discussion of effective time management is beyond the scope of this article, but 3 basic practices, when properly applied, can make a huge difference.

The first is to set and clarify priorities. Another prudent bit of advice from Covey’s, The 7 Habits of Highly Effective People, emphasizes the importance of prioritizing one’s daily activities: “Put first things first.”7 There aren’t enough hours in the day for everything you would like to accomplish, so you must identify which activities deserve preference.

Significant daily time devoted to study must be a high priority. Among your other priorities, be sure to include adequate rest. Pharmacy school will have your brain operating on overdrive much of the time. Lack of sleep due to late-night studying is counterproductive and undermines learning. Include sufficient sleep in your study plan. Take care of your brain. It can neither learn well nor perform well on exams when it is exhausted.

Another element of effective time management is to eliminate or reduce unnecessary time-wasting activities. Consider how much time you spend watching television, playing video games, surfing the Internet, etc.

Other activities, such as socializing with friends, are important, but can be done to excess and might need to be cut back to more reasonable levels. Some time-consuming habits may be hard to break. Break them anyway.

Equally important is making the most of your study time by minimizing distractions. Choose a location conducive to focused mental concentration. Learning should occupy your full attention, without disruptions from text messages, e-mails, or Facebook friends.

Likewise, avoid the potential distraction of a television or loud music playing nearby. Multitasking is considered by some to be a valuable skill for pharmacists—not so for pharmacy students trying to learn. When you study, put your whole brain into it.

Good time management is not possible without creating a schedule that lists what you should be working on every day. Quality learning does not happen by chance. It must be mapped out as part of a sensible and balanced plan to ensure that important tasks are neither forgotten nor overlooked. Knowing that major upcoming tasks have been accounted for in your plan helps to combat worry and reduce stress.

The final step to better learning is to put forth the effort required to execute your study plan. Learning is hard work, or at least it should be. If you find learning to be relatively easy, that could be an indication that you aren’t learning deeply enough. You might need to ramp up your studying. If you are putting forth maximum effort, but achieving less than optimal results, a different approach to learning might be warranted.

In either case, if you continue to put forth the same effort and study the same way you have in the past, you will continue to experience the same results.

Change begins with a sincere desire to improve and the willingness to do what it takes to make it happen. There are no legitimate shortcuts or magic pills; you’ve got to put in the time and accept that it won’t be easy.

These 10 learning strategies are likely to force you outside of your academic comfort zone. Be prepared for a struggle. If you persevere through it, you will begin to see the fruits of your labor, and over time, your new learning methods will become second nature.

You might find 1 or more of these strategies are not well suited to you. That’s okay. It’s not an all-or-none phenomenon. Each one can enhance learning in its own right. The more of them you apply, the better you will learn, and the better you learn, the more you will grow.

It is by continually growing—academically, professionally, socially, spiritually, and emotionally—that your calling as a pharmacist will be fully realized. It all starts with learning to learn better.


Daniel Brown, PharmD, is the director of faculty development at Palm Beach Atlantic University, West Palm Beach, Florida, and professor of pharmacy practice in the university’s Lloyd L. Gregory School of Pharmacy. In addition to performing faculty development functions, he teaches courses in spiritual and professional values, critical thinking, and clinical pharmacokinetics. Dr. Brown has over 30 years of academic and professional experience, much of which has been spent working in hospital pharmacy management. He served as the dean of the Gregory School of Pharmacy from 2005 to 2010 and has been a clinical practice faculty member at 3 other schools of pharmacy, holding such positions as director of drug information, director of experiential education, director of ambulatory care, and program director for an ASHP-accredited pharmacy practice residency.

His primary areas of research include the professionalization of pharmacy students, growth of the pharmacy academy, and clinical pharmacokinetics. Dr. Brown is an active member of AACP, ACCP, ASHP, TBLC, and Rho Chi. He has served on the board of directors of the North Carolina Pharmacist Recovery Network and Christian Pharmacists Fellowship International.


References
  1. Persky AM, Alford EL, Kyle J. Not All Hard Work Leads to Learning. Am J Pharm Educ 2013; 77 (5) Article 89.
  2. Zorek JA, Sprague JE, Popovich NG. Bulimic Learning. Am J Pharm Educ 2010; 74 (8) Article 157.
  3. Bain K. What the Best College Students Do. Cambridge, MA: Harvard University Press; 2012.
  4. Brown PC, Roediger HL, McDaniel MA. Make It Stick — The Science of Successful Learning. Cambridge, MA: Harvard University Press; 2014.
  5. Nilson LB. Creating Self-Regulated Learners — Strategies to Strengthen Students’ Self-Awareness and Learning Skills. Sterling, VA: Stylus Publishing; 2013.
  6. Ambrose SA, Bridges MW, DiPietro M, et al. How Learning Works — 7 Research-Based Principles for Smart Teaching. San Francisco, CA: Jossey-Bass; 2010.
  7. Covey SR. The 7 Habits of Highly Effective People. New York, NY; Simon & Schuster; 1989.
  8. Hendry GD, Hyde SJ, Davy P. Independent Student Study Groups. Medical Education 2005; 39: 672–679 doi:10.1111/j.1365-2929.2005.02199.x
  9. Sibley J, Ostafchuk P, Roberson B, et al. Getting Started with Team-Based Learning. Sterling, VA: Stylus Publishing; 2014.