Dr. Strangekidney, or How I Learned to Love Renal Pathophysiology

The year was 2006.  The class was renal pathophysiology, the bane of medical students everywhere.  Our text was from Harvard Medical School, and even Harvard admitted on the back cover that this is a “difficult subject for even the most advanced students.”  I don’t remember such a depressing statement–before or since–on any other textbook in my 30 years of studying all kinds of difficult subjects, including organic chemistry I and II, physical chemistry I and II, differential equations, formal languages and automata, advanced calculus/physics for engineers, and everything I’ve studied in medicine!

Certainly not the most advanced student in my class, I nevertheless resolved to somehow conquer this untamed beast of medical knowledge.   I don’t know what I was thinking.  Nephrology is, perhaps, the most difficult subject taught during the basic science years of medical school. The material is extremely complex, the time allotted to learn it too short, and the student finds it difficult to retain the numerous relationships between facts long-enough to place them into a top-level or conceptual context.  What made it more difficult was that there were several other subjects to learn during that block of basic science.

After seeing a fellow classmate use a story mnemonic for a set of facts in another class, I suddenly realized how I can use a giant story mnemonic to learn all the renal pathophysiology we had to learn.  By imposing a mnemonic system onto individual facts, and onto relations between them, a story arises, a concrete story that significantly facilitates retention of this abstract subject. Retention, in turn, facilitates reasoning about the subject on a higher level.

Even though I’ve never used any illicit drugs, nor even tried a cigarette, I began to spend bizarre, psychedelic afternoons and evenings learning renal pathophysiology while writing a very strange, nonlinear story in the margins of our textbook and printed PowerPoints.

For example, I represented sodium (Na) as a Morton salt container.  Since sodium moves into the renal tubular cell from the luminal membrane (the side that faces the tubule) and out of the cell from the basolateral membrane (faces away from the tubule), I visualized Morton moving toward the light (lumen ~ light) inside the cell. Once inside, Morton runs down a ladder to first base (“base-o-ladderal”).

We learned that charged particles can’t diffuse freely across lipid bilayers; they must use channels or transporters to move across cell membranes (which are lipid bilayers). Morton was charged with a crime, so he can’t move across a cell membrane without personal transporters or without showing up on a TV channel.

The loop of Henle is the portion of the nephron between the proximal and distal convoluted tubules.  I represented the loop of Henle as Don Henley, the famous singer-songwriter.  Na is reabsorbed in the loop of Henle via Na+-K+-2Cl- cotransporters. In my story, this became:  Don Henley eats salted (Na+) bananas (K+), then drinks swimming pool water (Cl-) to quench his thirst. (Mr. Henley himself never did this, of course, to my knowledge.  This was only a memorizational tool.)  The loop of Henle is regulated by the tubular flow rate: Henley flows, baby!

The distal tubule became the Orient.  Na is reabsorbed there via Na+-Cl- cotransporters.  This became: in the Orient, Morton salt containers float in pool water which empties into the Ganges river.  The distal tubule is regulated by the tubular fluid flow rate: the Ganges ebbs and flows, regulating life in the Orient.

I represented the collecting tubules of the nephron as museum collections.  Na is reabsorbed there via Na+ channels. The museum collections display televisions that show Morton salt containers 24/7!  The collecting tubules are regulated by aldosterone and atrial natiuretic peptide.  Aldosterone became Aldoster, the Spanish playboy, a collector of Morton salt containers, while atrial natriuretic peptide became an atrium filled with nature art: the collections include an atrium filled with nature paintings that pep you up.

And so on for hundreds of associations (including renal biopsies and other images, equations, etc.) in an ever-enlarging story involving the same “characters.”  I studied this mnemonic system twice before the exam:  once while building it, and once as a review.

The exam was a multiple-choice, Scantron-based affair.  We were under a lot of time pressure.  Halfway through, I suddenly realized the exam was misnumbered–it didn’t correspond to the Scantron!  I had misbubbled at least fifteen questions and felt I had no choice but to erase everything and start over.  Trying not to panic, I carefully erased everything, went back to the beginning, and quickly filled everything in again, question after question.  By the time I reached the point where I’d left off, I didn’t have much time left.  I picked up the pace significantly and still managed to finish.

Walking out of the examination room that day, one of my classmates (who was a bona fide “most advanced student”) told me she thought this was the hardest test she’d ever taken.

Some time later, we got the results.  I got one of the highest scores (if not the highest) on the exam–nearly a perfect score.  So, this crazy technique works.  Or it worked in that case.  I think it worked by imposing a concrete story onto abstract facts that are otherwise poorly associated (e.g., not intuitively associated) with other facts.

Years later, I discovered that Scott Young, the celebrated learner/self-improver, used an analogous strategy for learning new things.  He recommended practicing mnemonic techniques over and over until they become second-nature.  (I don’t know if he still recommends this because I haven’t kept up with his work.)

However, I didn’t ever use a giant story mnemonic again.  It was just too unwieldy for me.  I found that it’s more efficient to use a variety of learning techniques.

We moved on to the next block of material, I didn’t have any reason to practice my mnemonic system, and by the time I took a nephrology rotation during our clinical years of medical school, I found I had forgotten much of what I had learned and had to spend time relearning it.

How about you?  Do you use mnemonics on the fly while studying?  What’s your approach to learning subjects that are extremely rich in detail and in relationships between details?

My next essay was going to be on the following topics:  how I prepared for the SAT by myself and scored at the 99.9th percentile; scored 5 (highest) on multiple AP exams (Calculus AB, Literature and Composition, Biology, etc.); used the same pattern of preparation to study for the GRE in a month and got a similarly high score as on the SAT; and studied for the MCAT in less than two months and scored high-enough to impress any med school admissions committee.  However, I found this excellent article today that says much of what I wanted to say:  How to Get a Perfect SAT Score, by Allen Cheng.  Pair it with A Mind for Numbers and with How We Studied for the Boards and you have a complete top-level strategy for all of these exams.

If you’d like for me to publish my essay, let me know, and I’ll see if I can add to the excellent advice presented by Mr. Cheng.

Update 2/15/16: a friend read this essay and recommended that I check out Joshua Foer’s Moonwalking with Einstein.

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Two Hawks Sketched Quickly From Life

It was difficult to draw these birds.  They moved their heads, flew from perch to perch, and glared at me with suspicion (or curiosity).  The drawing on your right is more accurate than the one on your left.  However, the point of field sketching is not to create an accurate or beautiful representation.  The point is to gain a deeper understanding of and connection with what is drawn.