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Medical Education: How do you take notes?

Over the past year I have interviewed well more than 100 clinicians and educators to better understand how they learn, and how they employ what I have come to call the four natural learning actions. These structured conversations have been enlightening – and if you are interested in participating in the process, just let me know. Over the next few months I will be blogging about these finding, submitting a few manuscripts for publication, and extending the research. In the meantime I thought I would begin to share a few of the more interesting ‘learning architectures’ that I discovered.

Case #1: “I’ve used the same notebook for my two big annual meetings since around 1994…”

One clinician told the story of the one notebook that he has used for nearly 20 years. For 350 days a year this notebook sits in plain sight in his office bookcase. Twice each year he takes this book – including every note that he has jotted down from the two major medical meetings he attends each year – and packs it in his brief case as he prepares to travel to the upcoming meeting. Two meetings times 19 years equals 38 separate learning experiences. As he boards the plane to the next meeting he will use the time to flip through the pages of past meeting notes. He mentioned that this is always a time of both shame and learning – shame in that he had forgotten most of what he wrote down at the last meeting and learning because this exercise prepared him to be a better learner at the next meeting.

Over the course of the meeting he would take notes from the sessions he attended, from the hallway conversations he had, and even from the chance meetings he might experience on the exhibit hall floor. Each night he would try to revisit what he captured that day. And over the three or four days of the meeting he would take anywhere from 4-10 pages of notes. On the flight home he would flip back through his notes and even flip (once again) through the notes of prior meetings so that he could identify any actionable items – these became his “to do list”…though he readily admitted that he rarely acted on these items. Once back in his office the book would be replaced on the bookshelf.

As he described it, “Simply looking at the spine of the book a few times each month served in some small way as a trigger to think about the meeting, and think about the notes I took…I just never figured out a better system to ensure I took action on what I knew was important…”

Case #2: “I use the back of my business cards to jot down anything (and everything) I think is important from my annual meetings…”

One educator suggested that he too was struggling with his note taking and reminder system – he went so far as to ask me not to judge him on the system that he had used for the past decade.

While packing for a major medical meeting he would bring up to 50 business cards. Though some of these cards would be shared with folks he met at the meeting, the primary purpose of this stack of cards was for note taking. With each conversation or learning moment that he accumulated over three or four days at the meeting he would also accumulate a set of cards with notes. Over the course of the day each business card with a note on the back would go into his front left chest pocket. Each night these cards would become ‘flash cards’ allowing him to review what he had learned that day before being stacked neatly on the hotel room night stand. Before the return flight home he would collect the week’s worth of cards so he could continue to flip through these cards and would even begin to organize and prioritize the cards before putting a colored rubber-band around the deck. Upon returning to the office he would try to find time to review the cards once more, but more often than not the banded stack was immediately deposited in the bottom right drawer of his desk.

As he described it, “I know what is in that desk drawer – stacks and stacks of banded business cards. Each stack represents a major meeting I attended. And at least once a week I bang my shin on that drawer! The black and blue marks on my shin serve as a reminder of just how bad my note taking system really is!”

These are just two of the the stories I have been told over the past year – there are dozens just as eccentric, just as frustrating, and just as painful. To be clear, I would never judge a clinician or educator for the jerry-rigged system they have tried to engineer for themselves. The reality is so little effort has been devoted to building better structure for note taking and reminders, that we are each left largely to our own devices…and each tend to do what we have always done!

Over the coming weeks as I share more stories about note taking, reminder systems, search models, and social learning skills I hope you will see that these systems are rarely ever refined or evolved. Yet it is these very systems that support the four natural learning actions which are requisite in each and every medical education program and model we employ.

If you have similar stories to share, please do. And, perhaps together we can help learners and educators alike realize that a well-structured learning architecture is critical to driving change in our lifelong learning models.

All the best,

Brian

Brian S McGowan, PhD

Written by

Brian is a research scientist and educational technologist. He helped transform Pfizer’s Medical Education Group and previously served in educational leadership roles at HealthAnswers, Inc.; Acumentis, LLC.; Cephalon; and Wyeth. He taught graduate medical education programs at Arcadia University for 10 years. Dr. McGowan recently authored the book "#socialQI: Simple Solutions for Improving Your Healthcare" and has been invited to speak internationally on the subject of information flow, technology, and learning in healthcare.

5 Responses to “Medical Education: How do you take notes?”

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By Bryan Vartabedian - 24 February 2013

I have found Evernote to be invaluable in this regard. The problem with notebooks and business cards is that you will very likely have no way to access those notes once the meeting is over. Even in the most organized filing system, you’ll likely need that information at some point when you’re no where near your file cabinet. And taking them is one thing, but retrieval is the critical back end step.

My process these days is that I use my 13 inch MacBook Air at meetings. I begin a new note for each lecture. I type away, add a title and a couple of tags and I’m done. Months later when I remember hearing a lecture about whatever the topic was, I can either search the word or the tag. If that doesn’t work, the notes are geotagged so that if the meeting was in San Francisco, I could narrow the notes down to the Moscone convention center. I can also record the presentation right in Evernote if I’m seated near a speaker.

It’s been a system that’s hard to beat.

Brian S McGowan, PhD
By Brian S McGowan, PhD - 25 February 2013

Thanks for leading off the conversation Bryan – not surprised that you have taken the effort to ‘hone your craft’ as it were when it comes to note taking. It seems logical that the use of new apps and software would make one a better note taker – though creating the definitive study to prove this would be an interesting project. But I still have a few questions perhaps you would consider weighing in on…

In my interviews about 85% of docs self-identified as being a note taker but the vast majority of admitted to never having thought much about their technique or efficiency. As Clay Shirky suggests, ‘we don’t have an information overload problem, as much as a problem of filter failures.” I like to say it a different way: ‘there is no lack of content to be learned, but we are (broadly) lacking any structure to support learning.’ So my first question is: “How can we help the vast majority of clinicians come to the realization that they could more easily manage the lifelong learning process (and save themselves dozens of hours each year) if they would simply evolve and refine their note taking (filtering) acumen and efficiency?”

The 2nd question has less to do with how notes are taken, and more to do with what notes are taken. Clearly, lacking a structure for lifelong learning significantly undermines the efficiency of meded and CME, but even if learners were convinced to leverage new technology to evolve their own jerry-rigged system for information management (Evernote + emails + to do lists + post-it notes = ???), the clinician learners would still have to know what to record/archive. This might sound like a simple matter and indeed many underestimate the relevance in medical education, but the reality is the extraction of insight from experience (learning) is only as good as the fidelity of the learner’s filter…and I have learned enough in my career to know that what a learner hears or reads may not always be accurate…such is adult learning…so what the learner records is often missing nuance or context or accuracy or action. It’s great to know that some docs are evolving the way they take notes, but as the saying goes, ‘the devil is in the details.’ And so my 2nd question is, “What are we actually recording within our notes and is the detail sufficient to support your lifelong (and rapid) learning?”

Love the dialog!

Brian

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By Steve Daviss - 24 February 2013

I also used to use the banded cards technique, bringing the last meetings’ cards onto to the plane of the next meetings’ with the idea of reviewing and entering the information into my device du jour. It mostly resulted in ziplock bags of cards with great ideas, no doubt.

Thanks to the ipad, Simplenote, Dropbox, and gmail, I now use a “system” that at least encourages me to put the information down in real-time, such that I can find information pretty easily and quickly by just opening Simplenote or gmail and typing in the words or dates of interest. I date notes using YYYYMMDD so that I can find a note I think I made in December using 201212, even though I used the date 20121219.

I also tweet microblogs of info during meetings, allowing me to go back over my send tweets as a way of reviewing my notes. I favorite others’ tweets so that I can come back to that info later. This works surprisingly well.

=Steve @HITshrink

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By John Mandrola - 25 February 2013

Agree strongly with Dr_V. I’ve used Evernote both on the MBP or Ipad in a meeting. You tag the notes or place them in a separate folder and there they are later. You can even check or update them with your smartphone on the bus back to the hotel.

I learned about Evernote from Dr_V from an old post of his. Thanks for the tip.

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By Eva Montgomery - 4 April 2013

I use the Notes feature on my iPhone and iPad. I like it because the notes I take on one device synch with the other device. Haven’t tried Evernote but worth checking out. I think the challenge is ACTION. Taking notes is the easy part: you sit in a room, listen to a lecture and take notes….now what?

BTW, our company has a note-taking APP for courses where people can take notes on the slides rather than just a generic note feature. Our medical clients are using it to replace paper-based workbooks. Feedback from doctors/dentists has been extremely positive, however, it remains to be seen if digital versus paper improves learning and ultimately outcomes.

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