Flashcards vs. Immersive Learning: What Language Courses Have To Say About This Debate To Medical Education

by Christopher Cimino, MD, FACMI, VP of Medical Academics, Kaplan Medical | February 17, 2021

How Do You Say, ‘Hello?’

My father was once invited to give a talk at a medical conference in France. The standard at such international conferences is that the presenter speaks in their native language and multiple interpreters simultaneously translate for the audience. Still, he felt strongly that, out of respect for the audience and conference organizers, he wanted to at least give the opening part of his presentation in French. Needless to say, he didn’t know a word of French, but with my mother’s help, he prepared some flashcards and started drilling some basic French phrases. 

She also helped him with pronunciation but recommended they make a trip to Montreal so he could get some immersive practice. On the drive from New York City to Montreal, my mother continued to drill with him while he drove. Shortly after crossing into Quebec, they got off the highway to get gasoline but no station was in sight. They pulled up to a hotel and my mother gave him some last-second advice on asking for directions. He walked into the hotel and returned 5 seconds later and asked, “How do you say, ‘hello’?”

Fear of Public Mistakes Trumps the Efficiency of Immersive Learning

There is a wealth of evidence that language immersion is more effective than “traditional” language learning approaches. The evidence has been around for so long that we might need reminding what the traditional approach was: vocabulary memorization, flashcards, workbook exercises, and drills. These approaches include a great deal of tedium and a long time before the learner actually has a useful command of the language. So if these approaches are tedious and proven to be less efficient, why do they remain so popular? 

One reason is that immersive learning is anxiety-provoking. If you dropped someone in the middle of Paris with a phrasebook, they might have reason to fear ending up in the wrong neighborhood and coming to harm, but we are unlikely to force that extreme kind of immersion. Still, even the fear of appearing stupid and making mistakes is a powerful force. 

Medical students describe this issue when talking about why they hold back in small group settings. The most common stated reason is they worry about how they will appear to their peers. In contrast, flashcards are very private and solitary and your mistakes are your own. That is a strong attraction and probably explains people’s initial gravitation toward flashcard exercises. 

Of Course Flashcards Have Value, But They’re Not La Seule Option

There are tasks for which flashcards are uniquely suited. Learning a language that has unfamiliar components such as unique alphabets, new grammatical elements, or new concepts is a daunting task because you first have to recognize these elements. In this case, flashcards can help learners identify and memorize necessary concepts that are the building blocks of language. 

For a task like pronunciation or writing, expanding aspects of vocabulary can be accomplished with drills and flashcards. For example, a typical high-school graduate has a vocabulary of around 15,000 words. A typical college graduate has a vocabulary of around 40,000 words. And a typical medical school graduate has a vocabulary of around 80,000 words (much of which is only useful for speaking to other health professionals.) This drastic increase in words can be attributed to memorization for academic use, not necessarily everyday or practical use. Additionally, what these have in common is we are tying “vocabulary” to “motor skills”, not “reasoning skills.”

Memorization is Learning Out of Context

It is certainly important to be able to correctly pronounce the word “bonjour” if your goal is to speak French. But if your only experience saying this word is when seeing it written on a card or when someone asks you to translate “hello,” then you are less likely to retrieve that information when seeing a person standing behind a hotel counter. 

In my father’s case, the problem was aggravated by anxiety. If he was in a more familiar context he probably knew he needed to say hello and what the word was in French. Flashcards and drills promote learning out of context which is less helpful when placed in the context for which you were learning the material. It also keeps knowledge in discrete chunks and doesn’t promote a knowledge structure. 

How Can Someone Know When It Is Time to Wean Oneself Off Flashcards?

These things may be self-evident but it may be too late to impact learning. Once begun, flashcards become more attractive because they represent both simple discrete tasks and measurable progress. The progress may be slow but it is steady and the apparent solution is just to do more of the same. The discrete nature of the task helps since it means it can be done in short bursts whenever small amounts of time are available. A student is building a broad consistent basis for the content but it can take a long time before that content proves useful. 

So, how can someone know when it is time to wean oneself off of flashcards? 

A sign that it has gone too far is when students talk about their studies in terms of the number of cards in their deck or the number of times they have been through their deck. Even if they recognize this, making the transition can be difficult. 

While flashcards are more active than simply reading or listening to content, it is only slightly more active. In talking to high USMLE and COMLEX scorers, many of them reported moving away from flashcards in their studies and toward still more active activities like creating summaries and outlines of the content. This allowed them to model the knowledge connections they wished to make for themselves and provided a richer basis for recall of relevant material for different contexts. The knowledge they are building is narrow and may be inconsistently connected, but what they have is immediately useful for specific situations. Over time, the disparate narrow pieces of knowledge become interconnected creating a firm foundation broader than the approach based on drills. 

High Scorers Recommend Utilizing Practice Questions to Provide Context to the Material

Another known behavior of high scorers is they make use of practice questions. If your goal is practicing medicine then hopefully they provide the context of a patient case to frame the question. If your goal is a high score then the question is the context you are working towards. Something I have heard from second-year students across the class is, “I wished I had done more questions in first-year.” Meanwhile, first-year students say, “I’m saving my questions. I only use them right before an exam. I’m using flashcards instead.” For all the advice first-year students take from second-year students, this seems the one piece that they bypass. The irony here is that questions are viewed as only good the first time while flashcards increase in value with multiple uses. 

As anxiety-reducing as flashcards may be with repetition, practice questions highlight your flaws and weaknesses and provoke anxiety in much the same way as any other immersive technique. 

So, how do you convince someone to choose the higher anxiety approach because it will save them time in the long run? 

It must be a little like trying to convince people with stage fright to take a public speaking course. The change is made harder by the fact that medical students are dealing with a tremendous amount of content, insufficient time, and any change in study methods is bound to be less efficient in the short term. As the challenges mount, there is an innate desire to stick with what has worked in the past. It makes me wonder if medical students who have learned another language as an adult are more likely to take an immersive approach to medical school?

Tips for Helping Medical Students Make the Transition to Immersive Study Practices

  • For students who are ready to wean off flashcards, but need a structured, turnkey option: Recommend that they introduce practice questions into their study practices, such as Qbanks. Qbanks are great for all levels of medical students to start putting their knowledge into practice long before it’s time for an actual exam. 

  • For students who fear making mistakes in public: Virtual simulation programs, like i-Human Patients, offer learners the opportunity to practice their knowledge and skills in a risk-free environment. Set the bar low for practice questions. Getting correct anything better than chance is a good start. Expect gradual, not dramatic, improvements. 

  • For students who are looking to expand beyond flashcards: Talk to them about additional options for studying (study groups, creating outlines of the content, etc.) and explain the value of active as well as passive learning. Left-brained students respond well to breaking down the WHY behind new concepts.

Prend Soin de Toi. (Take care.)

がんばってね    (Do your best.)

References:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6706270/

Dr. Cimino has earned a reputation internationally as an award-winning medical educator. He was the founding Assistant Dean for Educational Informatics at Albert Einstein College of Medicine and former Associate Dean for Student Affairs at New York Medical College. He is board certified in Neurology and Clinical Informatics. He served as a member of the NBME Step 1 Behavioral Science Committee and the NBME End of Life Care Task Force. 

See more posts by Christopher Cimino, MD, FACMI, VP of Medical Academics, Kaplan Medical