Mastering Medical Knowledge with the Rule of Threes: A Study Technique for Improved Learning and Recall
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The student once asked me, how do you remember everything in medicine? How can you possibly learn it all and keep track of everything you need to know? There's so much to learn, there's so much to do and see. How can you possibly do it all? Well, medicine is difficult. It's hard to remember things, but you've got to work out a technique that works for yourself. Today, we're going to discuss a technique that I used going through many years ago. It's a way of dividing things up into simple little aliquots of information to help me remember things. It's called the rule of threes. G'day and welcome to Aussie Med Ed.

G'day and welcome to Aussie Med Ed, the Australian medical education podcast designed with a pragmatic approach to medical conditions by interviewing specialists in the medical field. I'm Gavin Diamond, an orthopaedic surgeon based in Adelaide and I'm broadcasting from Karnaland. I'd like to remind you that this podcast is available on all podcast players and is also available as a video version on YouTube.

I'd also like to remind you that if you enjoy this podcast, please subscribe or leave a review or give us a thumbs up as I really appreciate the support and it helps the channel grow. I'd like to start the podcast by acknowledging the traditional owners of the land on which this podcast is produced, the Kaurna people, and pay my respects to the elders both past, present and emerging. G'day and welcome to Aussie Med Ed. Today we're going to talk about a study technique, one that relies on a simple pattern using the rule of threes. It's a method I use going through medicine and one that I tend to use in teaching orthopedics.

I'll start off by saying that there's only one method, and one that works for me, but it may not be suitable for everyone. This method can be used for any study or learning technique, but obviously my area is medicine, and that's why I'm applying to it today. Now there are methods of learning medicine. One technique that many of my colleagues would use was using acronyms. This is where a letter of a word is used to spell out a list. Often the acronym might involve a catchy phrase. Despite having an amazing musical type memory, I always found these very difficult to remember. I also found them not that relevant.

The classic one that I always did remember was vitamin D as a way of recalling a generalized list and attempting to provide a differential diagnosis for a condition. The clinician might have asked me, so Gavin, what's the differential diagnosis for chest pain? I never found that recalling vascular, inflammatory, traumatic, etc. was all that helpful. Whilst it produced a list, often it starts with quite rare conditions and the list always seems quite haphazard.

On top of this, the numerous lists of acronyms were always difficult to recall. My approach to this was going down a very keep it simple approach, breaking up diagnoses into how patients might present, that is picturing how I might come across the patients with a condition. This involves dividing into small divisions which builds upon themselves. I always did this for many years, but I didn't realise this technique had a name.

Years ago, my daughter asked me to check an English essay. I came across obvious metaphors and similes that she discussed, which I all knew about, but then I noted that she had classified one part of her essay into the rule of threes. I didn't even know what this was. I went and looked it up and thought, God, that's the technique that I've been using all my life. I realized my technique, which involved learning small subsets using a very simple approach, had a name, and that's called the rule of threes.

This approach of learning less helps you learn more, in my mind. What is this rule of threes? What does it involve? The concept of rule of threes is a writing principle. It's actually one where you divide things up into three subsets of information. In doing this, it helps you recall information, and when answering a question, offering three options, that gives you some substance to your answer. It's probably something you've been exposed to throughout your life.

You might have heard nursery rhymes or children's stories involving it. The Three Blind Mice, Goldilocks and the Three Bears, the story of the Three Little Pigs. Popular music often involves three chords or has three divisions, verse, chorus and bridge. And of course, famous speeches also often involve just three words. Julius Caesar, I came, I saw, I conquered. And also when you talk about location in a property market, location, location, location. Even in social life, how often do you go out with two other friends making up a group of three?

When you're going for job interviews, a structured answer to the question of what your goals are in life sounds so much better when answering about your short, intermediate and long-term goals. In the same way, when offering advice or if someone asks you what do you think the options are, thinking of three things sounds so much better. They just roll off the tongue. When you try to think of anything further, it makes it hard. And if you only offer one or two options, it doesn't look quite as impressive.

In medicine, diagnosis is the key. The diagnosis is what dictates treatment. The role of assessing a patient is to determine diagnosis. Diagnosis is formed by taking a history, performing an examination, and then undertaking investigations. Three things again. The history is predominantly what helps you make the diagnosis. It's the most valuable. Examination helps you confirm the diagnosis.

While the investigations again help you back up the diagnosis, they help you stage the conditions, determine treatment options and determine prognosis. Investigations then also help you further confirm the diagnosis, but also assist you in staging the condition, one, determine treatment options, two, and determine prognosis, three. Now, whilst I would always start by stating that in medicine, you don't need to know everything, we need to know the most common and serious conditions. But often we have the advantage of time, in what I call, who wants to be the millionaire approach.

If you don't know the answer, you can always phone a friend. That's when you get a specialist opinion or consult someone. One. You might need to ask the audience. Therefore, you present the scenario at a grand round. Two. Or you may need to come back and play the next day, see the patient back again. This is after you've had time to research the diagnosis. Three.

So really medicine can be quite simple. If you keep getting into this sort of rule of threes, it makes it even easier. The most and best way of being a safe and effective doctor is by learning the more common things and then expanding upon it. This will help you learn medicine in a very effective way. Returning to the rule of threes has benefits in that dividing things up into three helps memory retention by combining brevity and rhythm to combine into a creative pattern. Now I can hear you say,

Do we really divide everything up into threes? Does it always work? Well, if you think of a three as the most common number, and you think of a Gaussian distribution of numbers, the bell curve, if three is the most common number, then I think we can stretch the scenario to occasionally incorporate the rule of twos, threes, and fours. So you might say to me, okay, that's all very good, but how is this useful for learning the whole of medicine? Well, again, when I'm assessing a patient, I'm trying to form a diagnosis, and unless you know all the possible common diagnoses, you can't possibly do it.

The way I can remember what conditions can occur is by thinking about how the patient might present. They usually can present in one of three ways. They can present in an emergency scenario, traumatic condition, or elective scenario to a clinic, or as a mixed picture, something that comes in through casualty but then becomes more elective. And that's my three definitions. In my area with a shoulder condition, traumatic conditions can be one of three options. Fractures, dislocations, and infections.

Now you can actually get a fourth option of which involves tendon tears such as we get a tear of the rotator cuff. This often is usually an elective presentation. It usually presents slowly. You can think of three or four conditions. In the shoulder, I often say to the student, what can be fractured? When I ask a medical student what can be fractured, they often get a bit confused and pick a bone at random like a clavicle or a humerus. If you break it down in the shoulder, there are three bones that make up the shoulder. The clavicle, proximal humerus and scapulae.

I say then what can be dislocated? Well obviously a joint and the three are sternoclavicular joint, chromioclavicular joint and the glenohumeral joint. Now what can be infected? Well either the bones, the joints or the soft tissues around it. If we consider what can be torn or ruptured, well obviously the tendons. And these tendons can be the most common ones of the rotator cuff of which there are four tendons, the supraspinatus, infraspinatus, subscapularis and teres minor. But in reality the teres minor doesn't really tear quite as easily as the other three.

Obviously, you can have a rotator cuff torn, but the other tendon that tears quite commonly is the long-headed biceps. And again, the third one which you've got to think about is the pectoralis major. So again, you've got to get group of three to think about. So you can see why knowing anatomy is quite useful. And in our course, we actually combine and do a vision of anatomy as a way of trying to help learn medicine and orthopedics.

Now if we look at elective conditions, it's a similar scenario. However, the rule of threes doesn't always apply quite as easily when it comes to the elective conditions as we need to know more than just the anatomy, more the specific diagnosis. But often there are only a few conditions that can occur.

For instance, when it comes to the shoulder, there's only really about four conditions effectively. And only really three of these relate to the shoulder. You've got the rotator cuff spectrum, you've got the frozen shoulder condition, and you've got arthritis. The fourth thing that can occur in the shoulder is preferred pain from the neck. Now again, looking at the rotator cuff, there are four muscles that make up that rotator cuff. Really, there's only three stages of rotator cuff conditions.

there's the bursitis or tendinopathy there's rotator cuff tears and then there's secondary arthritis so in other words initially the person may present with bursitis and tendinopathy with a painful arc then they may have similar features with a small rotator cuff tear but as it gets bigger it can lead to weakness and then as it gets even bigger again it can lead to secondary arthritis we think about frozen shoulder there are actually three main stages of frozen shoulder there's the acute painful stage then there's a stiff phase and then there's the thawing phase

Again, three type stages of a frozen shoulder condition. When it comes to arthritis, I like to think of arthritis as being primary osteoarthritis, one that goes out of the blue and is related to genetics. Secondary, secondary trauma or infection or post-rheumatoid conditions or inflammatory arthritis.

And then you can get inflammatory-type conditions, rheumatological conditions, which is a huge number. And, of course, we can look at that in a separate talk. We've already got two very good talks on Aussie Med Ed from Sam Whittle regarding this.

Finally, if you look at referred pain from the neck, you can divide that up into three aspects too. You can either get referred pain, the cervical pain into the scapula. You can get neck pain with radiculopathy, secondary to nerve entrapment. Or you can get cervical spine pain with actually long track signs and myelopathy. Finally, when I'm thinking about cause of shoulder pathology, I've already mentioned traumatic and elective conditions, but there's also that mixed picture, the third type of presentation.

In the shoulder, this involves an acute dislocated shoulder becoming elective with recurrent subluxation episodes secondary to labral tears after the initial acute dislocation. Therefore, you can see that by dividing things up into groups of threes, it's a simple way of easily remembering things. This rule of threes can also be used when looking at other things such as complications. You think about complications as being divided up into sure, intermediate and long-term complications. And of course, being localised or generalised.

The rule of threes can also be used for investigations. Start off with simple bloods or ECGs, basic radiology, x-rays and ultrasounds, or advanced radiology, CT or MRI. When it comes to treatment options, particularly in fractures, you might think of non-operative procedures, manipulation under anesthetic and plaster, or surgical fixation. Again, three different options. So my technique of trying to remember things in a simple approach is to keep it simple.

use the rule of threes, and by doing this, I can honestly say I learned medicine using only the rule of threes or knowing only three things, albeit it's quite a wide selection of three things. Over the next few months, I'll look at other conditions and how they can be divided up into smaller groups.

Remember, three is the most common number, and of course you can always have twos, threes, fours or fives, but having small aliquots of information, expanding upon it, also helps you remember things in more detail. Thanks very much for listening to Aussie Media. It's really been great to have you on board again today. Remember, this is just my technique of learning things. It may not work for you, but it's a good technique as a way of trying to help people for the long term.

Thanks again and until next time, stay safe. Thank you very much for listening to our podcast today. I'd like to remind you that the information provided is just general advice and may vary depending on the region in which you are practising or being treated. If you have any concerns or questions about what we've discussed, you should seek advice from your general practitioner. I'd like to thank you very much for listening to our podcast and please subscribe to the podcast for the next episode. Until then, please stay safe. I'd like to let you know that Aussie Med Ed is sponsored by AVANT, Medical Legal Indemnity Insurance.

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