Rote learning: a necessary evil

Dear editor

We read with great interest the short report by Sayma and William¹ exploring the teaching of physical examinations to junior medical students. The article highlights many salient points in aiding the memory and understanding of practical medicine and preparation of the clinical years ahead for preclinical medical students. The excellent use of interesting and engaging cases in teaching the physical examination is to be lauded, however, there is some debate to be had over the distaste for rote learning expressed in the article which we believe to be not ideal, but essential in progressing through medical school.

As final year medical students from Imperial College Medical School, London, who did not receive teaching on physical examinations until the third year of medical school – our first year in hospital – we applaud the recent efforts to apply more practical based learning sessions for our younger peers. Fresh out of school, these students are often itching to learn practical procedures, yet are met in more traditional medical schools with a hefty weight of core science that is a far cry from their aspirational dreams. The application of core clinical cases with the use of “famous” cases, making the learning scenarios humorous and engaging is a popular technique in medical schools, making the sessions more fun and interactive resulting in improved enthusiasm and recall.

Despite our appreciation of the article, which we feel is a valuable addition to promoting new styles of education, we believe the distain for rote learning (defined as “learning by repetition rather than by really understanding it”)² expressed in the article is misplaced. Sayma and William correctly identify rote learning as a less efficient way of learning and this has been shown to be the case in other studies.³ The drive for full understanding of medical concepts, however, has two fundamental flaws.

First, as the authors acknowledge themselves, a vast amount of knowledge is required to understand all components of a physical examination. Their results reflect this with nine out of the 20 students in the first cohort feeling overwhelmed by the amount of knowledge required. We feel a method of piling information upon students so that they can look for, recognize, and understand all the differentials for all the signs in a physical examination is asking the students to run before they can walk. As doctors and intellectuals we love working from first principals where the answers can be deduced from basic knowledge; however, in a rapid-paced physical examination superficial knowledge needs to be gleaned before more complex deep understanding can consolidate this learning and there often is no time to work back to first principals for every sign you encounter, although there would be in an ideal world.

Second, medical concepts are littered with myriad idiopathy, and thus understanding of why particular signs occur is impossible however hard a student may try to learn this. As students, soon to be doctors, we are very familiar with proposed theories of why signs occur which have little basis in fact, for example, the examiners favorite sign – clubbing, whose pathophysiology remains shrouded in mystery.⁴ Learning the physical examination is much the same as learning scales on a musical instrument where muscle memory needs to be trained and in place before more complex melodies can be performed and this has been shown to have scientific merit.⁵ This unfortunately requires rote learning which is tedious but essential in honing practical skills so that further detailed knowledge can be built upon this foundation.

The core concept of a core clinical case based approach outlined in this article is an excellent idea, regardless of our disputes with some of the claims made in the article. As an introduction to the physical examination and also as an aide memoire for history taking, the techniques proposed are a popular way to educate students in an entertaining fashion. The drive to teach concepts that will lead to understanding and thus better utilization and recall is the most efficient and effective method, however a combination of learning styles is generally required if one is to have a wholesome repertoire of skills to practice as a doctor. We believe that rote learning is still unfortunately an essential part of medical school and will remain that way for the foreseeable future.