make it stickBookstore shelves and Amazon lists are filled with self-help titles that promise to make you a better manager, a better parent, or a better fishmonger. But most of them suffer from the same weakness: 2 pages of good practical advice is padded with 298 pages of filler.

Our new column TLDR (Too Long Didn’t Read) is a solution to what we call the McNugget Problem: trying to find the 5 bullet points of meaty goodness suspended within a mass of stale anecdotes, overcooked platitudes, and bad food analogies. Our TLDR goal is to find the critical take-aways in each book we review, and present them to you in a concise, easy-to-apply format. We read the books so you don’t have to!

make it stick: The Science of Successful Learning

We’re launching our TLDR book series with “make it stick,” [Amazon link] a title whose provocative claim and bold use of improper capitalization made us certain that it would be a perfect candidate for our project. Is there any real chicken under all that golden breading? Let’s find out.

The Take-Aways

  1. Study all year, not just the night before your O.W.L.s or your EM boards (spaced repetition)
  2. Learning should be tapas, not a hot dog eating contest (interleaving)
  3. You think you are good at learning, but you are the opposite of good at learning (illusions of knowing)
  4. Thinking makes you smarter (retrieval practice)
  5. You hate tests but you shouldn’t (testing to learn)
  6. You learn better when it’s difficult (desirable difficulty)

Take-away 1: Spaced repetition

Cramming (or ‘massed practice’ as the kids are calling it these days) is bad. We’ve all done it. Remember when you, Ron, and Hermione stayed up late into the night in the Gryffindor common room trying to learn Summoning spells right before your exam? Sure, you Exceeded Expectations, but 2 weeks later, when the Death Eaters attacked, you couldn’t even Accio your broomstick.

Numerous studies show that knowledge learned by ‘cramming’ is ephemeral. In contrast, knowledge sticks if it is acquired over repeated practice sessions spaced over long intervals. Surprisingly, this spaced repetition works best if practice sessions are far enough apart that some ‘forgetting’ has occurred. So repeat material that you’ve learned over a long period of time: after a day, after 3 days, after a week, after a month. It’s a hassle, but no one becomes an Auror by taking life easy.

Take-away 2. Interleaving

You know how you practice free throws? Over and over again, hundreds of shots until it becomes second nature? Yeah, that’s not a good model. It may make you a better free-throw shooter, but it won’t make you a better shooter in a real game when the state championship is on the line and you’re going up against Big Ike and his gang from Central Valley.

Interleaving refers to varying the way in which you practice and the kinds of skills you practice, rather than repeating just one skill in the same way over and over. Studies have shown that interleaved learning is a better model, even in sports. You build connections between skills that would never be developed if you focused on only one skill at time. In the same way, learning that mixes up different types of knowledge, different types of questions, and different skills, ideally in a way that closely approximates real-world conditions, will be ‘stickier’ and more relevant than batched learning.

Elaboration is another technique that improves learning. Restate the information you learned in your own words. Create analogies to other subjects or relate the knowledge to your own experience.

Take-away 3: Illusions of knowing

Trust your instincts? Student-driven learning? Wrong.

When polled, students prefer cramming or ‘massed practice’ to spaced repetition and interleaving, even though they perform better and learn more when practice is spaced and tasks are interleaved. Why? Because massed practice creates the illusion of mastery, especially in the short-term. We just know in our hearts that it works and if I know in my heart that it works, then it really does work, and ARE YOU REALLY SUGGESTING THAT 8 DECADES OF DISNEY MOVIES WERE WRONG?

Yes. Don’t follow your heart; follow the experimental evidence.

Take-away 4: Retrieval practice

Here’s another popular study method you may have used: rereading. Rereading and highlighting. Rereading and highlighting and underlining. Yes, “Dancing with the Stars” was playing in the background the whole time, and I mainly just highlighted the first sentence in each paragraph, but I’m sure I learned stuff, right? Nope.

Students who just reread and re-highlight the material experience a “double whammy”. They don’t learn the material well, while at the same time deluding themselves into thinking they have learned the material. Rereading supplies you with information, but does not make you engage with it. One of the metaphors the authors used in the book was that of finding a lost object. If I were to just teleport you to its location (i.e. tell you the answer), you would have no idea how to find it on your own. Only if you struggle to the correct answer yourself, with some guidance, can you find your way back to it later.

For long-term learning to occur, we need to retrace and reengage the neural pathways and connections that were created during initial learning. That process of strengthening is better facilitated by retrieving and manipulating information in an active way than by simply being exposed to it by reading it again and again.

Take-away 5: Testing to learn

Do you know what forces you to engage in retrieval practice? Tests. Frequent tests. Everyone loved the college class with one midterm, one final, and no homework . But what do you remember of the content of the course? Probably very little.

There are many ways to incorporate regular testing into study routines and classes. Regular, short, low-cost quizzes can be scheduled in advance throughout the semester or even at the end of each class. These tests should be cumulative (spaced repetition), varied in content (interleaving), and graded (retrieval practice). Life-long learners can create flash-cards or jot down questions after reading articles for self-testing later. Moreover, failure is crucial. The goal is not to ace these quizzes, but to use them to engage in retrieval practice and to identify areas of weakness. We should move from seeing tests as the GOAL of learning to seeing them as a TOOL for learning.

Take-away 6: Desirable difficulty

Effortless learning is a myth, like the Loch Ness Monster or Hawaiian “pizza.” In fact, research shows that learning can be facilitated when material is deliberately made more difficult. For example, when students are asked to read text written in an out-of-focus font, they retain more of the content than students who read a normal font. When students are asked to read sentences containing words with missing letters, they retain those sentences better. Why? It’s likely related to a phenomenon known as generation; our brain is forced to supply missing information, and that facilitates engagement with the material. We can make use of this when lecturing or teaching by having learners write in answer to questions, or having them supply answers de novo rather than select a multiple choice response. When we can’t just drift through a lecture as a passive audience playing Candy Crush on our phones, we learn.

Application to EM

We have a lot to learn as emergency physicians. We can learn more effectively and efficiently if we put the nuggets from ‘make it stick’ into practice. It is important that we not simply learn the facts in a rote fashion, but that we engage with information and learn to apply it along with other concepts and ideas that we already know. If you are an educator, use some of these learning practices to help your learners master new material and concepts. If you are a physician, then you must also be a lifelong learner. When you are reading or listening something new, practice self-assessment by frequently summarizing to yourself what the authors are saying, what the salient points are, and whether the information makes sense with what you already know or is contradictory. Take notes (active attention), scan through them again in a week or so (spaced repetition), and think about how you have or should apply them (self-assessment).


The best learning is intentional and challenging. Practicing deliberate, daily reflection on your performance allows you to learn from your mistakes. This is metacognition. Reflecting on your learning involves retrieval, elaboration, and generation.

Dr. Martin Fischer, a turn-of-the-century physician, complained –

“Education should be exercise; it has become a massage.”

So get off your  gluteus maximus, throw your highlighter in the trash, and get your desirably difficult learning on. “make it stick” shows you how.

If there are books that you would like to see reviewed in the TLDR format, leave a comment and let us know.

Further Reading:

Gooding H, Mann K, Armstrong E. Twelve tips for applying the science of learning to health professions education. Med Teach. 2017;39(1):26-31. [PubMed]
Larsen D, Butler A, Roediger H. Test-enhanced learning in medical education. Med Educ. 2008;42(10):959-966. [PubMed]

[box secondary]”make it stick: The Science of Successful Learning” Brown, Roediger III, and McDaniel, 2014, Harvard University Press.[/box]

Christina Shenvi, MD PhD
Associate Professor
University of North Carolina
Christina Shenvi, MD PhD


Emergency Medicine and Geriatrics trained, Educator, Professional nerd, mother of 4, excited about #educationaltheory, #MedEd, #EM, #Geriatrics, #FOAMed.
Christina Shenvi, MD PhD

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Neil Shenvi, PhD

Neil Shenvi, PhD

South Durham School of Science and Math
(The Shenvi Homeschool)