MAD: mnemonics are dangerous. Like many of the concepts taught today in medical school, this opening phrase is an oversimplification of a complicated idea. A mnemonic is a mental device used to assist recollection of memories, and in medicine these often take the form of acronyms. Every student uses mnemonics at some level to remember facts. Preclinical medical education, however, overflows with mnemonics that are so far removed from their subject matter that they promote rote memorization and impede understanding. When overused, mnemonic-based learning can undermine both the complexity and the humanity of medicine.
I like to think of the implications of mnemonic overuse through a topography metaphor. If medical knowledge is a landscape, mnemonics are just the tips of the tallest mountains. While a map drawn from these dots would give a general gist of the land, any attempts to use it to navigate would omit treacherous valleys and gorges. The prepared explorer would develop a more comprehensive framework that includes the mountain bases, the connecting rivers, the flora and other features that would allow for safer passage. The preclinical period is the time to develop this mental map through the study of evidence in the medical sciences, which can later be recalled using key mnemonics.
Mnemonics are even more dangerous when an entire healthcare team is missing the same part of their map. Dr. Tobias Kollmann, a clinical professor at the University of British Columbia, gives the example of the acronym “ToRCHES.” This well-known mnemonic lists infectious agents that can cross the placenta (toxoplasma, rubella, cytomegalovirus, herpes simplex and syphilis), but Dr. Kollmann advises that narrow focus on this one mnemonic leads to the omission of many other important infections that must be considered in pregnancy. This narrowing can ultimately affect patient safety, especially when all one’s colleagues hold the same starting point of misinformation.
The importance of seeing patients as whole people can also be undermined by mnemonics. For instance, take the well-known mnemonic “DEATH.” It is taught to medical students in order to remember the activities of that a patient should be able to complete independently in order to function: dressing, eating, ambulation, toileting and hygiene. But what does memorizing these activities in the form of the acronym “DEATH” really teach? Whether consciously or subconsciously, we will be inclined to write off a patient who requires assistance as terminal. This paradigm paints palliative care — and geriatric care in general — in a negative, dehumanizing light.
This is not an isolated example. The mnemonic “DIAPERS” is a common way to remember causes of new onset urinary incontinence: delirium, infection, atrophic vaginitis, pharmaceuticals, excess excretion, restricted mobility and stool impaction. While it may be useful diagnostically to have common etiologies at the tip of our tongues, reducing an incontinent patient to the mental image of a diaper is degrading. We might consider what our patients would think if they knew how we remembered them.
Through all of this, mnemonics do have a place in medical education. One appropriate use of mnemonics is for diseases that are not well understood. A classic example is “SOAP BRAIN MD,” whose every letter stands for one of the signs or symptoms of systemic lupus erythematosus. Lupus has an extremely complex pathophysiology. As such, it would not be feasible for students in a clinical setting to quickly rationalize all of the possible manifestations of lupus from an understanding of the disease, and so this helpful mnemonic provides direction to the clinical exam.
Overall, mnemonics need to be tied much more firmly to their limitations, and medical schools should teach layers of knowledge, rather than isolated fragments. An increased emphasis on the molecular and biologic processes of disease is a good place to start, and learning is more sensible and fun when there is a foundation upon which to build new knowledge.