“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.”   William Osler.

Every day you are in the hospital or clinic is a day you will learn something new.  You will see patients with conditions that are new to you and procedures you have never seen.  You will attend conferences and lectures on topics that will be new to you.   It’s a huge amount of information.   A year later (or even a day or two later), most of this new information will be gone if you don’t develop a system to review and learn it.

Keeping track of what you are learning in clinical situations is a simple database problem – You need a simple way to record the information and a way to file it so you can find it again.  Whatever system you devise has to be carried in a white coat pocket and has to be easy to use “on the job.”   Technology will prevail, I’m sure, and an electronic based system that meets those criteria will be possible in the future.   Until then, this is a system that will work. And – you can make it “searchable” and electronic by scanning into Evernote.

Where do you learn new information as a clinician?  On any given day, you will likely

• Interview a patient with a disease you have never seen before
• See a procedure that will be done in a way you have never seen before
• Attend a formal lecture, like grand rounds
• Attend a teaching conference, like a tumor board
• Read a chapter in a textbook
• Read an article pertaining to one of your patients

The system described here is cheap, portable, and it works.  It lets you take information from this wide variety of sources and collate it into a usable database.  It starts with buying unlined 3×5 cards and putting them in your pocket.   3×5 cards work the best because they fit in a shirt pocket.  Larger cards tend to get left behind.  When you buy the cards, buy a file box (at least 8-12 inches long) to store them, as well as a set of alphabetized file markers for the box.

When you pull out a card to make notes, start by putting a small rectangular box in the upper left hand corner.  This box will be used (for a label) to file the card later.  You can develop your own system, but for most people the easiest way to label the cards is an anatomic system e.g. “Biliary tract, gallbladder, cholecystitis” or “Lung, pneumonia.”  There will be a few exceptions – there’s not a good organ to file general information about bacteria or antibiotics, for example, so you’ll want to use “ID, bacteria, gram negative, Pseudomonas” or “ID, antibiotics, aminoglycosides, gentamicin”.   You’ll most likely fill in the information on your card in pen, but you may want to fill in the label box in pencil.  As you progress in your career, you’ll realize that you originally filed leukemia under “Oncology”, but you really rather have it as “Blood, white cell, leukemia”. If it’s in pencil, it’s easy to change.

General rules for the 3×5 card system

• Always have cards with you
• Never make notes with the intention of putting them on cards later.  Always take the notes directly on the cards.  If they are really messy and you want to redo them, great – but have at least one set of cards with the info to start with.
• Always put the date you made the card and the source
• File them when you get home

Most of the cards you’ll make will come from these 6 sources:

1.  Lectures or grand rounds.  Depending on the lecture, you may end up with 5 or 6 cards.  Number them to keep them in order. When you look them over later, you may want to highlight the 2 or 3 most important concepts you learned.  Even better,  you may want to make a separate card with those key concepts.

2. “Pearls” cards.  On rounds when the attending gives you the 6 reasons a fistula doesn’t close, write it down on a card.  Put the name of the attending and the date at the bottom.  In the operating room, when the chief resident pimps you on the critical anatomy for deciding if a hernia is direct or indirect, remember it – and then at the end of the case make a card.  If on rounds you get assigned something to look up at home, make the card and have it in your pocket the next day.  This is also a great way to record mnemonics.  It’s hard to remember lists of things, so use mnemonics liberally when faced with a list to memorize.  For example, the 6 reasons a fistula does not close spontaneously can be remembered by “FRIEND” : Foreign body, Radiation, Infection/Inflammation, Epithelialization, Neoplasm and Distal obstruction. There are many famous mnemonic in medicine, some of which you couldn’t repeat to your mother.  If there is not a common usage mnemonic, make one up yourself.  They really work.

3.  Patient information.  This is probably the most important card you will make.  Put the patient sticker on the end of the card, or at least write down their number and date of birth.  You want to be conscious of patient confidentiality, so, be careful about information that could identify the patient if the card was accidentally lost.  Put the “hooks” that will make you remember this specific patient.  If your patient is an 80 year old lady who knit you a red hat, make sure that goes on the card.  Then put what you learned about the patient’s disease from this specific patient.  How many days did she have symptoms?  What did she report that was different from the textbook”?  What treatment did you use?  Did it work?

4.  Procedures.  I must have watched 30 or 40 different people repair an inguinal hernia.  Each of them had some minor variation or “trick” that make the exposure easier, or the results better.  When you watch a procedure, try to find those details and then write them down.  Consider this a “procedural patient card”.  Put the same memory “hooks” on this card – details that will let you remember this specific case.  You can do this for any procedure, not just surgical procedures – lumbar punctures, central lines, radiological procedures, cardiac catheterizations, etc. etc.

5. Chapters.  When you admit a patient with Crohn’s disease (for example), read the chapter.  And then carefully and completely summarize the key points on 3×5 cards.  As you do your annual reading of the textbook, make your notes on 3×5 cards. Do it once, compulsively, and you don’t ever have to do it again.  When it’s time to review for an exam, you can just use your cards.

6. Articles. When you take the time to pull articles for a presentation, or just to better understand a patient you are caring for, make cards.   Most articles will have an introduction that summarizes  what has been written before that will serve the same purpose as a chapter in a textbook.  But the reason they are publishing is because they are adding something new to the literature.  Make a list of the 2 or 3 key points they are making in the article.

It is incredible how many cards you will add in a week to your “database.” In an average day, you may see 3 new patients, attend a lecture, learn 3 key new points on rounds and sit through a teaching conference.  At the end of the day you will have made 10-20 new cards.  With almost no effort, you have added substantially to your file.   When it comes time for exams, particularly if you have been diligent about making notes from a textbook, you can use the cards to study. More importantly, as time goes by, it adds to your ability to teach.  Let’s say that overnight your team admits a gentleman with diabetic ketoacidosis.  You have teaching rounds that afternoon so, in the morning, you go to your file and pull out all your cards on diabetes and DKA to bring with you to work.  You have, in your pocket, clipped together, notes from 2 grand rounds, 5 patients you admitted and cared for, 4 articles you read, and a chapter.  During the day, you can spend 5 minutes here and there reviewing your notes.   You’ll have a real grasp on the topic and the important points.  You’ll look like a star on rounds!