Today is the “official” first day of residency. If you are one of the ~16, 000 new interns starting today I have good news and bad news. The bad news is that you are already behind in terms of what you need to know. The good news is that you can come up with a plan that will make a big difference. If you are a PGY2 or greater, this is a great time to reapply yourself to your studies – even if you let it slide last year.

 “The best time to plant a tree is 20 years ago.  The second best time is today.”  Chinese Proverb

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As an intern or resident, you learn your specialty from a variety of sources. Each of them is important. Some of your studying will be just like medical school with your gluteus maximus in a chair (or feet on a treadmill or ischial tuberosities on a bike or an exercise ball) reading a textbook. But the rest of what you learn is absorbed as you make rounds, attend conferences and take care of patients.

The challenge is organizing what you learn.

Sometime this week you will do your first central line, or see a case of bile gastritis, or attend a conference where they discuss a patient with a rare fungal infection. The amount of new information you will learn in these first few months will truly be astounding. But how is what you learned going to be available to you 8 months from now when you see the second patient with the same unusual infection? How are you going to be able to review what you have learned when January rolls around and its time for your in-training exam? At the end of your residency, will you be ready to take the boards?

There is no right or wrong way to create a system for studying clinical medicine, but there are a few principles that will help.

1.  Record what you learn as you learn it. 

There’s no way around it. If you really want to learn clinical medicine, you have to make notes. Until there is a good digital solution, start by going to work every day with blank 3×5 cards in your pocket. When you learn something on rounds, write it down on a card. When you look up something related to a new patient you are working up, write it down on a card. Make it brief, legible and to the point. If there are “hooks” (i.e. the patient had a tattoo of a star on his face) put it on the card. It’s how our brains remember. If there is specific information that identifies the patient, do not lose your cards! (It’s a HIPPA violation). To be safe, it’s better not to put patient names, ID numbers, etc on the card.

There is no way any trainee will see every disease or condition in their specialty, but being comprehensive in your studying will help.  For example, let’s say you admit a patient with dyspnea and an arrhythmia who turns out to have a Morgagni hernia.  This is rare, and it’s not likely you’ll see multiple cases during your training.  You make a card on how the patient presented and another card on what the treatment was.  But then you go to the literature and find a case of man presenting with an acute abdomen from a torsed accessory liver lobe in his Morgagni hernia and another case of an octogenarian who presented with dyspnea and constipation.  You have now created “virtual” patients in your mind that add to your pattern recognition. Most importantly, you do it at the time it means something.

One other important thing – don’t ever use scratch paper with plans to copy the notes later.  It just won’t happen. Make the notes once, no matter how bad they look!

2.  Be comprehensive. 

Find a major textbook in your field and write down every topic it covers. (BTW most textbooks are available at the library in electronic form, so you don’t have to actually buy the book) Make it your goal to cover the textbook in a year. Come up with a system to monitor your progress. This is the time to pull out your “Type A” personality to your advantage! Make a spreadsheet and check off topics as you study them and make notes for later review. But – don’t read the chapters in the order of the table of contents. If you are on call tonight and see a patient with pneumonia, read the chapter on pneumonia tonight. If you have time to make notes, great. If not, make your study cards from the chapter tomorrow. The idea here is to read each chapter once and make notes that are complete enough for your review so you never have to go back to the chapter again to study.

Alternates to the 3×5 card system

1. Use 8×11 pieces of paper to record what you learn. Fold them up in your white coat pocket. Scan them with something like Scannable and then save the pdfs in Evernote with key words so you can search for them later. Don’t put more than one topic per page or you will have trouble organizing them to find information later.
2. Use your phone. We are on the verge of having facile enough (and small enough) handheld digital devices to do this just as well (or better) than my 3×5 card system. The problem is being able to make your notes on the spot because the device isn’t with you. It never works to plan to make the notes later and, as I said above, it never works to copy notes. There are just too many things you’ll be writing down to make this work.  If you figure out a good way to use your phone for this, please let me know!
3. Use your computer. There’s no reason you couldn’t type 3 lines of what you learned and email it to yourself, add it to Evernote, or save it directly to the cloud. The advantage of cloud storage is that all your notes are available all the time and are searchable. Just remember, most cloud storage like DropBox is not HIPAA compliant!  Don’t put any patient identifiers in the notes if you choose to use the cloud.

3.  Stay curious.

Being excited by what you are learning will always make it easier. “Set up habits that encourage, and don’t squash, your natural curiosity: Look up answers to your questions, not just subjects you are instructed to read about.”

 “The very first step towards success in any occupation is to become interested in it.”

William Osler

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3.  Repeat. Repeat. Repeat.

Learning is iterative. You don’t really know something until you have studied it multiple times over a period of a month or two. Don’t make your notes, file them away and pull them out the week before the in-training exam. Sit down once a week and just glance through them all.  Develop a system that lets you review them 24-48 hours after you make the notes, a week later, a month later, and 3 months later.

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“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