Studying In Medical School is Different!

Posted on September 5, 2023 by marylbrandt

It’s the beginning of the academic year in medical schools around the world, and that means there are thousands of students who feel they are suddenly being asked to drink from a fire hydrant. The information you are asked to learn in medical school is different in two really big ways – It’s voluminous and (unlike in undergraduate education) all of it is relevant (albeit to different degrees) to what you will be doing the rest of your life. Learning how to make the transition to this new kind of studying is one of the biggest tasks a new medical student has to accomplish.

The following is a guest post from Preston Tsang, a medical student at Tulane University School of Medicine. The main take home message?

You have to study how to study if you are going to succeed in medical school!

All of us arrive to medical school with a successful strategy for studying… which we then have to seriously revise. The incredible volume of material means you either rethink how to study, learn, and recall info from the beginning… or you are forced to do so when you stumble – after realizing the way you studied in college won’t cut it in medical school.

Every medical student quickly learns that standardized exams are a necessary objective measurement of how “well” you do in school … especially the mammoth exam called STEP 1. This exam (as you might guess) is the first of three “steps” to getting a license to practice medicine. But Step 1 in particular (and now Step 2) are also an important way residency programs assess the academic standing of students applying to their programs. #Pressure

Just like college, you need to study to pass the exams in each of your courses, but unlike college you need to prepare for Step 1 (which means everything you learn in basic sciences!). And BTW you also need to remember that you are not just studying to pass an exam or ace the Step exams. Learning (not just memorizing) this information is essential to being a good physician.

So how best approach this overwhelming task? Only one way – You need to study how to study if you want to succeed in medical school. Make some notes as you study how to study, create your own way… but to get you started, here are the key points I learned as I’ve gone through this process.

It’s all about active learning. Gone are the days of cramming, or just reading something three times to learn it. It’s all about active learning, and – fortunately – there are a lot of people who study this and have come up with methods to promote active learning. All of them involve taking notes to synthesize (not just list) the material and interacting with the material.^1,2

Studying in groups helps! Asking each other questions and having to “teach” each other is a great example of active learning.¹ Studies have shown being quizzed about material is superior to traditional learning and basically halves the time it takes to learn the material.⁵

Take notes, but not too many. Notes are key, but should reflect your synthesis of the information, not every detail. There are lots of studies (and stories) about people who spend hours and hours creating spectacular notes and then don’t have time to review them. Guess what… they don’t do that well.¹ There’s lots of literature on note taking, with many different strategies. Add this to your “studying how to study” list!

Review, review, review. It seems obvious, but you don’t learn something on the first pass. There is science here, too! It’s takes 5-7 repetitions, spaced further and further apart, to really learn something. It doesn’t work as well if you review something 5 days in a row… it should be almost a logarithmic spacing to get best results.^3,4,6

Flash cards (e.g. Anki) work great for details. Once you have the big picture summarized, go back and look for details that you need to know. Anki (and other similar apps) build in spaced repetition – they have you repeat things you don’t know well until you know them. Using this technique (i.e. using Anki) to learn a subject versus reviewing the material multiple times (i.e. re-reading notes) has been shown to improve learning.⁴

To enhance Anki flashcard learning even further, I discovered that there are certain structures to flashcards that make them more effective. In one study 80 students were randomized into two groups. One group used flash cards designed as a test (testcard) while the other half was randomized into flash cards using the more typical “studycard” format (see below). The group using the testcard format retained more of the information when tested. ⁷

UWorld has its place, but it’s not what you think. Despite what every upperclassman will tell you, your professors are right – you can’t learn medicine from multiple choice questions alone. But… once you have the concepts down, testing yourself and learning why you were right or wrong is a great form of active learning. More importantly, study questions are a great way to review (once you think you’ve learned the information) to find where you have gaps.

Don’t underestimate the power of mnemonics ². Make them up and make them something you can’t repeat in public (a known strategy for successful mnemonics). Ask older students, residents, and even attendings for theirs.

So here is how to succeed at Step 1, based on what I’ve learned. When tackling a standardized exam with a vast amount of material, studies have proved the effectiveness of retesting, spaced repetition, and active learning. Start off with a solid base by learning initially from the notes you make in class and from class readings. Then, instead of just rereading the information, distill it down into summaries, draw diagrams, and create your own questions. On top of this find ways to promote active learning and retesting as you study like using practice questions or reviewing your Anki cards. This system of learning may not be best for every learner, but is a good place to start. Add to it with your own research into study techniques.

p.s. Don’t forget to build in (and schedule) time for self-care and sleep.¹

References

1. Dattathreya P, Shillingford S. Identifying the Ineffective Study Strategies of First Year Medical School Students. MedSciEduc. 2017;27(2):295-307. doi:10.1007/s40670-017-0396-2

2. Roffler M, Sheehy R. Self-reported Learning and Study Strategies in First and Second Year Medical Students. MedSciEduc. 2022;32(2):329-335. doi:10.1007/s40670-022-01533-w

3. Ericsson KA, Chase WG, Faloon S. Acquisition of a Memory Skill. Science. 1980;208(4448):1181-1182. doi:10.1126/science.7375930

4. Larsen DP, Butler AC, Roediger HL. Repeated testing improves long-term retention relative to repeated study: a randomised controlled trial. Med Educ. 2009;43(12):1174-1181. doi:10.1111/j.1365-2923.2009.03518.x

5. Morris PE, Fritz CO, Jackson L, Nichol E, Roberts E. Strategies for learning proper names: expanding retrieval practice, meaning and imagery. Applied Cognitive Psychology. 2005;19(6):779-798. doi:10.1002/acp.1115

6. Effect of uniform versus expanding retrieval practice on the recall of physiology information | Advances in Physiology Education. Accessed August 8, 2023. https://journals.physiology.org/doi/full/10.1152/advan.00090.2011?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org

7. Schmidmaier R, Ebersbach R, Schiller M, Hege I, Holzer M, Fischer MR. Using electronic flashcards to promote learning in medical students: retesting versus restudying. Medical Education. 2011;45(11):1101-1110. doi:10.1111/j.1365-2923.2011.04043.x

And a few more things to help you on this journey!

Study tips for first year medical students

It’s the first day of medical school… what should I do?

Learning medicine: #SmartNotes

Things I Wish I’d Known From the Beginning: Informed Consent

Posted on August 3, 2023 by marylbrandt

“Can you go get the consent?”

New interns and their more seasoned senior residents are asked this almost every day. So let’s talk about this for a minute and what that question really means…

What you are being asked to do.

The hospital requires a signature on a consent form (always printed with very small font and several pages long). This part of the consent process that has a long history guided primarily by legal counsel for hospitals and, yes, you need to get the signature. But…

The signed form isn’t the consent.

Maybe I should say that again….

Photo credit

So what is?

Photo credit – from a great article on disclosing the presence of learners in the OR

There are five things that must be present for informed consent. If any of them is missing, it’s not informed consent.

The patient must have the capacity and ability to understand. (No intoxication, translation when needed, etc).

The patient must actually understand. (This means you have to confirm they understood with a conversation – Can they explain it to another family member? Do they have questions?)

The person performing the procedure (or their designee) must describe the procedure and must discuss alternatives, risks (and how likely they are) and the expected benefits (and how likely they are).

The patient has to agree without coercion. (If you aren’t sure about this, don’t proceed)

The consent has to be documented.

Photo credit

There are questions that every intern would like to ask about this process but can’t/won’t. Here are a few that come to mind…

What if you’ve never performed (or even seen) the procedure yourself? It’s hard to get truly informed consent if you aren’t competent in doing the procedure. But – you know (intellectually) the alternatives, the potential risks and benefits, and the “big picture” of the procedure. Particularly for complicated procedures, you can assume that the attending has discussed these (and therefore is the person who actually got the consent!). Here’s a way to make this easy… “Hello, I’m Dr [xxx}. I know that Dr. Attending has already talked to you about your surgery. I’m here to go over the alternatives, risks and benefits again – to make sure you don’t have any questions I can take back to Dr. Attending for you.”

p.s. If you are “Dr. Attending” in this scenario, you are the one who is ultimately responsible for the informed consent (and liable if it’s not done properly).

Is it important to get the consent just before the procedure? No, in fact it makes it legally more sound and much more efficient to document informed consent when you first see the patient. For elective or semi-elective surgery, it takes no time at all for “Dr. Attending” to put this phrase (or one like it) in their clinic (or ED) note: The procedure including alternatives, risks, and benefits was discussed with the patient, all questions were answered, and informed consent was obtained. This documentation often holds more water than the signed form (at least according to most attorneys I’ve talked to). Best yet – do both. Get the consent form signed at the same time! It’s easy to scan into the medical record to be there for the day of surgery, which is a win-win for almost everyone involved.

What if It feels like you are scaring the patient/family when you review the list of the possible complications? First of all, that’s a normal feeling. But we have to learn to handle the anxiety that is always part of this process. In addition to trying to be really calm and supportive, here’s how I handle that: “When we decide about doing surgery, we always ask which is riskier… to do it or not do it. For you, we’ve decided together that it’s risker not to do the surgery… which is why you are here. But because there are risks, I want to make sure you understand them and we can talk about them before the operation.”

What if they don’t speak English but the family says they can translate for you? It’s not informed consent unless it’s translated into their language by a professional medical translator. Imagine the shoe on the other foot. What if your best friend the artist was travelling in a country where none of the doctors or nurses spoke English and they needed surgery? They would be terrified and so would any family member who was with them (even – or maybe especially – if they were being asked to translate). Don’t cut this corner. Please.

Isn’t this blog post oversimplified?

Yes!

Informed consent is a fascinating and rapidly changing area of medical ethics. I hope I’ve hit the critical highpoints and addressed a few unspoken questions many trainees have, but it’s unquestionably a “30,000-foot view”.

p.s. If you have more questions, even ones that seem naïve, please comment on this post or email me (if you don’t want them to be public).

Photo credit

Here are some other great resources to learn more:

American College of Surgeons educational pdf on informed consent

ACS and Association of Surgical Education student curriculum on informed consent

Informed Consent for Academic Surgeons: A Curriculum-Based Update (with links to all the slides for the course!)

Whose Decision Is It? Teaching Students and Physicians About Informed Consent

Informed Consent and Shared Decision Making in Obstetrics and Gynecology

Fantastic You Tube video on obtaining informed consent

Treating Patients as Partners, by Way of Informed Consent – column by Pauline W. Chen in the New York Times

Things I Wish I’d Known From the Beginning: SOPs

Posted on June 19, 2023 by marylbrandt

No matter how many times a pilot has flown a specific airplane, 100% of the time before takeoff, they review the SOP (Standard Operating Procedures) for that plane.

A while ago I realized that I prepared for complicated surgical cases by reviewing the same set of things every time – how to prepare the patient for surgery, the pertinent anatomy, the steps of the operation, potential complications (and therefore how to try to avoid them i.e. what to include in my informed consent), and post-operative care.

The day I learned about SOPs for pilots a lightbulb went off.

What if I did the same thing?

What if I took the books, articles, and websites I usually review, standardize the process, and create a single “living” document to review for every major procedure I do? It would be a document I could update as I got more experience – and as new findings and recommendations were published, too.

What I quickly realized was that the practice of creating, reviewing, and updating these surgical SOPs made me a better surgeon…and it made me a better educator. I could share my SOP for a specific case with the residents and students in advance – which let them prepare more efficiently for the case. I could also give the SOP to my anesthesia colleagues and the rest of the OR team to help them prepare, too.

The structure of my SOPs is more or less the same for any procedure and is demonstrated below with an example. Use it, modify it, or create your own… but if you are learning procedures as part of your medical training I strongly urge you to give this a try! The other piece of advice I would give you is to use a digital platform (like Google drive or EndNote) so you can access your SOPs from any computer and your phone. (Disclaimer: SOPs, like the one below, are only the starting point I use to prepare for a specific case. Since every patient is different, not everything below will apply to an individual patient.)

BTW – There is a decent time investment the first time, but after that it’s really a living document. Every time you have the privilege to scrub on the same case again, check PubMed, Google images, videos and update your SOP with what’s new before the case. After the case use it to make notes about different attending preferences and/or new information or techniques you learned from the case (but please be HIPAA compliant!).

The Healing Power of Farmers Markets

Posted on May 6, 2023 by marylbrandt

Rituals have great power, but some more than others. For me, going to the Farmers Market has become a ritual that is almost as important as the food I buy there. So I spent some time this morning pondering why…

It’s outside. Sun, clouds, breeze. Sometimes a little cool, sometimes too hot… but always the season that matches the fruits and vegetables being sold that day.

There is music. And dancing… people dancing with children, children dancing alone, folks dancing in their wheelchairs.

Everyone is happy. Seriously. Not a dour face anywhere!

There is delight in the colors, odors, and tastes.. It’s beautiful… and that sensual beauty evokes all kinds of good emotions – delight, joy, and even awe.

It anchors you to the season. We don’t have peaches in January at the farmer’s market. So when they show up in May it’s a day of celebration! Eating what is being grown in the season keeps you somehow anchored to life around you and, according to some traditions, is better for your body. It’s certainly better for the planet, since this is food grown within miles of where it’s sold… not half way across the world.

You develop relationships with the people that grow your food. Lisa’s new tortoise gets a spectacular salad every day, so we chat about his salads and her goats. I get to practice my French with the Congolese farmers who grow their produce on an inner city farm developed to provide new refugees a place to farm. Some of the vendors know my name, most of them know and recognize me with a smile (even if they don’t know my name), and all of them are happy to share how to prepare their food and what’s happening on the farm.

And then there is the food. There is no question it’s often (but not universally!) more expensive to buy your food at the farmer’s market, but for the reasons above it’s worth it. But there is one other reason … which is probably the most important reason of all.

How to Harvest and Store Potatoes -- Harvest to Table

Photo credit

One of the very first times I went to a farmer’s market, I bought potatoes. I remember distinctly thinking that it would not be worth the extra money because “it’s just a potato”… but I did it anyway. Every potato I had ever bought in a store tasted the same as every other potato … so I didn’t expect these to be any different. Wow… I was SO wrong. A potato that has been pulled out of the ground the day before you cook it is absolutely amazing. A light went on. Fresh food raised in smaller quantities by people who are devoted to doing it tastes better. It just does.

Plant It Forward CSA shares ready to be picked up

There is most likely a farmer’s market near you if you live in a city, but if there isn’t you have a other options (The USDA Local Foods Directory is a wonderful way to find farmers markets, gardens, and local farms near you if you need help. )

CSAs (Community Supported Agriculture). Google “CSA’s near me” to find farms that make up boxes with small portions of anything they are harvesting that week to distribute to people who have signed up with them.

Community Gardens. If you love to garden (and you can spare a few hours every once in a while) you might want to actively participate – it’s also pretty soul soothing to dig in the dirt and grow your own tomatoes. But it’s also worth asking if you can buy any produce that isn’t otherwise promised.

A local farmer or neighbor who has a big garden. You don’t know unless you ask. Offering to buy some of their produce might end up being a win-win. They may have too much produce, need a little extra income, or both. And you end up with fresh produce and a relationship with the person who grows it!

To Those Whom Much Is Given…

Posted on April 10, 2023 by marylbrandt

96. everything is power-law distributed

97. everything is power-law distributed

When someone writes about 137 life hacks and two of them are a) identical and b) something you have never heard of, you can’t help but dive down that rabbit hole…

Photo credit

So, what is a power-law distribution?

A power-law distribution is the statistical description of change that is proportional to the power of the change, in other words, change that is logarithmic, not linear. One of the classic examples of a power-law distribution curve is how income is distributed in society.

Although there are many uses for this principle in the world of finance and economics, power-law distribution can also serve as a mental model to help us understand ourselves, each other, and the world we live in.

Photo Credit

For those who are healers, or who are studying to be healers, there are three uses of this mental model that I think are particularly relevant:

1) Hacking your studying

2) Investing in your future

3) Understanding inequities

Hacking Your Studying

I unknowingly wrote about power-law distribution when I explained the “forgetting curve” in this post: “How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards”. I recommend you read the entire post, but the take home message is this: Cramming never works if your goal is learning how to heal. What works? Repeating information you want to learn at least five times in gradually increasing intervals (ok, you type A folks… get out the spreadsheet).

Photo credit

The best time to plant a tree was last year. The second best time is today.

The power-law distribution also helps you understand why you need to start investing for your future – today. The chart below is what happens if you invest $100 a month starting as a new grad and keep doing it for 35 years (assuming a 6% return on your investment)

p.s. Here’s the website to do this calculation with different variables- investor.gov calculator

This kind of “investment strategy” also works for exercise. Wow, do you gain strength and fitness fast at the beginning… and how sad that it only takes about six weeks to lose most of what you previously gained if you stop (both are examples of power-law distribution). Like financial investment, investing in your body with small “doses” of consistent exercise is the best strategy. For most of us who work in a hospital, the amount of walking we do at work is close to the recommended minimum for fitness (#GoodNews). Just accumulate a few more minutes at a higher heart rate (take the stairs, speed walk to the next consult, etc), add some body weight strength exercises like pushups, and you are good!

Photo credit

Understanding Inequities

Investing for the future and how to hack your studying are important, but there is an even more important use for this mental model… It can help us better understanding the inequities in our society and in our work.

It’s easier to accumulate resources if you start with more. This principle is why young faculty members with limited mentorship or disproportionate service at home or at work end up not advancing. It’s why marginalized youth without resources to obtain education or connections struggle to break free from the cycle of violence and poverty. It’s why those who “have” (money, education, privilege) end up with disproportionate success (or access to care) when compared to those who started with less. Yes, there are exceptions, but they are just that… exceptions to the powerful force of power-law distribution.

Photo credit

There are hundreds of examples of power-law distribution including the beauty of fractals like the pattern in this beautiful head of romanesco broccoli or the curve of a beautiful seashell. (It’s worth looking at the list… some of them are fun!)

Maybe Alexey Guzey is right…

96. everything is power-law distributed

97. everything is power-law distributed

A Hundred Words for “Tired”

Posted on March 1, 2023 by marylbrandt

It has been said that the Inuit people have a hundred words for snow. When you live in a dangerous environment, it’s important to learn the variations of snow to survive. But, when you look into the origin of the “hundred words for snow”, it turns out it’s not exactly true – Inuits don’t have more words for snow than other languages…Their detailed understanding of snow is a lived, not spoken vocabulary.

The same is true for those who spend nights awake working in a hospital. We, too, have a lived vocabulary that includes hundreds of subtle variations of fatigue, even though we don’t have words to describe them. (The closest I’ve come to being able to describe this fatigue is in “sleep equivalents”, specific events or things that makes you feel like you have had more sleep than you actually did. For example, a shower after being up all night can give you the equivalent of anywhere from 20 to 60 minutes of sleep depending on how tired you are. Brushing your teeth after a hard night of call is usually 5-10 minute sleep equivalent. A good strong cup of coffee can be as much as 45 minutes of sleep equivalent – although it’s important to titrate it so you don’t end up with anxious jitters instead of just being awake.)

Knowing how to manage this level of fatigue it is part of medical training. (Don’t get me wrong… I’m not advocating that trainees must get tired on a regular basis to “learn how to manage it”) Learning to successfully manage the fatigue of long days and nights on call hinges on two things and both have to do with deliberate choices.

Learning not to trust your first instinct if you are sleep deprived is the first important lesson. Even if it’s a drug you know well, or the chest x-ray looks ok, stop and be deliberate. Consciously review the data, look at the options and, for really important decisions, ask someone to look at the situation with you.

The second lesson in managing fatigue is maybe even more important. The bone deep fatigue of medical training is not solely the result of sleep deprivation. When you stay up all night you also lose the liminal spaces of waking and falling asleep, the threshold between night and day. In scientific terms, this means there is a major disruption of your circadian rhythms. But it’s more than just physiology. The drowsy moments between sleep and being awake take place in the liminal spaces of dawn and dusk. We lose more than orientation to daylight when we lose this liminal space. The Irish poet and priest John O’Donoghue, teaches that liminal spaces are moments and places where the spiritual touches the finite. By losing the profoundly important rhythm of rest – including these liminal spaces – we end up physiologically, psychologically, and spiritually unmoored.

You have to be deliberate here, too. By trial-and-error work to find the things that ground you, the things that help you recover in a deeper way than just catching up on the sleep. Make lists of anything and everything that helps you recover from call for the times you are too tired to remember or choose. Look at those lists before you leave for your call day and choose something to do for yourself when you leave the hospital the next day. It might be going to the gym for a light workout, having a great cup of coffee in a cafe, a slow, grateful walk outside, playing with a pet, a hug from a loved one…or finding a way to “play” outside.

May the sacrifice of time and sleep you make for others come back to you as joy … and may you find deep rest in knowing you make a difference in so many lives.

Why don’t we do the things that bring us joy?

Posted on November 16, 2022 by marylbrandt

All of us have a list of things we know we should do every day… and usually don’t. They shouldn’t be that difficult to fit into our day, but we somehow end the day holding our intentions and the struggle rather than the completed task. I’m not talking about the things other people need from you, or the requirements of jobs or school. I’m talking about the things that bring you joy (whether immediate or delayed), things that are really important to you.

Why don’t we do the things that bring us joy? The first step to conquer this paradox is to make a master list of the things that bring you immediate joy (e.g.prayer/meditation, reading, journaling, playing music, calling or writing to a friend you haven’t seen in a while, walking in nature, checking in with older relatives if it’s been more than a couple of days, learning something new, cooking for your family and/or friends) …and things that might be hard at the moment but will bring you joy in the long run (e.g. working out, organizing and cleaning your living spaces, working on a big writing project)

Once you’ve made this master list, acknowledge there is no way you are going to be able to do all these things in a day. It’s important to name these things, to make this list and revise it as new things are recognized… but it’s equally important to acknowledge that you are going to have to make some choices. Pick what you currently think are the two or three most important things on this list and make a covenant with yourself that you will do them “every” day. The “every” is in quotes because let’s be real… life happens. Promise yourself that you will do these things every day, but give yourself grace for the occasional day when it’s just not possible.

Photo credit

Next, pick a way to remind yourself and keep track of your progress:

Schedule them on your calendar. This is probably the best way to do this for most people, but you have to build in a “what if” plan. If for some reason you don’t accomplish it at the time you scheduled it, it doesn’t break the promise you made to yourself. Move it on the calendar, commit to doing it later, but don’t blow it off.

Keep a “routine checklist”. This is separate from any other to-do list you create. This is for you. Not the things you have to do for other people, but the things you are doing for yourself, the things that add goodness to your days.

Morning is best (if you can). There is an adage in finance that you should pay yourself first. In other words, the first thing you do with your paycheck is to put money aside for investment in your future. Time is no different. Doing the important things first, the things that are just for you, is an investment in the day and your future.

The power of streaks. Put an X on a calendar every day, like Jerry Seinfeld or get the app that lets you put the Xs on a digital calendar. (There are other streak tracking apps, too.) Alternatively, create your own visual record of a streak with Excel or a Word document. The power of a streak is that you become more and more invested in not breaking the streak as time goes on.

Final thought. We are all busy, and we are all tired. This era, more than most, is one of being pushed and pulled in so many directions and in so many ways. Take the time to identify the things that bring you joy. If that’s all you do, it will be a good start, because just making that list will make it more likely you will add joy to your days. When you are ready, make a real covenant with yourself, a promise that you will do the one, two or maybe three (no more that three!) things at the top of that list every day. And then, do your best. Give yourself grace when you stumble… and start over.

Rethinking “Exercise”

Posted on September 4, 2022 by marylbrandt

I recently read a book that changed the way I think about exercise…for real. It not only provided scholarly (but very readable) insights – it also made me feel less guilty about “not exercising” while giving me some new tools to think about caring for my body.

If you are in the 10% of people who exercise regularly without thinking about it, great. For the rest of us, here are my key takeaways from Daniel Lieberman’s book, Exercised.

Along with many other aspects of our daily life, exercise has been “medicalized”.

Every week in clinic, I talk to young parents who have been sent home from the hospital with instructions to feed their baby [xx] mls of formula every three hours. They set alarm clocks! They often end up feeding their baby when the baby isn’t hungry, and don’t give a little more when they know the baby is still hungry after they are fed. This is “medicalizing” food and it is not only silly, it can be harmful.

In our personal lives we medicalizing food (aka diets… which don’t work in the long run)…and we medicalize exercise. We have all learned the “dose” of exercise that is now recommended: 150 minutes per week of moderate exercise or 75 minutes/week of vigorous exercise (plus weight training twice a week). When you step back and think about it… really? The same “dose” for all of us? The same “dose” every week?

We evolved to be couch potatoes

Photo credit (and article on the origin of the term “couch potato”)

The struggle to exercise is normal! We are fighting evolutionary pressure to not waste energy, to move only enough to take care of our needs and the needs of our community. Our bodies haven’t changed over the centuries. What has changed is our environment, which has become so efficient that we don’t have to move as much to walk through our day. So how do we fight back against our programing to be couch potatoes while honoring the need to keep our bodies physically healthy?

Just move (which you already do)

“… if you are a typical person who barely exercises, it would take you just an hour or two of walking per day to be as physically active as a hunter-gatherer. (p. 19)

The average healer in a hospital easily meets the goal of walking for more than an hour a day, Congratulations! You don’t need to “go to the gym” for another hour! There are other reasons to exercise (you will have to find a way to lift weights and stretch), so don’t take this as carte blanche to ignore your need to be fit, but quit beating yourself up for not “exercising”.

Stand up.

Sitting for prolonged periods is not good for you, primarily because it promotes the slow burn of mild inflammation. You don’t have to medicalize this, either, but don’t sit without breaks. Just stand up, fidget, walk to the water fountain… whatever it takes to move.

Play.

Breaking a sweat doing something you love is not only good for your body, it’s also good for your soul (and your sleep). Reframe! Find something you love to do that will let you break a sweat. (Note, the key word is “let”, not “have to”). If it’s outside, even better, but just go play.

Even a little exercise can make you happier!

Learning Medicine #SmartNotes

Posted on July 18, 2022 by marylbrandt

What if I told you there’s a system that makes it easy to remember the things that you need to remember for exams, but also creates links that make it easy to study and understand the network of knowledge that you really need to learn to heal?

And what if you could start using this system beginning on the first day of medical school…or at the beginning of your PGY2 year… or wherever you are on this journey now?

Here’s how:

Step 1. Create a folder in Google Drive*

Step 2. Take notes. About everything.

Step 3. Put the notes in your digital folder, filed by date and time, identified by hashtags and keywords.

Step 4. Synthesize, summarize, and link.

Step 1: Create a folder in Google Drive*

Don’t panic. Yes… just one folder.

Mine is labeled “card file”. You can always rename it. Maybe start with “My digital brain”?

If you just can’t stand it, you can create sub folders based on an anatomic filing system (e.g. Appendix, Colon, Heart, etc) but trust me – no sub-sub folders!

*I like Google Drive because it’s very flexible and you can access it from any computer and your phone. There are other ways to store digital data that can work as well, like Evernote, OneNote, etc.

Step 2: Take notes. About everything.

Keep a notebook in your pocket, use paper out of the printer, use a white board, or dictate directly into Google drive… but just take notes!

This practice is a leap for most of us, but it not only leads to phenomenal learning, it fundamentally transforms how you interact with your day. There is power in a practice that makes you more present in your day. Every encounter, every lecture, every article you read becomes a potential adventure, a source for new insight and growth.

There are only two rules

Rule 1: One concept per note.

Rule 2: Write the note only one time – don’t rewrite or retype notes. (If its’ a paper note, take a photo, or create a pdf to file in your google drive.)

What kind of notes will go into this system?

Lectures. You know how to do this from other classes! Just because we call it “Grand Rounds” or “Path-Rad conference” doesn’t mean it’s not a class. Take notes!

Notes from Reading. Textbook chapters, articles, handouts…

SOP (Standard Operating Procedure). This one is key if you are in a procedural specialty. Keep a single “note” for each procedure and update it with new information as you scrub with new attendings. Put in links to good videos, photos from textbooks and anatomy books. Anything that will help you review what you know and have learned before you do the procedure again.

Milestones. The first time you….listened to a murmur, talked to a patient about their prognosis, did a Whipple.

Questions, thoughts… “Why isn’t there a way to diagnose malrotation that needs surgery (vs.nonrotation) with diagnostic imaging?”

What you learned from patients. Make it your goal to learn something from every patient you take care of. Write it down. Make sure it’s HIPAA compliant – no patient identifiers that someone else could decipher.

Sounds. Yes, you can digitally store recordings!

Summary Notes. One page summaries of complex ideas

Unanswered questions. Ideas for possible publications, future investigations, etc.

Step 3. Put the notes in your digital folder, filed by date and time, identified by hashtags and keywords.

File the notes by date and time + description e.g. 2022-07-18 1645 Creating a filing system for studying medicine.

Why?

Imagine… It’s the last year of your residency, it’s 2am, and you are admitting a patient with Hemophilia A who needs emergency surgery.

You open your phone, go to your folder and search for #Hemophilia… and you find these notes:

First year lecture on coagulation

Second year lecture on disorders of coagulation

Second year lecture on the pharmacology of factors given for the different types of hemophilia

Your summary notes on coagulation, coagulation disorders, and the meds used to treat them

Notes from a review article on caring for patients with hemophilia

Notes about that really cute 6 year old on your pediatric rotation who had hemarthrosis

Notes from Grand Rounds on your medicine rotation about disorders of coagulation

A lecture during your surgery rotation on pre-op preparation of patients with clotting disorders.

Notes from Sabiston’s Textbook of surgery on patients with Hemophilia

What you learned taking care of the diabetic hemophiliac who needed an amputation when you were an intern

Last years’ conference with the visiting professor who was an expert on Hemophilia B

Step 4. Synthesize, summarize, and link.

There are so many details in medicine that we often lose track of the big picture. That takes thinking, creating one page summaries of complex topics, and noticing connections.

Maybe it would be easier to show you rather than tell you. Let’s say you are in a lecture about how to read a chest x-ray. In your notebook (or on your computer) you are taking notes… lots of notes… how to tell what’s a pneumonia vs atelectasis, what different lung tumors look like, how to tell if the mediastinum is too wide. As a result, 2 years from now when you see a patient with a lung mass, you will be able to search your drive for “lung cancer” and these specific notes will come up.

But as you sit and think about this lecture, you’ll realize that in addition to the details, there were more general concepts that were important, too. For example, how important it is to systematically review every diagnostic image so you don’t miss the lytic lesion in the bone that was behind the big mass in the chest. (Link to my favorite study describing how this happens)

So you create a digital note that describes, in your words, how important it is to have a system to look at images. Which makes you remember that this is very similar to how we always follow a system to do a history and physical. So you search in your drive for the card you made about how to do an H&P and you link them, using the “insert link” command. And, as you look at your H&P card, you notice that you had already linked it to cards you made about Basic Life Support (BLS) and ACLS (Advanced Cardiac Life Support), two certificates you were required to obtain, both based on a system to not miss important steps in resuscitating patients. And suddenly you are interested in why systems like this make it so much easier, so you do a quick search and find a fascinating article on memory and learning (as opposed to memorizing).

This post represents a modification of the amazing Smart Notes system described by Sönke Ahrens in his book How to Take Smart Notes: One Simple Technique to Boost Writing, Learning and Thinking. I highly recommend it, especially if you are considering an academic career!

Other things I’ve written about studying in medical school and residency:

Studying for the In-Training Exam 2022-01-30

Study Tips for First Year Medical Students 2018-08-11

How to Succeed in Clinical Rotations (and residency, too) 2018-01-09

Top Ten Tips on Starting Medical School 2022-06-18

How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards 2017-04-14

Advice for Graduates

Posted on June 15, 2022 by marylbrandt

The following is a guest post from my father, Professor Floyd Brandt.

At the time I decided to retire, I experienced two thoughts: First, I had been in a footrace for several years between retirement and obsolescence. The second thought was the closing line from Stephen Sondheim’s song Send in the Clowns — “Isn’t it rich, isn’t it queer, losing my timing so late my career.” Given the issue of obsolescence, I declared that my retirement was a trip from doing to being and then discovered that being is as challenging as doing, and often more so—learning to pause, meditate, and seek the joys of solitude requires new thoughts and habits.

Many, if not most, professors are inclined to think about what they would say in their Last Lecture and some even write it for the millions who will never read it and for students who will never remember it. My final lecture to my graduate classes could be divided into the pragmatic and the personal—I have included the pragmatic here:

After graduation, be your own professor. Keep asking questions. The quality of your life and the organizations you inhabit are dependent upon the quality of questions posed and answered.

During the interview with a potential employer, ask as carefully as possible, “What stories can you tell me about the company or organization”. If they have no stories, you may want to consider another company or organization.

As soon as possible, assemble a “Go to hell” fund equal to six months of salary available in case you need to refuse to engage in an unethical, illegal or extremely distasteful activity.

Attempt to locate the leaders in the organization who has real concern about defining the next decade.

Find out and then think about the years your boss was a teenager.

Begin to develop a flexible plan for the future. It is a truism that individuals and organizations that plan, seldom follow their plans, but they tend to perform better than those who do not plan.

Recognize the value of patience and silence. It usually takes a few years to achieve a top position in an organization.