Category Archives: Education

Advice for Graduates

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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.

No Time to Teach? Try This.

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I’ve started a new practice as a medical educator that has been working so well that I thought I should share it. 

Once (or twice) a day in every teaching hospital every service makes rounds and, while managing and treating their patients, the attending (and/or senior residents) teach. 

https://middlemarch.com/film/making-rounds/

Inevitably, there are unanswered questions that come up as we discuss patients. Many of them are questions I don’t know the answer to, or are related to a hot topic that might have new information just published. Here are some examples of questions that have come up on rounds on our pediatric surgery service:

  1. Are there new recommendations about how to manage gallstone pancreatitis and/or choledocholithiasis in kids? 
  2. What is the caloric content of the different formulas we prescribe?
  3. What is the best way to calculate calorie needs for a burn patient?
  4. How and why do you swaddle a baby?
  5. How do you manage supplemental oxygen after you extubate a patient with severe facial burns? 
  6. Where does “second line” come from?

Typically in the past, each student and intern would be assigned one or two of these questions to answer. They would be expected to report back to the team the next day – which might or might not happen depending on how busy the day was (and if the attending remembered to ask them). But to be honest, this way of teaching has become harder with time. There is a post-call resident who is not there the next day, the students often have didactic sessions that are required so they aren’t there, and the day can get so busy that there isn’t (perceived) time to teach on rounds.

But it’s our responsibility to teach (the word doctor means teacher!). Teaching is also a powerful antidote for burnout because its so important and so meaningful. It was clear – I had to come up with a way to make this work in spite of the limitations created by our schedules and clinical responsibilities. So here is what I do now in addition to teaching on rounds:

  1. During rounds we come up with one question per person (everyone, not just the students and interns). 
  2. Each person is responsible to answer their question via a group email that, as the attending, I start on the first day I’m rounding. 
  3. The answers are short and helpful – as though each person is taking notes for themselves. No PowerPoint presentations, no extensive diatribes. 
  4. The email answer is due before the next morning… but no one is allowed to stay up late to do this. 

Here’s what was sent on our group email to answer the examples I listed above.  (Disclaimer – These are unedited. Don’t use these for patient care unless you look things up yourself!): 

What is the “board answer” for treatment of gallstone pancreatitis? 

  • Usually mild as the stones pass spontaneously in the majority of patients but can be severe (even life-threatening) although this is rare. This is due both to fluid loss (equivalent of a severe burn) and to SIRS 
  • initial Tx: Fluid resuscitation, pain control, nutritional support (oral when patients are subjectively hungry – low fat diet) 
  • Surgery during the same hospitalization (Munoz, 2022) (Berger, 2020) (Noel, 2018) 
  • ERCP only if there is cholangitis or persistent cholestasis (Schepers, 2020) 

What is the “board answer” for treatment of choledocholithiasis. 

  • First step: Is it asymptomatic or symptomatic (i.e. pancreatitis, cholecystitis, cholangitis)? 
  • Emergency ERCP (<24hrs) for cholangitis, cholecystitis and/or pancreatitis with obstruction  
  • Stones must be cleared. There is no benefit to waiting and there is a downside to waiting since there is always a risk of cholangitis or pancreatitis with a stone in place.  
  • Most surgeons use pre-operative ERCP for known choledocholithiais followed by cholecystectomy, but ERCP at the time of cholecystectomy in adults (Rucci, 2018) (Cianci, 2021) and kids (Fishman, 2020) has been shown to be safe – and perhaps better.  

Calorie content of available Tube Feed/Supplements:

Two Cal HN – 2 Calories/mL – high protein

Glycerna 1.2 – 1.2 Calories/mL – lower glycemic index

Nepro Carb Steady – 1.8 Calories/mL – high fiber, gluten free, for lactose intolerant

Impact Peptide 1.5 – 1.5 Calories/mL – supposedly decreases risk of enteral infection in surgical/trauma patient with peptide formulation

Vital 1.2 – 1.2 Calories/mL with 1.2g of NutraFlora per 8oz for gut health

Pediasure Peptide 1.5 – 1.5 Calories/mL – designed for those with malabsorption

Ensure Plus – 1.5 Calories/mL with 16g protein

Osmolite 1.5 – 1.5 Calories/mL – fatty acids for different digestive profile

Jevity 1.2 – 1.2 Calories/mL with 4g fiber/8oz and 1.9 NutraFlora for gut health

Kate Farms 1.5 Peptide – 1.5 Calories/mL – supposedly marketing for smaller tubes without needing to be watered down

Nutritional needs for burn patients

Calorie calculator is complex: https://burnstrauma.biomedcentral.com/articles/10.1186/s41038-017-0076-x/tables/1

2.5-4.0 g/kg/day protein for burned children vs 1.5-2.0 g/kg/day for adults

Fat should be less than 15% of total calories

Carbs 7g/kg/day for burned children

Where did swaddling begin and why do we do it? How do you swaddle a baby?

Etymology/History

  • Swath (a strip in a field or a strip of cloth) 
  • 1325 first recorded use in English – Cursor Mundi (Gött.) l. 1343   A new-born child..Bunden wid a suadiling band (OED)
  • Almost universal in the 18th century, with or without a cradleboard

Benefits of Swaddling (van Sleuwen, 2007)

  • Infants arouse less and sleep more 
  • Soothes pain in infants 
  • Prevents hypothermia
  • Decreases excessive crying due to stimulation

Adverse effects of swaddling  (van Sleuwen, 2007)

  • Hyperthermia if not monitored
  • Increased risk of hip dysplasia
  • Increased risk of SIDS if prone
  • Promotes skin infections in hot, humid climates

Video showing three different methods of swaddling

Facial burns and airway management: 

*The mortality associated with orofacial burns or smoke inhalation is related to the degree of lung damage, patient’s age, and the extent of the burn; it is not related to the method of upper airway control.  Arch Surg. 1976

*In Facial burns, edema of the head and neck, supraglottic, and glottic areas is the most common cause of airway obstruction

Modified Tube for Endotracheal Airway Management of Children with Facial Burns Antonio G. Galvis, MD,

The team from this article designed a particular ETT setup

Treatment for postextubation stridor was required after 11 (37%) of 30 extubations, with five reintubations and one tracheostomy. The best predictor of postextubation stridor was absence of an airleak at the time of extubation (sensitivity 100%, positive predictive value 79%, p less than .001), followed by type of injury (facial burn vs. all others; sensitivity 64%, positive predictive value 88%, p less than .001). 

Kemper KJ, Benson MS, Bishop MJ. Predictors of postextubation stridor in pediatric trauma patients. Critical Care Medicine. 1991 Mar;19(3):352-355. DOI: 10.1097/00003246-199103000-00012. PMID: 1999096.

What a second line means!

The “second line” refers to the spectators who join or follow the main line (usually the brass band) and contribute to the walking parade.  This is what separates a second line from any other New Orleans parade: groups are not only welcome but encouraged to follow along, allowing the second line to grow as it marches.  The term “second line” doesn’t only refer to the parade itself, it also speaks to the type of dancing you will find during those parades.  “Second lining” is a highly recognizable strutting, chicken-like dance move that many people use to keep pace with the band.  So “second line” is a term with many meanings; it applies to a type of parade, a part of the parade, and a dance move used within that parade.

@Teachers_Matter

Studying for the In-Training Exam

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Every year every resident in the United States takes an exam (called the In-Service or In-Training exam) that covers all of their specialty. It’s meant to be a formative exam for residents and their programs, which means it’s supposed to let everyone know which areas need more focus. Unfortunately, because there are numbers associated with this test it has become a higher stress exam than it should be, especially for residents who are applying to competitive sub-specialties.

First a word to Program Directors. When you think about this test there are only three categories for the results

1) Possibly at risk to pass the boards (< 10th% ile?)

2) Going to do fine (11-79th %ile)

3) Extraordinary test takers who really know the info (>80%ile)

This is a comprehensive (and long) exam that often has a VERY narrow bell-shaped curve. What that means is an incorrect answer on 2 questions (some years) can drop a resident up to 10%ile points. Doesn’t it seem silly to think that 70th%ile is somehow “better” than 60th% or 50th%ile? (I’m looking at you, subspecialty PDs)

Now for my colleagues in training. You stressed about this exam, you “crammed” (yes, we all did it – even those of us who know it’s stupid) and now you are breathing a sigh of relief that it’s over…

Take a good break from studying. For the next two weeks, use all the time you would have been using to study to binge watch something on Netflix, read a few novels you’ve been meaning to read, or do whatever gives you rest and joy. Then….

Put this in perspective. At the end of your residency, you will be launched into the wonderful, scary, amazing world of practice. You want to know that you know enough to do this, right? So back away from the idea of the In-Service exam as a pain in the gluteus, and see if you can think about it as a formative exam. Which leads me to…

Learn About Deliberate Practice. The best way I’ve found to think about deliberate practice is to understand how musicians practice. I wish I could remember where I read this so I could properly attribute it (please let me know if you know!), but here’s the best example I’ve found to understand deliberate practice – Serious amateur musicians and professional musicians practice a similar amount of time… say 2 hours a day (for the sake of this discussion). But how they practice differs. The amateur will play the piece from beginning to end multiple times, occasionally stopping to repeat the stanza that trips them up. The professional will play it once or twice, spend an hour on a stanza that trips them up, then start over. That’s deliberate practice. Taking the things that are hard (or you don’t like) and repeating them until they aren’t hard.

So, putting this all together, here is what I suggest you do to get ready for the In-Training Exam:

Step 1: Make notes.  

Take one of the major textbooks in your field and make a spreadsheet of every chapter, topic, and subtopic in the book. Your goal is to make notes on every topic in the book from March 1st to December 1st.  Start with some simple math… March 1st to December 1st is 39 weeks, so take the total number of topics in your text book and divide by 39 to set your weekly goal.

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But you won’t start with page 1 and work sequentially to page 846. (Yes, for those not in medicine, the books are usually that long). When you are on call, and you admit a patient with pneumonia, read the chapter about pneumonia and make notes to store in Google Drive? EverNote? OneNote? It doesn’t matter as long as they are in the cloud and searchable. If you hand write notes that’s ok, too, just use an app like Scannable to turn them into PDFs and store them on the web (don’t forget the keywords and/or tags so you can search for them when you are reviewing). What should the notes look like? You graduated from college and medical school, so I’m betting you have a system that works for you. But, if you’ve never heard of it, take a look at the SQ3R system for studying. (Spoiler, it really works.)

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A few other words of advice. It is VERY helpful to link your notes to a specific patient. You’ll remember everything much better; I promise. So, mention the patient with COVID pneumonia who always wore their yellow baseball hat… but don’t put any PHI in your notes so you don’t get in HIPPA trouble.  Also, don’t limit yourself to notes from the textbook. This system allows you to make and store notes when you read an article, learn a pearl on rounds, create a mind map, use questions banks, or do a presentation…

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Step 2: Deliberate practice. There will be sections of your textbook that thrill you. Parasites? For some reason we are all fascinated by them. Coagulation cascade? Not so much. Recognize that it will always be easier to learn about parasites than the intrinsic and extrinsic pathways. (Unless you are going into blood banking, in which case I apologize). Which means you need to spend more time on the coagulation cascade. Darn. #DeliberatePractice

The fundamental thing that differentiates learning (for your patients) from memorizing (for the test) is repetition. Your goal is to see everything you need to learn at least 5 times, spaced over at least 3 months. If it’s a topic that is difficult for you, it will probably be more times over a longer period of time. #DeliberatePractice

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One of the best ways to learn specific pieces of information you need to know (like the coagulation cascade) is to use an app like Anki or other flashcard apps. The advantage of these apps is they force you into spaced repetition (remember the minimum of 5 times over 3 months?), but if you are more comfortable with the old-fashioned (but effective) analogue system of actual flash cards, go for it!

But – write this down and put it over your desk – You can’t learn to practice medicine from Anki. You may be able to learn the coagulation cascade and the ratios for Massive Transfusion Protocols… but you won’t learn how to care for a patient who is bleeding out. That’s why you read and that’s why you are in residency.

Another great way to learn something is to teach it. Put together a brief presentation and handout for your medical students on the coagulation cascade… and make notes about their questions, who was there (maybe even a team photo?) before storing your handout with your other notes.

Step 3: Review. This system builds in review of everything you learned over the year (by reviewing it at least 5 times over at least 3 months, remember?) but for next year’s In-Training Exam, plan to take a full month before the exam to stop making notes. Spend this month before the exam to go through question banks, review your notes, and memorize the coagulation cascade. 🙂

Simple way to log your cases

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I just taught two of my residents an easy way to log cases without stickers, notebooks, cards (or any other HIPPA risky methods). They were all but jumping up and down with happiness, so I decided this might be worth sharing.

(For those that aren’t in medicine, this is a requirement for everyone training in a procedural based field in medicine.)

Step 1:At the end of the case, when you open the computer for the orders and notes, highlight and copy the patient info at the top of the screen.

Step 2:   Open your Outlook calendar. Every institution gives you an Outlook account for your email and (even if you haven’t found it yet) this has a calendar, too. Hospital and medical school Outlook accounts are password protected and HIPPA compliant. (It would be a good idea to double check at your institution, but I haven’t found one yet where this isn’t true).

Step 3: Create an “appointment” for your case.

Paste what you copied from Epic into the “note” portion of the appointment. It will look like the green box in the image below.

Copy the name and MRN to the subject line of the “appointment”

Add the attending’s name if it’s not in the info copied from Epic.

Step 4: To officially log your case, open the ACGME site in a window next to your open calendar. Copy and paste the information from your calendar to log the case (isn’t that better than typing all that info?!?!…. you’re welcome!)

Step 4b: Put an asterix by the patients name in your calendar entry to show that you logged this case.

Hope that helps!  If you discover any important tricks or shortcuts to add to this system, please contact me or comment below!

Happy New Year’s Resolutions!

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Like most of you, my New Years resolutions in past years have been something like “Exercise every day” or “Eat fruits and vegetables with every meal.” And, I bet that you had the same experience I did… a few weeks of “success” and then they seemed to fade away. The problem with these kinds of goals are how they are structured. They end up being “either-or” goals … you are either able to do them or, more often, you miss a day (or two… or three) and feel like a failure.

I recently read a blog post by Ryder Carroll, the originator of the Bullet Journal which profoundly changed the way I think about goal setting and New Year’s Resolutions

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It’s a simple, but very powerful concept. Set your goal as a destination… as a “lighthouse” in the distance, and then head in that direction every day. As Ryder Carroll explains, “When goals are lighthouses, success is defined by simply showing up, by daily progress no matter how big or small…”

So instead of the usual New Year’s Resolutions, pick a few “lighthouse goals”. Write them down and keep track of how you are doing (every journey needs a map). This can be as simple as one piece of paper for each goal, but I am such a fan of the Bullet Journal, I hope you consider using it.

When you get up every morning think about how to move towards your goal(s). If you veer off course, that’s part of the journey…. look up, find your lighthouse, and correct your course.  Every once in a while (maybe monthly?), look at the progress you’ve made and celebrate it! If, on the other hand, the goals you originally chose don’t make sense for you any more, pick some new goals, draw a new map and start over.

Potential New Year “Lighthouse” goals

  • Learn more about compassion and practice it
  • Be a better friend
  • Write genuine thank you notes to people who have helped me
  • Become more fit
  • Eat real food for as many meals a week as I can
  • Find out more about who I really am through meditation
  • Keep a “stop doing” list
  • Be better at my work through deliberate practice (practicing and learning the things I don’t like and aren’t good at until I’m better)
  • Stay organized so I don’t waste time (and end up focusing on trivial things instead of what’s really important)
  • Read things that bring me joy
  • Learn about and use a Bullet Journal
  • Find a community to support me
  • Learn the names of as many people at work as I can
  • Take the stairs as often as I can
  • Make my living spaces enjoyable spaces
  • Keep a journal to remember milestones and work out struggles
  • Get good sleep as often as possible
  • Learn Spanish (or any new language)
  • Be on time
  • Remember people’s birthdays and send a card
  • Start the day with intention
  • Appropriately limit email and social media time

How to Succeed in Clinical Rotations (and residency, too)

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Today I have the incredible joy of talking to the medical students on our rotation.  No agenda, just a conversation that they requested for some “advice”. They just started their surgery rotation last week and it’s their first rotation.  First rotation, beginner’s mind, unbridled enthusiasm… it is so wonderful!. I decided I would come up with what I wish someone had told me at the beginning of my rotations…

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Be mindful, deliberate and excited about learning.

This is probably the most important piece of advice I can give.  Clinical rotations are often a whirlwind of work and you can be swept away without realizing it. Residents can ignore you, people can be cranky, patients can be difficult… and in the midst of all this, you are expected to learn to be a doctor.  You have to stay in charge of that mission, no matter what is happening around you.

Take a little time to reflect on why you are doing this and what kind of person/doctor you want to become.  When times get tough (and they will) hold on to it.  If it helps you, come up with a slogan to repeat, keep on a piece of paper in your wallet or on your wrist

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Learn about the practice of mindfulness.  Mindfulness has been shown to be effective in decreasing stress and may help to prevent burnout.  It’s not hard to learn, but it’s hard to master … which is the point of a “practice”. (e.g. the practice of medicine)

Learn to keep a “beginner’s mind”.  When I was a student on core medicine I had a senior resident that showed me what beginner’s mind looks like.  It was 2am and I was tired.  We were seeing a gentleman at the VA hospital for his diabetes, hypertension and some electrolyte abnormalities.  I presented the patient to the resident and then we went to see him together.  He had a rash, which I thought was so insignificant that I didn’t even include it in my presentation.  But, instead of scolding me, this resident got excited.  Yes, you read that correctly, 2am and excited about a rash – because he didn’t know what it was. (This next part will date me, but it’s a great example to make us grateful for the access we have to information now).  He called security and had them open the library.  We spent a wonderful hour looking through books – like a treasure hunt when we were little kids – until we found the rash in one of the books.  We were laughing, excited and couldn’t wait to get back to start the appropriate therapy.

 

Understand what you are going to learn (the big picture)

On every rotation, you will be given a list of learning objectives.  By all means, know them, study the things listed and make sure you know them (they will be on the test).  BUT… please realize that diseases don’t stay conveniently siloed in a single specialty so this is not learning “surgery”, it’s learning about how surgeons approach a specific disease you will see elsewhere, too.   You also need to know that what is listed as learning objectives today may well be obsolete tomorrow  (if they aren’t already).

You have chosen a career that ethically demands life-long learning.  That means that one of the most important skills to learn is how to develop a system of learning that you can use in medical school, residency and later in practice.

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Develop a system for lifelong learning now

Learning is iterative.  You will learn broad concepts on each rotation along with a “fly over” of the entire terrain of the specialty  You will need the information you learn on your surgery rotation on your medicine rotation when you are consulted on a patient with an ischemic leg who needs surgical treatment, or on your pediatrics rotation when your patient with a pneumonia develops an empyema.  If you choose surgery at your career, you will read and learn the same topics throughout your residency (and after) but with increasing depth.

The practical points on how to develop a system to learn during your rotation are here: How to Ace the NBME Shelf Exams: How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards, but the key points are summarized below:

  • Remember it’s school.
  • Make a list of all the topics in the textbook.
  • Breathe deeply. You are not going to read every page in the textbook in addition to your assigned reading.
  • Create a schedule to SKIM every chapter
  • TAKE NOTES. All the time.
  • Figure out how to store your notes so you can find them in the future
  • Go through your daily notes in the evening and then store them in your system
  • Review, review, review

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Take care of yourself.

Pay attention to ergonomics, diet, exercise and sleep.  Most importantly, take care of yourself emotionally and spiritually.  You can’t learn or serve others if your tank is empty.  Come up with what is important for you and make a list.  Seriously.  Make a list of what you find helps you stay on track and then check it off every day.  Look at it before you go to bed.  Celebrate the things you did and don’t be hard on yourself for the ones you didn’t get to.

Don’t forget to take a “Sabbath” every week.  True time off is critical for recovery from this stressful work.

If it gets too hard, seek help.  It’s a sign of strength, not weakness, and most (if not all) of the people around you have been there.

We have the most amazing job on earth.  When the administrative issues or political conflicts get to you (and they will), just remember – you get to take care of another human life with the goal of relieving their suffering.  What could be more important than that?

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Applying to Residency: Tips for Medical Students (from MS1 to MS4)

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Applying for a residency starts with choosing your specialty.  The application for residency includes personal statements, curriculum vitae, letters of recommendation, transcripts and all the other components required by ERAS.  This application is then used by the NRMP to match medical students to their residencies.  It’s a fairly complex process on a relatively short timeline.

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The prezi below was put together to walk medical students through the process – from picking a specialty to matching in the specialty and program which is the best fit for you.

 

I’d love feedback from anyone if I’ve missed something or could explain this in a better way – please comment below!

Best of luck to the students who are starting this process to match next spring – and thanks to all the faculty, administrator and deans who help them along the way!

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Top Ten Tips on Starting Medical School

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Starting medical school is one of the most exciting moments in a physicians career… but it can be a little daunting!  This talk is one I gave recently to the college students in the Baylor College of Medicine Summer Surgery Program.  In addition to talking about how medical school is different from college, I also included my top 10 tips for successfully making this important transition.

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Download [5.49 MB]

How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards.

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Ok, now that I have your attention, let me share something with you. I’m going to show you how to maximize what you learn from the “school” we call rotations in medical school and residency so you can be an awesome master clinician. And, yes, it’s going to help you with your exams, so stay with me.

Clinical rotations are a strange blend of learning and work. You learn from the work, but we all forget that the work is not the purpose of these clinical experiences. The purpose of rotations is to be able to “practice” medicine (as a student) and then master the art of your specialty (as a resident.)

There are six basic principles to learn medicine, and then learn your specialty …and on the way ace the exams:

  1. Remember it’s school.
  2. At the beginning of each rotation, decide what topics you need to learn during the rotation and make a list.
  3. Take notes. All the time.
  4. Figure out how you will store your notes so you can find them quickly and organize them for review.
  5. Go through the notes you make every day to review them and then store them in your system.
  6. You can’t learn medicine from a review book (yes, including UWorld)

Somewhere around the beginning of my third year of residency, I was sitting in the “dome” (the chief resident’s “office” above OR 1 in our County Hospital) when Fred, one of my fellow 3rd years, walked in. He sat down and started to look through a stack of 3×5 cards so I asked him what he was doing. We all knew that he had scored the highest in our class on the ABSITE (the surgery in-service exam) and I was about to find out why.

REMEMBER IT’S SCHOOL

Fred figured out from day one that there was no way he was going to be able to study like he did in college and during basic sciences. Instead of hours to sit and read, it had to be flexible “on the job” learning.

This mindset is probably the single more important thing to cultivate. It’s the thing that drives you to constantly ask questions about why things are done the way they are and then go look up the answers.

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AT THE BEGINNING OF EACH ROTATION, DECIDE WHAT TOPICS YOU NEED TO LEARN DURING THE ROTATION AND MAKE A LIST. 

Your list can be pretty simple, or more complex, but it needs to be enough.

First hint – There is a curriculum that has been defined for your rotations. Everything your professors have decided should be taught should absolutely be on your list.   (By the way….If it’s in the curriculum, it has to be part of an objective. If there is an objective, it has to be linked to a test question)

Second hint – There is no way in medical school that “surgery” (or any specialty) can be covered in 8-12 lectures. The same is true for your rotations in residency. You have to do more.

This is one time that an example may be better than a formula. Let’s say I’m a brand new clinical student on my core surgery rotation….

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 Step 1. Find a textbook of Surgery and make a list of the topics from the chapters. A spreadsheet may be best for this, but any kind of list will do. 

For example, our library has Sabiston’s Textbook of Surgery (20th edition, 2017) on line:

 

 Step 2. Breathe deeply. There are 72 chapters and no, you are not going to read all these pages.

Man carrying books

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Step 3. Create a schedule to SKIM every chapter during the rotation. Look only at the “big picture” i.e. headings, section titles, diagrams, tables. Your schedule should leave the last week or two free. So, for example, if your rotation is 2 months long, plan to SKIM 12 chapters a week to get them done in 6 weeks.

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 Step 4 – Now we get to the real deal (remember, this is graduate school and/or specialty training).

List the sections on your spreadsheet.

As a student, you won’t read every section – unless they are very general (Acute Abdomen, for example) or if you have a patient with that particular problem. Here’s what it might look like:

 

TAKE NOTES. ALL THE TIME.

After I learned Fred’s system, I always kept a stack of blank 3×5 cards in my pocket. Like him, for the last 3 years of my residency, I made notes ALL the time.  Here’s the kind of notes we are talking about:

  1. Reading textbooks or other curricular readings. Take the time to make the notes and make them well so you never have to go back to the chapter to review it.
  2. On rounds when someone teaches an important point (e.g. the 7 things that keep a fistula from closing)
  3. During Grand Rounds
  4. During conferences
  5. When you look up a paper to read about a patient
  6. And – most important – what you learn from specific patients. Do NOT put the name of the patient or their MRN (HIPPA). But, do put specifics that help you remember the patient (e.g. pt that always wore a red baseball cap and had a tattoo of a dragon)

As you can imagine, once I started this system, I was making 10-20 notes a day. It is remarkable how much you learn in a given day… and how it’s almost instantly gone if you don’t write it down.  In three years I filled up two boxes with cards. These cards were the only thing I reviewed for my Board exams.

 

FIGURE OUT HOW YOU WILL STORE YOUR NOTES SO YOU CAN FIND THEM QUICKLY AND ORGANIZE THEM FOR REVIEW

This is why using a notebook isn’t the best way to keep notes on rotations. You’ll take them chronologically and, unless you have an amazing index at the back with all the key words and pages listed, you’ll never be able to find a specific note.

The key is being able to “file” the notes so you can find them.  For the 3×5 system, leave a blank square at the top to put the topic you’ll use to file them.

I used anatomy as the basis for my filing system. So I would use a pencil (so I could change it later if I needed to) to put the topic in the box.  For example

Pancreas, pancreatitis

Appendix, neoplasms, carcinoid

This is very old-fashioned (but very effective) system.. I personally think there are better ways to do this now using scanning, cloud storage, key words and tags.  For some ideas, check out this post.

What doesn’t work well is to try to type notes on your phone.  What REALLY doesn’t work is to make notes and then decide to copy them, type them or somehow redo them later. (It never happens).

 

GO THROUGH THE NOTES YOU MAKE EVERY DAY TO REVIEW THEM AND THEN STORE THEM IN YOUR SYSTEM

The key to learning (as opposed to memorizing for a test) is review. Simply filing the cards means you are reviewing them. Plan to pull them out to look at them (and all the work you accomplished!) every week or two.

More importantly, when you see a patient with pancreatitis 5 months from now on a different rotation, pull the cards you made on this rotation. You’ll find you have 20 or so cards (or card equivalents) on pancreatitis … a review of the Surgery textbook, notes from Grand Rounds, the 3 patients you saw with pancreatitis that taught you about the disease and a few pearls you learned on rounds from your chief resident.

 

YOU CAN’T LEARN MEDICINE FROM A REVIEW BOOK (YES, INCLUDING UWORLD) 

I’m really serious. Not only will you suffer when you are taking care of patients, you won’t do as well on the tests (despite what the upper level students or residents tell you).

Remember the last two weeks of the rotation that you saved?  Now’s the time to pull out the review books.  It’s a wonderful way to review what you have learned from your skimming and patient oriented reading.  It’s also a great way to identify gaps and look up information.

p.s. Take more notes while you are doing this.

p.p.s Review all your notes, including the ones you make from the review books.

p.p.p.s Review them again.

Link to the Wikipedia article about the forgetting curve