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

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.

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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

How To Study in Medical School

Congratulations to all the first year medical students who are starting or getting ready to start medical school.  As you will soon seen, from day one there will be an overwhelming amount of information to process and learn … much more than any you have seen during college. It’s going to take a new strategy!

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Unlike college, the information you learn during your preclinical studies will be important when you take the first part of your licensure examination (Step 1) and when you start your clinical rotations in 2 years or so, and when you start your residency.

It’s not just about learning this information for your exams, it’s also about creating a system to organize this information for the future.

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What should an ideal system let you do?

  1. Hand write or type your notes
  2. Highlight and annotate notes to make them more easy to remember
  3. Import images, pdfs, powerpoint presentations or other digital information
  4. Review the notes on your phone or iPad as well as your computer
  5. Revise or reclassify notes as you learn more
  6. Make sure your notes can’t ever be lost or destroyed

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What “notes” should you use to study?

  1. Use the notes provided by your professors, usually in the form of a powerpoint presentation or pdf of the presentation. Many students download the presentations into OneNote and annotate the slides during the lecture. If you use this system, it will be very important to make a one page summary of the key points. Going back to review each slide is very time consuming and not a good “juice to squeeze ratio”. (the effort you put into it is not worth what you get out of it).
  1. Take notes in class or to review like you did in college (highlighters and all!). If you choose to do this, use the SQR3 method or the Cornell note taking method to prepare i.e. don’t come in cold to class. Write down the big topics to be covered, and come up with questions you expect to be answered in class. The key is active listening!
  1. Try mindmaps. Your brain doesn’t organize things into bullet points. If you use colors, images and this more “organic” organization, it’s amazing how much you can remember. Like mnemonics, the more outlandish the images and colors, the easier it is to remember.   You’ll find an example of a mindmap to learn about pilonidal disease below. Note, for example, that the image for obesity is a stick of butter surrounded by fat globules. It’s creating your own images that makes this so powerful. Even though you can share mindmaps, or use software to create them, it’s more effective to draw your own.
  1. Handwritten may lead to better learning…. Worth thinking about!

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How should you organize your notes?

Here’s where it gets fun. Organizing notes with Evernote is the best way I’ve found (ever) to do this.  Evernote is an app for your computer and phone/iPad that allows you to store “notes”. But, the notes can be a lot of different formats:

  1. New notes, typed directly into the software
  2. Imported notes from OneNote or a powerpoint presentation
  3. Scanned notes. Evernote has an amazing free app called Scannable that converts any document into a pdf using your phone. So. if you draw a mindmap, doodle about the anatomy of the rotator cuff or have a typed handout from someone, you can scan it into EverNote.
  4. Photos of whiteboards, paper notes, images.
  5. Videos, like your professor showing you how to examine the knee for instability.
  6. There is an Evernote “web clipper” that can be used on your computer to download any webpage.
  7. Audio notes. You can record a review for yourself and save it as a note.

 

Other advantages to using Evernote

  1. You can share notes with others
  2. You can find information by searching. Both typed and handwritten words will be recognized.
  3. When you store a link to a video it’s active, so you can click and go directly to the site.

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What should I do before I set up this system?

  • Start the notes now – even though you don’t have the system in place.  Listen actively and take notes actively. Make sure you create one page summaries of every lecture. Keep these to scan in when you start your account.
  • Download Evernote for your Life | A Practical Guide for the Use of Evernote in Your Everyday Life by Brandon Collins and read it before you create your system. This ebook is concise, easy to read and will explain why you can’t think about EverNote as a “filing” system in the usual sense.

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A few other words of advice

  • Create your Evernote account with an email address that will follow you through your training. (By the way, if your personal email now is sexyguyfromthecity@gmail.com, it’s time to get a new and more professional address!)
  • I’d create one huge notebook called “Everything I need to know to be a doctor” (just kidding.. but don’t fall into the trap of creating a lot of different notebooks, either.)
  • When you start, be very deliberate about your tags. You don’t want to end up with “Penicillin”, “penicillin” and “penicillinV” as three tags for penicillin… Decide how to standardize your tags before you start i.e. when to capitalize, generic names of drugs only, etc.
  • Evernote is not HIPPA compliant.  Don’t EVER put any patient information (including photos) that could be identified.
  • Go ahead and spend the money for Evernote premium. You’ll be using all the storage and the bells and whistles.

What Big Magic Can Teach Those Who Serve

“Do what you love to do, and do it with both seriousness and lightness.”*

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On the flight home yesterday I finished Big Magic: Creative Living Beyond Fear by Elizabeth Gilbert (She’s probably known to you for her NY Times Best Seller Eat, Pray, Love). For me, one of the overarching messages of her book was this – When you see what you do as your vocation (from Latin vocātiō, meaning “a call or summons”), and not just your job, it will transform how you view your work – a concept which I believe may be necessary (but not sufficient) to treat or prevent burnout.

As I read her thoughts on how to live a creative life, I realized that there were other ideas  that applied to physicians, physicians in training and others who serve:

 

Just show up. Every day.

“Most of my writing life consists of nothing more than unglamorous, disciplined labor. I sit at my desk and I work like a farmer, and that’s how it gets done. Most of it is not fairy dust in the least”

Learning and practicing medicine (or any other field) means showing up – really showing up – every day. Everyone in the first year of medical school learns that it is different than college. Cramming for exams is not only ineffective, it’s just wrong. You are no longer studying for a grade on a test…. it’s now about the patients you will take care of in the future. The same holds true during residency and when you begin your practice. It’s not just when you are a trainee.  Part of the “work” of medicine remains “unglamorous, disciplined labor”… keeping up with the literature, going to teaching conferences when you could be doing something else, finishing your hospital charts, being on call.

But the work of medicine is also about showing up every day in another sense, too – truly showing up for the people who rely on you – no matter what. That, too, can be “unglamorous, disciplined labor” when you are tired or stressed.

“Work with all your heart, because—I promise—if you show up for your work day after day after day after day, you just might get lucky enough some random morning to burst right into bloom.”

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They are your patients… from the first day of medical school until you retire.

Most of all, there is this truth: No matter how great your teachers may be, and no matter how esteemed your academy’s reputation, eventually you will have to do the work by yourself. Eventually, the teachers won’t be there anymore. The walls of the school will fall away, and you’ll be on your own. The hours that you will then put into practice, study, auditions, and creation will be entirely up to you. The sooner and more passionately you get married to this idea—that it is ultimately entirely up to you—the better off you’ll be.”

Caring for others gives us joy but also gives us the responsibility to know the best thing to do for them. Whether you are a first year student, 3rd year resident or a PGY35 attending, we are all still learning. “Life long learning” is not just a phrase, it’s the reality of what we do.

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It’s called the practice of medicine for a reason.

“It’s a simple and generous rule of life that whatever you practice, you will improve at.”

Learn the art of deliberate practice early. Deliberate practice, to use a musical analogy I learned in Cal Newton’s fantastic book So Good They Can’t Ignore You: Why Skills Trump Passion in the Quest for Work You Love, doesn’t mean playing the piece from start to finish 20 times in an hour. It means spending 55 minutes on the small section that you struggle with, repeating it 100 times before you play the piece through once. It means instead of reading the comfortable material on the anatomy of the kidney, you deliberately tackle how the nephron works. It means that instead of doing the computer-simulated cholecystectomy 10 times you spend an hour tying intracorporeal knots in the trainer. Find the thing that is not easy and practice it over and over until it becomes easy.

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There is Peril in Perfectionism

“There are only so many hours in a day, after all. There are only so many days in a year, only so many years in a life. You do what you can do, as competently as possible within a reasonable time frame, and then you let it go.”

One of the greatest attributes of those who care for others is their devotion to the people they serve. But perfectionism, taken to its extreme, is dangerous. Extending your time to study for Step 1 beyond what is reasonable to try to get a higher score, revisiting decisions about patient care to the point of anxiety, worrying that your GPA has to be perfect are all counterproductive. The motivation to do well is like a cardiac sarcomere – a little worry will make you more effective, but stretched too far, there won’t be any output at all.

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Curiosity can overcome fear.

“No, when I refer to “creative living,” I am speaking more broadly. I’m talking about living a life that is driven more strongly by curiosity than by fear.”

It’s something most students don’t realize, but no matter how long you practice medicine, there are days when you are afraid. It takes courage to do what we do. Remember, being courageous is not an absence of fear, it’s being able to do what’s right despite the fear. I agree complete with Elizabeth Gilbert that curiosity helps. When you have something that doesn’t go the way you expect or frightens you, instead of beating yourself up (“I should have studied more”….”I could have made a different decision”…etc…etc) become curious. If you are thinking about a complication, commit to finding everything you can about the procedure and how to prevent complications. If you didn’t do as well on your test as you thought you should, look up different techniques to study, take notes, and remember information, and go back to make sure you really understood what was being tested.

Even more powerful than curiosity is gratitude. Fear and gratitude cannot exist at the same moment. Try it – the next time you are about to snap because your EMR freezes be grateful that you can see the computer, be grateful you have work, be grateful you have been trained to help other human beings …and see what happens.

“We must have the stubbornness to accept our gladness in the ruthless furnace of this world.”

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Your worth is not the same as your “success”.

“You can measure your worth by your dedication to your path, not by your successes or failures.”

Wow…. This one is so important.

It’s not what you make on Step 1. It’s not how many cases you do, how many patients you see or how much money you make. This concept is taught by every religion and philosopher I know – for a reason. Be devoted to doing the best you can and to forgiving yourself (and learning from it) when you fall short.

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One last thing….for medical students trying to choose a specialty – forget about finding your passion.

This is a little longer quote than the others, and mirrors a similar message in So Good They Can’t Ignore You: Why Skills Trump Passion in the Quest for Work You Love .

Find something, even a little tiny thing, that makes you curious (or fills you with wonder) and follow it. Dedicate yourself to following that curiosity and it will likely lead you to your career.

“May I also urge you to forget about passion? Perhaps you are surprised to hear this from me, but I am somewhat against passion. Or at least, I am against the preaching of passion. I don’t believe in telling people, “All you need to do is to follow your passion, and everything will be fine.” I think this can be an unhelpful and even cruel suggestion at times. First of all, it can be an unnecessary piece of advice, because if someone has a clear passion, odds are they’re already following it and they don’t need anyone to tell them to pursue it…..I believe that curiosity is the secret. Curiosity is the truth and the way of creative living. Curiosity is the alpha and the omega, the beginning and the end. Furthermore, curiosity is accessible to everyone…..In fact, curiosity only ever asks one simple question: “Is there anything you’re interested in?” Anything? Even a tiny bit? No matter how mundane or small?….But in that moment, if you can pause and identify even one tiny speck of interest in something, then curiosity will ask you to turn your head a quarter of an inch and look at the thing a wee bit closer. Do it. It’s a clue. It might seem like nothing, but it’s a clue. Follow that clue. Trust it. See where curiosity will lead you next. Then follow the next clue, and the next, and the next. Remember, it doesn’t have to be a voice in the desert; it’s just a harmless little scavenger hunt. Following that scavenger hunt of curiosity can lead you to amazing, unexpected places. It may even eventually lead you to your passion—albeit through a strange, untraceable passageway of back alleys, underground caves, and secret doors.

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*Italics are quotes from Big Magic: Creative Living Beyond Fear. Since I read this on my Kindle, I don’t have page numbers!

 

 

It’s the First Day of Medical School – What Should I Do?

I’ve written before about what to do before medical school starts, how to study in medical school and strategies for succeeding in the basic sciences. But how do you put this information about organizing your studying and your day into a system that works?   Everyone will have variations on how they do this, but there are some fundamental principles that apply to all.

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Don’t get behind

From day one, the material matters and, from day one, it is voluminous. If you get behind, it’s really hard to catch up.

Study, don’t just read and reread.

You have to actively engage this material and review it (multiple times) to really learn it. You are no longer studying for a test, you are studying to take care of other people. The SQ3R method is used by many students, but there are other systems as well. What is important is to develop a system that works for you.  One tool used by many students is Anki, software that allows you to create electronic flashcards to review key points.

Tips on active studying from UCSD

Tips on active studying from the University of Utah

 Use going to class as time to “study”

One of the important components to active learning is to review the lecture material before it is presented.  This is the opposite of what most of you experienced in college, but it’s key.   Survey the handouts or slides and make a list of the important points to be covered. Stay actively engaged.

p.s. You can’t learn medicine if you are on Facebook in class.

Create a summary page for each lecture

Include the big concepts, and key points. Include specifics that are stressed by the professor, but avoid listing all the details. You may choose to hand write this, but most of you will come up with an electronic format and will organize the class notes, and your summaries using One Note, Growly or an equivalent software. Although your personal notes are fine on the cloud, don’t put copyrighted material or your professor’s slides where other people can see them (it’s illegal).

Begin with the end in mind

In the long term, what you are learning (yes, all of it) will be applied to taking care of patients. In the slightly less long term, you will be tested on this information on the USMLE Step 1, a high stake exam and the first part of your medical license.   Although some dedicated time to study for Step 1 is important, having a system to really learn the material in your basic science courses is by far the best way to do well on this exam.

Don’t sacrifice sleep.

If you don’t sleep you don’t learn as well. Organize your schedule so you get at least 7, but preferably 8 hours of sleep every night.

Eat well, play hard and stay connected.

Clay Goodman,MD the Associate Dean of UME at Baylor, tells our first year class that the first year of medical school is a 60 hr/week job. They need to get up in the morning and “go to work”, using the afternoon and evening to study. He then points out that if they work 60 hours and sleep 56 hours (8 hours a night) they still have 52 hours to work out, spend time with family and friends and do whatever else they want.

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So, what should you do the first day of medical school?

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Here’s what your schedule might look like…

The night before – pack your breakfast for the morning break and lunch for the next day. Review any posted slides – survey them to understand the “big picture” and use them to start your summary of the lecture. Write down what you don’t understand from the slides (yes, at this stage it may be every line… but that will get better!).

7am – wake up (If you prefer morning workouts, you can get up earlier and workout before class)

7:30 Grab a piece of fruit or a smoothie if you don’t like to eat an early breakfast. (If you are ok with it, eat the full breakfast now, but whatever you do, don’t skip breakfast)

8-12 Attend class – Stay engaged. Take notes, make sure the questions you asked yourself in the review are answered, raise your hand and ask questions if they weren’t. Eat your breakfast or a snack at the 10 am break.

12-1 – Lunch with your classmates. Play foosball, talk, or just eat, but take a real break.

1-5 Study. One hour of studying for each hour of class is about right for most people.   This may need to go until 6 or 7 if you have afternoon labs.

7 – Workout and then make and eat dinner. Working out is an important part of self-care. Exercise is essential to decrease stress and also will help you avoid the “freshmen 10”. Your dinner should be healthy, not processed, and definitively not Ramen noodles. Make sure you have fruits and/or vegetables at every meal.

9-10 Look over tomorrow’s lectures and start your summary pages for those lectures. Once you are a week or two into this, you’ll be adding in reviews of material from previous weeks on a schedule.

10-11 Read a novel, watch TV, decompress.

11 Go to sleep!

You are starting on one of the most amazing journeys any human being can have… enjoy it! Don’t forget to keep a journal and take photos (but not of patients). The first time you actually interview a patient, put on your white coat, hear a heart murmur or take a test in medical school are just that … the first time. Write about the experience.

Let me know in the comments what other advice you have for the students starting medical school this summer!

 

 

Top 10 ways to survive (and maybe even enjoy) being on call

Like our residents (but not nearly as frequently), my group has started taking “in house” call.   For every one who is currently or has been a resident, this is an experience we all know…. and one that’s hard to describe to those that haven’t experienced it.   Spending 24 hours on call in the hospital can be emotionally and physically draining, but it has moments that make it a special experience, too.

There are ways to make the experience easier.  Here are my top 10 ways to survive (and maybe even enjoy) being on call:

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1. Drink water. Put a water bottle in the lounge refrigerator, drink from every water fountain, put your water bottle next to your computer, or come up with other ways to stay hydrated. If you want more flavor, bring a zip-lock with cut up lemons or limes to put in your water or add a splash of fruit juice.

2. Be kind. No matter how stressed or busy you are, knock on every patient’s door and enter their room with the intention to help. Sit down or put a hand on their arm when you are talking to them. Smile.

3. Take breaks. On purpose. No one really expects you to work non-stop for 24 hours and it’s not good for your patients. Deliberately stop to do something else every few hours, even if it’s just for 5 minutes. Go outside for a few minutes for a short walk to catch some natural light and breathe some fresh air. Get a good cup of coffee or tea, listen to some music or just sit. If you want something more active, climb a few flights of stairs, stretch, or even do a light workout.

4. Eat well and eat often. Do not rely on fast food or the hospital cafeteria. By far the best plan is to bring really good food from home. You need to have “comfort” food on call. If you don’t cook, buy really good prepared food that you can look forward to. Make sure you have “plan B” ready if your call day gets completely out of control by having an energy bar (my favorite is Kind bars), peanut butter sandwich or other “quick” food in your white coat pocket.

5. Be part of the team. Notice and encourage the unique camaraderie you share with everyone else who is on call. It’s a small “band of brothers” who find themselves in the hospital at 3am. Be kind to each other, help each other, and use this unique opportunity to get to know someone you might otherwise not get to know.

6. Wear good shoes. If you are in house for 24 hours, bring a second pair that’s completely different (clogs and running shoes for example). Ditto socks. Buy really good socks and change them after 12 hours if you can.

7. Use caffeine wisely. It’s practically essential for many of us at the beginning of the day, but beware trying to “wake up” with caffeine after 2pm.   Not to mention that if you “caffeinate” all night, you’ll have that sickly post-call-too-much-caffeine feeling in the morning.

8. Take naps. Any sleep is good sleep on call. If it’s possible, 20 minutes will make you more alert and effective in your work.

9. Make your beeper a “Zen bell”. Use your pager or phone as a tool for mindfulness. When it goes off, take a deep breath, relax the muscles in your face and shoulders and be present.  This is a proven practice to decrease stress – try it, it works!

10. Learn. Take advantage of the unique educational opportunity of being on call. The fact that there are fewer people around at night and on the weekends has a real impact on how and what you learn on call.   If you are a student or junior resident, you are more likely to be the first person evaluating new consults and admissions. You are also more likely to have one on one time with your senior resident or faculty as you care for patients together.  If you are further along in your training,  the “down time” on call (if there is any!) is a great time to catch up on reading.

 

 

Organizing Notes in Medical School and Residency

Among my other educational roles, I have the real pleasure of teaching embryology for the Baylor College of Medicine MS1 class.  Recently, while visiting with students before a lecture, I happened to see a set of notes on several of the students’ laptops. They had the slides from my lecture with additional notes, all organized to study efficiently.  I asked them if they would mind sending me information so I could post it here since I thought this might be useful to other medical students.

The following is a guest blog from Samuel Buck and Sara Fish, both first year medical students at Baylor College of Medicine with assistance from Sam Rogers, an MS3.

There are several apps that make studying easier in medical school.  In retrospect it would have been great to know about this the first day of class, so I’m happy to share them now.  I use OneNote and EverNote but there are other apps I know other students use like Growly Notes. Here’s the key notetaking apps (and a few others):

One Note
OneNote – This is the program that I use for notes during class. Using OneNote, you can import entire power point presentations (even the notes at the bottom of each slide) into a single document and add your own notes and drawings as well. OneNote allows you to organize all the lecture materials and slides in one place.  Word documents, powerpoints, PDFs, images, and Excel sheets can be placed in tabs in your “notebook”.  From here, you can easily navigate, add your own notes and text, highlight, or draw on the slides.  I usually use the draw functions to add arrows to radiographic images or to circle important points on slides.  I usually organize my notes by subject but other students organize by date, with tabs for each block, each week within the block, and day of the week, and individual note pages for each lecture that day. Other students organize notes into separate digital “notebooks” by block or by course (i.e one for embryology, one for anatomy, etc)  The most convenient thing about OneNote is that all of your notes are synced to a Microsoft SkyDrive (their version of the iCloud) so that you can access your notes on the iPad and phone. If I’m studying and ever need to consult my notes from class, I can just take out my iPad or if I’m on the go, my phone and reference the lectures or notes in a really organized fashion.  Having OneNote on my iPad let’s me review notes when I am on the bus or in other situations where it’s hard to get your computer out.  This is one feature that Mac users with Growly Notes (basically the OneNote equivalent) do not have since there is no Growly Notes app for the iPad. One of the most useful tools in OneNote is the find function.  You can type in a keyword and OneNote will search your entire notebook and show you every instance when that word is used.  This is very helpful because a huge number of documents can be scanned at once.  Since many concepts in our classes overlap, it helps to make connections between subjects.  For instance, if something is mentioned in embryology and you feel like you have heard that word before, but you don’t know where, you can search it and find the lectures in which it was previously mentioned.

Here are links to additional “tutorials” on using OneNote in medical school from the University of Kansas and UT Health Science Center in San Antonio that will give you more details on using OneNote to organize your studying in medical school.

som.uthscsa.edu/StudentAffairs/documents/OneNote_Presentation.pdf

www.kumc.edu/Documents/…/kumc-onenote-instructions.pdf

One of the most useful tools in OneNote is the find function.  You can type in a keyword and OneNote will search your entire notebook and show you every instance when that word is used.  This is very helpful because a huge number of documents can be scanned at once.  Since many concepts in our classes overlap, it helps to make connections between subjects.  For instance, if something is mentioned in embryology and you feel like you have heard that word before, but you don’t know where, you can search it and find the lectures in which it was previously mentioned.

 

 evernote

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EverNote – Although there are some students who use Evernote to organize their notes in medical school, I found that format is not really conducive to good organization of notes. I do really like the mobile layout of the app and I use EverNote extensively for “every day” note taking. Grocery lists, work out programs, random ideas, to do lists, jotting down an email or name I want to remember. One thing I really like about EverNote is that when you make a note, it generates a time and location stamp for the notes.

 growly-notes

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Growly Notes – This is probably the most popular note taking program for our class because it is made for Apple computers. I personally don’t have any experience with it as a PC user, but it has a great organization format as far as I can tell.

dropbox

DropBox – Online file storage and sharing service that is very useful for sharing study materials between students. Our anatomy buddies group uses this extensively to share quizzes and study guides. It is a really great service, and DropBox will load thing directly to and from your personal DropBox, which is very convenient . One thing to remember is that it’s not HIPPA compliant, so if there is any patient information, it shouldn’t be put in DropBox

Google Drive – Not to be overlooked is the tried and true Google Documents. Whether it be study guides or notes, it’s hard to beat the convenience of Google Drive if your goal is mass editing and sharing. Sharing the link to your document is easy, and it can be set up so that anyone who views the document can also edit it. Just like DropBox, this isn’t HIPPA compliant, so don’t share patient information.

TurboScan – This is an app that takes pictures of documents and turns them into PDF files that you can email to people (or yourself) or upload to DropBox. I do this for all class handouts to have an immediate digital copy of any paper items we get in class or study groups. I can email files to myself and post them into my OneNote documents. I also use this app for personal finances. I take a picture of my receipts from grocery shopping and going out as well as my bills so that I can better budget myself and keep track of purchases.

 

How to Succeed in Residency: Studying

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

Tree-of-Learning

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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. Go 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 Spiderman on his face) put it on the card.  It’s how our brains remember.

One of the consequences of duty hour regulations is that any given resident today will see fewer patients than residents did 10 years ago.  I’m not at all against duty hour regulations (although I do think there might be some better ways to organize time for learning), but you have to take this reality into account.  You can never completely replace seeing patients, 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 a woman with a Morgagni hernia who presented with a complete right middle lobe compression and another case of an octogenarian who presented with life threatening vomiting.  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!

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 into your computer or put them in a binder.  Don’t put more than one topic per page, though, or you will have trouble organizing them.
  2. Use an iPad or other electronic device. 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 an iPad or other device, please let me know! (use the comments below).
  3. Use the computer.  We live on computers.  There’s no reason you couldn’t type 3 lines of what you learned and email it to yourself 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.  DropBox is not HIPAA compliant!  Don’t put any patient identifiers in the notes if you choose to use the cloud.
  4. Look for software, devices or storage that makes sense for you.  Here’s a place to start.

2.  Be comprehensive. 

Get a major textbook in your field and write down every topic it covers.  You’ll see patients with a majority of them in most training programs.  When you see the patient is the time to read the textbook.  Make it your goal to cover the textbook in a year.  Come up with a system to monitor your progress.

When you are sitting/walking/cycling as your study the textbook, make cards to review later.  These can be a little more complete, a little fancier and have more detail.  The idea here is to read each chapter once and make notes that are complete enough that you never have to go back.

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

high-tech-surgeon-copy

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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