I asked a simple question to my colleagues on Twitter yesterday.
Thanks to all my colleagues for their amazing responses! This list is almost the curriculum for a course on how to do well (and be well) as an intern.
Enjoy…and take notes!
I asked a simple question to my colleagues on Twitter yesterday.
Thanks to all my colleagues for their amazing responses! This list is almost the curriculum for a course on how to do well (and be well) as an intern.
Enjoy…and take notes!
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.
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
Yesterday was my first embryology lecture of the year to the new MS1s at Baylor College of Medicine, as well as the PA, DNP and Genetic Counseling students. For years, I’ve been including a few slides at the end of each lecture to help with the transition to medical school. Yesterday’s lecture ended with tips on how to study. I promised the students I’d share these slides in a written formate. I realized sharing them here might be the most appropriate way to do that!
Medical school (or any high volume graduate school) involves a dramatic change from what students have previously experienced. As you know, if you read this blog, I believe there are a lot of “tools” that can help students “thrive, not just survive”
The biggest change for many students is it really isn’t about the grades anymore. It’s about studying for the patients you will be caring for in the future. That means really learning the material, not just knowing it for a test.
Even though there is still a lot unknown about how the brain works to learn material, what is certain is that it is a physical process. You create new synapses when you experience or learn new things. As they are repeated, these synapses get stronger and stronger.
So, to organize the advice, I’ll share some basics, some specifics and then a little refinement.
Learning this volume of material at this level of complexity is about consistency. You can’t run a marathon by running 20 miles every weekend. This is no different. You need to study every day (except one). One of our great teachers at Baylor, Dr. Clay Goodman, tells our students that they have signed on for a 60 hour a week job. (which roughly means 1-2 hours of studying for every hour in the classroom). If you map out your week as a 60 hour job, it will work a lot better than ever trying to “catch up.”
The SQ3R system is the best system I know to learn what you need to know during the basic sciences. So, how do you translate the SQ3R system into practice?
The night before lectures, spend 30-40 minutes skimming the lectures. No “studying”. Be curious. What questions are going to be answered during the lecture? How is it organized? (BTW “Mike” is a fictitious patient with muscular dystrophy that Dr. Goodman uses in an introductory lecture to show how everything you learn in medical school matters – from the DNA to the psychosocial context of the family)
This 30-40 minutes is basically the “S” and “Q” of the SQR3 system.
During the lecture stay ACTIVE. Don’t sit in the back row and look at FaceBook – even if the professor is reading the slides.* You’ll need to take notes for this to be really active. Put the questions you want answered on an outline you prepare the night before lecture and fill it in during the lecture. Use mind maps or other powerful visual aids to learn. Click here to get to my post on taking notes during basic sciences.
*(If you are a lecturer who does this, stop it! – otherwise you are guilty of “death by PowerPoint.” Find someone who is a good lecturer and ask them to coach you.)
After the lecture, you move on to the 3Rs. Now you get down to the real studying. Read through the printed notes (or slides). Did everything get answered? MAKE NOTES that synthesize what you learned.
Review. Review. Review. Here’s the deal. Medical school is a lot like learning a new language. The first part of basic sciences (anatomy, physiology, embryology, etc) is learning the vocabulary. The second part of basic sciences (diseases, pharmacology, etc) is learning the grammar. When you get to the clinics, you are practicing the language until you are fluent. “Flash cards” such as Anki are great at learning “vocabulary”. They are terrible at synthesizing and learning connections and concepts. That’s why you need a single page summary of every lecture. The summary is the “forest”, your notes (plus or minus flash cards) are the “trees”. If you really want to succeed, you need both. BTW, I made the class repeat (out loud) after me (twice) – “You cannot learn medicine from Anki alone.” (It’s on tape. I really did this.)
Here’s an example of a single page summary of the embryology lecture I gave the class yesterday. I spent time to make this really look nice – more time than you will want to spend. It doesn’t need to be typed, it doesn’t need to be particularly legible to anyone but you, but take the time to do these summaries!
Did I already mention that you need to review?
This is probably the single most important slide I show when explaining how to best study in medical school. It’s the basis of many apps in medical learning, including the NEJM Knowledge+ courses. There are two really important points in this graph. First, it takes at least 5 repetitions to really learn something. Second, they have to be spread out in a logarithmic fashion over time.
Here’s how to do it. The first three repetitions should be same day, next day and 2-3 days later. The more times you review it, the better, but it should at least be 1 week later and 3 weeks later. More is better. Plan another review a month later and three months later, too. For the Type A folks in medical school (i.e. all of you), make a spread sheet!
Another thing about our brains and learning. Pushing through for hours without rest is as stupid as thinking you can build up your biceps by doing an hour of uninterrupted reps. Speaking of reps… use “study reps”. Get an app if you think it will help. 50 minutes of studying.
Stop studying for 10 minutes (no matter how engrossed you are) when the alarm goes. Repeat.
People sitting next to you in your study areas are going to look like they have it more together than you do. It might be true… but it probably isn’t. If someone has a study technique that looks like it will work for you, by all means try it! Just don’t change too often. I was a liberal arts major in college. If you come from a non-science background, the first 6 months are going to be a little tougher on you because you have more “vocabulary” to learn but don’t worry, after that you’ll be caught up,
Read this slide. Believe this slide. The most important point on this slide is the last line. You cannot make those physical synapses you need to really learn without 8 hours of sleep.
Keep notes about what works for you and what doesn’t. Everyone is a little different, but you will find a system that works best for you through conscious effort.
It’s like running. Some of this is just “time on feet”. Remember the 60 hours a week job concept and you’ll do fine.
I end with this slide to remind my students that there has to be balance for this to work. Most of what I tell my students about finding and keeping that balance is in this blog, so feel free to use the word cloud to the right or search for what you might need. Please contact me if you have a specific question I can answer or if you have an idea for a new blog post.
Welcome to the best career in the world! We are all happy you are here!
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…
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
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.
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:
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?
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.
Everyone hates exams. Most of us hate regulations. But, exams and regulations in medicine came about because of abuses in the past that led to the public distrusting doctors. It’s a fascinating, and somewhat terrifying history that starts with changing “medical schools” from for profit (and horrible!) businesses into what we know today. As general doctors started doing ophthalmology, surgery, or obstetrics full time, it was became clear that defining what constituted a specialty, and demonstrating that practitioners were competent was important.
What does it mean to be “board certified”?
Being “board certified” means that one of the 24 specialty boards in the United States attests that you have met all the requirements and have passed rigorous exams to show that you are qualified to practice in that specialty.
Does the board certification last forever?
Short answer, no. Family Medicine was the first specialty (in 1970) to realize that initial certification was not enough. As the public continued to ask for evidence that physicians remained up to date, Surgery (1976), Emergency Medicine (1980) and Ob/Gyn (1986) added a recertification examination. As of 1990, the remaining boards became “time-limited” which means board certification expires after 6-10 years, unless physicians take and pass the recertification examination. So, many internists who are now in their 60s and 70s didn’t have to do anything other than pass the initial examinations. (This is referred to as being “grandfathered”).
Who makes up “the board” for the specialties?
The members of most boards are volunteer physicians in the specialty. In surgery, which I know the best, the board members are called “directors”. There are 41 directors of the American Board of Surgery who represent a variety of organizations and specialties in surgery. These volunteer surgeons spend 20+ days a year away from their practices with no pay (although their expenses are paid) to give the oral examinations in surgery, and to design and validate the written examinations. They also have a variety of committees and projects which focused on one critical question: “What do we need to do to make sure we maintain the public trust in surgeons?”
How do the specialty boards decide if specialists are up to date?
Since 1990, boards have to be “maintained”. If you don’t maintain your board, you lose it. Hence the term, Maintenance of Certification (MOC). So what do you have to do for “MOC”? In addition to having a license, most boards have requirements to document hospital privileges and provide letters of reference. Here’s a summary of the other requirements for four of the largest boards:
|Continuing Medical Education (CME)||Recertification examination||Practice Assessment||Cost|
|Internal Medicine||Must do some CME every 2 years.
Must get 100 MOC points every 5 yrs. (roughly 20-25 hrs/yr)
|Recertification examination every 10 years (counts as 20 hrs MOC points)||Nothing required.
Can earn MOC points by QI or by teaching.
|$1940 ($194/yr) for General Medicine.
$2560 ($256/yr) for specialties.
|Ob/Gyn||Read at least 30 of the 45 articles provided by the board annually and answer four questions/article (=25hrs CME credit)||Exam every 6 years but may be exempt if excellence demonstrated by answers to articles. (pilot program)||Completion of ABOG practice improvement modules
Additional fee of $175 if exam is required.
|Pediatrics||100 MOC points/5yrs. At least 40 in CME, 40 in practice assessment
“Question of the week” delivered by email. 20 questions = 10 MOC pts.
|Recertification examination every 10 years (counts as 60 hrs of CME)||Institutional or practice QI projects||$1300/5yrs ($260/yr)|
|Surgery||90 hrs in 3 yrs. (30 hrs/yr) of CME (lectures or online)
60 hrs (20/yr) have to be Level 1(test questions involved)
|Recertification examination every 10 years (counts as 60 hrs of CME)||Participation in an outcome or quality improvement program||$1600 ($160/yr)|
What happens if doctors decide to not do MOC?
Being board certified is voluntary and so is maintaining a board. But, if doctors choose not to do MOC, they will lose their board certification.
Here’s some of the possible implications if a doctor loses board certification:
My bottom line on MOC
Since the new MOC requirements went into place I have increased both the quantity and quality of the materials I use to stay up to date, which I strongly feel has made me a better surgeon. I still don’t like taking exams, but every time I do (I have three boards, so I take a lot of them!) I learn so much that I find the experience invaluable. (Yes, that’s after the exam, not before or during… that hasn’t changed since medical school.)
MOC isn’t perfect, but it’s evolving, and the reason it exists is a good one. Passing laws state by state to make MOC “optional” has the risk of hurting the public’s trust in physicians – and the risk of creating quite a bit of chaos for hospitals, training programs, and others. For what? Saving $200 a year? Not having to take the test every 10 years? Not having to log the CME that is required by almost all state medical boards?
“Here’s what’s at stake: we physicians are granted an extraordinary amount of autonomy by the public and the government. We ask people to disrobe in our presence; we prescribe medications that can kill; we perform procedures that would be labeled as assault if done by the non-credentialed. If we prove ourselves incapable of self-governance, we are violating this trust, and society will – and should – step into the breach with standards and regulations that will be more onerous, more politically driven, and less informed by science. That is the road we may be headed down. It is why this fight matters.” Robert Wachter, MD
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:
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.
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….
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.
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.
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:
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
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.
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!
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.
What should an ideal system let you do?
What “notes” should you use to study?
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:
Other advantages to using Evernote
What should I do before I set up this system?
A few other words of advice
“Do what you love to do, and do it with both seriousness and lightness.”*
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.”
“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.
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.
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.
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.”
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.
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.
*Italics are quotes from Big Magic: Creative Living Beyond Fear. Since I read this on my Kindle, I don’t have page numbers!
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.
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.
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.
So, what should you do the first day of medical school?
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!