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:

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):


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.

 

 

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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.

 

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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 – 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

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

The challenge is organizing what you learn.

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

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

1.  Record what you learn as you learn it. 

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

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

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

2.  Be comprehensive. 

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

Alternates to the 3×5 card system

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

3.  Stay curious.

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

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

William Osler

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3.  Repeat. Repeat. Repeat.

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

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“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” William Osler

Starting Internship (I know what you are worried about)

I sat at the table this week with our new interns and the outgoing chief residents. Listening to our new interns as they asked questions, I realized everyone starting their internship has the same fears, whether or not they express them:  Will I kill or hurt someone?  Will I look stupid?  What if they find out I’m not as smart as everyone else?  Will I get divorced/separated/alienated from my friends?  Will I gain weight?  How am I going to find time to take care of myself?

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What you are feeling is normal. Every doctor who ever started an internship felt exactly the same way.  The best way to manage your (healthy) fear is to have a strategy.   I’ve written in the past about how to succeed as an intern.  But if I were going to condense that advice into three easy rules (for every day except your day off)  it would be these:

1.    Read at least one section from a textbook in your field every day

2.    Learn something (in detail) from at least one patient every day

3.    Do something to take care of yourself every day

 

Read at least one section from a textbook in your field every day.

Your goal for the year should be to read a major textbook in your field cover to cover.  You don’t have to buy the physical book.  It’s fine if it’s on line or downloaded onto your iPad.

Once you have the book, make a list or spreadsheet of all the sections in all the chapters.  For most textbooks, it’s probably going to be a list somewhere between 150 and 200 topics.  When you look at the 48-50 weeks you will be working this year, it works out to basically a topic a day (with some days for review).

The real goal is not just to read these topics, but to really learn them.  So, when you read, don’t just skim.  Read to learn.  That means taking notes – and reviewing them.

Put a chart on the wall with the list and give yourself a gold star when you finish a topic if you have to, but find a way to make sure you cover all the topics (at a steady pace) during the year.

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Learn something (in detail) from at least one patient every day.

It’s really easy, as an intern, to get caught up in the work and forget that you are fundamentally here to learn – not to provide service.  Make it a daily habit to learn in detail about one patient in your care.  It will overlap nicely with your goal to read a complete textbook.  When you admit a patient with pneumonia, read the section (and make notes) on pneumonia and then check it off your list.

One other important point (that none of us like to hear) – You will make mistakes. Be humble, be honest, and learn from your mistakes. The mistakes you make (and maybe more importantly your “near misses”) are absolutely your most valuable teacher.  When you do make a mistake, use it as the topic you will review for the day. You are going to be really upset but be easy on yourself.  Being upset is the mark of someone who cares, but don’t let it escalate beyond a healthy response. Talk to your mentors and senior residents.  They’ve been there.

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Do at least one thing to take care of yourself every day.

This may sound trivial, but it’s not. If you can, try to eat well, get some exercise and be social every day.  At a minimum, though, pick one specific thing you are going to do for yourself and then do it.

Eat well

Get Some Exercise

Be social

Getting Ready to Start Medical School

This morning we had a group of medical school applicants at Baylor for a “second look”. They asked some very good questions including the question that prompted me to write this post:

“What should I do to get ready to start medical school?

Set up your environment

The amount of material you will be asked to master in your first year of medical school is more than you’ve ever been asked to master before.  You have to approach it with a different strategy than you used in college.  One critical component of this strategy will be to keep up with the material – starting from the first day.

If you try to hook up your cable, organize your electricity and straighten out parking at your apartment during the first week, you will fall behind.  Take the time to come explore your new environment and get settled in at least a week before classes start.  A week doesn’t sound like much to miss, but it’s a significant amount of information in medical school! One of the important tasks to check off the list during the week you are settling in is to set up your study area.  Make sure you have a computer that will meet your needs and an area to study that is pleasant, ergonomic and comfortable.  Most students find a dual screen to be very helpful as you are moving through notes and slides to study.

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You’ll be spending 1-2 hours studying (at a minimum) for every hour of class.  Given the number of hours you’ll spend studying, you might want to think about an “active” desk that lets you stand, walk or pedal as you study.

Develop (or strengthen) an exercise habit

Use this summer to develop a daily exercise routine that you can take into your new (and crazy) schedule.  Your goal for the summer should be to develop a balanced exercise program (cardio, strength training and flexibility) that works for you.  If you’ve never done any strength training, hire a trainer and learn about it. If you develop a balanced exercise routine this summer, it will be much, much easier to continue this once you start medical school or your internship. Commit to doing at least 30 minutes of exercise a day this summer and it will be a lot easier to continue once the pressure of school really kicks in.

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Running is one of the best (and most convenient) cardio exercises for medical students and residents (because it’s cheap, efficient and effective)  Use this summer to become a runner. If you hate running, find another good cardio exercise habit to develop instead – but pick one!

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If you don’t own a bicycle, think about getting one.  There will be places to ride for fun when you have time off.  You can also use your bike to commute to school which is a great way to sneak in exercise and save money.

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If you don’t know how to cook, learn.

Good nutrition is an important part of doing well academically.  It’s hard to concentrate and learn if you are eating junk. There is one simple trick to eat well during medical school: Learn to cook.  This is a skill that will become progressively more important as you enter your clinical work in medical school and then move on to your residency training.

Learn some basic skills to cook simple things.  If you have good cooks in your family, have them teach you.  If you don’t have family members who can teach you, find cooking classes near you and sign up.  Many high end grocery stores and gourmet stores offer classes for beginners – look on line for classes near you.

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Come to medical school rested.

Do not study. Seriously.  We will give you what you need and nothing you can do this summer will make it any easier.  It’s far more important to arrive rested and ready to go than to try to learn material that may or may not be relevant. Take a real vacation (or two). Visit family and friends – take a road trip and connect with people you haven’t seen in a while  Hang out on a beach, go for some great hikes, read some great novels.  Sleep in late, eat well, and just rest!

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Studying For the USMLE Step 1 Exam

The USMLE Step exams are important.  Even though they weren’t designed for this, many residency programs use these scores (especially Step 1) to decide who to interview for the NRMP match.  By far and away the best way to decrease the stress associated with this exam is to be prepared when you take it.

The best way to study for Step 1 is to start the process early.  As soon as you can (now, if you are in the first year!) look at examples of Step 1 questions.  This will give you an idea what to expect and will guide you in how to organize your studying.  The strategy for Step 2 will be similar.   Do this systematically – keep notes on your computer or in a notebook, or use the 3×5 card technique to make cards to organize and review later.  Whatever system you choose to use, be consistent.  You really can’t “cram” for the Step exams – it has to be a review.

In addition to developing a systematic approach to preparing for Step 1, it’s a good idea to spend dedicated time reviewing for the exam.  If your schedule allows, taking a full month or two to prepare for this exam is probably a good idea.  If it doesn’t, spread it out over more time, but devote the same amount of time.

The following recommendations are from two 4th year students on how to review for Step 1.   Use specific ideas that fit you, leave the ones that don’t.  There are many ways to succeed and not all of these recommendations will apply to you.

  • First week: Read quickly through First Aid cover-to-cover
    • This reminds your brain of everything you’ve ever studied and gives you the book’s lay-out
    • Read complicated or new information out loud
    • By reading out loud or skimming/reading quickly, it should take  about 6 days
  • Second week: Start UWorld as arranged in First AID
    • 46 “randomized” questions per set (2 methods of organization below)
      • Choose the organ system on the right hand side of the menu screen but not any subset groupings;
      • Alternatively, do biochem, behavioral science, and micro questions separately (everything for which there is a section in FA)
        • Then move onto organ system and the associated anatomy/physiology/ path/pathophys
  • Don’t worry about time at first, but ultimately you should be well under an hour/block
    • Practice good test-taking strategies
    • Read the last line of the question, skim the answer choices, read the full question for necessary buzzwords/data
    • No phone/gmail/chatting etc. during this time (it’s your “exam” time)
  • Take a 10 min break after answering all 46 questions
    • Do all the activities you put off – check your texts/email, go to the bathroom, read ESPN/NPR per preference, etc.
  • Review the answers from the 46 q block
    • Keep the 45-50 min “ON” study time (no distractions! No phone/email!) & 10-15 min “OFF” (see above)
  • Look up anything you don’t know / can’t explain to yourself
    • Make sure you really understand the explanation, but don’t get bogged down
    • Annotate any crucial information into First AID, using First AID as your primary textbook & notebook
  • Repeat above cycle until you have completed all q blocks for that organ system
  • Review associated First AID chapter (cardio, GI, etc)
    • Go over your freshly annotated chapter by yourself or with a study partner
      • “I sat down with my BFF and we took turns explaining each page & our annotations, covering details the other might have missed and adding mnemonics/stories.”
      • Review related annotations from other sections (micro/biochem/BS, etc)
      • Optional: listen to the related Goljan section while driving/exercising/etc
  • Repeat: Q-Block –> Review –> Annotate –> Q-block…etc… until you have completed all organ systems
  • Arrange some question blocks by topic (biochem/micro/etc)
    • You will already have completed all of these questions, but it is easier to review the First AID chapters for biochem/micro/BS if you take a couple question blocks to focus your mind
    • If you are consistently performing poorly on a non-organ based section, you can always interrupt your “organ based learning” and focus on your weak area for a couple of days using the above format (qs, review, annotate)
    • Identify weak areas based on score data & personal comfort
      • Retake question blocks, answers & related First AID chapter
  • If you have time during the last 2 weeks, as you go through First AID and your annotations in FA, write down everything you don’t know (don’t get stressed out if you end up writing a lot of stuff down…I think I had 1-2 pages handwritten front and back per section at this point). Then study only your notes and stop looking at First AID. The rationale behind this is that you don’t want to spend too much time rereading the stuff that you are 100% sure you know at a time when you should be focusing on what you don’t know. Note: you may need to start this while you’re still going through UWorld questions, but I think it’s worth your time.
  • Last Week:
    • Review First AID from start to finish with emphasis on weaker areas
    • Continue with random blocks of questions or NBME purchase exams to keep in “practice question shape”
  • Last couple days
    • 2-3 days before:  review behavioral sciences, write down any formulas for memorization, cram “regurg” factoids/formulas/graphs, cram the things in your notes that you still don’t know
    • Day before: NOTHING
      •  Hang out, relax, distract yourself, go to a movie…
      • You’re not going to change your score for the better by studying/stressing now (but it might make you fatigued the next day)
      • Pack your bag with all your documents, directions, First AID, notes for the next day (& lots of food) so you don’t have to worry in the morning
      • Try to sleep (you’ll be nervous but do your best!)

       

PRACTICE EXAMS

  • There are many opinions on how to best use practice exams.  The timing of them is as much an emotional consideration as a fact-based or practice based benefit.  Here’s one way to organize the practice exams that has worked for some students:
  • 2-3 Weeks into studying: Free NBME practice exam
    • Get a sense if you are on track, this score will underestimate you’re final score
      • If close to your goal, the score can be reassuring that you should keep doing what you’re doing
      • If significantly lower, the score can be motivation to pick up the pace/cut out distractions

       

  • 1 week before the exam: 2x 4 block UWorld practice exams
    • I took all 8 blocks back-to-back to simulate the exam experience (timing of breaks, fatigue, etc)
    • Do NOT review the answers on the same day, in fact, you should probably take most of the next day off to recover
    • Use the results as a comfort that you are on track (my actual score was 1 pt off my practice exams —- and despite fatigue & feeling like my second block of 4 was worse, I actually got identical scores throughout)
    • Look at the stats and focus on any weaker areas (my weakest areas became my strongest by the actual exam)

     

  • Last week: fee based NBME Exams
    • I paid for NBME 7, which tells you your estimated score, your percentile in each area, and reproduces the questions you answered incorrectly (but does not give you the correct answer) – again, within 1-2 pts of my final score
    • I worked through many of the exams (some easier, some harder than the my step) during the last week as a way to practice the random mix of qs….I found it helpful
    • Some of the questions on the NBME practice exams were on my REAL Step exam

 

BALANCE!   You’re job is study and do well on this exam —- but it can be very stressful, even just on a subconscious level.  For most people it works better to really structure your time.

Keep work hours:  go to a library/coffee shop/school on a regular schedule

  • 8 am – 5 pm (5/7/8 pm…whatever you decide)
  • Taken an hour off for lunch & hang out with friends
  • Go home & be DONE until the next day (get good food & sleep!)
  • Keep a life
    • Partner, work-outs, family, etc. should be in your life every day
    • Take at least one day off a week at the beginning

 

RESOURCES

  • First AID & UWorld: you must use & love these, everything else is just bonus
  • Others (Wiki, BRS, textbooks, Goljan, etc.)
    • Resources other than FA and Uworld will not help your score significantly.
    • Use them to explain specific questions or concepts from UWORLD or FA that you don’t understand or can’t remember
    • Use them if for some reason you have a ton of extra time and already know FA and Uworld like the back of your hand
    • If you choose to use external resources, BRS physiology and the first part of Goljan Rapid Review Path (through the neoplasia chapter) might be worth your while, but seriously don’t worry if you don’t have time to get to them.

 

Traci Fraser and Natalie Gwilliam, Class of 2012, Baylor College of Medicine


The Best of Wellness Rounds 2011

HAPPY NEW YEAR TO EVERYONE!

Advice for interns

Why I hardly ever drink diet drinks

How to choose your specialty

What to do on your day off

Studying basic sciences – strategies for success

Studying clinical medicine

Getting (and staying) motivated to exercise

How to succeed on clinical rotations

Gifts for medical students and residents

Why I’m spending more time on Twitter

How not to have sore feet after a day in the hospital

How to Succeed in Clinical Rotations

Next week will be the start of clinical rotations for students at Baylor College of Medicine.  It’s an exciting time, but a big transition!  After seeing this a few times, I thought the following advice on how to approach clinical rotations might help.

 

Don’t sit in the back of the plane.

The basic sciences are important to learn the vocabulary and grammar of medicine.  Clinical rotations are different – it’s where you learn to speak the language.  There are tricks for learning clinical medicine but fundamentally it’s about realizing you are still in school and not just observing.

If you use the analogy of learning to fly, there’s a simple concept that summarizes learning on the wards: You cannot learn to fly a plane by sitting in the back.  In basic sciences you are studying the book on how to fly the plane.  In your clinical rotations you are in the plane, watching and learning from the pilot.  Which means you have to be in the cockpit.

In every situation you encounter in the hospital, imagine that you are “flying the plane.”  When the resident starts to write the admission orders say “Do you mind if I write them and you show me how?”  On your surgery rotation, get to the holding area early and ask the anesthesia resident if he/she will explain how to intubate, show you how to intubate, or even let you try.  When you are writing an admission H&P on a baby in the ER, imagine you are the only doctor who will be seeing that patient.  Let the adrenaline of that thought guide you to the computer to look up more about the condition, how to treat it and what you would do if you were the only person making the decisions.

Yes, you need to be pushy and, yes, sometimes it will backfire.  Be reasonable, but stay engaged. If it’s not an appropriate time to be assertive, stay in the game mentally by asking yourself what they will do next, what you would do if you were making the decisions, or what complication might occur from the decisions being made.  Write down questions you will ask after the smoke clears if it’s not appropriate to ask during a stressful situation.

 

Know what you are expected to learn before you start.

If learning objectives for the rotation are done well, they are very helpful, but many people don’t take the time to do them well (or don’t know how to do them).  For the rest of your professional life, you are going to have to define your own learning objectives.  So, in a way, learning how to do this early – during your core rotations – is also part of the skill set you need to know.  (Word of advice, though – even if they are very poorly written, you need to read any objectives you are given and make sure you accomplish them.)

To define your learning objectives for the rotation, start with a basic textbook.  Textbooks are written for residents and practicing physicians so don’t get overwhelmed – You will NOT be responsible for learning all the details in the textbook!

The strategy:

1.     Make a list of the topics covered in a general textbook for the field.  There are usually 2-3 good textbooks for every specialty.  Ask other students or residents which one(s) they recommend.  You will probably rotate on sub-specialty services during your core rotation, but don’t get bogged down in looking in sub-specialty textbooks.  Stay with the general textbook.

2.     Plan to skim and make notes on every major topic.  These should be “big picture” notes, not every detail.  If there are 60 chapters in the book and your rotation is 2 months long, you should be shooting for one chapter a day.  Keep track and make sure you get them all covered during the rotation (not after).  When you are done with the rotation, these notes should be all you will need to review for the shelf exam. These notes will also be incredibly helpful when you are studying for your Step 2 exam.

3.     Don’t read the chapters in order – read them as you see patients (see below). But, make sure that all the chapters are covered since it’s unlikely you will see patients with every disease in the book.

 

Practice being professional.

It’s really important to be professional and to be seen as professional in all your interactions.  First of all, it’s the right thing to do.  Secondly, a bad interaction with a nurse on the floor can lead to a poor evaluation by your attending.  Make learning how to behave as a professional one of your learning objectives.  Learn from those around you.  Which residents and attendings are the most professional?  Why?  When you see bad behavior (and you will), think about it – what would you have done differently?

 

Learn from every single patient you see.

Use every patient to learn about their specific disease.  Even if it’s the 30th patient with hypertenion you’ve seen you’ll still learn something new.  (or use it to learn about a different problem they have instead)

The strategy:

1.     Keep a notebook with an entry for every patient you see.  You can use 3×5 cards, if you prefer.  In fact, many hospitals have 3×5 cards with the patient info available in the patient’s chart for docs to take. (don’t lose them or leave them lying around though – which is a violation of HIPPA!)

2.     Make yourself read something about every patient you see.  If you haven’t read the textbook chapter on the subject, that’s where you start.  If you have read the textbook, review your notes and read something new (UpToDate, PubMed, or a journal article for example)

3.     Make yourself write down a minimum of 3 things you learned from the patient in your notebook (or on your 3×5 card).

 

Be the doctor for patients that are assigned to you.

You will be assigned patients to follow during your rotations.  When this happens, make up your mind that you are going to “wear the white coat”.   What if you were the only doctor taking care of Mr. Smith after his surgery?  In addition to reading (see above), ask the residents to help you write all the orders.  Write a daily note and make sure your notes are at the level of the residents (ask them to review and critique your notes).  When a drug is prescribed, know the dose you are giving, the effects of the drug and the potential side effects.  When a x-ray is ordered, be the first person to actually see the image and know the result (and make sure you call the resident as soon as you do!).  Don’t get any information second hand – make sure you see the results and the images yourself.  At any point in time, if the attending asks, you should be able to present your patient as though you are his/her only doctor, which means how they presented, their past history, social issues, test results, procedures performed and how they are doing now.

 

Prepare for conferences.

Every service has at least one or two weekly teaching conferences.  In most cases, the topic (or cases) are known before the conference.  Ask your residents or attendings the day before the conference for the topics and/or cases that are going to be discussed.  Use the strategy outlined above to prepare e.g. consider these “vicarious” patients and learn from them as if they were a patient assigned to you.

 

Come early, stay late and keep moving.

Taking care of patients in the hospital is a team sport.  The best medical students become part of the team early and are taught more just because of the relationships that are developed.  It’s human nature and it’s just the way it works.  Don’t brown nose, don’t show off…. just show up.   If there are labs to look up before morning rounds, be there 10 minutes early and look them up for the residents. If you don’t know the answer to a question the best response is “I don’t know, but I’ll find out!” If there is scut work to be done that you can help with, volunteer to help before you go home. Trying to show off on rounds will backfire. It’s particularly important not to try to one-up your residents.  You will have more time to read than the residents, so you may actually know more than they do about a specific topic.  But, if the attending asks a question and the resident gets it wrong, don’t correct them in front of the attending.  (Unless it’s a critical issue and you think the patient might suffer in which case you have to speak up!)  Whenever you can, set up the resident to succeed.  “A rising tide floats all boats” – if you help them look good, you will look good and the team will look good. Take breaks when you are tired but don’t sit in the lounge waiting for someone to come tell you what to do.  There are patients to see, conferences to attend, rounds to do, labs to look up… the hospital never sleeps!

 

Practice having a balanced life.

Compassion fatigue is a constant threat to practicing physicians.  Taking care of yourself, staying connected to family, friends and the outside work are all critical components of preventing compassion fatigue.  This, too, is a skill you need to learn during your rotations so you can carry it with you into your residency and your practice.  Use this time to develop strategies for how you will eat a healthy diet, including when you are on call, and find time to develop an exercise habit.

 

Wear the Right Shoes

Dressing correctly is part of professionalism, but shoes deserve a special note of their own.  The hospital is not a place to worry about how your feet look.  At the end of a long day, you’ll appreciate picking the right shoes to wear in the hospital.

 

Enjoy!  You are finally a “real” doctor!’’

Your experiences on your clinical rotations will be among the most special of your life. Buy a new journal and take time to jot down the funny and not-so funny occurrences of daily life in the hospital.  You will see some extraordinarily beautiful moments of human life. and some horrendous examples of what people can do to other people. We all learn to deal with these extremes by telling stories.  Make sure you find the right people and the right setting, but realize that this is an important way to cope with the transition you are making.

It’s a special world you are entering.   You’ll want to remember it by taking notes, recording stories and with pictures of your team and unique sights around the hospital. (No patients, though – remember HIPPA!)  Don’t forget to record your “firsts”… the first time you set a fracture or hear a murmur of aortic stenosis will be the only “first time” you have.

Congratulations! You are well on your way to the privilege and joy of practicing medicine. Enjoy the journey!

 

Starting Medical School: Strategies for Studying

Today is the first day of medical school at Baylor College of Medicine!  Welcome to our students, and to new medical students starting at other schools in the United States (and the world!).  The following is a guide on how to study for new medical students written by senior medical students and faculty for our Transition to Medical School course.  I thought it was exceptional – and worth sharing.

Your goals

  1. Learn material for long term retention
  2. Pass exams
  3. Develop skills for lifelong education & studying (nope, it never stops but it can get faster!)

1. The Basics

  • No magic formula for studying except for diligence and consistency
  • Goal is to learn and apply pertinent material – NOT perfection
  • Efficiency is a skill developed through practice, persistence, and reflection – not the result of drinking more caffeine or a genetic trait that skipped your generation
  • Studying is not a competitive sport – some student take (much) less time to learn than you will, but some take (much) MORE time than you…that’s life! Good news – in the end, we are all doctors.
  • Be gracious.  To yourself and your peers as you pass through the basic science crucible that brings out some less than pleasant coping mechanisms.  It’s normal and will pass.
  • You will succeed!  Don’t believe us some days?  Ask any of the thousands of physicians, professors and mentors around you – we’ll be glad to remind you!

2. The Specifics

  • Choose one way to study and stick with it for at at least 1 week
    • Switching study methods costs more time than it saves and there is a learning curve to all of them
  • Start with the first lecture and go sequentially to be sure you don’t miss topics
  • For all study techniques
    • Study reps: 45-50 min “on”, 10-15 min “off” (see below)
    • Skim before lecture (assigned readings, ppts, syllabus, etc)
      • SKIM to familiarize yourself with how to spell new words and the general outline/concept of the lecture – this is not learning time
    • Attend > stream lecture and actively listen by taking notes, drawing pics, writing qs, etc.
    • Take a lunch break after lectures to get good nutrition, socialization and to recharge
  • Techniques for LEARNING
    • Mind maps
    • Review notes with ppts, syllabi and text book and create a condensed 1 page review
    • Rewatch the lecture while condensing notes and focusing on main points
    • Flash cards of high yield material
    • Single page flow chart of material
  • Techniques for REVIEW
    • Practice questions (online, review BRS books)
    • Small group discussion, lecture by lecture (max 4 ppl)
    • Small group quizzing of lecture material
    • Peer or upperclassman tutoring

Study Reps: 45-50 min “on”, 10-15 min “off”

  • “ON”
    • Close email, g-chat, FB, other distractions, put phone on vibrate/silent
    • Set an alarm and STOP studying when it goes off
    • Write down other tasks that come to mind on a sticky note but do NOT stop studying to do them (ex: reply to email, wash dishes, make a snack, look-up question from another lecture, chat with nearby friends, etc.)
      • These tasks can be done during your “off” period
      • You will be amazed at what distracts you and feels “urgent” while studying, but there is almost NOTHING that can’t be put off for <45 min, including perez hilton
    • Don’t be frustrated if the first 15-20 min (or more) feel “wasted” bc you can’t focus – this is NORMAL and the time from sitting to focused productivity will decrease as you adjust to a daily routine (the same as exercising)
  • “OFF”
    • Set an alarm
    • Reward time! NO STUDY RELATED ACTIVITIES!
    • Grab a snack, read a NYT article, catch up on the FB developments (OMG, so much happened in 45 min!!!), chat with a friend, send off a quick email, check off the list you made during  your “ON” period
    • Get up and stretch, walk around for a couple min – it’ll wake you up, get you out of your “study zone” (wherever  you are working)
    • Congratulate yourself on sticking to your study schedule and breaks
    • Relax and don’t worry about how much time you have/not spent studying, let the alarm clock guide you rather than checking your watch constantly

3. The Refinement

  • What works for others may or may not work for you – don’t be discouraged!
  • Study methods evolve as you discover what sticks best in your own head
  • New topics/blocks may require different approaches
  • At the end of the week or block, reflect on what worked well (timing, setting, method)
    • Adjust study methods to what works best for you – but remember, DILIGENCE and CONSISTENCY are king & queen
  • Exam results not reflective of your efforts?  Ask for help! Professors, upperclassmen, mentors and strong peers can enhance your study skills.
  • STUDYING is STUDYING – it is never wasted.

4. The Balance

  • All work and no play makes a miserable and burned out student, resident and physician
  • Set aside at least 1 hour as sacred for meeting your personal needs (NOT chores)
    • Examples: exercise, cooking a nice meal, calling friends and family, reading a great book, prayer or meditation
  • Sleep on a schedule: go to bed and get 7-9 hrs of sleep every night, your brain needs that time to literally build memory
  • Eat well: again, your brain and body need good protein to build synapses for memory, carbohydrates for fuel to burn while studying, and plenty of water to keep you going in the Houston heat
  • Break up your week: take Sat. afternoon/evening off for fun activities with friends/family (movies, restaurants, dancing, bars, parties…), sleep in Sunday morning and have time for yourself and your personal development (reading, writing/journaling, church, chats with significant other)
  • Schedule it: if we write it, we do it.  Use your gmail calendar, phone app, planner, etc. and plot out your week including your studying, exercise, family/friends and other activities.  It will give you a sense of control over your life as you plan your days, rather than your days ruling you.

5. The Non-Science Major

  • You’re not alone – great physicians come from a variety of backgrounds!
  • You may play catch-up at first, but you undoubtedly can succeed
  • Writing and theoretical dissection of literature/theory/philosophy/art will be applicable in medicine – but basic sciences throws you back to the forgotten days of multiple choice exams and memorization.  Dusting off those skills and learning to study for regurgitation/application rather than creation may take some time, so don’t despair if you are spending longer in the library than the Bio-E major.
  • Link up with a science-major classmate who is good at identifying high-yield material AND explaining it.
  • Contact the upperclassmen study tutors – many of us had limited science exposure starting med school (“Wait, is it 2 livers or 2 kidneys – I’m not really sure?” – General Surgery Bound MS 4) and more than succeeded — but we’d love to make that transition easier for you!