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

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

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Be mindful, deliberate and excited about learning.

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

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

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

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

 

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

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

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

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Develop a system for lifelong learning now

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

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

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

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Take care of yourself.

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

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

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

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

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How To Study in Medical School

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

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

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

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What should an ideal system let you do?

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

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What “notes” should you use to study?

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

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How should you organize your notes?

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

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

 

Other advantages to using Evernote

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

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What should I do before I set up this system?

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

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A few other words of advice

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

What Big Magic Can Teach Those Who Serve

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

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

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

 

Just show up. Every day.

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

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

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

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

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

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

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

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

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

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

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There is Peril in Perfectionism

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

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

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Curiosity can overcome fear.

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

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

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

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

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

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

Wow…. This one is so important.

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

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

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

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

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

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

 

 

Choosing Your Specialty

By January of the 3rd year of medical school, most medical students have had rotations in 3-6 medical specialties (out of the 145 specialities in medicine).  With what feels like really limited knowledge, they have to decide on their specialty and move forward.  They apply through the NRMP in the summer, interview at training programs in the fall, and in March go through “the match” to find out where they will train.

I started off believing that if you pay close attention, you will find the specialty that is “right” for you.  Cal Newport, in his book So Good They Can’t Ignore You: Why Skills Trump Passion in the Quest for Work You Love, calls this the “Passion Hypothesis”.  The “Passion Hypothesis” states that “the key to occupational happiness is to first figure out what you’re passionate about and then find a job that matches this passion”

I moved past the “passion hypothesis” as the sole way to choose a medical specialty when I realized that there were other variables like debt and family obligations that were important, too.

Here’s where I am now….

There may be a few people who have a lightening bolt hit them and know instantly what specialty they should go into, but they are few and far between.  Most people gravitate in a direction without a clear destination i.e. more medical than surgical, more procedural than not, more or less direct patient care, children vs. adults.  At some point they pick a specialty that is in their “zone” of interest…. and then they worry that they haven’t seen enough specialties or they may be making a bad choice.

“The more I studied the issue, the more I noticed that the passion hypothesis convinces people that somewhere there’s a magic “right” job waiting for them, and that if they find it, they’ll immediately recognize that this is the work they were meant to do. The problem, of course, is when they fail to find this certainty, bad things follow, such as chronic job-hopping and crippling self-doubt.” – Cal Newport

Here’s where it gets interesting.

What Cal Newport explains in his book parallels what I have seen in the happiest physicians I know, regardless of their specialty.  We have all seen the chief resident or seasoned attending light up when they learn something new at 2am, or when the complex diagnosis becomes clear with steady, deliberate investigation.   Cal Newport calls this the “craftsman mindset”.  It’s the process of devoting yourself to deliberate practice in order to master your field.  When you adopt the “craftsman mindset”, the passion follows.  Or, as Cal Newport summarizes it “working right trumps finding the right work.”

If you want to love what you do, abandon the passion mindset (“what can the world offer me?”) and instead adopt the craftsman mindset (“what can I offer the world?”) – Cal Newport

As I’ve thought more about it, I have also begun to wonder if picking a specialty isn’t somehow similar to how we choose the important relationships in our lives.  You may fall head over heels in love with another person or slowly realize you have met the person you want to spend you life with – but either way, the real relationship comes with time and “practice”.

One other thought, if you are currently struggling with your specialty choice.

There are no bad choices.

All the specialties in medicine are noble and important.  It’s a privilege to serve others… and we need all the specialties to be able to do it well.  Take the plunge.  Make the best choice you can and then devote yourself to being a craftsman in that field.

Cal Newport video from Authors@google.com

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 “We are here to add what we can to life, not to get what we can from life.” – William Osler

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

Thoughts From the White Coat Pocket – Part 2

Last week was the White Coat Ceremony at Baylor College of Medicine.  As part of the ceremony, several upper classmen are asked to address the entering class, speeches that we call “Thoughts from the White Coat Pocket”.

Good evening ladies and gentlemen. Dear colleagues, let me introduce to you: your first white coat. Brand new, tailored for your size, just came out the plastic bag – it is a pretty cool object to own.  Let me assure you it is far more than that.  This inanimate, fairly non-complex thing will soon become an integral part of you. It will determine greatly how you see the world and how the world sees you, even when you are not actually wearing the white coat.

First of all it is a symbol. It is a symbol of relying on scientific evidence for patient treatment, symbol of honesty and respect, symbol of healing, of trust, of being non-judgmental and accepting. Whatever specialty you choose, everyday you will be dealing with people. Many of those who will come to seek your help will do it on the worst days of their lives. Yes, they will be angry, upset, confused, tearful and cranky and from this day on, you no longer get to turn and walk away or let them figure it out on their own. They will be there to see you, not you as a person, but as someone who wears the white coat, thus capable of making things better…

Because you white coat is also a shining armor that was strengthened by the reputation and effort of multiple generations. This armor will make you stronger than disease, often, but not always stronger than death.  You can hide your fear behind the white coat, it is ok. You’ll learn how to ask uncomfortable questions and how to deliver terrifying news. And you will have many opportunities to be scared: your first day of rotations, your first delivery, the first: “Doctor, what do you want to do?” from a nurse. And, believe me, you will hear these words much earlier than you expect…

And, of course, the white coat is a magic cape. It makes hearts beat faster, it suddenly makes it ok for people to discuss most personal things with you, they will believe in your superpowers, because I don’t know how otherwise explain the call from my former co-worker with a request to cure his dog’s arthritis.

Some may say that this white coat is short, because our knowledge is not so impressive yet. Perhaps, but I view it as foundation. We have not build a house yet, but the moment this white coat touches your shoulders – you’ve started. And when you see your first patient at your preceptors office, remember that although you don’t have the letters MD after your name yet, you, just like, your preceptor, have an obligation to be respectful, empathic and knowledgeable.

So, do you feel those butterflies in the stomach? It is a great feeling, so hold on to it. It is similar to falling in love. You are starting a relationship that is going to last a life time. It is going to have ups and downs, routine, exasperation    and fatigue, but stay determined and work for it. Stay motivated, true and inspired. You are in one of the most exciting professional fields. And I know you have dreamt about it for a very long time. Today, finally, it is official. Congratulations!

Katya Jordan, MS3

Thoughts From the White Coat Pocket

Last week was the White Coat Ceremony at Baylor College of Medicine.  As part of the ceremony, several upper classmen are asked to address the entering class, speeches that we call “Thoughts from the White Coat Pocket”.

When I think back about my white coat ceremony 4 years ago, I remember being really worried about what outfit I was going to wear that day. I went through every tie and shirt combination at least 10 times. Eventually I just decided this occasion was too big of a deal and went out and bought a brand new outfit…which I never wore again. I must have taken a million pictures in it…I mean I needed just the right lighting, a smile that said “I’m a professional young doctor with a great bedside manner but could also be an extra on a daytime soap opera,” and if I cropped the picture just right you couldn’t even tell it was a short white coat. Admittedly, it was my Facebook picture for almost a year, marking the beginning of a great journey. Little did I know that both the pristine, little white coat and I would never be the same.

See the funny thing about the white coat is that it changes just as much as you do during medical school. I remember the first day of preceptor for PPS1. I was so proud to wear it. To my shock and horror, that same day a 15 year old boy with a bad stomach bug would defile my coat. I scrubbed it, took it to the dry cleaners, and yes even sent it to my mother. The coat was clean, but something felt different about it…the coat had changed…I had changed. It no longer represented the promise of clinics. It had seen it’s first battle with disease and survived, and a part of me was proud of that.

My little white coat would not see battle again until my second year during my first day of clinics. I woke up that morning and had my best friend take once again a million pictures for Facebook. It was that year that the coat and I transformed again. It was no longer a symbol but rather a tool that I could not live without. During my internal medicine rotation, it held my books, my stethoscope, my penlight, and my history and physicals as I anxiously waited to present. During surgery it held my trauma sheers, bandages, and my granola bar to get me through heart transplants. During psych, it distinguished me from the patients so they didn’t put me away! I couldn’t live without it and a part of me didn’t want to think of a world where I didn’t have 4 massive pockets. True story – I once put a Venti iced coffee in the pocket of my white coat and walked from BCM to Ben Taub with no spillage….these coats are indestructible!

Then something happened this year. I started my sub-intern month on the brink of being an MS4 and decided to leave my coat in the team room. These were MY patients, I was the acting intern and I needed to go into battle without my security blanket. The white coat and I grew apart…and I started needing it less and less. This trend continued as I began my fourth year and started taking more responsibility for my patients. Suddenly the coat felt too small, it could hold my stethoscope and my books, but it could not hold all the responsibilities I was going to face next year.

I will always be grateful to my short white coat. This is a very important day for all of you, take care of your coats and remember what they stand for. When you wear them you are representing BCM and all the generations of amazing physicians this school has produced. And when you get to your fourth year and feel those pockets getting heavier, when your coat feels small and you are ready to take on the challenges and joys of being a first year doctor…that’s when you know you are ready for the long coat.

Welcome to the family BCM class of 2015 and Congratulations!

Tony Pastor, MS4

Learning Clinical Medicine

Flash back for a minute or two to college… and then to the pre-clinical years of medical school.  You went to classes, read textbooks, reviewed slide presentations, studied for tests….   For any of you who made it this far there was one other, critical skill you used on a daily basis to make sure you really learned what you needed to know.  You took notes.

So why is it such a rare sight to see students and residents in clinical settings taking notes?

Take notes?  Why??? It’s all on the internet anyway….

Taking notes is not about storing information, it’s about learning information.

I recently read The Art of Changing the Brain: Enriching the Practice of Teaching by Exploring the Biology of Learning by James E. Zull, a great book that that changed the way I think about how we learn (and why notes are important).

  • Learning is a physical process.  You physically create new synapses to make connections in your brain when you learn something.
  • There is a cycle that is necessary to make these changes and it’s interactive

  • Just reading (or listening to a lecture) is only the first step in the process and won’t lead to real learning.
  • Repetition is the key to strengthening new synaptic pathways (i.e. the key to real learning, not regurgitation of information)

So, how do you learn the information you need to be a surgeon (if you are surgery resident) or a pediatrician (if you are a pediatric resident)?  How do you learn the fundamentals of all the different specialties (if you are a medical student?)  You not only take care of patients and learn in the operating room or clinic … you study.  And you make notes.

Taking notes works because it involves all four aspects of the learning cycle

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GATHERING DATA:    Every interaction in clinical medicine is part of gathering data.  Gather it deliberately.  Make notes on patients you see, procedures you do, lectures you hear (like Grand Rounds) , discussions at M&M conference, patients presented at conferences, “pearls” on rounds…

REFLECTION.    Just making categories and listing information in notes is reflective.  (this is why it works, in a nutshell).  You can expand on this (and make it even more effective) by intentionally being more reflective.  i.e. I wonder if it’s true for all patients or if this is an exception?  Is this the only way this illness presents?  etc. etc.  This can also lead to pulling up more information on PubMed, UpToDate or other sources.

CREATING.    The act of writing = creation.  The more creative you are with your notes, the more this works.  Create  outlines, graphs or other visual aids to help you remember. Use colors, arrows, diagrams, mindmaps.  Use different color paper, photos.  Create your own mnemonics (the dirtier or weirder the better).

TESTING.    You’ll end up with a series of notes on different clinical issues (from patients you’ve seen, lectures, reading, etc).  The last part of this cycle is to apply what you’ve learned to a new situation.   When you see a new patient with pneumonia, for example, you pull out your notes on pneumonia and see if what you wrote applies to this patient.  Get in this habit for two reasons.  First, it completes the cycle of learning (the “testing” portion) and secondly, repetition is the key to learning.

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Practical issues

1. Electronic or hand written? We are on the verge of having electronic tools which will make on the spot notes possible.  The iPad (with Note Taker HD) is as close as I’ve seen.   For some people (but not all) typing or writing on an electronic device will be as effective as writing by hand.  For most people, the actual act of writing is key to learning.   If digital note taking is effective for you , you might consider sites for on line storage of your notes such as Evernote or Zotero.  There is a new device coming out soon called noteslate which might work well for some.  It’s 21×31 cm (~8×12 inches) in size, so it probably doesn’t meet the “white coat pocket” criterion for easy note taking on rounds.

2. How I did it. In the middle of my third year of my residency, I realized I wasn’t effectively organizing what I had to learn.  There was a superstar in our group (99th%ile on the inservice and always knew the answer on rounds)… so I asked him what he did.  He carried blank 3×5 cards in his pocket and made notes on every chapter he read, lecture he heard, patient he cared for, operation he did… you get the idea.  That’s where the 3×5 card method I’ve described in other posts came from.  At the end of my chief year, I had 2 long boxes full of 3×5 cards.  Those cards were all I studied for my boards.

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3.  Build in a system for repetition.  Go through your notes in cycles.  From the chart above you can see that it’s really at the 4th and 5th repetition that you learn.   You might want a way to display the notes you want to keep reviewing to remind you to look at them.

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4. Other options

  • Use regular note paper for notes – but keep it to one topic per page so you can physically file topics together (or scan them)
  • Use a small notebook for each rotation, but figure out a way to tear out pages to file them.
  • It doesn’t matter how you do it, as long as you come up with a system that you can organize and review every time the topic comes up again.

So much of this is about your mindset.  We don’t learn medicine for a test, we learn it because we are given the privilege of caring for other people.  It’s really hard to think about “adding on” hours to study when you are working 80 hours a week.  It’s not so hard to incorporate that study time into your work day by making notes in the 10 minutes you have between cases, or the 5 minutes you have at the end of clinic. Learning medicine doesn’t stop when you finish your training, so it’s important to develop a style of learning during your training that will serve you well when you start to practice.

One other thing – if you make notes and study what you are seeing every day you will enjoy your work more – if you don’t believe me, just try it.

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

Choosing Your Specialty or Sub-Specialty

I just found out about your blog through Scrub Notes, where your topic “failure”was reposted. And I had more fun exploring the topics you’ve discussed especially about how you chose surgery. I am doing my post grad internship now and have (i think) ruled out surgery–but i keep on reading surgeon’s blogs! Would you have another topic about choosing your specialty?

I’ve had a lot of recent conversations with medical students and residents about how to choose a specialty (or subspecialty).  I have to admit, they have changed the way I think about this a little.   I’ve begun to realize that there are different forces at play, including some I used to discount.

The Philosophical View

Your work is to discover your work
And then with all your heart
To give yourself to it.

Buddha

In the ideal world, your speciality picks you.  (How to Choose Your Medical Specialty).  In a nutshell, I think if you are paying attention, you will be pulled towards the specialty that fits you best. If the pull towards a particular specialty is very strong, you really shouldn’t ignore it.  Some of the most miserable doctors I know picked their specialty based on income,“lifestyle” (more about that in a minute), or other “practical” issues…and then were miserable.

As I’ve thought about it more, and talked to more and more students and residents, it’s clear that the “pull” towards a specialty can be really strong… or not so strong.  So, how do you figure out what you should do if you don’t have a strong calling for a specific field of medicine?

I believe that most of us are either “surgical” or “medical” in the way we view our professional world.  It’s like the Yin-Yang symbol – the two halves that make up the whole.  There is no judgment here – patient care needs both medicine and surgery.  It’s not an either-or proposition, either –  just like the Yin-Yang symbol, there is some “medicine” in every good surgeon, and some “surgery” in every good internist or pediatrician.  So, the first step in deciding on your future career is to decide where you fit on the medical-surgical spectrum.  At one extreme, the most “surgical” specialties are general surgery, vascular surgery, cardiac surgery, and trauma surgery.  At the other end of the scale, the most “medical” specialties are general pediatrics and internal medicine, as well as many of the subspecialties in pediatrics and medicine (e.g. nephrology, rheumatology, etc).  There are surgical specialties that have more of a “medical” component (e.g. ophthalmology, ob-gyn) and medical specialties that have a significant “surgical” component (e.g. gastroenterology, invasive cardiology, interventional radiology). As you are exposed to specialties, think about where you fit on the “medical-surgical spectrum” and how wide your “bandwith” is i.e. is it a larger number of specialties that fit your personality and talents, or is it really a relative limited number of specialties?   It’s important, too, to realize that you will be exposed to only a small percentage of the 145 specialities in medicine.  Take time to learn about the specialties you haven’t heard about – one of them might be a perfect fit.

The second step in thinking about your future career is to decide if you want to work with adults, children or both.  If you have a strong pull towards (or against) working with children, it will narrow the specialties you are considering.  If you don’t feel strongly one way or another, keep an open mind as you go through pediatrics and family medicine.

If, at the end of this process, you find you have eliminated a few specialties but still have a list of possibilities, that’s ok.  You will end up choosing one and – it will be the right one.  All field of medicine are important and all of them allow you to impact the lives of other people.  As I’ve gotten more experience helping people through this process, I realize that there are some people that choose the work and then make it their passion (instead of the other way around).

What if you make the wrong choice?

There is nothing that is set in stone.  Despite your best effort to make a good choice, you may find that it’s just not a good fit.  There are plenty of examples of people who started in one field and realized that they had made the wrong choice.  This isn’t a personal failure!  The only failure would be staying in a field you really don’t like.  Yes, starting over will add some years.  But if it’s really clear that you should be in a different field, make the choice and move on.

The Practical Issues

As I’ve talked to more and more trainees, I’ve realized that practical issues are important to consider when you are choosing your specialty.  Practical issues cannot and should not be the only thing you consider though.  Please don’t talk yourself out of something you really love because you are worried about your talent for the field, money or lifestyle.

Your talents.  “I really want to be a heart surgeon, but how can I know if I have the hands to do it?”  Physical skill, in my opinion, is a bell shaped curve.  There probably are 5% of people on the right side of the curve who are truly gifted when it comes to technical skills (and, yes, 100% of surgeons think they are in that 5%)  Likewise, there are 5% of people on the left side of the curve who simply won’t be able to do it. These people will self select out of a career that requires technical skill – they just aren’t comfortable with working with their hands (and never have been). Everyone else can absolutely learn the technical skills needed in their specialty.  Physical talents may be the most obvious talent we think about, but there are other talents that play a role as well.  How well can you sit still?  How easy is it for you to listen to other people’s stories and feel empathy for them?  Are you more comfortable knowing a smaller amount about a lot of things, or being a real master of a smaller area? It’s a good idea to consciously think about your talents and ask people close to you to help you with this task.

Money. The average amount of debt a medical student incurs is currently $160,000 Loans for medical education can only be deferred for 4-5 years, which means if you choose a career that requires 7 years of training, you will be paying back your loans on a resident’s salary.  The math is scary – and our system is flawed.  One of the best explanations of this problem is a post by Benjamin Brown, MD called The Deceptive Income of Physicians.  If you have a family to support, I understand that choosing something that requires more years of training is problematic.  If you are in this category, your issue is going to be how much to let financial considerations affect your decision… without letting them totally drive the decision.

Lifestyle.  I was talking to a colleague in pediatrics the other day who told me a great story about when she was an intern.  She had been taking calls from families and had a family call around 5pm about their baby.  After talking to them, she decided the baby probably had croup, but it was not dangerous.  The next morning, in morning report, the chief resident asked her how the baby was when she called back.  When he found out she hadn’t called, he responded “If a family calls you about croup at 5pm and you don’t call back at 9 or 10 to find out how the baby is doing you haven’t done your job.”  Medicine – no matter what your specialty – is not “easy”.  Every field has issues that will keep you up at night and working at times you wished you didn’t have to work.  There are some that are worse than others, but don’t confuse “lifestyle” (i.e. the ability to have a balanced life and be happy) with an idea that your specialty will be “easy”.

Starting Clinical Rotations: Practical Advice

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 actually learn to be a physician.   If you use the analogy of learning to fly, 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.  You cannot learn to fly a plane by sitting in the back.

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, be in 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.

I am not a fan of “learning objectives”.  If they are done well, they are very helpful, but most 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 it 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.)

Start with a basic textbook.  You will NOT be responsible for learning all the details in the textbook!  Textbooks are written for residents and practicing physicians.  But – a good textbook will give you an overview of the topics.

The strategy:

1.     Make a list of the topics covered in a general textbook.  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.

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 appendicitis you’ve seen you’ll still learn something new.  (or use it to learn about their hypertension instead)

The strategy:

1.     Keep a notebook with an entry for every patient you see.  You can use 3×5 cards or an electronic equivlaent, 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. (Remember HIPAA – it is better to do this without any protected information!)

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 or PubMed 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 appreciated and – therefore – taught more.  It’s just 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. Anytime you can, make the residents look good. It’s particularly important not to try to one-up the 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. Don’t ever 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.

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. Write down these stories when you can.  It’s also special 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.  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!)

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