Studying In Medical School is Different!

It’s the beginning of the academic year in medical schools around the world, and that means there are thousands of students who feel they are suddenly being asked to drink from a fire hydrant. The information you are asked to learn in medical school is different in two really big ways – It’s voluminous and (unlike in undergraduate education) all of it is relevant (albeit to different degrees) to what you will be doing the rest of your life. Learning how to make the transition to this new kind of studying is one of the biggest tasks a new medical student has to accomplish.

The following is a guest post from Preston Tsang, a medical student at Tulane University School of Medicine. The main take home message?

You have to study how to study if you are going to succeed in medical school!

All of us arrive to medical school with a successful strategy for studying… which we then have to seriously revise. The incredible volume of material means you either rethink how to study, learn, and recall info from the beginning… or you are forced to do so when you stumble – after realizing the way you studied in college won’t cut it in medical school.   

Every medical student quickly learns that standardized exams are a necessary objective measurement of how “well” you do in school … especially the mammoth exam called STEP 1. This exam (as you might guess) is the first of three “steps” to getting a license to practice medicine. But Step 1 in particular (and now Step 2) are also an important way residency programs assess the academic standing of students applying to their programs. #Pressure

Just like college, you need to study to pass the exams in each of your courses, but unlike college you need to prepare for Step 1 (which means everything you learn in basic sciences!). And BTW you also need to remember that you are not just studying to pass an exam or ace the Step exams.  Learning (not just memorizing) this information is essential to being a good physician.

So how best approach this overwhelming task? Only one way – You need to study how to study if you want to succeed in medical school. Make some notes as you study how to study, create your own way… but to get you started, here are the key points I learned as I’ve gone through this process.

It’s all about active learning. Gone are the days of cramming, or just reading something three times to learn it. It’s all about active learning, and – fortunately – there are a lot of people who study this and have come up with methods to promote active learning. All of them involve taking notes to synthesize (not just list) the material and interacting with the material.1,2

Studying in groups helps! Asking each other questions and having to “teach” each other is a great example of active learning.1   Studies have shown being quizzed about material is superior to traditional learning and basically halves the time it takes to learn the material.5

Take notes, but not too many. Notes are key, but should reflect your synthesis of the information, not every detail. There are lots of studies (and stories) about people who spend hours and hours creating spectacular notes and then don’t have time to review them. Guess what… they don’t do that well.1 There’s lots of literature on note taking, with many different strategies. Add this to your “studying how to study” list!

Review, review, review.  It seems obvious, but you don’t learn something on the first pass. There is science here, too! It’s takes 5-7 repetitions, spaced further and further apart, to really learn something. It doesn’t work as well if you review something 5 days in a row… it should be almost a logarithmic spacing to get best results.3,4,6

Flash cards (e.g. Anki) work great for details. Once you have the big picture summarized, go back and look for details that you need to know. Anki (and other similar apps) build in spaced repetition – they have you repeat things you don’t know well until you know them. Using this technique (i.e. using Anki) to learn a subject versus reviewing the material multiple times (i.e. re-reading notes) has been shown to improve learning.4

To enhance Anki flashcard learning even further, I discovered that there are certain structures to flashcards that make them more effective. In one study 80 students were randomized into two groups. One group used flash cards designed as a test (testcard) while the other half was randomized into flash cards using the more typical “studycard” format (see below). The group using the testcard format retained more of the information when tested. 7  

Photo credit

UWorld has its place, but it’s not what you think. Despite what every upperclassman will tell you, your professors are right – you can’t learn medicine from multiple choice questions alone. But… once you have the concepts down, testing yourself and learning why you were right or wrong is a great form of active learning. More importantly, study questions are a great way to review (once you think you’ve learned the information) to find where you have gaps.

Don’t underestimate the power of mnemonics 2. Make them up and make them something you can’t repeat in public (a known strategy for successful mnemonics). Ask older students, residents, and even attendings for theirs.

So here is how to succeed at Step 1, based on what I’ve learned. When tackling a standardized exam with a vast amount of material, studies have proved the effectiveness of retesting, spaced repetition, and active learning. Start off with a solid base by learning initially from the notes you make in class and from class readings. Then, instead of just rereading the information, distill it down into summaries, draw diagrams, and create your own questions. On top of this find ways to promote active learning and retesting as you study like using practice questions or reviewing your Anki cards. This system of learning may not be best for every learner, but is a good place to start. Add to it with your own research into study techniques.

p.s. Don’t forget to build in (and schedule) time for self-care and sleep.1 

References

1. Dattathreya P, Shillingford S. Identifying the Ineffective Study Strategies of First Year Medical School Students. MedSciEduc. 2017;27(2):295-307. doi:10.1007/s40670-017-0396-2

2. Roffler M, Sheehy R. Self-reported Learning and Study Strategies in First and Second Year Medical Students. MedSciEduc. 2022;32(2):329-335. doi:10.1007/s40670-022-01533-w

3. Ericsson KA, Chase WG, Faloon S. Acquisition of a Memory Skill. Science. 1980;208(4448):1181-1182. doi:10.1126/science.7375930

4. Larsen DP, Butler AC, Roediger HL. Repeated testing improves long-term retention relative to repeated study: a randomised controlled trial. Med Educ. 2009;43(12):1174-1181. doi:10.1111/j.1365-2923.2009.03518.x

5. Morris PE, Fritz CO, Jackson L, Nichol E, Roberts E. Strategies for learning proper names: expanding retrieval practice, meaning and imagery. Applied Cognitive Psychology. 2005;19(6):779-798. doi:10.1002/acp.1115

6. Effect of uniform versus expanding retrieval practice on the recall of physiology information | Advances in Physiology Education. Accessed August 8, 2023. https://journals.physiology.org/doi/full/10.1152/advan.00090.2011?rfr_dat=cr_pub++0pubmed&url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org

7. Schmidmaier R, Ebersbach R, Schiller M, Hege I, Holzer M, Fischer MR. Using electronic flashcards to promote learning in medical students: retesting versus restudying. Medical Education. 2011;45(11):1101-1110. doi:10.1111/j.1365-2923.2011.04043.x

And a few more things to help you on this journey!

Study tips for first year medical students

It’s the first day of medical school… what should I do?

Learning medicine: #SmartNotes

No Time to Teach? Try This.

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

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

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

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

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

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

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

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

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

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

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

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

Calorie content of available Tube Feed/Supplements:

Two Cal HN – 2 Calories/mL – high protein

Glycerna 1.2 – 1.2 Calories/mL – lower glycemic index

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

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

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

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

Ensure Plus – 1.5 Calories/mL with 16g protein

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

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

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

Nutritional needs for burn patients

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

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

Fat should be less than 15% of total calories

Carbs 7g/kg/day for burned children

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

Etymology/History

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

Benefits of Swaddling (van Sleuwen, 2007)

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

Adverse effects of swaddling  (van Sleuwen, 2007)

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

Video showing three different methods of swaddling

Facial burns and airway management: 

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

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

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

The team from this article designed a particular ETT setup

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

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

What a second line means!

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

@Teachers_Matter

Gifts for folks about to start medical training – of any kind!

Every year about this time I put out a list of the best presents for folks about to start medical school, nursing school, physician assistant school or any medically related school … as well anyone “leveling up” to the next level of training in their field (i.e. internship, residency, fellowship, etc). This is my edited post for 2023. I hope it gives families and friends ideas on how to support the people they love who are learning how to heal.

The Gift of More Free Time

The everyday needs of a household can become oppressive if you are working 80 hours a week. And, because bathrooms need to be cleaned, and floors need to be vacuumed, this is time that takes away from downtime needed to recover from hard work.

Here’s a list of things that just about every healer or healer in training would appreciate to help free up time:

  • A cleaning service. Hire someone to do a “deep clean” of their home once a month. Look on the internet for bonded cleaning services or call people who might know the best companies.
  • Car washes. Who doesn’t love a clean car…. and who has the time to wash and vacuum their car?
  • Roomba vacuum cleaner. One task taken care of!
  • Someone else to cook meals (see below!)

The Gift of Nourishing Food

  • Instant Pot. The number one time saving kitchen appliance for busy people is the Instant Pot. My Instant Pot has fundamentally changed the way I cook – and has made it easier to eat well.
  • Air Fryer. I’m a new convert to air fryers. 15 minutes to get wonderful roasted or air fried veggies is amazing! Hard to choose between this and the instant pot. There is an instant pot with both, but I’m not sure it does quite as good a job as an air fryer.
  • Gift certificates for food. Do a little sleuthing and find a healthy grocery store near where they live. Other ideas might be a smoothie or juice shop, their favorite restaurant(s), or coffee shops
  • Prepared meals. Most cities have small, local companies that deliver prepared meals to your door. That would be my first choice (support local!) but there are also national companies and do this, too. Most companies offer gift certificates which is probably the best plan to give flexibility between a subscription or a la carte ordering.
  • Home cooked meals. If you live near, think about cooking a batch of favorite food(s) and putting them in single serving containers to freeze. You might also want to create a certificate for your personal “cookie/meal/soup of the month club” with a promise to deliver food once a month.
  • A Good Cookbook. Mark Bittman’s cookbooks are all wonderful, but How to Cook Everything Fast is a particularly good choice for busy people.
  • Vitamix. It may seem expensive for a “blender”… but this is much more than a blender. These are the blenders you see in professional smoothie stores. Smoothies become a lifesaver for busy healers. (The Vitamix also makes great soups, sauces, etc…..)

The Gift of Good Beverages

  • Insulated Coffee Mug. Rounds in the morning often starts with “running the list” around a computer, often at “dark thirty” when the rest of the world is just thinking about getting up. Having good coffee or tea from home or a local shop that stays warm for several hours is such a pleasure. The mug of choice for just about everyone I know is a 10 or 16 oz Yeti tumbler.
  • Water Bottle. No one drinks enough water at work in the hospital (and we all agree on this). Again, having a great water bottle that you can fill in the morning with ice water (and a slice of lemon if you like) makes the day better.
  • Nespresso (or other) coffee maker. If they are a coffee drinker, a good coffee maker is key. Nespresso is my personal favorite, but be creative and look at all the options!
  • Good coffee (or tea). There are local roasters in most cities, so rather than support the big chains, look for them and consider a gift of coffee.

The Gift of Music

For those who find solace and joy in good music (and isn’t that just about all of us?):

  • A good Bluetooth speaker for their home or study space. I love the Klipsch The One II speaker I have at home, but I’m sure there are other equivalent speakers, including some that aren’t as expensive.
  • Air pods or noise cancelling headphones
  • A subscription to one of the many streaming music services like Spotify or Apple Music.
  • Tickets to the symphony, ballet, jazz performances, or opera in the city where they live.

The Gift of Good Sleep

  • Good mattress, pillows, sheets. How we sleep determines how well we function the next day, particularly in high stress jobs. Is it time for a new mattress? Is there a better mattress that might help? High quality sheets are usually a welcome gift, too.
  • Light blocking curtains or shades. Post-call sleep is during the day and sunlight can interfere with sleep. Special curtains or shades to block the sun really help.
  • A Weighted Blanket.
  • Nothing Much Happens. This is a free podcast with the subtitle of “Bedtime stories for adults”. Since it’s a present, think about supporting this wonderful series with the very cheap subscription (which means you get the stories without ads.)

The Gift of Healthy (and not aching) Feet

Working in the hospital means a lot of time on your feet. John Wooden, probably the most famous basketball coach of all time, spent the first week of training every year teaching his players how to put on their socks…. because he recognized that if you didn’t pay attention to your feet, it would affect your game. The same is true in medicine.

  • Comfortable shoes for the hospital which can be thrown  into a washing machine. High on the list are Atoms, AllBirds, and Merrells. I have shoes from all three companies and so, for some one like me (a surgeon) who walks and stands a lot, I can recommend these specific shoes! Atoms Sneaker, Allbirds Tree Runners, Merrell Encore Breeze, Merrell Antora 2 Rainbow,
  • Good socks. Don’t go for cute, go for high quality, well padded, and functional.
  • Compression socks. There is some debate about whether compression socks can really prevent varicose veins, but there is no debate that your feet feel better at the end of a long day when you wear them!
  • Pedicures. Lots of women (and some men!)  have learned the joy of a professional pedicure for tired feet. Don’t underestimate the power of a gift certificate for  pedicures. But, as an alternative, put together a kit for home pedicures.

The Gift of Fitness

This might not apply to everyone, but most people who work hard know that they feel better if they exercise a little every day. But – a word of caution – tread lightly with fitness gifts since they can be misinterpreted as conveying a “need” to exercise.

  • A bicycle. For many people a good bicycle can make it easy to add some exercise by commuting to work by biking instead of driving. Regardless, it’s a great way to get some exercise outside. If they have a bike they use to commute, you might think of some ways to make it easier such as
  • A gym membership. You may have to do a little detective work to find the right gym that is close to where they live, but it’s worth it.
  • New shoes. Runners are supposed to get new shoes every year or so. Give them a gift certificate from a running store near them, if there is one. Or, be creative and put cash in a tiny toy shoes and wrap them in a shoe box.
  • Fitness equipment for home. Resistance training is important for all of us, regardless of gender or age. Although a bench and weights are part of the classic home gym, they take up a lot of room (and weigh a lot!). I’m a big fan of the TRX system, which makes a great present. Since it has become almost a cult among physicians during the pandemic, I have to at least mention Peleton as another potential fitness gift for healers and healers in training.

The Gift of Calm

Massage and/or Spa Services. This, too, may take a little effort to find the right place, but this is a wonderful gift for stressed people.

Headspace. This might seem a little unusual as a gift idea, but I can’t recommend it enough. Meditation is discussed in most medical schools and hospitals as a tool to gain insight and recover from the depletion that is part of the work we do. The best way I’ve found to learn this practice, and then stick with it is Headspace, which is a great app. The first 10 lessons are free, but for a gift, go ahead and get the annual subscription.

The Gift of Time and Stories

Human beings heal their hearts and souls by telling stories. Although there are many stories your loved one can’t tell you (at least not the specifics) you can totally ask how what they are seeing and doing is making them feel. Set aside some time for a coffee or another beverage and ask – with intention – “How are you doing?” And then just listen. Don’t try to “fix” anything … just listen.

Along the same lines, think about a letter… yes, a handwritten letter or note. Maybe a long one for a specific holiday or birthday, maybe a series of shorter ones through the year. Imagine how you would feel after a particularly hard week if you had a letter to reread that talked about how proud someone was of you, filled with funny stories and words of support.

“Running the List”

Where did this term come from?

For those not in medicine:

  • A busy hospital service needs a way to keep up with the “to dos” of the day.
  • The junior residents and students responsible for these tasks need a way to know what they’ve done and what still needs to be done.
  • The senior residents and attendings need to keep track of the information and what is happening to guide and supervise the junior residents and students.

And all of this means keeping an accurate and up to date patient list. This can happen digitally in Epic, which is often what attendings use, but for most residents and students it means printing out the Epic list to keep in their pocket as they move through their day (and/or night).

p.s. If by chance you are still making your residents use Excel i.e. they have to physically create the patient list, shame on you! (Unless you don’t have Epic or another digital way to keep the list, in which case, I’m really sorry.)

And how do residents and students use the patient list?

  • Almost everyone draws little boxes for every detail they need to check off … and then puts a check in the box when it’s done.
  • Different colors for different tasks? Doodles? Notes during rounds or lectures? All of these and more, I’m sure.
  • Fine tipped pens are key (Every resident has a favorite type of pen which they hide from their attendings).

And then we run the list

“Running the list” means starting at the top of the list and discussing each patient sequentially, one at a time. We make sure to go over the plan for each patient, discuss what has changed, learn what has been “checked off”, and decide what needs to be added to the list.

This happens routinely at the beginning and end of the work day, and during handoffs. But, on a busy day, it may happen even more often.

So back to the original question

Although it sometimes actually feels like the intellectual equivalent of running, I suspect that the origin of “running the list” has to do with the idea of a “running list” i.e. a list that you add to as new things come up. But that’s just an educated guess, since I couldn’t find any actual data. If you have other thoughts, let me know!

Final thoughts

Running the list is an important part of caring for patients, but it can also be a practice.

What if, like a competitive runner, you took a moment before you “run” the list to center yourself, take a few deep breaths and get ready to run?

What if you tried to visualize each person on the list as you review the day’s tasks to remember that these aren’t just tasks… they are human beings in your care?

What if we consistently made it a goal to teach just a little bit (or a lot, if the time permits) every time we run the list? (Would this be “walking” the list? 🙂 )

And at the end of the day, when you put your patient list in the shredder (don’t forget this important step! #HIPPA), what if you did it intentionally – to mark the end of the work day and the transition to not being in the hospital?

Photo credit

Study Tips for First Year Medical Students

Yesterday was my first embryology lecture of the year to the new MS1s at Baylor College of Medicine, as well as the PA, DNP and Genetic Counseling students. For years, I’ve been including a few slides at the end of each lecture to help with the transition to medical school. Yesterday’s lecture ended with tips on how to study. I promised the students I’d share these slides in a written formate. I realized sharing them here might be the most appropriate way to do that!

Medical school (or any high volume graduate school) involves a dramatic change from what students have previously experienced. As you know, if you read this blog, I believe there are a lot of “tools” that can help students “thrive, not just survive

The biggest change for many students is it really isn’t about the grades anymore. It’s about studying for the patients you will be caring for in the future. That means really learning the material, not just knowing it for a test.

Even though there is still a lot unknown about how the brain works to learn material, what is certain is that it is a physical process. You create new synapses when you experience or learn new things. As they are repeated, these synapses get stronger and stronger.

So, to organize the advice, I’ll share some basics, some specifics and then a little refinement.

Learning this volume of material at this level of complexity is about consistency. You can’t run a marathon by running 20 miles every weekend. This is no different. You need to study every day (except one). One of our great teachers at Baylor, Dr. Clay Goodman, tells our students that they have signed on for a 60 hour a week job. (which roughly means 1-2 hours of studying for every hour in the classroom). If you map out your week as a 60 hour job, it will work a lot better than ever trying to “catch up.”

The SQ3R system is the best system I know to learn what you need to know during the basic sciences. So, how do you translate the SQ3R system into practice?

The night before lectures, spend 30-40 minutes skimming the lectures. No “studying”. Be curious. What questions are going to be answered during the lecture? How is it organized?  (BTW “Mike” is a fictitious patient with muscular dystrophy that Dr. Goodman uses in an introductory lecture to show how everything you learn in medical school matters – from the DNA to the psychosocial context of the family)

This 30-40 minutes is basically the “S” and “Q” of the SQR3 system.

  • SURVEY to get the big picture
  • QUESTION = what questions are going to be answered during the lecture? What else do you want to know to really understand this? (write them down!). Do not try to look up anything now.

During the lecture stay ACTIVE. Don’t sit in the back row and look at FaceBook – even if the professor is reading the slides.* You’ll need to take notes for this to be really active. Put the questions you want answered on an outline you prepare the night before lecture and fill it in during the lecture. Use mind maps or other powerful visual aids to learn. Click here to get to my post on taking notes during basic sciences.

*(If you are a lecturer who does this, stop it! – otherwise you are guilty of “death by PowerPoint.” Find someone who is a good lecturer and ask them to coach you.)

After the lecture, you move on to the 3Rs. Now you get down to the real studying. Read through the printed notes (or slides). Did everything get answered? MAKE NOTES that synthesize what you learned.

Review. Review. Review. Here’s the deal. Medical school is a lot like learning a new language.  The first part of basic sciences (anatomy, physiology, embryology, etc) is learning the vocabulary. The second part of basic sciences (diseases, pharmacology, etc) is learning the grammar. When you get to the clinics, you are practicing the language until you are fluent. “Flash cards” such as Anki are great at learning “vocabulary”. They are terrible at synthesizing and learning connections and concepts.  That’s why you need a single page summary of every lecture. The summary is the “forest”, your notes (plus or minus flash cards) are the “trees”. If you really want to succeed, you need both. BTW, I made the class repeat (out loud) after me (twice) – “You cannot learn medicine from Anki alone.” (It’s on tape. I really did this.)

Here’s an example of a single page summary of the embryology lecture I gave the class yesterday. I spent time to make this really look nice – more time than you will want to spend. It doesn’t need to be typed, it doesn’t need to be particularly legible to anyone but you, but take the time to do these summaries!

Did I already mention that you need to review?

This is probably the single most important slide I show when explaining how to best study in medical school. It’s the basis of many apps in medical learning, including the NEJM Knowledge+ courses. There are two really important points in this graph.  First, it takes at least 5 repetitions to really learn something. Second, they have to be spread out in a logarithmic fashion over time.

Here’s how to do it. The first three repetitions should be same day, next day and 2-3 days later. The more times you review it, the better, but it should at least be 1 week later and 3 weeks later.  More is better.  Plan another review a month later and three months later, too. For the Type A folks in medical school (i.e. all of you), make a spread sheet!

 

Another thing about our brains and learning.  Pushing through for hours without rest is as stupid as thinking you can build up your biceps by doing an hour of uninterrupted reps. Speaking of reps… use “study reps”. Get an app if you think it will help. 50 minutes of studying.

Stop studying for 10 minutes (no matter how engrossed you are) when the alarm goes. Repeat.

People sitting next to you in your study areas are going to look like they have it more together than you do.  It might be true… but it probably isn’t.  If someone has a study technique that looks like it will work for you, by all means try it!  Just don’t change too often. I was a liberal arts major in college. If you come from a non-science background, the first 6 months are going to be a little tougher on you because you have more “vocabulary” to learn but don’t worry, after that you’ll be caught up,

Read this slide. Believe this slide. The most important point on this slide is the last line. You cannot make those physical synapses you need to really learn without 8 hours of sleep.

Keep notes about what works for you and what doesn’t. Everyone is a little different, but you will find a system that works best for you through conscious effort.

It’s like running. Some of this is just “time on feet”. Remember the 60 hours a week job concept and you’ll do fine.

I end with this slide to remind my students that there has to be balance for this to work. Most of what I tell my students about finding and keeping that balance is in this blog, so feel free to use the word cloud to the right or search for what you might need. Please contact me if you have a specific question I can answer or if you have an idea for a new blog post.

Welcome to the best career in the world! We are all happy you are here!

 

 

 

 

 

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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What’s for dinner? How to eat well if you are too busy to cook….

I wish someone had taught me this when I started medical school.  Seriously, I would have loved it…  Let me walk you through what I did today to prepare for my week, and I think you will understand.

So, first… it’s summer… In Houston.

The weather makes a difference in how this unfolds, since I’m talking about cooking… i.e. (usually) adding heat.

So here’s what I did today..

  1. I spent about 20 minutes looking through what is my current favorite cookbook for three recipes that a) I liked b) were easy and c) were summer appropriate.

2. I entered all the ingredients I needed into GroceryIQ, … plus stone fruit (that is so ripe and delicious right now), a watermelon (because it’s summer and I love them), bread and ingredients for sandwiches for lunch.

(how can you not love a cookbook that says “Heat a big glug of olive oil in a skillet”?)

3. I went to the grocery store and bought everything on the list. When you have a list, it’s really fast, so you make up the time you spent looking up the recipes and making the list. Also, you are much less likely to buy more than you need (which leads to interesting microbiology experiments in your refrigerator) or things you really don’t need (i.e. junk food).

4. I took a nap. (I was on call Friday, up all night, so I’m still catching up). Plus, Sunday          naps are amazing… so don’t think you EVER have to justify them!

5. I spent about 20 minutes preparing the ingredients for Joshua McFadden’s recipe for the tuna melt “casserole” and for one of my summer favorites, ratatouille. Every time I make ratatouille, I think of Maryvonne, Monique and Maddy, my French “mothers” who taught me this recipe when I lived in France as an undergraduate.

6. Here’s where the Houston weather comes in. To minimize stove top and oven time, I roasted the squash for the tuna melt and the vegetables for the ratatouille at the same time – while they were cooking, I sautéed the onions and garlic for the ratatouille and added the tomatoes (canned). (In case you were wondering, the sweet potato is for snacks or something else TBD.)

So, we’ll have the tuna melt tonight, with some store made coleslaw (Brussel sprout and kale), and there is enough for the same meal another night, or lunches if we choose.  The ratatouille can be sides to our sandwiches, or can be another meal with a protein (we are mostly “pescetarian” so probably fish… but you can choose what you want).  Ratatouille is also delicious cold on it’s own or with cottage cheese, or you can add it to broth with chicken meat and make a great soup/stew.Bottom line… maybe an hour today for a week’s worth of amazing food… which is what I wish I’d been taught when I started medical school.

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 p.s. Since you were wondering…  The other two recipes for this week are cooked seafood salad with fennel, radish basil and crème fraiche (p115) and crunchy mixed bean salad with celery, tarragon and soft boiled eggs (p260).

p.p.s Do not get intimidated if you don’t know how to cook. YOU CAN LEARN.  (and you should).  Find someone to help you.

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Top Ten Tips on Starting Medical School

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

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

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

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

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

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

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

REMEMBER IT’S SCHOOL

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

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

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

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

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

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

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

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

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

 

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

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

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

List the sections on your spreadsheet.

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

 

TAKE NOTES. ALL THE TIME.

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

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

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

 

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

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

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

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

Pancreas, pancreatitis

Appendix, neoplasms, carcinoid

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

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

 

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

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

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

 

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

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

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

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

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

p.p.p.s Review them again.

Link to the Wikipedia article about the forgetting curve

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!