Medical training is based on active learning – studying textbooks and articles, listening to experts, seeing patients, setting up procedures and then performing them, reading images, looking at slides. This kind of learning is straightforward – You do the task, get feedback (in a variety of ways), and then adjust to improve.
I’ve never really thought about passive learning in medicine … until I learned about this recent study from the Institute of Neuroscience at the University of Oregon that clearly showed that passive exposure improves active learning (at least in mice).
Based on my experience as a medical educator, that rings true for medical students and residents, too. Watching experts do a procedure over and over won’t ever replace learning to do the same procedure – but it does seem to be a habit embraced by superstar medical students and residents (in addition to their deliberate and very active learning).
“The core insight here is appealing precisely because it’s so easy to act on. Passive exposure costs almost nothing. No extra willpower, no additional scheduled practice time, no special equipment. You just need to put yourself in contact with the material you’re learning.”
How can you add a little passive learning to your day (in addition to rereading and highlighting notes or listening to a recorded lecture)?
Just listen. The ideal way to take advantage of the didactic courses in the first two years of medical school (and subsequently in clinical rotations and residency) is to engage actively with the material during the lecture. (Yes, I’m serious… and here is how to do it). But if you find yourself unable to really engage it turns out that “just listening” (i.e. being a passive learner) isn’t a complete waste of time. You can also attend departmental Grand Rounds or other interesting lectures as a first year medical student (Most of them are before your classes start or during lunch). You won’t understand much… until you do (which is always exciting!) . You can find a list of these lectures on every hospital and medical school website (Here’s an example from Baylor College of Medicine). These are public lectures so you won’t be out of place. If anything, they will be delighted there are basic science students interested enough to attend. (p.s. there is often food, too…)
Just watch. “Shadow” in the first two years of medical school…ask senior students or residents (who will ask their attendings) if you can watch surgery, follow someone in clinic, or go on rounds with a team. When you are on a rotation, “just watch” surgeries that you aren’t assigned to (which is a lot easier in minimally invasive procedures because you can watch it on a screen). The same goes for “just watching” a pathologist looking at slides, or a radiologist reading images, etc. You can also take advantage of YouTube to “just watch” videos of procedures, how to do a physical exam, etc, etc.
Passive exposure will never replace active learning (a really important point!) but just watching and just listening aren’t a waste of time… and may help make active learning a bit easier.
I recently came across the powerful concept of “hourglass learning” in this post by two professors who teach teachers and, not surprisingly, wondered how it might apply to teaching physicians and other healers.
That being said, if you love learning (or love someone who is trying to learn), these concepts can be applied at any age to anything – from bird watching to learning math!
Basic Sciences (Medicine taught in a classroom)
For basic sciences, the hourglass paradigm works well, but I added some practical points from the equally powerful SQR3 (Survey, Question, Read, Review, Repeat) system using a typical hour-long lecture and assigned reading as an example.
Survey (Establish a purpose).
It’s easy to forget that you don’t actually study medicine to pass a test… you are learning to heal, to serve those who need you. In that light, the first step – “establish a purpose” – can be thought of in two ways. The first is to set an intention, to remember why you are studying. And then, more specifically, to ask “What is the purpose of this lecture?” That’s where the tool of “surveying” comes in.
This is an exercise in curiosity not “studying”. Skim over everything to get the big picture. Look up words you don’t know (and their roots). Look at how the lecture is organized. Are there obvious sections? Are there lists that look like they will be important? Can you tell what the most important points will be?
Question (Extract evidence)
This is an interactive process that starts with your survey.
Before the lecture: As you are surveying make notes (on the slides, in the margin of the notes, or as a separate list) with what questions the lecture will and, more importantly, won’t answer about the topic.
During the lecture: Listen for and jot down the answers to the questions you wrote down the night before. If there are questions that aren’t answered in the lecture, ask the professor afterwards.
Read (Make sense)
After the lecture but on the same day (don’t wait!), add to your notes to make everything as clear and as organized as possible, look up anything that is missing, and then make a one page “30,000 foot” review of the lecture.
Review (Form meaning).
The 4th step is to return to the “why” by linking the lecture to how the information applies to actual human beings. Even though search engine AI may point you in the right direction, it should never be your sole source as a professional. (That’s in bold for a reason.) As a professional you need to make sure the information you have is vetted (i.e. peer reviewed).Start with PubMed or UpToDate to find a review article on the topic.
Repeat (Reproduce knowledge).
Real learning only happens with repetition, so setting up a schedule to review your notes with progressively longer gaps between reviews is the secret to success. This is where Anki or other similar systems can really help.
An important note on question banks… You can’t learn medicine from UWorld. (Again, in bold for a reason.) BUT, question banks are an awesome way to confirm you’ve learned the important stuff – and to identify where there might be some gaps. So please use them as an adjunct to, but not core of your studies.
Explain (Reproduce knowledge).
A great way to make sure you have “metabolized” what you are trying to learn is to share it with others. This is where study groups come in. They take as many forms as there are students, but in general, the most effective groups work as “out loud” reviews of the topics after everyone has spent time reading, reviewing, and repeating.
Teach (Share knowledge)
Teaching in the basic sciences is not as easy as in the clinics (other than “teaching” each other in study groups). But having a goal to to teach makes you organize your material in a way that insures you really understand it.
Rotations, Residency, Fellowship, and Practice (Medicine taught in clinic and hospitals)
The same “basic science” style of learning continues in clinical training, but there won’t (usually) be hour-long lectures or assigned reading. Instead, you’ll be seeing patients, attending conferences, and, yes, you will still be taking tests (shelf exams, in training exams, board exams, maintenance of certification tests, etc).
We want to and need to stay current in our field… but how? Here’s the best way I’ve found to do it, a practice that will serve you from starting rotations in medical school until you retire:
Find the most current and thorough textbook for your specialty
Make an Excel spreadsheet of every section/chapter
Set a goal (and make a plan) to cover the entire book in a year (which will look something like covering 12 sections/ week with weeks off for vacation and holidays)
Repeat every year! (It gets progressively easier after the 1st year since you are editing or adding to your notes)
Here’s the good news… Most of the 12 sections for the week (or whatever it works out to be for your textbook) will be chosen based on the patients you are seeing (It makes it a lot more fun…). The bad news is that all textbooks have really boring sections that still need to be learned, so spread them out over the year to make sure you cover them (but not all at once).
Repeat (Reproduce knowledge). Teaching and explaining on rounds is a built in way to make sure you understand enough to explain it to others. (Plus you look really good). This is where one page summaries and/or mindmaps really help since they make it easy to remember (and teach).
(Share knowledge) In clinical medicine, there are many opportunities to share … rounding, informal teaching for medical students on our rotations, formal lectures, presentations at conferences, handouts, etc, etc. Take advantage of this unique form of “group studying”!
“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.” William Osler
The definition of “knowledge” in English is pretty straightforward – To “know” something means being familiar and/or aware of it in a way that lets us understand. I find it fascinating that English has only one word for “knowledge”, where other languages use multiple words to reflect the depth and nuances of the concept. “Once widespread in Germanic, the verb [to know] is now retained there only in English, where it has widespread application, covering meanings that require two or more verbs in other languages (such as German wissen, kennen, erkennen and in part können; French connaître “perceive, understand, recognize,” savoir “have a knowledge of, know how;” etymonoline
How we understand “knowledge” affects how we teach, how we learn, and how we see the world.
The philosophers of Ancient Greece saw acquiring knowledge as an important part of the human quest for wisdom. Enter episteme, techne, phronesis, gnosis, and doxa. These nuanced ways to think about knowledge and wisdom have a lot to offer us as we navigate the misinformation and philosophical chaos of our time. For those in medicine, these nuanced definitions add beautiful complexity and understanding to our work, with special inspiration for those who teach the healing arts.
Techne refers to the technical skills of a profession – the grasp of grammar for a writer, pedagogical skills for a teacher, the ability to perform specific procedures for a surgeon.
I recently read this remarkable essay by Sami Sinada in which he states: “Medical school teaches episteme. Residency builds techne. But phronesis? We assume it appears through osmosis. It doesn’t.”
The entire essay is well worth your time to read, but Dr. Sinada makes an important point – Our medical school and residency curricula have gaps when it comes to teaching practical wisdom (which is the core of doctoring). He goes on to argue that we can close that gap with five important pedagogical choices:
What strikes me about doxa is that it has no moral weight associated with it. Doxa can refer to the deep orthodoxy of thousands of years of tradition in a culture … everything from how we greet each other to what we believe… as well as culturally accepted, politically motivated lies.
Gnosis is most often associated with gnosticism, a religious and philosophical movement in the 2nd century. But I wonder if the concept of a deep inner knowing (whether or not you view that as divine) isn’t worth refurbishing for our time as an important way to “know”. Contemplation, meditation, prayer can all open spaces that defy our intellectual understanding, leading to a way of “knowing” that, in some ways, we need now more than ever.
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
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
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
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!
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:
Are there new recommendations about how to manage gallstone pancreatitis and/or choledocholithiasis in kids?
What is the caloric content of the different formulas we prescribe?
What is the best way to calculate calorie needs for a burn patient?
How and why do you swaddle a baby?
How do you manage supplemental oxygen after you extubate a patient with severe facial burns?
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:
During rounds we come up with one question per person (everyone, not just the students and interns).
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.
The answers are short and helpful – as though each person is taking notes for themselves. No PowerPoint presentations, no extensive diatribes.
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
*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.
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?
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.
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.
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.
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.)
“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!
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?
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!
Today I have the incredible joy of talking to the medical students on our rotation. No agenda, just a conversation that they requested for some “advice”. They just started their surgery rotation last week and it’s their first rotation. First rotation, beginner’s mind, unbridled enthusiasm… it is so wonderful!. I decided I would come up with what I wish someone had told me at the beginning of my rotations…
Be mindful, deliberate and excited about learning.
This is probably the most important piece of advice I can give. Clinical rotations are often a whirlwind of work and you can be swept away without realizing it. Residents can ignore you, people can be cranky, patients can be difficult… and in the midst of all this, you are expected to learn to be a doctor. You have to stay in charge of that mission, no matter what is happening around you.
Take a little time to reflect on why you are doing this and what kind of person/doctor you want to become. When times get tough (and they will) hold on to it. If it helps you, come up with a slogan to repeat, keep on a piece of paper in your wallet or on your wrist
Learn about the practice of mindfulness. Mindfulness has been shown to be effective in decreasing stress and may help to prevent burnout. It’s not hard to learn, but it’s hard to master … which is the point of a “practice”. (e.g. the practice of medicine)
Learn to keep a “beginner’s mind”. When I was a student on core medicine I had a senior resident that showed me what beginner’s mind looks like. It was 2am and I was tired. We were seeing a gentleman at the VA hospital for his diabetes, hypertension and some electrolyte abnormalities. I presented the patient to the resident and then we went to see him together. He had a rash, which I thought was so insignificant that I didn’t even include it in my presentation. But, instead of scolding me, this resident got excited. Yes, you read that correctly, 2am and excited about a rash – because he didn’t know what it was. (This next part will date me, but it’s a great example to make us grateful for the access we have to information now). He called security and had them open the library. We spent a wonderful hour looking through books – like a treasure hunt when we were little kids – until we found the rash in one of the books. We were laughing, excited and couldn’t wait to get back to start the appropriate therapy.
Understand what you are going to learn (the big picture)
On every rotation, you will be given a list of learning objectives. By all means, know them, study the things listed and make sure you know them (they will be on the test). BUT… please realize that diseases don’t stay conveniently siloed in a single specialty so this is not learning “surgery”, it’s learning about how surgeons approach a specific disease you will see elsewhere, too. You also need to know that what is listed as learning objectives today may well be obsolete tomorrow (if they aren’t already).
You have chosen a career that ethically demands life-long learning. That means that one of the most important skills to learn is how to develop a system of learning that you can use in medical school, residency and later in practice.
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.
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.
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?
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..
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.
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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