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Starting Medical School: Strategies for Studying

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

Your goals

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

1. The Basics

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

2. The Specifics

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

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

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

3. The Refinement

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

4. The Balance

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

5. The Non-Science Major

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

Starting Medical School: Rules of the Road

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In the next few weeks 17,000 college graduates will start the process of becoming lifelong students of medicine.   Medical school is a wonderful, but at times difficult experience.  Here are five “rules” that I hope will help with this exciting transition.

 

1. You can drink from a fire hydrant, but you’ll need to learn how.

The amount of information you are going to be exposed to in medical school is logarithmically more than you had to learn in college.  At Baylor (where I teach) we calculate that the first year of medical school is the undergraduate equivalent of 22 hours of course work per semester.  It really is like being asked to drink from a fire hydrant.   You are going to have to study more, study better and actually use the time in class to learn.  The first year or two of medical school may, at times, seem like an obstacle course you have to “get through” to get to the “real stuff”.  But these first two years are important; You are learning a new vocabulary… a new language.  If you don’t learn the breadth and depth of this new language, when it comes time to apply it to patient care you won’t be “fluent”.   By the way, sometime during the first month or two of medical school you will think that a) everyone here is smarter than I am, b) the admissions committee must have made a mistake and I’m not really supposed to be here and c) there is absolutely no way to read all of this material.  But, like everyone who has done this before you, will discover that a) you are just as smart as everyone else (sometimes in different ways, but equally effective) b) nobody made a mistake – you really are supposed to be here and c) you have to change the way you study, but you really can learn this much material.

 

2. Make your bed.

You wanted to become a doctor for a myriad of reasons, but one of them was surely because service to others is important for you.   Therefore, you are already primed to sacrifice a lot of your needs for other people.  Sacrifice is part of the culture of medicine.  But, it’s like a Starling curve… a little sacrifice makes you better, but too much makes you ineffective.  “Make your bed” is a simple rule (and action) which helps you remember that you need to take care of your environment, your fitness, your nutrition and your spiritual wellbeing as you are learning how to become a physician.

 

3. Act like a doctor – starting now.

We (all practicing physicians) see you as a doctor already.  I know this is a really hard concept for first year medical students, but it’s absolutely true.  You have started your apprenticeship and, unless you are one of the very, very few who change their mind, you will have an MD after your name in 4 years.  With all of the joys and privileges that come with this role, there are a few responsibilities to start thinking about as well.  Start thinking about your decisions, words and actions and how they might be interpreted by patients or colleagues.  It’s no longer acceptable to put anything you want on YouTube, Facebook, Twitter or other social media.  How you dress and act when you are in professional settings will be important.  You’ll learn more specific details about professional behavior from your professors and colleagues as your training progresses, but the core values of medical professionalism start when you enter the profession, which is now.

 

4. Kindness matters.

It is remarkable how our paths in medicine cross over and over again.  The person sitting next to you on the first day of medical school may be someone who will be an intern with you in 4 years or who will refer you patients 10 years from now.  You and your classmates will be going through classes together (like you did in college), but this is different.  You are starting your professional life together as well.  The camaraderie that results is a gift and is also very important personally and professionally.  Don’t blow off the class events.  Don’t stay home to study instead of going to class.  Go out of your way to meet everyone in your class and really get to know them.  Cultivate and nurture these important friendships.

 

5. Enjoy the journey

You are about to embark on a life changing (and fulfilling) journey.  This journey is a privilege and it is very, very special.  Take a few minutes everyday to write down the events of the day.  The first time you hear a murmur in a heart will be just that – the first time.  Take a minute to record what that was like.  You are going to have a lot to process as you start studying anatomy – more than just the names of the structure.  “Talking” about it in a journal is a great way to make the transition we all make in the anatomy lab.   There are also going to be some hilarious stories and events that you’ll forget if you don’t write them down.  When you look at them later, you’ll be glad you recorded them with words, photos, or drawings.

 

“Our study is man, as the subject of accidents or disease. Were he always, inside and outside, cast in the same mould, instead of differing from his fellow man as much in constitution and in his reaction to stimulus as in feature, we should ere this have reached some settled principles in our art.”

William Osler, from Teacher and Student, in Aequanimitas.

 

 

 

What To Do This Summer

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This week approximately 16,000 US medical students are going to receive their diplomas and become physicians. There are also about 16,000 college graduates who will start medical school later this summer or early in the fall.  Congratulations to you all!

Nearly all of you have a well-deserved month (or two)  to rest and get ready for the next step in your training.  So, I thought it might be helpful to pass on a few words of advice on how to spend your time this summer.

Photo credit

 

Do NOT study!

  • If you are starting your residency and you think it might help relieve your (normal) anxiety, here is what to do:  Buy one of the major textbooks and use it to get excited about what you are going to learn.   If you want to, plan how you are going to study for the year.   Skim the book if you really have to do something to feel less anxious, but don’t spend hours studying.
  • If you are getting ready to start medical school – step away from the books!  Seriously, there is nothing you can do that will make it any easier, so just enjoy your time off!

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Take a vacation (or two or three…)

  • Visit family and friends – take a road trip and connect with people you haven’t seen in a while
  • Hang out on a beach, go for some great hikes, read some great novels
  • Sleep late, eat well, and just rest

Photo credit

 

Develop (or strengthen) an exercise habit

  • Use this summer to develop a daily exercise routine that you can take into your new (and crazy) schedule.  Overall, your goal for the summer should be to develop a balanced exercise program (cardio, strength training and flexibility).  If you’ve never done any strength training, hire a trainer and learn about it.  Your goal should be at least 30 minutes of cardio 4-5 times/week, 2-3 strength training sessions/week and stretching every day. If you develop a balanced exercise routine this summer, it will be much, much easier to continue this once you start medical school or your internship. Commit to doing at least 30 minutes of exercise a day this summer.
  • Running is one of the best (and most convenient) cardio exercises for medical students and residents (because it’s cheap, efficient and effective)  Use this summer to become a runner. If you hate running, find another good cardio exercise habit to develop instead – but pick one!
  • If you don’t own a bicycle, think about getting one that you can use to commute to school or the hospital.

Photo credit

 

If you don’t know how to cook, learn.

  • Unless you want to gain a lot of weight, have poor energy and feel bad, you are really going to have to cook for yourself (or at least plan for good food cooked by someone else).  You won’t be able to eat what you need, particularly as an intern, unless you bring the food with you.
  • Learn some basic skills to cook simple things.  If you have good cooks in your family, have them teach you.
  • If you don’t have family members who can teach you, find cooking classes near you and sign up.  Many high end grocery stores and gourmet stores offer classes for beginners – look on line for classes near you.

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Gifts for Medical Students and Residents

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Gift ideas for college graduates who are getting ready to start medical school and medical students getting ready to start their residencies are surprisingly similar.  Medical school and residency are both times of hard work, less free time and increased stress.  The following are gifts that should make life a little easier (and more enjoyable) for medical students and residents:

  • A maid or housecleaning service once a week.  No one in medical school or residency has time to clean (or likes it)!  This will be one of the most appreciated gifts you’ve ever given someone.
  • Along the same lines, a highly functional laptop computer is a critical piece of equipment.  For new medical students, the laptop they had in college is probably not going to be enough.  For residents, if it has been several years since their last computer, an upgrade will make studying and research easier.  To avoid getting the wrong computer, a hand-made certificate that you will pay for the computer of their choice may be a better idea (to make sure they have a computer that really meets their needs.)
  • A year’s subscription to EverNote premium (to allow them to store notes on a cloud server)
  • If they are avid readers (of non-medical works), consider a Kindle, Nook, or other electronic reader.  (If you are considering an iPad, it can be used as a reader, so this might be redundant).  These devices can easily go into a backpack or call bag and make it easy to take 5-minute breaks from studying or work.
  • A really good alarm clock.
  • Membership to a gym for a year.  Working out is important both for physical and mental health during medical training.  But – unless you know which gym is the closest to where they live (or most used by their friends), it might be better to create a homemade “gift certificate” and let them decide.
  • Anything to help promote more exercise.  A bicycle to commute to school or the hospital?  A gift box with exercise equipment?  Yoga classes?
  • An iPod nano or other mp3 player to listen to music while studying   Electronic speakers for their computer will also help provide music while studying.
  • A subscription to Pandora One to create and listen to internet radio stations without commercials.
  • A gift certificate to Whole Foods (or any grocery store that makes take out food), or a healthy prepared food service.  In Houston, we have My Fit Foods, Snap Kitchen, Diet Gourmet, Real Meals 365 and several other services.  These types of businesses exist in almost every major city and can be easily found with an internet search.
  • If you are going to buy a watch to celebrate graduation, don’t make it an expensive watch.  No one wears them in the hospital for fear of losing them (they have to be removed when procedures are done).  It also is inappropriate when caring for patients who may not have many resources.  Ditto for expensive pens.
  • A digital camera or small digital video camera.
  • Anything to support a hobby that they enjoy (but will have to work to keep up during their training)
  • A couple of comments about what not to buy.  Don’t buy stethoscopes, otoscopes or any other medical equipment (unless you are a physician yourself… and even then it’s probably not a good idea).  Don’t buy anything for an office (they won’t have one for a long time) and – absolutely – don’t buy a “black bag” (no one uses them anymore).

Starting Clinical Rotations: Practical Advice

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Don’t sit in the back of the plane.

The basic sciences are important to learn the vocabulary and grammar of medicine.  Clinical rotations are different – it’s where you actually learn to be a physician.   If you use the analogy of learning to fly, in basic sciences you are studying the book on how to fly the plane.  In your clinical rotations you are in the plane, watching and learning from the pilot.  Which means you have to be in the cockpit.  You cannot learn to fly a plane by sitting in the back.

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

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

Know what you are expected to learn before you start.

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

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

The strategy:

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

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

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

Practice being professional.

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

Learn from every single patient you see.

Use every patient to learn about their specific disease.  Even if it’s the 30th patient with appendicitis you’ve seen you’ll still learn something new.  (or use it to learn about their hypertension instead)

The strategy:

1.     Keep a notebook with an entry for every patient you see.  You can use 3×5 cards or an electronic equivlaent, if you prefer.  In fact, many hospitals have 3×5 cards with the patient info available in the patient’s chart for docs to take. (Remember HIPAA – it is better to do this without any protected information!)

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

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

Be the doctor for patients that are assigned to you.

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

Prepare for conferences.

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

Come early, stay late and keep moving.

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

Practice having a balanced life.

Compassion fatigue is a constant threat to practicing physicians.  Taking care of yourself, staying connected to family, friends and the outside work are all critical components of preventing compassion fatigue.  This, too, is a skill you need to learn during your rotations so you can carry it with you into your residency and your practice.

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

Your experiences on your clinical rotations will be among the most special of your life. Buy a new journal and take time to jot down the funny and not-so funny occurrences of daily life in the hospital.  You will see some extraordinarily beautiful moments of human life.. and some horrendous examples of what people can do to other people. We all learn to deal with these extremes by telling stories. Write down these stories when you can.  It’s also special to record your “firsts”… the first time you set a fracture or hear a murmur of aortic stenosis will be the only “first time” you have.  It’s a special world you are entering.   You’ll want to remember it by taking notes, recording stories and with pictures of your team and unique sights around the hospital. (No patients, though – remember HIPPA!)

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

Starting Clinical Rotations: Wear the White Coat

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Every year, I end up counseling a student who, from day one, was absolutely certain they wanted to go into surgery.  They scheduled their rotations to put surgery last, so they would get really good evaluations.  They cruised through pediatrics, medicine, ob-gyn, etc as observers, rather than real participants, because they were so sure they were going to be a surgeon.  Finally, the big day arrives – they start their surgery rotation.  Within a few weeks they begin to realize….. they hate surgery.  Now they are really stuck.  What kind of doctor should they be?

There is an easy way to prevent this from happening.

Wear the white coat.

When you start your pediatrics rotation, be a pediatrician. When the residents and attendings ask what you are interested in, tell them you think pediatrics is really interesting.  It will be true, if you are “trying on the white coat”.  (It will also inevitably lead to better evaluations, by the way, but that is secondary gain.)  When you are on medicine, be an internist.  When you are on surgery, be a surgeon.  You get the idea.  Really immerse yourself in the field, imagine it will be your future.  It’s necessary, but not sufficient to learn what you need to know for the shelf exam.  If you are going to wear the white coat, you have to go beyond what you learn from patients and about patient care.  How does an internist think?  What makes a particular case in surgery more challenging than another?  How does an obstetrician deal with a difficulty delivery at 2am?  What defines the culture of pediatrics?  Does the “coat” of a neurologist fit you?

Over 80% of students change their mind about what specialty they want to pursue as they go through their rotations. Choosing your specialty is not hard, but you have to genuinely keep an open mind as you “try on” all the specialties.  One of them will fit better than others, but it’s probably not the one you expected!

“Failure”

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Dear Dr. Brandt,

I enjoy your blog very much. As a second year medical student, I know that my peers and I all struggle with what we view as ‘failure’ at some point or another. I imagine this problem doesn’t stop (…ever), especially since medicine seems to attract people who hold themselves to extremely high, if not impossible, standards. If you’re looking for topics, I wonder if you might have some insight to offer on how to deal with the downfalls along the way.
 

Dear colleague,

It is part of our profession that we will never stop trying to be perfect and – just as true – that we will always fall short. As a student, it tends to be about the tests you are taking and the feeling that you will never study enough. As a resident, it’s the feeling that you don’t know enough to make the decisions you are being asked to make. As a practicing physician, you will at times stay awake at night worrying about your decisions, even when you know you did the best you could. All of this sounds like a huge downside to the profession we’ve chosen, but it’s actually a blessing.  One of the core personality traits of physicians is that they care. In a way, all of the stress about not doing well enough happens only because you have empathy and compassion for your patients.

Although it’s hard to believe at the beginning, with time you will realize that the feeling of having “failed” is actually a gift.  You’ll discover that “mistakes” and, more importantly, “near misses” become your most valuable teachers.  What’s important is that you grasp the opportunity to learn from falling short, rather than beating yourself up.  “Failing” at a task (or test) is different than being a “failure.”  When you have moments you feel you could have done better, use it as motivation to study a little more, go back to the textbook, look up one more article, or review all the facts again.   William Osler, in his famous book to medical students (Osler’s Aequanimitas) talked about keeping a journal of mistakes:   “Begin early to make a threefold category – clear cases, doubtful cases, mistakes.  And learn to play the game fair, no self-deception, no shrinking from the truth… It is only by getting your cases grouped in this way that you can make any real progress in your post-collegiate education; only in this way can you gain wisdom with experience. “

So, to answer your question about how to deal with the downfalls along the way –  Start by revisiting your motivation. Remember why you started down this path in the first place. If you are trying your best to do the right thing, and are humble about the fact that you are human (and will therefore fall short) you can end every day with satisfaction and a sense of accomplishment. That being said, make sure that you work with focus – that when you study or work it is with dedication to the patients and families who are trusting you with some of the most precious decisions of their life. When you fall short, use it as motivation to learn. But, in this process, make sure you are taking care of yourself. The worst thing you can do when you feel inadequate is to just work more and more. This leads inevitably to compassion fatigue which makes you less effective (and will make you suffer). Compassion fatigue is a common diagnosis for care-givers; it happens to every medical student, resident or physician at some point in time. Just like any other diagnosis, the next step is treatment. In a nutshell, the treatment is self-care. Start with a great walk somewhere beautiful, and as you walk ask yourself how you can best care for your body, your mind, and your soul. Be as kind to yourself as you would be to a good friend as you recover. And just like you would tell that friend… Eat good food, sleep enough, get some exercise, get outside, and look for joy and wonder everywhere you can!

Studying in Medical School – Making it Relevant

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One of my rules of the road for Medical School applies to studying:  “You can learn to drink from a fire hydrant but you have to learn how.”

(this image is from the online Palm Beach Fire Department coloring book)

There are three issues you have to come to grips with as you start medical school (i.e. the things that are different from college)

  1. You are going to have a volume to study that is overwhelming
  2. You have to memorize a good portion of this overwhelming material because you are learning a new (foreign) language
  3. Most of the information you will be given is actually important  (i.e. there’s not much you can blow off)

It’s hard at first to distinguish between the things that you need to know on a permanent basis (all of the cranial nerves) and what you need to know for the tests (foramina of the skull… unless you end up a neurosurgeon).  At first you just have to assume it’s all important, but, as time goes on (particularly after you are in the clinics), you will become more adept at compartmentalizing things into permanent memory, retrievable memory and “look it up” memory.

“A man should keep his little brain-attic stocked with all the furniture that he is likely to use, and the rest he can put away in the lumber-room of his library, where he can get it if he wants it.”  Sir Arthur Conan Doyle

It’s easy for anyone to study the night (or week) before the test.  The pressure is on, and the deadline that looms tends to make you efficient and driven.  But there is no question that this is not the way to go for things you really want to learn.  You don’t want to be the kind of doctor who treats a seizure based on what they “crammed” for a test… you want the concepts of treatment in your memory, accurate and retrievable. (The details are another thing… that’s what the internet, drug formularies and books are for.)

How to drink from a fire hydrant, lesson 1:  The core of adult education is relevance.

I remember the drudgery of learning cardiac physiology my first year of medical school.  Hour after hour of the physics of contraction, the list of receptors, the details of the cellular organization.  I tried to memorize it over and over, but this was really boring stuff.

One day a classmate dragged me along to a “noon conference”.  I’d like to say it’s because we were really motivated, but actually it was because there were free sandwiches.  But a funny thing happened…. It was fascinating – a discussion of how patients with heart failure present, how to treat them and why it was important.  And all of it was based on the physiology I had been studying!  I actually understood what they were talking about!  When I went back to look at what had previously been boring, I now understood why it was important.  It was relevant and, therefore, it was easier to learn.

Every medical school has a long list of conferences open to anyone in the medical school.  Many of them happen in the early morning, the late afternoon or at lunchtime and, therefore, they fit in to the schedule of basic science students.  Check out the calendar on your school’s web site. Start with the departmental grand rounds (weekly lectures given to teach the entire department from the medical students to the full professors).  Don’t limit yourself to medicine and pediatrics.  Go to the grand rounds given by orthopedic surgery, rehabilitation medicine, psychiatry.  Ask clinical students you know if there are interesting lectures that you might be able to attend.  Look on the medical school web site for visiting professors or special lectures.  This is not only a good way to make studying more relevant, but you may find something so interesting that it could end up being your future career.

There are other ways to make it relevant.  Spend a minute on PubMed or UpToDate (both of which should be free to you through your medical school) to find clinical information that makes the topic interesting.  If you are studying the rotator cuff in anatomy, look up rotator cuff tears and how to treat them for 5 minutes before you start studying.  If you are learning about peristalsis in the GI tract, find a review article on abnormalities of peristalsis.  But – Don’t get bogged down.  You won’t understand much of it to start with (which is normal!).  Don’t try to be a “gunner” (the slang at Baylor for the students who sit in the front row and try to get every question right) and try to learn the clinical information.  That’s not your job in basic sciences!  Just use it to motivate you – to undertand that there is a context for this new language you are being asked to learn.

How To Exercise Despite Your Busy Schedule

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“I used to run 6 miles a day but I haven’t done any exercise at all since I started my clinical rotations.”

The medical student who was talking to us on rounds today isn’t alone.  Exercising regularly during basic sciences isn’t that hard.  But it’s an entirely different issue when you start your rotations.  Figuring out how to exercise as a resident is even harder.

The first step is to realize why it’s important.

  • It’s the right thing to do.  Physicians do physical as well as intellectual work.  You are taking care of people’s families.  It doesn’t surprise you that policemen, firemen, astronauts and soldiers have physical fitness as a requirement.  It’s no different for us. .
  • You will have a life after training.  In your 20s and 30s, you may be able to get away with not being active, but those years of inactivity will be paid for later.
  • You will feel better physically.  You will have more energy.
  • You will feel better emotionally.  There is a direct effect of working out (stress reduction), but there is also the psychological benefit of taking care of yourself.

Once you recognize that regular exercise is important, you then have to realize that it’s not going to be easy.   There are two ways you can look at exercise in the context of a busy schedule.  First, think about it as activity, not “working out”.  Your goal is to be active, which you can approach by adding little bits of activity into your day:

  • Park your car in a distant lot, or at least at the back of the lot, to add walking.
  • If it’s safe, walk or ride your bike to work.
  • Take the stairs in the hospital (no matter how many flights!).
  • Buy a pedometer that counts steps and try to walk at least 10,000 steps per day.
  • Take a jump rope, stretching bands or dumbbells to keep in your locker or the break room to use when you have 10 minutes.
  • Do pushups and/or situps before you go to sleep or anytime you have a break in the call room.

Although increasing activity is essential to maintaining fitness, you really do need to have some “real” workouts in your week to build and maintain your overall fitness.  The goal for your week should be 3-4 sessions (at least 30 minutes long) of cardiovascular training, 2 sessions of weight training and stretching every day.

So, how do you actually fit this into the hectic schedule of clinical rotations or residency?

Step 1:  Make a list of things you like to do (not things you think you should do) in each of the three categories (cardio, strength training and flexibility).

Here’s an example for cardio workout:

Cardio – at home

  • Fast walk around the parking lot or neighborhood
  • Run (list different routes that work out to about 30 minutes to start with)
  • Jump rope in the driveway

Cardio – at gym

  • Treadmill
  • Elliptical trainer
  • Stationary bike
  • Racquetball
  • Basketball league on Tuesday nights
  • Monday – 5:30 am spinning class, 6:30 pm aerobics class
  • Tuesday – 5:30 am circuit weight class, 7 pm boxing aerobics
  • Thursday – 5:30 am aerobics class, 7pm spinning

Cardio – 10 minute workouts at work

  • Stairs
  • Fast “rounding” (do loops of the floors)
  • Jumping jacks
  • Up and down off a chair
  • Jump rope

Step Two:  Make a plan for every day of the week.

The real key to making this work is to plan ahead.  It’s just too hard, when you are leaving the hospital and every fiber in your being wants to go sit on a couch somewhere, to overcome that gravitational pull with the thought “but I should go to the gym”.  The only way you will be able to resist the gravitational pull of the couch is to have a plan.

Start by looking at your week and writing down what is likely to happen.  For instance, if you are on a q3 day call rotation it may look something like this

Schedule Comments
Sun Off
Mon On call
Tues Post call
Wed Out with friends after rounds
Thur On call
Fri Post call
Sat

Once you have the outline of the week, fill in the chart with the most reasonable option for exercise for the day… and then a back up plan in case the first option falls through.

Schedule 1st choice Back up Comments
Sun 24 hours off! Racquet ball with friend then weights at the gym Long bike ride with friend then weights at home
Mon On call 5:30 am spinning class or run before work Do stairs at work for total of 30 minutes
Tues Post call 8:30 aerobics class at the gym Swim at the YMCA
Wed Work at 6am Run before work Out with friends after rounds
Thur On call Take stretch bands and do weight work out on call. Do stairs at work for total of 30 minutes
Fri Post call Run before going home Gym before going home for 30 minutes on elliptical trainer
Sat Rounds 6-9 Gym for weights30 minutes on bike at gym Gym for weights after roundsRun in the evening

Step 3:  Cut yourself some slack (i.e. be flexible)

This is an ambitious schedule and there is no way it’s going to happen.  But – if you plan for 7 days, you’ll probably do at least 3 or 4.  If you plan for 3, you are likely to do just 1.   It’s also important to remember this isn’t another task on the scut list.  Above all, going to work out should feel like time to play and decompress … not another “task”.   If there’s a day you leave work to go to spinning class.. but realize you really want to be outside, go play in the park!

Step 4:  Keep a gym bag in your car

Load up a bag with anything you might need to work out – for any contingency.  Get a big bag so you can have your gear for swimming, spin class, running… whatever you like to do.  Even though it’s rare, there will be some days that you get out earlier than planned .. or the call schedule is messed up and you really aren’t on call.  Every once in a while you get a totally quiet day (yes, they are rare, but they do happen) and you can “run an errand” with the permission of your chief resident.   Take advantage of those days to take care of yourself by going to work out.

An Open Letter to All Graduating Medical Students: Academic Medicine 84:539-540, 2009

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This is a wonderful letter to all graduating medical students from Steven L. Kanter, MD, editor in chief of Academic Medicine.

“Remember that you take with you such an amazing gift to offer to society. Some of you will advance our understanding of medicine by discovering new knowledge, some of you will ensure our future by teaching others, and some of you will attend to the very meaning of life, one patient at a time.”

http://journals.lww.com/academicmedicine/Fulltext/2009/05000/An_Open_Letter_to_All_Graduating_Medical_Students.1.aspx

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