Learning Clinical Medicine

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

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

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

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

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

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

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

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

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

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

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

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

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

photo credit 

Practical issues

1. Electronic or hand written? We are on the verge of having electronic tools which will make on the spot notes possible.  The iPad (with Note Taker HD) is as close as I’ve seen.   For some people (but not all) typing or writing on an electronic device will be as effective as writing by hand.  For most people, the actual act of writing is key to learning.   If digital note taking is effective for you , you might consider sites for on line storage of your notes such as Evernote or Zotero. Remember HIPAA, though – no patient identifiers!!

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

3.  Build in a system for repetition.  Go through your notes in cycles.  From the chart above you can see that it’s really at the 4th and 5th repetition that you learn.   You might want a way to display the notes you want to keep reviewing to remind you to look at them. You might consider using an electronic flash card system like Anki which changes the repetition based on whether you’ve really learned it or not.

4. Other options

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

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

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

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

How to Spend Your Day Off

“I know I should study for the Absite this weekend, but I haven’t had a real day off in over a month”.

Here’s the scenario. It’s Friday evening. You’ll be back at work on Sunday. You’re sleep deprived because you are a resident.  You haven’t spent any quality time with your significant other, friends or family because you haven’t had any real time off. Next week has plenty of call and it would really help if you planned out good food for the week and cooked something.  And, by the way, you have the inservice exam coming up, so you really should study.

There is no one answer how to balance these things. Everyone will be a little different in what is most important to them, and different weeks will be different, too. But, there are some basic concepts to think about that might help you plan how to spend your time off.

  • Sleep is actually a high priority even though it feels like you are giving up social time.  Whether it’s visiting friends, studying or just goofing off, you won’t get the benefit of your time off if you are completely exhausted. If you are sleep deprived, try going to sleep really early (8 or so) the night before your day off and see if it doesn’t make a big difference.
  • Good food is important. Be efficient, but be conscious about what and when you eat. Use a little of your down time to think about your week, plan what you are going to eat, and go shopping. Find a good recipe for something easy to make and make a big batch for the week. Or at least buy good quality frozen food that serves the same purpose.
  • Get some exercise, but be realistic. A serious workout can use up a big hunk of a day off. For some, that’s great – the hours will be more than worth it. For others, don’t beat yourself up. It’s far better to figure out how to do 30 minutes 3 or 4 times a week than to be a “weekend warrior” for 4 hours on your day off.
  • Don’t plan for huge blocks of study time on your day off. You’ll wear out your neural pathways and you just won’t remember what you are trying to learn. Like exercise, a little every day is much, much more effective than a big block on the weekend. Plan now for the big test months from now… pace yourself!  (If you’ve just started studying for the Absite later this month – go for it. But, as soon as the exam is over, map out a way to study for next year so you don’t do the same thing again.)
  • Absolutely use a significant part of your day off to socialize with your family or friends. It’s very isolating to live in the hospital and these hours are critically important.
  • Once you think about what’s important to you, and make a decision about your day – enjoy it! The worst way to spend a day off is to spend the time worrying that you should be doing something else. There’s a reason that almost every religion in the world has the concept of “Sabbath”. Human beings need real down time once a week to refuel.  It’s not “wasted” time, it’s essential time.


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!

How to Study During Your Residency

The study habits you set during your residency will be the foundation for the rest of your professional life.  Even though that sounds really melodramatic, it’s not.  If you don’t want to end up one of the “stupid” doctors, you’ll need to keep learning.  Medicine changes so dramatically that it is critical to stay on top of things.  Sounds easy, but it is amazing how few doctors develop a disciplined practice of being able to read and study.

Residency, despite what it may feel like some days, is the time that you are learning, and hopefully mastering, your specific profession.  All residents have an annual examination called the “in-service training exam”. It’s a nice marker of how you are doing when compared to the other residents in your field, and it’s motivation to stay on top of the didactic part of your education.   It is easy, like in medical school to try to “cram” for this test in a few weeks, but that’s really stupid.  The test is supposed to motivate you to learn, not to cram.  That being said, how you do on this exam is important, so you will want to review in the few weeks before the exam.  Your in-service score is predictive of how well you will do on your board exam and may be considered by programs if you end up applying to subspecialty fellowships.

So, what is the best way to learn your field and, as a secondary benefit, do well on the in-service exam?  How do you stay on top of the reading, and learn what you need to know?  Just like exercise, it’s far more important to be consistent than intense.  You can’t train for a marathon by running 15 miles once a month… and you can’t learn your field by “cramming” before the exams.  One way to do this is to set up a “training” program for your reading:

Buy the textbook in your field.  For many fields, there is more than one major textbook.  If that’s the case, ask around to see which one is considered the “best” (it will be subjective, but you have to start somewhere!).   If the textbook is on line at the medical school’s library you don’t have to actually buy the book, but you will miss out on the highlighting!  If there is more than one good textbook, plan to read a different one next year.

Map out the year into 46 week “blocks” (3 off for vacation, 1 off for the winter holidays and 4 off to review for the inservice exam).  Divide the textbook into 46 sections and assign the sections to the blocks.  Since I’m a surgeon, I’ll use an example from one of our major textbooks:

  • July 1:  Chapter 1 – Systemic response to injury and metabolic support and Chapter 35 – Soft tissue Sarcomas
  • July 8: Chapter 118 – Chest wall, lung, mediastinum and pleura
  • July 15: Chapter 6  – Trauma
  • Etc
  • Etc

Most textbooks front load with the basic science chapters (which are a little dry compared to the clinical chapters).  I don’t recommend you try to do the textbook in order or you will drown in the basic sciences (and forget why the field is fun!).

Make the textbook portable? If you are reading on line this may not apply.  If not, print out the chapter you are studying for the week from the online source or make a copy of the chapter from the book.  You may have to spend 5 or 10 minutes here or there getting through the chapter – being able to keep it folded up in your white coat pocket helps!

Read ahead and be flexible. If in the 2nd week of your study program you get a patient with breast cancer (for example), go ahead and read the chapter on breast.  It will be much more meaningful if you are applying it to a specific patient which means you are much more likely to learn the information.  Double up the chapters for that week if you can, swap if you can’t – but don’t lose track of the “training grid” (i.e. make sure you read enough to finish the textbook)

Use the SQ3R method when you are reading.  This is a great technique for actually learning what you read, rather than having it go in one ear and out the other (so to speak).

  • Survey – Look through the chapter at the section titles, graphs and tables.
  • Question – Go through a second time (again pretty superficially) but this time create questions that are likely to be answered in the chapter and write them down (this part is actually important, so take the time to write them down!).  For example, on a chapter about appendicitis, the questions would be something like:   What causes appendicitis?  What is the most accurate diagnostic test?  Is there an advantage to laparoscopic over open appendectomy? Etc etc
  • Read – Read with intention to answer the questions you generated and make notes for later review.  Take the time to actually write the answers to the questions you generated.
  • Review – Look over the notes you made and questions you answered.  Force yourself to list the key concepts to tease them out of the details.  Think about what questions you might ask on an exam on the topic.   Most importantly – you should review the material the next day (<5 minutes), a few days after that, and then a month later.  Set up a schedule and a method to make sure you keep track of this review.  Of all the steps that lead to really learning the material, this is probably the most important!
  • Recite – This is the one that seems stupid to most people, but it’s not.  Based on what is known about learning, reciting the things you really want to remember (out loud, not in your head) every time you review the material really helps with retention.  (Thank goodness for call rooms!)

Make notes so that you never have to go back to the book to review.   Use whatever system works best for you.  If you use the 3×5 card note system it will integrate with the other notes you are taking in the hospital.

There are other systems to make notes that work, too – so find the one that works best for you and then use it!  Some people type their final review notes in Word, Evernote or OneNote so they can search their notes.  Another unique way to make notes that are easier to remember is to use Mindmapping . Mindmeister and Xmind are on line for making these kind of notes, if this is what works best for you.

Organize your system for review. Your goal should be to read something every day and to complete the week’s reading every week.  In addition, you need to have a rotating system of review to make sure you look at your notes a day or two after you make them, a week later and a month later (at a minimum).  The more you review the more you retain, so build in as much review as you can.

Exercise for Medical Students and Residents

There is no question that there are many people who have integrated exercise into their daily routine so successfully that they don’t even think about it.  It becomes part of their day, just like brushing their teeth, or putting on their pants in the morning.  But even though it seems like the majority of people around you are in this category, it’s just not true.  There are the real exceptions – like the guy who gets up at 4 every morning (even if he went to sleep at 2) to run.  If you have never been an “athlete” you may feel really intimidated by these people.  .

The benefits of exercise during your training can’t be overestimated.

  • 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.

Consistency, not intensity is the key

One of the biggest mistakes you can make is to view working out as something that you do as an activity “outside” of your day.  A 45 minute work out, plus the time to get to the gym, plus showering and changing can easily take an hour and a half.  For many residents, that kind of time commitment is a luxury they can’t afford.  So, we have great intentions to get to the gym 3 times a week… and next thing you know, a month has gone by with no trips to the gym at all.  One of the ways to improve consistency is to have a list of a variety of things to choose from.  Although it’s expensive in most cities, a gym membership will help.  See if it can’t be part of your holiday “wish list” for your family.  The other thing that should be on that list, by the way, is a maid once a week to do your laundry and clean your house.  Unless, of course, you want to use housecleaning as one of your calorie burning activities!

It’s a skill, and there are teachers

Most people know about cardiovascular training and have probably run, swam, or biked at some point in their life.  The nice thing about running, swimming and biking is that everyone can do them, often at any time of the day, and it doesn’t take a lot of money, or a gym membership to do.  But there are other options for cardiovascular fitness that you can explore – spinning classes, martial arts training, aerobics classes – when these are offered at gyms, there will always be a teacher to help you learn.

Even though the emphasis is often on cardiovascular training alone, fitness is a composite of cardiovascular, strength and flexibility training.  If you’ve never participated in team sports, and haven’t had a reason to be in a gym, there is a good chance you don’t know the basics about weight training.  You are not alone, and it’s normal to feel a bit intimidated.  You can find a fellow resident to show you, but, often they haven’t learned proper form, either.  It’s better to have a pro show you.  If you join a gym, there are several options.  Many gyms have circuit classes using free weights – which is a great combination of cardiovascular and strength training.  There are also personal trainers.  Although you probably won’t want to spend the money for a trainer on a regular basis, you can hire one for 2 or 3 sessions to teach you about each of the machines, and help you plan a workout routine or two.

Unfortunately, morning is usually the best time to work out

There are a few people who, no matter how tired they are can get to the gym, or go for a run after work.  If your day started at 5 or 6 and is ending after 5 or 6 (or 7 or 8 or…), most people are just too tired and the call of the couch is too strong to go workout.   In general, the most consistent exercisers usually get it done first thing in the morning.  For most medical students morning will usually work.  As you enter your residency, you are going to have to be more flexible.

Different days = different workouts

Call days are tough… and, for exercise, the day after call is the toughest of all.  The key here is consistency.  On the post-call day, don’t plan for long workout at the gym, but do plan for a 20 minute brisk walk when you get home.  If there is a way to have someone cover you for 30 minutes before morning rounds, go for an early morning run outside, or climb the stairs in the hospital for 20 minutes.  Don’t forget to plan in a day or two of rest, every week.  It’s tempting to use the post-call day for your recovery and that may be the best thing some weeks.  However, recovery from call is easier if it includes some working out.

Energy for Call

Food is fuel.  It’s also solice if you are stressed, and face it – it’s fun to eat. Other professions that deal with stress and physical labor have learned the lesson about not paying attention to nutrition.  The culture of medicine demands a “selflessness” that borders on the absurd.  It is often a badge of honor that you can go all day without eating.  But, when you consider the consequences of such behavior, it is really crazy.  There is no benefit to the patients, and clear harm to the doctor.

Eat often and eat well

When you are physically and intellectually busy (an average day on call in the hospital) you need to plan to eat every 3-4 hours.  In general, you will have one “meal” (i.e lunch) in the middle of the day and two snacks.  It’s not always going to possible to stop for lunch at lunchtime, but you should be able to find 10 minutes at some point in between 11 and 4 to eat a meal.  Different rotations have different demands, and you can certainly take this into account when planning your meals.  A peanut butter and jelly sandwich on whole wheat requires no preparation, and no refrigeration (it can even go in the pocket of your white coat).  Alternatively, buy a loaf of whole wheat bread every week, and put the bread, a jar of peanut butter and a jar of jelly in your locker. It takes 2 minutes to make a sandwich to put into your pocket on the way to a conference or a brief break.  Bring leftovers from the previous night’s dinner to reheat and have for lunch.  You need to plan to include fruits and vegetables as part of every meal and your snacks.  Buy a bag of apples once a week and put them in your locker.. and then make sure you eat the entire bag every week.  The snacks don’t need to be elaborate, but you do need to watch the clock and eat them – even if you are not hungry!

Examples of easy snacks for the hospital

  • “Meal replacement bars” (power bars, Luna bars, Kind bars etc)
  • “Meal replacement drinks” (Ensure, Boost, etc)
  • Skim milk with either graham crackers/peanut butter or a banana
  • Cheese stick and an apple
  • Melba toast or other crackers with sliced cheese plus some fruit
  • Yogurt