How to Succeed in Residency: Studying

Today is the “official” first day of residency. If you are one of the ~16, 000 new interns starting today I have good news and bad news. The bad news is that you are already behind in terms of what you need to know. The good news is that you can come up with a plan that will make a big difference. If you are a PGY2 or greater, this is a great time to reapply yourself to your studies – even if you let it slide last year.

 “The best time to plant a tree is 20 years ago.  The second best time is today.”  Chinese Proverb

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As an intern or resident, you learn your specialty from a variety of sources. Each of them is important. Some of your studying will be just like medical school with your gluteus maximus in a chair (or feet on a treadmill or ischial tuberosities on a bike or an exercise ball) reading a textbook. But the rest of what you learn is absorbed as you make rounds, attend conferences and take care of patients.

The challenge is organizing what you learn.

Sometime this week you will do your first central line, or see a case of bile gastritis, or attend a conference where they discuss a patient with a rare fungal infection. The amount of new information you will learn in these first few months will truly be astounding. But how is what you learned going to be available to you 8 months from now when you see the second patient with the same unusual infection? How are you going to be able to review what you have learned when January rolls around and its time for your in-training exam? At the end of your residency, will you be ready to take the boards?

There is no right or wrong way to create a system for studying clinical medicine, but there are a few principles that will help.

1.  Record what you learn as you learn it. 

There’s no way around it. If you really want to learn clinical medicine, you have to make notes. Until there is a good digital solution, start by going to work every day with blank 3×5 cards in your pocket. When you learn something on rounds, write it down on a card. When you look up something related to a new patient you are working up, write it down on a card. Make it brief, legible and to the point. If there are “hooks” (i.e. the patient had a tattoo of a star on his face) put it on the card. It’s how our brains remember. If there is specific information that identifies the patient, do not lose your cards! (It’s a HIPPA violation). To be safe, it’s better not to put patient names, ID numbers, etc on the card.

There is no way any trainee will see every disease or condition in their specialty, but being comprehensive in your studying will help.  For example, let’s say you admit a patient with dyspnea and an arrhythmia who turns out to have a Morgagni hernia.  This is rare, and it’s not likely you’ll see multiple cases during your training.  You make a card on how the patient presented and another card on what the treatment was.  But then you go to the literature and find a case of man presenting with an acute abdomen from a torsed accessory liver lobe in his Morgagni hernia and another case of an octogenarian who presented with dyspnea and constipation.  You have now created “virtual” patients in your mind that add to your pattern recognition. Most importantly, you do it at the time it means something.

One other important thing – don’t ever use scratch paper with plans to copy the notes later.  It just won’t happen. Make the notes once, no matter how bad they look!

2.  Be comprehensive. 

Find a major textbook in your field and write down every topic it covers. (BTW most textbooks are available at the library in electronic form, so you don’t have to actually buy the book) Make it your goal to cover the textbook in a year. Come up with a system to monitor your progress. This is the time to pull out your “Type A” personality to your advantage! Make a spreadsheet and check off topics as you study them and make notes for later review. But – don’t read the chapters in the order of the table of contents. If you are on call tonight and see a patient with pneumonia, read the chapter on pneumonia tonight. If you have time to make notes, great. If not, make your study cards from the chapter tomorrow. The idea here is to read each chapter once and make notes that are complete enough for your review so you never have to go back to the chapter again to study.

Alternates to the 3×5 card system

  1. Use 8×11 pieces of paper to record what you learn. Fold them up in your white coat pocket. Scan them with something like Scannable and then save the pdfs in Evernote with key words so you can search for them later. Don’t put more than one topic per page or you will have trouble organizing them to find information later.
  2. Use your phone. We are on the verge of having facile enough (and small enough) handheld digital devices to do this just as well (or better) than my 3×5 card system. The problem is being able to make your notes on the spot because the device isn’t with you. It never works to plan to make the notes later and, as I said above, it never works to copy notes. There are just too many things you’ll be writing down to make this work.  If you figure out a good way to use your phone for this, please let me know!
  3. Use your computer. There’s no reason you couldn’t type 3 lines of what you learned and email it to yourself, add it to Evernote, or save it directly to the cloud. The advantage of cloud storage is that all your notes are available all the time and are searchable. Just remember, most cloud storage like DropBox is not HIPAA compliant!  Don’t put any patient identifiers in the notes if you choose to use the cloud.

3.  Stay curious.

Being excited by what you are learning will always make it easier. “Set up habits that encourage, and don’t squash, your natural curiosity: Look up answers to your questions, not just subjects you are instructed to read about.”

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

William Osler

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3.  Repeat. Repeat. Repeat.

Learning is iterative. You don’t really know something until you have studied it multiple times over a period of a month or two. Don’t make your notes, file them away and pull them out the week before the in-training exam. Sit down once a week and just glance through them all.  Develop a system that lets you review them 24-48 hours after you make the notes, a week later, a month later, and 3 months later.

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“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

Starting Internship (I know what you are worried about)

I sat at the table this week with our new interns and the outgoing chief residents. Listening to our new interns as they asked questions, I realized everyone starting their internship has the same fears, whether or not they express them:  Will I kill or hurt someone?  Will I look stupid?  What if they find out I’m not as smart as everyone else?  Will I get divorced/separated/alienated from my friends?  Will I gain weight?  How am I going to find time to take care of myself?

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What you are feeling is normal. Every doctor who ever started an internship felt exactly the same way.  The best way to manage your (healthy) fear is to have a strategy.   I’ve written in the past about how to succeed as an intern.  But if I were going to condense that advice into three easy rules (for every day except your day off)  it would be these:

1.    Read at least one section from a textbook in your field every day

2.    Learn something (in detail) from at least one patient every day

3.    Do something to take care of yourself every day

 

Read at least one section from a textbook in your field every day.

Your goal for the year should be to read a major textbook in your field cover to cover.  You don’t have to buy the physical book.  It’s fine if it’s on line or downloaded onto your iPad.

Once you have the book, make a list or spreadsheet of all the sections in all the chapters.  For most textbooks, it’s probably going to be a list somewhere between 150 and 200 topics.  When you look at the 48-50 weeks you will be working this year, it works out to basically a topic a day (with some days for review).

The real goal is not just to read these topics, but to really learn them.  So, when you read, don’t just skim.  Read to learn.  That means taking notes – and reviewing them.

Put a chart on the wall with the list and give yourself a gold star when you finish a topic if you have to, but find a way to make sure you cover all the topics (at a steady pace) during the year.

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Learn something (in detail) from at least one patient every day.

It’s really easy, as an intern, to get caught up in the work and forget that you are fundamentally here to learn – not to provide service.  Make it a daily habit to learn in detail about one patient in your care.  It will overlap nicely with your goal to read a complete textbook.  When you admit a patient with pneumonia, read the section (and make notes) on pneumonia and then check it off your list.

One other important point (that none of us like to hear) – You will make mistakes. Be humble, be honest, and learn from your mistakes. The mistakes you make (and maybe more importantly your “near misses”) are absolutely your most valuable teacher.  When you do make a mistake, use it as the topic you will review for the day. You are going to be really upset but be easy on yourself.  Being upset is the mark of someone who cares, but don’t let it escalate beyond a healthy response. Talk to your mentors and senior residents.  They’ve been there.

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Do at least one thing to take care of yourself every day.

This may sound trivial, but it’s not. If you can, try to eat well, get some exercise and be social every day.  At a minimum, though, pick one specific thing you are going to do for yourself and then do it.

Eat well

Get Some Exercise

Be social

Getting Ready to Start Medical School

This morning we had a group of medical school applicants at Baylor for a “second look”. They asked some very good questions including the question that prompted me to write this post:

“What should I do to get ready to start medical school?

Set up your environment

The amount of material you will be asked to master in your first year of medical school is more than you’ve ever been asked to master before.  You have to approach it with a different strategy than you used in college.  One critical component of this strategy will be to keep up with the material – starting from the first day.

If you try to hook up your cable, organize your electricity and straighten out parking at your apartment during the first week, you will fall behind.  Take the time to come explore your new environment and get settled in at least a week before classes start.  A week doesn’t sound like much to miss, but it’s a significant amount of information in medical school! One of the important tasks to check off the list during the week you are settling in is to set up your study area.  Make sure you have a computer that will meet your needs and an area to study that is pleasant, ergonomic and comfortable.  Most students find a dual screen to be very helpful as you are moving through notes and slides to study.

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You’ll be spending 1-2 hours studying (at a minimum) for every hour of class.  Given the number of hours you’ll spend studying, you might want to think about an “active” desk that lets you stand, walk or pedal as you study.

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.  Your goal for the summer should be to develop a balanced exercise program (cardio, strength training and flexibility) that works for you.  If you’ve never done any strength training, hire a trainer and learn about it. 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 and it will be a lot easier to continue once the pressure of school really kicks in.

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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!

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If you don’t own a bicycle, think about getting one.  There will be places to ride for fun when you have time off.  You can also use your bike to commute to school which is a great way to sneak in exercise and save money.

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If you don’t know how to cook, learn.

Good nutrition is an important part of doing well academically.  It’s hard to concentrate and learn if you are eating junk. There is one simple trick to eat well during medical school: Learn to cook.  This is a skill that will become progressively more important as you enter your clinical work in medical school and then move on to your residency training.

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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Come to medical school rested.

Do not study. Seriously.  We will give you what you need and nothing you can do this summer will make it any easier.  It’s far more important to arrive rested and ready to go than to try to learn material that may or may not be relevant. Take a real vacation (or two). 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 in late, eat well, and just rest!

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Studying For the USMLE Step 1 Exam

The USMLE Step exams are important.  Even though they weren’t designed for this, many residency programs use these scores (especially Step 1) to decide who to interview for the NRMP match.  By far and away the best way to decrease the stress associated with this exam is to be prepared when you take it.

The best way to study for Step 1 is to start the process early.  As soon as you can (now, if you are in the first year!) look at examples of Step 1 questions.  This will give you an idea what to expect and will guide you in how to organize your studying.  The strategy for Step 2 will be similar.   Do this systematically – keep notes on your computer or in a notebook, or use the 3×5 card technique to make cards to organize and review later.  Whatever system you choose to use, be consistent.  You really can’t “cram” for the Step exams – it has to be a review.

In addition to developing a systematic approach to preparing for Step 1, it’s a good idea to spend dedicated time reviewing for the exam.  If your schedule allows, taking a full month or two to prepare for this exam is probably a good idea.  If it doesn’t, spread it out over more time, but devote the same amount of time.

The following recommendations are from two 4th year students on how to review for Step 1.   Use specific ideas that fit you, leave the ones that don’t.  There are many ways to succeed and not all of these recommendations will apply to you.

  • First week: Read quickly through First Aid cover-to-cover
    • This reminds your brain of everything you’ve ever studied and gives you the book’s lay-out
    • Read complicated or new information out loud
    • By reading out loud or skimming/reading quickly, it should take  about 6 days
  • Second week: Start UWorld as arranged in First AID
    • 46 “randomized” questions per set (2 methods of organization below)
      • Choose the organ system on the right hand side of the menu screen but not any subset groupings;
      • Alternatively, do biochem, behavioral science, and micro questions separately (everything for which there is a section in FA)
        • Then move onto organ system and the associated anatomy/physiology/ path/pathophys
  • Don’t worry about time at first, but ultimately you should be well under an hour/block
    • Practice good test-taking strategies
    • Read the last line of the question, skim the answer choices, read the full question for necessary buzzwords/data
    • No phone/gmail/chatting etc. during this time (it’s your “exam” time)
  • Take a 10 min break after answering all 46 questions
    • Do all the activities you put off – check your texts/email, go to the bathroom, read ESPN/NPR per preference, etc.
  • Review the answers from the 46 q block
    • Keep the 45-50 min “ON” study time (no distractions! No phone/email!) & 10-15 min “OFF” (see above)
  • Look up anything you don’t know / can’t explain to yourself
    • Make sure you really understand the explanation, but don’t get bogged down
    • Annotate any crucial information into First AID, using First AID as your primary textbook & notebook
  • Repeat above cycle until you have completed all q blocks for that organ system
  • Review associated First AID chapter (cardio, GI, etc)
    • Go over your freshly annotated chapter by yourself or with a study partner
      • “I sat down with my BFF and we took turns explaining each page & our annotations, covering details the other might have missed and adding mnemonics/stories.”
      • Review related annotations from other sections (micro/biochem/BS, etc)
      • Optional: listen to the related Goljan section while driving/exercising/etc
  • Repeat: Q-Block –> Review –> Annotate –> Q-block…etc… until you have completed all organ systems
  • Arrange some question blocks by topic (biochem/micro/etc)
    • You will already have completed all of these questions, but it is easier to review the First AID chapters for biochem/micro/BS if you take a couple question blocks to focus your mind
    • If you are consistently performing poorly on a non-organ based section, you can always interrupt your “organ based learning” and focus on your weak area for a couple of days using the above format (qs, review, annotate)
    • Identify weak areas based on score data & personal comfort
      • Retake question blocks, answers & related First AID chapter
  • If you have time during the last 2 weeks, as you go through First AID and your annotations in FA, write down everything you don’t know (don’t get stressed out if you end up writing a lot of stuff down…I think I had 1-2 pages handwritten front and back per section at this point). Then study only your notes and stop looking at First AID. The rationale behind this is that you don’t want to spend too much time rereading the stuff that you are 100% sure you know at a time when you should be focusing on what you don’t know. Note: you may need to start this while you’re still going through UWorld questions, but I think it’s worth your time.
  • Last Week:
    • Review First AID from start to finish with emphasis on weaker areas
    • Continue with random blocks of questions or NBME purchase exams to keep in “practice question shape”
  • Last couple days
    • 2-3 days before:  review behavioral sciences, write down any formulas for memorization, cram “regurg” factoids/formulas/graphs, cram the things in your notes that you still don’t know
    • Day before: NOTHING
      •  Hang out, relax, distract yourself, go to a movie…
      • You’re not going to change your score for the better by studying/stressing now (but it might make you fatigued the next day)
      • Pack your bag with all your documents, directions, First AID, notes for the next day (& lots of food) so you don’t have to worry in the morning
      • Try to sleep (you’ll be nervous but do your best!)

       

PRACTICE EXAMS

  • There are many opinions on how to best use practice exams.  The timing of them is as much an emotional consideration as a fact-based or practice based benefit.  Here’s one way to organize the practice exams that has worked for some students:
  • 2-3 Weeks into studying: Free NBME practice exam
    • Get a sense if you are on track, this score will underestimate you’re final score
      • If close to your goal, the score can be reassuring that you should keep doing what you’re doing
      • If significantly lower, the score can be motivation to pick up the pace/cut out distractions

       

  • 1 week before the exam: 2x 4 block UWorld practice exams
    • I took all 8 blocks back-to-back to simulate the exam experience (timing of breaks, fatigue, etc)
    • Do NOT review the answers on the same day, in fact, you should probably take most of the next day off to recover
    • Use the results as a comfort that you are on track (my actual score was 1 pt off my practice exams —- and despite fatigue & feeling like my second block of 4 was worse, I actually got identical scores throughout)
    • Look at the stats and focus on any weaker areas (my weakest areas became my strongest by the actual exam)

     

  • Last week: fee based NBME Exams
    • I paid for NBME 7, which tells you your estimated score, your percentile in each area, and reproduces the questions you answered incorrectly (but does not give you the correct answer) – again, within 1-2 pts of my final score
    • I worked through many of the exams (some easier, some harder than the my step) during the last week as a way to practice the random mix of qs….I found it helpful
    • Some of the questions on the NBME practice exams were on my REAL Step exam

 

BALANCE!   You’re job is study and do well on this exam —- but it can be very stressful, even just on a subconscious level.  For most people it works better to really structure your time.

Keep work hours:  go to a library/coffee shop/school on a regular schedule

  • 8 am – 5 pm (5/7/8 pm…whatever you decide)
  • Taken an hour off for lunch & hang out with friends
  • Go home & be DONE until the next day (get good food & sleep!)
  • Keep a life
    • Partner, work-outs, family, etc. should be in your life every day
    • Take at least one day off a week at the beginning

 

RESOURCES

  • First AID & UWorld: you must use & love these, everything else is just bonus
  • Others (Wiki, BRS, textbooks, Goljan, etc.)
    • Resources other than FA and Uworld will not help your score significantly.
    • Use them to explain specific questions or concepts from UWORLD or FA that you don’t understand or can’t remember
    • Use them if for some reason you have a ton of extra time and already know FA and Uworld like the back of your hand
    • If you choose to use external resources, BRS physiology and the first part of Goljan Rapid Review Path (through the neoplasia chapter) might be worth your while, but seriously don’t worry if you don’t have time to get to them.

 

Traci Fraser and Natalie Gwilliam, Class of 2012, Baylor College of Medicine


The Best of Wellness Rounds 2011

HAPPY NEW YEAR TO EVERYONE!

Advice for interns

Why I hardly ever drink diet drinks

How to choose your specialty

What to do on your day off

Studying basic sciences – strategies for success

Studying clinical medicine

Getting (and staying) motivated to exercise

How to succeed on clinical rotations

Gifts for medical students and residents

Why I’m spending more time on Twitter

How not to have sore feet after a day in the hospital

How To Succeed In Medical School

Yesterday was the first day of orientation for the new medical students at Baylor.  One of our traditions is to announce the winner of the DeBakey Scholar Award at the beginning of orientation.  The DeBakey Scholar award is one of the most prestigious awards given at Baylor; it is awarded to the rising senior whose academic success and character best emulates Michael E. DeBakey.  This year’s award winner, J. Mason Depasse, was asked to give some advice to the new class of medical students.  His remarks were so exceptional I asked his permission to post them here.

Welcome and congratulations on your admission to Baylor College of Medicine. My name is Mason, and I spoke to many of you during your interview day and second look weekend, when I told you why I loved Baylor. I hope that, after your retreat, you are already beginning to love it here as well. You made an excellent choice, and you will appreciate that more and more as you progress. I could go on and on about what makes Baylor great, but today I’m not here to talk about that. Today, I’m here to talk to you about how to succeed in medical school.

I remember my first day of orientation, and I know the mix of anxiety and excitement you are all feeling. I’m sure you have been told about the flood of information coming your way, and many of you may already be bracing yourself for the impact, particularly those who have had time away from biology or those who have an eye for a highly competitive specialty. While nervousness is perfectly natural, I want to stress that, when the material starts building up – and if you remember nothing else from this talk, remember this – you should not panic. Don’t freak out. People from all manner of academic backgrounds do it every year, and no matter what you’ve been doing or studying for the past four or ten years, you will get through it. It might take a little elbow grease, but you’ll make it.

To help you get started on the right foot, I’ve compiled a short list of things to keep in mind as you begin the basic science curriculum.

First and foremost, try to keep up. This is far harder to do than it may sound, but try your best not to procrastinate. The easiest and most reliable way to successfully tackle any seemingly overwhelming task is to break it into stages, and absorbing the enormous volume of information in basic science is no exception. In college, most of the testing in the sciences focuses on concepts, particularly for upperclassmen. You studied a set of rules for how to calculate electric fields and… something about nucleophiles, and you demonstrated that you could apply those rules. You all have the aptitude and the study skills to succeed in those courses, or you wouldn’t have gotten into medical school. Unfortunately, these skills will not be as effective here because you can’t outsmart basic science. You can’t do it. It’s a whole world of knowledge, and as our professors told us, you just “gotta know it.” You have to put in the hours, and keeping up with the material by regular studying makes this manageable. Get into a routine, and try to stick to it. And when you get a bit behind, and we all get behind at times, catch up as soon as you can.

Second, find a way to study that works for you. This may sound obvious, but I’ve seen students become concerned that they are not in a study group, or aren’t making flash cards, etc. But study groups and flash cards may not work for everyone. There is no “wrong” way to study; if it works, then you’re doing it right.  Your PRN leaders can give you all manner of suggestions for study tips and tricks, and you should feel free to try them out. You have a practice diagnostic exam before your first set of real exams, and you should use it to determine whether your method is working. But even when you find a strategy you like, your study method may not always work. Medical school is a long haul, and there are a lot of different challenges to face. Keep in mind that succeeding here is about adapting and persevering in the long-term. I wasn’t always happy with my performance, I was frustrated at times, but I found that it’s not worth beating yourself up about it. Adjust and prepare for next time.

Third, use your resources. Your professors will provide you with documents and powerpoints of their lectures, and these will sufficiently cover the material. However, you may find it helpful to supplement your reading with outside sources. Don’t overwhelm yourself, but there are all manner of texts and reviews available. Even looking over a topic in First Aid, the Bible of USMLE Step 1, can be helpful for solidifying your knowledge. Furthermore, don’t be afraid to ask for help. Baylor has a culture of cooperativity. Your classmates, your PRN leaders, upperclassmen, and professors are all here for you and will be happy to provide advice and support.

Fourth, stay balanced. Medical school can be very demanding, and it is easy to burn out if you don’t take care of yourself. Go out with your friends. Join IM sports. Go to the gym. If you’re applying to orthopedics, go to the gym again. Whatever you do, take a break. Two productive hours of studying are far more effective than four hours of staring blankly at the same page. Believe me, I know. There will be weeks along the way during which you will work a ridiculous amount of hours and balance isn’t really feasible, and when those come along I recommend trying to make it up afterwards.

Finally, once you’ve gotten settled into a routine, be aggressive. You’re here because you want to be physicians, and you’re paying through the nose for it – though not quite so much at Baylor. Thankfully, you chose an institution with just about every opportunity for research, service, and clinical experience that you can imagine. Seize them. Join student groups. Email professors you want to shadow or work with in the lab. Go to Ben Taub and learn how to start IVs and suture. When you’re on clinics in what feels like forever from now, I want you to remember that you are the only member of your team who is paying to be there. So get your money’s worth. Know your patients, and I mean really know them, and imagine that you are making all of the decisions. Think of your own treatment plans, and ask questions if yours differs from the final one. Medical school shouldn’t be four years you just have to get through in order to become a physician. Don’t let medical school just happen to you. Medical school is your chance to sample the spectrum of clinical medicine and gain the experiences necessary to begin forming more concrete career goals. So once you’ve got your rhythm going and you’re comfortable with your routine, I strongly encourage you to get out there and explore.

J. Mason Depasse, MS4

 

Starting Medical School: Strategies for Studying

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!

Advice for New Interns

The summer is the time that the roughly 16,000 new doctors in the United States start their residency training. For all new interns, even though it doesn’t feel like it, you are ready!  The first year of medical school gave you the “vocabulary” you needed for this new language. The second year gave you the “grammar.” Your rotations in the clinics taught you the “language”.  Now you get to actually use it every day!

This year will be one of the most profound transitions you will ever make…. and it will also be a year of intense and fabulous memories. Take some time to write down the stories, or take some photos (but not of patients unless you have their permission!). These notes and images will be precious memories in the future.

In talking to other physicians and thinking about my own experiences, here are a few words of advice for you as you start your internship:

Learn from every patient.

As an intern, you will need to know a lot of detailed information on your patients. You’ll need to use a system to keep track of all this information so that when you are asked, you know the last potassium level, which antibiotics were ordered and what the ID consultant said. If you have a system you developed as a 4th year medical student, great! If not, start with 3×5 cards. Keep one card per patient, clipped together or held together with a metal ring. In the era of the EMR, much of the information you need can be easily accessed… but not really organized the way you need it. If you have developed a good system that doesn’t require physical cards, please send me a message so I can see it!

That covers the information, but not the learning. Learning is something that should be actively integrated into your day, not something you do at night when you are falling asleep. Work on a system that lets you record what you are learning during your daily tasks in a way you can review later. 3×5 cards are a simple, cheap and very effective system for studying medicine, which I’ve described in a previous post. Make a separate card (or use the back of your rounding card) to list something (anything) you learned from every patient you see. p.s. Don’t lose your cards!!!! (HIPAA violation)

Don’t confuse gathering information with studying information. Taking notes is a critical part of learning. Don’t just store chapters and articles in your Google drive… summarize them to review later by taking notes.

Be the doctor for your patients.

This may sound obvious, but in the everyday world of the hospital, it is really easy as an intern to get lost in the details of patient care… and forget about caring for the patient. Stop every once in a while and remember that you really are their doctor. Take a few deep breaths and put yourself in their shoes for a minute to ask something about their family, hold their hand, or just sit with them for a minute.

It’s very easy to get swept away by the velocity of the work most interns experience and lose the “big picture”. When you are confronted with something you haven’t seen before, push yourself to make a plan before you call your upper level resident or the attending. What if you were really the only doctor around? What would you do? Spend 2 minutes on UpToDate if you have to, but don’t just be a clerical worker – be their doctor.

Part of being a good doctor to your patients is to recognize your own limitations. You should never feel bad about calling someone with more experience, no matter how “dumb” you think the question is.  It’s the right thing to do for the patient.

Be deliberate about learning your field.

From day one, commit to an organized plan of study to cover everything you need to learn in your field. Make a plan to read (and then study to learn) a textbook every year. Make notes that are easy to review, so you don’t have to go back to the textbook to review the material.   Whatever system you use, make it easy to integrate the notes you are making in the hospital (e.g. the 3×5 card on each patient) with your organized study system. Adding articles into the mix is fine – but only after you have mastered the basics. Don’t let reading the latest finding take the place of really learning the material in the textbook.

Be kind and be part of the team.

Hard work is made easier when it’s done with your friends. You will all be tired, you will all be stressed, but be kind to each other. Staying 5 minutes more to help out a fellow intern is an investment that will help both of you. Look for ways to apply the golden rule of internship:  “Help others the way you would liked to be helped”.

Make your bed.

Do this simple act every morning to remind yourself to take care of yourself. Find time to consciously take care of your emotional, physical and spiritual health. Take good food to the hospital for your nights on call. Find ways to get stress reducing exercise into your weekly schedule, or at least find ways to increase your activity while you are at work. Watch your weight – if you are losing or gaining, it’s a sign that you need to focus on your own well-being by improving your nutrition and working on your fitness. Nurture your relationships – make your family and friends a priority. Take care of your spiritual needs in whatever way is best for you, but don’t ignore this important aspect of self-care.

Smile!

You have the enormous privilege of caring for other people and learning the art of medicine. Take a little time every day to notice the moments of joy in this work and, if you can, write them down to look at on the days you are tired.

Congratulations to you for all you’ve accomplished thus far!  Enjoy this incredible journey!

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

Exercise Balls

Here’s a great post from a medical student on exercise balls.  I’ve added some links at the end of the post if you are interested in learning more. 9 Of The Best Stability Ball Exercises You’re Probably Not Doing

 

First of all, I wanted to tell you how much I’ve enjoyed your blog. I started reading it about 7 months ago when a friend suggested it. I especially appreciate the recipes and notes on working out (great running post !!!!).

While it’s not a major topic, I did want to suggest you might do a post about exercise balls. I’m going to rave a bit, but that’s the gist of this comment. I got one last year when I noticed that while I was able to stay aerobically fit with an efficient running routine, I was too busy to do consistent weight-lifting and ab exercise.

The exercise ball has been AMAZING – I use it as a study chair to keep myself awake if I’m especially restless or sleepy (it works!) and I take 3-5 minute “ab breaks” fairly often when I’m studying to work my abs and refocus. The results have far exceeded my expectations. It’s more effective (for me) because it adds consistency to ab workouts, which I’ve found especially critical to seeing any improvement at all. My back also tends to stiffen up a lot when I study for hours on end and switching to sitting on the ball alleviates that tension/stiffness, as it forces me to engage “core” muscles.

There are countless free online tutorials for different exercise ball workouts (abs, arms, back, etc) for those interested in getting creative.

Given your post on push ups, I might add that I use the ball for push-ups as well to get emphasis on those core stabilization muscles. Also, these are CHEAP (less than $20 from plenty of sites found through Amazon).

Katy Bowman

Choosing and Using an Exercise Ball from about.com

Core exercises with a fitness ball from mayoclinic.com

10 Reasons to Use an Exercise Ball as Your Chair