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

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.

Starting Clinical Rotations: Practical Advice

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.

Why You Should Eat Breakfast

Most of us start very early in the morning and have a variety of excuses why we don’t/won’t eat breakfast, most often “I’m never hungry this early” or  “I’m in too big a rush”.  You don’t have to go to medical school to realize that your blood glucose levels will be low after 8-10 hours of no food.  It’s why things like donuts and sweet cereals are so popular for breakfast  But a quick infusion of sugar to spike your serum glucose leads to a spike of insulin which leads to hypoglycemia.  Not a good idea if you want to stay awake in class or be sharp when seeing patients.

It’s much better to eat a breakfast with carbohydrates, protein and little fat if you want to sustain your glucose levels.  There are a lot of other advantages to eating a good breakfast.

No one with a busy schedule is going to spend time preparing a “fancy” breakfast in the morning.  But there are many, many good options that don’t take any time at all.  I’ve listed some great websites and recipes below – but don’t limit yourself to these.  Look into typical breakfast choices in other countries, eat the leftovers from last night’s dinner…. Just don’t skip breakfast!

15 ways to eat a beautiful breakfast

18 Quick Breakfast Recipes for Busy Mornings

12 Smart Ideas for Breakfast On the Go

“Failure”

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!

Osler’s desk

Sir William Osler was probably one of the most prolific, most loved and most respected physicians in American history.  Osler is credited with the concept of journal clubs, with being responsible for bringing medical students onto the wards for “clinical clerkships” and for the structure of the modern medical residency.   Osler is also famous for quotes about medicine and teaching medicine.  But, for this post, I want to focus on something that recently caught my eye … his desk.  Osler wrote the first definitive textbook of Internal Medicine in the United States, The Principles and Practice of Medicine.  I can only assume that a lot of his writing took place at this desk:

Which made me look at my desk and think about desks in general.  There are many of us, particularly in the era of the laptop computer, who use our desks as storage space.  But maybe we are missing an opportunity.  What if, instead of stacking things on our desks, we actually created a space that made it easy to study, read, think and be creative?   Organizing your desk will unquestionably lead to being more productive.  But being productive isn’t the only goal. It’s also important to create a space that makes you look forward to spending “non-productive” time thinking, dreaming and being creative.

Organizing a desk.

  • Keep pens, highlighters, etc that you use in a holder – but only the ones you use.  Get rid of the pens that don’t really work, and the ones you don’t like.
  • Declutter the surface of the desk by hiding electronic wires, filing stacks of papers, etc
  • Keep a scratch notebook on the desk to replace scraps of paper.  Use it for phone messages, ideas, etc.
  • Keep the surface clear of everything except what you are working on (and put it away when you are done)
  • Position your computer screen so it’s ergonomic

Personalizing a desk (and the space it lives in)

  • Make sure you have a great (and very comfortable) chair.
  • Get a really good light.
  • Make sure the area is quiet
  • Keep the area decluttered to decrease visual “stress”
  • If you listen to music when you work, get good speakers for your computer (or a good sound system)
  • Put things in the space that motivate you – art, photos, quotes, etc

Tips for an organized desk from Productivity501.com

Taking Notes

There was a really interesting article in the New York Times this morning on new technologies that help with taking notes.  The focus of the article was Livescribe, a pen that records what is being said at the time it is being used to write (so you can play back what you missed later).

Medical school is a lot different from other educational experiences.  Most of the time, you will be given notes for your classes (either powerpoint slide handouts or a syllabus).  So, it’s not so much about taking notes, it’s about how you organize that information, annotate it and then review it.   I’ve already covered some general advice about taking notes in basic sciences, during clinical rotations and during your residency, but I didn’t really go into how to organize that information.  After reading the article this morning, it struck me that there really might be some new technology out there which might make this task a little easier  In the spirit of full disclosure:  I haven’t used any of these, so this shouldn’t be taken as an endorsement!

Perfectnotes.  This is software that, much like the pen developed by Livescribe, creates an audio recording of a lecture while you are taking notes on the computer.  It creates a timeline that links your notes and the audio recording so you can go to specific points in the lecture, rather than having to listen to the entire lecture.

Notescribe.  This is a desktop and/or online note taking software.  It looks well designed and has the benefit of being able to search your notes by category, key words, sources, etc.  It also has the ability to share notes between people, which would be very helpful for study groups.   The online version gives you access to your notes from any computer, which would be very handy on clinical rotations or as a resident.

OneNote.  This is a Microsoft product for organizing notes.  If you take notes during class from PowerPoint slides provided by the professor, this program can link your notes to the source document. You can share your notes or create “common” notebooks using the OneNote web app

Evernote This is a great program for organizing your peripheral brain for the clinics, but probably not as powerful for taking and using study notes. For the Mac, there are several other options similar to Evernote – for example:  Circusponies NoteBook, Aquaminds Note Taker, Soho notes,  and Yojimbo

From a forum on studentdoctor.net I found this advice: “The cheapest and easiest thing is to print powerpoints to pdf, then use the annotate tool in preview.app to make notes directly on the slide. From there, you can drag and drop the pdf into iTunes, and manage all of your pdf’s in there (just like music files).”

Any and all comments or suggestions are welcome either by commenting below or sending me a message!

How to Study in Medical School (Basic Sciences)

Tomorrow is the first day of school for the Baylor medical students so I thought I’d write this to welcome everyone to the fold!  That goes for the rest of you at other medical schools as well – you are now part of the field of medicine and we’re glad you are here!

The classes you will have and the way you’ll have to study are completely different from what you experienced in college.  So I thought I’d share a little advice to expand on the rules of the road.

1.  It all matters.

Unlike college, you don’t get to choose your courses.  And, during the first year or two there are no electives  – they are all required.  So, the first big difference from college is that you don’t get to choose what is important.  There are a lot of people who have worked very hard to integrate your curriculum, so the good news is that a lot of it should be related (and therefore easier to learn).   One of the nice side effects of this system is that everyone in your class takes every course… so it’s a team effort!

2. Some of it doesn’t matter.

I know this sounds a little contradictory, but bear with me.  The first year of medical school is designed to teach you a new language. There is a huge vocabulary to master before you can move on to speaking this new language.  Some of the vocabulary is necessary to be fluent, but won’t be critical later when you start seeing patients.  Unfortunately, when you start, there is no way to distinguish which is which.  Probably the most important thing to take home from this idea is that you have to force yourself to make sure you have the concepts down before you set out to memorize a lot of details.

3. You just spent 4 years learning how to think and now you’ll have to memorize lists.

I think this is one of the hardest parts about transitioning to medical school.  It’s not that you won’t be asked to think (trust me!), but the first task is to teach you the language.  Unfortunately, that means a lot of memorization.  Until you understand the names of the muscles, enzymes, etc it’s hard to learn how they function and… more importantly, what happens when they don’t function the way they should.

4.  You have to “use” going to class to learn.

At Baylor (and I assume most medical schools), the basic science classes are video recorded and are available on line.  In addition, our students are given notes, slides, handouts, etc for each class.  That means that it’s possible to skip class and still have access to all the information.  You can learn this way, and do well, but it’s not optimal.   In college, most of the time, you heard new information for the first time in the classroom.  That was followed by assigned reading, note review, studying, etc to learn the material.   You can follow that paradigm in medical school and do well – but it’s not as efficient.

Here’s the ideal way (my opinion) to “use” going to class in medical school.

1.  The day before the class, read the notes and assigned reading.  You won’t know this material, so don’t get bogged down!  This is really more “skimming” that studying.  But – when you read, make sure it’s active, not passive. (no “in one ear and out the other”).  The best method I have found for active reading is the SQR3 method:

  • Survey – Look through the notes (and any assigned reading) 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 this material and write them down (this part is actually important, so take the time to write them down!).
  • Read – Read with intention to answer the questions you generated and make some notes for later review.  Take the time to actually write the answers to the questions you generated if you found the answers.  If not, leave it blank to be answered in class the next day.
  • Review – Look over (quickly and once) the notes you made and questions you answered.
  • 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.  (better not to do this in Starbucks, though…J..)

2.  Go to class to hear the answers to your questions, make sure you get answers for any unanswered questions, and to create new questions you didn’t think of.  If there is something you don’t understand, or one of your questions wasn’t answered – ask!  I tell my classes all the time that there is no such thing as a stupid question.  If you are thinking it, chances are there are at least 10 other people wondering the same thing.  Ask out loud (to help the other 10 people) or, if you prefer, ask the professor after class. I also ask my students to email me questions they have or things that weren’t clear from my lecture. I post their questions (with the answer) on the first year class listserve (without their names) so everyone in the class benefits from the question.

3. In the afternoon or evening, after your classes are over, sit down with your notes, the handouts and any assigned reading.  Study it.  (The SQR3 method ) Then make a one page summary for each of the lectures – concentrate on the concepts and what you think is most important.   For anatomy, this might be a drawing rather than words. This will be the sheet you use to review before exams, so make sure it has the basic concepts as well as the important “vocabulary” (i.e. memorization) that you’ll need to know. Take the time to list what you think might be on an exam i.e. what questions you would ask if you were writing the exam. Force yourself to stick to one page. It’s how you process and condense your detailed notes into the overview and big points that you will need later in the clinics.

4. Review the material again the next day and a week later.  This review (which does not take long) is the most important step.  It truly is what makes the difference between learning the information and cramming before the test.

What this means, as an example, is that on Wednesday afternoon/night you will

  1. Review all the lectures from Wednesday with the goal of making a single review sheet for each lecture (this is real studying)
  2. Prepare for all the lectures on Thursday by actively skimming (note, this is not really studying) the notes and assigned reading for the lectures
  3. Quickly review your notes from Tuesday’s lectures
  4. Quickly review your notes from the lectures 1 week before

By the way – even though you will be working very hard, this is going to be a wonderful year!  Learning a foreign language is exhausting but exhilarating.  You have worked hard to get here, and you will do well.  Like everyone else who has gone through this, you will become fluent – and learn that it is a remarkably beautiful language.

Studying in Medical School – Making it Relevant

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.