How to Study During Your Residency

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Creating Your “Peripheral Brain”

My last post was about how to keep track of the information you are learning on different services.  http://wellnessrounds.org/learning-clinical-medicine-tips-for-the-hospital-and-clinic/

A related, but slightly different issue is the best way to create a “peripheral brain” for your clinical work.  Every medical student and resident creates their own “peripheral brain” to access reference material that they use on a regular basis.  In it’s simplest form, it can be a list of phone numbers for the rotation, faculty dictation numbers, etc.  In a more advanced form, it can include normograms for drug dosing, tables for probability of survival in the ICU,  lists of attending preferences for patient care, etc.

The internet has become a vast  “peripheral brain” for everyone in medicine.  We all use it to find information.   But it’s not ideal because it’s not specific for your needs.  For reference material you need over and over,  it’s more effecient to have it with you.   Unlike the system I described for studying (which is based on 3×5 cards), your peripheral brain should be digital.  My current recommendation for students and residents is to use Evernote.

In a nutshell, here’s how Evernote works:

1.  It’s free. (You can pay $5/month for the Premium version to have your data encrypted and to increase your storage, but you probably won’t need it)

2.  You create “notes” that are stored on a server by Evernote in your account.

3.  “Notes” on Evernote are more than just notes you type – they can also be photos you take, voice recordings, websites, clippings from websites or articles (tables, graphs, normograms, etc), pdfs, scanned images or text.. you get the idea.  Anything that can be stored digitally is a “note” in Evernote.

3.  You can access your notes on any computer, on your desktop (i.e. separate from the internet) and on your smart phone.

4.  You can search your notes.  This is by far the most amazing part of Evernote.  In essence it converts your notes to your own personal “Google”.  Evernote has text recognition for photos which really increases your ability to search.  For example, if you take a picture of a business card, you can search for it by any word that is on the card.

One big caveat.  Do NOT put any information about patients on Evernote.  Even if you pay for the encrypted version, it does not meet HIPPA requirements and you are breaking the law.

Here’s some links to more information about using Evernote:

http://academiclifeinem.blogspot.com/2010/02/evernote-redefining-my-organizational.html

http://computersoftware.suite101.com/article.cfm/why-evernote-is-made-for-medical-students

http://www.healthline.com/blogs/medical_devices/2008/09/evernote-for-doctors-revisited-privacy.html

http://efficientmd.blogspot.com/2008/08/how-doctors-can-use-evernote-as.html

http://www.screencast.com/users/rmacdona/folders/Default/media/63f89060-271d-405e-a544-d463ee267a2c

Learning Clinical Medicine: Tips for the Hospital and Clinic

“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.

Every day you are in the hospital or clinic is a day you will learn something new.  You will see patients with conditions that are new to you and procedures you have never seen.  You will attend conferences and lectures on topics that will be new to you.   It’s a huge amount of information.   A year later (or even a day or two later), most of this new information will be gone if you don’t develop a system to review and learn it.

Keeping track of what you are learning in clinical situations is a simple database problem – You need a simple way to record the information and a way to file it so you can find it again.  Whatever system you devise has to be carried in a white coat pocket and has to be easy to use “on the job.”   Technology will prevail, I’m sure, and an electronic based system that meets those criteria will be possible in the future.   Until then, this is a system that will work. And – you can make it “searchable” and electronic by scanning into Evernote.

Where do you learn new information as a clinician?  On any given day, you will likely

  • Interview a patient with a disease you have never seen before
  • See a procedure that will be done in a way you have never seen before
  • Attend a formal lecture, like grand rounds
  • Attend a teaching conference, like a tumor board
  • Read a chapter in a textbook
  • Read an article pertaining to one of your patients

The system described here is cheap, portable, and it works.  It lets you take information from this wide variety of sources and collate it into a usable database.  It starts with buying unlined 3×5 cards and putting them in your pocket.   3×5 cards work the best because they fit in a shirt pocket.  Larger cards tend to get left behind.  When you buy the cards, buy a file box (at least 8-12 inches long) to store them, as well as a set of alphabetized file markers for the box.

When you pull out a card to make notes, start by putting a small rectangular box in the upper left hand corner.  This box will be used (for a label) to file the card later.  You can develop your own system, but for most people the easiest way to label the cards is an anatomic system e.g. “Biliary tract, gallbladder, cholecystitis” or “Lung, pneumonia.”  There will be a few exceptions – there’s not a good organ to file general information about bacteria or antibiotics, for example, so you’ll want to use “ID, bacteria, gram negative, Pseudomonas” or “ID, antibiotics, aminoglycosides, gentamicin”.   You’ll most likely fill in the information on your card in pen, but you may want to fill in the label box in pencil.  As you progress in your career, you’ll realize that you originally filed leukemia under “Oncology”, but you really rather have it as “Blood, white cell, leukemia”. If it’s in pencil, it’s easy to change.

General rules for the 3×5 card system

  • Always have cards with you
  • Never make notes with the intention of putting them on cards later.  Always take the notes directly on the cards.  If they are really messy and you want to redo them, great – but have at least one set of cards with the info to start with.
  • Always put the date you made the card and the source
  • File them when you get home

Most of the cards you’ll make will come from these 6 sources:

1.  Lectures or grand rounds.  Depending on the lecture, you may end up with 5 or 6 cards.  Number them to keep them in order. When you look them over later, you may want to highlight the 2 or 3 most important concepts you learned.  Even better,  you may want to make a separate card with those key concepts.

2. “Pearls” cards.  On rounds when the attending gives you the 6 reasons a fistula doesn’t close, write it down on a card.  Put the name of the attending and the date at the bottom.  In the operating room, when the chief resident pimps you on the critical anatomy for deciding if a hernia is direct or indirect, remember it – and then at the end of the case make a card.  If on rounds you get assigned something to look up at home, make the card and have it in your pocket the next day.  This is also a great way to record mnemonics.  It’s hard to remember lists of things, so use mnemonics liberally when faced with a list to memorize.  For example, the 6 reasons a fistula does not close spontaneously can be remembered by “FRIEND” : Foreign body, Radiation, Infection/Inflammation, Epithelialization, Neoplasm and Distal obstruction. There are many famous mnemonic in medicine, some of which you couldn’t repeat to your mother.  If there is not a common usage mnemonic, make one up yourself.  They really work.

3.  Patient information.  This is probably the most important card you will make.  Put the patient sticker on the end of the card, or at least write down their number and date of birth.  You want to be conscious of patient confidentiality, so, be careful about information that could identify the patient if the card was accidentally lost.  Put the “hooks” that will make you remember this specific patient.  If your patient is an 80 year old lady who knit you a red hat, make sure that goes on the card.  Then put what you learned about the patient’s disease from this specific patient.  How many days did she have symptoms?  What did she report that was different from the textbook”?  What treatment did you use?  Did it work?

4.  Procedures.  I must have watched 30 or 40 different people repair an inguinal hernia.  Each of them had some minor variation or “trick” that make the exposure easier, or the results better.  When you watch a procedure, try to find those details and then write them down.  Consider this a “procedural patient card”.  Put the same memory “hooks” on this card – details that will let you remember this specific case.  You can do this for any procedure, not just surgical procedures – lumbar punctures, central lines, radiological procedures, cardiac catheterizations, etc. etc.

5. Chapters.  When you admit a patient with Crohn’s disease (for example), read the chapter.  And then carefully and completely summarize the key points on 3×5 cards.  As you do your annual reading of the textbook, make your notes on 3×5 cards. Do it once, compulsively, and you don’t ever have to do it again.  When it’s time to review for an exam, you can just use your cards.

6. Articles. When you take the time to pull articles for a presentation, or just to better understand a patient you are caring for, make cards.   Most articles will have an introduction that summarizes  what has been written before that will serve the same purpose as a chapter in a textbook.  But the reason they are publishing is because they are adding something new to the literature.  Make a list of the 2 or 3 key points they are making in the article.

It is incredible how many cards you will add in a week to your “database.” In an average day, you may see 3 new patients, attend a lecture, learn 3 key new points on rounds and sit through a teaching conference.  At the end of the day you will have made 10-20 new cards.  With almost no effort, you have added substantially to your file.   When it comes time for exams, particularly if you have been diligent about making notes from a textbook, you can use the cards to study. More importantly, as time goes by, it adds to your ability to teach.  Let’s say that overnight your team admits a gentleman with diabetic ketoacidosis.  You have teaching rounds that afternoon so, in the morning, you go to your file and pull out all your cards on diabetes and DKA to bring with you to work.  You have, in your pocket, clipped together, notes from 2 grand rounds, 5 patients you admitted and cared for, 4 articles you read, and a chapter.  During the day, you can spend 5 minutes here and there reviewing your notes.   You’ll have a real grasp on the topic and the important points.  You’ll look like a star on rounds!

Getting Ready for Your Internship

Everyone who has ever graduated from medical school worries that they aren’t ready.  If you aren’t a little worried, there is something wrong.  It’s a big transition!  But, that being said, I can reassure you that first, you are in good company; every new graduate feels the same way!  Second, your attendings and senior residents understand.  Not only did they feel the same way, but they’ve been through it a few times before with other interns.  They are there to teach you and help you learn your field.  It’s not always going to be easy, but you are never going to be completely alone as an intern – there will always be someone there to help.

Many of you will have the feeling that you need to review everything from medical school in the next 2 weeks, and read the entire textbook in your field after that.  STOP!  It won’t help and it will drive you crazy!  Here’s what I recommend instead:

1.  Develop a new exercise routine that you can stick with when you get really crunched for time.  Figure out something you can do for 20 minutes every day consistently.  After you move in to your new place (assuming you are moving to a new town), check out the gyms near work and/or your home.  Joining a gym should be a top priority.  But – you may want to wait until you’ve been at work for a few weeks.  There may be a preferred gym for most of the residents, and that’s the one you should join.

2.  Think about how you are going to eat well as an intern…. which is VERY hard.  Find the good grocery stores, prepared food places, take out (healthy) restaurants that are near where you work and/or live.  Read about nutrition, ask your family for favorite recipes.  Take a class or two to learn easy cooking techniques.

3.  Do spend a little time thinking about your new role.  You are going to have to master your field in a short time (it sounds long now… but just wait).  This is a good time to go through your medical school notes and take out the ones you know you’ll use during your internship.  Don’t read or study, just organize them so you can find them again when you need them.  If you know which textbook is the most recommended in your field, this is a good time to get it.  Don’t study … just skim through it.  You are NOT expected to know it yet, so don’t let this scare you.  Instead, take some time to marvel at all the amazing things you are going to learn, and the people you are going to be able to help with that knowledge and skill.

4.  Take a vacation.  I’m serious.  Spend most of this month visiting family, reading novels and hanging out on the beach.  Read poetry, call friends.  You’ve earned it!

Starting Medical School: Rules of the Road

If you are reading this because you are preparing to start medical school – welcome!  You are now part of one of the most noble professions in the world.  You are no longer just a student, you are part of a profession… as of now.

Medical school is a wonderful, but at times difficult experience.  As you start this fantastic journey, there are a few “rules” I think might help:

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

The amount of information you are going to be exposed to in medical school is logarithmically more than you had to learn in college.  It really is like being asked to drink from a fire hydrant.   You are going to have to study more, study better and actually use the time in class to learn.  (more posts to follow with concrete tips on how to do this.)  But – here’s the good news.  You’ll be able to do it.   Everyone who has gone through this has thought at various times that a) everyone here is smarter than I am, b) the admissions committee must have made a mistake and I’m not really supposed to be here and c)  there is absolutely no way to read all of this material.  And… we all discover that a) we are just as smart as everyone else (sometimes in different ways, but all effective) b) nobody made a mistake – we really are supposed to be here and c) you have to change the way you study, but you really can learn this much material.

2. Make your bed.

You wanted to become a doctor for a myriad of reasons, but one of them was surely because service to others is important for you.   Therefore, you are already primed to sacrifice a lot of your needs for other people.  Sacrifice is part of the culture of medicine.  But, it’s like a Starling curve… a little sacrifice makes you better, but too much makes you ineffective.  Doctors are notorious for this; we forget that if we don’t take care of ourselves, we really can’t take care of others.   “Make your bed” is a simple rule (and action) which helps you remember that you need to take care of your environment, your fitness, your nutrition and your spiritual wellbeing as you are learning how to become a physician.

3. Act like a doctor.

We (all practicing physicians) see you as a doctor already.  I know this is a really hard concept for first year medical students, but it’s absolutely true.  You have started your apprenticeship and, unless you are one of the very, very few who change their mind, you will have an MD after your name in 4 years.  With all of the joys and privileges that come with this role, there are a few responsibilities to start thinking about as well.  Start thinking about your decisions, words and actions in this context.  You’ll learn a lot of specific details about professional behavior as your apprenticeship goes on, like protecting patient confidentiality, peer review, etc.,  but the core values of professionalism start when you enter the profession, which is now.

4. Kindness matters.

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

5. Enjoy the journey

The first year or two of medical school may, at times, seem like an obstacle course you have to “get through” to get to the “real stuff”.  The basic science curriculum is not a rite of passage!   It turns out that even the “trivia” (or at least that’s what it will seem like) is important.  You are learning a new vocabulary… a new language.  If you don’t learn the breadth and depth of this new language, when it comes time to apply it to patient care you won’t be “fluent”.

You are about to embark on a life changing (and fulfilling) journey.  This journey is a privilege and it is very, very special.  Take a few minutes everyday to write down the events of the day.  The first time you hear a murmur in a heart will be just that – the first time.  Take a minute to record what that was like.  You are going to have a lot to process as you start studying anatomy – more than just the names of the structure.  “Talking” about it in a journal is a great way to make the transition we all make in the anatomy lab.   There are also going to be some hilarious stories and events that you’ll forget if you don’t write them down.  When you look at them later, you’ll be glad you recorded them.  Recording these moments doesn’t have to be by writing.  If you are an artist, you may want to use drawings.  Photos of your classmates (and some of those humorous moments) will become a treasure in the future as well.  (but remember the professionalism rule!)

iPhone apps for Docs

1.  Epocrates – this is probably on the phone of every medical student, resident and practicing doc in the United States.  It’s a great database of information that’s easy to navigate. 

http://www.imedicalapps.com/2010/02/epocrates-app-review-iphone-medical-app-ipod-touc/

2.  Medscape – similar to Epocrates, but not as commonly used (at least where I practice).  It sounds really good, though.

http://www.medscape.com/public/iphone

3.  MedCalc.  The name says it all – easy calculation of medical formulas.  This is another app that is on the iPhone of every doctor I know.

http://www.imedicalapps.com/2009/06/medcalc-v12/

4. Eponyms.  Medical students struggle with learning the eponyms associated with diseases, anatomy, etc.  This is a mini dictionary of 1700 eponyms.

http://app-store.appspot.com/?url=viewSoftware%3Fid%3D286025430%26mt%3D8

4.  Medical Spanish.  This really lets you do the basics (until the interpreter gets there)

http://www.imedicalapps.com/2009/09/app-review-medical-spanish-app-adds-audio-in-latest-update-and-were-definitely-smitten/

5. iMurmur.  You have to use the earbuds, but this is really good app to learn (and review) heart sounds.

http://www.imedicalapps.com/2009/07/imurmor-v10/

6. Evernote. You have to play with this to fully grasp how powerful it is.  In a nutshell, you store “notes” on a server for free.  (Premium, which is $45/year lets you add attachments and increases your storage and is well worth the money).  Notes can be web pages, text from the internet, documents, photos, or voice recording.  Most importantly, you can search all your notes (and it has text recognition for photos, too).  In effect, it’s like having a “google” of your own notes.  Download the desktop app as well as the iphone app if you choose to use this – it makes it even more flexible by letting you create folders.

www.evernote.com

7. Remember The Milk.  This is the “to do list” app that I use.  It’s gotten really good reviews, but I’m sure there are other task lists that are good out there to.  This has it’s own email address for you, so you can forward emails to your RTM account which then become “tasks” on your list.  You can create categories, set reminders, etc – all in all it’s a great app.

http://freelanceswitch.com/product-reviews/review-remember-the-milk/

www.rememberthemilk.com

8.  Pandora radio.  Check this out on the web first and then download the iphone app.  This started as a PhD dissertation on the “music genome” – trying to find out what make certain music similar to other music (and why that could be used to define what you like).  The end result is personalized music – for free.  It’s nice to have on your phone to listen to when doing paperwork or waiting on call.

www.pandora.com

9.  Peggle.  Ok, you may think this one is silly (and it is a little).  I’m not at all a video or computer game person, but I read about this game in an article on stress reduction.  It’s addicting, fun and most people who play it would agree with pilot studies that show it reduces stress.

http://www.popcap.com/games/peggle

If you have an app that you think should be added to the list, please comment!

Motivation

I worry that trainees who read this blog might think I’ve somehow figured all this out and they never will.  Nothing could be farther from the truth!   What I have figured out, though, is that working on wellness is a journey and not a destination.  The same holds true for anything that needs some motivation (studying for the inservice exams, etc).  No one does this perfectly – we all have times we do better on the journey, and times we don’t.  What’s important is not letting the momentum of a crazy schedule drag you away from taking care of yourself.  Getting off track is expected.  Getting back on is the key.  Last week, for example, I really wanted to work out every day (and thought I actually might have time).  I knew ahead of time that setting that goal might mean working out 3 or 4 times.  But the reality is that I only made it to the gym once.  Some of it was setting expectations too high for a predictably busy week.  Some of it was not having a back up plan with some lighter or smaller workout when “Plan A” fell through.  And most of it (which I know you can relate to) was fatigue that made being motivated difficult.

Which got me thinking about motivation in general and what I might be able to learn from last week.  Here’s what I found….

“Viewing motivation as the ability to resist the lure of “bad” foods or overcome the appeal of lying on the couch will only lead to frustration and self-blame. Things go much better when you see motivation as the ability to give yourself the chance to make conscious decisions and take responsibility for these choices. Therefore, the main “enemy” of motivation is the tendency to see yourself as the hapless victim of forces (or urges) over which you have no control.”

http://www.sparkpeople.com/resource/motivation_articles.asp?id=630

“Being healthy isn’t a decision you make once — it’s one you make every day. Recommitting to your goals is necessary to keep yourself on track.”

http://exercise.about.com/od/plateausmotivation/a/motivation_2.htm

You have to find ways to find motivation when it lags like “avoiding the feeling of yuck” (one of my favorites on this list)

http://zenhabits.net/2007/10/31-ways-to-motivate-yourself-to-exercise/