Many students enter healthcare with the idea that they will “memorize” their way to academic excellence. This strategy is useful for short-term memory of things such as pharmacology formulas that one can write down quickly in the exam margin until needed or a pneumonic such as “Mrs. Ass” for remembering whether a heart murmur is systolic or diastolic. Yes, rote memorization can get to a certain level but strong academic performance and life-long learning requires mastery of conceptual learning.Conceptual learning involves linking of information and building upon a knowledge base. When I entered medical school, my school’s curriculum was “classic” in that first year we learned “what was there”; second year we learned “what can go wrong” and third year we learned how to fix things that go wrong. (Fourth year was refinement of first, second and third year). First year set the concepts and basis for our mastery but we had to build upon those concepts and integrate learning from second, third and fourth year in order to have the tools to become competent and knowledgeable physicians.
Conceptual learning starts with a very strong undergraduate experience. I use the word, “experience” because one should acquire the tools to master conceptual learning as an undergraduate. Sure there are plenty of people who will say that they “party all of the time” and then “cram” right before the test so that the material is “fresh” in their minds. My suspicions, borne out by some of those people’s test scores, especially on exams of applied knowledge, supports that they don’t know and can’t remember concepts. In short, they crash and burn- usually stating “I can’t do standardized tests”.
The experience of concept mastery can start with that first pre-med course where one utilizes the syllabus to identify concepts for mastery. Your textbook can also provide valuable information as to conceptual mastery. Many textbooks will summarize concepts at the beginning of a chapter or at the end of a chapter. This doesn’t mean that one sits and memorizes the concepts as a list but it does mean that one utilizes the list of concepts as a “check off” in terms of mastery of a chapter or mastery of material for an exam. Sure, you can “cram” in information for undergraduate work but once one enters medical (or physician assistant) school, the volume of material tends to favor conceptual learning as opposed to rote memorization. For example, you may be studying the treatment of viral illness in particular course block. You have to understand the concepts of viral structure, viral pathogenesis, immunological barriers and cellular reception/structure. After one couples that information with viral transmission and resistance characteristics (host & viral), one gets a pretty good idea of how viral diseases are diagnosed and treated. One also gets the concept that antibiotics are useless against viral illness. As you are standing at the bedside of a patient who is suffering from a viral illness such as influenza, you understand the characteristics of the symptoms reported and the signs that you are observing. You add those to your clinical experiences in terms of a differential diagnosis and treatment plan which is your key to efficiently treating your patient.
In short, if any of the conceptual knowledge is missing, you will not become an efficient clinician and you will find yourself constantly “behind” in terms of “shoring up” your knowledge gaps. This is the main reason that many people become “overwhelmed” quickly by the volume of material that must be assimilated in a short period of time. For example, about the second week of the first year of medical school, I start to see some of the more obsessive/compulsive students begin to “unravel”. Later on, often after the first exam block, I see some of the more “laid-back” individuals start to up their “game” and make adjustments to their learning strategies.
The people who have the shortest conceptual learning adjustment periods are the folks who have been conceptual learners as undergraduates. They are usually the most disciplined students and they are generally the students who seek assistance when needed and they tend to have less “emotion” when it comes to the materials that they need to learn. In essence, they are just building upon a foundation rather than trying to memorize a stack of words and phrases. No matter how a concept is tested, they are ready for the challenge. No matter how complicated the patient disease presentation, they systematically take that presentation apart and develop strategies for patient care.
I recall my experience with Organic Chemistry, one of my least-favorite courses as an undergraduate chemistry major. My passion lie in analytical and physical chemistry rather than carbon chemistry but my goal was to become an excellent chemist. My career plans were not medical school but graduate study in Analytical Chemistry. Since organic chemistry was far from the math-based chemistry disciplines that I loved, I approached this course from a purely conceptual (and practical level). In short, I probably spent more time organizing this course for my learning style than my other chemistry courses but I had the assistance of excellent professors, whose office hours I frequented, and I sought their experience and assistance with my organization of this coursework. To do otherwise in any discipline or course as an undergraduate took away from the knowledge base and experience that I knew that I would need as a professional chemist. In the end, Organic Chemistry was one of my strongest course performances even though I didn’t plan on becoming an organic chemist. (I ended up in graduate school studying Biochemistry and Molecular Biology).
As a physician, I am required to participate in continuing medical education (CME) for the maintenance of my license and for the maintenance of certification in terms of my medical specialty. It would be difficult to participate in my CME/MOC activities if I didn’t have a strong conceptual basis for this coursework. Most of my CME/MOC activities involve week-long conferences with testing at the end in order to receive my certificates. If I did not have the knowledge base, I would not be able to add the new knowledge and assimilate it quickly. Many of my CME/MOC activities center around evidence based medicine which means that I have to know how to keep up with scientific/medical literature and either incorporate into my practice or reject what I am reading or studying. As an academic physician, I am charged with keeping my scientific knowledge up to date and accurate in both my research/teaching and my practice. This takes a strong conceptual basis for efficiency and accuracy.
As an example, new pharmaceuticals are entering practice weekly and one has to make decisions as to whether one will prescribe a newer pharmaceutical versus a pharmaceutical treatment that has been present for years. Drug company representatives will furnish practitioners with plenty of literature – supporting their new and most likely expensive pharmaceutical but one has to have the knowledge base or ability to quickly acquire the knowledge to fully evaluate drug company claims. We have seen plenty of examples where the newest drug is not always the best drug for treating certain disease entities.
Finally, how does one become a conceptual learner? The steps are generally:
· Look at your course syllabus for the course content and objectives. A well-designed syllabus should give you plenty of ideas as to how the information for the upcoming course will be organized and tested.
· Look at your textbook and determine how the textbook will supplement and reinforce the concepts of the course.
· Look at how the material will be tested. Will there be examinations (essay, multiple choice or oral)? Will there be performance criteria for mastery? How does any laboratory exercises and material fit into the grading/testing of the material?
· Take emotions and “what grade you have to have” out of the learning process. If you master the concepts, the grade will take care of itself. If you focus on what score you have to have on any particular exam, you will generally come up short. It’s a waste of time trying to figure out how to “beat the curve” rather than focusing on what you need to learn and how to get it mastered.
Starting this week, I will be teaching my students how to use an ophthalmoscope and how to perform an optic fundus examination as part of mastery of the physical exam. Many of my colleagues never mastered the use of this instrument and tend to dismiss fundal exams as not necessary in today’s world of modern medicine. As I begin to teach this skill, I am reminded of how my professors in medical school, placed importance on having this skill in my toolbox of weapons against disease. At my medical school, we saw plenty of people who were morbidly obese, hypertensive and diabetic. Being able to examine their retinas was a cheap and simple task that might make a difference in helping them to better health by control of their weight, blood pressure and blood sugars. In short, a fundal exam is a tool that can make a difference in the prevention of the complications of chronic diseases that afflict many people today.
As a vascular surgeon, I am happy to have ophthalmoscopic skills because an exam of the vessels in the retina can give me valuable information in terms of the condition of a patient’s peripheral arteries. The retina is often the first indication of lack of blood sugar control in Type II and Type I diabetics and after a couple of decades with Type II diabetes, just about all patients will show some retinal changes. Without careful blood sugar control, these changes can go on to blindness which is a huge complication of diabetes. In my trauma patients, retinal examination can give a clue to increased intra-cranial pressure right in the trauma bay if one knows how to look for the early signs of papilledema.
I first have my students learn how the ophthalmoscope works. This is an instrument that must be held properly and used properly for best results. The ophthalmoscope is not an instrument that one can simply pick up and use right away. The student needs to learn how to turn the diopter wheel, how to adjust the light for the best results and how to choose the proper aperture for viewing. Many people attempt to look through the instrument with their corrective glasses in place (the diopter wheel corrects for both you and the patient) or will start with the biggest and brightest light (believing that this will result in better visualization). If one starts with a smaller light spot and dimmer light, one get more time to look around before the patient becomes uncomfortable. Additionally, the brighter the light, the more reflection off the cornea which is quite distracting to a new user.
Many people forget to darken the room and forget to ask the patient to focus on a spot over the examiner’s shoulder. both of these techniques need to be utilized in order to see anything. In the dim light, one should place their other hand on the patient’s eyebrow to help the patient keep their eye open. I utilize this technique because when my head touches my other hand, I have moved into the proper position/distance, which is very close to the patient. Many new examiners are quite uncomfortable with the closeness that this exam requires but just as one needs to be pretty close to a door “peep” hole in order to see out, one needs to be close to the patient in order to see into the eye through the very small pupil. (Breath mints are handy so that you don’t have to worry about being too close).
The new “Panoptic” ophthalmoscope head allows for a longer distance from the patient but one needs to learn how to hold and use the “Panoptic” score in much the same manner as learning to use the conventional scope. The Panoptic scope gives a wider view of the retina which is helpful too. The Panoptic ophthalmoscopic exam is easier to learn but Panoptic heads are quite expensive and not readily available in most clinics. If you have a Panoptic ophthalmoscope, then you need to guard it carefully because these expensive instruments have a way of “disappearing” from their owners on a regular basis. It’s also very easy to learn how to use a Panoptic scope if you have mastered the conventional ophthalmoscope.
One of the biggest mistakes that teachers ( and medical students) will make when learning to use the ophthalmoscope is believing that you are going to see the pictures in your physical diagnosis textbook. You are first going to see only the “red reflex” which you will learn to follow in as your learn to visualize a retinal vessel (see these when you learn to focus by turning the diopter wheel). Once you see a vessel, you can follow it into the optic disk. Once you see the optic disk, you can move your eye and body so that you can examine the entire retina.
You won’t master the ophthalmoscope unless you look into every patient’s eyes on every exam. If you don’t stick with attempting to learn (frustration levels are high at first), you will not master this instrument. I can’t tell you how many of my students “give up” before mastery and join the legions of “naysayers” who don’t believe an optical fundal exam is a necessary part of a physical examination. Many of my colleagues will just send their patients to the ophthalmologist for ongoing retinal exams which is a better strategy than not following retinal changes. It’s good to know what your patient’s retinas look like for yourself because you are going to see those patient’s more often than the ophthalmologist will see those patients. It’s a good idea to find changes earlier rather than later.
A technique that I teach my students for them to practice using the diopter wheel as the move in closer and closer to the patient is to put a small dot on the palm of their hand. Then practice keeping that dot in focus as they move their hand closer and then more distant from the ophthalmoscope. If they can turn the diopter wheel and keep the dot in focus, then try doing the same thing with text in a book as you move in and out keeping a letter in focus. Once the student can see a red reflex (right eye of patient and opthalmoscope in examiners right hand) the examiner can move in closer to the patient and keep the red reflex in focus.
As you learn to use the ophthalmoscope properly, keep practicing with this instrument. At first you will only see a red reflex; then follow that red reflex as you move in (might see a vessel at this point). If you can keep a vessel in view, you can follow it into the optic disk. If you can see and focus on the optic disk, you can keep practicing until you learn to detect things like copper wiring, cotton wool spots, neovascularization , flame hemorrhages and other pathological findings. You will also learn to appreciate the different pigment changes from patient to patient which can be pretty interesting too.
With any new technique or procedure in medicine, one has to learn to practice to make that new procedure/skill second-nature. With ophthalmoscopic examination, the practice takes months of dedicated trial and error until you find what works best for you. The important thing to learn is not to “give up” , throw you hands in the air and then label the skill as “unnecessary” because you can’t perform it. Fundal exams are a worthwhile skill to master in order to give your patient’s the best care possible.
For US medical students who are in the beginnings of the second semester, or final weeks before your break to study for USMLE Step I, I have put some thoughts below, that will help you start thinking about preparation for Step I. You should have obtained (online) the bulletin for USMLE Step I and you should be thoroughly familiar with the procedures for taking this important exam. At this point, you want to finish your coursework strongly and begin thinking about your time frame for taking this exam. This exam should be respected but not feared. It is but one step in your career, that is, a career that will have many steps like USMLE Step I but this exam is very doable and should be given some solid preparation time. In short, don’t rush or make mistakes in your preparation process.
Most people who are taking the United States Medical Licensure Exam Step I (USMLE Step I) will take this exam after completing the basic science component of their medical school coursework. For many students, this will come at the end of Year 2 and for some, this test will come at the end of 1.5 years of coursework. No matter when this test comes for you, make no mistake, this test takes some preparation regardless of your coursework performance. For medical students who have attended an LCME-accredited medical school, you have the assurance that your school has provided the coursework content that you need to pass USMLE Step I. With additional review and preparation, those who have attended an LCME-accredited medical school can excel on this test. The key is review and preparation.
The first and most important component of your preparation for USMLE Step I is to master thoroughly your coursework. When you start medical school, through mastery of your coursework is your main goal and this does not run “counter” to preparation for USMLE Step I. Additionally, in your thorough mastery of your coursework, do not make the mistake of attempting to “memorize” USMLE Step I review books during your coursework mastery stage. You have plenty of time to utilize review books at the end of your course blocks.
It is very tempting to purchase USMLE Step I review books during your medical school orientation for use as you are going through your coursework but do not make the mistake of believing that what is in the review book is all that you need to know from your coursework. Review books are designed to “review” materials and one cannot “review” what one has not mastered in the first place. Again, having a review book such as “First Aid for Step I” is not counter to mastery of your coursework but a review book should not take away from your main study strategies in your courses.
The best use of review books is when you have completed your subject matter. For most students in integrated curricula, review books that are not integrated are not as useful. While a review book can give highlights of specific subjects, they are generally not integrated as much as your coursework will be. The other problem with review books is that they are deliberately written to give the major points without much detail. During the coursework mastery phase of your medical training, you need the details. Once mastered, you can refresh your recall of the details with a review. If you are finding that you need more details, then use a denser resource than a review book. You likely do not need to return to your textbook but you might need to look at note summaries or books such as the Costanzo’s Physiology or Goljan’s Rapid Review of Pathology that are of medium density.
Another mistake that many pre-testers of USMLE Step I will make is improperly utilizing question banks as their preparation for this exam. Question Bank-type preparation is great for pointing out knowledge gap needs in your study but do not utilize question banks as a means of learning the material. If you are missing a great number of questions on a question bank service, especially in a particular subject, you likely need to move to a medium-density preparation book. Even intensive prep courses will not overcome significant knowledge gaps as the coursework content needed for this exam takes 1.5 to 2 years and can’t be duplicated in a few weeks (typical length of intensive review courses).
Many pre-testers tend to memorize the right and wrong answers to specific questions rather than going to a strong review book, something more than an outline, for knowledge acquisition. The best use of question banks is to first point out your deficiencies and second, to get your brain used to thinking in the manner that USMLE Step I will test. A good question bank service should trigger your brain to analyze cases and apply your knowledge not feed you answers to specific questions.
If you are utilizing a particular Question Bank service and monitoring your scores with the sense that if you are getting a certain percentage, you are assured of a strong USMLE Step I performance, you may be living in a world of false security. I have had more than a few students stop by my office to report that they are scoring 70% and 80% on a specific question bank service only to find that their score on the actual test is much lower than they expected by their test bank performances. I suspect that the reason for the discrepancy in scores is that these students relied too much on the content of the question bank rather than on what the overall trend of the question bank was pointing out, i.e. that they had some gaps in their knowledge that needed solid preparation.
Now, what do I mean by “solid” preparation? This “solidification of preparation” can be pretty elusive for some people but in general, the people who are solidly prepared have an “approach” to how the identify the correct answers on USMLE Step I. This “approach” allows them to even take “educated” guesses on things that they can’t readily recall and allows them to quickly recall the materials that they need to answer the questions correctly.
Solid preparation takes a very strong knowledge base and knowledge/practice of how USMLE Step I will test that knowledge base. Again, if you have attended an LCME-accredited medical school and have thoroughly mastered your coursework, you have the knowledge base that you need to score well on that test. Your review should be focused on the development of a means of analysis of distracters in questions (Question Banks can help with this but use a question bank that utilizes case-based questions and more than one manner of questioning) and the application of your analytic/critical thinking skills. Armed with these materials, you are well on your way to a very strong performance. Remember, you want your Question Bank to challenge you with as many methods as possible during your review time.
Your other ingredient in your “strong” preparation for this test is the confidence that you can sit down, take each question as it comes, select the BEST answer to each question and move on to the next question on the computer. Remember, every question counts the same so there is no penalty for “guessing” but there are huge penalties for leaving questions unanswered because you ran out of time.
In short, you have to be able to answer your questions correctly and efficiently so that the clock is not your enemy. Again, plenty of practice questions is a good strategy for analyzing your question-answering abilities in terms of timing. Unanswered questions are always wrong answers but you might be able to guess the correct answer if you have been able to get to the question. Don’t leave any questions unanswered is the moral of this story which means that you have to have a strategy that allows you to at least “read” every question in each block at least once. Utilize your question banks to increase your efficiency of question analysis plus increasing your percentages of correct answers. You want to see an improvement in both time and reasoning.
Your next goal in USMLE Step I preparation is not to allow yourself to become emotionally “blocked” if you encounter something that you do not recognize in a question. There will be questions that contain material that you will not know which means that you mark that question and move onto the next question (likely will have something that you know). If you keep encountering questions with materials that you don’t recognize, note the subject matter (if you are using a test bank) and review those subjects as needed. If you are on the actual exam, keep moving forward as you can always return to the questions that you have “flagged” if you work efficiently with time moving from question to question without emotion. In short, emoting over questions is a poor utilization of your time and blocks your ability to reason.
As long as you have not exhausted your time in a particular question block, you can return to marked unanswered questions and have another shot at narrowing down the answer choices. Most of the times, as you move through a block, something further down the block will trigger knowledge that will enable you to return to a question and see the correct answer even if it eluded you on first read.
Resist the impulse to change answers unless you have a very compelling reason. Compelling reasons are that you remembered something that is key to answering that particular question or that you see something in the question that you previously missed on first read. If you find that you are missing things on first read through, slow down a bit, take a couple of breaths and focus on what each individual question is asking. Many people jump to what they “believe” the question is answering rather than what’s actually on the page. Again, if you don’t spend too much time on any one question, you should have plenty of time to go back and review your questions and answers in each block before you leave a particular block.
If you are finishing question blocks early, take the time to review each question and your answer so that you can be confident that you HAVE chosen the correct answer. The worst possible outcomes will happen when you are rushing through the questions and missing key evidence that points out the correct answer. You want to finish each block with enough time to review each question and assure that you have marked what you wanted to mark for each question. In short, don’t move so quickly that you make clerical errors in marking your answers.
I also cannot emphasize the importance of not taking USMLE Step I until you have completed your required coursework and until you have completed a systematic and thorough review. USMLE Step I is likely to test differently from your coursework but a strong knowledge base that you can apply to the questions will help you score well on this important test. If you do not feel prepared, that is, you feel that your preparation has been rushed or inadequate, change your test date but don’t keep “putting off the test” because you don’t feel 100% prepared. You should feel that you were able to review things that you needed to review but one never feels totally prepared for every step of USMLE. You have to reach a point of saturation and satiety in terms of mastering what you need but resist waiting for the “magical moment of total confidence” because it never comes.
Will you ever feel totally confident that you know everything on this test? No, you need to have a healthy respect for this exam. You also need to walk into that computer center with the feeling that you have mastered your coursework and review and that you will take each question as it comes. You can’t be paralyzed about the consequences of failure or of not getting the score that you wanted. You can be philosophical in terms of you are ready to give the exam your best shot and that is what you are going to do. You simply have to prepare and move forward and look at USMLE Step I as just another step in your preparation to become the physician that you want to be.
Every year, many of my students start a new semester with the aim of changing anything that will make them more successful with their upcoming coursework. If there is one thing that you can change in the very next instant that will make the greatest difference in your performance, it can be that “inner voice” that tells you, “you are not good enough” or “this is a hard subject that I can’t do well in” or “I am not going be able to get all of this work done”.
It seems to be much easier to have an inner voice that is negative rather than positive. Many people are quick to employ the negative rather than the positive because the negative seems to be more believable. Most people are taught that a positive inner voice is the same as “patting your back” for non-achievement but the truth is that a positive inner voice is more about self-confidence than false self-aggrandizement. It is the confidence that one has to master in order to keep moving in a positive direction with any long-term goal. One has to believe that you will reach your goal in a series of small steps toward it on a daily basis.
Since you have total control over your “inner voice”, you can change anything that is negative such as “you are not good enough” to the positive such as “you are as good as anyone else” or make the change from “this is a hard subject that I can’t do well in” to “this may be a challenge but I will have small victories every day and get help the moment I need it”. In short, you can decide in the very next second that you will not listen to the voice that tells you what you “can’t accomplish” and replace that voice with one that tells you “what you have accomplished” and how you will keep accomplishing to meet any challenges head on.
Yes, students will fail exams and quizzes but learning from those failures will help make failing the complete course more remote. If you have never failed at anything in your life, you haven’t actually been tested. People who are untested do not develop the skills to learn from their failures and put them behind so that they can keep moving forward. If you keep spending precious time telling yourself what you “can’t accomplish” because of one set back, then you are likely to fulfill that negative inner voice that seems to be so tempting.
You can control how you react to a grade on a test or quiz. You can look at what you missed and make a careful assessment of what you need to work on so that you don’t keep making the same errors and master the material in a different manner. If you are only focused on the numerical score and not on mastery, you are likely to have difficulty integrating concepts and keeping concepts in your long-term memory (your goal for professional practice).
As I have stated many times on this blog, there has never been a course of study developed by one human being that another human being cannot master. Mastery of your studies does not take any super-human mental feats or membership in high-IQ societies but does take diligent and disciplined study for efficiency. If you use large amounts of time worrying about the rigor or the amount of material that you must master, you lose a great amount of efficiency. In the long run, your learning time for tasks and concepts becomes longer rather than shorter.
For example, as a junior surgical resident, I had to master many surgical procedures. If I had made a list of all of the procedures and cases that needed to be mastered, I would have been overwhelmed at the first case. Instead, I took each case as it came and worked on the fine points after I had mastered the major points. In short, by “divide and conquer”, I was able to master my procedures. I didn’t have the luxury to “think” about non-mastery as I ticked off things as they came under my review.
In residency, there is no person or class that pushes one to undertake daily reading and study. As the hours grow longer, it becomes easy to get behind unless one is vigilant. I set a goal of a minimum of 30 minutes of journal reading and 30 minutes of textbook reading per night with 2 hours on each Saturday/Sunday. I told myself, that I could get my goal accomplished and would get my reading goal accomplished. Like brushing my teeth, I quickly embraced my reading “habit” which meant that I was never behind when review for our yearly in-training exams came around. On same days, I did more because the habit made the task easier and more efficient.
During my residency research years, my reading schedule time tripled during the weekdays and was cut in half on the weekends because my time schedules changed drastically. When I went back to clinical work, it was difficult to stop reading and study because the habit had become so ingrained. I was amazed at the exponential learning that my solid reading schedule had afforded me during those research years. My reading and study efficiency had increased exponentially during this time which was the same exponential reading and study efficiency increase that I had experienced when I started medical school. In short, anything that becomes a habit becomes more ingrained/grooved and more efficient.
One can work on increasing confidence and from that one step, increase efficiency in almost any area of life that needs improvement. This improvement is invariably the result of one good habit leading to improvement in other aspects of one’s life. Just as when one starts a daily work-out program (can start with as little as 10 minutes per day), as the habit grows and becomes honed, other aspects of one’s life such as eating healthy and sleeping better start to improve.
What works for physical fitness can also work for mental fitness too. It always follows that people who are generally physically fit will experience less stress and more efficiency in their mental tasks. There have been plenty of scientific studies that show overall improvement in mood and health with increased physical conditioning. If you add mental conditioning in the form of adherence to a daily positive mantra, you are likely to see improvement in all aspects of your life too.You can start with one small change and keep reinforcing that small positive change on a regular basis. It only takes a change in the very next instant to embrace the positive and confidence that you can keep going which will keep you on the right track.
In 2015, the Medical College Admissions Test (MCAT) will undergo changes to reflect current needs and changes in medical education. While this exam in its current form has been in place since 1991, the new changes that are in the pipeline for 2015 will likely stay in place for 15 years or more. This means anyone who is beginning their undergraduate career (starting college) or who is targeting their application year for 2016 (Medical School Class of 2020) should be making sure that their coursework is reflective of the 2015 MCAT rather than the current exam.
In terms of preparation, what has not changed is the need for a medical school applicant to be well-prepared for a rigorous medical curriculum. This means that a high ability to rote memorize is not going to be of much value in preparing for medical school. Rote memorization of facts without regard to application of those facts is not going to prepare you well for either the current or future MCAT
If you are currently enrolled in courses that do not provide the critical thinking, problem-solving and scientific literacy that you will need as a modern 21st century physician, you will need to make some drastic changes in your college coursework to get the preparation that you need. These changes might involve taking additional coursework that will challenge your ability to critically analyze and read resource from a variety of disciplines (philosophy, social sciences, literature, and history). In short, just majoring in biology and staying away from the humanities is going to be detrimental to your preparation for the MCAT.
Currently, you still need to take and master the premedical science courses (General Biology, General Chemistry, General Physics and College Math/Statistics) but additionally you will need to be well-versed in analytical skills. Medical school is the application of scientific principles to patient problem-solving. If you do not prepare yourself for critical reading of the scientific literature and the practice of evidence-based medicine, you are not going to be able to have much of a medical practice in today’s world.
There is currently so much information at the fingertips of today’s physician, that one must make a concentrated effort to analyze and incorporate the best knowledge for patient care. If you are not able to do this and do not have a strong foundation in critical reading and analysis, you will be left behind very quickly.
Medical schools today rely less on rote memorization of PowerPoint lectures and more on challenging the student to integrate and build a solid knowledge base for application in patient care. This knowledge base is not obtained by memorizing a review book but by solid reading and integration of scientific concepts coupled with the incorporation of new research (clinical and basic science). The foundation for this integration and incorporation comes from an excellent undergraduate preparation for medical school which will be more tested on the 2015 MCAT.
As an undergraduate student, you will need to demand that your premedical coursework be of sufficient rigor to prepare you for medical school and future medical practice. By the time you are sitting in your pre-clinical coursework, you have to already have the foundations to understand medical literature. Medical school courses today and in the future will rely on you coming in with more academic/scholarship skills rather than attempting to teach you these skills. With the vast amount of knowledge that has to be assimilated and integrated with clinical skills coupled with less time in the classroom, you as an prospective medical student will spend more time preparing yourself for practice (life-long learning) than expecting a course to do the preparation for you.
The premedical coursework in many colleges and universities lacks the rigor that will be required for success in medical school or on the current (or 2015) MCAT. Too many courses place emphasis on rote memorization of facts rather than building a broad knowledge base and application of that knowledge base. Today’s physician needs to be able to understand how scientific principles are obtained (research) and applied along with scientific reasoning and critical thinking at every juncture of practice. Modern physicians do not just follow checkboxes or memorize an algorithm but have to be able to synthesize information across various technologies, disciplines and practices.
The changes in the pipeline are very exciting for those of us who are involved in medical education. We have looked at everything in our various curricula and have examined how materials are presented to our students. With this examination of curricula has come an intense examination of how students are prepared for medical education and how students are not prepared for the changes that modern medical practice will demand.
The most alarming trends have come in looking at how undergraduate coursework in some areas has lost rigor and the observation of how many undergraduates do not know how to propose research and query scientific databases. Pre-medical and medical students today have to be well-versed in the use of scientific and medical informatics as research in this country is relentless.
In addition to being able to utilize scientific and medical informatics, today’s physician needs to be able to evaluate new medical education and research for incorporation in to practice on a daily basis. There are many information systems at the fingertips of today’s physician but that physician needs to be able to understand the strengths and weaknesses of information systems and databases in order to make the best use of their data.
Medical education is far more uniform than divergent in today’s world which means that emphasis on strong scholarship, personal challenge and self-reflection in terms your preparation for medical school. Additionally, you have to be sure that your premedical coursework is worth every penny of tuition money that you have paid for it. This means that you have to challenge yourself at every class, every course, every semester and exam, to make sure that you have thoroughly mastered what you need in preparation for the rigors of medical school. These needs can be met and honed by a very broad but very rigorous education at the undergraduate level as anything less is not going to work on the 2015 MCAT.
Reprint of a previous post
You have received your acceptance letter and sent in your deposit. You now know where you will be attending medical school in the fall -or should I say late summer. The next step in your adventure will be Medical School Orientation Week. Why does it take a week? How about Orientation Day and then you can get to the business of getting started with first year of medical school.
Orientation Week usually starts out with some type of “check-in”. In my case, the Dean of Students called names from a roll. We had previously been warned that if we were not present for roll call, our “seat” would be given to the next person on the wait list. Needless to say, everyone was present and accounted-for that morning. Following roll call, there was the obligatory introduction of the Deans. This was followed by a speech given by a speaker that was chosen by the second-year students the year before.
By the time the introductions and speeches were over, the greater part of the morning had disappeared. There was a meeting of your second-year advisers (second-year medical students) who would share their advice on navigating the curriculum. This meet-and-greet was filled with horror stories about certain professors and warnings about behaviors to avoid. With some of the tales of woe, I wondered how anyone survived the first year and made it into second year.
My own second-year adviser was a lovely but quite young lady. She was the daughter of a registered nurse and was very enthusiastic about all of the adventures that she had experienced in first year. She and her tight-knit group of friends, gathered us together and spoke to us (their advisees) as a group. We were able to get the benefit of a collective experience rather than single reports. This turned out to be a blessing. My second-year adviser also led me to her car where she presented me with a cardboard box of old exam, used and filled-in course syllabi and her books from first year. “I started putting this together for year after my first exams last year”, she said almost apologetically. I was speechless but thanked her profusely. That box turned out to be one of the major keys to my success during my first year. I happily passed on her stuff and mine to my two advisees when I became a second-year student.
After our meetings with our second-year advisers, it was time to get our photographs done for the student directory. We lined up and had out photos taken by the medical photography service. Following the photo for the student directory, we were taken to the Student Services building for photo identification cards. Our physical examination papers were collected along with our immunization records as we moved from Student Services to student health. Once we had accepted admission to medical school, we were told to bring proof of immunization and undergo a physical examination by a physician. (My uncle took care of this for me, had his office staff copy my records and put together a nice package).
During the evening of our first day, we were bused and car-pooled to a local park where the second-year students had prepared a cookout for us. This was our first introduction to the wonderful world of “free-food” in medical school. Our first day of orientation ended around 8pm.
On the second day, we were introduced to our microscopes and course syllabi. Each of us was issued a microscope (if you didn’t have your own as I did ) and were issued thick syllabi for Biochemistry, Gross Anatomy, Introduction to the Practice of Medicine and Psychiatry. In addition, we were given a couple of hours to purchase books (already furnished by my second-year adviser). We also had lockers issued (I could actually stand in my huge locker) where we could store our necessities. On this day, the student health department singled out students whose records were not complete and gave them strategies for getting their immunizations and records done. This meant downtime for me. At the end of the day, free pizza courtesy of one of the student organizations.
On the third day, which turned out to be a Thursday, we were treated to a morning meeting with Financial Aid and Student Organizations. The Student Organizations had set up tables with sign-up sheets for us to join groups. I signed up for the American Medical Association and new organization called “Students with Families” (a non-traditional student organization). The afternoon was spent organizing our class and electing temporary class officers. We elected temporary officers because we actually didn’t know anyone and would elect permanent officers later in the year. I actually volunteered to become the Vice-President for Education in charge of note-service because I had some experience from graduate school with running a note service.
The Dean’s Reception was held on the evening of the third day. This is where I met my best friend from medical school. Over the four years, we would share triumphs and tragedies but it was at this reception that we met the various Deans up close and shared a line or two of conversation. In addition, there was more free food and an opportunity to wear something other than our jeans and T-Shir’s that had become our orientation outfit.
On our last full day of orientation, we had information sessions from the chairmen of various departments. This gave us an opportunity to mingle with the faculty. We were also introduced to the school’s computing system and issued laptop computers if we didn’t already own a suitable laptop. Again, that locker was getting full. For students who were not immune to Hepatitis B, there was the first in a series of three Hep B vaccination shots (thankfully, I could bypass this step too). On the evening of our last day of orientation, there was a White Coat Ceremony where we were cloaked in our white coats by graduates of our medical school and issued the Hippocratic Oath.
Orientation had taken the better part of a week. Many of us were not ready to just get down to the business of attending classes and adjusting to the course schedule. Our syllabi need to be filled in and mastered, our textbooks read and highlighted. On the next Monday, we would be “going live” in terms of our classwork.
Over the first week, I came to have a list of things that I could not do without. These things were carried in my backpack and spread on my table in front of me during lectures. These were:
- My laptop computer for downloading power-points and the professors writing on the “smart board”.
- My pens of four colors: black for notes, red for emphasis, green for projects and blue for notes from the text book.
- My Easy Reader book stand that held my looseleaf notebook that contained pages from my textbooks that were cut and 3-hole punched.
- My highlighters in four colors: bright yellow, pink, green and blue.
- A micro tape recorder (now replaced by a digital tape recorder) for making sure I didn’t miss anything if I fell asleep in class.
- A sweatshirt as the lecture room was always freezing even if the outside temperature was above 100F.
- My travel coffee mug and a thermos of fresh coffee (Starbucks was a short walk from the lecture hall).
- A liter-bottle of water (kept me awake in the afternoon).
- My Walkman (now replaced by an MP-3 player).
These were my daily companions during first and second year of medical school. Even today, I always read and study with my pens and highlighters handy. My Easy Reader book stand is also with me as is my Sony Viao laptop computer for making notes and reading the myriad of PDF documents that I have downloaded.
Other things that I would learn but not mentioned during Orientation Week, was not to worry so much about not doing well on my first set of exams. I more than passed every exam but I saw many of my classmates head into a “tail-spin” after receiving their first failing grades. On our first Gross Anatomy exam, 85% of the class failed the exam. For some students, this was their first failure ever and they had difficulty shaking it off and moving on. In my case, I remembered that my wonderful second-year adviser had said, “You are going to encounter something that will give you problems, ask for help and put your failures behind you fast.”. She also encouraged me to help my fellow students who as she said, would “become colleagues that I would refer patients to in the future”. She was right because the more I helped my fellow students, the higher my grades became.
We all survived that first semester but we lost a couple of students at the end of second semester. One of my classmates decided that he wasn’t going to spend another moment doing that much studying for anything. Another had illnesses and just wasn’t able to keep up with the material. In the end, we all experienced the molding that would mark us as physicians.
As we move further into the 21st century, the presence of mid-level practitioners will become more and more prevalent in medical centers and in general health-care. Long gone are the days of one’s total health care being managed by a physician only in the ranks of primary care. For some patients (and practitioners), the presence of a mid-level practitioner is both confusing and unwelcome. Physician assistants make up a portion of the mid-level practitioners that will be found in many modern health care centers (along with nurse practitioners) but patients will often be unaware of their training and purpose in adding(extending) what a physician can do for them. Many of my physician colleagues will feel that physician assistants will somehow encroach on their areas of practice which is far from the truth. In essence, my physician assistants extend and reinforce what I am able to do in medicine. They function as my eyes, ears and hands in places that I physically cannot be present and my PA colleagues provide a very high level of care for my patients. In my practice it isn’t you see the physician or the physician assistant but in most cases, you will be seen by both.
Myth No. 1 -Most people who become physician assistants couldn’t get into medical school so they are physician “wannabes”.
In 2012, the entry-level for most physician assistant programs is at the level of master’s degree. Not only is a minimum 3.0 GPA required to apply to these programs, the competition to enter these programs is much stricter and more stringent than ever. Most of the folks who applied the Physician Assistant (PA) program at my university had over a 3.5 GPA and most who were accepted into the program had over a 3.7 GPA. This would indicate that the folks who were able to enter our PA program were definitely capable and would have been competitive for many medical schools in this country. Many of the people who entered our program sought to become a PA rather than an MD because they didn’t feel that they wanted to spend a minimum of 7 years before they could practice. Our program is 27 months from start to finish with our graduates being able to enter any area of medicine one would find physicians. In addition, they can seek additional training in anesthesia and critical care if they choose to work in these areas. The vast majority of our PA grads go into surgery, pediatrics , emergency medicine and internal medicine much the same as our MD graduates.
Myth # 2- PA school is easier than medical school so these folks give inferior care
In truth, PA school is a bit more difficult than medical school. In essence, I had two years of pre-clinical didactics before I entered the clinical phase of my medical school. PA students have about one year of pre-clinical didactics before entering their clinical phase and they are taught on clinical rotations alongside 3rd and 4th year medical students. PA students attend the same clinical lectures and are expected to carry the same clinical loads as the 3rd and 4th year medical students. We often don’t know whether a student is a PA student or a medical student unless we are able to read the name badges. I ask rotating students the same questions and expect the same level of functioning regardless of which degree they will complete. In the end, the PA student will leave at the level of a PGY-1-2 resident and function at they level for most of their career while the medical student will leave at the level of a PGY-1 resident and move through residency to become an attending physician. Most of the patients that are treated in clinics at medical centers are seen by a combination of PAs and residents on teams that are run by a chief resident or attending physician with no compromise of care.
Myth 3- PA don’t know things at the level of a physician so they might miss something in my care
Most PAs are very adept at self-directed learning in the same manner as a physician. Whether one attends medical school or PA school, one cannot expect that what is learned in school is all that is needed to be a competent practitioner. My state requires that I complete many hours of continuing education in order for me to maintain a license to practice with PA having the same licensure requirements. In addition to seeing patients, PAs are constantly upgrading and honing their knowledge often at the same conferences and meeting as physicians. Physicians often consult each other in terms of taking care of complicated patients and good PAs will consult with more experienced PAs or physicians in the care of their patients. The PA that work on my service know the scope of their practice and do not exceed this. While the PA may be able to do 90% of what I do as a physician, they are very aware of when a patient is beyond their scope of care the same as any physician is aware of when a patient is beyond their scope of care.
Myth #4- If I see the PA, I have to see the doctor too so why the extra step?
Many of my patients may not be seen by me on some office visits where they see the PA only. If the PA feels that the patient does not need to be seen by me, they will take care of the problem and the patient gets out sooner. On the other hand, most of the PA who work in my practice will state that, I know the doctor wants to see you so wait a couple of minutes until she is available” while in the meantime, I will consult with the PA on how the care of that patient is going along. PAs in our practice will perform treatments, manage wound care and work patients up for surgery. In most cases, just as with the residents who are on our team, the PA will assist in the surgery of the patient that they worked up unless the case is of vital learning for a resident.
Myth #5- PA education is inferior to physician education
PAs are educated under the same model as physicians. They take the same coursework in some cases but they don’t spend the same amount of time in school as a medical student and they don’t spend the same amount of time in post-graduate training as a medial student would. The ability to practice medicine with less training is something that is very appealing for most of the people who enter PA school. At the end of training and upon passage of their certification examination, most PAs start out at around $78,000 and max out around $110,000 after a few years in practice. For many people, spending a minimum of 3 years in residency above 4 years of medical school (expensive) only to earn about $47,000 as a resident is not something that they can afford financially. Most PA programs will cost far less than medical school and will enable their graduates to get into the health care work force much sooner at higher salary. Additionally, physician assistants can apply for and qualify for public health care scholarships that will pay back their student loans which are far less than the average $158,000 that a medical student will owe after medical school.
I wrote this post because many students have negative ideas of what the training and work of a physician assistant will involve. For many students who have a strong desire to work in the medical field but family and financial obligations that will not allow them to spend a minimum of 7 years in training above the baccalaureate level, becoming a physician assistant is something that they might find appealing. In today’s world of medical practice, PAs diagnose, treat and prescribe right alongside physicians. Often it’s the PA who gets to spend more time with the patient and who will develop a more personal relationship with their patient because the PA is not subject to the time constraints that a physician is often subject to. Good PAs build upon their clinical skills learned in school and spend as much time upgrading those skills through continuing education and journal reading as any physician would. It’s no accident that physician assistants enjoy the highest job satisfaction of any profession in health care with other professions not even coming close to their level of satisfaction.
I would encourage any premedical student to take a long and objective look at the physician assistant profession in addition to medicine. You may find that it’s a good fit for your professional ideals especially if you enjoy one-on-one interaction with your patients. One of our frequent questions for entry into PA or medical school is ,”What other health care professions have you looked at and what did you find out about them?”. I am always surprised at the number of students who have applied to PA or medical school that didn’t do a thorough investigation of health care careers besides physician or physician assistant. Certainly if one anticipates preparing for a career as a physician, one should definitely make sure that they have done a thorough investigation of everything that is available, including alternatives and make the most informed decision before they embark on a career that takes a minimum of 7 years beyond university. Additionally,every PA that works in my practice is far from envious of my practice and love the scope of their profession. As you look at becoming a PA, make no mistake in believing that compared to medicine, it’s inferior or easier because this simply isn’t accurate and you may find that this very modern career is a great one for you.
I have been teaching (involved in academia) in some form since 1994 which means that I have “been around the block a few times”. Teaching has been my way of “paying it forward” since I was in graduate school in the 1990s. I use the term “paying it forward” because I was fortunate enough to have outstanding professors at every juncture of my education. Medical school just added patients to the list of persons that I teach which continues to make my practice interesting and fun. I use the word “fun” to describe teaching but it’s not lost on me that my teaching is a way to show how my teachers affected the way that I learned science and medicine which I attempt to pass along to my students and patients.
The first influential professor
The first professor who had a profound influence on me was my undergraduate physics professor. A ”renaissance” man in every sense of that word, my physics professor would start the class off by playing a few minutes of a Beethoven symphony whereupon he would ask us to identify the work. I was usually the only person to do this as I had spent more than some quality time study the compositions of Beethoven, Chopin and Mozart in my harmony and ear training courses that I had taken when I studied music. My professor marveled at how I could “guess” the identity of the piece with little more than three or four bars. For me, Beethoven, Chopin and Mozart were so distinctive in their styles that my task was simple. If he wanted to “stump” me, J.S. Bach would do the job.
In addition to music, this professor was a prolific writer, photographer and collector of thousands of ideas. My favorite idea was when he spoke of walking though Einstein’s office at Princeton and breathing much of the same air as the famous physicist. My professor also had the gift of being able to explain extremely complex ideas and theorems in a language that added this knowledge to our fledgling knowledge bases. As he filled multiple chalk boards with derivations of quantum theory and mechanics, I learned how to approach a body of knowledge, immerse myself and convey my thoughts and findings within the language of those complex theorems. In short, my professor showed me how to look at the world from the standpoint of mathematics and precision. After one semester of university physics for scientists and engineers, I was transformed.
My mentor in analytical chemistry
My next influential professor was an analytical chemist from Hungary. His influence on me was teaching me to love electrochemistry from the standpoint of chemical analysis. Like my physics professor, my chemistry professor was able to teach the utilization of any and all “tools” in the craft of studying a body of work. My chemistry mentor taught me how to prepare a PowerPoint lecture of a complex subject for different audiences. He always said that one needed to be able to explain their research, no matter how complex, to other scientists, to scientists in other disciplines, to potential investors and to the lay public. His great lessons have proven invaluable to me over the year of graduate school, medical school and practice. He has a thriving research group that is putting out some amazing experiments because of his ability to bring out the strengths of each member of his team and his ability to get everyone to work toward a common goal. His lessons were great. Like my physics professor, my chemistry mentor was a man of ideas.
My biochemistry/physiology mentor
My mentor in biochemistry was actually a physiologist and a woman. She had a fine analytical mind but was very vulnerable in many areas. My greatest lesson from her was to be able to see collaborative possibilities in a multitude of situations. She had thousands of ideas every day which was refreshing to be around. When she needed to focus on one path, she was unshakable but she always saw the larger implications of everyone’s work and contributions which never went unrecognized. She admired my quest for knowledge and I admired her ability to cut to the “bottom-line” of any situation, scientific or political. Under her tutelage, I became exposed to the politics of academia and came to understand how to get what I needed to present my best to my students. From my studies with her and under her, I learned how to integrate basic science with clinical medicine. One cannot separate science from medicine as science drives medicine which is its practical application. I also came to realize that since she had been one of Sir Hans Krebs’ graduate students, I was by association, a student of Sir Hans Krebs. Yes, I know the citric acid cycle inside, outside and backwards. One of my favorite tasks in graduate school was to substitute nitrogen for carbon and rework the “Krebs” cycle. (Hint: follow the electrons because it’s oxidation and reduction that “fuels” life on earth).
My first clinical mentor
My first clinical mentor was another renaissance man whose broad interests and talents make him a character. He was a specialist in Internal Medicine who was fond of referring to surgeons as “Philistines” (Orthophilistines, Neurophilistines and others) in the sense that Philistines are ill-mannered and generally crude. Some of his favorite statements were, “Internists practice classical medicine while the Philistines practice common medicine”. To his delight and astonishment, I ended up choosing to enter the practice of “common” medicine and become one of the “Philistines” for which he always teased me when I encountered him.
The greatest thing about my clinical mentor was that he always gave his patients 100% of his attention and ability. He was a voracious reader and writer who encouraged me to begin reading the New England Journal of Medicine from the day I received my acceptance letter for medical school. He said that I probably wouldn’t understand much of the journal but have a daily habit of spending at least 30 minutes reading a journal would be of great utility to sound practice and education. He suggested that I read the Case Reports from Mass General first thing in every issue and then turn my attention to the Original Articles. To this day, this is the manner in which I approach the New England Journal of Medicine ( I have added about 30 additional journals each week). Again, I see the utility of putting the basic science with the clinical science which cannot be separated. I am a profound believer that medical students should make it a habit of reading Mayo Clinic Proceedings, Nature Medicine and The New England Journal of Medicine from day one.
My surgical mentor
My surgical mentor is a laparoscopic surgeon who was trained a Duke University. When I met him, I realized that he had the same approach as the rest of my mentors which meant that he is a man of broad interests and abilities. He is an avid distance runner for whom I suspect his running keeps his agile and always active mind on course. He is another mentor who is able to put a strong team together where everyone’s strengths are highlighted. From my surgical mentor, I learned to never give up on any patient for any reason. When that 30th hours is creeping up and one is fighting sleep and a wandering mind, my mentor taught me to find a “kernel of focus” and build upon it. He also taught me the utility of rounding alone late at night when one can see the patient with renewed perspective. His late night teachings were some of the best (yes, he was up at 4am too). He taught me to rely on my training and thinking rather than emotion though I suspect that his emotions are far deeper than he shows on the outside. Under his direction, I became fearless to a certain degree and confident in my skills as a surgeon. The most outstanding characteristic of my surgical mentor is that he loves to teach and thrives on the excellent training of those who are under his direction.
The common characteristics of my mentors over the years is that they are people of diverse ideas and interests. Every year at the start of a new year, I strive to get back to the characteristic that I most admire in my mentors. At each year’s end, I take stock of what I have learned and appreciate in this journey of medical practice. I know that I am fortunate to have had an opportunity to have been taught by many outstanding professors who have left their profound influence. I also know that there are those who I hear “whispering” in my ear on a daily basis. No matter where you are in your training in medicine, you should stop and take a minute to thank the people who have taken the time to teach you something. It’s good to remember that not all lessons are learned in the classroom and that it’s a privilege to have a mind that allows one to learn from a good professor.