Medicine From The Trenches

Experiences from medical school, residency and beyond.

Textbook Reading in Medical School

Introduction

Once you have started your coursework in medical school you quickly realize that there are many things to read and master in a very short period of time. If your reading skills are not excellent, your reading efficiency goes down markedly. Fortunately, reading skills can be upgraded with regular practice and fortunately, your efficiency can upgrade along with your reading skills. Your first strategy is to have an open mind and a willingness to do something different and practice that “something different” on a regular basis. In changing any study technique or tactic, go slowly and practice your changes regularly. After all, it took years of practice for you to have the skills you are presently using, thus change doesn’t need to completely revamp in a weekend. Make any changes slowly and sparingly unless you have a large amount of free time (not likely in medical school).

Adding textbook reading to your learning strategy

If you have been using your textbooks for exercise weights only, open one of them and take a look at how the book is organized. Most textbooks have a Table of Contents in the front and an Index in the back. These are always the first things to look at when you purchase a new text (or review book for that matter) so that you may become familiar with the book’s content and organization. The index gives an idea of the detail and the table of contents gives an idea of the breadth and scope of the text. As a surgeon, I always evaluate a surgical text by their treatment of rectal prolapse. If a surgical textbook has a complete and well-organized treatment of this topic, generally other topics in the text are well-written and organized.

When you move into a specialty and have acquired mastery of medical concepts, pick one, relatively obscure topic and do a quick perusal of a text’s treatment of that topic. This practice can be a quick means of evaluation of a text (or review book) while you are standing in the bookstore. If you are an online purchaser, I would not invest more than $40 in any textbook/review book that doesn’t provide a sample chapter/table of contents and index for preview. Wait until the book arrives in the bookstore so that you can scan it before making a sizable investment.

If you have a required textbook for your course, be sure to read the material assigned. Most medical school professors do not assign reading to “occupy your mind with busy work”. If the reading is assigned, get it done before you go to the lecture. Not only will you get a better grasp of the lecture material but you will have completed at least 1/3rd of you study of that material before you have actually heard the lecture as attending a lecture “cold” is worse than not attending the lecture at all.

You will hear your classmates brag and boast about “never cracking” a textbook but look past that strategy. You have one shot at not “screwing up” your coursework thus you need to get every dollar’s worth of tuition out of your classroom/course experience. Not only will you do better on your board exams, but you will do better in your coursework. Applying for residency with a string of just passing or nothing distinguished on your transcript is not going to help you get into a good residency program. Without having a good knowledge base that has some depth, you won’t interview very well either. Resist the temptation to just study a review book and Powerpoint lectures as they are not enough for boards or your course exams. In the medical education process, just passing or short-cutting is not a sound method for future practice.

Another strategy for getting your textbook reading into your study schedule is to read your text assigned readings the week before the lectures. This doesn’t mean that you waste time outlining a chapter and memorizing every word, but becomes more meaningful if you have an idea of where the details of a process are located in the text and if you have an idea of how important a particular topic might be to a body of knowledge. For example, it’s very difficult to master cardiovascular physiology if you do not throughly understand the Frank-Starling Principle. Most medical physiology texts will have plenty to explain concerning this principle but you need to know how this principle affects cardiac function in a very detailed manner. How does this principle translate in terms of myocyte function? How do pharmacological agents affect heart function within the context of this principle? How does cardiac innervation affect this principle of heart function? In short, you have to put new concepts within the scope of all of your didactic coursework and not just memorize the physiology for the sake of memorization so that you can “spit it back” on a class test. In short, you have to know that principle well enough to apply it across disciplines in medicine. This is where having the knowledge base of your textbook reading before you attend the lecture is crucial. If you don’t have a good base, you can’t listen with a discriminating and informed ear.

Getting overwhelmed

If you find yourself procrastinating because you have not been studying and reading on a regular basis, you can quickly find that you are behind your class and overwhelmed. Immediately sit down and write a schedule to get back on track immediately. Go to where the class is and catch up on the weekend. This means that you sit down on a Saturday and Sunday morning and check off materials on your schedule that you were not able to get around to during the previous week and get them mastered. Never, ever let yourself get more than one week behind in any of your courses. In medical school, playing “catch-up” is the beginning of the end and your grades will quickly fall. Students who are ashamed to ask for assistance are often the ones who will “put off” studying because they don’t understand one principle. If this happens, move to something else in the course material and keep moving forward. Get the help you need as soon as you can and fill in the details that you need but don’t just “quit”.

Reading a textbook chapter

First look at the subject headings to get an idea of what the chapter will cover and how it will be organized. Then look at how much space is alloted to each of the subject headings. This will give you and idea of the importance of each subject in terms of mastery of the entire chapter. Next, look at any chapter questions or objectives that are in your textbook. These are for you to check your understanding of the chapter materials. Many textbooks will have chapter objects at the front each chapter which are great in terms of allowing you to know what’s most important in the reading to come. The last thing that you do is read the material making pencil notes of the important explanations or of any questions that you want to answer in your reading.

One of my strategies is to pose each subject heading in the form of a question and see if I can answer that questions when I have completed reading that section. If you can’t answer the question, then figure out what you missed in your reading. Are you having a problem with the author’s style? Do you need to have a medical dictionary nearby so that you can look up any terms that you don’t understand?  Are you having difficulty concentrating because there are too many distractions in your study location? Are you finding it difficult to concentrate because you are tired, thirsty and hungry? If you are having any of these problems take no more than 10 minutes and get them solved immediately.

If you can’t understand or figure out an author’s style, then you need to check with your professor in order to get some help with your text reading. In short, don’t just sit and “throw up your hands” in frustration but take some immediate action. Consult with your professor in getting a grasp of the basics of your text so that you can utilize this resource regularly This is why getting down to your reading before you attend a lecture is a better strategy than waiting until a couple of days before an exam when you are far behind in your reading.

Use your study time wisely and regularly

Practice reading your textbooks and other materials on a regular basis. Having a large white dry-erase board is good for making concept maps from your reading or listing vocabulary words to look up (so that you can incorporate them into your knowledge base). The action of getting out of your chair at least every 50 minutes and writing something on that board will help to keep you focused. Reading and re-reading the same section or paragraph three or four times with poor understanding generally indicates that you are not concentrating on the task at hand. Don’t let lack of concentration derail your efforts as you just don’t have too much time to waste on being distracted. If something is bothering you, write it down on an index card (or “sticky note”) and think about it in the car, on the treadmill when you work out or when you take a walk.

Don’t sit in the same spot in the library for hours on end without standing up and getting your blood circulating. Just sitting in one spot is a good way to find yourself fatigued very quickly. Get some fluids to stay hydrated and walk around for 5 minutes or so to just let your eyes focus on other things besides your books and notes. If you are in a study room, read a passage or two out loud and take some deep breaths as you recite the material back to yourself. Stretch regularly and watch your posture as sitting “hunched” in an awkward position can cause muscle strain too. This is why getting some regular aerobic exercise plus strength training can actually make you a more efficient student and is well-worth taking an hour from your study to perform. Regular exercise will greatly decreased your natural stress level which will make your study more efficient in the long run.

Finally, practice reading your textbooks early and often. Anything that you practice regularly becomes a good habit. As you become more efficient and less stressed, your concentration will improve too. I am always amazed at how much many medical students will “talk themselves out” of high achievement and scholarship because they haven’t been used to studying at the level demanded of them in medical school. Don’t be one of those students. It’s easy to allow other things to interfere with your studies but planning and efficiency can give you more time in the long run. Learn to say “no” to demands on your time and remember that you have one shot to get the most out of every class. Retaking exams and repeating years is problematic if the reason for your retakes and remediation is poor study habits. Make good study habits a good habit.

28 October, 2011 Posted by | academics, first-year, medical school coursework, study skills, success in medical school | | 8 Comments

Being a good intern (PGY-1)

I was reading a post on one of my favorite blogs , Missionary  Doc in The Making  http://doctajay.com/?p=1489 , where a young orthopedic resident describes some of his experiences in striving to be the best intern that he can be.  I am reminded of my first months as an intern in General Surgery. I remember that my first chief resident chewed me out daily for the first week because of the things that I had missed in caring for the floor patients. By the end of that week, I was a better intern because of those “daily chewings” and my experience working under this chief resident. I learned how not to “miss” anything and how to become efficient enough to get into the operating room to scrub a case or two during the day. If I had not had a very demanding chief resident during my first rotation, I would not have learned as much as I did. It was an awesome experience and I am thankful for the heavy workload that helped in my early training. In short, I learned to “think on my feet” and to make detailed observations in a short period of time. I also learned to provide the very best care of the patients on my service that I could.

Yes, I was bone tired when I arrived home each day. I usually arrived at the hospital at 4:30AM and didn’t leave until after 7pm each day. By the time I arrived home, I took a shower and hit the bed so that I could get some rest to start the day over again the next day. If I was on call, the other interns would sign out to me around 6pm and I would generally make quick rounds on the sign-out patients so that I could see if there would be any issues. I was also a compulsive list-maker so that I could check off things that just needed to be done. I would try not to eat a heavy dinner because I found that the night would drag on. I kept myself well hydrated with iced tea (avoided coffee in the evenings) and generally used my call time (if I wasn’t busy) to dictate discharge summaries and get things ready for my patients who would be going home the next day. During the night, I would read and then nap (couldn’t really sleep soundly in the noisy call room) and rest as much as possible. At 4:45 AM, I started my post call day, did my morning notes and usually left the hospital around 12 noon after all notes were done. If there were many things to be done in the morning, I would help the on call intern and then leave when things started to slow down for him.  I learned quickly that teamwork was the best thing that we could do for each other to get the work completed as efficiently as possible.

On my very first rotation, my fellow intern on service was not much of a colleague. He left many things undone and generally refused to do work that needed to be done such as discharge summaries. I simply took over his paperwork and mine too. I knew that work had to be done for the service and I picked up the slack rather than complain. Again, it was good that I just pitched in and worked for the team and the patients. I wasn’t doing the other intern’s work for him, I was doing the work that was needed for excellent patient care. All of the patients on the service were mine as much as his. Again, the more work I did, the better I became at getting things done. I wasn’t long before my residency director figured out that I was keeping the service humming along and that I was always one for taking up the slack. I also earned the respect of every one of the chief residents who always wanted me on their services and were ready to teach me things that I was eager to learn.

The thing about being a good intern is that you learn to prioritize your life. You learn to appreciate how important your home life is to your work life. You appreciate just spending time with the people who you love. You also start to be come thankful for all of those hundreds of little victories that you get during the day. You learn to forgive yourself for missing things and you learn to not forget those same things the next day. The fortunate thing about medicine is that every day is a new opportunity to learn and grow as a physician if you take the time to do so. Medicine is a joy to practice and a daily reminder of those who are less fortunate than myself. In only a second, I can be the patient lying in that bed who is worried about recovery and how their life has changed by illness. One has to take good care of one’s life at home, one’s spiritual life and one’s health in order to be able to give our patients that best that we can.

I have written other posts about staying awake and keeping myself committed to the thousands of patient care tasks that residency will demand. Most of the things that I learned about patient care and keeping up with things, I learned as an intern. It took about two weeks into my first rotation as a new intern, to not be panicked with those “calls” from the nurses in the middle of the night. I learned that I actually know how to take care of patients and that I was confident in getting the best for the patients that were under my care. I learned to have a good relationship with the folks in the allied health care professions because they helped me take care of my patients. Medicine today is a team and not just one person doing everything.  Yes, the physician is at the head of the team but having good people around me who can do their jobs professionally, is worth gold. I am thankful that I am generally an easy-going person but can be pretty decisive when I need to make decisions.

If medicine becomes drudgery, then you have chosen the wrong profession. If you can’t keep your mind interested in the care of your patients, then you are likely not going to be a very good or very competent physician. Your patients teach you and your colleagues help you every day. Medicine is truly magical when every one and everything is in that zone where you start to appreciate the magic. Medicine is and never was a “job” for me but something that I feel blessed in order to do. When I read my friend’s blog about going through internship and all of the great learning that he has in front of him, I see myself and I see how far I have come.

16 October, 2011 Posted by | general surgery residency, intern, on-call | 3 Comments