Medicine From The Trenches

Experiences from medical school, residency and beyond.

What do I have to know in medical school?

Introduction

If you are asking the question,”What do I have to know in medical school?” then you have already started at a disadvantage. Medical school is not about “what” you “have” to know as much as it is about application of a body of knowledge to problem-solving. Sure, you can sit down and attempt to memorize a bunch of lecture notes so that you can repeat them verbatim but that isn’t going to get you past USMLE (any of the steps) or through residency. Medical school provides a foundation of knowledge that you can build upon. The more solid your undergraduate preparation, the easier you can add to your knowledge foundation that will enable you to treat patients.

Many medical students get into the “whine” about why they have to know so much detailed information when vast information resources are available at the “whisk” of a finger. In truth, the internet is as much of a blessing as it is a curse. No amount of information at your fingertips is going to be very useful unless you know how to evaluate that information and how to apply that information to clinical problems. While many undergraduate institutions are adept at getting students into a mode of being able to “memorize and regurgitate”, they fall far short in terms of providing a solid foundation in research and problem-solving. While there is no lack of information, learning what information to utilize and how to utilize the information that you learn is the biggest hurdle for most pre-clinical medical students. In short, all of the things that are on the internet are not useful or helpful when it comes to patient care.

Becoming an efficient learner in preclinical medicine

Many students start out with the idea that they are going to go home every night and re-copy their notes in order to memorize them for the upcoming exams. They quickly find that this strategy is neither useful nor efficient. The notes are generally an outline of what needs to be mastered in detail with the details largely coming in the form of the information that is stated in class between the bullet points on a lecture outline. Simply recopying notes will largely get one to the point of being a good “clerk” but generally doesn’t provide much of a basis for the depth of understanding that is needed for knowledge base mastery. In short, the Powerpoint lecture notes and the review books are just not enough by themselves for a thorough understanding. One just cannot “memorize the bold heading” and expect to be ready for board exams or course exams for that matter.

What is “efficiency” in learning pre-clinical medicine?

Efficiency is largely making the most of your attention span plus making sure that you synthesize and incorporate new knowledge within the context of the knowledge that you came into to school with. Many students who didn’t major in the sciences will lament that they just don’t have the background that their fellow students would have in subject A or subject B but an efficient learner will not only have the background regardless of major but will be able to add to that base with ease. In short, everyone who takes the pre-med coursework, has the background knowledge base to do well and be efficient in medical school.

If a person majored in biology as pre-med, the upper division biology courses required General Biology as a pre-requisite the same as Gross Anatomy and Biochemistry only require General Biology and General Chemistry as pre-requisites -note that I didn’t mention anything about Organic Chemistry as Biochemistry is far more related to General Chemistry than Organic Chemistry. If a first-year medical student didn’t major in science, they are at no more of a disadvantage as long as they know how to add to their pre-med base and build upon that base. In short, it’s a good idea to stop “talking” or “thinking” ones self out of a strong performance because of perceived perception that upper division science courses give an advantage. In short, the upper division science courses are only advantageous to folks who anticipate graduate school in that  subject matter.

In one wants to become an efficient learner, the subject matter is fairly irrelevant but the study techniques are quite relevant. One has to have an approach to new information that is devoid of emotional reaction, self-deprecation and a willingness to adapt to whatever comes next. Adaptability is a very useful characteristic for learning new material and thankfully, your brain is “wired” to adapt to new situations if you allow it to do the job without emotional checking. One has to have the confidence to dive into what needs to be learned, master what needs to be learned and to readjust if their first attempt at mastery falls short.

Confidence, the best learning tool

When I speak of confidence, I don’t mean that one boasts or constantly “pats their own back” but I mean that one has to have the ability to move past and learn from those myriad of small mistakes that will come with adjusting to any type of professional school. Some folks mistakenly believe that once they achieve a “high” board score or a good grade on a course exam, that they are in the upper echelons of medicine and can’t make any mistakes. Being able to bounce back and learn how NOT to do something is a valuable as knowing HOW to do something.  In every aspect of medicine, it’s the experience that will trump anything read in a book or in lecture notes but with experience should come making mistakes and making adjustments from those mistakes. In surgery, for example, skills are honed from practice and more practice but experience with practice is the best teacher and the best method of learning.

Learning in isolation

I hear over and over from medical students that they are just “not group studiers”. In medicine, one has to learn to interact, learn from and teach other members of the healthcare team. Nothing in medicine is done in isolation which means that the sooner one gets used to working with a variety of others both friends and colleagues, the better they become as physicians. I always remind the residents who are rotating with me on my service that it was a physician assistant who taught me the skill of closing the chest. This PA had spent years doing chest closures and knew how to teach in a manner that was great for a resident who was in the learning stages. My thoracic surgery attending was brilliant and guided me in many ways but that cardiothoracic PA taught me how to handle sternal wire efficiently and safely in the step-by-step manner that a junior resident needs to be taught. In short, the best physicians learn to appreciate knowledge from any good resource and learn to appreciate anyone on the team who is dedicated to the perfection of their craft. This holds most importantly for pre-clinical medical students as well as residents who are further along in their learning. Work with anyone at anytime who is willing to share their knowledge with you or who needs the benefit of your counsel. The ability to work with others and learn from them  will pay back in the years to come.  One cannot afford isolation in any part of medicine.

Getting along with others

While most of your learning is your responsibility, you have to be able to work with potentially any number of diverse people on a health care team. I vividly remember overhearing one of my fellow medical students  who was from India talk about a resident who was from Kenya. This medical student joked about how he “had it made” because the attending on the service was from India and the resident’s opinion wouldn’t really “count” in his grade for the rotation. Well, that medical student was pretty surprised to find out that his “honors” didn’t materialize because he just wasn’t receptive to learning from a resident whose ethnicity was different. He appealed his grade to the attending and to the dean of education but it stood because he wasn’t ready to work professionally with another person who had earned the right to be a resident and who attempted to teach. In short, professionalism means that one has to be able to work with a broad range of people and treat a broad range of people with respect.  The first mistake that many medical students will make on a rotation of any sort, is believing that they can’t learn from anyone except the attending physician who is in charge of the service or that they can treat anyone associated with patient care in a manner that is disrespectful.  I will often question nursing assistants, environmental service workers and nursing staff about the manner that students and residents treat them on a day-to-day basis. In short, everything on a clinical or in pre-clinical coursework always “counts”.  It’s just as easy to treat everyone  with respect (becomes a habit after a while) and not have to worry about offending  (or impressing) anyone.

So what DO you have to know in medical school?

You have to KNOW:

  • How to be an efficient and self-directed master of course materials.
  • How to work within a very diverse population of patients and healthcare workers.
  • How to make adjustments after trying something that didn’t work as well as you thought.
  • How to recognize that every experience is a learning opportunity and be open to the learning.
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13 December, 2011 - Posted by | academics, difficulty in medical school, medical school |

4 Comments »

  1. Hello Dr. NJBMD,

    Thanks so much for your post. I have the option of taking either a Medical Genetics course, an Immunology course, or an Endocrinology course (Physiology). Which course do think would be the most helpful in preparing me for medical school?

    Thanks!

    Comment by Pam | 8 January, 2012 | Reply

    • To Pam:
      Take the course that is of most interest to you so that you may get the highest grade. Any of these course are fine for medical school and no particular course (outside of the pre-med courses) is better than another course.The best strategy for medical school prep is to take something that interests you, do well and of course perform well in your pre-med courses (General Biology/lab, General Chemistry/lab, Organic Chemistry/lab, General Physics/lab). Many medical schools require additional course thus you may want to look at the admission requirements for the schools that interest you to see if one of your courses is a pre-req for a particular school. Outside of that, take what you are passionate about and do well. Good luck.

      Comment by drnjbmd | 8 January, 2012 | Reply

  2. I’m amazed given your busy schedule that you still have time to pass on a little bit of wisdom to those who seek it. Though I’m not a medical student, much of what you write apply to any field of study and where medicine is concerned (healthcare in general), it is vital to learn on improving weaknesses than resting on our laurels.

    I’m a pharmacy student at a very top university with an emphasis in rigorous clinical applications. We assess patients with medical, nursing and dental students. When I fret about the rigorous and extremely challenging topics in medicinal chemistry, pharmacokinetics, pharmacology (not just learning drugs and mechanisms of action, but with respect to patient care and symptoms x y z), and in particular the myriad of info in pharmacotherapy, I’m reminded on rotations at hospitals or clinics, about how I needed to continually work hard to be up to date and be an efficient learner while NOT losing a sense of caring. As far as medicinal chemistry, it is impossible to just memorize. For example, one must understand the pathways of phase I or phase II of drug biotransformation that can be induced by cytochrome P450 enzymes (and some people lack certain enzymes) in the given patient. And given that advanced calculations play an important role in pharmacokinetics, one begins to realize why calculus was an important prerequisite.

    Truly, science is rewarding and challenging. And although it is not unlike any other endeavor, as the author states, it is about learning to work with a diverse population, it is about tweaking one’s strategies to maximize life’s currency: knowledge. After all, a better informed individual can indeed learn to work better on an interdisciplinary team. It is about so much more and this is what makes a field such as healthcare challenging.

    I refer your readers to this great article I found that delineate what you (with experience and skills) and I (cyp 450) wrote about:

    http://publications.nigms.nih.gov/findings/mar10/rightfit.asp

    Thanks again for your time!

    Comment by Kenny | 17 December, 2011 | Reply

  3. Thanks for your helpful post!

    By the way, some of it reminds me of what the Jews have said in Pirkei Avot. For example:

    “Who is wise? He who learns from all men, as it is written ‘I have more understanding than all my teachers, for God’s words are my meditation'” (Psa 119:99).

    “Who is mighty? He who subdues his passions, as it is written ‘Whoever is slow to anger is better than the mighty, and he who rules his spirit than he who takes a city'” (Prov 16:32).

    “Who is honored? He that honors his fellow men as it is written: ‘for those who honor me I will honor, and those who despise me shall be lightly esteemed'” (1 Sam 2:30).

    “He who learns in order to teach will be enabled both to learn and to teach. But he who learns in order to practice will be enabled to learn, to teach, and to practice.”

    “Let the honor of your student be as precious to you as your own, and the honor of your colleague as the respect due your teacher, and the respect towards your teacher as your reverence for God.”

    Comment by rockingwithhawking | 14 December, 2011 | Reply


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