Medicine From The Trenches

Experiences from undergradute, graduate school, medical school, residency and beyond.

End of semester (academic year) thoughts

Introduction

We have made it through another academic year. We will welcome the Class of 2015 into the fold of graduates (from undergraduate programs, medical school and other graduate programs). I always try to reflect on what has been surprising for me during this past academic year and what goals I will set for myself (as a professor and as a physician) for the upcoming year. I am reminded of my own graduation from medical school with my hopes and fears of the unknown aspects of starting the next chapter in my career/life. Now, many years out, I am very happy that I see that I have challenges ahead, goals ahead and things to reflect upon.

My Surprises

As this year comes to a close, I am surprised that the gaps in delivery of health care to under-served populations is getting worse and not better. I have seen people come into my office with conditions that have been left for years that could have been taken care of in early stages but now are life-threatening. I read many medical journals each week to keep up with new advances yet seeing a patient with end stage renal failure because of untreated/improperly treated hypertension and diabetes is rampant. My colleagues who are on the front lines of treating under-served populations are frustrated with systems that still marginalize their patients, are frustrated with fighting for and not being able to see their patients get even basic medical care.

I am surprised that there is a disconnect between those who are responsible for running health care systems are so dedicated to making a profit that they are comfortable with denying services to people who desperately need them. This disconnect is getting greater. I don’t understand how those CEOs can look only at the “bottom-line” and not see the implications of their decisions. Running a health care system is not like running an oil company or a bank. If patients don’t have access to basic health care, they don’t have life.

I am surprised that many of my colleagues can look at patients and blame them for getting ill. Being sick is not a moral failing but a fact of life in terms of being alive. Yes, one does need to look at lifestyle changes that will enhance health but it’s not a personal or moral failing if patients are not able to make those changes. In this time of economic troubles, many patients simply do not have the financial resources, community resources to make the lifestyle changes that will enhance their health. We also have companies that again, look for providing the cheapest foods (usually fatty and sugary) while making healthier food choices far more expensive. Many of my patients eat from the fast food “dollar menu” not because they want to but because they have to. They are simply making choices that allow them to live indoors and are one pay check away from being homeless.

I am surprised that in this world of so many electronic/web informational resources, my students are less informed rather than being more informed. I say this with a bit of ambivalence because I don’t believe that my students’ lack of information is because that resources are not there but that my students are overloaded and their way of dealing with that overload is to turn-off rather than be selective and critical in their consumption of informational resources.

My Challenges

As a professor, I am charged with providing the critical thinking skills for my students to navigate the world of medical information. We, as physicians, have unprecedented access to the best evidence-based/science-based health care resources in the world. As a scientist/scholar, I am charged with questioning everything that I read regardless of how my information is delivered. Critical thinking and evaluation of the vast amounts of data about populations and individuals is a challenge that I must meet and teach to the next generation of physicians and health care providers. I must and I am constantly striving to evaluate and deliver the best evidence-based medicine based on data and research. I have to be confident that I am making sound decisions and I have to teach how to make sound decisions.

I am challenged to provide preventive strategies to my patients, where they live, that they can incorporate into their lives for the best outcomes. If I overwhelm my patients, they disconnect with preventive strategies and with health care in general. This means that I have to be able to explain what and why I am recommending a treatment strategy and I have to be able to recommend other treatment strategies and why I am not recommending those strategies no matter what they have seen on the telly or read online. I have to keep “one ear to the rail” in terms of what is circulating online and I have to keep the “other ear” to what is sound medical practice.

All of our challenges

Practicing medicine is more difficult today largely because of documentation issues. We are clicking away into our computers with poorly designed electronic medical records systems and filling out duplicate “paper work” late into the evenings after a long day in the clinic where we have been charged with seeing an impossible number of patients (again because our employers want us to turn a profit for them). Our challenge is to provide good delivery of health care but we have little support and assistance to do just that. At the end of the day, even if one has completed all of the documentation, there are few feelings of a “job well-done” and more feelings of “I failed on some many levels today.” Our biggest challenge is to remember that we are not the problem but we can be part of the solution by demanding that our talents and energies be focused on our patients and not on “paperwork”.

Our challenge is to look at anything and everything that we can change from within. We cannot allow a flawed system to push us further away from treating our patients because we can’t even “look them in the eye” because we are typing into a computer. We can’t keep skipping lunch, dinner and priceless interaction with our families and loved ones (our sanity) because we are so tied to trying to keep up. We can’t keep looking at the color, size and sex of a patient and dismissing them as individuals with unique needs. We can’t keep “writing off” whole populations of people because they are difficult to treat and because their culture is so different from ours. We can’t afford to say, “It’s someone else’s job and I will just refer them because they are too complex”.

We have to be challenged to take care of ourselves in terms of spiritual, physical and emotional health. No, self-care can’t be our only focus but we need to look inside of ourselves and figure out what is most important for our health and do things to keep ourselves both physically healthy and emotionally healthy. We can’t allow a very flawed health care system to result in our individual spiritual and physical to deteriorate to the point that we become a liability to ourselves and our patients. We have to learn to be selfish with our time and we have to have some outlets that will nourish us spiritually and emotionally. In short, we are crucial to our patients and we have to keep ourselves healthy and happy. Anything less is not going to work.

We have to learn to question everything. Do not just “take the word” of professors, websites, books, journals and other information resources as the only truth out there. Medicine is based on science and not on faith. You can have faith in your spiritual life (valuable) but you have to have the ability to cast a questioning eye on information in medicine. Look at alternatives and look at alternative solutions. Evaluate everything with a questioning eye. It is fine to question someone who is advocating a treatment and it is incumbent upon the advocate to explain their ideas. If you have questions, get them answered and constantly question others and yourself.

Finally, think about your experiences and learn from them. None of us was born knowing everything and our experiences are always learning opportunities. To evaluate yourself and your learning experiences is a very healthy way to learn to discard  that are not working and to embrace the things that are working well for us. Always looking for a way to do our daily tasks, job and learning in new ways is a great growth exercise. Again, my professors and my colleagues who constantly questioned me make me stronger rather than tearing me down. We all lamented about those “pimp sessions” but in the long run, they are opportunities for growth and reflection. As long as one is alive, there is opportunity for growth and learning; seize those opportunities.

 

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30 April, 2015 Posted by | academics, medicine, stress reduction, success in medical school | 3 Comments

Strategies for Conceptual Learning (undergraduate and professional school)

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.

26 April, 2013 Posted by | academics, difficulty in medical school, physican assistant, study skills, success in medical school | 3 Comments

How to use the ophthalmoscope

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.

3 February, 2013 Posted by | medical school coursework, medical student., physican assistant, success in medical school | | 6 Comments

The Power of the Positive Inner Voice

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.

4 September, 2012 Posted by | academics, medical school coursework, medical school preparation, residency, stress reduction, study skills, success in medical school | 3 Comments

Taking Stock of the First Semester

For most people in school, it’s the end of your first semester of something. That “something” might be your first year semester of medical school, college, clinicals or even the first half of your first year of residency. With the end- of -year holidays brings a time of reflection and adjustments for most people. My first thoughts are to tell anyone who is doing a first semester “post-mortem” to make sure that you don’t forget that you actually were able to survive your “first”. The next thing to do is to figure out what might need to be tweaked, removed or started. For most folks, no major changes are needed but don’t be surprised at how a small adjustment in one area can reap huge benefits in others. It turns out that life just works in that way.

There are some things that I have been telling my patients to institute for the last two weeks of 2011. I don’t call these “New Year’s Resolutions” because they can become habits for the new year rather that something that will be forgotten by the second week of January. These are:

  • Perform at least 10-minutes of exercise of some type per day.
  • Give up meat for three dinner meals each week
  • Don’t patronize any restaurant with a “drive thru” window (Sorry Dunkin Donuts!).
  • Don’t add salt (NaCl) to any food before tasting it
  • Try a new vegetable each week (most stores have a great selection).

Taking each one of my goals

I know that every study out in the news media states that one needs at least 30-minutes of exercise 5 to 6 times each week but I know that if one strives for 10-minutes, they will increase to 20 minutes and get to 30 pretty quickly. I am a person of small increments of change working better than one large increment that does not work. Like your studies, exercise can be divided into small manageable bits that can be checked off and mastered. A 40-page paper is written one letter and one page at a time. Daily systemic practice of one small change can lead to larger and better results as that practice becomes a welcome habit.

I also encourage my patients to allow their 10-minute exercise break to be a time when they don’t multi-task. This means that this break should be a true break from cell phones, tablet computers (well maybe the I-pod/MP-3 player) were the mind can be refreshed and renewed. Couple that with getting one’s heart rate up and you have a true “mini-vacation” that decreases stress and makes the rest of your day more efficient. If you want more of a challenge, go up flights of stairs on your 10-minute break. Your brain and joints will be grateful for the movement.

In getting to know vegetables/fruits again, one can develop a relationship with color, texture and anti-oxidants. While I know that fast-foods are wonderful time savers, those heavy fat meals are terrible for keeping alert later in the day. If one does the burger/fries routine for lunch, the rest of the afternoon is spent trying to overcome “food-coma” so that you can get through the day. If you do the burger/fries routine for dinner, one finds that “food coma” can make your studying particularly inefficient. Try making a nice light dinner/lunch of rice noodles and grape tomatoes which can be appealing for the eye and add some “zip” to your taste sensations. One can also have a bag of cut and uncut vegetables, carrots, bell peppers (red and green), carrots and those lovely grape tomatoes in your backpack so that you can snack on something that won’t put you into nap time during your study time. One can also invest in great spice mixtures, curry powders and chilis for waking up taste buds and mental clarity.

If I have one vice, it’s a hot, fresh cup of Dunkin Donuts  (DD )coffee. I just have to stop by the shop, get out of the car and walk in to get my steaming cup. I can drink this coffee black and enjoy its rich aroma and flavor. For me, DD coffee is less harsh than Starbucks (though I will drink Starbucks when I can’t get DD) and is a nice break during my day. In the late afternoon, I often reward myself with a nice hot cup of coffee or tea (Twinings Earl Grey) rather than something fatty or sweet. I try not to drink anything with caffeine after 5pm if I anticipate getting into bed at my usual time. Since I get up around 3AM most days, I find that I need to be in bed before 11PM most night for sleeping. If I am on call, all bets are off and I enjoy my coffee/tea at any hour. When my favorite Dunkin Donuts shop put in a drive thru window, I had to change shops because I don’t want to break the drive-thru habit.

Finally, the NaCl habit is one that most of my patients need to skip. The American diet has increased the love of that salt taste in most people in this country. Since most of my patients have more than a passing experience with hypertension and diabetes, I do encourage them (and my students) to tread lightly where sodium is concerned. This is why most “fast foods” are not good diet choices. Couple the high sodium content with the high fat content and one has a potentially troublesome combination. Do keep in mind that it takes some time to get used to eating foods without salt and to lose that love of salt. For me, it was difficult to get used to eating baked potatoes with no added salt but now I use pepper and happily enjoy munching on the potato (with skin) with nothing other than pepper added to this vegetable.

Taking Stock

Be willing to forgive yourself for doing things that were counterproductive to a strong performance in your academics or in any area of your life. Everyone, even the person who has the highest grades in class, would like to perform better and more efficiently. Efficiency comes with experience and with adaptability. If you can make some shifts and learn from things that didn’t work well for you, then your efficiency and performance will increase. Remember that every day is another chance to do better than the day before. One test, one semester or even one year do not define a lifetime. One can just decide to change your thinking about any subject or taking one step ahead rather than remaining stagnant. No one’s past defines them but the past does allow one to have thousands of experiences to draw from and to learn from.  As you move into the new year, look at one or two small things that you might like to try to do differently and try a to change them one day and one small experience at a time.

16 December, 2011 Posted by | academics, first-year, organization, study skills, success in medical school | , , | 7 Comments

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

It’s medical school (or any other school) orientation day (week)!

Well, you made it into medical school! Congratulations on that accomplishment but resist the urge to look around and size up what you believe is the “competition”. Your fellow classmates are far from your competition. They are a bit like your family in the sense that they are going to annoy you in the years to come. Additionally, you have no control over their identities or actions (waste of time to be annoyed with them) and you will come to appreciate them when they bail you out of a struggle or provide “comic relief” when the stress is causing you to lose part of your soul. In short, you inherit a bunch of brothers and sisters who will travel the experience of learning with you. Take a minute to take in the atmosphere, test out the “vibe” that you get from your class and enjoy orientation because it’s one of two periods of time that medical school will be totally enjoyable. Once the classes start, the work begins.

Many orientation sessions will have loads of information for you. Just like your coursework, get this stuff mastered! The check in and schedule is most important so that you know where you want to be and when you need to be there. This is also a time when you realize that you need to spring for a 140 db alarm clock without a snooze button for those days that you just can’t hear the one with the buzzer. My “super alarm” was my best friend on many a Monday morning when I was in medical school. By general surgery residency time, I found that I didn’t need it as I woke up when the curtains rustled; surgery makes one a light sleeper by necessity. You also do not want to get into the habit of hitting the snooze because you can’t hit that beeper once you get into practice. In short, you have to get up and get rolling on the first alarm. You will also need comfortable walking shoes and a car with a trunk so that you can carry home all of those books that you will buy, or in my case inherit, from your upper-class advisers. I watched in amazement as a few of my classmates carried what looked like a “house” on their backs as they marched to the underground or bus stop to go home. I drove during orientation week so that I could get my “loot” home comfortably.

If you haven’t done so, get all of the stuff that you need for your apartment (crib/loft) arranged and unboxed. I can’t emphasize more, how little time you are going to be spending there during first year but you don’t want to waste any time trying to arrange things when you need to be studying. Orientation week for medical school is also orientation week for getting your housing together too. Make your place as efficient as possible. Stock up on “the noble necessity – bathroom tissue” , soap, deodorant, ramen noodles- can be enjoyed in 2 minutes 1,000 ways, laundry detergent and most important for me, coffee. If you don’t purchase at least a semester’s supply of the necessities, it will be during exam week when you have no time that you discover you have no TP! Don’t let this happen. (If you have a roommate, put a couple of extra rolls under the foot of your bed so that you always have a stash in emergencies).

I will also recommend finding a 24-hour gym that is close-by because you never know when you are going to get an hour for a workout. My biggest mistake in medical school was not keeping in good physical condition.  Regular aerobic exercise diminishes stress and just makes you a more efficient student.  It also helps to keep your immune system polished (drinking tap water helps too) and ready to fend off your classmates’ viruses and bacteria that they will try to share with you. In short, driving yourself to burnout is less likely if you have a means of working out. You don’t have to have an elaborate routine just 30 minutes or so of walking on the treadmill plus 30 or so minutes of weights. I can’t tell you how much weight work helps to keep you focused on your studies. I have learned that fact after many years of teaching and practice. Take the time to pump some iron for your sanity and your health!

Go to all of those social events during orientation. They may seem stupid but you want to get to know as many of your fellow students as possible. No, you are not running for office (don’t run for office unless you know you can get your class work mastered well- our class president didn’t do so well first year and being a class officer is pretty meaningless for residency so don’t take a chance on this) but you want to have a cordial/professional  relationship with everyone in your class. Resist the urge to form cliques (many students do this by ethnicity) because your future colleagues are going to be every ethnicity and color and you have to work with them. Get along with everyone and have a sunny relationship with everyone even if you have a family at home. You need to be able to work with your classmates on projects and in the future on the wards. It’s also your classmates that will cover for you when you need to take that sick kid to the doctor or leave early because there’s an emergency. Go to those social events and get to know everyone. I met my best friend from medical school while we were in a line to shake hands with the deans at the Deans Reception. We studied together, cried together and graduated together. Even today, I miss those great times that we had even though we thought we were suffering.  The greatest thing about my best friend is that she spoke to everyone in the class and worked easily with everyone. She is truly a gifted person.

Make sure that your study area at home and at school is well equipped (plenty of note paper, pens and highlighters) and easily accessible. Don’t seek out the darkest and most remote area of the library (too dangerous) and don’t seek out the most popular area ( you won’t get much accomplished). Find a place where you and a couple of like-minded individuals can study (watch each others stuff when you need to use the facilities) and get something accomplished. I found that I studied best at home (not an option if you have a family that will compete for your attention) with a couple of beagles at my feet. My “facilities” were next to my office and any telly, video games and other distractions were far away. Once a week or so, I would do a group study with my study partners but not until I had mastered my work (see my post about my study habits).

As I have said in other posts, the two times that you can truly enjoy medical school are during orientation week and during fourth year after you match, unless you haven’t taken Step II. Orientation week is a time to get to know as much as possible about your school, your classmates and how you can set a strategy to navigate the next year or two. I can’t encourage you more strongly to read all of the information in those handouts and student handbooks so that you know where things are  and know who to contact if you have trouble. If you are given course syllabi (we were), look though them and get an idea of how much work you are going to need to set aside for your courses. Planning and organization are two of the most important tasks for medical (or any other professional school) success. Have fun for this week because the classes are going live too soon!

4 June, 2011 Posted by | medical school, orientation to medical school, success in medical school | 1 Comment

The Day to Day Work of Getting Your Schoolwork done.

This is a re-post from some time ago. Since I have been asked by some of my present students about this type of material, I thought a re-post of this might be in order.

“The Thrill of Victory or the Agony of Defeat”

The Drama of Human Competition as the opening lines of ABCs “Wide World of Sports” promised. By now, many students have had their first blocks of exams in medical school. Some people have done very well and some people have “breathed a sigh of relief” that they passed and some people have not passed one or or more of their exams. To fail an exam at this stage can be a huge personal blow but your actions after discovering that you have not passed (I am going to avoid the word “failure” here) are critical to figuring out what you need to do to get “above the yellow line”. Sure you NEED to do a bit or mourning in terms of the loss of those wonderful feelings that infused during orientation week but don’t let the mourning phase go on longer than a couple of minutes. Replace mourning with a very objective strategical look at what might have gone wrong and how you are going to fix the situation.

There is something in medical school that will throw every person. It may be that first round of exams, that USMLE score or a patient contact that just did go well. The important thing is that out of every experience, good or bad, you learn something about yourself and what you are capable of achieving. It is out of experience that you will learn to treat your future patients so let your experience become your teacher and move forward from here. Not passing an exam just doesn’t feel good and can play with your “head” in terms of how your look at your future. My point here is that nothing except that round of exams is over at this point. You mourn a bit and then you push forward because (and I am not wrong on this), the material for the next round of exams is already upon you.

As soon as you know that anything has not gone well for you academically, ask for help. Your first action should be reviewing the test and trying to figure out where you went wrong. Do you need to rely on more detail? Did you move too fast and not answer the question that was asked? Did you neglect to read every answer choice with a more correct answer further down? Did you not fully understand the material? Were you distracted by something outside of school such as a relationship or illness and not put in enough time studying? In short, try to figure out what went wrong and take steps to make sure that you don’t repeat your mistakes.

What if I fail a whole course, like Biochemistry?

The consequences of failing an entire course in medical school are largely school-dependent. Some schools will want you to retake only the material that you did not pass while others will have you go through an entire summer remediation course. In any event, look at your remediation/retesting as an opportunity to hone this material well. You definitely want a strong knowledge base for your upcoming classes and you will have made some steps toward review in terms of preparation for USMLE. In this light, having to retake or remediate is not totally the worst situation that you can find yourself going through.

Plunge into your review with total concentration on the subject at hand. If you have one course or one area of subject matter, this is easier than if you have multiple subjects to remediate. Your only resolve in this situation is to not miss this golden opportunity to thoroughly master this material. You are not a “lesser person” because you need a second review and keep in mind, that you are reviewing at this point. In most cases, you have learned the material on the first shot but this review gives you insight into the material that you likely previously missed.

I am always more concerned about those students who “barely” passed than the students who failed and are re-mediating. In most cases, the student who re-mediates does not carry a knowledge gap forward while the student who barely passed likely has gaps in their knowledge base. It is those who barely pass that will need the most intensive review and preparation for board examinations.  I always encourage students who scored below an 80% to study for and take any optional shelf subject exams if offered by their school. These shelf exams can pinpoint knowledge gaps that can be filled in before taking Step I.

Class Attendance – Is this time well spent for me? 

In some medical schools, class attendance is not mandatory. If this is the case, and you ran out of study time, try figuring out if there is one day a week that you can stay home and study the material using note service/lecture tapes or vids/textbook and syllabus reading. Many students do not attend class and find that home (or away from school study) works best for them. This may work for you but be careful if you have too many distractions at home or find that not attending class puts you behind. (Getting behind in medical school is deadly.)

If your work is not detailed enough, figure out which classes do not require the detail and which ones DO require more detailed study. In short, give each course what it demands. Many schools have integrated courses that definitely demand loads of detailed work coupled with “professional-type” courses like Practice of Medicine that are more performance-based. Try to look at your coursework from this perspective and see if you can give your integrated course a bit more time and your performance course a bit less time.

Another problem is that in many first year courses, the load of information can seem overwhelming. Resist the urge to dwell on what seems overwhelming and nibble away a chunk at a time. I always remember that scene in the movie “Shawshank Redemption” where the protagonist chips away at the prison wall over the course of 17 years with a small rock hammer. Eventually, he gets through the wall and escapes. Extreme but I think you get my drift in terms of divide your work into manageable chunks and stay on course. Keep moving forward because you can only affect what is happening now and use that to impact the future. Weekends are your friend because you can breathe a bit, relax a bit and catch up if you have fallen a bit behind your class. In the middle of the week, go to where the class is and use the weekend to “catch up”.

Wasting time and less efficient practices

I discourage students from recopying notes as a means of study. When you have volumes of material and information, you can become more of an excellent clerk in terms of producing a beautiful set of notes that you have not mastered. Organizing your material is good (can be done with a highlighter or in the margins of your notebook) but total recopying of every word may be too time consuming and not as beneficial as when you were an undergraduate student with less volume. You may need to review the material and then constantly question yourself or recite the material back to yourself rather than a complete recopy. If you can recopy your work in an efficient manner while learning and your grades are good, then recopying is working for you and don’t change your strategy.

Another problem that can interfere with some freshman medical students is feeling that they “need” to study for boards. You don’t need to take time away from your coursework mastery to do board study at this point in your career. If you absolutely feel that you NEED to do some board study, then do it during the summer between your first and second year but the best preparation for boards is to thoroughly master your coursework and then study for boards at the end of your second year. You cannot “review” what you have not “learned” in the first place. Don’t take valuable coursework study time to do board study. Board review books are most useful because they summarize material but most medical school courses require the details and not summaries. Beware of the “I am going to use a review book to summarize” method of study because it might work against you in terms of you not getting enough of the details to pass your course. The other extreme is to attempt to memorize the textbook which is most likely too much detail. In short, strike a happy medium that will work for you.

Don’t be afraid (or ashamed) to consult your instructor or your dean if you are struggling. Not to reach out for help (especially because of the amount of money that you are paying for your school tuition) is not wise. It really looks great to a residency program director to see comments from your dean or professor that state that you were able to overcome a deficiency and excel. These types of comments indicate excellent problem-solving skills which are highly prized in a physician.

Finally, tune out the boasting of your classmates who say that they “didn’t study” and “aced” their exams. They are lying period. You have to do what you NEED to do for yourself. Congratulate them for being so “brilliant” and don’t waste a second of your precious time worrying that you are somehow deficient because you studied like a demon and didn’t do so well. There is nothing wrong with you that correcting your study strategy will not solve. Just don’t add “questioning your worth” to your list of things to overcome. It isn’t necessary and it won’t get the job done.

Striking a Balance

Finally, one key aspect of medical school, residency and the eventual practice of medicine is that you will have to constantly “strike a balance” between study, personal life and professional obligations. The first semester of medical school will definitely test your resolve to keep working away at your studies until you get them mastered but this should not be at the cost of your personal integrity or sanity. Try to find ways of incorporating some stress relief (physical exercise) and socialization (away from your classmates) into your life. Nothing, including the practice of medicine is one-dimensional and there needs to be balance.

For example, if you are studying in the library and know that you won’t make it to the gym, try to walk up at least 8 floors of steps on the days that you don’t get to the gym. Take 10 minutes and take a brisk walk around the corridors to get your brain relaxed before you keep “grinding” away at your study materials. Study and pace at the same time while reciting the material to yourself in your own words. Try making some study-drill tapes and drill yourself while you are on the elliptical trainer/treadmill in the gym. Finally, picture that professor’s head when you are doing your bicep curls or on the fly machine and pound things out. You will be more relaxed, less stressed and more efficient in your studies. In addition, you can enjoy eating without worrying about gaining weight.

Statistics (and odds) state that if you were accepted to medical school, you will get through the four years successfully. Some people make the adjustment to the rigors of medical school academics faster than others but trust yourself enough to know that you will get the job done. There is very little difference in intellect between the person who graduates first in their medical school class and last in their medical school class. Residency program directors know this which is why the person who graduates last in their class is still called “Doctor”. Run your own race and get what you need.

19 January, 2011 Posted by | academics, medical school coursework, study skills, success in medical school | 2 Comments

First Semester of Medical School (it’s over and done)…

For many people, the first semester of medical school is complete. By today – barring being snowed in and delayed at one of the east coast airports – you are on your way or at home for the holiday break. Many folks worked harder this first semester than in any aspect of their previous academic endeavors only to find that they didn’t do as well as they wanted or anticipated. The good news is that the semester is over and the bad news is that you have to go back and face second semester in a few short weeks.

My first piece of advice is to take a bit of time to assess what worked (and didn’t work) in terms of getting the material mastered for this past semester. There is little use in anguishing over grades (you get what you get when you get it) or what you “could have done”.  You put everything regardless of good or bad, behind you and move into the next semester renewed. If you failed, it’s behind you until you have to re-mediate. If you passed, it’s behind you and you have to move forward. That’s one of the great things about medical school in that it carries you along at a relentless pace.

As you take stock of the things that worked well for you, see if there is something that you can do to enhance your efficiency. You are going to have to be more efficient in the upcoming semester and into next year so why not take a look at what you can “tweak” to make better. If you are totally satisfied with your work, still look at adding some activities such as physical conditioning or stress relief. Trust me on this one, stress can come out at any time in medical school no matter how well you are doing. Having some kind of a stress relief plan is a good thing. Even if you walk around the block a couple of times, it will just relieve some of the stress.

Resist the urge to try to study for Boards during this holiday. You NEED rest and relaxation. If  you feel that you must do something, then have a cursory look at First Aid for Step I but there is little that you can do that will make any meaningful “dent” in what you will have to review after next year is done. Your best prep now is rest and relaxation. Don’t even try to use these next couple of weeks to “read ahead” for the next semester. Work on a plan for increased efficiency but you know that you will have ample time to study for the next semester of coursework.

Take this time to catch up with old college mates who have gone into something besides medical school. I found this practice most fulfilling because they wouldn’t allow me to “talk shop” during our get-together. I could hoist a brew or enjoy the holiday lights without feeling compelled to study something or plan to study something. If you were fortunate enough to complete your Gross Anatomy course, relish in the fact that you can burn those formaldehyde-scented scrubs now. See, there is always something to put behind you. If you are not done with Gross Anatomy, well, you are at least further along that when you started.

I also used the holiday break to catch up on some of the latest movies, non-medical reading and other nice non-medical pursuits. Even today, as I have completed submitting grades and evaluations for the students that I teach, I am contemplating the movies that I will catch up on this week. I have some holiday clinical duties but as I have posted in past posts, I actually enjoy the hospital during the holidays. The patients are grateful that you are working in addition to the wonderful decorations everywhere. I love to take a couple of minutes to sniff the branches of the huge lobby Christmas tree just to get that holiday feeling.  I also enjoy hearing the Christmas carolers strolling the halls to serenade the few patients who are left in the hospital.

In short, take the time to enjoy your time with your family and friends, to celebrate that you have gotten through your first semester and to face the upcoming semester with some anticipation.  Try to remember that this whole “medical school thing” is a process and not a commentary on your worth as a human being. My bet is that you are far more complicated than your studies. 

If you didn’t get the grades you wanted or feel that everything you have learned has “leaked out of your brain” relax because that hasn’t happened. You definitely know more than you think you know. Every medical student feels that they are forgetting everything that they have learned. You may not remember every tiny detail but the neural pattern is there and can be recovered with a bit of review. In short, relax, that knowledge is in there and will be there for you. Next semester will build upon what you went through this semester but isn’t dependent upon you having done a “perfect” job with this semester’s material. You will have another shot at anything presented this semester next year and for Step I study. Again, this is why you can relax right now.

Finally, to those who may have to re-mediate, put off the self-flagellation. You have learned what not to do so concentrate on thinking about what you will do differently. Assess what worked and resolve to hone that what worked for you. Don’t be ashamed and don’t keep running thoughts around in your mind that you have closed any doors to having a fine medical career. You haven’t closed off anything. Remember that the vast majority of medical students will have something to face in the future that will cause a hiccup or a step-back. If you had your hiccup now, you are done. Put it behind you and know that you are going to move forward to enjoy a great career.

Happy Holidays!!!!!

21 December, 2009 Posted by | academics, failure, first-year, medical school coursework, success in medical school | 3 Comments

Surgical Clerkship 101 (Part 1)

I thought I would take this opportunity to spend some time listing some helpful hints to moving through your surgical clerkship seamlessly. Surgery is one the the third-year “required” clerkships during medical school. It doesn’t matter if you are interested in surgery or not, you still need to master this important portion of your medical school training. Many student look at surgery as something to be dreaded but this approach will not serve you well in surgery (or any class or clerkship). It is most useful to go into this clerkship with an open mind and a willingness to learn and master what you need from this required clerkship to become an excellent physician.

As a third-year surgical student, you will be required to keep honing and using your Physical Diagnosis skills. Your acumen with the abdominal history and physical exam will be sharpened. In addition, you can pick up some valuable procedures and skills that will serve you well on any rotation regardless of specialty such as scrubbing and interaction with a sterile field, central venous access, suturing and simple skin closure. As a third-year surgical student, you ARE part of the team and you can either “carry your weight” or “drop the ball” but 95% of what you get out of this and any clinical rotation will be directly related to your attitude. In short, open your mind (and your ears) so that you get the most for your experience and money.

Surgical patients may present at any time of the day and from various sources such as the clinic, the emergency department or from your preceptor’s private office. In general, you will be assigned to a team (trauma, general surgical, surgical specialty) where you can expect patients from the above sources. You will be expected to take overnight “call” along with the interns and residents since many surgical patients will present in the middle of the night with emergencies. Your surgical clerkship is a very nice opportunity to interact with the “late-shift” personnel in various departments such as radiology, lab and nursing so that you can learn who to see when you need to get something done or when you need information.

The intern (PGY-1) is your first point person. Try to learn the scope of their role on the surgical team and how you can assist this person. The intern will usually be the busiest person but remember, that regardless of specialty, in two years, you will be in their position. Watch how the intern performs their job and learn how to function as an intern. During your fourth year “acting” internships or (AIs), you will want to have mastered time management and multi-tasking. It is great to have a good relationship with your intern and learn as much as possible and become as helpful as possible.

Being helpful does not mean that you become the person to “go fetch” coffee, radiographs and laundry but it does mean that you know more about your assigned patients than anyone on the team. You will pick up three to four patients on each rotation (more if you are efficient) that you will follow through their hospital course. It is your responsibility to follow-up on all orders, consults, labs and studies on your patient. The intern on your service will be covering every patient on the service so the more closely you can work with your intern the better. This means reading in your surgical text about your patients’ pathology and the surgical treatment of that pathology. This means reviewing and following up on every order, medication, dressing change and complication.

Typically, you will enter the hospital early in the morning to pre-round. In some cases, pre-rounding means heading over to a computer to gather any laboratory work, checking in with the overnight (post-call team) and reading any nurses notes/checking with the nurses who have been on duty overnight. Armed with this information, you should quickly check the previous 24 hours of vitals, intake and output. Finally (if this is allowed), you should do a quick (no more than 5-10-minute) focused physical exam on your patient. Armed with this information you can prepare your AM presentation which should make up the bulk of your AM progress note.  If you encounter any problems, discuss these with your intern and be prepared to present this patient to the AM rounding team.

On AM rounds, the chief (or most senior resident) will listen to your report presentation. If you are not ready, the intern will present the patient but you should step up and have your presentation ready. Other good things to do will be to be at the bedside with things like extra bandages, scissors and tape if needed for your patient. I learned very early, how to “peek” under a dressing without removing it. In general, dressings may be removed at 48 hours but never remove a dressing unless you have cleared it with your intern. You can peek and examine the wound to figure out if it is intact. Also, be sure to note any dressing drainage (dry or fresh) and note if nursing has been reinforcing the dressing overnight (or since surgery). If you are on the vascular service, one of your tasks will be to “take down” your patient’s dressing so that the team may examine the wounds on rounds. You may be asked to replace the dressing (great skill to learn) by your resident. Get help from the intern (or nursing) if you have difficulty or questions with this.

If you have read about your patients’ pathology and surgical treatment, you should know (or learn) what complications to look for and how to monitor your patient. For example, you should know what to do if your patient develops a post-op fever at 8 hours, 24 hours, 36 hours or 72 hours. You should have a differential of things to check and monitor. You should know what to do if your patient has an extreme amount of pain that is unrelieved by their current analgesic regimen. You should know how to monitor electrolytes and when to replace them. You should keep your intern informed of the results of all consultants and any studies that have been ordered. In short, you micromanage the patient and you keep on top of things.

Another wonderful experience of your surgical clerkship is assisting in the operating room. I am going to devote an entire essay to this very important task. You will be performing tasks such as retracting tissue, driving camera (on laparoscopic cases) and closing skin. Do not underestimate the importance of these duties and do not underestimate the importance of thoroughly mastering the surgical anatomy of the cases that you scrub. Here again, is a great opportunity for you to show what you know and hone what you learned in Gross Anatomy and physiology. During many of your cases, you are going to be questioned by the senior resident/attending surgeon about the anatomy,  physiology or procedure on which you are assisting. I will give you some tips to make you shine and guide you through this process.

Textbooks for your surgical clerkship: The big “three” texts for General Surgery are Greenfield’s, Sabiston’s and Schwartz. You need not purchase these texts (even if you are going into surgery) as they are readily available in your library (medical school or hospital) for research and consultation for presentations and projects.  My favorite clerkship text is the Lawrence text for both General Surgery and the text for the Surgical Specialties. This book (or one like it) should constitute the bulk of your reading on this clerkship. In addition, you may want to invest in a smaller “pocket-type” book such as Surgical Recall that you can keep in your pocket for downtime during cases. Other good books in addition to your main clerkship text (Lawrence or something else) are NMS Surgery and NMS Surgery Casebook which contain excellent and compact information.

With Lawrence, NMS and the NMS Casebook, I cut the bindings off [FedEx/Kinko’s] and placed these in binders. I could then take pages with me and keep up with my reading between cases. The pages were held together by a ring and would fit in my jacket pocket or back pocket of my scrubs. I always had something to read with me be it Surgical Recall or my pages. This was the easiest way to keep reading and prepare for your surgical shelf exam. Surgical Recall was great for pointing out the surgical anatomy, surgical instrumentation and other answers to “pimp” questions for a particular procedure or pathology.

In my next essay, I will review scrubbing and assisting in the OR. In addition, I will comment on being a great third-year on call and keeping yourself “in the game” when you are exhausted and ready to “give up”. In my last essay on the Surgical Clerkship, I will point out some strategies for when things go wrong and how to prevent getting into situations where things can go wrong.

10 August, 2007 Posted by | success in medical school, surgery, surgical clerkship | 3 Comments