Medicine From The Trenches

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

Some Thoughts for Those Starting Medical School this Month

As you get settled into your first-year coursework, I want to share some thoughts that come to mind:

  • Remember that you are fortunate to be on the doorstep of pursuing a magical profession. For everyone who achieves a seat in medical school, there are many who wish to be in your place. Honor them and remember them as you gather the knowledge that will make you a good physician.
  • Medicine is not easy, especially the study of the art of practice. There are many “all-or-none” tests along the way. There is a large volume of material to learn, master and apply to the practice of medicine and as such, you must make peace with that volume of material.
  • There are no “short-cuts”. This means that you have to make a concerted effort to be willing to take the long road. If you are looking for a short way around your work, medicine likely isn’t the profession for you. Get out early rather than later because medical school is expensive and quite unforgiving.
  • You are going to be working on people and not pathology. While pathology is interesting, always remember that the person with that pathology is loved by someone. Be willing to put yourself in the place of the patient or their loved one and treat them as you would wish to be treated.
  • Don’t believe what you hear but trust what you experience. Don’t go into any class or any rotation with preconceived notions of how it will be. Medicine is interesting and absorbing. Allow yourself to learn with a fresh approach and with fresh energy. While people who go before you will tell you horror stories about certain professors and certain subjects, it’s up to you to figure out and navigate them. You may be pleasantly surprised at how much you will enjoy this process.
  • Take some time to do something outside medicine at least once per week. Go to a movie, visit a museum or attend worship services. These outside activities keep your studies in perspective and keep your brain alive.
  • Keep yourself physically fit. Walk the stairs, take a 30-minute run daily and eat/sleep well. These physical activities will decrease stress and keep you healthy in the long run. Junk food, while quick, can make you overweight, sluggish and prone to picking up infections. Take time on weekends to prepare healthy (minimally processed) food and freeze it for ease during the week. You will save money, something that is always good.

Don’t forget to enjoy the process. Remember that you WANT to be here. Before you complain/gripe about something, try to figure out a couple of solutions or if the complaint/gripe is worth your time. If not, then focus on your studies and keep moving forward.


15 August, 2016 Posted by | first-year, medical school | , , | 1 Comment

Make Your Life Simple

As many are starting medical school, the most important task to master is getting your life under control. You are starting a journey of study that will absorb most of your waking hours in the next couple of years. Because of this, you have to take more than a few moments of time and figure out your basic needs. Starting medical school without taking a bit of life inventory is asking for problems that may cut into your precious study time. You have to figure out what you need and separate your absolute needs from the things that you want.

All of us who sit in that first lecture; open that first syllabus or textbook want to do well. We didn’t come to medical school to do poorly in our coursework. We seek out the wisdom of those who are a year in front of us and we start with the intention of “learning it all”. This drive for mastery comes largely from our premedical coursework where we always knew that in order to get into medical school, we had to have high grades and scholarship. Once in medical school, staying there and doing well becomes our next tasks as we adjust to the volume of information that will be presented in our pre-clinical coursework.

Making your life simple means that your living arrangements have to stable and comfortable. I largely used my apartment for showering, eating and sleeping. Much of my eating was done as I poured over my lecture notes and textbooks. I quickly found that doing much of my study at school was less distracting at first but I also found that heading off to bed early, getting up around 1AM and studying at home was also good for me. There were fewer interruptions from the phone and others as I was getting up when many were heading to bed.

My bed and bedroom were quiet, dark and restful. I refused to have any study materials in my bedroom; using my bed only for sleep. I also found that breaking my study time into 50-minute chunks worked well for me as I would often pace and recite my coursework, as a review, into a tape recorder so that I could listen to my study tapes on the subway as I made my way to class each day.

Making my life simple also meant that I bought my food for the week, on the weekends; making grocery shopping a break from studying. I had a great study group that like to meet on Saturday afternoon which meant that Saturday morning was great for food shopping. I also cleaned my house on that precious Saturday morning; getting rid of clutter that made me tired and less efficient.

Making my life simple meant that I planned each of my study sessions carefully. I made a list of what I needed to accomplish and marked off tasks as I completed them . Seeing those check marks gave my brain a sense of accomplishment that helped make the volume of material seem less intimidating. Still, I never felt completely ready for an exam but I always felt that I had a chance to do well because I studied for mastery (took no shortcuts during first and second year). “You can’t review what you haven’t learned in the first place.” was a favorite quote from one of my professors.

I always attended class prepared for the upcoming lecture by putting the previous lecture in perspective. This task helped me to see the “big picture” which can be neglected if one focuses solely on memorization. I sought understanding and perspective; organizing my studies around mastery rather than memorization.

If I have one regret in terms of my medical school work, it is that my physical conditioning suffered. As a graduate student, I was a middle-distance runner. My running helped manage stress and kept my weight down. I gained weight in medical school because the fastest foods were the ones that were unhealthy (high fat, high sugar). When I finally lost my medical school weight, it was my distance running that brought calm and organization to my life. Find a way to incorporate a minimum of 30 minutes of aerobic exercise in your schedule. Trust me, your grades will improve; your sleep will be more sound and efficient; your life will be simpler but more effective.

At the first sign of trouble, see your faculty instructors for help. They are the experts on the curriculum and should be your first and best resources if you need assistance. Your classmates are great but you should do a knowledge check with your instructor long before the exam comes up. Your instructor can also help you with organization should you become overwhelmed (very easy with the volume of material to master).

Finally, don’t forget family and friends. These people keep you sane but they can take up time if you don’t plan your interactions carefully. I often stated at the outset, “I have a couple of hours, let’s have a quick cup of coffee or breakfast”. I would set a timer on my watch so that I didn’t go overtime. It may seem rude but they adjusted to my general absence and helped my stay on task.

28 July, 2016 Posted by | academics, medical school | | 2 Comments

New Beginnings!

A couple of weeks ago, I attended a STEM (Science, Technology, Engineering and Mathematics) presentation for young women (ages 7-9) from the inner city. I watched wide-eyed young people explore experiments with wonder and discovery. For many of these children, this was the first exposure to science at this level. Each young woman more excited to see the next and the next station. I found myself just enjoying their pure joy and excitement in learning new materials; with much encouragement from the professors (male and female) in attendance. I brought some of my surgical instruments with me combined with photos of them in use in the operating room. The whole experience was joyful and wonderful for me. I found myself back in primary school, excited at the prospect of all of the new knowledge that was in front of me. It made my heart glad once again.

This past week, I was notified by one of my colleagues who works in the Information Technology field, that she has been accepted into Physician Assistant school, the culmination of several years of careful preparation to change into a completely different field. The sheer joy that she expresses with the prospect of entering medicine is visceral. Once again, I saw and felt the same joy as seeing those young woman who dream of something far beyond their everyday worlds. It’s a great feeling. I was taken back to the time when I received that first medical school acceptance, something that I didn’t anticipate was possible yet was in my hand.

Many folks are in the residency application process, the medical school acceptance process, the university acceptance process and other changes from their present state. I would invite you to dream big but enjoy the process, even the uncertainty. From my vantage point after years of practicing medicine I can say that there is nothing better than solving problems for my patients and their families. I can say that to have the privilege of the practice of medicine, in spite of the flaws in our health care systems, is still quite magical.

I can also say that the privilege of teaching those who seek to first prepare themselves to enter this profession is one of the greatest gifts for me. Just recently, a colleague, one of the greatest academics that I will ever know, said that the hours I spend in office are a sign of a “true academic”. These words from him touched my heart like no others. My response is that at this point, as I am teaching physical exam skills, my students need my presence and my guidance at this critical time. In short, I remember wanting as many “skill-checks” from my physical exam professors in medical school as I could find. I always thought I was worrying them but now I know that as true professors of medicine, they welcomed my presence.

As I watch young women daring to dream, my IT colleague about to enter Physician Assistant school and my wonderful students, some struggling but all “testing ” themselves with new horizons, I find myself grateful, no thankful for being here to witness these new beginnings.

6 March, 2016 Posted by | medical school, medical school admissions, medicine, physician assistant school | , , | Leave a comment

New Year and new things!

We have changed into a new calendar year and some of you will be taking on new challenges in academics or medicine. The important thing to remember is that challenges are to be looked upon as a chance to change anything that needs to be changed but keeping a good course if your course has been fine. Change is inevitable in life and medicine thus embrace the change/challenge and keep your perspective.

Your perspective must include facing each challenge/change as it comes and doing your best. If you need help, don’t be afraid or so caught up in your ego, that you don’t reach out if you need to reach out. At the first sign of a problem, analyze situation and take care of it, seeking help when you need help. I am always amazed when residents or students tell me that they were afraid of what I might “think” if they sought help.

What I actually “think” is that if you need my assistance, ask and it will be provided. No one was born knowing everything in medicine. I certainly seek the assistance of my colleagues when I need them and never give a passing thought because the welfare of my patient is my only concern.

This tactic applies in academics too as you need to seek the help of your faculty even if you believe you are on the right track. Check your understanding to make sure that you are on course. If nothing else, you make get a better perspective and do even better. Faculty office hours are there for you to get help, get an understanding check and to keep you on course for your best performance. I can’t emphasize this fact with any more emphasis.

Your faculty are experts in their subject matter without exception. Take full advantage of that expertise and strive to get the best instruction possible. You are paying good money for that expertise so get everything that you can. It is far easier to be proactive concerning your studies than to do “damage control” because your ego was in the way of your judgment.

If you are starting clinical rotations, remember that your evaluations will be subjective. A good first impression can often make more of a difference in your clinical grade than anything else. You don’t have to “fake” an interest in everything clinical but you do have to learn to perform your best in a clinical situation. Be enthusiastic about the learning even if you don’t plan on entering a particular specialty. There is a baseline clinical knowledge that every clinician needs thus you need to be sure that you are well above that baseline.

I entered medical school with the idea that I would be a pediatrician, as I had an interest in adolescent medicine. I savored all of my tasks on my pediatric rotation (my first). Midway through clinical year, I found that I loved surgery more than anything I would ever do but that pediatric, family medicine and psychiatric knowledge (the rotations that I did before surgery) have been very useful in my career as a surgeon. In short, while you may change your mind as you are getting clinical experience, everything clinical is useful. Listen, learn, read, learn and ask questions as you go.

My last clinical rotation was Neurology/Neurosurgery. I learned to perform an accurate and thorough neurological exam. These skills have proven to be invaluable in the treatment of trauma and burned patients. In short, all clinical knowledge is useful for a physician or a physician assistant. In the middle of the night, that sound clinical base may make the difference in a patient’s outcome.

Again, mastery of the knowledge of a discipline is useful at the pre-med or pre-PA level too. Don’t approach a course as just something that you have to get an “A” in but look upon those courses as learning practice and useful for your future patients. I remember when I remembered that exogenous insulin did not contain Peptide C (cleaved out when endogenous insulin is synthesized by the body) thus checking a Peptide C level is a good idea in a patient who appears to have high insulin levels. If the Peptide C levels are low and the insulin levels are high, that insulin is coming from outside the body and not from something like an insulinoma (insulin-secreting tumor). I learned about Peptide C as an undergraduate student at university; reinforced in medical school.

Also remember that your faculty, undergraduate, graduate or medical school is there to see you successful. No faculty member gets “points” by having a high number of students fail to navigate their coursework. As a faculty member, my job is to help my students and residents to become the best professionals that they can become, without exception. I can’t “dumb down” the curriculum but I can give you every strategy that I know, to help you get the material mastered. My only hope is that you seek out help and get any assistance that you need.

My next point is for you to try to put yourself in the place of your patient. They are putting their health and trust in you to give them the best care that you can achieve for them. For me, this is the honor of being able to practice. The trust of a patient is something that I cannot violate under any circumstances. I might not have all of the answers but I have the stamina and the resources to get those answers. As I said above, I do not hesitate to consult a colleague when I need their expertise for my patient.

Finally, take time on a regular basis, to relieve the stress of being in an educational system. As a faculty member, I place a premium on my stress relief. For me, physical activity in the form of running, has been great for stress relief. I use that time for meditation/prayer, problem-solving and for the sheer enjoyment of pushing myself to the limit of my stamina. When I feel as if I am too tired to exercise, I go to the gym (or for a run) and I always feel better. If you can’t do 30 minutes, do 10 minutes but do something physical.

Trust the process because the process will get you where you want to go. Trust yourself and your feelings along with the process. If you find that your anxiety level is too high, do something to alleviate the stress. School or residency is not torture but a chance to see something new or learn something new. I can promise you that even a jaded old surgeon as myself, learns something new everyday!



5 January, 2016 Posted by | medical school, physican assistant, residency, stress reduction | , | Leave a comment

Applying for Residency

Each year since 1952, seniors in US medical schools have applied for first-year, post-graduate-1 (PGY-1) positions through the National Resident Matching Program (NRMP). Prior to 1973, these positions were termed “internships” but now, the term PGY-1 (and in some cases PGY-2) positions are more accurate. This service is open to several applicant types who are divided into the following categories: seniors of US medical allopathic medical schools, previous graduates of US medical schools, student graduates of Canadian medical schools, student graduates of osteopathic medical schools , US citizen IMGs and Non-US citizen IMGs and student graduates of fifth-pathway programs. In the last year (2012) that the match was held, there were more than 26,000 positions offered with about 38,000 registrants vying for them. Most of the positions were for PGY-1 positions and a small number were for PGY-2 positions.

By far, US graduates were successful in terms of securing a position (more than 95%) and this meant that fewer positions were left over for the scramble [now SOAP] (open to those who were not able to match). This also meant that US graduates held a distinct advantage when it came to securing positions in the SOAP. It also means that applicants who enter then 2013 application and match need to be very savvy in terms of making sure that they are competitive for the specialty that they seek, that they are competitive for programs within that specialty and that they don’t make any mistakes in their applications that might cost them a position.

The “lifestyle” specialties, Anesthesiology, Dermatology, Emergency Medicine, Radiology and Orthopedic Surgery had fewer than 10 unfilled positions and far more applicants vying for those positions. These specialties filled almost 100% with US graduates who had USMLE Step 1 Board Scores well into the 230+ range (three-digit score) which is considerably above average in terms of performance on that exam. Also key to being successful in matching into the more competitive specialties was membership in Alpha Omega Alpha (AOA) which indicated a high level of scholarship in medical school.

With the numbers of applicants higher but the number of post-graduate positions staying about the same, would mean that academics, grades/USMLE scores are very important for securing a position in the match.  Additionally, making sure that one obtains the best advice from reliable and trusted resources at your medical school become crucial in this process. To go into the process of residency application without the best and more reliable advising can mean costly mistakes that will affect a process that is more crucial to your career as a physician-more crucial than selection of a medical school in the first place.

The other aspect of the application process is that an applicant has to be as realistic as possible in choosing a specialty and program for postgraduate medical training. Similar to medical application, seeking and applying to residency programs where you are far from competitive doesn’t enhance your chances of securing a PGY-1 position in the Match. While it’s great to “dream” of entering a particular specialty or program, you have to make sure you are 1) competitive and 2) suited to a particular specialty or program.

If your medical school academics, licensure board scores and general performance are less than those of people who generally match into a particular specialty, you are not going to secure an interview or secure a match. If you are choosing a specialty because of “what you heard” without regard for whether you have the interest, ability and temperament for said specialty, you may find that you are in for a miserable time and career.

Specialty choice is the most subjective portion of your career in a couple of significant ways. First, you choose a specialty that you know you will love for the rest of your career. This means that you have to love that specialty at 3AM when you are exhausted. This means that you love the scope of practice and the patient population that you will treat. Second, you have to be a good “fit” for the reasons that I have outlined above. You have to be able to enter a training program and thrive in the learning environment that is provided. This means that you have to be suitable for a particular program and they have to be suitable for you. Your medical school may open some doors in this process but in the end, you have to like the program and they have to like you (and your application).

If you are a pre-med student, this post has little reference or impact on what you need to be getting taken care of. Your first task is to get into a medical school where you can thrive in the atmosphere of learning provided by that medical school. Looking at match lists and specialties of the graduates of a school that you have yet to enter will have no impact on your career. Your performance in medical school and on licensure exams is not tied to previous graduates of a particular school. Work on your application/undergraduate coursework and leave specialty/residency selection/residency application for a more appropriate time. If you don’t get into medical school, specialty/residency selection/residency application won’t figure into your life.

If you are a first-year medical student reading this post, your immediate job is to make sure that your academics are as strong as possible. If you are struggling with coursework, you have to get your coursework under control before worrying about what residency you can get into at this point. In short, you have to take care of the tasks that are immediately on your plate at this time.

If you are a second-year medical student, you need to keep your academics strong and make sure that you enter third-year with an open mind. Keep in mind that you may have an idea of what you might like in a specialty but you may find something that you love more once you get to the clinical years. You also need to be thinking about your timing for reviewing and taking your licensure board exams (USMLE or COMLEX Part 1). You don’t want to take this exam too late to have a passing score before you enter third year or too early so that you don’t do well.

If you are a third year medical student, you should have some idea of what you want to do and you should be “scouring” your medical school for as much information as you can find on the residency application process. If you haven’t chosen a specialty at this point, I would encourage you to seek out trusted faculty advisers who can get your selection process underway. I would also encourage any third-year student not to make a specialty choice because they had a “good time” on a particular clerkship.

To Recap:

  • Take “dreaming”, “wishing” and “hoping” out of this process and replace these items with “research”, “realism” and “sound advice”.
  • Make sure that you have comparable or that you exceed the characteristics of applicants that have been successful in matching into a particular specialty/residency program or choose something else.
  • If you are currently in medical school, be proactive about learning as much about the specialty selection process, residency application process and keeping your academics strong.
  • Resist the urge to choose a specialty based on its competitiveness or lack of competitiveness because you just want to impress others or “get a job” because you don’t have any “do-overs” in this process. You have to choose something that you love and for which you are competitive.

14 February, 2013 Posted by | applying for Residency, residency, summer school | , | 10 Comments

Preparing for and taking USMLE Step I

For US medical students who are in the beginnings of the second semester, or final weeks before your break to study for USMLE Step I, I have put some thoughts below, that will help you start thinking about preparation for Step I. You should have obtained (online) the bulletin for USMLE Step I and you should be thoroughly familiar with the procedures for taking this important exam. At this point, you want to finish your coursework strongly and begin thinking about your time frame for taking this exam. This exam should be respected but not feared. It is but one step in your career, that is, a career that will have many steps like USMLE Step I but this exam is very doable and should be given some solid preparation time. In short, don’t rush or make mistakes in your preparation process.

Most people who are taking the United States Medical Licensure Exam Step I (USMLE Step I) will take this exam after completing the basic science component of their medical school coursework. For many students, this will come at the end of Year 2 and for some, this test will come at the end of 1.5 years of coursework. No matter when this test comes for you, make no mistake, this test takes some preparation regardless of your coursework performance. For medical students who have attended an LCME-accredited medical school, you have the assurance that your school has provided the coursework content that you need to pass USMLE Step I. With additional review and preparation, those who have attended an LCME-accredited medical school can excel on this test. The key is review and preparation.

The first and most important component of your preparation for USMLE Step I is to master thoroughly your coursework. When you start medical school, through mastery of your coursework is your main goal and this does not run “counter” to preparation for USMLE Step I. Additionally, in your thorough mastery of your coursework, do not make the mistake of attempting to “memorize” USMLE Step I review books during your coursework mastery stage. You have plenty of time to utilize review books at the end of your course blocks.

It is very tempting to purchase USMLE Step I review books during your medical school orientation for use as you are going through your coursework but do not make the mistake of believing that what is in the review book is all that you need to know from your coursework. Review books are designed to “review” materials and one cannot “review” what one has not mastered in the first place. Again, having a review book such as “First Aid for Step I” is not counter to mastery of your coursework but a review book should not take away from your main study strategies in your courses.

The best use of review books is when you have completed your subject matter. For most students in integrated curricula, review books that are not integrated are not as useful. While a review book can give highlights of specific subjects, they are generally not integrated as much as your coursework will be. The other problem with review books is that they are deliberately written to give the major points without much detail. During the coursework mastery phase of your medical training, you need the details. Once mastered, you can refresh your recall of the details with a review. If you are finding that you need more details, then use a denser resource than a review book. You likely do not need to return to your textbook but you might need to look at note summaries or books such as the Costanzo’s Physiology or Goljan’s Rapid Review of Pathology that are of medium density.

Another mistake that many pre-testers of USMLE Step I will make is improperly utilizing question banks as their preparation for this exam. Question Bank-type preparation is great for pointing out knowledge gap needs in your study but do not utilize question banks as a means of learning the material. If you are missing a great number of questions on a question bank service, especially in a particular subject, you likely need to move to a medium-density preparation book. Even intensive prep courses will not overcome significant knowledge gaps as the coursework content needed for this exam takes 1.5 to 2 years and can’t be duplicated in a few weeks (typical length of intensive review courses).

Many pre-testers tend to memorize the right and wrong answers to specific questions rather than going to a strong review book, something more than an outline, for knowledge acquisition. The best use of question banks is to first point out your deficiencies and second, to get your brain used to thinking in the manner that USMLE Step I will test. A good question bank service should trigger your brain to analyze cases and apply your knowledge not feed you answers to specific questions.

If you are utilizing a particular Question Bank service and monitoring your scores with the sense that if you are getting a certain percentage, you are assured of a strong USMLE Step I performance, you may be living in a world of false security. I have had more than a few students stop by my office to report that they are scoring 70% and 80% on a specific question bank service only to find that their score on the actual test is much lower than they expected by their test bank performances. I suspect that the reason for the discrepancy in scores is that these students relied too much on the content of the question bank rather than on what the overall trend of the question bank was pointing out, i.e. that they had some gaps in their knowledge that needed solid preparation.

Now, what do I mean by “solid” preparation? This “solidification of preparation”  can be pretty elusive for some people but in general, the people who are solidly prepared have an “approach” to how the identify the correct answers on USMLE Step I. This “approach” allows them to even take “educated” guesses on things that they can’t readily recall and allows them to quickly recall the materials that they need to answer the questions correctly.

Solid preparation takes a very strong knowledge base and knowledge/practice of how USMLE Step I will test that knowledge base. Again, if you have attended an LCME-accredited medical school and have thoroughly mastered your coursework, you have the knowledge base that you need to score well on that test. Your review should be focused on the development of a means of analysis of distracters in questions (Question Banks can help with this but use  a question bank that utilizes case-based questions and more than one manner of questioning) and the application of your analytic/critical thinking skills. Armed with these materials, you are well on your way to a very strong performance. Remember, you want your Question Bank to challenge you with as many methods as possible during your review time.

Your other ingredient in your “strong” preparation for this test is the confidence that you can sit down, take each question as it comes, select the BEST answer to each question and move on to the next question on the computer. Remember, every question counts the same so there is no penalty for “guessing” but there are huge penalties for leaving questions unanswered because you ran out of time.

In short, you have to be able to answer your questions correctly and efficiently so that the clock is not your enemy. Again, plenty of practice questions is a good strategy for analyzing your question-answering abilities in terms of timing. Unanswered questions are always wrong answers but you might be able to guess the correct answer if you have been able to get to the question. Don’t leave any questions unanswered is the moral of this story which means that you have to have a strategy that allows you to at least “read” every question in each block at least once. Utilize your question banks to increase your efficiency of question analysis plus increasing your percentages of correct answers. You want to see an improvement in both time and reasoning.

Your next goal in USMLE Step I preparation is not to allow yourself to become emotionally “blocked” if you encounter something that you do not recognize in a question. There will be questions that contain material that you will not know which means that you mark that question and move onto the next question (likely will have something that you know). If you keep encountering questions with materials that you don’t recognize, note the subject matter (if you are using a test bank) and review those subjects as needed.  If you are on the actual exam, keep moving forward as you can always return to the questions that you have “flagged” if you work efficiently with time moving from question to question without emotion. In short, emoting over questions is a poor utilization of your time and blocks your ability to reason.

As long as you have not exhausted your time in a particular question block, you can return to marked unanswered questions and have another shot at narrowing down the answer choices. Most of the times, as you move through a block, something further down the block will trigger knowledge that will enable you to return to a question and see the correct answer even if it eluded you on first read.

Resist the impulse to change answers unless you have a very compelling reason. Compelling reasons are that you remembered something that is key to answering that particular question or that you see something in the question that you previously missed on first read.  If you find that you are missing things on first read through, slow down a bit, take a couple of breaths and focus on what each individual question is asking. Many people jump to what they “believe” the question is answering rather than what’s actually on the page. Again, if you don’t spend too much time on any one question, you should have plenty of time to go back and review your questions and answers in each block before you leave a particular block.

If you are finishing question blocks early, take the time to review each question and your answer so that you can be confident that you HAVE chosen the correct answer. The worst possible outcomes will happen when you are rushing through the questions and missing key evidence that points out the correct answer. You want to finish each block with enough time to review each question and assure that you have marked what you wanted to mark for each question. In short, don’t move so quickly that you make clerical errors in marking your answers.

I also cannot emphasize the importance of not taking USMLE Step I until you have completed your required coursework and until you have completed a systematic and thorough review. USMLE Step I is likely to test differently from your coursework but a strong knowledge base that you can apply to the questions will help you score well on this important test. If you do not feel prepared, that is, you feel that your preparation has been rushed or inadequate, change your test date but don’t keep “putting off the test” because you don’t feel 100% prepared. You should feel that you were able to review things that you needed to review but one never feels totally prepared for every step of USMLE. You have to reach a point of saturation and satiety in terms of mastering what you need but resist waiting for the “magical moment of total confidence” because it never comes.

Will you ever feel totally confident that you know everything on this test? No, you need to have a healthy respect for this exam. You also need to walk into that computer center with the feeling that you have mastered your coursework and review and that you will take each question as it comes. You can’t be paralyzed about the consequences of failure or of not getting the score that you wanted. You can be philosophical in terms of you are ready to give the exam your best shot and that is what you are going to do.  You simply have to prepare and move forward and look at USMLE Step I as just another step in your preparation to become the physician that you want to be.

3 January, 2013 Posted by | academics, medical school coursework, USMLE, USMLE Step 1 | | Leave a comment

Textbook Reading in Medical School


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

Getting Through The Semesters (or what if I Fail Something?)

“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.

23 November, 2008 Posted by | academics, difficulty in medical school, medical school coursework, study skills, Uncategorized | , , | 16 Comments