11 November 2011

More updated blog

I have an more updated version of this blog at Wordpress (Click on the name of this post to access it. Feel free to go over there and read posts that were done later. This site tends to have troubles on a regular basis thus I don't have as many updates here as on the Wordpress site. Both blogs have the same name but the other site is more stable. Enjoy.

22 October 2011

It's Medical (or any other professional )School orientation 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!

20 September 2011

Why Students Fail USMLE Step I ( or any of the steps)

False sense of security Every year no matter what medical school a student attends, some people are going to fail one or more of the USMLE Steps. (This can apply to COMLEX as well.) I have heard students say that because they attend school X that has a 100% pass rate, they are assured of a pass. Well, that pass rate for School X is characteristic of the class that it applies to. If you are not a member of that class, you have no assurances. Your medical school attended is no assurance of anything other than they have met the standards set by the LCME (Liaison Committee for Medical Education) and that if you have passed your coursework, you will be eligible to sit for your USMLE/COMLEX exams. With that being said, you have to understand and be proactive if you want to pass and score well on licensure exams regardless of school attended. In short, passage and performance of these very important exams is dependent on how well you prepare for these exams.

The big mistakes

Many students purchase tons of review books and start memorizing questions, outlines and isolated facts as soon as they have been accepted into medical school. You can’t MEMORIZE your way into a pass on licensure exams because these exam require you to master and understand concepts in basic science, clinical science and application of the concepts to patient care. Just memorizing board review books is not sufficient knowledge to do well. Daily and consistent mastery of your coursework with systematic review will enable you to pass and do well on these exams. Many students discount the importance of their coursework with the idea that they will cram in what they need for a course exam and spend the rest of the time memorizing a board review book for the licensure exam. This is the biggest and more common reason that students fail these licensure exams.

Coursework is too detailed for the boards!

While your coursework is very detailed, your mastery of those details (and I mean thorough mastery) is a very significant strategy for doing well on your licensure exams. It’s the details that enrich your understanding of the basic concepts that will be vital to your eventual practice of medicine. Rather than looking for shortcuts or complaining about the rigor of your curriculum, set a strategy for mastery of your materials and get the job done. As a medical student, I complained about the level of detail in many of my basic science courses but was quite happy when Step I came around and I know those details. The more experience and exposure to the details of concepts, the greater your likelihood of being able to rule out incorrect answers and rule in the correct answer. In short, those coursework details are invaluable both for boards and for “pimp” sessions during clinicals. Get out of the “I will just memorize this” mentality You have to learn to evaluate and synthesize concepts in both basic science and in clinical medical science. For the rest of your career, you will largely be teaching yourself the things that you need to keep a mastery of for your practice. In short, keeping up with medical literature means that you master how to read what you need and how to incorporate what you need into your practice. Where do your learn these tasks? You learn these tasks in mastery of your coursework and in preparation for you licensure boards. Just taking a review course and memorizing everything in a review book will set you up for an unpleasant surprise when you open your score report because you must have a solid knowledge base in order to review for a board exam. Every licensure exam will post a list of key topics to be mastered for the exam. These are never secret and are why books such as First Aid for Step I are so crucial for preparation for USMLE. First Aid contains all of the topics but none of the details. It’s up to you to provide the details and provide the thorough grounding and mastery that you need. This can’t be done in a month-long review course unless you have a solid knowledge base to begin with. The solid mastery that you need can’t be done by memorizing the answers to questions on a website either. While practice questions are good, they are not useful memorization and can give you a false sense of security in the long run. I can’t tell you how many times student Y had told me that they were scoring 70% on Q-Bank but they turn up with a failing score on Step I. Kaplan’s Q-Bank is great but it’s an adjunct to solid study and mastery of basic and clinical science materials (coursework).

Giving Step I more power than it deserves

In today’s world of residency application, residency directors know how much time you as a student have to master the knowledge needed for the USMLE/COMLEX steps. While there will be people who want to take a “year off” to study for Step I in order to insure a high score, this is not a sound practice. Residency directors do not want to see students taking “time off” from medical school unless you are pursuing a higher degree such as MPH or a Ph.D. Utilize the time that you are given wisely and efficiently and you will be able to review completely and comprehensively for this exam within that alloted study time. Residency directors also realize that IMGs also often have years off to study for the USMLE Steps and take that into consideration when evaluating scores from these individuals. This is why IMGs are usually required to post higher scores on Step I than their AMG counterparts in order to be competitive for a residency program. Another caveat for IMGs is do not attempt any of the USMLE Steps if your language is not up to the standards of that exam. You can’t blame lack of language understanding as a reason for failure of Step I. Residency slots are more competitive (more AMGs now) and failure of any steps can be very problematic for an IMG. In short, if you are an IMG reading this, prepare well and be prepared to pass any of the USMLE Steps with at least a two digit score of 85 (even for medicine programs) on one try. Does this mean your are doomed if you are and IMG and you fail? No, but you have greatly decreased your chances of match in the USA and may have shut yourself out of many residency programs (other than prelim slots) because of the sheer numbers of US grads and the lack of categorical slots.

Passing USMLE

•Your first stop is the USMLE website. On that site, you will find the subject lists for what’s covered on the exam and the characteristics of that exam. •Your next step is to thoroughly master your coursework with regular and systematic study (if you haven’t done this in the past, start now). •Obtain the most recent copy of First Aid for USMLE (whatever step) and read it from cover to cover so that you know what tools are available for the particular exam you are taking. •Look into a commercial prep course only if you are certain that your knowledge base is poor or that you know you need plenty of feedback and practice with USMLE-type questions (most US grads don’t need this). •Don’t tell yourself that you can’t get into residency if you don’t get a two-digit score of 99. Chances are, you are not going to get that score even if you follow the exact study schedule of someone who did. •You have to figure out what works best for you, in terms of mastery and review so that you can prepare your best. •If the worst happens and you fail, look at my post “Failing USMLE and how to get beyond it” for strategies for passing on a retry. Remember, USMLE is not the MCAT. You don’t get “do-overs” for this exam unless you fail. If you fail, you have significantly made yourself less competitive but you are not out of the residency game. You will need to make sure you don’t fail any other steps and you need to accentuate other things (excellent coursework for one thing) in your residency application. Plenty of US grads who have failed Step I but gone on to have a strong third year have managed to match into very strong university-based residency programs. In short pick up and keep moving forward. Also keep in mind that wishing and hoping for a pass/high score isn’t going to make it so. Plot a strategy and get busy doing what you need to get the job done. Don’t discount the value of consistent strong coursework performance but realize that you have to have mastery of coursework before you can “review” for boards. Board review is not the same as study for your medical school courses. Good luck!

29 March 2011

Standardized Tests

Standardized Tests
Let’s face it, standardized tests are a “fact of life” if you attend public school in the United States, anticipate attending college/university in the United States, want to enter professional school in the United States and practice any profession (especially medicine) in the United States. These tests are required for medical licensure in every state and most medical colleges require applicants take and score well on the Medical College Admissions Test (MCAT) for admission. These standardized tests need not engender any great “fear” in the test-takers as they are simply tests that are administered (and scored) under some kind of standard conditions. They are tests and like any test, they have characteristics that need to be examined in terms of preparing yourself. Just as you prepare for a course examination, you need to prepare for any type of standardized test that you need to take and score well upon.

Getting your “head” in the game
If you constantly tell yourself that your “bad at” standardized tests, you will fulfill your prediction. You can’t give any standardized test any more deference than you would give any examination in your academic history. Every test tries to measure something and that “something” is what you have to maximize your knowledge of , in order to do well on any test. In short, you survey,prepare, and master the knowledge that is tested on any test under any conditions. Every standardized test has a description which needs to be read, analyzed and used as a guide in your preparation for taking the test. If you decide ahead of time, that you can’t do well on a particular test, you have made your preparation that much more difficult. Any standardized test can be prepared for, taken and mastered by anyone who diligently and systematically prepares for the test.

Timing is everything
Once you know that you have a standardized test (in addition to your course exams), get a description of what will be covered on that particular exam. In the case of the MCAT, there are detailed descriptions of the subject matter for each section of that exam. Download those descriptions when you start your pre-medical preparation (when you start college if you know that you want to enter medical school) and pay close attention to your coursework in order to make sure that you have adequate coursework to cover the subject matter of the MCAT. Make sure that after you download a test description, prepare for the test according to the description and not according to how you prepare for other tests.

If a description says that a test requires that you apply knowledge from a specific knowledge base, simply memorizing that knowledge base is not going to prepare you for that test. In addition to thoroughly mastering the knowledge base, you have to be sure that you master the application of that knowledge base to problem solving. Standardized tests such as USMLE, MCAT and COMLEX have such broad knowledge bases that you can’t hope to memorize every factoid in those bases. You must master the prerequisite coursework (not memorize/cram for each exam) and build upon each courses within that knowledge base in order to apply that knowledge to problem solving.

What about problem-solving?
For many people, anxiety and poor reading skills can destroy any chance that they had of actually answering each question as it comes. If you are thoroughly familiar with the manner in which each test will construct problems, you can greatly decrease your anxiety level and improve your experience and reading skills. You can find reading skills courses (critical reading and analysis) that will hone your ability to pick out the significant parts of any argument, problem, question or survey that will help you extract the information that you need to answer a question about that argument, problem, question or survey. You can practice self-questioning as you read textbooks, newspapers, position papers and peer-journals to learn how to extract pertinent information for problem-solving. Turning off the television and getting away from the social media sites on the computer can free up valuable time for reading and analysis of a wide-variety of journal, texts and other learning materials. In short, you can read and analyze something every day that will hone your reading skills.

Get away from the Powerpoint!
Just attempting to study anything from a Powerpoint summary can be problematic. Professors use Powerpoint to summarize facts which may not be detailed enough for through mastery of any subject matter. If there has been assigned reading from a textbook, make sure that you have completely and critically covered the material. As you are reading, be sure that you look up any unfamiliar words and constantly question yourself in terms of knowledge mastery. If you have a Powerpoint lecture summary, be sure that you thoroughly cover and understand (in the textbook) the material that has been outlined in the Powerpoint lecture. Only after you have completely summarized and learn complete concepts, can you utilize a review-type book for reinforcement of learning. Trying to learn the basics from a review book is not going to give you the in-depth knowledge base that you can use to apply to standardized test problem-solving.

Review courses
A review course is worthwhile if you have a thorough mastery of your coursework in the first place. Just like review books, Powerpoint reviews and other review-type materials, you can successfully utilize these things unless you have had a through underlying knowledge base in the first place. If you are a medical student and you anticipate taking any of the USMLE/COMLEX step exams for medical licensure, you need to have thoroughly mastered your coursework before you begin any type of review course for these exams. This is why review courses are most valuable as soon as you have completed the prerequisite coursework that will be covered in the review. These review courses are not a substitute for thorough mastery of coursework. This same strategy works for pre-med students in that purchasing and taking a review course before you have completed the pre-med courses is largely a waste of time and money.

Most standardized tests have a recommended study time frame. If you can’t find this study time frame, make sure that you ask people who have taken (and done well) on a standardized test, how much time they put in. Also be sure to ask a number of people (not just one person) so that you can get an average. Keep the following in mind:

•Don’t tell yourself that you are “bad” at standardized tests because you add to the difficulty of any prep for a particular exam.
•Don’t expect to memorize a review book and be prepared for a particular test or exam.
•Don’t tell yourself that your “whole career” depends on one exam as no exam can totally determine your vocational destiny(influence yes but not totally determine).
•Regular if not daily systematic preparation for the major standardized tests is a sound strategy. Your daily prep can be as simple as practicing your reading comprehension.

11 March 2011

Match Week (and the scramble)

Most fourth-year medical students are eagerly awaiting noon on Monday of Match week to find out if they matched. If they didn't match or matched to a second-year position but not first-year, these is a process called the "Scramble" that they will be taking part in if they do not have a PGY-1 position. The majority of US medical school seniors will match if the process has worked well. By process, I mean that they have ranked places that interviewed them and the places that interviewed them, have ranked them. The computer attempts to match the applicants highest choice with the place that ranked them the highest. Most of the time, the process works out fine but sometimes it doesn't and an applicant will know on Monday if they need to actively look for a position.

There will be a scramble list published on noon of Tuesday that will include programs that didn't fill all of their PGY-1 slots. Some programs will elect to offer positions to people who applied outside of the match. This means that you need to be aware that many programs that you might have applied to will fill from people who have either applied and are eligible to accept a position outside of the match which means that those programs may show open slots but those slots are filled (usually by FMGs who have already signed contracts). The only way to find out that a slot on the scramble list is truly open is to call the program on scramble day and find an open slot. You also need to have your application materials ready to fax/send by e-mail thus you would need to be next to a fax machine or have your materials in electronic form and ready to send if requested.

On scramble day, programs that didn't fill (and want to fill) will have the program director and a couple of faculty, reviewing applications received and ready to make an offer of a contract on the spot. This is why is makes sense to be at your medical school (most schools will have a scramble set up) and have your materials ready to send. On scramble day, some programs that show openings will be literally deluged by unsolicited faxed applications from commercial services for applicants who didn't match. Most of those folks will receive an e-mail that stated that the program will not review unsolicited applications. Some unmatched applicants will spend literally hundreds of dollars with commercial services that will sent applications but be aware that unless you have spoken to a program, they are not likely to review your application.

Many very high-powered and excellent residency programs may not fill for a variety of reasons from clerical errors to not interviewing enough candidates. Every year some places that have national reputations may have openings. Most years, the preliminary spots at many programs will not fill completely because not enough people applied for those slots. This means that a US grad (who is at their medical school on scramble day) stands a good chance of getting into one of those unfilled preliminary spots. Many programs will call deans looking for unmatched candidates for slots which is a great way to snag an open position at a top-ranked program.

The scramble situation is very stressful for those who go through it but the worst case scenario is that an applicant spends one year in a preliminary position and enters the match as stronger candidate the next year having done one year of excellent work. If a candidate accepts a preliminary position, they have to work very hard to be sure that they get good letters and good experience to take into the Match for the next year. Most good program directors will help a preliminary candidate find a categorical position for the next year if they have done an outstanding job with the preliminary year. In short, doing a prelim year isn't the end of the world and can provide valuable time for making good contacts with programs that interest you for the next year. If you know that you will be going into the Match after a preliminary year, be prepared to make sure that your letters and application materials are sent to your medical school for uploading as early as possible. You don't want to risk not matching a second time.

My other piece of advice for anyone reading this post who receives a letter on Monday that says they are going to scramble, is that you need to immediately contact your dean of students at your medical school. You don't want to try to go through the scramble from a remote location without having the advantage of experienced people to help you through this. You need to learn as much about the process as you can in the 24 hours before the scramble starts. Positions, even the preliminary ones, will go very quickly. If you find that you don't have a PGY-1 position after the first 24 hours of the scramble, you are going to need to contact your medical school to let them know. Again, programs that don't fill (or who have open positions) will contact the deans at medical schools looking for candidates first. You want to be sure to let your school administration know that you are looking for a job.

To those that match and don't make the mistake of thinking that you are inferior because you didn't get your first or second choice. If you didn't have to scramble, you are definitely more fortunate that those who end up with no position for the next year. If you ranked the places that you would accept a job and you received a position, you are ready to start your residency. No one who goes through the scramble would ever say that the situation is wonderful but it's part of the experience and with that experience comes wisdom.

19 January 2011

Getting the Schoolwork Done.

This is a re-post of some material from a previous post. Some of my current students have asked about this subject matter and thus, the repost.

"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.

08 January 2011

Medical Reading

Now that I am out of medical school and residency, keeping up with my reading and study has become a major goal for me. I usually keep a weekly log of articles and book chapters that I have completed. For instance, I have been reviewing the medical treatment of esophageal disorders today. In addition to my last evening's read of the appropriate chapter in the latest edition of Sabiston's, I tend to keep my medical reading as up to date as I can. While Sabiston's is a great general surgery resource, I do find that reading in Harrison's Principles of Internal Medicine provides an in-depth review of physiology and pharmacology. I also tend to read from 20 to 30 journal weekly in addition to my textbook reading. The question would be, "Why do all of this work now that I am out of school?"

As a professor, I need to keep ahead of the textbooks on many topics. Human beings are incredibly complex entities that regularly present their physicians with diagnostic dilemmas. I have found over the years, that my diagnostic skills have greatly improved with both experience and reading. I find myself looking forward to my time with the "pulps of medicine" as being able to constantly learn and assimilate information is crucial to me in navigating those diagnostic dilemmas. There is always some new theory or different way of looking at a disease entity that I find interesting. Since medical school, I could never get enough of New England Journal of Medicine or Nature Medicine as a student. One of my internal medicine professors encouraged us to read journal (as much as we could between coursework study) in order to develop an early grasp of the language of medicine. It turns out that old habits die slowly for me which is a good thing in terms of journal reading.

Most weeks I will have an undergraduate student or two drop by my office to discuss entry into medical school. One of the first things that I encourage for these folks (not New England Journal of Medicine or Nature Medicine; these are better utilized in medical school) but just to read a variety of types of literature (scientific and non-scientific) from a scholarly perspective. Regular critical reading encourages regular critical thinking which is integral to the practice of good medicine. There will be plenty of opportunities to read medical journals in medical schools (great libraries online and on site) but training your mind to handle different types of writing is a good skill to have as an undergraduate. Most undergraduate college libraries have a wealth of well-written scholarly journals that are great to keep up with.

In addition to reading the scholarly journals, pick up a couple of newspapers (New York Times, Richmond Times-Dispatch, Wall Street Journal) and read the editorial pages. Most editorials are short and very well-written in the three newspapers that I have listed in the last sentence. The New York Times and Richmond Times-Dispatch are both published online for easy access. In addition to the editorials, compare how major front-page news stories are handled. Do both papers have the same stories "above the fold" on the front page? Look at your local newspaper, even if are from a smaller locale such as the Falls Church News-Press or the Marin Independent Journal to see how your local events are covered and discussed. The Marin Independent Journal is one of my favorite reads along with the San Francisco Chronicle as both newspapers provide a welcome change for my brain as I move through my weekly medical journal reading.

Being able to read efficiently and comprehensively is a habit that can be honed by regular practice. Just as walking/jogging on the treadmill or listening to my favorite recording artist is welcome change from my daily work routine, my journal and newspaper reading are welcome habits that I enjoy. It's great to utilize the social media such as tweeting and blogging but the best reads are still those that explore a subject (medical or otherwise) from a comprehensive standpoint. You won't get a comprehensive view of a topic from Twitter but you will get great opinions from that website. Blogs are also great for both opinion and information but force yourself to think creatively and comprehensively even when you are reading your scholarly journals.

Many people will say that they just don't have the time to do much reading outside of work. I generally find that I can make use of my "down time" when I am waiting for a patient or something else. I always have an article or two in my lab coat pocket for those stray minutes. I do find that I have to "mark my progress" so that I am not reading the same sections over and over. I have a list of my regular journals and then I have the journals that I scan sporadically for a change of pace. Most of the time, if a subject is getting loads of press in one journal, it's getting mention is many journals. Knowing what's "hot" is just one of the great aspects of regular journal reading. I also find that when the Nobel Prize winners are announced, I generally have some knowledge of their work from my journal reading.

If one keeps in mind that it takes approximately 2 to 5 years for something to become established enough in the journals to become published in a textbook, then the utility of regular medical journal reading for the physician becomes important. While I make my yearly read of Sabiston's, Cameron and Greenfield, I find that my journal reading enriches those topics that I encounter in the text. Regular reading when I was a resident, made study for the "in-service" exams much easier than some of my colleagues would find. Residency is the ultimate learning experience because one is learning both from a practical standpoint and from a scholarly standpoint which is the only time in training that you will have both types of learning so intimately connected. Journal reading during residency is an integral part of the process.

If you hang around me for any length of time, you will find that I have a journal article or book chapter in my hand/pocket most of the time. Over the holidays when I was traveling thorough some of the wonderful airports of New York and Chicago, I was able to get my journal and textbook reading off to a good start. Since there is so much waiting involved with air travel, having a good read is a necessity. I keep my Amazon Kindle jammed with .pdf copies of articles and chapters for airplane reading in addition to my paper copies of one or two things (they tell you to turn off all electronics until 10,000 feet). In short, I always have something to read.

06 January 2011

I can't (and maybe don't want) to get into medical school

Medical school has been the ultimate dream profession for many people (or their parents) for many years. In some cultures in this country, only four professions exist; medicine, law, dentistry and engineering. If a person didn't get into one of those professions, then they were seen as a professional failure in the eyes of their parents. For some unfortunate students, not only are they not going to enter one of those professions, they are not interested in the subject matter or practice of one of those four professions. Almost weekly, a parent will enter my office stating that they will "disown" their child if I don't "let" them into medical school. Many of these students will say that they have little interest in the sciences (unacceptable to the parents who are paying tuition bills) and even less interest in medicine. When questioned closely, many of these undergraduates will reveal that their parents would never "allow" them to seek other professions and that medical school is the only choice.

In today's climate of grade inflation and very high tuition costs, the sheer magnitude of maintaining the medical school matriculant average undergraduate GPA of 3.7 is a burden that many are not able to carry. For some students, a very poor freshman year can mean the end of being able to get that uGPA into the average range let alone a competitive range. For others who might enter university poorly prepared in math and science because of attendance in a poor secondary school, getting their academics off to a strong start and keeping them there may be problematic. Along those lines, I encountered a young Latina woman who was valedictorian of her secondary school class (inner city). While she had maintained a very strong academic record at her secondary school, the quality of instruction was extremely poor.She would be the first in her family of very hard-working immigrants whose dream was for her to become a physician so that she could come back to the neighborhood for practice. This was a huge burden for this young lady who was determined not to let her family down. She came to our university will poor study skills, poor reading skills and deficient math skills. He school had no IB or AP courses and offered few academic courses that would prepare her for becoming a biology major in preparation for medical school.

During her first semester, she proceeded to achieve a 2.0 GPA which lead to much discouragement and frustration. When she came to my office for assistance (she was in danger of losing her full-ride scholarship), I immediately contacted the school administration to allow her to shore up her academic skills before proceeding to lose her scholarship. She had determination and discipline but lacked guidance in being able to navigate the academic world (common in many students who are the first to enter higher education). She was allowed to spend the next semester working on basic writing, reading and math skills. Fortunately, she has and always had very strong problem-solving skills which is why she sought assistance when her performance was working in the first place. While she hadn't failed any courses, those "C" grades would not be enough for medical school.

In the next semester, she excelled in her academic remediation. She was able to make great strides and shore up her deficiencies. She learned to put her drive and determination into her studies but she also learned that she was not particularly interested in science and math. Over the course of the remediation semester and summer, she became interested in psychology which she pursued with vigor over the next fall semester earning a 4.0 GPA for that semester. Her reading and writing skills were excellent along with a very strong interest in studying her population in terms of achievement. In short, her interests lay not in medicine but in helping her community and those in her community to be able to achieve in the academic world. She went on to earn a degree in psychology and entered graduate school to earn a Ph.D in psychology. While her family was not happy, she continues to research, study and write articles which have been the cornerstone for closing the gap in Latino achievement in academia. Her most recent achievement was tenure in her department at the state university where she teaches. In short, if medical school is not your dream, all of the drive and push from your parents and family will not provide what you need to get into medical school and practice well in medicine.

Another undergraduate student had come from a family where his mother and father were both physicians. He freshman and sophomore years had ended up netting a uGPA of 2.5. He loved the university life and spent many hours with his fraternity brothers working on extracurricular activities. His father brought him to my office so that I could "talk some sense into him" before he destroyed his future. After a tumultuous weekend with his parents, this student returned to my office resigned to "dig in" and get his work done. As we calculated what he would need to do in order to raise that uGPA, he said that he just didn't have that kind of drive. He said that he would "do his best" because he didn't want to let his parents down. He said that it didn't help that his brother was in medical school and was very critical of his undergraduate performance.

Over the next couple of semesters, his academic performance improved but not enough for him to get his cumulative uGPA above 3.2. He became more and more discouraged. At one meeting, he expressed interest in looking at other careers besides medicine. He decided that he would look into becoming a physician assistant which didn't take as long but would enable him to have a career in health care. While his family wasn't pleased with his choice, after making the decision not to pursue medicine, he was better grounded and had more direction. He finished his undergraduate degree in biology with a cumulative GPA of 3.5 and entered a masters program in physician assistant studies. Today, he loves his job and loves that he can travel while practicing his craft.

I do not advocate trying to become a physician assistant because you can't get into medical school but it is a profession that is worth exploring if you have a strong interest in the practice of medicine but can't spend the minimum of 7 years above undergraduate school in order to enter the profession of medicine. In terms of love of their work, physician assistants have the highest job satisfaction in healthcare and earn a very strong salary which is quite appealing for people who have families whose needs won't allow an additional four years out of the workforce. In terms of academics, the same strong academic skills in reading, writing and math are needed by a PA that would be needed by a physician. I would also caution that the academic achievement to become a physician assistant is just a bit lower than what is needed for medical school with the average uGPA of the PA class that entered our state university being 3.6. In short, getting into PA school isn't that much easier than medical school but the training is shorter which is appealing to many people who have an interest in medicine but do not want the long training period.

Other careers worth looking at are anesthesia assistant which is a physician assistant who does anesthesia and perfusionist. The training programs for this profession are quite competitive but as with PA, the job satisfaction is very high. Anesthesia assistants work with anesthesiologists and provide anesthesia care in a variety of settings. This particular profession seems to attract people who have no interest in nursing and going the CRNA route but have a strong interest in working the operating room environment with anesthesia. The perfusionist runs the heart-lung machine (and extra-corporeal membrane oxygenator ECMO) which is used during cardiac surgeries such as coronary artery bypass grafting or valve replacement. If ECMO is used in a nursery, it is the perfusionist that maintains that machine too. Perfusion technologists earn a very high salary and enjoy very good job security. There are a limited number of perfusion technology schools (and training slots) in this country but for many people who find that medicine is not for them, perfusion technology can be a very good healthcare profession.

For the undergraduate who has applied to medical school more than twice, the chances of getting into medical school will not increase and are likely to decrease. Just reapplying is not enough to achieve admission as whatever kept you out in the first place has to be corrected and upgraded. Every year, the medical school matriculant average goes up along with the matriculant average score for the Medical College Admissions Test (MCAT). To continue trying to raise an otherwise undistinguished uGPA (graduate doesn't count) with one class here and there is a long and expensive process. One poor year as an undergraduate can be overcome but multiple drops and repeats of the pre-med courses (especially organic chemistry, calculus and general physics) do not bode well for medical school admission success. There are just too many medical school applicants out there who have completed their studies without drops and repeats. There are also many applicants who have very competitive uGPA/MCAT scores who will be admitted ahead of those who have a less distinguished record. No amount of research or extra curricular activities will off set a poor uGPA; nor will a high MCAT score do the same. In short, the admission process into medical school is long, unforgiving and quite expensive with little guarantee of success in any given year.

Multiple retakes of the MCAT with final scores less than 30 are going to be problematic for many who desire to enter medical school. One retake of the MCAT if you were ill (or severely distracted) is warrented but several mediocre scores with no or a 1 point improvement will no work will. Not releasing scores on more than one retake with mediocre scores is not a sound practice either. Students who have a less-than-distinguished academic record can't expect to "ace" the MCAT and get into medical school. This is why it takes both strong academic achievement and a strong MCAT in order to achieve admission success. Medical schools want to accept students who show evidence (by undergraduate achievement and scores on the MCAT) that they are able to master a very competitive curriculum. It is far from a certaintly that once you are accepted into medical school, that graduation will happen. In short, medical school is a very strong academic challenge that many of the strongest students find daunting at first. It takes a consistent and high level of scholarship to achieve the performance in medical school that is needed to become a physician. Also keep in mind that USMLE (United States Medicial Licensing Exam) steps are not retaken which means that multiple retakes of exams such as the MCAT do not bode well for USMLE success.

If you find that you are not successful in gaining admission into medical school, you need to do an objective and thorough inventory of why your application didn't work. After your inventory, you need to figure out how and what you can upgrade that will ensure successful admission. If you are on a waitlist, I strongly advise getting the application together for reapplication for the next year as soon as possible with updates and reworking of things such as your personal statement. In the intervening time, upgrade anything that is within your power to upgrade and apply early (exceed every deadline). If you didn't get any interviews or waitlist, then your application need a thorough upgrade (might take more than one year). If you can't upgrade your uGPA (t0 a competitive range) significantly in one or two years, you likely either need to look into a Special Masters Program for credential enhancement (if you enter one of these you need to do well) or look into another profession. Getting a Masters of Public Health (MPH) isn't going to offset a poor uGPA or MCAT nor is entering a Ph.D program as most medical schools require that you complete any graduate work that you start.

04 January 2011

Study Skills Part V


This is the fifth part of a series that I have been working on since starting this blog. From time to time, I will keep adding to this material as much as possible. For this installment, I want to "get into your head" for you to get the best results of your work. Previously, I have discussed things like taking notes and organization. You need to keep your studies as organized as possible. If you are working and trying to attend school, your organization skills have to be outstanding.

Adjust your thinking for best results

As you move into the next semester (or next class /group of classes), start working on getting your thought patterns together. There is no class taught at any university or college that cannot be mastered by any student who is willing to put in the time needed to master the material presented. As I have stated in other posts about study skills, consistent and regular study will get the best results for most students. It is extremely rare for an individual to be able to sit down the night before and exam and expect to master everything that is up for testing. If your fellow classmates are telling you that the "last-minute cram" gets the best results for them ("I always get an A when I only look at the material the night before the test."), they are likely lying to you about the time that they are putting in. For some people, lying about the amount of time needed for study allows them to believe that they have a superior mind over the rest of us. Congratulate them and keep to your plan to get your work mastered. What another student does (or does not do) is meaningless in terms of what you need to do for complete mastery of your studies. Keep in your thoughts that the "superior mind" is the one that get the best results period and retains the information over the long term not the last minute crammer who loses the knowledge because it is never in their long term memory.

Rate My Professor and other review sites

Going to sites like "Rate My Professor" might seem like a great idea but remember that most people who post to those "review" sites tend to be the folks who had problems in courses. Not all of the problems that a student might have is due to the professor. Most professors do not gain "academic points" for making sure that most of the students in their courses earn grades of C or less. Most professors do not gain "academic points" for making sure that most of the students earn grades of A either. In terms of teaching, the professor is most likely the most redundant element in your learning experience. A professor should know their subject matter and be able to point students in the right direction for the student to earn their best grade. It is counter-productive to learning at the college level, to expect that your professor is your sole resource in any subject matter. While your professor should be able to help you navigate a subject, you need to have the confidence that even if the professor wasn't there, you could master the subject material. In short, don't attempt to develop any personal reactions to or concerning your professor. Utilize a professor for what they do best which is, being a good resource for things about a subject that you, the student, might need. A professor doesn't care if you "like them" or you "don't like them". Since most professors are tenured, a student's likes or dislikes do not figure in the learning equation one way or another.

Since the professor is essentially a redundant element in your learning; this means that your actual "learning" isfar more dependent upon you being able to incorporate the information into your knowledege base so that you may be able to utilize it. The professor, while being a resource, it not your sole resource or the ultimate resource that will enable you to make the most of a class. If you anticipate application to professional school such as medicine or dentistry, you have to master the building of a solid knowledge base that you can tap for the situations that will present for you in the future such as your Medical College Admissions Test or the Dental Admissions test where you will be asked to apply your knowledge base to any of a variety of problem situations. Being able to problem-solve is a characteristic of an individual and not of any one particular professor or school for that matter. Learn to garner as much knowledge as you can in any particular class with the realization that any professor can provide what you need.

"Weed-out Courses"

I don't know how many times I have head the phrase, Physical Chemistry is the "weed-out" course for a chemistry major or Organic Chemistry is the "weed-out" course for a pre-med student. I have taken both of these courses and frankly, found Physical Chemistry more enjoyable than Organic Chemistry but both were the subject matter of my major which I mastered throughly. I refused to give any course, or subject matter, more deference then it deserved. Physical Chemistry was a great course that allowed me to use my math tools to describe the physical aspects of chemistry and chemical reactions. Organic Chemistry was a course that taught me much about developing synthetic themes and the mastery of carbon-based chemistry (useful for understanding Pharmacology). Since I took these courses as a sophomore in university, I just packed the knowledge from these two courses into my chemistry knowledge base.

As people around me spent hours lamenting how "rough" these two courses would be, I spent most of my time figuring out the best strategy to do well in these courses because I needed the information presented there. There was only one section of Physical Chemistry at my university that was taught by two professors fall and spring semester. In short, I didn't have a choice in terms of professor "shopping" if I wanted to take this course. I did make sure that I had the math background for mastery of the Physical Chemistry course material (I was taking Applied Differential Equations at the same time) and I did make sure that I thoroughly mastered the material presented both in problem-solving and in lecture. In the end, Physical Chemistry was a very enjoyable course that allowed me to apply physics to chemistry and solve problems. The course took plenty of time, especially the lab write-ups, but the course challenged me on many levels which was great. In short, don't have any preconceived notions that a course is going to be "so hard" that you can't perform well. If you keep telling yourself that the course is too difficult, the course will become too difficult.

Your Less than Helpful Classmates

Interaction with your classmate can be intellectually stimulating and provide an important and crucial means to solidifying your mastery of a course especially the science courses. While a great interaction experience is wonderful, in reality, you will encouter classmates (lab partners) who will be happy to allow you to do a bulk of the work while they receive an equal share of the grade for a collaborative project. You, will have to master the skills necessary to get the most out of the project and your less than "helpful" classmate. First of all, you grade depends on your finding a balance that will enable you to get the strongest grade. If your grade is important to you, then you do what is necessary and worry about the "sharing" of project duties later. This means that when you encounter a partner who isn't will to pull an equal share, you don't have all semester to try to "cajole" this person into being a good partner. Sometimes, you have to deal with the "hand" or in this case, the "partner" as best you can so that your work doesn't suffer. Don't let resentment for your partner's lack of participation cause you not to get the best grade possible. In short, sometimes you have to "take up the slack" and do what you know will provide the best grade. It's not "fair" but it get the job done. Just don't let yourself be partnered with the "slacker" under any other circumstances. You can also state clearly why you won't work with that person again unless there are no alternatives.

It's always important for you to keep your grade and work in the forefront of you efforts. I will state over and over for emphasis, "what another student does or does not do is meaningless in terms of your grade." In short, you have to look out for yourself and keep your work at the highest level. As a professor, when I assign group projects, it's very easy for me to see who is the leader, the follower(s) and the slacker(s). Most people do not change their style over the course of one project or one semester. As an educator, I also make sure that every person in a group project is not so dependent on the others in the group that one person who has worked strong and hard ends up "making up for" or "carrying" the slackers. Again, keep your work ethic and don't worry about others unless they are impeding your progress to the point that you can't learn. Under that situation, you need to write down specific instances of the impedements and present them to the professor after you have presented them to the person who is impeding you. Some people are so self-absorbed, that they don't realize they are not pulling their share or that they have become a weak link in an otherwise strong group.

Group Study

Having a study group is a great strategy for both undergraduate or professional school. Some things that make group study efficient are the following:

Keep the group to 4 or less people. Large groups become unmanagable. If you want to collaborate with another study group of 4 or less, then do so but keep your primary group small.
Have a study plan (agenda) for the amount of time that you will spend together. This should be no more than one week's worth of materials. Don't try to do a whole test's worth of review in one study group meeting. It's counter productive to full mastery.
Do your individual study before you work with a group. While other folks can give you a different insight, they can't be the sole source of your learning.
Get away from school if possible. A Starbuck Coffee Shop meeting or group study room in the library is good so that other folks in the class won't disturb your group study.
Distractions and interruptions abound when you and the group have an exam in the near future. Try to find a method of keeping the socialization to a minimum while keeping the study to a maximum. Sometimes having one person write down a summary of a discussion or questions that the group can't answer is a good strategy for getting back on track.

If you get hungry/thirsty and you find that the group is getting "off track", stop while you refresh so that you can get back to working more efficiently. Sometimes, walking around the room or getting a drink can help to clear your mind.
If you are having trouble with some of the material, get your questions stated and answered before you meet with your group. If some of your group members have a stronger grasp of the material than yourself, don't worry about it. This is why group study works well.

Finally, remember that you are the ultimate person who is in charge of your learning. Your coursework is your job and you want to be the ultimate professional on the job at hand. When you sit down to study, give it your best effort. If you are tired and distracted, try to get rid of the distractions, rest a bit and then move to your studies. I can tell you that as a medical student, resident and practicing physician, I had and have to study when I am sick, tired and distracted. I have learned to hone in on what I need to master while tuning out the rest. Learn to master study when you are tired and learn to refresh yourself often. Sometimes your brain just needs a break which means that you divide your study periods into shorter bursts rather than one long session if you are tired.