Tuesday, November 29, 2011

Does 'The Checklist Manifesto' Apply To Medical Students?

This post is long overdue, but I finally got around to reading Atul Gawande's most recent book The Checklist Manifesto: How to Get Things Right. Longtime readers of Scrub Notes are likely aware that I'm a big fan of Gawande's writing. His first book Complications has practically become required reading for pre-med students. His second effort Better continues along the same vein. However, The Checklist Manifesto is Gawande's first major effort to move beyond merely an anecdotal descriptive text on the trials and tribulations of practicing medicine into the area of shaping policy and medical practice. And, to this reader, he makes a fairly convincing argument, utilizing extended examples from diverse fields such as piloting, building construction, and finance.

Gawande's argument primarily targets his fellow surgeons. However, what can medical students learn from his text? Can the humble checklist help a medical student succeed in learning the necessary knowledge to succeed in medical school? I doubt any serious study has been done in this area, but intuitively, the answer is yes. As Gawande suggests, try a checklist.

But, what does trying a checklist mean for a student? The checklist is meant to address a systemic problem, not an individual one. Gawande targets fellow surgeons because they run the ORs: they have primary responsibility for the patient's well-being as well as for insuring that the OR runs well. A trainee like a medical student typically simply plays their assigned role. However, therein lies the problem.

By simply playing an assigned role, the student learns from their environment in a haphazard way. Some ORs meticulously run through time-outs and other preparatory procedures; others perfunctorily mention them or even avoid them except for the most necessary ones. However, the student's responsibility ultimately is to the patient, not to maintaining a culture of complacency that he or she may find herself in. By creating and running through their own mental checklist prior to any patient encounter or procedure, you can ensure that you and your team avoid making unnecessary mistakes that may cause the patient harm. Even if you feel powerless on a team or service, your personal checklist can help ensure that you are doing your utmost to serve the patient. Although this may not be the 'heroic' side of medicine, as Gawande notes, the effects can be profound in terms of safety and patient care.

Beyond patient safety, taking the time to craft a checklist can help you break down a complex procedure into simple steps. As you are learning and practicing the procedure, focusing on these simple steps will make it easier to learn the procedure and learn to do it the right way in a safe manner. Gawande emphasizes this in his subtitle: How To Get Things Right. And that's what any student wants to do: get things right.


Updated 2015-12-20

Thursday, November 24, 2011

Scrub Notes 2012 Med Student Holiday Gift Guide

Happy Thanksgiving! While this is a time to give thanks and count your blessings, tomorrow is a time to shop! However, most med students, residents, and other medical professionals may not be joining on these shopping trips: they're probably studying or on call! So, to celebrate their commitment to caring for others, here are a few ways to show them you care for them:

Kindle Fire by Amazon

The latest tablet from Amazon is quite a break from previous Kindles. Offering an Android-based operating system and full color, the Kindle Fire is Amazon's first foray into the competitive tablet space. While not as full-featured as the iPad, the one killer aspect of the Fire is the price: $199.

That's right, $199 - a full $300 cheaper than the iPad. For med students, the 7" form factor makes it much more portable than the iPad. While lacking 3G support, most students would likely use it in a library or lecture hall (or Starbucks), where Wifi hotspots are plentiful. And with access to Amazon's site well-integrated, it will be easy for them to purchase e-books... or TV shows whenever they need blow off some steam.

Giant Microbes White Blood Cell (Leukocyte)

A popular gift idea last year, the Giant Microbes are back! These stuffed toys are whimsical depictions of all things medical. From bacteria to neurons, check out all the options available. For the immunologically-minded, I put the white blood cell here. I can almost hear him saying, "Meep! A bacteria! Must defend!" Haha, almost like a Pokemon... but one that saves lives!

The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee

This book has been on my reading list all year long and hopefully I can get to it before the year is out. However, from all accounts, the book is well-written and lives up to its subtitle as a biography of cancer. Mukherjee details mankind's history in battling this scourage and how modern science has revolutionized the fight. However, with the great advances come new challenges and new concerns in how we deal with when our bodies fail us.

Looking for more gift ideas? Check out last year's med student gift guide. And if all else fails, you can't go wrong with a gift card =)

Updated 2015-12-20

Monday, November 21, 2011

How New Medical Students Should Learn To Learn

A confusing title, perhaps, but it's correct: newly minted medical students often have to reteach themselves the habit of learning medical knowledge in order to succeed in medical school. This guide from Wellness Rounds, originally intended for students entering Baylor College of Medicine, gives some good pointers for first year medical student study strategies

Your goals
  1. Learn material for long term retention
  2. Pass exams
  3. Develop skills for lifelong education & studying (nope, it never stops but it can get faster!)
1. The Basics
  • No magic formula for studying except for diligence and consistency
  • Goal is to learn and apply pertinent material – NOT perfection
  • Efficiency is a skill developed through practice, persistence, and reflection – not the result of drinking more caffeine or a genetic trait that skipped your generation
  • Studying is not a competitive sport – some student take (much) less time to learn than you will, but some take (much) MORE time than you…that’s life! Good news – in the end, we are all doctors.
  • Be gracious.  To yourself and your peers as you pass through the basic science crucible that brings out some less than pleasant coping mechanisms.  It’s normal and will pass.
  • You will succeed!  Don’t believe us some days?  Ask any of the thousands of physicians, professors and mentors around you – we’ll be glad to remind you!
2. The Specifics
  • Choose one way to study and stick with it for at at least 1 week
    • Switching study methods costs more time than it saves and there is a learning curve to all of them
  • Start with the first lecture and go sequentially to be sure you don’t miss topics
  • For all study techniques
    • Study reps: 45-50 min “on”, 10-15 min “off” (see below)
    • Skim before lecture (assigned readings, ppts, syllabus, etc)
      • SKIM to familiarize yourself with how to spell new words and the general outline/concept of the lecture – this is not learning time
    • Attend > stream lecture and actively listen by taking notes, drawing pics, writing qs, etc.
    • Take a lunch break after lectures to get good nutrition, socialization and to recharge
  • Techniques for LEARNING
    • Mind maps
    • Review notes with ppts, syllabi and text book and create a condensed 1 page review
    • Rewatch the lecture while condensing notes and focusing on main points
    • Flash cards of high yield material
    • Single page flow chart of material
  • Techniques for REVIEW
    • Practice questions (online, review BRS books)
    • Small group discussion, lecture by lecture (max 4 ppl)
    • Small group quizzing of lecture material
    • Peer or upperclassman tutoring
Study Reps: 45-50 min “on”, 10-15 min “off”
  • “ON”
    • Close email, g-chat, FB, other distractions, put phone on vibrate/silent
    • Set an alarm and STOP studying when it goes off
    • Write down other tasks that come to mind on a sticky note but do NOT stop studying to do them (ex: reply to email, wash dishes, make a snack, look-up question from another lecture, chat with nearby friends, etc.)
      • These tasks can be done during your “off” period
      • You will be amazed at what distracts you and feels “urgent” while studying, but there is almost NOTHING that can’t be put off for <45 min, including perez hilton
    • Don’t be frustrated if the first 15-20 min (or more) feel “wasted” bc you can’t focus – this is NORMAL and the time from sitting to focused productivity will decrease as you adjust to a daily routine (the same as exercising)
  • “OFF”
    • Set an alarm
    • Grab a snack, read a NYT article, catch up on the FB developments (OMG, so much happened in 45 min!!!), chat with a friend, send off a quick email, check off the list you made during  your “ON” period
    • Get up and stretch, walk around for a couple min – it’ll wake you up, get you out of your “study zone” (wherever  you are working)
    • Congratulate yourself on sticking to your study schedule and breaks
    • Relax and don’t worry about how much time you have/not spent studying, let the alarm clock guide you rather than checking your watch constantly
3. The Refinement
  • What works for others may or may not work for you – don’t be discouraged!
  • Study methods evolve as you discover what sticks best in your own head
  • New topics/blocks may require different approaches
  • At the end of the week or block, reflect on what worked well (timing, setting, method)
    • Adjust study methods to what works best for you – but remember, DILIGENCE and CONSISTENCY are king & queen
  • Exam results not reflective of your efforts?  Ask for help! Professors, upperclassmen, mentors and strong peers can enhance your study skills.
  • STUDYING is STUDYING – it is never wasted.
4. The Balance
  • All work and no play makes a miserable and burned out student, resident and physician
  • Set aside at least 1 hour as sacred for meeting your personal needs (NOT chores)
    • Examples: exercise, cooking a nice meal, calling friends and family, reading a great book, prayer or meditation
  • Sleep on a schedule: go to bed and get 7-9 hrs of sleep every night, your brain needs that time to literally build memory
  • Eat well: again, your brain and body need good protein to build synapses for memory, carbohydrates for fuel to burn while studying, and plenty of water to keep you going in the Houston heat
  • Break up your week: take Sat. afternoon/evening off for fun activities with friends/family (movies, restaurants, dancing, bars, parties…), sleep in Sunday morning and have time for yourself and your personal development (reading, writing/journaling, church, chats with significant other)
  • Schedule it: if we write it, we do it.  Use your gmail calendar, phone app, planner, etc. and plot out your week including your studying, exercise, family/friends and other activities.  It will give you a sense of control over your life as you plan your days, rather than your days ruling you.
5. The Non-Science Major
  • You’re not alone – great physicians come from a variety of backgrounds!
  • You may play catch-up at first, but you undoubtedly can succeed
  • Writing and theoretical dissection of literature/theory/philosophy/art will be applicable in medicine – but basic sciences throws you back to the forgotten days of multiple choice exams and memorization.  Dusting off those skills and learning to study for regurgitation/application rather than creation may take some time, so don’t despair if you are spending longer in the library than the Bio-E major.
  • Link up with a science-major classmate who is good at identifying high-yield material AND explaining it.
  • Contact the upperclassmen study tutors – many of us had limited science exposure starting med school (“Wait, is it 2 livers or 2 kidneys – I’m not really sure?” – General Surgery Bound MS 4) and more than succeeded — but we’d love to make that transition easier for you!

For more study strategies for first years, check out Wellness Rounds

Saturday, November 19, 2011

When Should I Start Preparing For The 2012 USMLE Step 1?

How about... right now?

That's right: even though the exam is several months away for most students, the time to start preparing for the 2012 Step 1 is today! Why so early, you ask? Simple: USMLE Step 1 is an exam that tests your cumulative knowledge. The sooner you start accumulating this knowledge, the better. This is not crammable knowledge. I repeat, this is not crammable knowledge. Yes, I know, you're a medical student - you live off of cramming. It's worked so far, right? Why not keep pushing your luck? Trust me: this is *not* the test you want to cram for, nor is it the test to take chances with. Most residency programs heavily weight Step 1 scores when determining which applicants to interview, let alone rank. Remember, this test is a means to an end: getting into a great residency program.

So, now that I've got you properly on edge, how do you start preparing for Step 1? The key is to gradually build up your knowledge in a Step 1-specific way while you are studying for your basic science exams. As I've mentioned before regarding Step 1 preparation, you should purchase a general USMLE Step 1 review book such as First Aid for the USMLE Step 1 2012 and annotate it with your own learning as you proceed through your basic science courses. Using this technique, when it comes time to study for Step 1, you are not reading some unknown professor's notes, but rather your own in a language you can understand. And, you will also become very, very familiar with the review book that you intend to use, which is quite helpful. You will start to notice certain topics end up being covered in multiple areas. For example: meningitis is both an infectious disease topic as well as a neurological topic. Both chapters will likely mention it but with a different focus. Knowing this well in advance can help you annotate one section with a note saying "Hey! Check out the other section for more info on this!" Remember, the body does not have chapters or sections. Disease is not neatly organized, so the key for your preparation for Step 1 is to be as organized as possible.

If annotating is not your thing, there are other options. You can purchase a USMLE Step 1 Qbank now and start looking at practice questions now. Simply take a section related to a topic you are working on and go through it. Figure out what your weak areas are and study them doubly hard. Whatever method works best for you is fine. It does not how you are reviewing for Step 1, but that you are doing something specific to prepare. Even doing as little as one hour per week can give you as much as a 30% head start over your peers in that final stretch before the exam. The key is to start doing something every week now so that when it is crunch time you feel prepared and confident to tackle the challenges that lie ahead. Good luck!

Updated 2015-12-20

Monday, November 07, 2011

What The Doctor Saw

I recently finished reading What the Dog Saw by Malcolm Gladwell. I enjoyed the book, although it's more a collection of essays rather a unified work like his prior works. Why mention it here? Well, one chapter/story heavily involves mammography. The chapter is actually two stories in one, but both basically relate to the premise that a picture is worth a thousand words... but are they the right thousand? The other story involves the use of satellite imagery by the U.S. military to assess foreign targets. Malcolm Gladwell compares this to a mammographer scanning for tumors on a mammogram. The analogy is reasonable... but like all analogies, it breaks down after a while.

So, what does Gladwell conclude? Honestly, it is kind of hard to tell. He notes the difficulties in mammographers being over- and under-sensitive, yet concludes by noting the benefit of mammography spread across the population. What I wish he had taken more time to address would have been the nature of a screening exam. What does it mean for an exam to be 'sensitive'? 'Specific'? I'm willing to bet the vast majority of people out there don't know. Heck, I imagine many people within medicine aren't 100% clear. The recent controversy over prostate screening guidelines highlights just how controversial this subject is. If healthcare professionals are not united in how such screening is presented to the public, how can we expect patients to choose the right course of action? Furthermore, in the long run, such revisions erode the public's trust in healthcare overall.

How do healthcare professionals strengthen this trust in an era of seemingly constant changes in recommendations? Simple: focus on the underlying reasoning behind getting screened. Explain to patients that such tests evolve over time as new technologies develop. Help patients make informed decisions on their own. Ultimately, the better we communicate the need for testing, the benefits *and* the risks, the better relationship we will have with our patients, and hopefully they will enjoy better health in the long run.

What do you think? Check out the book to see Gladwell's argument yourself... you might find yourself enjoying his other pieces as well!

Just want to read the chapter but not the whole book? Gladwell has it posted on his website here.

Site Note: Regular readers may have noticed the long pause in new posts. Apologies, but sometimes life comes at one fast... and the blog got pushed to the backburner. Again, thanks for sticking with us and we look forward to putting up lotsa great new Scrub Notes stuff shortly! Happy reading!

Updated 2015-12-20

Saturday, May 21, 2011

Attending Advice On Clinical Rotations

Many second years are soon to enter the clinics and wards for the first time come June and July. Dr. Mary Brandt, a Baylor College of Medicine pediatric surgeon who blogs at Wellness Rounds, provides the following advice to medical students starting on clinical rotations:

Don’t sit in the back of the plane.
The basic sciences are important to learn the vocabulary and grammar of medicine.  Clinical rotations are different – it’s where you actually learn to be a physician.   If you use the analogy of learning to fly, in basic sciences you are studying the book on how to fly the plane.  In your clinical rotations you are in the plane, watching and learning from the pilot.  Which means you have to be in the cockpit.  You cannot learn to fly a plane by sitting in the back.
In every situation you encounter in the hospital, imagine that you are “flying the plane.”  When the resident starts to write the admission orders say “Do you mind if I write them and you show me how?”  On your surgery rotation, be in the holding area early and ask the anesthesia resident if he/she will explain how to intubate, show you how to intubate, or even let you try.  When you are writing an admission H&P on a baby in the ER, imagine you are the only doctor who will be seeing that patient.  Let the adrenaline of that thought guide you to the computer to look up more about the condition, how to treat it and what you would do if you were the only person making the decisions.
Yes, you need to be pushy and, yes, sometimes it will backfire.  Be reasonable, but stay engaged. If it’s not an appropriate time to be assertive, stay in the game mentally by asking yourself what they will do next, what you would do if you were making the decisions, or what complication might occur from the decisions being made.  Write down questions you will ask after the smoke clears if it’s not appropriate to ask during a stressful situation.
Know what you are expected to learn before you start.
I am not a fan of “learning objectives”.  If they are done well, they are very helpful, but most people don’t take the time to do them well (or don’t know how to do them).  For the rest of your professional life, you are going to have to define your own learning objectives.  So, in a way, learning how to do it early – during your core rotations – is also part of the skill set you need to know.  (Word of advice, though – even if they are very poorly written, you need to read any objectives you are given and make sure you accomplish them.)
Start with a basic textbook.  You will NOT be responsible for learning all the details in the textbook!  Textbooks are written for residents and practicing physicians.  But – a good textbook will give you an overview of the topics.
The strategy:
1.     Make a list of the topics covered in a general textbook.  There are usually 2-3 good textbooks for every specialty.  Ask other students or residents which one(s) they recommend.  You will probably rotate on sub-specialty services during your core rotation, but don’t get bogged down in looking in sub-specialty textbooks.  Stay with the general textbook.
2.     Plan to skim and make notes on every major topic.  These should be “big picture” notes, not every detail.  If there are 60 chapters in the book and your rotation is 2 months long, you should be shooting for one chapter a day.  Keep track and make sure you get them all covered during the rotation (not after).  When you are done with the rotation, these notes should be all you will need to review for the shelf exam.
3.     Don’t read the chapters in order – read them as you see patients (see below). But, make sure that all the chapters are covered since it’s unlikely you will see patients with every disease in the book.
Practice being professional.
It’s really important to be professional and to be seen as professional in all your interactions.  First of all, it’s the right thing to do.  Secondly, a bad interaction with a nurse on the floor can lead to a poor evaluation by your attending.  Make learning how to behave as a professional one of your learning objectives.  Learn from those around you.  Which residents and attendings are the most professional?  Why?  When you see bad behavior (and you will), think about it – what would you have done differently?
Learn from every single patient you see.
Use every patient to learn about their specific disease.  Even if it’s the 30th patient with appendicitis you’ve seen you’ll still learn something new.  (or use it to learn about their hypertension instead)
The strategy:
1.     Keep a notebook with an entry for every patient you see.  You can use 3×5 cards, if you prefer.  In fact, many hospitals have 3×5 cards with the patient info available in the patient’s chart for docs to take.
2.     Make yourself read something about every patient you see.  If you haven’t read the textbook chapter on the subject, that’s where you start.  If you have read the textbook, review your notes and read something new (UpToDate or PubMed for example)
3.     Make yourself write down a minimum of 3 things you learned from the patient in your notebook (or on your 3×5 card).
Be the doctor for patients that are assigned to you.
You will be assigned patients to follow during your rotations.  When this happens, make up your mind that you are going to “wear the white coat”.   What if you were the only doctor taking care of Mr. Smith after his surgery?  In addition to reading (see above), ask the residents to help you write all the orders.  Write a daily note and make sure your notes are at the level of the residents (ask them to review and critique your notes).  When a drug is prescribed, know the dose you are giving, the effects of the drug and the potential side effects.  When a x-ray is ordered, be the first person to actually see the image and know the result (and make sure you call the resident as soon as you do!).  Don’t get any information second hand – make sure you see the results and the images yourself.  At any point in time, if the attending asks, you should be able to present your patient as though you are his/her only doctor, which means how they presented, their past history, social issues, test results, procedures performed and how they are doing now.
Prepare for conferences.
Every service has at least one or two weekly teaching conferences.  In most cases, the topic (or cases) are known before the conference.  Ask your residents or attendings the day before the conference for the topics and/or cases that are going to be discussed.  Use the strategy outlined above to prepare e.g. consider these “vicarious” patients and learn from them as if they were a patient assigned to you.
Come early, stay late and keep moving.
Taking care of patients in the hospital is a team sport.  The best medical students become part of the team early and are appreciated and – therefore – taught more.  It’s just human nature and it’s just the way it works.  Don’t brown nose, don’t show off…. just show up.   If there are labs to look up before morning rounds, be there 10 minutes early and look them up for the residents. If you don’t know the answer to a question the best response is “I don’t know, but I’ll find out!” If there is scut work to be done that you can help with, volunteer to help before you go home. Anytime you can, make the residents look good. It’s particularly important not to try to one-up the residents.  You will have more time to read than the residents, so you may actually know more than they do about a specific topic.  But, if the attending asks a question and the resident gets it wrong, don’t correct them in front of the attending.  (Unless it’s a critical issue and you think the patient might suffer in which case you have to speak up!)  Whenever you can, set up the resident to succeed.  “A rising tide floats all boats” – if you help them look good, you will look good and the team will look good. Don’t ever sit in the lounge waiting for someone to come tell you what to do.  There are patients to see, conferences to attend, rounds to do, labs to look up… the hospital never sleeps!
Practice having a balanced life.
Compassion fatigue is a constant threat to practicing physicians.  Taking care of yourself, staying connected to family, friends and the outside work are all critical components of preventing compassion fatigue.  This, too, is a skill you need to learn during your rotations so you can carry it with you into your residency and your practice.
Enjoy!  You are finally a “real” doctor!’’
Your experiences on your clinical rotations will be among the most special of your life. Buy a new journal and take time to jot down the funny and not-so funny occurrences of daily life in the hospital.  You will see some extraordinarily beautiful moments of human life.. and some horrendous examples of what people can do to other people. We all learn to deal with these extremes by telling stories. Write down these stories when you can.  It’s also special to record your “firsts”… the first time you set a fracture or hear a murmur of aortic stenosis will be the only “first time” you have.  It’s a special world you are entering.   You’ll want to remember it by taking notes, recording stories and with pictures of your team and unique sights around the hospital. (No patients, though – remember HIPPA!)
Congratulations! You are well on your way to the privilege and joy of practicing medicine.

Click on over to find more practical and healthful advice from Dr. Brandt at Wellness Rounds

Tuesday, March 01, 2011

How To Study For USMLE Step 1 While Working Full Time?

I have mentioned in the past that many times, readers of this blog write in to scrubnotes@gmail.com with specific questions. However, over time, I've noticed some questions being asked repeatedly, so I thought I might answer one of the common questions on the blog itself (with permission, of course):

Q: Thanks so much for posting your USMLE Step 1 strategy. It calmed my nerves a bit to say the least. I graduated from a foreign med school in 2001, am a US citizen, took a USMLE Step 1 Kaplan Course and failed step 1. Had to start working full-time (non-medical-related field) to pay off debt. Lost my confidence but not my desire to pass the steps and utilize my education. Any suggestions for someone who must work full-time (9-5), 5 days a week and has to start from scratch for preparing for step 1? (I really liked your advice about utilizing First Aid as a primary study tool). I have not, as yet, scheduled the exam. Thanks again.
- T.H., foreign medical graduate 2001

A: Thanks for writing in! I've received many similar questions regarding Step 1 study strategies / schedule. I think what you should do is first define your goals. The strategy to study can change quite a bit depending on what your goal score is. In general, I would say give yourself double the amount of time you actually need, so you do not feel time pressure while studying. Second, lets say you are taking the test on a Saturday - make sure that you take a practice test every other Saturday for let's say, 3 to 6 months prior to the real deal. In other words, practice being in a serious testing environment. Sure, this is painful, but as you'll likely agree, it's less painful than failing. Try to match the real test environment as closely as possible - take it in a quiet place, starting at 8am, only 1 hr of breaks total. To make a practice test, just take qbank sections back to back. Lastly, don't stress too much about the outcome - if you fail again, reconsider your life goals - most people are in medicine for one of two reasons (or both): to help people, make money, or both. If you are not successful at medicine, then you can do many things to help people (teach, nursing, etc) or earn money (business, law, etc).

Hope that helped - feel free to ask more questions by emailing scrubnotes@gmail.com. Good luck!

Updated 2015-12-20

Thursday, January 20, 2011

Medical Physiology Study Tips

This guest submission by Igor Irvin Bussel, a second year medical student, describes tips on how to study for medical physiology with the aim of acing that inevitable physiology test. 

There is no topic more fascinating in medicine than physiology. Fundamentally, it is the study of life. To be more specific it is the science of function based on integration of systems, communication of signals, and elegant homeostasis.

As a former T.A. for Medical Physiology, I want to help students appreciate and succeed in their course without stress. There is a unique best way to study for each course/professor. I aim to have you study less but in a better fashion because nobody wants to study endless hours and still not score as high as they hoped.

Medical Physiology is a unique course because it is not about memorizing facts but rather
building a mind-set and framework for thinking about the function of the human body. With that in mind, realize that you are not taking medical physiology to become a doctor-- you will learn that by doing. You are a medical student. There is no M.D. after your name... yet. Study for the exams and all else will fall into place.

Even though everyone inherently understands that they have to study for exams, they still
study to be a doctor. Let me repeat and clarify myself: You are studying for exams on medical
physiology. You are not studying medical physiology to become a doctor.

Get the difference?

Once this is clear, you can actually use your exams for what they are-- directions for how to do
well in your medical physiology course.If you just study medical physiology without looking at past exams, you will not do as well on the actual exams as you would like. The course is just too broad for you to base your studies of what you assume to be important. As long as you went to lectures or have even a remote idea of what material you covered, you should take a look at the past exams that are available. Record what topics are addressed most often in questions and hyper-focus your studies to those high-yield areas. You should review all of the material presented but be sure that you have a thorough understanding of the high-yield concepts.

Do not wait to take practice exams days prior because you are not as ready as you would like
to be. You will never be fully ready -- ever. Nor will you achieve perfection. You can however
strive to be excellent. The very act of taking the practice exams will better prepare you for the actual exams and will provide further direction regarding your weaknesses. During your study
sessions, you should be in a constant state of awareness that there are critical points you still have not learned.

When taking the practice or actual exam, always do the easy problems first. Additionally, on
multiple choice sections, your attention should be devoted to finding the wrong answers. Since
there is only 1 correct answer and 4 wrong answers, it is not only easier to eliminate wrong
choices but it also increases the probability of having to make a guess if necessary. While you
are eliminating wrong answers and picking the correct choice, it is crucial to briefly write out your rationale for each decision. This redundancy not only ensures you didn't misread but also primes memories that may be advantageously accessed for later questions. I stress proving wrong and right answers because answer choices on exams are repeated more often than entire questions. More importantly, questions are often changed while answer choices are not.

After any exam, a post-mortem type of analysis must take place. What went well? What went
wrong? Stupid mistakes? Lucky guesses? Constantly evaluate performance, analyze trends, and
implement improvements. Do not waste time engaging in debates on minutiae and rationalization battles. The reality is that most rationalizations are based on faulty assumptions and unless evidence can be provided, these communications are a complete waste of energy, air, and time.

On a final note, while all courses will promote various text books, I think the best sources, if you need them, are the following:

1. Ganong’s Review of Medical Physiology by William Ganong

2. BRS Physiology by Linda S. Costanzo

Igor Irvin Bussel is a second year medical student at Chicago Medical School. Share your passion by publishing your writing on Scrub Notes today!

Updated 2015-12-20

Tuesday, January 18, 2011

Residency Interview Tips, Part 5: The Follow Up

So, you made it to the residency interview. You fit in well at the dinner and impressed on the interviews. Now you're walking out the door, back to your car, or to the airport, and off to your next interview. You're finished with this program til you place it on your rank list, right? Wrong! Now is the time to really seal the deal. Think about it: you were just granted this wonderful opportunity to interview for an actual job in a down economy. Not everyone is so lucky, whether they are trying to find jobs in allied health or pursuing careers in other professions like business or trying to get into law school.

There are a lot of myths out there about how to communicate with the residency program after the interview, and frankly, a lot of times, the answer is: it depends. But, there are some things you should do regardless, and here they are:

Write Thank You Notes To Your Residency Interviewers
This seemingly no-brainer move tends to the bane of the medical student after the interview. Writing thank you notes is tedious, time-consuming, and does not offer any guarantee of advantage in ranking let alone any guarantee that your interview will receive your note! Still, while this is not sufficient to gain any advantage, you should view it as necessary to avoid being at any disadvantage. The steps are simple:

  • Make sure to get contact information from each interviewer at the interview
  • Use a basic template to speed things up for yourself
  • Add in something unique that came up from each interview to trigger a positive memory of you when read
  • Do not be too verbose - keep it short and sweet
  • Put your contact information beneath your signature in case the interviewer wants to be in touch
One 'modern' question about the ritual: should the thank you note be handwritten or emailed? 
The answer is not so simple. Handwritten notes show more of an effort and seem more personal; however, they are harder for the interviewer to respond to and more likely to go unanswered / unacknowledged. One strategy is to write a thank you note within 24 hours of your interview and immediately mail it off. Then, a week later, send a one line email stating that you hoped the interviewer received your note and that you look forward to further discussing your interest in their field in the future. 

Another issue: should I thank the program director if I did not interview with them? The program coordinator?
Again, no straightforward answer, but remember that ultimately the PD is likely the one selecting residents and would be your future boss, so can't hurt to make a favorable impression there. Similarly, the program coordinator can have a huge influence on ranking decisions. Sending one or both a one-line thank you email cannot be anything but beneficial. 

The Penny Black: World's First Postage Stamp

Between Interviews and Rank Lists
Some programs begin interviewing as early as October. However, rank lists are formed in February. How do you keep yourself at the top of the list over 4 months of interviews and committee meetings? Make sure to keep in touch with the PD and PC as the months progress. Keep a list of questions that come up about programs in general (things such as health care benefits or how time off is given for board exams tend to become more pressing as interviews progress) and email the qs to each program director about once a month. That way, you not only gain more specific information about each program but also keep yourself fresh on their minds as time passes.

Should I do a second look visit to a residency program?
Again, it depends. You should really do it for your own informational benefit. While some programs view such visits favorably, others are neutral, and still others view them as intrusions into the workday of active residents. You also risk reversing the favorable impression generated on interview day. Lastly, there is the cost of visiting a program a second time. One approach is to inquire discreetly with the program coordinator about the feasibility of such a visit as well as ask around to see how such visits are viewed within the program of interest. 

Sunday, January 16, 2011

Residency Interview Tips, Part 4: The Interview

Okay, the big moment has arrived: the interview. You're on! But, don't worry - this isn't Larry King and this isn't nationally televised. You should view the interview as a chance to burnish your credentials for a residency program as well as gather more information about the program itself. The interview has four main components: the first impression & introductions, interview's questions, your questions, and conclusion. We break down the interview by each part:

The Residency Interview First Impression
While many interviews run late, make sure to be early to yours. Ask the program coordinator for detailed instructions on how to find the location if it is distant from the program office. Confirm the time and location. Ask people along the way if you feel unsure. There's no worse first impression than being late.

Since you should already be wearing standard interview clothes, that shouldn't be an issue. When you enter, smile - the interview should be fun for both you *and* the interviewer! Shake the interviewer's hand firmly while saying your name slowly and clearly. Take your seat promptly and place your items next to or below you. Sit up straight but don't lean forward too much. Make sure both feet are on the ground and your arms are relaxed by your side. Basically, your posture should convey quiet confidence. And keep smiling!

Hopefully, your interviewer is mirroring your actions. As you start in on the pleasantries, take a moment to note the office. Sometimes, you can introduce mementos on the wall in order to broaden the discussion as well as show that you are perceptive. However, be careful in this regard as sometimes interviews are conducted in borrowed offices. There are many other similar interview tricks you can employ in order to relate to your interviewer.

The Interviewer's Questions
After the introductions are complete, you can expect a short blurb from the interviewer about who they are and perhaps a bit about the program. Eventually, they will segue into the actual interview questions. Typical questions are covered in many places, and mildly vary by specialty. The key here is to be clear and straightforward in your answers. You should not spend more than 2 minutes answering any particular question. Avoid rambling. Stick to your points. Don't worry if you take a momentary pause to answer a question - it shows that you are actually thinking about your response versus just spitting out whatever comes to mind or whatever you have memorized. As interviews progress,  you will find that most questions revolve around "Tell us about yourself," "Why did you pick this specialty?" and "What do you find attractive about our program?" so be prepared to handle those adeptly.

Your Residency Program Interview Questions
After about 10-15 minutes, most interviewers will wrap up their questioning and ask you if you have any questions. You HAVE to ask something here, even if you have no real interest or question. Obviously, if you are curious about something the interviewer said during their portion, ask about that. Otherwise, you can go in one of two directions. First, ask questions about the structure of the program, whether it be rotations or what the interviewer views as strengths / areas that need improvement for the program. It is also helpful to ask about the future, with regards to fellowships or career prospects, or just where they feel the field is headed in general. The other line of questioning is to ask about factors outside work, such as how it is living in that city or neighborhood, or how the culture of the program is. This line of questioning is bigger risk / bigger reward. Some interviewers will view this as showing you lack seriousness, but for others, this is a good way to forging a bond that lasts beyond the interview. Judge how the interview has gone thus far before deciding to engage in this line of peripheral questioning.

Residency Interview Conclusion
Take about 5-10 minutes to ask your questions. Don't pepper / aggressively question the interviewer. If you have tough questions about say, accreditation or board pass rates, save those for the program coordinator or program director. Not every interviewer is up to speed about every aspect of the residency program. As the questions wrap up, try to leave the same way you came in, exuding a quiet confidence. Smile and shake hands firmly. Make sure to ask for a business card or note down contact information in order to send correspondence once you are done with the interview. You can frame it as wanting a way to communicate in case you have further questions. Some programs are more upfront about providing contact information, but you have to solicit it yourself in many places. Walk out the door with your head held high and move on to your interview.

By the end of the day, and certainly after several interviews, you will be a pro. Congratulations! You're basically done with all the heavy lifting of attaining a position as a resident physician!


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