Tag: medical school

Rapid Learning

How To Study Pharmacology

Stephen Goldberg
The Seven Dwarves' Medicine Chest

When I was in medical school, Pharmacology was taught by Alfred Gilman, a coauthor of  Goodman and Gilman’s Manual of Pharmacology and Therapeutics, a superb reference text, both then and now.

However, I had great difficulty in grasping an overall picture of the subject through this reference text.  It was too big; after reading one drug after another, the drugs soon started blending into one another, becoming difficult to sort out and remember.

What is the best way to learn Pharmacology?  This goes to the question of what facts are important to memorize and which are not so important to memorize but can be looked up in a reference text or computer program.

In Clinical Pharmacology Made Ridiculously Simple, the author, James Olson, has sorted out the general characteristics of each drug group at the top of the page, for understanding and memory.  Other details, particularly those contrasting the individual drugs in a given group with one another, are placed in a table for cross reference at the bottom of the page.  Such information can be looked up rather than memorized, except for certain features that are highly characteristic of one drug in comparison with the others.

It is helpful to have a good reference text in addition to the small book that quickly enables the reader to grasp general principles.

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What is your opinion about the usefulness of eBooks versus print books?  Which do you prefer?

Rapid Learning

How To Study Biochemistry

Stephen Goldberg

In 25 years of teaching medical students, I found that Biochemistry is the course that students have most difficulty relating to for clinical relevance.  While Biochemistry has much clinically relevant information, the material students are taught often does not reflect this.

I think this is because there is a big difference in what is important to PhD students and what is important to medical students.  For instance, ALT and AST are liver enzymes that are vitally important to the function of cells.  Their detailed biochemical reactions are important to the PhD student, but not to the medical student.  It is more important clinically to know that these enzymes leak out of damaged liver cells and are useful as markers for liver damage.

As another example, creatinine is a waste product of muscle biochemistry.  It is not so important to the PhD student, but very important to the medical student as a marker of muscle and kidney damage.

It would help to have more clinicians teaching the basic sciences and providing a more clinical focus.

Of course, if your instructor emphasizes topics of greater interest to PhD students, you need to learn that, as well as facts that are asked on the USMLE.  But teaching would be improved by emphasizing clinically important areas.

There is a problem with just rote-memorizing isolated facts.  Somewhere along the line it would help to understand Biochemistry as an overall whole, particularly in a clinical context, for future practical use.  For instance, there is much discussion about the value and side effects of HMG CoA reductase inhibitors (“statins”) in suppressing cholesterol synthesis.  It helps to see this enzyme in the context of a broader Biochemistry map to understand the pathways involved in cholesterol synthesis and what may be affected by suppressing it.

In Clinical Biochemistry Made Ridiculously Simple, I have tried to do just that, present the clinically relevant points in Biochemistry (particularly the metabolic pathways and the diseases that affect it) on a single map that can be grasped as a whole.  It is not a reference text, which disappoints some readers.  I suggest that readers also acquire a good reference text, bearing in mind that it can be very difficult to see the overall picture in a reference book.  The best way to study Biochemistry is to first grasp the overall picture in a small book, but also have a reference text and your class notes to fill in on other details.

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What do you think about using eBooks versus print books?

Medical apps, Rapid Learning

The Best Medical Apps

Stephen Goldberg
Treatment that works for one patient does not necessarily work for another.

The term “app” (application) generally refers to a small, specialized program that is downloaded onto a hand-held (mobile) device such as an iPhone or tablet, although the term is also used for laptop and desktop computers.

There are over 5,000 medical apps, which are continually evolving.  There can be “app overload,”  where many apps are downloaded, but few are used.  What sort of apps should you look for?

Ideally, a medical app for a mobile device should provide rapid, useful information at the bedside or office visit (“point-of-care”) in such areas as:

Drugs (dosages, side effects, drug interactions)
Differential diagnosis
Current workup and treatment
Lab values
Calculation formulas and algorithms
Specialty items such as heart sounds, EKGs, dermatologic diagnosis, radiologic images, and vision testing, depending on your needs.

The top 5 applications that are favored by students at Harvard Medical School (http://mobihealthnews.com/10745/top-five-medical-apps-at-harvard-medical-school/) are:

  1. Epocrates:provides drug dosages, drug side effects and interactions, pill ID, lab values, calculation formulas, and algorithms.
  2. VisualDx Mobile: contains dermatologic images and diagnosis algorithms.
  3. Dynamed: provides up-to-date approaches to diagnosis and treatment.
  4. Unbound Medicine uCentral: has many apps that can be combined and customized for your particular needs and interests.
  5. iRadiology: shows a compendium of radiologic images.

I add a few more:

WebMD provides a rapid guide to symptoms, conditions, drugs and treatments, including first aid information.

Medscape provides information about drugs, including over-the-counter and herbal medications, diseases and conditions, procedures and protocols, and drug interactions.

MurmurPro offers a set of heart murmurs.

Vision Test provides vision tests.

Mediquations:  While Epocrates offers calculation formulas, Mediquations provides more formulas and actually does the calculations.

In addition to the above apps, there are also Internet medical search engines that can look for reliable and specialized information, as opposed to the sometimes unreliable information that is found through general search engines, such as Google.  A list of these search engines can be found at the MedMaster website, which also offers a downloadable app, called MedSearcher (free), which allows quick access to the major medical search engines. MedSearcher presently is only available for computer use on Mac and Windows.

All the above apps offer isolated point of information.  Apart from individual facts, it is also important to have a general understanding of the subject and field.  This requires a fair amount of reading, which for many students would be tedious on a small hand-held mobile device like an iPhone.  It would require a print book or an eBook reading tablet.  MedMaster specializes in books that promote understanding.

Do you have a favorite app that you would like to share?  Please feel free to comment.

Rapid Learning

How To Study Neuroanatomy

Stephen Goldberg

The director of medical student cardiology training at the University of Miami once told me that cardiology was really not that difficult to learn, since it was based on a few general principles, but that neuroanatomy was difficult, since there were so many isolated facts that are difficult to digest.

I found this conversation interesting, since I had experienced just the opposite.  Cardiology to me was always nebulous; there were just too many facts to learn, especially drugs and their effects, and I always had difficulty with cardiology.  Neuroanatomy, though, seemed far simpler, since, to me, a few general principles conveyed the essence of the subject.  It occurred to me that the learning of a subject has a lot to do with the grasping of general principles.

For instance, there are some 100 billion neurons in the brain and in the range of a quadrillion synaptic connections (connection points between nerve cells).  This would surely be an overwhelming amount to learn.  However, it is interesting from a clinical standpoint that of all these synapses, there is only one that is of clinical significance to know about in evaluating a patient.  That is the synapse that separates an upper motor neuron from a lower motor neuron.  Where the synapse is located makes a big difference in the kind of paralysis that a patient experiences, whether of the upper motor neuron kind or the lower motor neuron kind (I won’t go into the details here).  Other than that synapse, it is the pathway along which information flows, rather than the number of synapses in that path that is important.  Whether or not the pathway has one synapse or many within it is unimportant in making a diagnosis as to where the problem lies. This simplifies the study of the subject.

As an example, the right side of the brain connects with the left environment of the body.  Thus, an injury to the right brain will result in sensory loss or weakness on the left side of the body.  It is not necessary to know where all the synapses lie along these pathways to know this.  Who would concern the physician more, a patient who complains of a right-sided headache and weakness and lack of sensation on the right side of the body, or a patient who complains of a right-sided headache and weakness and lack of sensation on the left side of the body?  It is the latter, because a problem with the right brain should not affect the right side of the body.  The location of the synapses is not so important in making this determination.

In learning neuroanatomy, then, it is more important, at least at first, to learn the general principles of pathway layout, rather than the location of synapses.  If you want to learn all about synapses too, it would be better to first understand the general principles of direction of flow of the pathways, then move on to greater detail.  This is the approach I have taken in Clinical Neuroanatomy Made Ridiculously Simple.

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Rapid Learning

How To Study Anatomy

Stephen Goldberg

In learning Anatomy, I think it is better to first learn through conceptual diagrams, rather than through photos of actual anatomy.  Photos of dissections, particularly those of formaldehyde-fixed specimens, contain fascia (connective tissue) and other features that obscure the conceptual picture of what connects with what.  In our medical school anatomy program, we had available a series of stereoscopic slides of actual dissections.  Few students used them.  During my ophthalmology residency, I also found relatively useless a book of photos of orbital dissections.  It is better to learn the anatomy conceptually, as through line drawings, and then fine tune this knowledge when learning surgery using unfixed tissue, having first learned the anatomy conceptually.

Anatomy is a very visual subject.  Here, a good way to learn the anatomy is to distort it into pictures that are common knowledge.  A typical vertebra, for instance, looks like a snowman, whose arms, legs, shoulders, and head resemble the actual vertebral anatomy (see below).  While learning other people’s mnemonics can be very helpful, they are often longer-lasting if they are your own.

From Clinical Anatomy Made Ridiculously Simple, by S. Goldberg, MedMaster

Ditties (e.g. “C3,4,5 keep the diaphragm alive”), acronymns (e.g. “SCALP” for layers of the scalp: Skin, Connective tissue, Aponeurotic layer, Loose connective tissue, Pericranium), and ridiculous associations (e.g. for cranial nerves 7 and 3, which open or close the eyes — see below) are also useful for learning anatomy.  A collection of such mnemonics may be found at medicalmnemonics.com.

CN7: A hook - closes eyes. CN3: 3 pillars - opens eyes. From Clinical Neuroanatomy Made Ridiculously Simple, by S. Goldberg, MedMaster.

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Which do you prefer, eBooks or print books?  Why?  Your opinion counts.

Rapid Learning

Benji’s Shot

Stephen Goldberg
Romance on the surgical service

Sometimes, an otherwise complicated diagnosis can be made with a simple observation, without requiring many procedures or expensive tests.  Witness the case of Benji:

One day, a neighbor frantically knocked on my door and told me that she could not arouse her 6 year-old son, Benji.  I raced over to the house to find Benji lying on the couch, and indeed it did not seem possible to awaken him.  A preliminary neurologic exam revealed nothing wrong.  I then raised Benji’s arm above his face and let go.  Now, when a person is really unconscious the arm will hit his face.  However, if he is faking, the arm misses, since the patient does not want to hurt himself.  Benji’s hand missed.

I then announced to Benji, that since I could not wake him up, I would have to give him a big shot in the behind with a needle that he would not feel since he was not awake, and that I was going out of the room to prepare the shot.  I left the room with Benji’s parents and came back about a minute later.  Benji was gone.  He was hiding behind the couch.

So arriving at a complex diagnosis is not always difficult when there is a pearl that shows the way.

Medical School Curriculum

Should Lectures Be Eliminated in Medical School?

Stephen Goldberg

Lectures have always been a staple way of educating in medical school, particularly in the first two years.  But are they the most efficient way to learn?

PROS:

•  There are excellent lecturers, who can provide insights and important points not presented in other sources.

•  The lecturer, as a facilitator, is available to the student for clarification of ideas that are not clear.

•  Lectures provide a different avenue of learning that can add to the learning experience.

CONS:

•  You can’t just stop in the middle of a lecture to mull over the ideas, or go back, as you can with a book or an electronic presentation.  Key points may be missed, especially if you can’t write fast enough.

•  Students learn at different paces, and books and computer programs allow students to learn at their own speeds.  The quality of computer teaching programs is continually improving.

•  In cases where a lecturer speaks poorly, or does not teach with clinical relevance, would it not be better to use computers or clinically relevant texts to learn?

•  Some lecturers in the basic sciences may be excellent researchers who would make better use of their time in the research lab, where their talents and interests lie.  The department could also save money by hiring fewer lecturers.

•  Clinicians can be good sources of clinically relevant information, but are often too busy to put in a consistent teaching schedule.

Some students do not show up at lectures, and others do so because it is more likely that what a lecturer says will show up on an exam.  Others rely on note takers.

Should the emphasis on lectures be reduced?  Should more teaching shift to self-learning?  Would it be better to provide students with a list of clinically important concepts and points to learn in the basic sciences and then allow the students to learn them at their own pace?

What do you think?

Medical School Curriculum

Medical Curriculum In The First Two Years Of Med School

Stephen Goldberg

 Say you have a juggler who wants to be the best ever, to juggle 7 balls at the same time as balancing a stick on his head and twirling 3 hoops around his leg.  How would he go about learning this amazing stunt, which combines three skills?  You might say to start off practicing all of these skills together, since this is the final result the juggler wants to achieve.  However, the juggler is more likely to succeed by practicing one skill at a time, and then, after learning each of them, practicing them together.

 It is similar in working with patients.  In evaluating patients, it is important to incorporate the considerable information you have acquired in the basic sciences.  For that reason, medical school education in the past consisted of spending the first two years learning the individual basic sciences and then putting this information together when seeing patients.

More recently, however, the trend  in some schools is to start right from the beginning seeing patients, before there is a background in knowledge.  Is this the best way to learn medicine?  I suspect that a leading reason for the change to seeing patients  right away is the impatience at having to wait so long before entering the clinical world.  In particular, since the basic sciences are typically taught by non-clinicians, and much emphasis is on information that the student does not find relevant clinically, the student wants greater clinical exposure right from the start.

 It seems to me that the better way to approach medical education in the first two years is the old way of learning the basic sciences first, but with a strong clinical emphasis, minimizing information that does not have clinical relevance.  By cutting down on the more esoteric, clinically non-relevant information, there would be more time in the second year to  study for the USMLE Step 1 (an exam taken at the end of the second year), put the information together, and better prepare for seeing patients.

 You, as a student, may have little control over how your school arranges the curriculum, but should not feel as if something is wrong with you if you feel somewhat lost in evaluating patients before you are prepared.  Some schools may offer the student a choice of following the more traditional curriculum or following one that emphasizes early clinical exposure.  Personally, I would opt for the former, but use a text that emphasizes clinical relevance.

 What do you think?

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Rapid Learning

Learning Speeds In Medical School

Stephen Goldberg
Heroic measures in cardiac arrest

In the classic fable of the Tortoise and the Hare, the tortoise wins the race against the hare by slow and steady persistence.  There are some students who quickly grasp concepts and facts, and have a steep rising learning curve.  Others are slower, but with persistence, can not only achieve the goal, but achieve a greater degree of knowledge and understanding than quicker learners.  Their learning curve may rise slower, but end up higher.

I was a relatively slow reader in medical school.  It sometimes felt like I was miles behind and would never catch up.  However, I eventually learned that understanding key concepts, as opposed to simple rote memorization of isolated facts, can quickly reduce the gap.  Once one has understanding, the facts are more easily organized and remembered.

If you are having difficulty keeping up,  you may not be as far behind as you think. Sometimes, understanding a few key points quickly closes the gap.  I suggest trying to understand, rather than simply rote memorize, and bear in mind that slow and steady adds up down the line.

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Rapid Learning

Studying In The Clinical Years

Stephen Goldberg
Hansel and Gretel luck out.

It is interesting that in medical school there is no course in medicine; you have to learn it through patient contact and deciding on your own what to read. It is a different kind of studying than in a course, where the instructor assigns a specific number of pages each day.

How should you study?

One way would be to set aside a certain amount to read each day in a large textbook, such as the excellent 4000 page reference book, Harrison’s Principles of Internal Medicine, reading it a little each day progressing from beginning to end.  Or you could read journal articles.  However, it can be  difficult, particularly when tired, to come home and focus attention when the literature does not pertain specifically to the patients you just saw.

It is more effective to prepare a number of questions each day that relate to the patients you encountered that day.  What is the differential diagnosis?  What are the diagnostic tests?  What are the treatment options?

There are a number of advantages to focusing study on the patients you encountered that day:

1.  You will be more attentive when looking up specific information that relates to the patients you have just seen than to read material that, however important, does not relate to the patient at hand.

2.  When presenting at rounds the next day, you want to appear sharp and informed.  You can do so by reading up on the patients who will be presented at rounds.

3.  Over the long run, by studying this way each day you will accumulate a knowledge of the most common presentations in the hospital.  You can’t know everything.  You can, however, know the most common situations.

In the old days, before computers and the Internet, one had to rely on reference texts, which could be out of date, and journals.  One could also go to the library and take out the voluminous Index Medicus and search out papers that pertained to your subject of interest.  Frankly, I was too tired to go to the library.

Now, with Internet access and medical search engines, it is relatively easy to quickly find the specific information that interests you.  Despite the explosion of new medical information, this is balanced by easier access to that information, and access continues to improve.

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Stress

The Lowly Medical Student

Stephen Goldberg

Students feel they are Big Man On Campus (or BWOC) at the end of elementary school, high school and college.  Not so in medical school.  While on the wards in the 3rd and 4th years of medical school, the student status is still low, below  interns, residents, and attendings.  The student is not paid, and often lacks confidence, due to a paucity of knowledge and experience, and the attitude of certain higher ups toward medical students.

You should not feel this way, however.  One of the great fears patients have is that they will be lost in the hectic hospital atmosphere.  Medical student histories and physicals tend to be longer than those of attendings, and the patient often is quite grateful to receive the extra attention.  In fact, the student history and physical may reveal important information missed in the sometimes hasty workup of others higher up in the hierarchy.  For instance:

When I was a medical student, I saw a young woman in the E.R. who complained of abdominal pain.  She had multiple surgical scars on her abdomen from operations in which she said nothing was found.  She had been placed on phenobarbital as a relaxant.  One of the first things I asked her was whether or not she had porphyria, a condition that affects the liver and could cause severe abdominal pain.  Now, this is probably way at the bottom of the list of important questions to ask, because the condition is so rare (about 1-5 cases per 100,000 population).  However, I had just learned about it in class.  She told me that she didn’t know if she had it, but two of her brothers died of it.  I told the chief resident about this.  A crowd soon developed around the patient when the urine test showed the disease.  Of course, the chief resident took credit and I was confined to the sidelines unnoticed, with no accolades for making the suggestion.  A lowly medical student.  But I felt good, especially since phenobarbital exacerbates porphyria, and it would be beneficial to discontinue the drug.

Another time, I was awakened one cold morning in the Einstein College of Medicine dormitory by a woman’s cry  “The baby is coming!”  I looked outside the window and there was a young woman lying in the frost on the dormitory lawn, with an older woman (her mother) standing at her side.  They had lost their way to the hospital (it was the young woman’s first child).  I rushed downstairs.  The baby’s head was already out.  I delivered the baby on the lawn, and by that time other students arrived. With me holding the baby still attached by the umbilical cord and other students lifting the mother, we carried both into the  dormitory and put the mother on the lobby couch.  The baby was not breathing.  I remembered my OB rotation several months before, where we were told “Don’t rush to cut the umbilical cord,” because the baby is still receiving oxygenation from the mother.  I rushed into the cafeteria, got a straw, and sucked out the baby’s mouth.  By this time, a dorm resident, who for some unknown reason was storing all sorts of surgical instruments in his room, used them to cut and clamp the umbilical cord.  The baby was rushed to the hospital, doing well.  Later that afternoon, I visited the mother to find out how she was doing.  Her response:  “Oh, another student who said they delivered the baby.”

Sometimes it is better to remain unknown.  As a student, I once walked into the floor exam room, where I found a newly admitted elderly woman lying on the exam table with no pulse or respiration.  Not having time to inquire about her history, I immediately started mouth-to-mouth CPR and called a code.  The code team arrived, but to no avail; the patient had died.  The code chief then angrily remarked, “Who called this code!!? this is a DNR (a patient with orders ‘Do Not Resuscitate’)!!”  I didn’t volunteer that I was the one, so sometimes it is better to remain in the background.

As comedian Rodney Dangerfield used to say, “I don’t get no respect.”

Well, there is always self-respect.

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Stress

Fatigue In Medical Education

Stephen Goldberg

When I was a student and intern, I wish I had the advice of Dr. John Preston in his two blog posts, Depression: Often Obvious, Sometimes Hidden, and Stress and Anxiety, particularly his comments about fatigue.

Once, as an intern (which for me was the most difficult year in my medical education), I was interviewing an elderly woman who was admitted about 2AM.  She was very slow to respond to questions and I actually fell asleep during the interview.  Perhaps it wasn’t that bad, because when I awoke, the patient was also asleep. But it shouldn’t have happened.

When I first began my internship, the chief resident told us that if there was any time during the year that we were just too overwhelmed and couldn’t see an admission that we should call him to arrange for someone else to handle it.  This happened to me once during the year.  It was about 3 or 4 AM and a new patient was admitted; I was just not functioning and needed a brief period of rest.  I called the chief resident, and he responded with a witch hunt against my incompetence.  Now, I realize that he must have had his own set of problems and didn’t want to be disturbed, but I continue to have bad memories of the time.

As a medical student, I remember overhearing an attending commenting to other students about what an idiot I was.  (I also remember him as a physician who was not especially kind to his patients either.)

Perhaps it was my sensitivity to the problems that even excellent students face in the course of medical education that influenced my decision to start MedMaster in 1979.  There is so much to know and so little time to learn it.  There is a battle between trying to study enough and also having enough sleep and personal time.  I have received many letters through the years from both students and instructors about the value of the small, clinically relevant book that provides understanding and rapid learning.  I hope these books continue to be of value.

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