Tag: medical students

eBooks vs Print Books

Is Remembering Harder With eBooks?

Stephen Goldberg
Cinderella’s untimely episode of pedal edema.

Previous posts have presented the pros and cons of eBooks versus print books, with particular emphasis on the eBook needs of medical students.

Another consideration has arisen.  Does reading on an eBook interfere with the remembering of what was read?

Some studies suggest that remembering may be harder with eBook reading (see Healthland and The eBook Skeptic) than with print books.  The associations one makes with landmarks in print reading (the relative positioning the text and figures, whether the information was at the top or middle of the page, on a left or right-hand page or column, etc.) is not set with eBook reading when there is shifting of text flow with resizing of the page or font size.  This relates to a memory technique called the Memory Palace (the method of loci) discussed in a previous post, where the context of the information, such as the surrounding visual landmarks, plays a role in memory ( also see Brier Dudley’s Blog).  Ebooks that have text reflow have fewer such landmarks, and  remembering may be more difficult.

Another issue is whether reading may be slower with eBooks than print books.  Some of the earlier studies suggested this, but were done years ago when the computer screen had lower resolution, so it is unclear whether this is still a source of concern.  It is also a question as to whether  linking all over the place slows down reading and makes it difficult for the reader to keep track of all the links.

The issues of remembering and reading speed with eBooks require more study.  If you have used eBooks, do you have any personal observations regarding your ability to remember, or reading speed with eBooks?  Do you prefer eBooks or print books?

eBooks vs Print Books

eBooks vs Print Books: Med Student Survey

Stephen Goldberg
"Easy, John, help will be here any day now."

As a medical student, which do you prefer, eBooks or print books?

A previous post summarized the pros and cons of eBooks versus print books in general.  Do the particular needs of medical students tilt the preference one way or the other?  I.e.:

Medical study is intense, involving a great deal of reading.  Does the glare  of reading on a screen for long periods outweigh the convenience of not carrying  around  heavy books and the generally decreased pricing of eBooks?  While eBooks provide the opportunity for sound and video, many subjects do not need sound and video for effective presentation, or the sound and video could be presented as a separate program on your computer.  Medmaster has done this for a number of its titles, with CDs that accompany the print books, the print books for the long stretches of reading, and the CD programs for additional interactivity.

Medical study often involves a great deal of text highlighting and page turning.  While you can do this with both eBooks and print books, the process seems slower with eBooks than with print books.  Is this enough of a problem to lead students to still prefer print books?

Another issue is the distraction that can occur when reading from an eReader.  Do all the links to other areas, to YouTube, apps, games, the Web, music, and news  steal time from the reading and study of the medical book, which should be the main object of focus?

What is your opinion?  If you have used eBooks, do you find that you prefer them to print books?  Would you use both?  Please send your opinion.  Your feedback is important.

Rapid Learning

Learning Through Case Problems

Stephen Goldberg
"Continue the antibiotic ..... and remember to drink lots of toilet water."

Previous postings on this blog pointed to a number of different memory methods useful for rapid learning in medical school:

•  Understanding

•  Visualization

•  Ridiculous Associations

•  Substitute Words and Pictures

•  Ditties

•  The Linking Method

•  The Peg Method

•  The Memory Palace

•  Chunking

•  Acronyms

•  Hands-On

Of course, once you use one or more of these methods it helps to review the information.  For certain subjects it also helps considerably to invest extra time to practice cases that put the information together into a clinically coherent whole.

For instance, in neuroanatomy, after learning particular structures in anatomy, it is important to practice clinical cases where you can combine this information to determine where in the nervous system a patient’s problem lies.

The subject of acid-base, fluids, and electrolytes contains a bewildering array of facts that have to be organized and put together in order to apply to a case.  What is the diagnosis?  What is the treatment?  Which fluid bottles should you hang up?  Case examples help consolidate this information for application to a patient.

In cardiology, it is not enough to just read a chapter on EKGs.  The real learning comes on practicing the interpretation of EKGs with many examples.

In psychiatry, clinical cases help to fine-tune what medications and dosages to use for the individual psychiatric disorders.

In some medical curricula, students in the first two years of medical school do divide into groups that discuss individual case problems.  This approach can be helpful for the particular case situation, but there is a drawback when a case takes up too much time in the group.  There are so many case situations that have to be mastered, and spending too much time on just a bare few can be an inefficient use of time.

Try to use textbooks that include case problems in those subjects in which it is important to bring diverse facts together to diagnose and treat patients.  Case problems alone, however, are insufficient to learn a subject.  You also need a background in the subject  before approaching the clinical problems.

MedMaster has a number of books that include case problems for those areas mentioned above:

Clinical Neuroanatomy Made Ridiculously Simple
Acid-Base, Fluids, and Electrolytes Made Ridiculously Simple
Clinical Cardiology Made Ridiculously Simple
Clinical Psychopharmacology Made Ridiculously Simple

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Which do you prefer – eBooks or print books?  MedMaster is considering converting a number of its titles to eBooks and is interested in your opinion as to the usefulness to medical students of eBooks, compared with print books.

Rapid Learning

How Reliable Is Your Medical Information?

Stephen Goldberg
Perhaps oxygen wasn't such a good idea!

When working in the hospital and medical office during the clinical years,  it is common to receive pearls of wisdom from interns, residents, and attendings.  How reliable is this information?  And how reliable is the information we receive from lectures, journal articles, books, and drug reps?

A lot of information is  passed around, and since some of it is wrong, it is important to rely on the best sources available.  In the 1980’s, some of the best minds in medicine made a disastrous mistake.  It was known that significant cardiac arrhythmias were correlated with death.  A search was undertaken for drugs that would reduce such deaths.  But rather than using reduction of deaths as an end point in the drug studies, it was easier to adopt a “surrogate” endpoint, namely whether the drug reduced arrhythmias.  If a drug reduced arrhythmias, it presumably would also reduce deaths.  It was not adequately considered that the drugs might have unexpected harmful side effects that would in fact worsen the problem and contribute to death.  Antiarrhythmics became widely prescribed, even for non-life threatening arrhythmias, leading to many unnecessary deaths (which initially were felt to be due to the heart disease, rather than the drugs), until studies were properly done to assess whether the drugs actually saved lives.  They didn’t; they killed thousands of people.

There is so little time to read and evaluate the medical literature, particularly the Materials and Methods sections of research articles, and there is an unfortunate tendency to rely on the word of physicians above us in the hierarchy, or on drug reps, or on research reports (particularly those funded by drug manufacturers) that may have biased and erroneous conclusions.  It is necessary to know how to read and evaluate a research article.  This requires some knowledge of biostatistics.  For further information, see Ann Weaver’s brief and intuitive book, Clinical Biostatistics Made Ridiculously Simple, which focuses on the pitfalls of clinical research reports and how to evaluate them.

It is also important to use reliable medical search engines on the Internet, since the Internet contains lots of unreliable information. Such search engines are described on the MedMaster search engine page.

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Do you prefer  eBooks or print books?  And why?  Feel free to comment.

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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Which do you prefer, eBooks or print books? And why? Your opinion counts!

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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Which do you prefer, eBooks or print Books?