Rapid Learning

Learning Speeds In Medical School

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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Which do you prefer, eBooks or print books?

Rapid Learning

Studying In The Clinical Years

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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Which do you prefer – eBooks or print books?

Stress

The Lowly Medical Student

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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Do you have an interesting experience to relate?  Email us at mmbks@aol.com.  We may publish it in a future blog.

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How do you feel about using eBooks vs Print books?

Stress

Fatigue In Medical Education

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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Do you have an interesting story to relate? Email us at mmbks@aol.com.  We may publish it in a future blog.

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How do you feel about using eBooks versus Print books?

Stress

Stress and Anxiety

"...and if the medication causes any headaches or hallucinations, please call me."

(by guest author John Preston, Psy.D)

Common symptoms of stress include:

  • Trembling; feeling shaky
  • Muscle tension
  • Nervousness; edginess
  • Sweating; cold hands and feet
  • Initial insomnia (difficulty falling asleep)

Symptoms associated with moderate to severe anxiety:

  • Shortness of breath
  • Tachycardia
  • Diarrhea ; frequent urination
  • Panicky feelings; fears of losing control

Symptoms associated with specific anxiety disorders:

  • Extremely intense, rapidly escalating anxiety generally lasting for 1-10 minutes (Panic disorder)
  • Recurring, significant worries about: maintaining order in ones environment (accompanied by checking behavior; e.g. checking and rechecking if doors are locked, oven is turned off, etc.); unrealistic fears of dirt, contamination  (accompanied by rituals, e.g. hand washing) (obsessive-compulsive disorder)
  • Recurring nightmares, intrusive memories, anxiety attacks, and times feeling numb (Post-traumatic stress disorder)

Note: these three anxiety disorders have very small rates of spontaneous remission. Without professional treatment they can last for years.

Symptoms that can significantly interfere with functioning at school or work

  • Impaired concentration and attention
  • Inability to maintain focus
  • Memory problems
  • Very low frustration tolerance
  • Irritability

The five symptoms listed above can severely interfere with functioning, and failure to succeed academically or occupationally can, in itself, become another source of increased anxiety.

Stress symptoms are often brought about by exposure to either very significant life events (e.g. the death of a loved one; being reprimanded or fired from a job).  But also such symptoms often arise not from specific, highly stressful experiences, but from the accumulation of many lower-level stressors (e.g. when people take on too much).

There are four factors that are at the root of many stress symptoms:

  • Loss of perspective which often leads to a perceived loss of control
  • Lack of adaptive outlets for reacting to the stressors
  • Sleep deprivation
  • The use/overuse of caffeine and/or alcohol, both of which can contribute significantly to stress symptoms.

These are causes, but also each point the way to effective stress management.

Stress management: First it is worth noting that when people are experiencing severe stress reactions it is very common for friends or loved ones to offer useless advice, such as “You just need to relax;” “Don’t take things so seriously;” “You are too sensitive.”  You better believe it, everyone who is experiencing severe stress has already done everything they can to turn the volume on stress symptoms. To have someone offer one of these platitudes never helps and often results in the person feeling misunderstood or angry.

Techniques that work: Continue reading “Stress and Anxiety”

Stress

Depression: Often Obvious, Sometimes Hidden

"And how long have you been, in my opinion, evil?"

(by guest author John Preston, Psy.D)

A number of factors can contribute to depression. There are the usual suspects, e.g. loss of a loved one (due to death, separation, or divorce), assaults to one’s self-esteem (e.g. being fired, demoted, failing an exam, or being rejected in a romantic relationship), developing a serious illness. Additionally, a number of situations that contribute to depression  are commonly encountered among those in medical school, internship, or residency:

  • Prolonged exposure to significantly stressful situations.
  • The perception of powerlessness. For example, the belief that “no matter what I do, I still cannot stay on top of things.” Chronically feeling overwhelmed.
  • A lack of self-confidence. Developing doubts about one’s self.
  • Sleep deprivation: This is a very common but often overlooked cause of depression. This can be due to the choice to regularly sleep less (e.g. spending long hours into the night studying or being on call).  Also, a loss of restorative (slow wave) sleep can be caused by the overuse of caffeine or other stimulants and by chronic anxiety.  Prolonged stress or anxiety disorders result in high levels of stress hormones such as cortisol and norepinephrine.  These hormones significantly reduce the time spent in slow wave sleep. Stress often results in difficulty falling asleep (initial insomnia) and, in addition, the loss of restorative sleep. The daytime exhaustion that results is often combated with increased caffeine use.  Caffeine also interferes with the ability to enter slow wave sleep.
  • In attempting to overcome initial insomnia, people often turn to the use of alcohol and benzodiazepines, most of which also interfere with restorative sleep.  Fatigue and chronic loss of slow wave sleep contribute to cognitive problems (especially the ability to maintain attention and concentration).

Stress may lead to impaired sleep, daytime fatigue, excessive caffeine, alcohol or tranquilizers use, and symptoms of depression. Continue reading “Depression: Often Obvious, Sometimes Hidden”

eBooks vs Print Books

eBooks Versus Print Books: Pros and Cons

“It’s the most complete book for the Medical Boards. Unfortunately, no one can carry it out of the store.”

In addition to classical print books, there now is the growing option of reading eBooks, whether on reading devices (e.g. Kindle, iPad, Nook, Android), on the Internet (e.g. Google Books), or as downloads from the Internet to your computer.

As I see it, the pros and cons of eBooks versus print books in medical education are:

Pros:
•  eBooks avoid the space limitations of print books.  In small living quarters, it is space-saving to have books in electronic form.

•  It is easier to carry books in electronic format than heavy print books.

•  eBooks are generally less expensive than print books.

•  Ebooks have the potential for interactivity, including searching and hyperlinking to other sources of information, as well as audio and video enhancements.

•  Ebooks can be updated more frequently than print books.

Cons:
•  While there are provisions in some eBook reading devices and applications to underline, take notes, bookmark, and jump to different areas of the book, some people may find it less awkward to do this in an actual print book.

•  If books are read via the Internet, the ability to read would depend on whether or not there is an Internet connection at the time.  This problem does not exist in a printed book or when reading eBooks that are already downloaded to a reading device or eReader application on one’s computer.

•  Hand-held pocket sized devices may be convenient to carry around, but their small screens make them impractical for certain kinds of books, particularly those that have many illustrations and charts.

•  Many medical texts are in color.  This would render it impractical to read them on a device that uses electronic ink, such a black and white Kindle.

•  It can be fatiguing reading a screen for extended periods.

•  If the eReader device only allows reading one book at a time, this may be problematical for those who want to study from more than one book simultaneously.

When I was a medical student, the saying was that the highest grade would go to the student who could write the fastest, in view of the need to write down the lecture notes.  Today, students can take classroom notes on a computer.  A standard computer keyboard allows more rapid typing than on other devices, such as an iPad or hand-held device.  While one can purchase a wireless keyboard to type on an iPad, this is an extra device to carry around.

What is your preference – eBook or print book?  Do the needs of medical students differ from those of other readers?  What is your opinion about the future use of eBooks versus print books in medical education?

Rapid Learning

Memory Techniques for Med School #11 Hands-On

Centipede referral for hands-on approach

HANDS-ON
Despite the value of the 10 memory methods discussed in the preceding posts, perhaps the best teacher of all is the hands-on interaction with the patient. There is great truth to the patient being the best teacher. While we struggle with difficult hours and clinical situations on the wards and clinics during medical school, internship, and residency, it helps to bear in mind that the experience will be very valuable.  There arises a solid core of judgment and knowledge, ingrained in memory, from the experience of interacting with patients.

Which memory and learning techniques do you find most valuable in your medical studies?
What do you think of eBooks versus print books?

Rapid Learning

Memory Techniques for Med School #10 Acronyms

Placebos feel out of place in party with other kinds of pills

ACRONYMS
With acronyms, the first letters of the items in a list are put together to form a word.  For instance, the acronym SCALP is used to remember the layers of the scalp:

S = Skin
C = Connective tissue
A = Aponeurotic layer
L = Loose connective tissue
P = Pericranium

Related to the word-type acronym is one in which you remember a sentence in which the first letter of each word corresponds to an item on the list.  For instance, to remember the carpal bones:

Some Lovers Try Positions That They Cannot Handle”

S = Scaphoid
L = Lunate
T = Triquetrum
P = Pisiform
T = Trapezium
T = Trapezoid
C = Capitate
H = Hamate

These are effective mnemonics, since the letters all are nouns and refer to specific anatomical structures in the region.  There is little else that the letters could refer to.

It is difficult to find good acronymns, however.  In many, the letters are not necessarily nouns, and they could refer to so many things that they are hardly worth the effort to memorize, except perhaps for an exam the next day.  They are quickly forgotten.

You can find many lists of acronyms by googling “medical mnemonics.”

Which memory and learning techniques do you find most valuable in your medical studies?
What do you think of eBooks versus print books?

Rapid Learning

Memory Techniques for Med School #9 Chunking

Difficult directions — one of the major causes of poor patient compliance

CHUNKING
In chunking, you try to break up a large list of items into smaller chunks, each of which can be easier to memorize than the whole.  A classic example is the phone number, which, rather than a list of 10 successive digits, is broken up into a 3-digit area code, then a 3-digit number followed by a 4-digit number.

In medicine this can be done with lists of words or with pictures. For words, say you want to memorize a large list of antibiotics.  They are easier to learn by first grouping them into categories (antibacterial, antifungal, antiviral, antiparasitic).  Antibacterials can be  further reduced to the subchunks of penicillin family, anti-ribosomal, anti-tb and leprosy, and miscellaneous, etc.  If you can create subgroups of items in a large list (also aided by placing them in charts for cross-reference comparison), it becomes easier to keep them in mind.

Chunking can also be done with complex pictures.  For instance, the metabolic pathways in biochemistry form a large and complex map of associations.  Breaking them down into visual chunks eases the learning process:

Expanding on the chunks
Further chunk expansion (from Clinical Biochemistry Made Ridiculously Simple, MedMaster)

Which memory and learning techniques do you find most valuable in your medical studies?

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What do you think of eBooks versus print books?

Rapid Learning

Memory Techniques for Med School #8 Memory Palace

Surgical team and patient with "Hi, I'm...." social name stickers
Adding the human touch to the operating room

THE MEMORY PALACE
The Memory Palace (also called the method of loci, or mental walk)  is a terrific memory method that was used as far back as ancient Rome, but has been largely underused since the invention of  printed books.  Neuropsychologist A.R. Luria, in his book “The Mind of  a Mnemonist,” describes an amazing patient he followed for many years, who never forgot anything.  The patient used the Memory Palace method, which is also praised highly by Joshua Foer, who won the U.S. memory championship and describes the method in his best-selling book “Moonwalking with Einstein.”

In the Memory Palace you simply visualize a walk through a place that you know well.  For instance, it may be your home, in which you first encounter a large tree outside, then the front door, then the foyer, then the den on the right, then the kitchen, the bathroom, the bedroom, etc., in succession.  You know this sequential list well, simply by the familiarity that you have with your home.

You use this walking list of places to associate each stop along the walk with an item on the list you wish to memorize.

In the case of the 7 cancer signs:

1.  A change in bowel or bladder habits
2.  A sore that does not heal
3.  Unusual bleeding or discharge from any place
4.  A lump in the breast or other parts of the body
5.  Chronic indigestion or difficulty in swallowing
6.  Obvious changes in a wart or mole
7.  Persistent coughing or hoarseness

You might associate a cancerous tree, shaped like a “7,” that had a bowel and bladder exploding from its trunk.  Continuing the walk:

The fecal matter would land on the door, causing a large sore on the door.

The sore would erode through the door, causing a massive pool of blood and discharge in the foyer.

The den on the right would be filled to the ceiling with lumps.

etc.

The advantage of the Memory Palace over the Link and Peg methods is that you can have numerous memory palaces.  There then is no problem of confusing one item in a list with the same item in another list (such as a list of drug effects or symptoms of a disease).  Just use a different memory palace. Trained mnemonists use hundreds of Memory Palaces.  Moreover, you don’t have to memorize the number/letter combinations of the Peg method.  You already have ready made pegs through the places you have visited and know well.

Which memory and learning techniques do you find most valuable in your medical studies?
What do you think of eBooks versus print books?