USMLE

Study For The USMLE

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

Medical student forums extensively discuss study for the USMLE exams.  While this is important, because you need to pass the exam, there is a problem with spending a lot of time on rote memorization of numerous facts, since it steals time from understanding the subjects.

Understanding is key to practicing medicine; it enables the physician to provide better individualized patient care than relying on rote cookbook facts.  Understanding also facilitates memory and retention.  For those of you who have taken large subjects such as Biochemistry or Physiology, have you at the end acquired a broad understanding of the fields, or are you left with isolated points that never quite gelled into a coherent whole?

There is a better approach to medical education than rote memorization of an impossible number of facts.  The medical school curriculum should instead insure that the student gains an overall picture and understanding of each subject, rather than cramming in an overbearing number of facts that will later be forgotten, even by the best physicians. These days, it is relatively easy to find isolated points on the Internet and elsewhere.  It is not as necessary to remember everything; computers do a better job at that.   The USMLE should also focus on understanding, but students are still required to memorize tons of information.

Over the past 32 years, Medmaster has tried to assist medical education by focusing on understanding, rather than rote memorization, through brief, clinically relevant books.

Since one has to study for the USMLE, it is important to maximize the efficiency of study, so that a great deal of material can be reviewed and retained in a short time. Andreas Carl has written Medmaster books for the USMLE Step 1, USMLE Step 2, USMLE Step 3, and NCLEX-RN exams using a unique approach.  Rather than just presenting isolated and unrelated points, he has made extensive use of charts that compare one point with related ones; this saves study time.  For instance, the chart below compares the most common causes of infection.  Apart from having few words, the chart quickly allows the comparison of one disease with another.  All his books do the same.   His supplementary USMLE and NCLEX-RN Question Banks (available as free downloads from the Medmaster website), make review quicker by combining a number of questions into one, so that 4 or  5 facts can be covered in the time that it ordinarily would take to cover one.

Rapid Learning

How To Study Biochemistry

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?

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How To Study Neuroanatomy

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!

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How To Study Anatomy

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.

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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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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?

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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?

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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?

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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?