Before I start my first clinical rotation, I thought that it would be helpful for me to articulate my goals for the next month.
My first goal is to give very good to excellent patient presentations. What this means to me is providing my supervisors with >95% of the information they're looking for in an organized and concise manner. My second goal is to start to suggest reasonable management plans. What this means to me is that the plans I suggest are medically appropriate and that my attending may modify them or add to them slightly. My overall goal is to improve my clinical skills and learn as much as I can during my Adult Outpatient rotation.
Sunday, April 24, 2011
ICC 7001: The Physician's Oath
ICC week was capped off by a ceremony honoring residents who were nominated by medical students for their exceptional humanism in the manner in which they practice medicine. Just like honoring rising fourth-year medical students during the White Coat ceremony, this is another example of leading by example: this ceremony was meant in part to show me what kind of doctor I should strive to be.
At the end of the ceremony, as per tradition, we all recited the Physician's Oath:
At the end of the ceremony, as per tradition, we all recited the Physician's Oath:
I swear to fulfill, to the best of my ability and judgment, this covenant:
I will educate my fellow humans so they may avoid illness, and whenever possible, I will prevent disease in the recognition that prevention is far better than cure.
I will counsel my patients to the best of my ability, and apprise them of all medical and social options, my own personal biases aside.
The health of my patient will be my first consideration, and I will apply for the benefit of the sick, all measure that are required.
I will recognize the privilege and art of medicine, maintaining that warmth, sympathy, and understanding may outweigh medicine's scientific interventions.
I will practice my profession with conscience and dignity, and I will maintain the honor and the noble traditions of the medical profession.
I will uphold and promote ethical conduct with my profession.
I will respect the sanctity of the patient-physician relationship, keeping those confidences entrusted to me.
I will recognize my limitations, and I will not hesitate to call upon my colleagues when the skills of another are needed.
I will give to my teachers the respect and gratitude that is their due, and I will help teach my colleagues and future generations of physicians.
I will be dedicated to medicine and my community. I will be true to myself, my family, and those close to me. I will celebrate this gift of life, as I help others.
-- Anonymous
ICC 7001: What is ICC?
So, what is ICC, anyways? I've been telling everyone who asks me that it is essentially an orientation week for rising third-year medical students about to start their very first clinical rotations. That's partly true.
Now that I have gone through my first ICC, I can affirmatively tell you what it is. ICC stands for Integrated Clinician's Course. Similar to the Foundations of Doctoring course that is spread out across all four years of medical school, ICC is spread out over the last two clinical years. Quoting from the packet of information given to us at the beginning of the week, ICC has two specific goals:
We've had some informational lectures about the clinical years; we've had some educational lectures on topics such as the history of health care in the United States (literally from colonial times to the current health care debate), coping with death and dying, end-of-life planning, and the legal obligations of medicine.
We completed another basic cardiac life support (BCLS) training session, which was notable for changing the alphabet from ABC to CAB. The new CPR guidelines say to prioritize chest compressions and worry about airway and breathing second. We also completed intubation and IV workshops, which were both helpful even though I've done them before.
I'll talk about some of the more memorable sessions in other posts.
Now that I have gone through my first ICC, I can affirmatively tell you what it is. ICC stands for Integrated Clinician's Course. Similar to the Foundations of Doctoring course that is spread out across all four years of medical school, ICC is spread out over the last two clinical years. Quoting from the packet of information given to us at the beginning of the week, ICC has two specific goals:
The first is to provide important skills and knowledge in areas that are vital to the practice of medicine, but often difficult to teach in the clinical care setting. These topics include health policy, ethics, clinical decision-making, and cultural competency, as well as clinically relevant basic science material and advanced clinical skills, particularly those that span multiple disciplines. The second but no less important goal is to provide time and opportunity to rhttp://www.blogger.com/img/blank.gifeflect on and discuss the process of becoming a physician.
We've had some informational lectures about the clinical years; we've had some educational lectures on topics such as the history of health care in the United States (literally from colonial times to the current health care debate), coping with death and dying, end-of-life planning, and the legal obligations of medicine.
We completed another basic cardiac life support (BCLS) training session, which was notable for changing the alphabet from ABC to CAB. The new CPR guidelines say to prioritize chest compressions and worry about airway and breathing second. We also completed intubation and IV workshops, which were both helpful even though I've done them before.
I'll talk about some of the more memorable sessions in other posts.
Asking for help from a resident
I saw a patient in the Emergency Department last night (while working with my Foundations of Doctoring preceptor Dr. Browne) who hit his head while falling due to a witnessed tonic-clonic seizure.
It came out in the interview that he has been homeless for 2 months, has been abusing alcohol and marijuana for the same amount of time, and had been sober from both for 5 years before that. In addition to hitting his head, he was complaining of left shoulder pain, right wrist pain, and right knee pain such that he couldn't bear any weight on that leg. His past medical history was also significant for a very serious car accident a few years ago that required surgery on his left eye and left leg.
On physical exam, I didn't notice any head lacerations or bruising (around the eyes or behind the ears) that would have indicated a more serious problem. I noticed that his left eyelid was drooping noticeably (ptosis). Both pupils reacted appropriately when I shone a light in his eyes, but I couldn't reliably compare the size of one pupil to the other. I could passively move his left arm only slightly before causing him pain; he could turn his head to the left and right against resistance, but he couldn't shrug his left shoulder.
During the course of the interview and physical exam, I noticed that my patient became less responsive to my questions. He could hardly keep his eyes open, but he was also not confused, and he was able to follow commands. I became very concerned when he asked me if it was alright if he went to sleep. "Try to keep your eyes open," I said, and after thinking about it for a moment, I decided to go get help.
I interrupted two residents who were talking about another patient and very succinctly described my patient and concerns. They rushed into my patient's room, talked with him briefly, and decided to order a head CT.
The CT came back negative, and the toxicology screen came back positive. The bump on his head wasn't serious; he just needed to sober up. The drooping left eyelid was most likely caused by the car accident a few years ago.
After the excitement was over, I asked my resident if he thought it was appropriate that I asked for his help in this situation. "Absolutely, you did the right thing," he said. The patient didn't smell like alcohol, so in the absence of the toxicology screen we had no way to know what was causing his neurological changes. It's better to err on the side of safety, he said, than to let something important slip by us unheeded.
What I've heard many times over is that the good third-year medical student is a strong advocate for his or her patients and will be appropriately aggressive in that advocacy when it's necessary. It was difficult to interrupt those residents, but I felt that it was necessary to ask their opinion in this case. It was also pretty neat to see how my input directly impacted this patient's care.
I expect that third year will hold many more situations similar to this one.
It came out in the interview that he has been homeless for 2 months, has been abusing alcohol and marijuana for the same amount of time, and had been sober from both for 5 years before that. In addition to hitting his head, he was complaining of left shoulder pain, right wrist pain, and right knee pain such that he couldn't bear any weight on that leg. His past medical history was also significant for a very serious car accident a few years ago that required surgery on his left eye and left leg.
On physical exam, I didn't notice any head lacerations or bruising (around the eyes or behind the ears) that would have indicated a more serious problem. I noticed that his left eyelid was drooping noticeably (ptosis). Both pupils reacted appropriately when I shone a light in his eyes, but I couldn't reliably compare the size of one pupil to the other. I could passively move his left arm only slightly before causing him pain; he could turn his head to the left and right against resistance, but he couldn't shrug his left shoulder.
During the course of the interview and physical exam, I noticed that my patient became less responsive to my questions. He could hardly keep his eyes open, but he was also not confused, and he was able to follow commands. I became very concerned when he asked me if it was alright if he went to sleep. "Try to keep your eyes open," I said, and after thinking about it for a moment, I decided to go get help.
I interrupted two residents who were talking about another patient and very succinctly described my patient and concerns. They rushed into my patient's room, talked with him briefly, and decided to order a head CT.
The CT came back negative, and the toxicology screen came back positive. The bump on his head wasn't serious; he just needed to sober up. The drooping left eyelid was most likely caused by the car accident a few years ago.
After the excitement was over, I asked my resident if he thought it was appropriate that I asked for his help in this situation. "Absolutely, you did the right thing," he said. The patient didn't smell like alcohol, so in the absence of the toxicology screen we had no way to know what was causing his neurological changes. It's better to err on the side of safety, he said, than to let something important slip by us unheeded.
What I've heard many times over is that the good third-year medical student is a strong advocate for his or her patients and will be appropriately aggressive in that advocacy when it's necessary. It was difficult to interrupt those residents, but I felt that it was necessary to ask their opinion in this case. It was also pretty neat to see how my input directly impacted this patient's care.
I expect that third year will hold many more situations similar to this one.
Saturday, April 23, 2011
Step 1: Bottom line
With this long description and many posts of how I studied for the USMLE Step 1, here's my bottom line advice for students who might have a similar style of studying to my own:
* Use First Aid as an outline for Step 1 studying throughout the first two years, starting as early in the curriculum as makes sense to you.
* Don't rely on First Aid as a stand-alone reference.
* Read as much of Robbins & Cotran's Pathologic Basis of Disease as you can during your course work, then refer back to it frequently to study specific diseases or answer specific questions during the dedicated study period.
* Use BRS Physiology when you start studying organ systems (for the University of Colorado curriculum, at the beginning of CVPR).
* Buy either a USMLE Rx or Kaplan question bank early (for the University of Colorado curriculum, at the beginning of CVPR), and use it to help you study for the current course.
* Also use your USMLE Rx or Kaplan question bank that you bought early to complete 5-10 questions per day. Research those questions that you get wrong, and be sure to read the explanations even for questions that you got right. Try doing these questions timed starting in Year 2 Semester 1 and drawn from all subjects starting in Year 2 Semester 2.
* Use your Summer vacation to review the course material from the previous year, but also be sure to relax and have fun.
* Don't study over Year 1 Winter break.
* Use your Year 2 Winter break to start targeted studying, but also be sure to relax and have some fun.
* For subjects that require rote memorization (Microbiology, Pharmacology), experiment with different ways of learning until you find what's best for you. Try making comprehensive tables or making your own flash cards. When you're in the middle of your dedicated study period, you will be glad for any study tool that you created during the first two years.
* Use First Aid as an outline for Step 1 studying throughout the first two years, starting as early in the curriculum as makes sense to you.
* Don't rely on First Aid as a stand-alone reference.
* Read as much of Robbins & Cotran's Pathologic Basis of Disease as you can during your course work, then refer back to it frequently to study specific diseases or answer specific questions during the dedicated study period.
* Use BRS Physiology when you start studying organ systems (for the University of Colorado curriculum, at the beginning of CVPR).
* Buy either a USMLE Rx or Kaplan question bank early (for the University of Colorado curriculum, at the beginning of CVPR), and use it to help you study for the current course.
* Also use your USMLE Rx or Kaplan question bank that you bought early to complete 5-10 questions per day. Research those questions that you get wrong, and be sure to read the explanations even for questions that you got right. Try doing these questions timed starting in Year 2 Semester 1 and drawn from all subjects starting in Year 2 Semester 2.
* Use your Summer vacation to review the course material from the previous year, but also be sure to relax and have fun.
* Don't study over Year 1 Winter break.
* Use your Year 2 Winter break to start targeted studying, but also be sure to relax and have some fun.
* For subjects that require rote memorization (Microbiology, Pharmacology), experiment with different ways of learning until you find what's best for you. Try making comprehensive tables or making your own flash cards. When you're in the middle of your dedicated study period, you will be glad for any study tool that you created during the first two years.
Wednesday, April 20, 2011
Step 1: Practice tests
The National Board of Medical Examiners (NBME) offers seven practice tests, two of which provide "enhanced feedback." At the end of all seven practice tests, you get an estimated score and a list of your performance in various categories as depicted by bars stretching over a range from below average to borderline to above average. These practice tests are all four hours long (four sets of 46 questions) as opposed to 8 hours long for the real McCoy (seven sets of 46 questions, plus 45 minutes of break).
Looking back, I question whether the extended feedback was worth the extra $10 per test. That $10 basically bought me the privilege of accessing all of the questions that I got wrong. However, they don't give you the correct answer or any explanations! This resulted in me spending much more time reviewing the two self-assessments that offer extended feedback than I spent reviewing a comparable number of typical USMLE Rx question sets. I found this annoying and am still not sure what reasons the NBME could have for not providing the correct answer.
I completed 5 out of the 7 NBME self-assessments, which I think is reasonable for a dedicated study period that is 29 days long.
In addition to these NBME self-assessments, USMLE World offers two practice tests that you can buy on top of the question bank. I completed both of those practice tests near the end of my dedicated study period, and they have the distinct advantage of providing both the correct answer and a detailed explanation of why that answer is correct and all the other choices are wrong. These practice exams also spit out a predicted score using what I assume to be a similar algorithm for calculating the score that NBME uses. I found these questions to be very reasonable and highly recommend using them.
If I could do it over again, I think I would complete one of the USMLE World practice exams at the beginning of my dedicated study period and the other practice exam near the end. The truly extended feedback at the beginning would help guide my studies for the rest of the study period while the truly extended feedback at the end would help me identify any gaps in my studying and fill them quickly before the Big Day.
Looking back, I question whether the extended feedback was worth the extra $10 per test. That $10 basically bought me the privilege of accessing all of the questions that I got wrong. However, they don't give you the correct answer or any explanations! This resulted in me spending much more time reviewing the two self-assessments that offer extended feedback than I spent reviewing a comparable number of typical USMLE Rx question sets. I found this annoying and am still not sure what reasons the NBME could have for not providing the correct answer.
I completed 5 out of the 7 NBME self-assessments, which I think is reasonable for a dedicated study period that is 29 days long.
In addition to these NBME self-assessments, USMLE World offers two practice tests that you can buy on top of the question bank. I completed both of those practice tests near the end of my dedicated study period, and they have the distinct advantage of providing both the correct answer and a detailed explanation of why that answer is correct and all the other choices are wrong. These practice exams also spit out a predicted score using what I assume to be a similar algorithm for calculating the score that NBME uses. I found these questions to be very reasonable and highly recommend using them.
If I could do it over again, I think I would complete one of the USMLE World practice exams at the beginning of my dedicated study period and the other practice exam near the end. The truly extended feedback at the beginning would help guide my studies for the rest of the study period while the truly extended feedback at the end would help me identify any gaps in my studying and fill them quickly before the Big Day.
Step 1: Question banks
Every medical student who has taken the USMLE Step 1 exam has most likely signed up for a question bank to practice doing USMLE-style questions. There are many question banks out there, but the main ones are:
1. USMLE World (2000+ questions)
2. USMLE Rx (3000+ questions)
3. Kaplan (2000+ questions)
I think that there's a general consensus that USMLE World is the best question bank of the three because its questions are drawn from a pool of "retired" questions from old USMLE exams and are therefore closest to the real thing. USMLE Rx has the advantage of being linked to First Aid such that the explanations for each question references relevant page numbers and even includes snap shots of relevant pages. Kaplan is generally regarded as being slightly more difficult than the actual exam, with the drawback being you might get frustrated or discouraged with Kaplan, especially early on in your studying.
I used both USMLE World and USMLE Rx but not Kaplan, so I will only discuss those two question banks.
I bought a year subscription to USMLE World near the end of Year 1 Semester 2 during the Renal block. I used USMLE World to study for all of my remaining courses by doing practice questions focused on a given topic. This usually happened during the day or two leading up to an exam. I found that this approach worked very well by helping me to think along the lines of what types of questions could be asked. Plus, I felt like I was being doubly productive by also studying for Step 1.
I worked on the USMLE World question bank over Summer break and Year 1 Winter break, mostly doing questions after studying a particular topic. You have the option of doing questions timed or untimed and setting how many questions are in each practice set. Over the Summer, I did all of my questions untimed with no more than 20 questions in each practice set. I spent a lot of time researching each question that I got wrong and some more time reading through the explanation for each question that I got right.
For most subjects, I also created question sets of all questions in that particular topic that I got wrong (this was only during Summer break and Year 2 Winter break). In that way, I re-did questions over and over again until I got all questions right within that topic. Looking back, I'm not sure exactly how useful that was to me. It certainly helped to drill some information into my head, but the reality is that there are some questions that are simply bad. I think my time could have been better spent doing more research into those questions that I got wrong.
When Year 2 Semester 1 began, I decided to ratchet it up by also doing 5-10 timed questions per day, still limited to the subject matter at hand. I was inconsistent in doing this and wish that I had actually stuck to that plan. When Year 2 Semester 2 began, I ratcheted it up again by doing 5-10 questions per day that were both timed and completely random (i.e. drawn from all subjects). I was more consistent doing those during Semester 2 than I was during Semester 1, and I'm glad for it.
I finished going through all 2000+ questions in USMLE World by the middle of Year 2 Semester 2, having gone through a substantial number of those questions multiple times.
I bought a month-long subscription to USMLE Rx at the beginning of my dedicated study period and used it almost exclusively for completing timed sets of 48 questions drawn from all subject areas. This graph summarizes how many practice questions I did per day during my dedicated study period:
I completed 52 sets at 48 questions each for a total of 2496 questions from USMLE Rx.
During the dedicated study period, I also went back to USMLE World occasionally when I wanted to do some subject-specific questions.
If I could do it over again, I would:
1) Buy a year subscription of USMLE Rx instead of USMLE World, then use USMLE World during the dedicated study period.
2) Buy USMLE Rx at the beginning of Cardiovascular block instead of during the Renal block.
3) Be more consistent about completing 5-10 practice questions per day during Year 2.
1. USMLE World (2000+ questions)
2. USMLE Rx (3000+ questions)
3. Kaplan (2000+ questions)
I think that there's a general consensus that USMLE World is the best question bank of the three because its questions are drawn from a pool of "retired" questions from old USMLE exams and are therefore closest to the real thing. USMLE Rx has the advantage of being linked to First Aid such that the explanations for each question references relevant page numbers and even includes snap shots of relevant pages. Kaplan is generally regarded as being slightly more difficult than the actual exam, with the drawback being you might get frustrated or discouraged with Kaplan, especially early on in your studying.
I used both USMLE World and USMLE Rx but not Kaplan, so I will only discuss those two question banks.
I bought a year subscription to USMLE World near the end of Year 1 Semester 2 during the Renal block. I used USMLE World to study for all of my remaining courses by doing practice questions focused on a given topic. This usually happened during the day or two leading up to an exam. I found that this approach worked very well by helping me to think along the lines of what types of questions could be asked. Plus, I felt like I was being doubly productive by also studying for Step 1.
I worked on the USMLE World question bank over Summer break and Year 1 Winter break, mostly doing questions after studying a particular topic. You have the option of doing questions timed or untimed and setting how many questions are in each practice set. Over the Summer, I did all of my questions untimed with no more than 20 questions in each practice set. I spent a lot of time researching each question that I got wrong and some more time reading through the explanation for each question that I got right.
For most subjects, I also created question sets of all questions in that particular topic that I got wrong (this was only during Summer break and Year 2 Winter break). In that way, I re-did questions over and over again until I got all questions right within that topic. Looking back, I'm not sure exactly how useful that was to me. It certainly helped to drill some information into my head, but the reality is that there are some questions that are simply bad. I think my time could have been better spent doing more research into those questions that I got wrong.
When Year 2 Semester 1 began, I decided to ratchet it up by also doing 5-10 timed questions per day, still limited to the subject matter at hand. I was inconsistent in doing this and wish that I had actually stuck to that plan. When Year 2 Semester 2 began, I ratcheted it up again by doing 5-10 questions per day that were both timed and completely random (i.e. drawn from all subjects). I was more consistent doing those during Semester 2 than I was during Semester 1, and I'm glad for it.
I finished going through all 2000+ questions in USMLE World by the middle of Year 2 Semester 2, having gone through a substantial number of those questions multiple times.
I bought a month-long subscription to USMLE Rx at the beginning of my dedicated study period and used it almost exclusively for completing timed sets of 48 questions drawn from all subject areas. This graph summarizes how many practice questions I did per day during my dedicated study period:
I completed 52 sets at 48 questions each for a total of 2496 questions from USMLE Rx.
During the dedicated study period, I also went back to USMLE World occasionally when I wanted to do some subject-specific questions.
If I could do it over again, I would:
1) Buy a year subscription of USMLE Rx instead of USMLE World, then use USMLE World during the dedicated study period.
2) Buy USMLE Rx at the beginning of Cardiovascular block instead of during the Renal block.
3) Be more consistent about completing 5-10 practice questions per day during Year 2.
Step 1: Studying pharmacology
I was probably most at a loss as to how to study for pharmacology than for any other subject. Even while going through the curriculum during the first two years, I had difficulty with the rote memorization that pharmacology demands. Because of this, I tried a lot of different approaches in order to figure out how to best study pharmacology for the USMLE Step 1.
It wasn't until the middle of Year 2 Semester 1 that I figured out the best way for me to learn pharmacology was a combination of making tables and flashcards. I have a table for antibiotics, antivirals, antifungals, antiarrhythmics, antineoplastics, diabetes medications, etc... The tables were (of course) made in Excel and provided the overall organizational at-a-glance picture of the pharmacology for a given field or disease. I really wish that I had started making these tables during CVPR. The act of making them was a means to learning, but then I also had this great resource for quick reference or for re-learning the material while studying for boards.
I caught on a little earlier to making and using flashcards for learning pharmacology. Like making tables of drugs, the act of making flashcards also helped me learn the material; then, I also had the flashcards as a resource for memorization. I made my flashcards in a program called Anki, which uses an algorithm that purports to maximize learning by spacing out the intervals at which cards repeat based on how difficult you rate it. Cards "mature" as you see them more often. A card that you repeatedly rate as "Easy" or "Very easy" may be presented next in a few months or longer. In that way, "mature" cards don't take away from learning other cards that are more difficult.
I started making Anki decks for pharmacology during CVPR and liked it enough to continue during Neuro and DEMS. By the time my dedicated study period rolled around, I already had a lot of great resources for studying pharmacology - all of which I had created myself. I consolidated all of my pharmacology tables into one Excel document with many tabs. I also consolidated all of my pharmacology-related Anki decks into a single deck with each card categorized with labels. That way I could easily quiz myself on, for example, only anti-epileptic drugs.
With these two consolidated resources in place, I then built upon them during my dedicated study period. I did this mainly through practice questions. Whenever I came across a pharmacology question, there was almost always at least one drug in that question that I didn't know. The obscure drugs were usually one of the answer choices. But I would look up the drug and make a flashcard for it.
I made two types of cards. The first type of card was standardized to look something like this:
The second type of pharmacology card I made was directed questions about very important facts. For example:
I bought a set of PharmCards and used them regularly over Summer break, but they didn't really work as well for me because they were too difficult to organize. I ended up giving them away to a friend of mine after they say unused for an entire semester.
I also bought Katzung & Trevor's Pharmacology Examination and Board Review and studied lightly from it over Year 2 Winter break. I became frustrated with it because it seemed that the questions at the end of each chapter did not really draw directly from the material presented in that chapter. I also wasn't a fan of the organization of the text. During the dedicated study period, I did return to this book for helping me to answer some specific pharmacology questions. I also used it to help me study anti-epilepsy and anti-neoplastic drugs, both categories that take a little extra effort to nail down.
Overall, I think that the pharmacology tables and the Anki flashcards together helped to drastically improve my performance on pharmacology questions. I make this claim by comparing my percent-correct performance in pharmacology questions on practice sets early in the dedicated study period compared to late in the dedicated study period.
Click here for the pharmacology Anki deck that I created.
It wasn't until the middle of Year 2 Semester 1 that I figured out the best way for me to learn pharmacology was a combination of making tables and flashcards. I have a table for antibiotics, antivirals, antifungals, antiarrhythmics, antineoplastics, diabetes medications, etc... The tables were (of course) made in Excel and provided the overall organizational at-a-glance picture of the pharmacology for a given field or disease. I really wish that I had started making these tables during CVPR. The act of making them was a means to learning, but then I also had this great resource for quick reference or for re-learning the material while studying for boards.
I caught on a little earlier to making and using flashcards for learning pharmacology. Like making tables of drugs, the act of making flashcards also helped me learn the material; then, I also had the flashcards as a resource for memorization. I made my flashcards in a program called Anki, which uses an algorithm that purports to maximize learning by spacing out the intervals at which cards repeat based on how difficult you rate it. Cards "mature" as you see them more often. A card that you repeatedly rate as "Easy" or "Very easy" may be presented next in a few months or longer. In that way, "mature" cards don't take away from learning other cards that are more difficult.
I started making Anki decks for pharmacology during CVPR and liked it enough to continue during Neuro and DEMS. By the time my dedicated study period rolled around, I already had a lot of great resources for studying pharmacology - all of which I had created myself. I consolidated all of my pharmacology tables into one Excel document with many tabs. I also consolidated all of my pharmacology-related Anki decks into a single deck with each card categorized with labels. That way I could easily quiz myself on, for example, only anti-epileptic drugs.
With these two consolidated resources in place, I then built upon them during my dedicated study period. I did this mainly through practice questions. Whenever I came across a pharmacology question, there was almost always at least one drug in that question that I didn't know. The obscure drugs were usually one of the answer choices. But I would look up the drug and make a flashcard for it.
I made two types of cards. The first type of card was standardized to look something like this:
Drug X:The reason for this standardization was to avoid memorizing a particular card and to instead encourage actually learning the material. It would have been too easy for me to start remembering the idiosyncrasies of various cards if they weren't standardized.
1. Mechanism of action
2. Clinical uses
3. Toxicities
The second type of pharmacology card I made was directed questions about very important facts. For example:
What drug has been shown to reduce mortality in patients with congestive heart failure?The answer, of course, is spironolactone. I made a card like this anytime an important fact like that came up in my studies, most often from practice questions. A lot of these cards were idiosyncratic toxicities of particular drugs.
I bought a set of PharmCards and used them regularly over Summer break, but they didn't really work as well for me because they were too difficult to organize. I ended up giving them away to a friend of mine after they say unused for an entire semester.
I also bought Katzung & Trevor's Pharmacology Examination and Board Review and studied lightly from it over Year 2 Winter break. I became frustrated with it because it seemed that the questions at the end of each chapter did not really draw directly from the material presented in that chapter. I also wasn't a fan of the organization of the text. During the dedicated study period, I did return to this book for helping me to answer some specific pharmacology questions. I also used it to help me study anti-epilepsy and anti-neoplastic drugs, both categories that take a little extra effort to nail down.
Overall, I think that the pharmacology tables and the Anki flashcards together helped to drastically improve my performance on pharmacology questions. I make this claim by comparing my percent-correct performance in pharmacology questions on practice sets early in the dedicated study period compared to late in the dedicated study period.
Click here for the pharmacology Anki deck that I created.
Tuesday, April 19, 2011
Step 1: First Aid
I bought First Aid for the USMLE Step 1 (2010) toward the end of the first semester of my first year, but I didn't open it and start studying from it until the middle of my second semester of my first year. This is a common story and a common mistake.
There's a lot of hype about First Aid, and for good reason. Back when I first started freaking about Step 1 (the vast majority of medical students do at one point or another), First Aid was to me like an anchor: something tangible and finite. I thought that all I had to do was learn everything in First Aid and I'd be fine. I'm sure many other medical students have felt the same way. In reality, First Aid is only a convenient outline of what must be studied to do well on the Step 1 and to be prepared for clerkships. That's why for me it became so important to study from First Aid as I worked through my classes: I came to view my coursework as one big Step 1 prep course.
I wish I had started using First Aid during my Blood and Lymph (Hematology/Oncology) and Disease and Defense (Immunology) courses at the beginning of second-semester-first-year, but I only began studying seriously from First Aid starting with the cardiovascular block. This consisted of taking notes in it during lecture and constantly using it as a reference as I moved through my courses. I read the relevant sections in First Aid before their corresponding lectures, which definitely helped in terms of repetition.
I did this for the pulmonary and renal blocks, too. During Summer vacation after my first year, I re-read the cardiovascular, pulmonary, and renal chapters and also went through the other chapters that we had already covered: hematology/oncology, immunology, biochemistry, behavioral sciences, psychiatry. I also read through the neurology chapter in preparation for that block in the Fall.
I similarly pre-read the gastrointestinal, endocrine, reproductive, microbiology, etc... chapters before the start of their respective courses. When I say "read," I really mean "read" and not "memorize." I just got a general feel for the nature of the material I would be learning, the general structure of how it would be presented, and when I came across something that looked interesting, I looked it up to learn more about it.
So, by the end of my second year, I had read through First Aid once all the way through, having read some chapters more than once. I think this is a reasonable goal for most medical students preparing for Step 1.
Some people like to un-bind the book, 3-hole-punch it, and stick it in a binder. I was resistant to that idea, mostly because I like to hold a book in my hands and flip easily back and forth from one page to another. The advantage to hole-punching First Aid, though, is that you can mix in useful diagrams or tables from lecture notes or other resources that complement First Aid or better summarize the material. I finally did this in the middle of Year 2 Semester 1 for less than $10 at Kinko's and wish that I had done it earlier.
By the time the dedicated study period rolled around, I was really only using First Aid as a guide for studying a given subject in greater detail. For example, when I first started reviewing embryology, I first flipped through that chapter in First Aid. I had already made a bunch of highlights and underlined what I thought to be important information and made notes in the margin, so this went fairly quickly. Then, as I was reading through a more detailed text or reference (in this case, Langman’s Medical Embryology), I would refer back to First Aid only when necessary.
Bottom line: Overall, First Aid is as necessary for studying for the USMLE Step 1 as everyone says, but its limitations should be recognized, and it should be used for studying while going through the basic science curriculum.
There's a lot of hype about First Aid, and for good reason. Back when I first started freaking about Step 1 (the vast majority of medical students do at one point or another), First Aid was to me like an anchor: something tangible and finite. I thought that all I had to do was learn everything in First Aid and I'd be fine. I'm sure many other medical students have felt the same way. In reality, First Aid is only a convenient outline of what must be studied to do well on the Step 1 and to be prepared for clerkships. That's why for me it became so important to study from First Aid as I worked through my classes: I came to view my coursework as one big Step 1 prep course.
I wish I had started using First Aid during my Blood and Lymph (Hematology/Oncology) and Disease and Defense (Immunology) courses at the beginning of second-semester-first-year, but I only began studying seriously from First Aid starting with the cardiovascular block. This consisted of taking notes in it during lecture and constantly using it as a reference as I moved through my courses. I read the relevant sections in First Aid before their corresponding lectures, which definitely helped in terms of repetition.
I did this for the pulmonary and renal blocks, too. During Summer vacation after my first year, I re-read the cardiovascular, pulmonary, and renal chapters and also went through the other chapters that we had already covered: hematology/oncology, immunology, biochemistry, behavioral sciences, psychiatry. I also read through the neurology chapter in preparation for that block in the Fall.
I similarly pre-read the gastrointestinal, endocrine, reproductive, microbiology, etc... chapters before the start of their respective courses. When I say "read," I really mean "read" and not "memorize." I just got a general feel for the nature of the material I would be learning, the general structure of how it would be presented, and when I came across something that looked interesting, I looked it up to learn more about it.
So, by the end of my second year, I had read through First Aid once all the way through, having read some chapters more than once. I think this is a reasonable goal for most medical students preparing for Step 1.
Some people like to un-bind the book, 3-hole-punch it, and stick it in a binder. I was resistant to that idea, mostly because I like to hold a book in my hands and flip easily back and forth from one page to another. The advantage to hole-punching First Aid, though, is that you can mix in useful diagrams or tables from lecture notes or other resources that complement First Aid or better summarize the material. I finally did this in the middle of Year 2 Semester 1 for less than $10 at Kinko's and wish that I had done it earlier.
By the time the dedicated study period rolled around, I was really only using First Aid as a guide for studying a given subject in greater detail. For example, when I first started reviewing embryology, I first flipped through that chapter in First Aid. I had already made a bunch of highlights and underlined what I thought to be important information and made notes in the margin, so this went fairly quickly. Then, as I was reading through a more detailed text or reference (in this case, Langman’s Medical Embryology), I would refer back to First Aid only when necessary.
Bottom line: Overall, First Aid is as necessary for studying for the USMLE Step 1 as everyone says, but its limitations should be recognized, and it should be used for studying while going through the basic science curriculum.
Thursday, April 14, 2011
Step 1: Daily routine during the dedicated study period
Last year, as the class above me was slaving away during their dedicated study period for the USMLE Step 1, I wondered about their day-in-day-out routine. Sometimes I saw them in the library or at Chiptole, but these rare sightings only offered proof that they were in fact still alive. So, I thought it might be useful for medical students who have yet to jump the Step 1 hurdle for me to briefly describe my daily routine during the dedicated study period.
I woke up every morning at 6:15 because that is the time I would be waking up to take the real test on April 11th. More often than not, I did some flash cards right after waking up or while making breakfast, just to wake up my mind. After breakfast, I usually did a set or two of 48 practice questions. Each set of practice questions takes 1 hour to complete, and I usually spent about the same amount of time reviewing them. So, if I did two sets of practice questions, that already took me to the afternoon.
I spent the afternoon focusing on a particular topic. That usually involved First Aid together with multiple other texts. For example, I relied heavily on Robbins and Cotran's Pathologic Basis of Disease and on BRS Physiology for pathology and physiology, respectively, while studying each organ system. I would continue studying that particular area until late afternoon or early evening before taking another short break.
Sometimes, particularly more toward the end of my study period, I would then do a third set of practice questions and review them in the evening. Then I would have dinner (which was usually take-out), go home and relax for a bit, then do some more flashcards at night before bed.
My daily routine obviously had a certain degree of variability.
First, my routine evolved as I figured out what worked best for me and what didn't, and as my needs changed. I was doing more subject-specific studying and fewer practice questions toward the beginning of the study period compared to the end, necessarily so.
Second, life does go on even when you're studying for the USMLE Step 1. I signed up for a 5k on March 20th, smack in the middle of my study period, and I also ran a half-marathon a week later. This kept me running almost every day, except during that last week before the exam. As difficult as it was for me to set aside time to run, I can't overstate how necessary running was to maintain my sanity. It helped to have family and friends keep me honest about my running. I usually fit my runs in after my morning practice questions or in the evening before dinner.
Third, I took the weekends a little easier, which for me meant only studying 8 hours or so instead of 12. This was also very helpful in keeping me sane, and I'm very glad that the MD/PhD student who took the exam a few years ago, and gave a talk on studying for the Step 1, impressed upon me the necessity of scheduling time off specifically to relax.
I woke up every morning at 6:15 because that is the time I would be waking up to take the real test on April 11th. More often than not, I did some flash cards right after waking up or while making breakfast, just to wake up my mind. After breakfast, I usually did a set or two of 48 practice questions. Each set of practice questions takes 1 hour to complete, and I usually spent about the same amount of time reviewing them. So, if I did two sets of practice questions, that already took me to the afternoon.
I spent the afternoon focusing on a particular topic. That usually involved First Aid together with multiple other texts. For example, I relied heavily on Robbins and Cotran's Pathologic Basis of Disease and on BRS Physiology for pathology and physiology, respectively, while studying each organ system. I would continue studying that particular area until late afternoon or early evening before taking another short break.
Sometimes, particularly more toward the end of my study period, I would then do a third set of practice questions and review them in the evening. Then I would have dinner (which was usually take-out), go home and relax for a bit, then do some more flashcards at night before bed.
My daily routine obviously had a certain degree of variability.
First, my routine evolved as I figured out what worked best for me and what didn't, and as my needs changed. I was doing more subject-specific studying and fewer practice questions toward the beginning of the study period compared to the end, necessarily so.
Second, life does go on even when you're studying for the USMLE Step 1. I signed up for a 5k on March 20th, smack in the middle of my study period, and I also ran a half-marathon a week later. This kept me running almost every day, except during that last week before the exam. As difficult as it was for me to set aside time to run, I can't overstate how necessary running was to maintain my sanity. It helped to have family and friends keep me honest about my running. I usually fit my runs in after my morning practice questions or in the evening before dinner.
Third, I took the weekends a little easier, which for me meant only studying 8 hours or so instead of 12. This was also very helpful in keeping me sane, and I'm very glad that the MD/PhD student who took the exam a few years ago, and gave a talk on studying for the Step 1, impressed upon me the necessity of scheduling time off specifically to relax.
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