Overabundance

After a long and philosophical monologue about turning us into "independent learners," I asked a faculty mentor if "brought to you by YouTube and Wikipedia" would be printed on the bottom of my diploma. He just laughed. I did, too, in order to hide my frustration. Physicians are required to have an absurd number of continuing education hours each year. Believe me, I appreciate that independent learning is a part of my future. What I'm not such a fan of is paying tuition, attending lecture, and then feeling clueless over what to expect from the exams. (Yeah, yeah, yeah: there is more to life than the exams, but when you fail an exam, you kind of don't care about all that other stuff.)

Medical school is radically different from anything else I've ever done. As an undergraduate, I attended lectures regularly and took meticulous notes. I was accustomed to looking at the chapter headings, skimming through the material, and reading the summary at the end. Sometimes I'd even read the chapter and do the practice problems. It wasn't easy, but it also wasn't that hard to master the material. That's not where I am any more. It's almost as though some maniacal mastermind saw me speed-walking on a treadmill and thought that I should pick it up a notch to (oh, I don't know) a sprint. It isn't an issue of what I need to learn that is hanging me up, as much as it is the sheer volume of it all. It's a lot. Fast.

So when you are overloaded with gobs of information to process in a short amount of time, you know what you really don't need more of? Resources. Really. You might think that you need more resources, or that if you found the right resource, you'd manage your time like a champ. The problem is, in medical school, they will be flying at you from so many directions. No doubt--having excellent study materials is vital; having a virtually endless number of sources to draw from is overwhelming. Oh, but wait. Isn't an "independent learner" someone who relishes spending hours hunched over her laptop Googling "galactose-1-phosphate uridyltransferase" and reviewing as many resources as it takes until she has a complete understanding of how this autosomal recessive enzyme deficiency is manifest as failure to thrive in newborns?

Seeing as I don't have an innate knowledge of galactose-1-phosphate uridyltransferase deficiency, and considering that it is only one of the hundreds of enzymes I will need to know by the time I take my step exam in 12 months (oh, wow! I hadn't even realized I was counting), I'd like a little more direction than "you should Google it."

In med school, there is simply no way to cover in lecture everything that you need to know for the board exams. I don't think it is even humanly possible to know all of the material I will be tested on by the time I become a fully licensed physician. My take on it: if I do my best to swim in this sea of knowledge, I ought to get at least a little bit wet. There isn't time for me to sit on a rock and study a solitary starfish.

And this is when I appreciate (and curse) the overabundance of resources with which I have been blessed. It's actually a nauseating number of resources, really. Wading through all of it to figure out what works for me is a real time-suck. Maybe you are starting your first year, and you just happened to chance upon my blog, at a time when you were just wondering if you'd ever run out of study material, and that got you feeling a little anxious. Well, you are in luck, my friend! I'm here to let you now that you won't run out of study aids and your anxiety is legit. Maybe, just maybe, my experience might be instructive. Or maybe it will simply distract you from that 40 minute YouTube video you were about to watch on galactose-1-phosphate uridyltransferase deficiency.

First, a Confession and Disclaimer. I know that the capstone of the first two years of medical school is the USMLE Step 1 exam. I've heard about it. (Duh.) I knew that that was the biggy. Schools use their Step 1 scores as a way of saying, "We are the best!" I've heard the advice to study for Step with each class you are in. Now, you've heard it too. Hearing and doing aren't necessarily the same thing.

Anatomy. No getting around this, I really did learn more from YouTube than attending lecture or reading the textbook. Sad, but true. Of course, spending 20-40 hours each week in the cadaver lab certainly helped. I bought an old edition of Moore's Clinical Anatomy. I earnestly attempted to do all of the reading...for the first week and a half of class. The textbook might be essential for understanding the clinical correlates, but YouTube videos tie them together more concisely. And there are so many clinical correlations that this class bears little resemblance to the undergraduate anatomy I took five years ago. Naming all those parts? That's "first-order," my friend, and it's time to be thinking "second-order." It's not adequate to know the blood supply to the head. Instead, you should appreciate how a pimple in the "danger zone" can lead to a brain infection. Thanks, YouTube!

Of course, you can't do second-order problem solving without having a good grasp of what you are looking at. Acland's Video Atlas of Anatomy is a fabulous resource! It is like being in anatomy lab, without the smell, and with everything labeled. Acland's can be a little creepy to watch. A friend told me that he was sitting in a coffeeshop reviewing the videos and heard a lady behind him gasp. He wasn't trying to be shocking; he was just wrapped up in the insanity of being an oblivious med student. He appreciated the situation and switched over to YouTube. Again, there are always way more resources than there are hours in the day, so you can change from one to another without wondering if you are leaving something out. (Which, of course, you are.) There really isn't one or two key sources for great videos on YouTube. Dr. Preddy's anatomy mnemonics were fantastic for the upper limb and the neck. Peter J Ward/Clinical Anatomy Explained has excellent material on embryology. I also like material posted by TheAnatomyRoom.

Studying for Step 1? No. Simply trying to keep afloat. Good thing that Step is only 5% anatomy questions.

Biochemisty. Memorize the enzyme deficiencies that result in disease! Wish someone had told me that. I was caught up in memorizing as many pathways as possible and really missed the boat on this one. I thought the class would be similar to what I had as an undergraduate, and it really wasn't. It followed the same topics, but the focus was on clinical derangements. It seems like a real "duh" for me to say that, but it wasn't what I was expecting based on the lecture material.

I purchased Rapid Review Biochemistry and used it a little. I (foolishly) thought it was too disease-focused for the test. It was exactly the level of focus I should have had. It will be a dear friend as I prepare for Step 1.

Cell Biology. Biochem was a rude awakening in how I prioritized the material to master. Clinical correlates! Yes, there was plenty of good, old fashioned memorizing of what goes from where when. Only now it seemed slightly more obvious that I should remember the synaptonemal complex that occurs during the diplotene stage of prophase I during meiosis I since that is when oocyte development is arrested in the five-month old fetus until ovulation. Duh! That is clinically relevant. There is a ton of pure memorization in medical school. It's way more than I will ever be capable of processing. I'm breathing a little easier now that I have a better idea of where to focus. I also switched from taking notes on my computer (annotating the PDF electronically) to printing up six slides per sheet and actually writing out notes the old fashioned way. Marked up papers were surprisingly faster for me to flip through and review.

Histology. Our professors really rocked this one! The lectures and handouts were surprisingly comprehensive. When I came across a concept that was unfamiliar, Wikipedia and the class text generally sufficed to fill in the gaps. Connecting clinical correlates to what I saw on the slides was easier for me to memorize than simply seeing words on a page. Shotgun Histology on YouTube is very good, and pretty quick. Attending histology lab and discussing slides with my classmates was probably the best way for me to learn the material. This was the first time I began really reviewing lectures asking myself what three questions would a professor ask. Of course, sometimes the answer would be "something from this table of 20 items." You'd be amazed at how memorizing that table meant that I was really narrowing things down.

Even with excellent material from the professors, there is so much to learn that it is easy to fall behind. At the end of histology, I made a pact with a friend. Daily review of lectures together or the one who backs out has to buy lunch.

Physiology. Costanzo's Physiology is written with greater clarity than most and is only 500 pages. This is slightly more manageable to conquer in the 8-week block than the other recommended texts (which I kind of abandoned anyway). The daily review with classmates made a difference in getting the knowledge to sink in. I started using Picmonic to aid in the absurd amount of memorization. Review questions on Firecracker was frankly overwhelming...too many to get through on a daily basis, though worthwhile if you can fit it in. (Friendly reminder, single mom with six school-aged kids. It's a bit hard to fit things in.) PreTest review questions are an excellent way to identify weaknesses.

My end of block self exam (aka, NBME) subscores reflected my performance on the five systems exams I took during the block. We are given one day of study time between our last system (endocrinology) and the comprehensive exam. It simply wasn't enough time to review. I had intended to relearn the subjects I had done poorly in throughout the block by reviewing on the weekend, but with exams every 10 to 14 days, "free" time was hard to find. Gastroenterology was my strongest area followed by pulmonology. YouTube videos of Dr. West teaching the concepts in his book is the way to learn pulmonology. Abandon Constanzo and focus on West.

I finally started annotating my copy of First Aid, though I anticipate using my annotated Costanzo a year from now when I prep for Step. Step 1 became real in January. I think the sooner if feels real to you, the better you will be studying for it.

Microbiology.  This is when I finally got smart. My focus went from preparing for the class exams and focusing on Step 1. Professors inevitably give detailed questions that are unique to their lecture material, but Step 1 study means that I'm spending my time learning the most high-yield, testable concepts. Picmonic is very helpful for drilling in the unique properties of microbes. Of course, the volume I needed to learn for in-class exams exceeded the content they offer. That's OK; at least I know that I am focusing on the ones that I am most likely to encounter on the board exams.

MicroCards! These "flashcards"--which really aren't flashcards--cover just about anything you need to know about microbiology for Step 1. I just purchased First Aid for the Basic Sciences. Um, yeah, I should have gotten that earlier, though, honestly, when I was told to get a dozen books for each class that lasts 6-10 weeks, I just knew there was no way on earth that I could get though all of that. I've returned to Firecracker, but still hate it when it tells me to do 112 questions today. Hate it might not be the right term. It's more like I resent it. Bossy, know-it-all, over-achiever telling me that I need to spend 2 hours cuddled up with it. The board exam for this material will be given with the immunology exam at the beginning of June.

Immunology. Think I finally figured this out. We just started this content a few days ago. I need multiple and varied exposure to get this stuff in my head and so I watched a series of videos at double speed as a preview. Tonight I will do the same thing with a different series to give myself more familiarity so that the concepts in class don't sound so foreign. I have been doing PreTest questions as my final review before the exam. I plan on doing them earlier this time in an effort to identify key words as I delve into the material.

Less than a month until I am officially done with my first year. Can't believe I've made it this far.

Random Confessions of an Optimist

There is so much that is ugly in this world, which is exactly why I believe in finding the beauty. Sometimes that takes no work at all. I look up and find myself lost in the colors of the sunset. Sometimes finding the beauty requires a little discovery. "Discover," in my book, means "hey, that wasn't exactly obvious, was it, but look what you got now!"

I've been told that people who are optimists have their heads stuck in the sand. I've also heard guys (why does this seem more male than female?) proclaim, "I'm a realist," as though being connected to reality makes their dour outlook on the world more legitimate.

I'm a realist, too, and I really believe in being optimistic. I believe in dreaming because I know people who have given up on their dreams. I hope for the best because there is nothing more desperate than an individual who is hopeless. I trust in the goodness of others because I know how imprisoning it feels to living with mistrust.

My first year of medical school will come to a close in one month. Focusing on the good of this experience is what has gotten me through.