Are Digital Notes better than Pen and Paper?

Officially done medical school!

And if studying for the LMCC last week taught me anything, it’s the importance if having a learning system in place. I’m now doing my big academic purge in preparation for residency. I almost feel guilty for throwing out so much stuff.

There are binders and binders full of notes. Anatomy diagrams that I once knew, important tables and flowcharts. The only reason I feel at ease for destroying these notes is that I have a digital copy of them.

Why Do We Take Notes?

It’s important to understand why we take notes and what is their purpose. When we learn something new, the first step is information capture. To insure that all important ideas, thoughts and facts are captured there needs to be a ubiquitous and consistent system.

Taking notes is a basic form of information capture. It can be transcribing a professor’s lecture or jotting down some points on an index card.

After all the data is gathered, it has to be processed through reflection and creation. We write our own notes in a way that makes sense to us. Through spaced repetition we remember the key concepts, synthesize knowledge and apply it.

Advantages and Disadvantages of Electronic Notes

Having been in school my whole life, I’m surprisingly a late-adopter to electronic notes. But since medical school, I have been using a hybrid approach of paper and electronic notes. Moving forward towards  residency, I believe a digital system is the best way to go.

How to Learn in Medical School

If I had to start medical school over again, I would strive to create a more organized knowledge database from the start. I would focus less on regurgitating lectures notes and more on understand how key concepts relate to each other. Using this method, I probably would have done worst on my tests but my knowledge would have been more solidified. Understanding the material you learn is the key to long term knowledge.

Most medical schools use a lecture based format with problem based learning interspersed during pre-clinical years. What I did was print off the lecture slides and studied off of them almost exclusively, memorizing all the fine details.

What I should have done was to summarize each lecture into just the key points (about 1 page). I should have then stored these notes in a comprehensive electronic system where I could easily retrieve them later. So that during clerkship, I wouldn’t dread having to go through old binders of notes to refresh my knowledge, but would have an accessible and personalized database to go through.

It’s through this repetition and rethinking of the same topics that finally lead to true knowledge. For example, I thought I understood the basics of heart failure the first time I learned about the anatomy and pathophysiology of the heart. I gained a new appreciation for this topic when I began seeing patients with heart failure. But it wasn’t until I combined the knowledge I had gained from the basic sciences with the clinical picture that I really understood it.

Potential Tools for a Digital Age

It doesn’t matter what tools you use as long as you use them consistently.

Your system could be as simple as properly labeled folders for each subject. Every time you learn about a new topic or read a journal article, you file away that knowledge in the right folder. I recommend using Dropbox (read my review) to make this simple system even more powerful, as your files can be accessible anywhere with an internet connection.

The system I used during medical school was to use Toronto Notes as a basic foundation. I would read up on specific topics and jot down additional information in the margins of TO notes. I would also try to incorporate class notes, clinical pearls and primary literature whenever possible. Clearly, it won’t be sufficient in residency.

At the start of third year, I started using Microsoft’s OneNote to keep track of all the pieces of information that didn’t quite fit in with TO notes. An alternative free option is EverNote. I made a notebook for each major specialty and found it a simple way of having all my notes in one place. I also found it useful because I could add new info to old topics. Using this method, I was able to keep track of stuff learned in teaching and bedside rounds. For residency, I plan to make condensed notes from a primary textbook that I can add on to my “knowledge database”.

Other tools I use include Mendeley which I use to keep track of journal articles I have read. What’s awesome about it is that it’s accessible anywhere. I can read a paper at the hospital, bookmark it or save it using just the browser, and have it accessible on my computer at home.

Organizing your browser bookmarks with something like Xmarks is another way to better manage information. Most of my go-to-sources are online now, including UpToDate and eMedicine. Similarly, there are so many good websites of knowledge out there for ECGs, Clinical pictures, and medical calculators that it’s important to keep track of your tools.

Furthermore, there are neat things you can do with electronic notes like make digital flashcards with programs such as Anki. You can even sync these cards to your phone.

There is also some really cool technology like Livescribe (15% off), which is a pen that digitally records everything you write. There’s even a built in voice-recorder.

Conclusion

The way doctors learned medicine thirty years ago is very different from today. Especially now when medical knowledge is expanding so quickly, there will always be too much to know in too little time. It’s time we use new methods and tools to enhance our learning.

In a time when medical information is changing so quickly, it doesn’t make sense anymore to use something as outdated as pen and paper. The dynamic nature of electronic notes plus the fact that it’s syncable and accessible anywhere, makes it the ideal format for learning medicine in the 21st century. With the abundance of portable laptops, tablets, and smart phones, I hope I have convinced you that electronic notes is the best way to go.

What's the best way to study for the LMCC? (Photo:Fanz)

I’m on my final stretch of medical school with only the LMCC exam to write. For those that are unfamiliar with the certification process, when you graduate from medical school in Canada, you are required to write the Medical Council of Canada Qualifying Examination Part I (MCCQE Part I). Part II, which is in an OSCE format, comes later during your PGY2 of residency.

The Challenge

There is only one goal when writing the LMCC and that is to pass the exam. That pass mark is set at 390, and scores range from 50 to 950 (MCC Scoring). How well or poorly you did doesn’t matter as long as you pass.

And for a $900 exam, you want to only write it once.

The MCCQE Outline

How does one study everything they have learned in medical school for one single exam?

The answer is you can’t possible know everything cold (objectives). But the secret is to know how the exam was written and what topics you must cover. You see the exam material tests you on six areas of medicine including

1. Internal Medicine
2. Surgery
3. Pediatrics
4. Obstetrics and Gynecology
5. Psychiatry
6. CLEO (Considerations of the Legal, Ethical and Organizational Aspects of the Practice of Medicine)

Obviously some of these subjects like Internal Medicine are much more extensive than the others. However, the test is weighted equally between all six subjects. Meaning that each of those subjects is worth 1/6 of the exam and they will all have the same number of questions allotted to each.

The LMCC Strategy

Knowing that each part is weighted equally, the only rational way to approach studying for this exam is to study the highest yield subjects first. To maximize your efforts you should spend the most time on sections which cover the least amount of information.

The order you should approach this exam is to study (1) CLEO (2) Psychiatry (3 & 4) Peds & OBSGYN, (5) Surgery and completely ignore (6) Internal Medicine.

And although you may think knowing how to treat a heart attack or read an ECG is important – and it is in a clinical setting – you will get much more points studying about occupational hazards and different types of study design.

MCCQE Study Materials

Almost everyone studies exclusively from Toronto Notes, which was originally a study guide for the LMCC! Looking at the Table of Contents, the high yield topics of CLEO consists of 2 chapters, Psych – 1 chapter, Peds 1- chapter, Obsgyn – 2 chapters. Surgery has 9 chapters and Internal Medicine has a whooping 13 chapters, almost as much as the rest combined.

I also had some friends who tried Essentials for the Canadian Medical Licensing Exam and Canada QBank with poor reviews, so I would recommend against them.

Execution

So for the last few weeks, I have been ignoring my chosen field of specialty (Internal) and have been reading exclusively the other five topics. The result has both refreshing and frustrating at times.

It has been good to refresh my memory on a lot of topics I had forgotten. It’s been almost a year and a half since I last did obstetrics, so a quick refresher was nice. I even learned something new about health care and public health in Canada. But it’s also been frustrating because the topics that I intrinsically am interested in – Cardio, Pulm, Nephro, Rheum, etc – are also the ones that are the lowest yield.

In a way, the LMCC will not prepare me at all for a residency in Internal Medicine.

But I think I’ve resigned myself to that fact. Afterall one of the perks of being in Internal is little to no off service rotations for the next few years. Now… if there only wasn’t a Part II…

]]> http://www.medaholic.com/lmcc-study-plan/feed/ 1 http://www.medaholic.com/lmcc-study-plan/ http://feedproxy.google.com/~r/Medaholic/~3/Vg6FynxYnMk/ http://www.medaholic.com/medical-school-admission-biases/#comments Fri, 27 Apr 2012 15:10:18 +0000 medaholic http://www.medaholic.com/?p=2024

Cracking the admissions process (Photo: grandmaitre)

I have been recently reading Thinking Fast and Slow by Daniel Kahnmen, the only psychologist to have ever won the Nobel prize in economics for his work in decision making and behavioral economics. Based on over three decades work on cognitive psychology, Thinking Fast and Slow delves into how our brain thinks, comparing our subconscious intuition and our deliberate cognition.

Apart from being a fantastic read, probably the best book I have read in, it got me thinking about how we select medical students. Long time readers may know that I help out at my medical school’s admission committee with choosing applicants each year. Our school is not unique in its way of selecting from the applicant pool. We use a criteria of GPA, MCAT, Interview Scores, Extracurricular Activities and References to score and rank each applicant.

After reading this book, I am more aware of many flaws in the current system. Specifically, when it comes to the many methods and heuristics that we use in evaluating applicants. Heuristics being problem-solving methods our brain uses to solve complex problems by experience. a mental short-cut if you will.

Evaluating Attributes

One of the cognitive biases that medical school admissions use is attribute substitution. This heuristic occurs when an individual has to make a judgment of a target attribute that is complex. Instead of having to work through the more complicated problem, you substitute a more easily calculated attribute.

Rather than having to evaluate students holistically, medical schools use quick substitutions.  GPA are used as a measure of diligence, the MCAT of raw intelligence and interview scores a test of interpersonal communications. There is little to no evidence that these criteria will select great doctors, but hundreds of medical schools continue to use these criteria. For example, when an applicant who has good grades and a high MCAT score but did poorly on their interviews, they are automatically judged as someone who is a bookworm, even when they make in fact be outgoing and social. More important attributes such as empathy, communications and integrity are left ignored as they are difficult to assess.

Anchoring Biases

Similarly, anchoring is a commonly seen phenomenon. It is a cognitive bias that makes one piece of information weigh more heavily than it should when it comes to decision making. I previously wrote in a post that the best way to increase your chances of medical school is to Not Get Eliminated. I didn’t truly understand at the time why this was true other than by personal experience working on the adcom. After reading Thinking Fast and Slow I can see that the admission committee often gets blinded by anchoring biases.

When the admission committee reviews which applicant to accept, they are more drawn to red flags that then effectively “blinds” them to neglect the rest of the application. If an applicant said an off-hand remark during the interview, they are all of a sudden seen as unprofessional and deemed unfit for a career in medicine. Similarly, a negative sentence in a reference letter might just sink your whole application.  It becomes anchored in the minds of the admission committee and becomes weighted more negatively than it should. Even if the rest of the application is outstanding, “red flags” can create an anchor bias and lead us to make insufficient judgments.

An Imperfect Process

After reading Thinking Fast and Slow and understanding all the different heuristic methods our brains employ, it’s not hard to see the flaws in the current admissions process.

The first point is that it is extremely difficult to predict whether an applicant will be a good physician or not. We are given scant information, some academic numbers and a quick interview before we have to decide whether to accept them or not. There’s not enough concrete evidence to know whether someone will be an innovative leader or whether they will be involved in multiple lawsuits.

Secondly, we employ many cognitive biases that ends up screening out great applicants. Someone who is quieter and shyer may in fact be a great physician one day, but we might score them poorly on the interview because they don’t have as much to say. Every admission committee member has their own biases as to what attributes to look for. Even the discrepancy between different adcom members can affect the application process. There is a lot of variability on how well your application would score based just who reviews your file.

Finally, there’s not a lot of data for the correlation between the criteria to select a medical student to how they will eventually perform as a doctor. We have to realize that we need to have all sorts of doctors from including surgeons, family doctors and even pathologists. And I think it’s naive to believe we know how to best select those will succeed in each field. Especially if all we are trying to do is extrapolate marks and extracurricular activities.

Where to go from here?

The current admissions process is flawed but by no way is it broken. Medical schools still manage to graduate great doctors every year and have no problems filling their classes with amazing applicants.

But in order to improve, I think admission committees have to be more aware of the potential heuristics and biases that we have when we evaluate medical school applicants. Furthermore, there needs to be a stronger push towards a more holistic evaluation of individuals instead of one where each person is evaluated on their numerical scores. And above all we need to make the admissions process as fair and transparent as possible, so that great applicants are not excluded for the wrong reasons and that bad applicants do not end up gaming the system.

If you want a sample of what Thinking Fast and Slow is like, the Nobel prize site has an excellent lecture that summarizes all the main points of the book. I also didn’t realize the influence of Kahneman’s work. It was the basis of many of the books I have read in including How Doctors Think, Blink, Paradox of Choice…

To study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all – William Osler

Medical School – One Last Exam

Fourth year is flying by fast and I’m in the final stretch before my licensing exams. It’s pretty neat to see how much medical knowledge you learn (and forget!) in just four years. While revisiting old notes, I’m surprised as to how much deeper I now understood and appreciate topics after some clinical experience. For example, long term management of diabetes can be quite boring in your first year but after you’ve seen many patients with it, learning becomes more meaningful. Even the weird and wonderful zebras become more fun to read about.

There is however one big regret I have about my learning during medical school.

I wish I had organized my “knowledge” better

Classroom Learning – A Flawed Approach

In the first two years of medical school, you spend a lot of time in the classroom. You listen to a lecturer speak, you go through the ppt slides and you try to summarize all the facts in a way you can understand. You cram all this knowledge in your head and regurgitate it for an exam.

This method works pretty well for passing your courses. It’s not a great approach for mastering clinical knowledge.

Classroom learning can be dangerous for several reasons. One is that your learning becomes centered around what teachers present to you, instead of on what you should and need to know. It’s easy to be complacent and have knowledge spoon fed for you. You start to memorize minutiae and trivia questions because that is often what they put on the test. You stop thinking and asking questions beyond the scope of the course, and instead focus on maximizing your grades. The classroom teaching often narrows the scope of your knowledge.

And the worst part is that the school system encourages this type of learning. You do well for being able to recite all the fine details that was taught in class. You get marks for remembering minutiae. You pass the exam, your marks are good, you feel reassured.

Learning Outside the Classroom

It’s not until your clinical years when you realize that learning from what they only give you can be a blunder. What you have learned in the classroom might not be relevant knowledge. On the wards, there is no longer someone telling you what you need to know to do your job well. You have to determine what knowledge you need to acquire to be a successful medical student.

You might still refer to your class notes initially but you soon begin searching for answers elsewhere. You start to learn from many different resources. When there was a topic I wanted to know more about I would consort more comprehensive textbooks, read journal articles and electronic references such as UpToDate.  I picked up clinical pearls from nurses, residents and staff doctors. I learned through experience and identified gaps in my knowledge that I could address.

My Dilemma – The Consolidation of Knowledge

The problem I face currently is consolidating all this knowledge. It can be quite tricky to put everything you learned into a system that works for you – one which you can translate into clinical knowledge. What I found in my clinical  years was that it was easy to study for each rotation by itself. You choose the right resources and you can focus your attention. The hard part is when you try to consolidate all these separate pieces of information together.

My Previous Solution: During third year, I separated each section of Toronto Notes as a basic study aid during my rotations. I would read around my cases and annotate any additional information in the margins of my notes. This turned out to be a sufficient method in creating a comprehensive guide to each specialty. I read every section of TO notes while marking it up with my own mnemonics and flow charts. I used a different approach to each rotation and it worked pretty well.

The Current Problem: What I face now is creating a consistent learning system that can capture information and turn it into knowledge. I have become adept at passing individual exams but I want to improve my learning to a point where I can be a master clinician.  Going into residency, I will have to start understanding each topic more in depth and be more evidence-based with my knowledge. It will require newer and better ways of learning.

Another issue is I am at a crossroad for is deciding on what medium to learn from. I enjoy studying from paper notes but find it lacks the flexibility of digital notes. I remember I had tried implementing Dr. Brandt’s strategy of index cards and her studying system but found that it wasn’t possible to keep up with the paperwork involved. I have tried digital strategies like OneNote but have found creating notes from scratch a time-consuming process.

An Ideal System

In a perfect world, I would remember everything I read, file it away in the right folder in my brain and have the ability to recall it whenever I wanted.

For those less than super-human, creating a study system is crucial to long-term learning. As I continue my medical training, my learning continues to evolve. What worked for me in the past might not be the best solution for my current studies.

My Goals, Strategies and Tools to Get There

My objectives are to have a deep and long term understanding of medical knowledge that I can apply clinically. I want to further develop a system of life-long learning and skills development. Passing my exams will be a measurement of my progress and not the end in itself.

Strategies I plan to use for residency include

• Reading around patient cases and related topics
• Aiming to learn something everyday – even if it’s on a topic I have gone over a dozen times
• Be inquisitive and come up with relevant clinical questions and find the answers to it
• Creating concise key summary notes that I can refer back to and update

Being more Evidence Based – Some tools I have started using to keep track of medical literature include Mendeley for keeping track of journal articles and Xmarks for organizing webpages. For keeping up to date with new medical literature I subscribe to the CMA’s Infopoems and the ACP Journalwise. I also subscribe to NEJM’s clinical cases and images via RSS.

Doing my Homework, Reading Textbooks – Next year, I’ll eventually purchase one of  “big texts” for internal medicine (deciding between Harrison’s or Cecil’s) and break it up into readable chunks. If I am motivated and lucky, I hope to get through it before my PGY3 year.

Notes, Notes, Notes – Finally, I have yet to determine if my notes will be paper, digital or some type of hybrid.

Experimenting – Just like how medical school was a new challenge, I’m sure residency will have its unique challenges. Being open and adaptable will be an important part on this new journey.

I guess you don’t really think about consolidating and organizing everything you have learned in medical school until a big exam like this forces you to do it. Just as we went from elementary school to high school, university to medical school, residency will require a new higher level of learning.

Would love to hear your opinion on what kind of a learning system you use? How do you collect your information and process it into knowledge? Are there any tools that you use to make learning more effective and efficient?

You may have seen this comic strip on the 12 types of Med students by Michelle Au. There are all sorts of personalities in medicine and they often correlate with a medical specialty too!

Research on Medical Student Personalities

A recent research article titled Associations of Medical Student Personality and Health/Wellness Characteristics With Their Medical School Performance Across the Curriculum got me thinking about personality types and performance in medical school.

The authors did a retrospective study of medical students who had just finished their first clinical year (3rd year). What the results show was that personality traits of conscientiousness, extraversion, and empathy were strong predictors of clinical skills, interpersonal behavior and humanism.

Looking through the literature, there was another study a couple years back that looked at Medical students’ personality characteristics and academic performance: a five-factor model perspective. They similarly concluded that extraversion and agreeableness were important in interpersonal communication in a clinical setting.

Self Reflection on My Own Personality and Performance

These studies and having recently finished reading Success on the Wards got me thinking about my own personality type and its influence on my medical school performance.

Out of the Big Five Personality Traits, I would probably score high in Openness, Conscientiousness, Agreeableness, low in Neuroticism (the lower the better) and Extraversion.  Not surprising, my clinical rotation evaluations often reflected these traits. Many preceptors have commented on my excellent organization, preparedness and empathy. However, many have also encouraged me to participate more in discussions, a shortcoming of my introversion.

How Can Identifying Personality Types Make Better Doctors?

I think identifying and measuring a student’s personality traits can be a powerful tool.

For myself, I know my introversion may be a source of miscommunication. With this knowledge I can make a concerted effort to talk more with other team members despite my introversion. Similarly, you can find role models who have traits you lack and emulate their behaviors.

Another way that personality types can help shape our future doctors is in through our medical school admissions. Currently schools mainly use a number based system (GPA, MCAT) in making their decisions. But clearly the numbers don’t tell the whole story.

In a way, we are using these numerical criteria as an indirect measure of personality traits. Applicants who have high grades tend to exhibit conscientiousness. Applicants who volunteer are probably compassionate and empathetic. Applicants who have leadership positions probably have extraversion and confidence.  If there were a way to measure an applicant’s personality traits directly and objectively, it might even be a better metric than what we use now.

What Makes a Good Doctor?

Ultimately, medical schools want to produce good doctors who will show empathetic care to their patients, inquisitiveness in their research and leadership in their health care teams. To think that looking at a GPA, MCAT score and list of extracurriculars can determine what kind of a doctor an applicant will be is a joke. Unfortunately, it’s very hard to predict what makes a good doctor. I can only hope admissions continue to evolve to a holistic evaluation of an individual.

The new MCAT 2015 is already hoping to address some of these deficits by adding a social and behavioral sciences section. Perhaps there will be a personality assessment in the near future. Who knows what will come next?

Do You Think Personality Types Matter in Medical School Admissions and our Doctors?

What can you do to maximize your medical school chances? (Louish)

Each year, I help review the hundreds of applications we receive at our medical school. Each year, I’m impressed by so many great applicants. It seems like each class just keeps getting better.  So in a pool of hundreds of applicants, many who I have no doubt would make  fine doctors, how do we differentiate each applicant and select a medical class?

Stand out, by NOT standing OUT in the wrong way

Conventional advice is that you should do well in everything. A perfect applicant is someone with a 4.0 GPA, 42T MCAT, tons of research, leadership positions, volunteering opportunities, stellar references and an outstanding interview. On top of all that, you must excel in one thing that makes you unique and memorable.

In reality, I don’t think that’s a realistic goal for most applicants. In fact, only a handful of those “perfect” candidates exist. Instead medical classes are made up of a more diverse group of people. Some medical students have taken time off before applying while others have had alternate careers. Many people have grades that are great but not perfect and MCAT scores that are good enough. They may be play the piano but are not anywhere near a concert pianist.

I think a much better strategy for getting into medical school is to NOT stand out in the wrong way.

You see, when every application is superb and similar, it’s hard to deem one as better than another. It is much easier instead to look for red flags that can help us eliminate an applicant. Finding the right people for medical school is not so much a process of choosing the right applicants as it is a process of elimination.

Your Application is Only as Strong as the Weakest Link

I often get emails from people asking which extracurricular they can do to stand out in the eyes of the adcom. What unique leadership position should they be in to get a better chance for medical school? Would an exceptional research project overcome a poor freshman GPA?

Time and time again, I tell them the same message. Grades matter first, and then your MCAT and finally your extracurriculars / references. If there’s something that’s going to eliminate you first, it’s your GPA and MCAT scores. Without meeting these requirements, the rest of your application doesn’t even get looked at!

Similarly, when we interview students, it’s far easier to spot applicants with red flags than it is to differentiate great applicants. If they seem unethical, unable to speak or have questionable responses, they will be cut. It’s the same with reference letters. Most letters will read the same. When you’re reading through hundreds of them, very few letters will leave a lasting impression. The admission committee is instead trying to screen out students that might be a problem in the future.

It’s about Picking Out the Rotten Apples

When there are twice as many great applicants as there are spots, as a medical school your main concern is to make sure you weed out the bad apples.

Because who’s to say applicant #140 is that much of a better student than #220 who just missed a spot. I’m sure they both could be good doctors. The supply of great applicants far exceeds the number of medical school seats.

Instead, it’s much more important to weed out the psychopaths and sociopaths who will be troublesome down the road. Medical schools aren’t worried about not filling their class with great people, they are worried about letting in people that will cause them headaches in the future.

Don’t Focus on being Perfect, Minimize Your Weaknesses Instead

A more realistic strategy for medical school admissions is to make sure your application does not have a fatal flaw. A bad grade could be what’s keeping you from getting an interview. An unbalanced MCAT score with one low section could be the difference.

Similarly, writing something controversial in your essays or choosing the wrong referee may sink your application.

So stop trying to be perfect with your medical school admissions. Realize that medical schools are looking more for people without any major flaws than the perfect applicant. A person with perfect grades, lots of extracurricular activities and awesome interview skills is still a bad applicant if they have something that doesn’t seem right, especially if they are unethical or lying.

Evaluate your application, is there something that’s holding you back? Let me know in the comments or by email, and I will give you my feedback!

May I have your attention please!

In a world abundant of information and distractions, time is no longer your most precious resource, your attention is.

How we manage our time and attention is something I have put a lot of thought into. As students, we have a finite amount of time for our school work. As a resident, there will be many clinical responsibilities fighting for my attention. There will always be more tasks to do than there is time, so how we manage our attention becomes increasingly important.

Back in December, I made a choice to live a more minimalist life, to cut back on the clutter and distractions, and focus on what matters. More recently, I’ve read a few books that really solidified the point that your attention-management is more important than time-management.

Tim Ferris states in his book The 4-Hour Week – “Time without attention is worthless, so value attention over time.” He goes on to state that “Attention is necessary for not only productivity but appreciation.”

“in an information-rich world, the wealth of information means a dearth of something else: a scarcity of whatever it is that information consumes. What information consumes is rather obvious: it consumes the attention of its recipients. Hence a wealth of information creates a poverty of attention and a need to allocate that attention efficiently among the overabundance of information sources that might consume it.” – Herbert Simon, Nobel Prize in Economics 1978

There are many things in life that are renewable such as money. Resources like time are scarcer though because once you use it, you can never get it back. But there’s something even more limited than time. It’s your attention. Attention is a subset of time, therefore it’s more limited. How you spend your attention is more important than how you spend your time. (source)

If we measure the quantity of our time in minutes, hours and days, undoubtedly the quality of our time is measured in attention.

Without attention, it is hard to focus on the priorities we know we should do. It determines what will appear in our consciousness, how we will process it and what decisions are to be made. Attention gives value to our time – it is a multiplier of each minute we spend. Many students spend hours and hours “studying” but achieve minimal results. Instead, if you approached your studies with full concentration, a hour of focused studying will be worth much more.

“I went to the woods because I wished to live deliberately, to front only the essential facts of life, and see if I could not learn what it had to teach, and not, when I came to die, discover that I had not lived. I did not wish to live what was not life, living is so dear; nor did I wish to practise resignation, unless it was quite necessary. I wanted to live deep and suck out all the marrow of life, to live so sturdily and Spartan-like as to put to rout all that was not life, to cut a broad swath and shave close, to drive life into a corner, and reduce it to its lowest terms.”
― Henry David Thoreau, Walden: Or, Life in the Woods

So now nearing the end of my four years of medical school, I resolve to have more focus in the career ahead of me. With exams coming up, I hope I can have full attention and concentration in acquiring this knowledge, so that come July, I can do what’s best for my patients. It is my aim to live each day deliberately and not be unwise to misspend a minute.

Further Readings

• In Defense of Distraction
• Rapt: Attention and the Focused Life 
• The Attention Economy: Understanding the New Currency of Business 
• The 4-Hour Workweek: Escape 9-5, Live Anywhere, and Join the New Rich
• Find Your Focus Zone: An Effective New Plan to Defeat Distraction and Overload

Success on the Wards – 250 Rules for Clerkship Success (Amazon) is easily the best book I have read on how to succeed in clerkship. It is comprehensive, thorough and jam-packed with valuable information. Dr. Desair and Dr. Katta provide an all encompassing look into what clerkship is really like.

A lot of the 250 rules that Dr. Desai and Dr. Katta discuss may seem like common sense to you: Rule #13 – First, Do No Harm. But hidden away are also finer aspects of clerkship that often are missed: Rule #157 – When presenting the patient, provide an assessment and plan. However, it also not a book without its faults. At times the book can appear disorganized and certain chapters can be overly verbose and repetitive.

While reviewing this book, I appreciated the efforts of the authors to make the book as “evidence-based” as possible, citing primary literature and quoting relevant people. There were some sections that were so important that I thought every clerkship medical student should have read it. Then there were sections I thought could have been omitted altogether. Read on to see why I think this book deserves such mixed reviews.

Breakdown of the Book

The book is starts with an introduction of what clerkship is like and what are the expectations. The next six chapters cover the core rotations and the specific details of each of them. Afterwards, the book goes over clerkship situations such as admitting patients, being on call, oral case presentations, write ups and receiving evaluations.

Sitting at 400 pages long, the book requires multiple readings to get through and at times can seem drawn out. I would even say the book could probably have 100-150 pages omitted if a newer edition ever came out.

Each “Rule” is followed up with an explanation ranging from a few paragraphs to several pages. There are tips interspersed in between the pages and “Did you know…” boxes of facts and tidbits. What this book does not cover is any medical knowledge.

Pros

The best part of the book is it analyzes every aspect of clerkship. Whether it’s taking caring of patients or presenting a topic, Success on the Wards outlines some of the best practices. The latter half of the book is where it shines best. The section on Oral Case Presentations and Evaluations is eye opening experience to how preceptors evaluate students. It teaches you to focus on high yield activities. Rule #115 – Avoid a verbatim reading of the patient’s write-up is a classic mistake many clerks make. Similarly, not having confident answers and not preparing and practicing your presentations are correctable problems.

Furthermore, a lot of the tips (there are about 80 of them) are as valuable as the rules themselves. Tip #63 – Displaying enthusiasm regularly can have a “halo effect” on your work. Team members may tend to view all aspects of your work in a more positive light.

Cons:

Despite all the good things I have to say about this book, there are a number of aspects that make this book less than ideal to read. The first is the book tends to be repetitive. Especially the first seven chapters where they review the different rotations. Most of them repeat what the last chapter said, some sections are copied and pasted from the previous chapter. The fact that the first ten rules are pretty much identical “If you’re considering a career in X specialty, recognize advance planning can strengthen your application” takes away from strength of the book.

Furthermore, the differentiation between tips and rules can be confusing, considering the tips are often times just as valuable as the rules. Combined with the fact that there isn’t a summary list of all the rules, the organization of the book is one aspect that can be improved on.

Considering that the last 100 pages contains over 100 rules, the last half of book is a much better read than the first part. There is also a random section on an approach to hyponatremia that I thought was out of place.

One of the unique aspects of the book is the amount of primary evidence and literature it uses. Each chapter has dozens of references that lend the book credibility. However at times the “evidence-based advice” can be disruptive to the flow and overly wordy.

I believe a lot of the formatting problems arise from how the book was written. Prior to this publication, a lot of the advice given was written for another book and a lot of the new material was written independently of this. When the book was put together, the way things were worded was not always helpful to flow of the book. Perhaps later editions will resolve this issue.

Conclusion

Overall, Success on the Wards is a great resource to have and the information provided will be invaluable to any clerkship medical student. A lot of the rules and tips are common sense but in a book this thick there will bound to be something for everyone. I can easily recommend this book to medical students as a good starting point for preparing for clerkship.

Compared to similar reads like How to be a Truly Excellent Junior Medical Student and First Aid for the Wards, this book is more comprehensive in breadth and depth. The other books also lack the section on getting feedback and evaluations will also help you understand how your clerkship performance is evaluated.

I would recommend this book to any pre-clerkship student who has questions about clerkship and who want to get started with the right step. This book would be best read before clerkship but current clerks and even residents may find it helpful. The only thing is that it can be quite long so buy it early and read through relevant chapters as necessary.

Disclosure

This book review was made possible by md2b who provided medaholic with a copy of the book to review. There are no other financial incentives.

If you are thinking about applying to medical school, then you know the hard work and dedication it takes to fulfill that goal.  Endless hours of studying and lab studies, writing term papers, and succeeding in all areas of your studies are hurdles to overcome to gain acceptance into the medical school.  Everyone knows the importance of MCAT scores and undergraduate GPA, but is that all it is about?  Do you need anything else to get in?

I do think there is an area that is not tapped into by the majority of applicants.  Activities beyond the scope of the classroom are a great way to gain knowledge and hands on experience. These experiences a volunteer gains from their selfless actions is something that cannot be taught in the classroom.  Although some people may choose volunteerism to bolster a resume and to look good on an application, the feelings of satisfaction felt from volunteering are major motivators for participants to continue to volunteer. Below are some topics that, aside from undergrad grades and MCAT scores, give medical students a competitive edge when getting into medical school

Volunteerism

Volunteerism encompasses many areas of life both on campus and off campus. From cleaning up communities, serving meals to the poor, spending time with seniors, to tutoring disadvantaged students there are so many people and organizations in need.  Any type of volunteerism is going to make you a better person and eventually a better doctor. For example, volunteering at a local blood drive can help you familiarize yourself with the blood donation process. As a volunteer, you can calm people down who may be afraid of needles, monitor a donor’s vital signs or even help distribute cookies and juice after the donation. Although you do not have to focus on the medical aspects of volunteering, the experience you will gain in that area will help you in the field. Blood donation services such as, United Bloog Services, help you to see the positive work that is being done to help people in need of blood donations.

Local assisted living facilities, nursing homes and senior care centers are always looking for young volunteers to help out with various activities.  Sometimes the light and enthusiasm that a young person brings to a lonely senior is something that can touch a patient far beyond medicine.  The intimacy of getting to know someone in such a weakened state can give you that human touch and empathy needed to connect future patients.  As a doctor, you will be working with patients that are very diverse. Developing exposure, compassion and communication skills through volunteering is an excellent opportunity to grow in one’s profession.

Charity Work on a Global Scale

There are numerous global organizations that help connect a willing participant with a medical mission of their choice.  Sites like: Missionfinder.org make it easy to see what missions are available.  If you choose a mission based on your interest, you will have more success while there and enjoy the experience.  Having the opportunity to witness firsthand the medical challenges that others in third world countries face is a reality check for many pre-med students, who may not know this pain and suffering exists in the world. For example, when medical students go to third world countries, they are responsible for disbursing medication and completing simple medical tasks, such as cleaning infected wounds. Many people have been unable to cleanse their wounds or treat themselves with simple antibiotic ointments. Your visit to their remote village can save them from developing gangrene or another flesh eating bacteria.  You will bring back experience that can be shared with fellow students and educators, as well as a new found gratitude for advancements in medicine.

Using Volunteer Experience to Develop Basic Interview Skills

We are all sums of our life experiences. When a student is preparing for a medical school interview, one should reflect upon their own experiences as a volunteer. Take the skills you learned as a volunteer: compassion, empathy, teamwork, communication, determination and perseverance and apply them to your interview. The ability to be human and relatable is also an important factor when on an interview.  Be sure to showcase your personality, teamwork and communication skills, as these are critical skills for medical professionals to have.

When in the interview, be sure to paint a complete picture of who you are as a person. Your grades and test scores are important, but having a personality is equally crucial. Be sure to check the nerves at the door; keeping in mind, the interviewer was once in your shoes! Remember to tell engaging stories and share examples of your work ethic though prior experiences, perhaps explaining a particular experience from a volunteer mission trip.

Follow Medical News and Journals

Finally, when on an interview, be sure to let the interviewer know you are staying abreast on medical news and medical reading. There is a chance the interviewer may ask you what medical books and magazines you read. It is importance you familiarize yourself with important journals such as  The Lancet and Science Daily.

Conclusion

When you are selected for an interview for medical school, your MCAT scores will speak for themselves.  Everyone knows that those who are dedicated and work hard will earn high grades and high MCAT scores.  A well rounded applicant needs to be able to relate to his or her future patients and medical staff. A calm, self assured individual are desired traits for prospective doctors. Emulate this within your interview.  Interviewers are looking not only an intelligent individual to cure and prevent illness, they are also looking for personality traits, such as a calming bedside manner, patience, compassion and empathy. Medical schools want to know that the students they are training to become future doctors will represent all of these qualities.

About the author:

Elsevier Health is a leading publisher of medical journals and textbooks such as The Harriet Lane Handbook and Goldman’s Cecil Medicine, used in universities around the world. Elsevier Health has also extended a promotional code to Medaholic readers. Please enter the code 61015 at checkout to recieve 10% off your purchases from http://www.us.elsevierhealth.com. Unlimited use. Offer expires 1/1/13.

Packing Tips

• Pack for the right weather – if you are going to Vancouver bring an umbrella, if you will be in the prairies bring a warm winter jacket. Dress accordingly to the climate
• Stuff socks in your dress shoes and wrap them separately in plastic bags to make packing easier
• Have a waterproof ziploc bag for your toiletries
• Roll your clothes to pack more efficiently and to save space
• Your interview clothes should never leave you – bring it on the plane as carry-on
• Bring a lint roller

Finances

• Book flights on Tuesday/Wednesday when there are seat sales
• Use points to book flights if possible
• Stay with friends to eliminate accommodation costs
• Travel with other people to split the costs of hotels/car rentals
• Use public transportation – it’s a lot cheaper than taxis
• Save money on breakfast and lunch by attending the free refreshments provided by residency programs

Traveling

• Avoid backtracking during the tour, ideally you should go from West to East or vice versa, once.
• Have a pitstop at your home school midway to re-energize, repack, relax
• Explore every place you go to, get a feel for the place  – you may end up there
• Walking is one of the best ways to see a city
• Meet up with friends staying in other cities

Personal Sanity

• Enjoy the process and mix your interviews with some sightseeing
• Don’t have regrets – always focus on your next interview at hand
• Spend some time with people who are not on the tour for perspective
• Visit home if/when possible