Things I learned in Medical School (and wish I’d learned earlier) Casey Darrah, MD, MSBS - So, you got into medical school! Congratulations. Now the fun begins. - What is this guide for? It's not a compendium compen dium of review work. You're not going to get a single question right because of information learned here. he re. What you are going to get, though, are some tips for how to make these next four years as painless as possible, so you can finish with that tha t MD or DO, hopefully without losing your mind. - Who am I? Well, to be specific, I'm a family medicine resident, class of 2012 medical school graduate. Were my scores great over the course of medical school? Nope. However, that's a good thing. There are thousands of guides out there written by the 99s, the guys who got insane scores on this exam and that exam, and that's just great. What there aren't are bo oks on the living of medical school. The coursework, I can make some suggestions, but material is left o those better than me. Making it through mentally intact and without wrecking your body in the process? That's where I come in. I'm the Virgil to your Dante, the Samwise Sa mwise to your Frodo, the Van Helsing to your Harker. I can't walk all the paths with you, but I can at least show the way. - First off, let's start with a very basic concept. concep t. It doesn't matter how good a student you were in undergraduate, you're automatically in a different league now. It doesn't matter if you were the top one percent, the competition just got that much harder. If you expect that you're going to keep with a perfect GPA and put in the time you did in college, you're in for a surprise. This works two ways, though. Competition is harder, but that can be a good thing to remember. re member. Using my school as an example, exa mple, they accepted four thousand applications a pplications for my class. Four thousand applications generated two thousand requests re quests for secondary applications. Two thousand secondaries became four hundred interviews. inte rviews. Four hundred interviews became two hundred acceptances for a class of one hundred and seventy. For all the toughness of the program, you're already in the top five percent pe rcent of their applicants, just by virtue of getting accepted. Re member that. If they didn't think you could do it, they wouldn't have given you the spot in the class. Now that you're in, though, it looks daunting. It's like drinking from a fire hose, as the common analogy goes- too much data to really try and get it all. It looks daunting, and it is. It is more information and work than any other program you've ever done, and it can be a shock. That's okay. Remember that everyone else in that room is in the same boat. Even E ven those who finished other degrees along the way (your narrator has an MSBS) are going to struggle. Even Eve n those who seem like they have it all down, the AOA locks, aren't getting it e asily. This is not the worst thing that can happen.
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Since you're all in the same boat, you're able to attack the material from a wealth of different ways. That's a good thing! - "As the Cadeuceus Turns". Often ignored is the social aspect of medical school. In a lot of ways, med school is like high school. You have little money (unless your loan overage just came in), lots of stress, and a reasonably homogenous group of people- same age and station in life. This leads to the same dramas that are more common to high schoolers, with some of my classmates attending class in clothing more fit for a club than a graduate school lecture. Some would end up in highly drama-laden relationships, where people were urged to shun a given classmate as they broke up with them, and other such immaturities. You can make some great friends in the crucible that is medical school, but be wary. The drama can be draining. I was lucky. My wife and I married right before med school started, so I was essentially considered an outsider as far as drama was concerned. This suited me well enough. I was a neutral party, so the drama just flowed around me without involving me. Friendships, though, those can be highly useful and rewarding. Unfortunately it's just like starting college- the same lack of knowledge of your peers, the same fresh start. Most schools hold events to get the class to know each other, and those can be a double edged sword. As someone who hates most of the forced togetherness activities that are endemic in the pro fessional world, they were tortuous. I did find a good friend in one, though- he detested them as much as I and we ended up mocking the system together. The rest of it isn't anything you shouldn't already know. Drinking is common as a stress reliever in med school, with the bar near the school getting slammed right after every exam. Be careful, of course. Same with any sexual relationships- while there weren't any unplanned pregnancies during my time in med school, there were quite a few scares floating around in the ether. - Keeping your head on straight. These are set to be some of the most stressful years of your life. Accept it. There are ways to help limit the problem, though. Let's go with the basics, as these a re ones most people won't tell you. They assume you know it already. First off, diet and nutrition. Eating right is tough to do in med school. Free pizza is everywhere, and you're spending lots of time sitting and studying, a recipe for weight gain and feeling like crap. Go buy a rice cooker (should be less than 30 bucks) and a slow cooker (should be under fifty). These make it possible to make reasonably healthy and cheap food with a minimum of fuss and interaction, saving time, calories and money. There's also a nice benefit of being able to cook- makes you look like a god to whomever you're dating, if you can offer them good food. Nice side benefit! Limit caffeine as much as you can- while it helps push back tiredness for a while, it will eventually burn you. You'll crash and burn. However, there's another problem. Caffeine is a diuretic. Slam a Monster, sit down for your three hour exam, and you'll need to use the bathroom soon enough. This is a problem- stopping takes time, breaks your concentration and slows you down. On the other hand, though, I often would bring a bottle of Gatorade along for exams- a sip here and there gave me a break to refocus, which helped keep me calm.
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Exercise is a great stress reliever in med school, and can be useful even as a study aid. During my first two years, I would record the lectures, edit out the breaks and crud, speed it up to about 140%, and go for a ride on the stationary bike. Stress relief and studying! Core exercises are also great for stabilizing your back, which really helps on long days standing. - Required textbooks. 99.44% of the time, “required” means no such thing. There’s almost never a time where a professor says “Open your book to page xyz…”, save one; There is gross anatomy, and they do require an atlas for that. It’s a consumable atlas, and will likely never leave the lab. Split the eighty bucks 4 ways with your group, buy a decent used one, or snag an old copy out of the lab. You will be tossing it, burning it, or leaving it in the lab anyway, so no need to buy a perfect specimen. Older editions are nearly always fine, as are similar ones- the 2006 edition of Bates’ Guide to Physical Examination can be had for $20, compared to $100 for the crisp new 2009 edition. Just make sure your edition is not too old- ten years for physiology is no problem. Five years for pharmacology is ancient. Always check to be sure, of course. These are rare, but make sure before spending on the old ones. - Textbooks in general. When I said old editions and similar books are good enough, I meant it. My 1997 printing of Guyton & Hall Physiology was leftover from a Junior year physiology course. Cost to use it in medical school, $0. Cost of the new printing, $100. Work Google to death, and you can nearly always find old editions, used books and international editions for any book you may need. Shaving ten bucks off the price of a book may not seem like much, but it adds up quickly. Talk to those in years ahead of you, and sometimes you will find great buys on books they’re done with. I picked up nearly every book I could need for my Medicine, Family Medicine, Psychology and Surgery rotations for $150 from a fourth-year. The First Aid for the Medicine Clerkship book was unused. The price new? $50. I got Blueprints for Pediatrics and Family Medicine and First Aid- Surgery for less than $10 a book. Adding another point, textbook piracy is common. Look online long enough, you can find any review book you want in handy .pdf form, along with the majority of textbooks. The legality is of course questionable, though I know many people who pirated everything they couldn’t buy cheaply. This is especially common with Case Files books, as they normally cost about $40. Forty bucks for a small case review book is usurious, and online copies are plentiful. Even if you want a print copy to study from, having a .pdf version where you can simply copy a few cases to read during rounds is immensely valuable. - Mnemonics, study groups, review books. All three of these are generally personal decisions, though there is a general guideline. Mnemonics are best when they are short, simple, and quick to memorize. Spending an hour developing a 27-word mnemonic for the branches of the aorta between the pontine arteries and the aorta may be an interesting way to review, but if the mnemonic is too long to remember, it is useless. Studies have shown
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that a person’s short-term memory can hold seven items fairly easily, with retention dropping rapidly as the number increases. With that in mind, I keep my mnemonics short, usually to six words or less. Some classics (cranial nerves with twelve, causes of anion-gap acidosis with eight, parts of the patient history with nine) are longer, but shorter is better. Keep the mnemonic as short is effective to communicate the information, no longer. Study groups are useful in some cases, but this is highly dependent on the dynamic you have between you and your group. Some groups can accomplish a great deal very quickly, while others flounder and die within weeks. My school, for example, has attempted for years to start a peer-mentoring program with representatives of all four years. It has failed miserably in the majority of cases, due to the lack of chemistry. The group we supposedly started my first year, as well as the second-year, third-year and fourth-year versions, have never met aside from the mandatory orientations. Review books are extremely individualized. Every student has their favorite series- the Board Review Series, High Yield, First Aid, and (blank) Made Ridiculously Simple are four common groups- but which ones you use are your call entirely. Some series are excellent for one subject, and junk for others. The BRS Pathology and Physiology books are superb. Their Gross Anatomy one is mediocre. High Yield Biochemistry is superficial at best, while HY Neuroanatomy has a few tables that are lifesavers. Clinical Microbiology Made Ridiculously Simple is phenomenal, their other book s more hit-andmiss. Read and discover which you can use best. I have appended a list of my favorites at the end as a guide, but feel free to use what works best for you. - Study techniques. Medical school is unlike any other educational scenario you have seen. Unlike college, where one study method can work across a wide range of courses, medical school is a different game entirely. My tried and true method through college was to attend lecture, take notes, and record the lecture. I would later rewrite the notes, appending in useful data from the recording. It served me well in undergraduate, to the tune of a 3.95 grade point average over the two years where I had this method perfected. Others swore by reading and rereading the book, with the common consensus being that reading the text three times was sufficient to crush any exam that would be encountered. Unfortunately, medical school is different. There simply is not enough time for a method like that to work. While in undergraduate there may only be one or two classes for which this level of attention is needed, in medical school such attention has to be given on a daily basis. Devoting 3 hours per hour of lecture is a noble goal in undergraduate, and one that my advisors swore by. It fails when you have 4-6 hours of lecture daily, and devoting 12-18 hours strictly to studying leaves little time for worthless things such as sleep or basic human hygiene. Efficiency is the name of the game. I popularized the use of a triage system in undergraduate, and it persisted among many friends of mine even into medical school. It’s based off the classic black -red-yellow-green tags seen in triage, where red tags are those patients who need care the most and will benefit, yellow tags can wait, green tags
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can go without care, and black tags are the dead and dying who won’t benefit. Classes would be “tagged” on a daily basis. Exam coming up in Anatomy next week? Red tag. Need to read over a disease or two for PBL in 2 days? Yellow tag. Have an FCP discussion tomorrow that you can handle without prep? Green tag. Focus on red first, then yellow, then green. If you have black tags at all, you’re doing something dramatically wrong. The key is to be efficient, and to tune your study to whatever course you are taking at a given time. The good news with that is that you may have more time to spend on extracurricular activities, but the bad news is that the most efficient study method can take time to develop and perfect. Never commit fully to one, and never be reluctant to change it. Your study methods deserve no loyalty if they aren’t producing results. - Study techniques while on clerkships. Here, questions are king. Do as many questions as you can, as often as you can, and from as many sources as you can. It is not uncommon to do 500 or more questions in the course of a five-week clerkship, or more than 1000 questions while studying for the Step exams. What question bank you use is largely up to you. However, there are better or worse question banks depending on the subject. The MKSAP questions and book are excellent for the internal medicine shelf, but only for the internal medicine shelf. The NMS book is decent for surgery, but tends to fall apart quickly with the other exams. The king of this particular ring is the USMLE World question bank, which, though expensive, is one of the best that there is. It's a 2000 question bank, cost approximately $300 a year or $30 a month, and comes the closest to simulating both the Shelf exam and the Step exam. There are other question banks, Kaplan is one that many students like. However it tends to be easier than the actual shelf exam, and thus a poorer preparation tool. - Lecture attendance. The following is predicated on your school, like most medical schools, not requiring attendance at all lectures. Of course, know your school’s specific attendance policies, and attend those lectures deemed mandatory without fail. With that said… In my experience, lectures are quite schizophrenic things. Some instructors, the lectures are immensely valuable. You’ll go to every single one, take copious notes, and that’s the most efficient way to study. However, those are rare. My general advice is to attend the first lecture for every single instructor, and base further attendance on that sampling. If it turns out, as it did in my case, that a certain professor is simply a poor lecturer, discontinuing attendance can be the best move. Similarly, if a given lecturer seems to think that summarizing the textbook passes for an enthralling lecture, feel free to simply review the material on your own. Lecturers tend to do a very poor job of summarizing, and those hours can be better used studying on one’s own. As a quick and dirty guideline, look at the letters after the lecturer’s name. Unless it’s a clinical correlate lecture or similar, seeing “M.D.” is exactly what you don’t want to see. Yes, it’s medical school, but the very people who sat in your chair are the same ones you don’t want to teach you. MDs tend to be very poor lecturers indeed, especially if they’re stuck teaching an introductory level of something that they actually work on. They
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generally can’t make the mental leap from teaching well-versed PhD candidates to teaching first-year medical students who may have never seen the material before. Their lecture style is often stilted and dry, either cramming 150 slides into 2 hours, or taking an hour to work through 12. Either way, it’s painful. Yes, I’ll say it again, nice and clear. Lecture attendance is optional. There will be courses, instructors and material where going to lecture is simply a waste of 2 -4 hours. The hardest part is making the first leap, and skipping that first lecture. It is strange, the day you skip that first one, but I promise you this. No lightning bolts will fly from the heavens, the Dean isn’t going to be pounding on your door, the most that might happen would be a few snide comments from the professor if only forty of 170 students attend a lecture. It’s really their own fault. If they can’t provide a product worth attending, why should a student feel guilty for skipping? - Shopping List for the First and Second Year 1. Rice cooker, preferably electric, eight cups or so capacity. Lets you put on some slow carbs, and do something else while it cooks. 2. Slow cooker. The king of your cookery- great for long cooking, throw something in when you leave in the morning and it's ready when you get home. 3. Digital recorder. While many schools offer downloadable lecture recordings, this has the added benefit of being useful for making notes to yourself. 4. First Aid for USMLE Step I. Excellent review book for the first Step exam (or COMLEX, I'm told), worth annotating during first and second year with extra materials. 5. Inexpensive stethoscope. While many will recommend the Littmann Classic II, it's expensive, about eighty bucks. I have one, but I found I can hear just as well with a ten dollar stethoscope from the bookstore. 6. Binders, three ring, preferably D ring. Hold a ton of material, hold up well, and are reasonably priced. Makes organizing the mountain of material easier. 7. Micromedex, Epocrates or Medscape application for your phone or tablet. If you don't have a tablet or smartphone, don't rush out and buy one unless you feel you need. They're nice to have, but if you're low on cash, that money can be better spent elsewhere. Micromedex and Medscape aren't quite as good as Epocrates, but they are free. If you don't have a tablet or smartphone, Tarascon's Pharmacopeia can be had for about ten bucks. 8. Whiteboard. Optional, but highly useful in my experience. If you're low on money, or just want to do it cheaply, melamine board can had easily- Lowe's sells a four foot by eight foot sheet for less than fifty bucks, it wipes clean with Windex, an d while it's not as good as a true whiteboard, it works quite well and is large enough to work with. My whiteboard was twenty bucks from a store closure- four feet by ten, and my wife and I still have it up for note taking and other randomness.
FIRST YEAR Block I- Cellular and Molecular Biology
- Shopping List for Block I
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1. Books as mentioned below. 2. Binders. Lots of binders. My school gave enough materials for Block I that I managed to nearly fill an entire bookshelf between the binders and the textbooks. 3. Colored pencils, pens or fine felt tip markers. Highly useful for filling in drawings and descriptions, helps to cement things. This block goes under many names. Microbiology, cell and molecular biology, biochemistry, others. I will simply use them interchangeably, as they're the same thing with different titles. It's almost always the first block, and by far the one most like the courses you would have taken in college. Attacking it, then, isn't too far different from what you've been through before. At many schools it's a combination of embryology, histology and cellular biochemistry. Useful books include High Yield Biochemistry, HY Embryology. As for other resources, the Blue Histology site at http://www.lab.anhb.uwa.edu.au/mb140/ is spectacular. Free, highly detailed and more than adequate to get you through. This block is the one case where I highly recommend a study partner, or at least some way of breaking the boredom. There are so many similar paths, so many similar and foreign names, that simply having another set of eyes can make life far simpler. Nothing can make it easy, but working with a friend can make it a little less mentally draining. It's interesting for another reason, in that at my school, this bloc k was also used by Master's students, when they were taking a one year MSBS program to enhance their chances of getting into medical school. They (and I was amongst them) were in Limbo. They are with you for that block and several others, but they cannot descend further yet. Their judgement from Minos awaits. They may join you, and I would encourage working with them- as they only have that block to worry about, they can bring an interesting perspective to the material that may be useful. There's the First Circle of this Dantean descent, first of the nine blocks most medical schools use to break up the first two years. Let us bid farewell to those in Limbo, and drop down a circle. Things get interesting further down. Block II- Gross Anatomy
This block only really has two names I've commonly seen, gross anatomy and human structure and development. It's the widowmaker block, the king of hell, in a sense. Standing there, taunting you, a twenty week course where people have to face all their fears about death, dying, surgery and disassemble a human being, all the while trying to master such arcana as which laryngeal nerve is most commonly injured in thyroidectomy (left recurrent laryngeal, by the way). At least, that is what they want you to believe, from the second years all the way up to the faculty.
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So what's the scoop? What's really going on in that lab, that place of dark corners, foul smells and weird noises? Well, if you've hung with me this far, let's go a little further. Down the steps from Limbo, one finds the Lustful Sinners. Oddly apropos, wouldn't you think? Now, first off, a warning. If you've never sat down and really come to terms at a deep and abiding level that you are going to die, make sure you have it down now. If you don't the first few days on anatomy will be exceptionally difficult. I don't mean an intellectual knowledge that you're mortal, I mean a Fight Club style, knowledge and acceptance, though hopefully without the lye burns. Make your peace with your God if that is what you need, but either way, you're going to be slicing open a human being. Better get used to the idea. Got it? Still here? Good. Grab a scalpel and get to work. This is the first real kick in the teeth from med school. Netter's Atlas is huge, and it's not all you need down. Let's go. First off, a few good review books and resources. High Yield Gross Anatomy is great for embryology and has a few life saving tables and figures. BRS Anatomy is nice as a general review, though a bit simplistic. Best of the reviews, though? Go to anatomy.med.umich.edu. Bleed that site DRY. There are tons of useful lists and tables, especially the ones listed under Anatomy Tables. There are also a lot of useful quiz questions and videos of dissections, good both for in the lab and in the exam. However, though, that's only a start. The material guides are nice, but not what I'm here for. So how do you survive anatomy? First, start thinking directionally. Don't just memorize names and say that's it. It's not. What will work for you is to know why they are named as they are. For example, it is my contention that a passing knowledge of Greek or Latin would be invaluable, and I'm not asking much. Taking the musculature as an example, let's take the latissimus dorsi and the biceps brachii or biceps flexor cubiti. Break the names down. Latissimus looks a bit like latitude, something running laterally. Dorsi, same as dorsal, back. So, the long muscle of the back. Sure as hell, it is. Biceps brachii or biceps flexor cubiti? Biceps is Greek for two-headed. Brachii, Greek for arm. Cubiti, cu bit, elbow. So, it's known as either the two headed muscle of the arm, or the two headed flexor of the elbow. Bingo. If you're stumped on what a muscle, artery or nerve is named, try either its location (pectoralis, supraspinatus), what it looks like (deltoid, rhomboideus), or where it is going (brachiocephalic artery, thoracodorsal artery). Saved my bacon more than once. Another way to get the anatomy square in your head is to start mentally performing major surgery or major injuries. If you stab into the abdomen, what gets cut first, then next? If you snip the musculocutaneous nerve, what happens to the arm? If you're doing a left nephrectomy, why don't you cut the left renal vein at its origin? You sacrifice the left ovarian vein- very bad.
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There are useful computer programs for the anatomy as well- Anatomy and Physiology Revealed is nice (and I'm not just saying that because I know all the creators- it was my school), but can be spotty. Nice for exam review, not so nice for lab practical exams. Anatomy is also the one block where you HAVE to rely on your classmates to survive. I'm not saying you need to be best friends with your three to five labmates, but at least be on good terms with them. You're going to be working in close quarters for hours on e nd, it's just tough to do that unless everything is copacetic. I had issues with this, in that two of my lab partners were great, but one simply conflicted with my personality from day one. About five weeks in, when he joked he was going to meet me in the parking lot after I trimmed a renal vessel too tight, I just gave him a thousand yard stare and said he was welcome to try. That solved that- we weren't friends, but at least things were civil. Chip in a few bucks each to buy an atlas to keep in the lab, and get one yourself that stays clean. The lab atlas is going to get incredibly nasty over the next twenty weeks, most of my classmates just left it in there. Use your clean one in lecture and to study from, leave the lab copy behind at the end of the year. It's twenty bucks each, but worth having one where you don't care if it is gross. Managing the smell is a persistent problem in anatomy lab. I have two secret weapons, though. First is Vicks Vaporub. Smear some around your nostrils when you know it's going to be a rough day, and it cuts the smell down a bit. I used it for day one, when we first opened the bag, the day we opened the abdominal cavity, and the days we ran the bowel. Aside from those, the smell isn't that bad. My other secret weapon is to get rid of the formaldehyde smell. For that one, go to the pharmacy and buy a bottle of UltraSwim chlorine removal shampoo, and use it as a shampoo and body wash. It gets the smell off, and formaldehyde is a persistent smell unless you use something similar. I tried other brands, and this was what worked for me. Less than ten bucks a bottle, and you don't smell like formaldehyde when you go out later that night. Though the school provides gloves, they’re usually cheap and crappy vinyl or latex. Spend the few dollars for a box of nitrile gloves- easy to recognize, usually purple. Double-glove on those, and you’re not only better protected, you’re also not going to get lab odors sticking to your hands nearly as often. Last of the tips before further descent is attire for the lab. Scrubs are common, but unnecessary. Wear whatever you like as long as you don’t mind the crud. Shoes, though- there, it’s worth the money to do right. Crocs, boots, whatever works, but get something you can stand in all day long. - Shopping List for Block II 1. UltraSwim shampoo 2. Vicks Vaporub 3. Nitrile gloves 4. Comfortable shoes you don’t mind gunking up
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5. Books as listed. Block III- Neuroscience and Behavioral Science
Welcome to the glutton’s circle. Compared to anatomy, this block can seem like a vacation. Much calmer hours working, only a few labs in neuroscience in most cases, and not a really large amount of information in behavioral science. It's a combination block, neurology and psychology, and can be tough in some cases if you don't have a background in psychiatry. So how to survive? Behavioral science is arguably the hardest block to care about, to be blunt. To a lot of clinicians, the psychiatric curriculum is not considered real medicine. Believe that at your peril. Whether you want to go into psych or have anything to do with psych, it is at the very least easy points on the Step exams and the Shelf exams in third and fourth year. When I took Step I, about ten percent of the questions were psych derived, so knowing your psych can make a very large difference in your board scores. Neuroscience is essentially anatomy, except brain-only. Pretty much, just using the same strategies for neuroscience as you did in gross anatomy will serve well. For psych, a different tack is needed. Oe that worked for me was to read as many case presentations as possible, to try and get a complete picture of what is seen with each disorder. I also know a number of students also would role play various disorders, psychoanalyze movie characters (horror movies are best for this, though Gollum was also popular), or e ven psychoanalyze professors and lecturers. Anything to get it in your head! As a trick for the exams, when doing a psych exam, obtaining a more focused history and exam is always a possible answer. Adjustment disorder is also very common on exa ms, and works well as a fallback if you have no other ideas as to what the answer might be. For the neurology exams, know well how to do the neuro exam, and why various altered results can be seen. Getting a better neuro examination with a patient is always good. For possible stroke patients, never use contrast- if they're bleeding, contrast mimics blood. Books are a bit personalized. HY Behavioral Science and Neuroanatomy are both nice and cheap, and if you're interested in psych, Andreasen and Black's Introductory Textbook of Psychiatry can be useful. Case Files Psychiatry is great for presenting a ton of cases, which is golden for exams. - Shopping list for Block III 1. Good reflex hammer that is heavy enough to elicit a good reflex. The cheap triangular hammer that is very common isn't the best for smaller reflexes, while a round hammer works well at getting borderline reflexes to appear. 2. Good tuning fork. 256 Hertz tends to work well for the Weber and Rinne tests, and is often loud enough to work nicely for hearing tests. 3. Books as above.
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Block IV- Fundamentals of Clinical Practice
This and Block V are essentially your vacation blocks. Dante used the fourth circle for greed, and you can greedily catch up on sleep! Very easy indeed, low hours, minimal work and studying. It's telling just how expendable this pair of blocks are when they hold the pair during anatomy at many schools. So what is it? This block goes under many names. FCP was my school's name, others call it other names. From the description it should be reasonably clear what block at your school is the same. FCP is your medical skills block, how to do an exam, how to do a history, ethics and other issues that might show up with your medical career. For examination, your skills should come fairly naturally from your coursework- while there are thousands of videos all over YouTube and other places to do the H&P, your exam still relies on what you've been shown. If you know a way that works better for you, use it as you wish, but toe the line with the examination days. A complete history and physical is vital for effective care. There are many mnemonics for the history, and I have my own. My favorite is this format. First is chief complaint. Next is history of present illness, which I break into nine sections. Not all problems use this, but LOTSACRAP works for a base. l is location, O is onset, either sudden or gradual, T is timing, S is severity, A is associated symptoms, C is characterization - exactly what does the problem look or feel like? R is remitting factors, what makes it better. A is aggravating factors, what makes it worse. P is progression, so what the problem is doing. Next is MASH, FS. M is medical history and medications, A is allergies (list what, what happens and any detail you have), S is surgical history, H is hospital history. F is family history, S is social history, marital status, work status, alcohol, tobacco, drug use, sexual history. - Shopping List for Block IV 1. Maxwell’s pocket guide- essential for the next four years, dirt cheap 2. Nothing else, really Block V- Problem-Based Learning
This is kind of a catchall block, and Dante’s use of the wrathful here is appropriate. At many schools, there’s a block dedicated to solving clinical cases, usually linked to whatever you’re studying at the time. As it’s mostly just a review of the other blocks you’re actually in, my stay is short. Survival is easy as pie. It’s usually once or twice a week, meeting with a preceptor to discuss a case. Easy, usually pass-fail, and nothing you can’t already do. Guess what? You just survived first year! Go enjoy summer- it’s the last worry-free one you’ll have for a while. After second year is Step 1, after third is worrying about applying to residency, after fourth, residency prep. Go chill on a beach.
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SECOND YEAR Back to the grindstone, folks. If you’ve made it this far, you’ve learned a few things. First, your “genius” classmate who thinks he doesn’t need to study is an idiot. Second, that you can do this thing! As a first non-block idea, it's time to start studying for Step 1. Nothing intense, just working through some questions. You're going to get a lot wrong at this point, but drop the 300 bucks for a yearly subscription to USMLEWorld and work through questions related to what you're studying. At this point, study using tutor mode, and read the explanations for each answer. Don't worry about getting questions wrong, just figure out the logic why. Getting either Step Up to Step 1 or First Aid for Step 1 is also a good plan. Annotate it with useful bits you find in your courses, and it'll make life a bit easier when in crunch time for your exam. If you find a good way to remember something, add it into the margins in the book! If you get a question wrong in the bank, annotate it into the book with more details. My copy of First Aid is noticeably heavier than it was new, from pencil, ink and highlighter. Also, save up some cash to pay for Step I. It's expensive, and make a note to schedule it for a convenient time over summer. Most schools let out in early May, and require you take the exam before third year starts in July. I scheduled mine mid-June, though some took it as early as the Monday after class let out and as late as the first week of July. Block VI- Immunology and Infection
Say hello to the heretics, Dante. Just when you thought you were loose, this one comes along to slap you around some more. It is just as it sounds, immunology along with study of the bugs- bacteria, viruses, parasites, prions. So how to survive? Oddly, the same techniques that worked in Block I are valid again. This one’s essentially a grad school immunology course. There are useful books- I would not have passed without Clinical Microbiology Made Ridiculously Simple - but most is just finding your own way to get the words into the brain. Helpful things include reading as many articles on disease outbreak as possible- some only clicked for me after finding the older works. Beyond that, mnemonics are nice but limited. Going for a 34 word version simply isn’t going to work for 99% of people. Whatever works for you to get it in your head, acronyms, silly rhymes, that's something that needs to be personalized. Read as many cases as you can, and do what you can to hammer it home. No real shopping list for this one, aside from what I mentioned above. - Block VII- Organ Systems
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Behold, the block of nearly infinite names! Organ Systems, Pathology and Pharmacology, many others. If there is a block where it covers pathology and disease processes, drugs and other stuff, that's this one. It can be a fun block, to be very honest indeed. It's hard as hell, but unlike the others (exception of Neuro) it links up easily with the more practical aspects of medicine- the diseases and how to treat them! Survival is actually a bit easier than the first year blocks and Block VI. In this case, one thing that worked for me was to grab a disease, build a patient with it, then figure out what to do with them. For added difficulty, start adding comorbid diseases, then see what happens. Change race, age, sex, occupation, and so on, and see now what you do. Treating a standard 70 kg, 25 year old white male with no other problems for hypertension is one thing. Altering it to a 77 year old, 125 kg black female with sarcoidosis, kidney disease, heart disease and depression? Much more difficult, and also much more realistic for what you'll be seeing in the real world. Another thing that worked was practice questions. Grab the question book that goes along with Robbins' Pathology, and work through it. In addition to being useful for understanding, it's also common for proofs to cheat the rules a bit and lift questions from it for exams. For pharmacology, one useful trick is to remember the major members of classes, how they work, and any reason you wouldn't give them, be it a person, situation, disorder, whatever. Exams tend to give the prototypical members of each class (say, captopril instead of the more common lisinopril), and tend to hang on the classic reasons and side effects around each. Knowing one or two members of each class is usually sufficient, and there are usually naming tricks to identify members of each class. Beta blockers, for example, all end in -olol, looks like two B's next to each other. Angiotensin converting enzyme inhibitors all end in -opril. Antibiotics always carry the last name of the class, cillin, -mycin, and so on. Clinical Micro from above is also key. The ultimate secret, though? Master one concept, the low energy state. It's the key to all disease processes. What does that mean? Well, let's make two patients. Bill is a 19 year old white male with no medical issues, starting out at 70 kg, a Sergeant in the US Army during World War Two. He's been captured by the Japanese, and placed on starvation rations at a camp in the Philippines. John is a 77 year old black male with hypertension, diabetes, and severe lung cancer for which he's in methotrexate, a classic chemotherapy drug. Come back in two years, and they look the same. Hair falling out, skin thin, impotent, depressed, nausea, vomiting, diarrhea, slow healing, lung and kidney infections. Why? The low energy state. You need energy to replenish cells. In the case of our POW, he's starving to death and has nothing coming in. John is on a medication that blocks the formation of new cells. Which ones are a problem? Those are the cells that divide quickest- skin, hair, germ cells, gastrointestinal lining, lining of the bladder, cilia of the airway. Cancer does the same, constant stress, starvation, many, many disorders.
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It's the core of all diseases. Master that, and everything else comes far easier. It's a tough one to get used to, but it works! Med side effects have a similar trick. It doesn't matter what the leading side effect is- the leader for captopril is cough- but the reason people stop using the medication is different. It's shortness of breath and weakness. Why? With weakness, the patient is afraid they can't work. With shortness of breath, they're afraid they're dying. Logical, no? There isn't much of a list for this one. You should already have everything aside from the books I mentioned above. Block VIII- Fundamentals of Clinical Practice II and Block IX- Problem-Based Learning II
Nothing to report here. It's the same as the first go, just a bit more intense. STEP I Okay. Now it’s time to get serious about Step I. It’s a tough exam, sure, but we will get you through it. Just take a deep breath, relax, find your center, and let's do this thing. If you're a loyal reader of this guide, and if you're still here I know you are, then you should have been doing a few things all along. Your copy of First Aid or Step Up should be gloriously festooned with tons of colors and ink, you should have hundreds of questions under your belt, and you should have started to think you can do this. What's that, you say? I'm insane, you say? Yes. That's true. For those of you who actually have been doing all the above for a while, you're sitting reasonably well. If you haven't, don't sweat too much. It is a long way to go and a short time to get there, but we can do this. First off, grab a calendar. The day after your last day of classes is day one. Your scheduled date for Step I is whatever number. Let's say forty five, for sake of argument. Give yourself one day in ten to relax and breathe, totally off from coursework. Aside from that, split up the remaining forty amongst the sections of the exam, preferably with the ones you struggle with last. That will put them closer to the exam and fresher in your mind- I did pharmacology last, as it is most amenable to quick review and point memorization. Next up, grab your book and your computer with your question bank. Split those up as well, according to the calendar you just made, but leave every ninth day open for more, the day before your listed break day. Each day, you'll be doing those questions that correspond to your section, except for the nines. On the nines, in addition to the sections and questions for that day, you're going to do a short overall review. Say, fifty to one hundred questions, all subjects. Also add to the calendar times to do three full length exams in addition to your questions. How should you do the full length exams? There, pull out a question book or bank you only use for those, and make a full length exam. Take it strictly, on the clock with breaks and
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timing to best simulate the real exam. When done, use the next few days to wade through and review it. For prepping the few days before the exam, it's actually counter to what most people say. Most cram, power through on Red Bull and adrenaline, and that's the exact wrong answer. The answer is this. Day before the exam, relax. Go watch a movie, take a walk, work out a while, whatever helps you chill out. Get plenty of sleep, and exam day, eat something! Hold off on the caffeine for a while, take something reasonably balanced for lunch, and plenty of fluids. I'd rather take an extra five minutes of break during my day and feel normal than have those five to spare and feel dehydrated. During the day itself, listen to your body. If you need a break, take one. If you need a sixty second break in a block, take one. I used deep breathing techniques during Step II to stay calm, which was very helpful. Does it slow me down? Yes, and that's the point. Slow down, there is plenty of time per question, over a minute. Taking sixty seconds to slow down and breathe won't wreck your chances. Afterward, go forget about the exam. Don't go home and look up answers. Don't talk about it, don't worry about it, don't even think about it. Just let go. Go enjoy your time off before third year starts. Doctor's orders. But what if the worst happens, I hear your inner doubts say? If you fail, you take it again, and again if you need to. Not the end of the world, unless you had your heart set on dermatology, radiology, plastics or ortho. Aside from those, if you fail, take some time to take stock, see if you can get into either some flex time (what my school called time off) or a low-hour rotation for a while to prep and go at it again. Not the end of the world. THIRD YEAR Welcome to actually using all this knowledge the y've been cramming in your brain for the last two years. It's a bastard of a year, but there are ways to smooth the transition out a bit. Biggest question my class had was what order to take the rotations in. There is no real right answer; some say to take the rotations you're interested in first, to make the start easier. Some say to save those for last, as then you'll have a better chance to do well on the exam with more knowledge under your belt. There is no right answer. I'll write them in the order I took them, but it's not necessarily the right way. As some general survival techniques, there are many useful points. One key one is to know your rights. I made this mistake. Certification board maximum that a medical student or resident can work in a week is eighty hours, though they recommend no more than sixty. I routinely got stuck doing over a hundred on OB, and I paid a heavy price for that. Another key point is to keep time to study. Doing a hundred procedures a week is nothing if you don’t have time enough to actually get some studying done.
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As for floor work, a lot comes from simply knowing the service and its temperament. I’ve been on services where if you were told to be there at 0630, you were considered late at 0615. I’ve been on services where saying to be there at 0800 meant just be there by about 0830. If it’s a strict service, being there early is always a good plan. Know your patients well, and keep a small notebook or something similar on hand for keeping track of their results. My strategy was to date the top of a page, sticker it with the patient’s label, then add in all their lab results, vitals and other bits below. In addition to making an easier note to write, it also makes life a lot easier on rounds. Presenting is tough, but that knocks off the edge. Last out, always keep a spare, blank progress note on you. Makes you look prepared, very important. These write-ups will be a bit shorter than the other ones. Most of them are about the same- do questions, read, pay attention, but I will list out as many tips as I have. - Shopping List for Third Year 1. Folding clipboard- mine’s from whitecoatclipboards.com. It’s plain steel, painted red, and makes writing notes a bit easier. You always have a flat surface to write on, and it comes with some stickers on the outside that contain lab values and other useful bits. I peeled them off since they started to get ratty, but they were nice while they lasted. 2. Moleskine notebook or something similar in size- mine’s roughly 3x5, and small enough to hide in a pocket to carry. Works very well indeed for keeping notes for rounds and later logging. 3. Maxwell’s pocket guide- without a doubt the best ten bucks you’ll spend on a book in med school. I still use mine, and it’s held together with tape and prayer. It has the basics of the neuro exam, MMSE, lab values, a small eye chart and other bits. It’s an absolute mainstay. 4. Pens. Anything that writes cleanly and for a long time is good, I love Pilot G-2 pens in either the medium 0.7mm or fine 0.5mm. I tried 0.38mm and it’s too fine for me, and 1.0mm is great, but hard to write small in the very small spaces. 5. First Aid for Step 2. There are many, Step Up to Step 2, First Aid, Crush Step 2, but my favorite is First Aid. It’s not enough to be a primary guide, but helps. 6. USMLEWorld Step 2. - Obstetrics and Gynecology and Pediatrics
OB was the absolute last thing I wanted to, period, so I chose to knock it out as early as was practical. Now, come learn from my mistakes. First of the mistakes I made, and you won’t if you’re wise, was not studying enough. When I was working 100 hours a week, not counting 2-hour long commutes, it was impossible to actually find time to work. Make the time, no matter how you need to do so. When it comes to procedures, most comes down to how much you want to do. If you want to do the bare minimum to survive, you can do that. If you want to deliver a baby on day one, you can do that. Get your hands dirty and decide from there.
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Review questions are key for every shelf exam. My favorites are Case Files and the OB section out of First Aid for Step 2. UWorld questions are essential. I tried using the textbook to study, and found it wasn’t for me, though there are those who adored Beckmann for such. Master the STDs and contraceptives, and pick up those easy points. Pediatrics almost seems like a vacation compared to OB. Far easier hours, but much more complex patients. Study is the big key here, same two resources as the OB version. However, for this one, also filter in some Psych- a lot of the psych disorders start to show up in childhood, and it’s an easy group of points to lock down. Next up, just flat memorize the milestones and the vaccination schedule. Those are reasonably straightforward to memorize, impossible to logically derive if you don’t know them, and very common on the exams. When dealing with kids, many students, nurses and clinicians try to act more informal and at their level. I can’t do that- it makes me thoroughly nuts, and it’s pretty clear the patient can tell. Just be who you are, and don’t fake it. - Medicine Internal medicine is the big daddy of the blocks. It’s by far the most important one in terms of the Step 2 exam, it’s one of the long blocks (12 weeks at my school), and covers a ton of material. Master the preventative medicine segments of the course, and you’ll be in good stead for the others. Never refer to a specialist on the exam unless it’s ABSOLUTELY necessaryyour job is to solve the patient, and 99% of them can be figured out based off what you have available. Study for this one pulls out essentially all the stops. Treat it like Step 2, use First Aid and a ton of questions, and also go get the MKSAP book. It’s a book of almost all medicine questions, and a fantastic one- it’s mostly retired Step 2 questions and is spectacular for the exam. I know people who used only that book for the exam and did well enough. I also like the Osler Medical Handbook, though it is a bit expensive and a bit detailed for the third year. Still excellent, and I’m glad I got it. - Family Medicine Family medicine is essentially medicine in a different coat. FM is mostly outpatient, medicine mostly inpatient. Study is much the same, and the rest essentially applies. As such, this one is just a small blurb!
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- Neurology and Psychiatry
Most schools link these two, and so will I. Master the neurologic exam, and your life becomes much simpler. Read as many MRIs and CTs as you can, and learn what the various disorders and injuries look like, and you’ll thank me later. Practice your neuro exam as much as you can, as many reflexes as you can, and see as many oddball cases as you can. Neuro is a very picky exam, and seeing a bunch of odd stuff makes it a bit easier. MS, Alzheimer ’s, Parkinson’s and the other dementias are very key, and the more cases you see, the better. For Psych, learn the interview process very well, and master as many of the personality disorders as you can. Adjustment disorder is key, and you’ll see it over and over again on the exam. Same with depression, anxiety, bipolar disorder and ADHD. Master those and you’re 99% of the way there. Bookwise, the Andreasen and Black book I mentioned above for Behavioral Science is great, as is Case Files. For Neuro, Case Files is king along with First Aid. - Surgery
The last one standing. Kill this and it’s all over. Now, how? Read everything you can get your hands on- don’t worry so much about techniques for surgical procedures, but more the medical management of surgical patients. That’s the bulk of the exam, as it’s really written for primary care specialists. FA Surgery is good, but my savior was the Mont Reid Surgical Handbook. It’s superb for rounds and lectures, and stuffed with very useful information. It’s expensive, about fifty bucks, but well worth it. As for surviving the wards themselves, always eat something before surgery. Not much, but a protein bar, peanut butter sandwich, or something similar will keep hypoglycemia at bay without risking needing to back out to use the facility. If you feel sick, back away from the table, and collect yourself. If you’re going to pass out, be careful to not fall into the patient or the instrument tray. I’ve seen both happen. - Guess what? That’s all third year has! Now for two little considerations, exams you may have heard of, Step 2CS and Step 2CK. - Step 2 CS This one is kind of weird. It was originally designed as a required exam for foreign medical graduates, to verify they could communicate with patients effectively. Now, though, we all need it. There are only a few sites for it, so register early. You can take it essentially whenever you like in third year, most take it after Medicine. It’s a simple exam, 12 patient exams, 25
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minutes each, of which 15 are for the exam and 10 for the writeup. It’s not a difficult exam, but take it seriously. Oddly, though, it is pass/fail. People do fail, but the passage rate for an American/Canadian medical grad is about 98%. - Step 2 CK Studying for this one is really beyond the scope of this guide, but treat it a lot like Step 1 in terms of how you approach it. Use the same materials you used for the shelf exams, and a similar schedule to the Step 1 exam. Other than that, it’s the same. - Review books: The Good, the Bad, and the Ugly The Good- Definitely worth it 1. Board Review Series Pathology 2. BRS Physiology 3. Clinical Microbiology Made Ridiculously Simple 4. Step-Up to USMLE Step 1 5. First Aid for the USMLE Step 1 6. Pretest series- Pathology, Physiology and Pharmacology 7. Rapid Review Pathology (Goljan) 8. High Yield Neuroanatomy 9. HY Embryology The Bad- Worth the money if you like them, but make sure they’re best for you first. 1. Goljan USMLE Step 1 review (Deserves an addendum- Goljan RR Pathology is excellent. His Step 1 review is mediocre at best- disorganized, and the audio is in essence a seemingly demented person yelling pathology facts at you. Doesn’t work for me.) 2. Kaplan MedEssentials 3. Lange Road Map to USMLE Pharmacology 4. HY Pharmacology 5. Vander’s Renal Physiology The Ugly- Use only if you know they’re best for you. Normally to be avoided. 1. HY Gross Anatomy 2. HY Biochemistry 3. Underground Clinical Vignette series- mediocre explanations at best 4. Blueprints- any of them. Blueprints OB/GYN is so bad as to be banned recently at my medical school, Psychiatry is so basic as to be insulting, Pedia trics is maddening in its alternating over-complexity and over-simplicity. If all has gone well to this point, you’re a fourth year. Congratulations, you just graduated medical school! No, seriously. It’s all over at this point. The Match and residency application process will wait for another day, but that day is coming!
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