Saturday, October 11, 2014

Medical School: Round 2

Image from here
I’m sure you could tell from the distinct lack of posts over the past couple of months, but second year has started. In fact, we’re already about half-way through the semester and in the middle of our week-long fall break (the existence of which is probably one of my favorite things about Loyola). Finally, a chance to catch my breath.

Our pace has essentially doubled compared to first year. For example, last year we had about one test per month per class, and each test covered maybe 20-25 lectures. Not too bad, really. This year, though, we've had a test every two weeks, with each test covering about the same amount of lectures. So that’s been fun.

As I've talked about previously, the first year at Loyola – especially the first half – is sort of a hodge-podge of classes meant to get everyone up to speed and then cover some of the fundamentals. We started off with two classes that ran for about a month covering behavioral sciences and basic cell biology/genetics, followed by anatomy, and then picked up after winter break with physiology and added in immunology near the end of the spring semester. All throughout the year, we had our patient-centered medicine course (which covered things like patient interviews, basic physical exam skills, and various other topics that didn't quite fit in elsewhere).

Second year is a bit more systematic. We essentially have two courses – pathophysiology and pharmacology – that run simultaneously and complement each other throughout the year. So, for example, right now we are learning cardiac pathophysiology and also learning the relevant cardiac pharmacology as we go along. And of course we still have our patient-centered medicine course that runs throughout the first three years.

Although it’s been busier, the actual information has been quite a bit more interesting. Also, I’ve finally given up on going to classes. I essentially went to classes religiously all throughout first year, except for the last few weeks when my wife had our son. This year, though, keeping up on studying while also making sure that I can take evenings and most weekends off means that time has become even more of a precious commodity, and the time spent going back and forth from school, waiting in between classes, etc., could be better spent.

So, to try and be a bit more efficient, I purposely put myself a day behind so that I watch the previous day’s lectures each morning. The advantage of that is that I can get started a bit earlier than classes actually would normally start – and thus finish my day earlier as well. So far, it’s working out pretty well. I usually have to go in once or twice a week or so for various small groups and things, but that’s fine.

As far as resources go, I HIGHLY recommend Pathoma for pathology and SketchyMicro for microbiology, at least for the bacteria. Incredibly helpful. I’m still using Anki – I’m trying to really only make cards for so-called “high-yield” information. I’m basically converting the Pathoma lectures into cards, along with stuff from First Aid as we cover it, plus whatever information from lectures I think is worth including. Hopefully this will all come in handy for Step 1 – which, really, is not all that far away at this point. More than that, though, my hope is that this will drill this information in for the long term. We’ll see.

My son is about five months old now, and really starting to develop his own little personality. He’s also growing like a weed – he’s a little over twenty pounds and fitting into twelve month clothes now. Still not quite sleeping through the night, but hopefully that will come soon. Hopefully.

Although things have been busier, it’s been a good year so far. I’m thoroughly enjoying the time off with my family, and finally having the opportunity to catch up on all those little things that get pushed to the back burner when life gets crazy.

Wednesday, July 23, 2014

Staying Fit in Medical School

Medical school can be a busy time. The first two years can be managed fairly well if you play your cards right, but as you add things on top of the basic goal of passing your classes (e.g. volunteer activities, research, family, or whatever hobbies you might have), you’ll quickly find your time becomes a precious commodity. To make time for other (often good) pursuits, we sometimes take shortcuts when it comes to our health – we sleep less, eat more, and move less.
Don't do this. Please.

I’ve lifted weights for a few years now, but before medical school I usually worked jobs that kept me pretty physically active on top of just lifting. That translated into not really having to worry much about, for example, what I ate – I could pretty much down whatever I wanted and top it off with two large bowls of ice cream lathered in chocolate syrup and be fine. While that was a blessing (obviously – ice cream is delicious), it also turned out to be a somewhat of a curse. When I got to medical school and suddenly became quite a bit more sedentary, I started to put on a bit of weight. Nothing outrageous, and it wasn’t all of the sudden. I continued to regularly lift, and for a while I told myself that I was just getting “bigger.” But my lack of attention to my food intake caught up with me, and my waistline started to grow. Suddenly, I wasn’t fitting into my clothes quite as well as I used to.  Before long, I was over 190 lb. at about 5 ft. 9 in. and around 22% body fat. Not good.

Time for Change

Before I go any further, I want to take a second and say a couple of things. First, if you are looking to get healthier, that’s great. I personally want to be around for a lot of years so I can spend a lot of time with my wife and family, and want to be able to not get tired out after just a few minutes of wrestling with my son when he is older. Additionally, something like strength training just has a lot of carryover to real life – things that run the gamut from being able to lift heavy things to help friends move, carry in the groceries, or protect my family if the need ever arises. The desire to lose weight, on the other hand, might stem from wanting to improve your various lab profiles, reduce your risk for cardiovascular disease (a big one for me, since I’ve got a pretty strong family history for it), or reduce your risk for all of the other diseases that come hand-in-hand with an expanding waist line.

So if something along those lines is providing you with the intrinsic drive you need to eat less and move more, that’s awesome. However, some people take this whole fitness thing way too far. Being “fit” should not become your identity or sole purpose in life – it’s a means, not an end. Also, don’t be ridiculous about things. Sometimes you might miss a session to hang out with family, or will eat “bad” food when you are out with friends. Whatever. Don’t freak out about it. Enjoy it. While you obviously don’t want to eat crap all of the time, every once in a while (and probably more often than you think), it’s perfectly fine. So relax, and enjoy life a bit. And whatever you do, do NOT go around telling people how they can be healthier, or what they should and shouldn’t eat. I know people like that, and it’s not helpful or pleasant at all. Changing your lifestyle is a personal decision, and if someone actively wants your help, then by all means help them – but don’t force anything on anyone.

Ok. So Now What?

Alright, so back to my waistline. I knew things needed to change. So I started doing a little research. Here is a brief summary of what I found.

Losing the Chub

First off, you have to get something straight – the most important determinant of how lean you are, or even how muscular you are, is not how much “cardio” you do, how much weight you lift (although lifting is important – more on that later), whether or not you eat gluten free, paleo, your micronutrient profile, or whatever. The single most important determinant of your body composition is simply your energy balance – in other words, the calories you take in vs. the calories you expend.

If you want to lose fat, then you have to eat less.

If you want to gain muscle, then you have to eat more and provide the proper stimulus (e.g. weight training).

You can stop reading now if you want. That’s really how important that concept is.

All of the common diets out there – low carb, paleo, Zone, Atkins, Weight Watchers, or whatever – all work. At least for a while. Why? Because in one form or another, they get you to eat less. That is really the crux of the issue when it comes to losing weight. Cutting out carbs, for most people, cuts out a significant food group and thus removes a lot of calories from their daily intake. Eating only so many “points” worth of food each day does the same thing. And so on. Where some of these diets fail, in my opinion, is by failing to hammer home some basic nutritional concepts that help people keep the weight off in the long run. When they add carbs back in, the weight comes back. Or they might start increasing their intake of low-carb foods to the point that they are once again eating a caloric surplus. Once the meal replacements are replaced with real foods, people haven’t learned about portion size, so they just go back to doing what they were doing that made them gain weight in the first place.

So paying attention to the amount of calories you eat is important – that should be clear. Problem is, most people are terrible at estimating how many calories they are eating. They might think they are eating less and are confused as to why they are not losing weight or even still gaining it, but they don’t realize that they are still eating at a surplus, or perhaps have just reduced their intake down to maintenance levels.

So how best to keep track? I started using a free app on my phone called MyFitnessPal. It’s an awesome, easy-to-use way to keep track of things. They have a huge food data base and you can typically just type in whatever you are eating and find it. They have pretty much every major restaurant’s food and a lot of smaller restaurants as well, which makes it convenient when you are eating out. You can also build common meals and save them to use them again later. It remembers what you typically eat, which makes it easier to use the longer you use it. It also can keep track of your weight and other markers as well. For someone like me who likes data points and keeping track of things, it’s awesome. Additionally, it only takes maybe 3-5 minutes a day – tops – to use once you have things down. So it takes minimal time, but it allows you fairly fine control over your caloric intake – which is THE MOST IMPORTANT STEP when it comes to losing fat or gaining muscle.

Of course, as with any data, if your data is trash then your conclusions are useless. Be honest about what you enter. When in doubt, I try to overestimate what I’m eating (because most people usually underestimate).

That said, I’m not a huge fan of weighing or measuring everything you eat. My guess is most people aren’t. It’s just inconvenient. For some who are trying to get into peak condition, it might be necessary. For most of us, though, it’s probably not. You might find it helpful to weigh something once or measure something once just to get an idea of what a cup of this or 12 oz. of that actually looks like, but don’t get too crazy.

Once you’ve downloaded the app (you can just use it on the computer as well, but the app is way more convenient), track your intake for a few days. Be honest. You have to figure out where you are to figure out why you got there and where you are going to go.

Finding Your Numbers

So you have the tools to keep track of your calories, which, if you haven’t caught on by now, is IMPORTANT. Now what?

The next step is to figure out what your goal is. For most people, this will be something like, “Well, I want to lose fat and gain muscle.” That’s great, but with the exception of rank beginners, it’s unlikely to occur. It’s possible, of course, but progress will be exceedingly slow and you are really working at counter-purposes with yourself. Remember, to lose fat you have to eat less, and to gain muscle you have to eat more. You can’t really do that at the same time – you cannot serve two masters. So pick your goal, and go with it.

But getting back to the topic of this section. You need to establish your caloric maintenance requirements – the amount you need to eat to stay the way you are. The calculator I like (which has lots of features, which we’ll talk about later) can be found here. Plug in your numbers, be honest about your activity level, and select which formula you want to use to calculate your caloric needs (I would just choose the one with the most conservative values for starters – it’s easier to add in calories later if needed than it is to remove them). That’s your maintenance caloric requirement.

If your goal is to lose fat, you need to eat less than that number to achieve that. The typical recommendation is to eat 500 calories under your maintenance each day – over a week, these leaves you with a caloric deficient of about 3500 calories. Traditionally, this is the amount that is touted as necessary to lose a pound of fat a week. You can also set your deficit by using a percentage of your maintenance - so, for example, you might decide to eat 20% less calories than your maintenance level each day. If you want more information on choosing the correct deficit, I would recommend reading this article. This one is also a good read on the topic. 

That’s one way to do it. Problem is, over time, as you eat a deficit your metabolism does slow a bit. Additionally, traditional dieting like this tends to lower the levels of a number of important hormones in your body (you can read more about this effect here). All bad things.

Enter the Cycle

One way around this is calorie cycling – eating less one day and more on another such that you still eat at the deficit you need to lose fat, but while sort of “tricking” your body into thinking that you’re not actually starving it – this helps keep it from hanging on to stubborn fat and generally making you feel like crap.

So how do you do this? There are a couple of ways. First, start looking at your calorie requirements over a week rather than just over a day. So, for example, say Person A needs 2500 calories a day. Over a week, that’s 2500 calories x 7 days = 17,500 calories/week. If you wanted to eat at a deficit of 3,500 calories, then that means you need 17,500 calories – 3,500 calories = 14,000 calories over the course of the week. You can then choose to divvy up those calories across the days as you see fit – you might want to eat more on days you work out and less on rest days, or save some calories for that meal out with some friends. You can wave your calories throughout the week to avoid the pitfalls of straight dieting however you choose. That said, I personally just like to use the old rule of thumb that says eat 10 times your bodyweight in calories on rest days and 12 times your bodyweight in calories on work out days to lose fat. I’ve had the most success with this method, and have so far lost about 20 pounds. You can work out the numbers, but when training 3x a week, this puts me at the perfect deficit.

Alternatively, you can go back to the calculator I gave you earlier and select one of the fat loss options. It will run the numbers for you and show you how much you can expect to lose per week (these are only estimates, of course) and how much you should eat per day on both work out and rest days.

An important note: as you lose weight, you will need to account for this. Recalculate your caloric requirements every 5-10 lb. Otherwise, your deficit will over time become your maintenance.

One More Important Tool

One final thing I will say here is that, for weight loss in particular, one tool that I’ve found particularly helpful is something called Intermittent Fasting (IF). This isn’t a diet – it’s more of a pattern of eating. The basic idea is that you set up an “eating window” – typically something like 4-9 hours – and then fast until your next eating window. It may have some health benefits in terms of reducing risks for various diseases and improving lipid profiles and speeding up fat loss, but more than anything it’s just darn convenient. A typical way to go about it is to eat from, for example, noon to 8 pm and then fast for 16 hours until noon the next day. It takes a little getting used to at first, but after a while some people report increased mental clarity and focus, as well as a feeling of well-being, during the morning part of the fast. I’ve found that to be true, as well.

But what about breakfast? Isn’t that the most important meal of the day? And don’t I need to eat every 2-3 hours to keep my metabolism speeding along? My body will consume itself!!!

Slow down. All are valid concerns, but have been addressed elsewhere. I recommend reading this for a great overview of IF and answers to many common questions. This is a good overview too. Another great read can be found here - it discusses some of the common myths surrounding fasting. Also here. This is a great overview and analysis of different ways to go about fasting. If you're going to do IF, I'd recommend taking a few minutes to read through those links. (Update 2/18/15: A comprehensive guide about how to "do" intermittent fasting can also be found here. In the interest of full disclosure, I'll note that the owner of the site contacted me about listing his link here, but it seems like a solid website that's definitely worth looking over if you are interested.)

One of the things I like about IF, especially while eating at a deficit, is simply that it allows me to “save” a lot of calories for later so that, when I do eat, I get to eat a couple of larger meals instead of eating like a bird throughout the day. Also, it’s a lot easier to get out of the door in the morning not having to worry about making and eating breakfast.

A brief note about weight lifting while using IF – there are several ways to go about this, most of which are addressed in the links above (which you should read if you are going to do this). I personally tend to usually only fast on rest days, since I tend to lift weights in the mornings (which means a whey protein shake beforehand and then a meal after working out) and am not a fan of stopping eating at 3 pm in the afternoon to keep my “eating window” intact. And it’s ok. Do what you can. If you work out in the evenings anyway, then this won’t be an issue.

Keeping Track

So you have the tools for fat loss. I’ll talk a bit about weight training here in a bit, but first let’s talk about tracking your progress.

The first thing I’ll say is that changing your body composition takes time. Weeks, months, even years. So don’t be discouraged if you don’t see changes right away. When you make a change, give it at least three weeks or so – preferably more – to see if something happens.

But how do you know if something is happening? By seeing if your metrics are changing. Personally, I use the scale, calipers, and the mirror. The scale is great for keeping track of weight changes, but doesn’t tell you if you are losing or gaining fat or muscle. That’s where calipers come in. Get a cheap pair of reliable calipers (I use the Accu-Measure Fitness 3000 Calipers - they are about six bucks and well-regarded), and learn how to use them (this website is great for both learning how to use them and calculating your body fat percentage). Note that the body fat percentage might not be spot on accurate, but it’s more important that you are consistent so that you can track changes. I’d recommend weighing and taking caliper measurements once a week under the same conditions – I do this Saturday mornings, after getting up and using the restroom and before eating or drinking anything. Once again, be patient. It takes time for your body to change.

Note for females: you might find that you retain water differently throughout your monthly cycle, so your weight may vary from week to week. Thus, it might be more helpful to compare weights/body fat measurements from week 1 of cycle 1 to week 1 of cycle 2, week 2 of cycle 1 to week 2 of cycle 2, and so on.
One More Word about Diet

Image courtesy of Home Fitness Life
So you know how important calories are, how to keep track of them, a bit about intermittent fasting, and how to keep track of changes in your body composition. I haven’t discussed much yet though about what to actually eat. I won’t say much about this except that I really just make sure my protein intake is on par (at least 1.5 g/kg body weight) and let the rest (carbs, fat, etc.) fall where they may while generally eating quality foods. Also, drink plenty of water – you want at least five clear/light yellow pees a day. That’s the easiest way of doing it, in my opinion. You can get a little more crazy with this if you want to – see this website for more information.

I will say that I typically still eat ice cream, albeit in smaller portions, fairly regularly. Remember, at the end of the day, your goal is to meet your calorie requirements for whatever you are trying to do. If you can squeeze in a cup or two of ice cream into your calorie log, so much the better. Like I said before, you don’t want to eat crap all of time, but life is too short to go too crazy with this stuff and you can change your body composition successfully while still enjoying yourself.

To Gain or to Lose?

If you aren’t sure where to go from here, figure out where you are at first. For guys, a healthy body fat percentage is about 10-15%. For gals, that can be more like 18-25%. If you are a guy who wants to gain muscle, but are at 19%, then you need to lose some weight first. This is for a variety of reasons, but for now I’ll just say that first, fat is not functional tissue. It does not make you stronger; it just slows you down. Second, the fatter you are, the more likely your body is to just gain more fat. The leaner you are, the more like your body is to gain muscle (see here for more). Conversely, the fatter you are, the easier it will be to lose fat. The leaner you are, the harder it is to lose fat (unfortunately). So, getting down to a leaner you will, on a lot of levels, be better for your overall progress. I would recommend getting down to at least 10% or so before starting to gain weight again. Hold your diet there at maintenance levels for about two weeks to allow your body to “settle.” When you decide to gain, try to only gain about one pound per week (will be some fat and some muscle) until you get up to around 15% body fat or so. Again, hold there for two weeks before starting to cut weight again. Repeat until satisfied.  

As far as eating for weight gain goes, just eat more. I would recommend calorie cycling still – use the calculator above to figure out what you need to eat on rest and work out days for weight gain. Keep track of your progress weekly, and don’t let things get out of hand.

A Brief Word on Weight Training

Weight training is an important component of any exercise program. Or, at the very least, it’s a very valuable addition. Obviously, be realistic and consult with your physician if you have any question about whether weights, or any exercise for that matter, is right for you.

I also want to make a note that weight training is for both men and women. Women sometimes fear that it will make them bulky, but short of using exogenous hormones, they just don’t have the hormone profile for this to be even remotely true. Guys, similarly, sometimes don’t want to get too big. Don’t worry – you won’t just wake up huge. These things take time. That said getting stronger has multiple benefits for life in general and can be just darn helpful.

I’m a big believer in safely performing basic compound exercises – squats, deadlifts, bench press, overhead press, rows, dips, and chins. Do those, increase your weight over time, and you will get stronger. If you are just starting out, I would recommend something like Starting Strength (can be found here; I like the Practical Programming version) or Stronglifts (can be found here). After you’ve progressed as far as you can on those, check out Jim Wendler’s 5/3/1 (the basic program can be found in various places online, but you should buy and read the book Beyond 5/3/1: Simple Training for Extraordinary Results and pick your variation) or some of Paul Carter’s programs. I wish I had progressed like that when I first started.

(Edit: Since I wrote this, some excellent resources have been put out by Greg Nuckols - a very strong and very smart guy. Head on over to his website (a good place to start is here) and enter your email [don't worry - this guy is legit. The worst he'll do is send you some awesome information that you can unsubscribe from at any time] to get his free training programs. He'll send you an excel file with a bunch of programs that can be used at essentially any level and that you can progress through as you get stronger. That is probably one of the best ways that anyone could get started on their strength-training journey.)

Note that I said that I’m a believer in SAFELY performing these exercises. Spend some time learning and refining your technique before adding much weight. These exercises are not inherently dangerous or bad for you – unless you are doing them wrong. Check out ExRx for pointers. Also, I really like these articles for technique:

Squat: read this.
Deadlift: read this and this.
Bench Press: READ THIS – Part 1, Part 2, this, and this.

Check out ExRx for form instructions for the other exercises.

A Brief Word on Cardio

“Cardio” is what people typically first think of when they think of trying to lose weight. By now you should know that that is not necessarily the case – calories are most important. That said, you can use cardio to help create your deficit, and it’s also useful for increasing your overall work capacity. It’s useless to be strong but unable to walk down the block without doubling over or finish a fight. I try to lift three times a week, and fit in at least two cardio sessions. What you do isn’t really that important. Swim, ride a bike, do bag work, sprint, go for a walk. Just be active and do something you enjoy. Set a goal and achieve it. I used to be a lifeguard, and at least once a week we had to swim a 500 (20 laps in a 25 meter pool). I used to be able to knock that out without a second thought – now I can barely get 10 continuous laps. So that’s my goal. I try and hit the pool twice a week, and am working towards getting better every time.


So that’s that. Medical school is busy, but it’s entirely possible to set up a routine that has you lifting two to three times a week and doing some form of cardio at least twice a week. Controlling your food intake is made much easier by using the tools that I discussed above, and after a while won’t take much thought at all. Getting started is the hardest part, but once you’ve overcome that initial inertia, it will begin to work in your favor. Good luck.

Tuesday, July 15, 2014

Anki Q&A: Part 2

Since my last Anki Q&A post, I’ve received several more questions on how I’ve been using Anki and how to integrate the program into the workflow of medical school. For those of you who are interested, I’ve put together some of the questions (slightly edited for brevity’s sake) and my replies below.

Q: So prior to class, you upload the PowerPoint slides into OneNote, annotate them during the lecture, and review things afterwards, correct? Are you taking extensive notes during class or just focusing on the big picture and highlighting things the instructors stress? Do you also create review notes in OneNote as well? Or do you use Anki exclusively as your studying and reviewing tool? How do you know what to put into Anki? Do you use First Aid?

A: Some of the details of how I studied for each class varied, but the general process was something like upload PPT slides to OneNote the night before, go to class in the morning, take notes (I usually took pretty extensive notes in class, but since I’m typing notes this really isn't too bad. In undergrad, I took handwritten notes, but that wouldn't work for me now. Some people do it, though…), and go home/wherever I'm going to study. By this point, I've usually finished or at least started reviewing my old cards. If I haven't, then I do that now. Once that's done, I'll start making new cards – this is where I would go back over my notes for the lecture (not necessarily watching it again, but you could) and try to integrate things. I know of at least one person who makes Anki cards while sitting in class. I personally couldn't do that, just because I feel like sometimes the professor will say something or show a slide that makes something he or she said 20 slides ago make much more sense.

Anyway, this is the time where I really integrate the details. I usually walk out of lecture with a decent idea of the big picture, but how all of the details come together is often still a bit fuzzy. While I'm going over the details of my notes and making sure I understand things, I’m also bringing in other resources as needed (e.g. BRS for physio or your text of choice).

How I make cards has changed a bit over the past year. I used to make a lot of basic, front/back flashcards. Which are fine, depending on the subject. I started using a lot of image occlusion for anatomy, which is where Anki really shines. For more process-oriented subjects like physiology, I started using more cloze deletions at first, and then started basically creating mega cards in OneNote (e.g. compiling all of the information I need to know or found interesting about, say, sodium handling in the nephron - usually in the form of words and a few pictures - on one screen-sized page, screen-capturing it (using OneNote's super-helpful screen capture tool), and then using image occlusion over that.

Now, technically speaking, that's a really bad card. Personally, though, I found it helpful in terms of keeping enough details in one place such that it was reviewable three months later when the details might start getting a little fuzzy. I have an image-occluded answer that I have to answer, but then I also have context surrounding it that brings that answer to life if I forget why it's right. Again, your mileage may vary. That's something I found helpful, but different things are obviously going to be more helpful for different people, as you mentioned.

As far as what I try to include, I just put in there anything the professor stresses, anything that's in First Aid or a USMLE-oriented review source like BRS Physio, anything I need to understand the concept, or just anything that I find interesting. Again, one advantage of the mega card is that I can have more information on one screen than I actually need to memorize (that is, I don't need to cover over a word in every sentence or over every item in every figure - just over some of the key points. Then, if I need to remind myself of why those key points are important later on, I can just read the context for a quick review).

I hope that made sense. I know the mega card concept might be a bit confusing, so I've included some pictures below. Basically, for a card about renal sodium handling, I might write up a few short paragraphs about the process, throw in a couple of pictures that proved helpful, and screen-capture the whole thing, using the image occlusion tool to then block out of a few key words or image labels (basically using it as a cloze tool for the paragraphs).

The first year is over now, and looking back I'm super glad I used Anki. It made it much easier to review for tests (since I'd already seen the info several times using Anki, I usually would just do a quick review of my notes in the couple of days before a test), and score-wise on tests things went great. So it seemed to work. Now the test will be to see how it helps me retain things long term, and it will be interesting to see what, if any, tweaks to the process I make next year.

Q: I have a question for you about when you said you "looked back at your notes". I ask because some people first do a megareview sheet that compiles class notes, FA material and review books (ie BRS Physio, Lippincott's Biochem etc) before transferring some/most of that info into Anki cards. Did you use Anki as your primary review source like that youtube video in your blog of that student who annotated his notes in OneNote and then made Anki cards as he went along or did you have a separate review sheet? 

A: I didn't really make a separate review sheet per se. What I did do was sit down with my OneNote notes and review books after lecture and, within the OneNote program, create a “megacard” that covered part of the lecture. I might make 3-8 megacards per lecture, depending on what we covered. I would then screen-capture the megacard and use image occlusion to make cards out of it (note: in the videos I posted, you might remember there were two ways to use image occlusion - in one way, depending on the button you pressed to create the cards, if you had occluded, say, 15 words in a megacard, all of them are whited out except for the one you are reviewing. If you use the other way, then you can see all of the other answers while reviewing the one card you are actually on. It's not super important right now, except to say as a side note that I've found it more helpful to use the latter option - it's not very helpful three months down the road when you are reading over the entirety of a megacard to grease the wheels a bit and half of it is whited out. Sure, it might make the first review a little easier, since all of the answers are right there, but some would argue that you really don't need that review anyway....).

Within OneNote, I would just make a note to myself within that lecture of which pages the megacards were on, just so that when I came back around right before the test I wouldn’t have to flip through all 40 pages within a lecture - just the few that I had created the megacards on. Other than that, I never really used them. They're there, though, I suppose, in case I ever needed to reference them. But again, my primary purpose in making them was to create something I could make a card out of rather than make a review sheet. I never really was big into making review sheets, personally, except for things like some of the metabolic pathways. So all that to say that, yes, I did review my notes at least once before tests, but really Anki was my primary study source.

Note: To help explain the “megacard” concept, I’ve included some pictures below.

Q: How do you know what is important and what is not? That is like the million dollar question but I believe you had said that after your exams you turn off some of the review cards because it was stuff that your Prof has said that were exclusive to the class/exam. Is it just by asking upperclassmen? 

A: That is indeed the million dollar question. I personally chose to border on the side of making too many cards. Of course, that meant that there were seasons where I was reviewing 500 or so old cards per day (usually took about 1-2 hours, depending on the material). That's a good way to burn out, but again, it's also my primary method of studying, so there's that. I've said before that 20-50 cards per lecture is a good target, and that's true, but there are just some lectures that require 150 cards. Of course, part of that is just me learning how to make good cards and separating the wheat from the chaff, and part of that is the fact that some lecturers try to cram a huge amount of information into an hour long lecture.

In the beginning, you really won't know exactly what's important. You'll learn quickly, though, based on how your teachers test and what they emphasize. As a baseline, I'd recommend getting the bulk of what's in First Aid for whatever topic you're studying. You can also include information from a relevant review book that's directed at Step 1 prep, since FA can be sparse at times with respect to M1 material (which is also somewhat of a hint about what's important...that said, it is important to have a good foundation, especially when it comes to a course like physiology).

So I guess in order of importance I would definitely try to get information from FA (if any), then get most of the stuff on the topic from a review book (if you can get access to a digital copy, that works great for incorporating them into megacards), then include any major stuff that your professors emphasize that's not in those resources. That's a decent baseline. After that, you can debate with yourself about including stuff that is extraneous or perhaps that you just find interesting. As a side note, again, the cool thing about megacards is that you can include all of that stuff (the baseline stuff + the interesting stuff/extra explanations/etc. that really don't merit their own card) on one megacard, but just make actual cards out of the important stuff. The extra stuff, then, is just there to review at your leisure.

Q: I kind of get what you meant about the OneNote megacards – could you possibly print screen a few of your cards to clarify? Also, I am new to OneNote but am impressed by the interface and like it much better than EverNote. However, my problem is this: let’s say that your class notes are in one tab and your personal notes are in another tab or section, can one open your class notes in a new window and have them next to your personal review sheet in terms of referencing and creating these Megacards? I hope that makes sense. Also, are you using Office 365? I ask because I am wondering how one can backup their OneNote data and/or be able to access it from a remote computer if needed. By the way, do you have Windows 8? If so, how do you like it compared to Windows 7?

A: Pictures definitely help. I attached a couple of pictures from my review today as an example. In the "Card Front" picture, I just took a screen shot of Anki - you can see that there is a megacard on hormonal changes during pregnancy, in this example. For this card, I used image occlusion to block out a word on the top right - that's the red box. When I answer the question, the box disappears and the correct answer is revealed. I probably have 10-15 cards or so within this one megacard, so not only do I see all of the information repeatedly (though I don't necessarily take the time to read through everything that's not related to the question at hand), but the individual "cards" are located within the context of the overall subject. In this case, for example, if I forget what some of the other hormones are doing, I can just read the megacard to find out. 
Card Front
Card Back
On a side note, for this card I basically just screen-captured some text from BRS Physio. It's a review book, so it doesn't necessarily have all of the detail necessary for class, but I found it helpful for capturing the big picture. So in this case, I might make a similar card using class notes with more detail, but also make this one as a general overview, making sure that the cards complement each other rather than just making a bunch of duplicates.

For OneNote: I make a new notebook for each class. Within each notebook, I make a new tab for each lecture. Within each lecture, on the sidebar, I'll have a spot for the handout and the lecture PPT. You can see this in the attached picture "OneNote Image 1." 
OneNote Image 1
During lecture, I'll follow along with the PPT and take notes next to the individual PowerPoint slides. You can see an example of this in "OneNote Image 2."
OneNote Image 2
After lecture, I'll start reviewing the lecture and make Anki cards. Part of this is creating the megacards, if the lecture/class/topic calls for it. You can see in the first OneNote image how, under the handout of the Complement lecture, I've written "Review" in some of the page titles. Those are the pages where I've created megacards. If I were to click on that page, it would bring up the handout page, but if I scroll to the right, I would see what you can see in "OneNote Image 3" - a megacard. I would screen capture this to use it in Anki, and then come back to it later just before the test to review it. 
OneNote Image 3
As far as backup goes, OneNote is tied in with OneDrive (formerly Skydrive), which is a cloud storage option with Microsoft. If you log into your OneDrive account online, you can theoretically remotely access your Notebooks. I honestly don't use this that much. But it's there. I also back up my notebooks to my computer in a separate file, and my entire computer is backed up using a program called Carbonite. So I'm not too worried about losing any data, but you never know.

I bought a computer before medical school, and it does run Windows 8. I really liked Windows 7, and wasn't too excited about switching, but I was surprised at how much I actually ended up liking it. It takes a little getting used to. I spent some time watching videos online about how to use it and navigate the system efficiently, since it's really not as intuitive as Microsoft likes to think it is. I probably wouldn't like it as much if my computer wasn't a touchscreen, although it really shouldn't make much of a difference.

Q: I'll keep this short; I'm a busy student myself! Here's a link to a paper. If you have time, there is some interesting information there. One part that stood out to me was the superiority of free-recall vs. Cloze deletions in strengthening of memory in one of the papers cited.

A: Great article – thanks for sending that along. I will just briefly say two things about this: first, in the paper in question (Glover, 1989), free recall techniques were in fact shown to be more effective than cloze deletions (“cued recall” in the paper). That said, cloze deletion was still shown to be a superior method of learning for the purpose of retaining information. Second, there are always “better” ways of doing things, but in life – and particularly in a busy environment like med school – sometimes being efficient means striking a balance between “best” and “good” ways of doing things in order to maximize the time you have available. In an ideal world, sure, free recall is probably best for most things, but I’ve found that, practically speaking, cloze deletions get the job done and allow me to do well on tests while retaining information and still spend time with my family at night. At the end of the day, that’s a win in my book. Other students might find other methods to be more suited to their preferences and goals. That said, this is a pretty awesome paper in that it really goes into detail about the “why” behind the theory of spaced learning.

Monday, May 26, 2014

The End of the First Year

As May fades away in the rearview mirror and we delve deeper into the first hints of summer, it’s hard to believe that the end of the first year of medical school has arrived. Much has happened in the past months. It seems as though we have learned more information in one academic year than many of us learned in most of our undergraduate experiences. We’ve been transformed from relative newcomers in the world of medicine to perhaps the most basic level of initiate – familiar enough to poke our way around and recognize a thing or two here and there, but with so much remaining incredibly foreign to us. We’ve been taught the basic skills of patient interviews and exams, and have gone from bumbling around in our standardized patient sessions (what do you do with this otoscope? Or is it an ophthalmoscope...?) to being able to perform relatively fluid interviews and make our way through a rudimentary exam (although, really, we’re still bumbling around – perhaps just in a slightly more polished fashion). Finally, my wife gave birth to our son almost four weeks ago – a busy addition to an already busy life, but a more than welcome one. We’re happy to have him here.

We’ve learned so much that sometimes it’s easy to think that we have come far in our medical education. And, to be sure, we have – but by no means as far as we might like to think. I was reminded of this once again while recently shadowing my third year student preceptor while he was rotating on pediatrics. While listening in on their table rounds, I was able to pick up on certain little things here and there (hey, beta-2 microglobulin? I know what that is!), but most of it flew far above my head. But while I don’t understand most of the finer points of what was being discussed, or at least only understand certain things on a rudimentary level, I found it incredible to watch how the providing team took all of these random minutia (most of which I hadn’t learned, some of which I had but was surprised to see show up in such a practical way) and fit the seemingly-unrelated pieces together to construct a coherent diagnosis and treatment plan. It was simultaneously daunting (we have to learn all this stuff?) and encouraging (it will be pretty cool to be able to do that…) to watch their finely-tuned performance.

Though I’m frequently reminded of how far I have yet to go, sometimes we get the opportunity to flex our “clinical muscles,” so to speak, and practice what we’ve learned – which is always a satisfying experience. One of the ways I was able to do this was while shadowing my physician preceptor, an internal medicine/pediatrics physician, at her clinic. There, I was able to interview several patients, including one who came in concerned that she had been feeling down for a while. She put on a brave face for the first few minutes of our interview, but when we began delving deeper into what was going on her life, she broke down into tears. My first instinct was to reach out and comfort her in some way, but I had to stop myself – this wasn’t a loved one, but rather a patient, and it probably wouldn’t help her much to have some random medical student wrap her in a bear hug. Still, though, I tried as best as I could to talk through things with her and encourage her. After I finished the interview, I presented her case to my preceptor and she came in and arranged further follow up with the patient. It was encouraging to see the patient leave with at least some hope for the future and a definitive plan in place to take care of her.

I also had the opportunity to volunteer at some of the different free clinics around the greater Chicago area. With a multitude of patients to be seen and oftentimes only one, maybe two, attending physicians present, it’s a place where bright-eyed medical students can actually, sort of, kind of be somewhat useful. Or at least we’d like to think so. In any case, it does give us the opportunity to take our interviewing and examination out of the safe walls of our clinical skills center and into the world of real medicine.  One patient in particular that I remember came in complaining of pain and swelling to his right lower leg over the past two weeks. He had a vague history of surgery to the area around six years ago or so in a different country, though he wasn’t sure what the procedure was or what it had been for. He’d now quit work because it was too painful to stand, and thus didn’t have insurance. I had the opportunity to interview him and perform an exam, noting things like pitting edema, good pulses, calf tenderness, and a distended area in his popliteal fossa that was tender to the touch. From some prior experience working in an emergency department, I was concerned that one possible cause for his symptoms might be a deep venous thrombosis. After leaving the patient’s room, I presented the case to the sole attending that was there, and after examining the patient he was also concerned that that might be the case, and started the process to get the gentlemen the care that he needed. While the role I played was small, it was still satisfying to have reached a point where I at least could recognize that something wasn’t right and build a case, using different points of evidence from the history and exam, to support what I thought was going on.

So it’s been a busy year. Even though we’ve been done for almost a week, it took me a few days to realize that it was all over and I really, actually, honestly didn’t have any more material to study. I remember thinking over Christmas that it was cool to be halfway done with our first year, but then I would remember that it was only an eighth of the way through the entire thing. It’s nice to be able to say we’re now a quarter of the way done, and half of the way through the bulk of the classroom stuff. This summer, I’ve got a clinical research project lined up that shouldn’t consume too much time, at least after a couple of semi-busy weeks, which will leave me free to hang out with my wife and our new son. We’re all looking forward to it.
P.S. I’ve been receiving more questions about how I use Anki. I’ll probably be doing a Anki Q&A: Part 2 sometime in the near future (the first one can be found here). That said, feel free to send me any questions you’d like to see addressed, either via email ( or the comment section below. 

Thursday, May 1, 2014

Our Little Human

It’s been a while since I’ve written a post. We’ve been going at breakneck speed through all of the organ systems in our physiology class, and just when I was starting to get a handle on that pace, we started immunology as well. Also, as I’m writing this, my newborn son is sleeping quietly next to me in his hospital bassinet. So yeah. Life has been busy.

Since starting with the cardiovascular system, we’ve slogged through respiratory physiology, the renal system (bleh), gastrointestinal physiology, metabolism, nutrition, endocrine physiology, and now we are just about to start our reproduction block (how’s that for timing...).

Image politely stolen from here

So far, school has continued to go pretty well. Physiology has been, for the most part, an enjoyable class. It’s not like there is a ton of practical medicine contained within those hallowed PowerPoint slides, but you’ve got to start somewhere and it’s definitely more applicable than something like the molecular biology and genetics course we started out with. Immunology has also been surprisingly interesting. It’s one of those classes where getting the big picture is essential, but once you’ve got that down things start falling into place and making a lot more sense. Also, we’ve got less than a month left in our first year of medical school, which is awesome.

But the most exciting development in the past few weeks has been the arrival of our son. He was actually a little late, going by estimated dates and whatnot, since he finally rolled into town at 41 weeks. We actually thought he might come at least a couple of weeks sooner – my long-suffering wife had started feeling nauseous, really tired, and having more frequent Braxton-Hicks. Anecdotally, those things sometimes point towards impending labor, which was exciting. Of course, the weekend that she started feeling these things was the weekend before an extremely front-loaded test week, so we were crossing our fingers (or at least I was) that we’d be able to make it past at least two of the three exams we had that week before our son decided to arrive.

Make it past the tests we did. We also made it through the rest of the week, and the next weekend, and the rest of next week, and… you get the idea. Be careful what you wish for and all that, I suppose.

Finally, last Friday, we had another routine appointment at the hospital. My wife was a little bit dilated, which was exciting. Afterwards, they wanted my wife to have a non-stress test, just to assess fetal health since she was a couple of days past 40 weeks. The test involves her belly being hooked up to devices that measure the fetal heart rate and indicate whether or not she is having a contraction. Just like when we stand up or something and our heart rate increases a bit to compensate for it, when a baby is turning circles in his mother’s womb his heart rate should also go up. The test is basically looking for that to happen a certain number of times within 20-30 minutes. It’s a pretty basic screening test, though – if it’s “reactive,” or if the heart rate increases like it’s supposed to, then everything’s usually fine. If it’s “non-reactive,” though, or the test says that it didn’t pick up the heart rate changes, it’s actually wrong a little over half of the time.

Our test on Friday, of course, was non-reactive. It didn’t help that the nurse we had, while nice, was obviously new and wasn’t really doing much to inspire any confidence. We knew things were probably fine (my wife could feel him moving around quite a bit), but as a follow-up test they do something called a biophysical profile – basically an ultrasound where they measure various criteria and assign the baby a score that describes fetal health – the higher the better. Our son got the highest score possible, which was reassuring. That said, it turned into an unexpected four-hour hospital visit.

The doctors at the hospital wanted us to come back in on Saturday for another non-stress test, just to make sure things were fine. That one was fairly quick and painless, which was good. We had a fairly relaxing day on Sunday (with lots of walks! Walking is one of those things that is supposed to speed things along, so we spent a lot of time walking in the last couple of weeks).

On Monday, we had another follow-up appointment at the hospital. Everything was still looking good, but my wife hadn’t really progressed much since Friday. Which was fine, except having a large child inside of her belly was quickly getting really old, really fast. She spent most of Monday doing everything she could to get things going (massage, acupuncture, walking, various positional changes, etc.). Finally, Tuesday morning, she felt like her water might have started leaking. She really honestly wasn’t sure and otherwise felt fine (and we found out later it was really a pretty small leak), so she and her mother (who had flown in a few days earlier) went to the hospital to get checked on, honestly expecting to be sent back home. Since we thought that she would likely end up coming back home, and I had an exam that day at school, I went in that morning but kept my phone close. Before I got a chance to take the exam, though, they called and said it was in fact her water that had started to break. Finally!

I grabbed my stuff and headed out the door. For whatever reason, today of all days was one of the darkest, stormiest days we had had for a while. To get to the hospital, I was driving into the heart of the gloomiest-looking thunderstorm I had ever seen. Which was fine, except that when I got there it was raining cats and dogs and by the time I made it from my car to my wife’s car in the parking lot (to grab some bags) to the hospital, I looked like I had decided to take a noon-time swim in my dress shirt and slacks (we had dressed up for standardized patient interviews that day).

Originally, we wanted to stay at home as long as we could before going into the hospital, but since she had tested positive for Group B Strep (a type of bacteria that different people normally colonize at different rates – about 1 in 4 women or so are positive, but it can be very harmful to a baby that is exposed to it during the birthing process), she needed to come in a bit earlier to get antibiotics, which is really the only reason she called and came in when she did. Also, she really wasn’t having super strong contractions yet – they were still pretty basic Braxton-Hicks that she had been having all along. But again, since she was GBS positive, she really needed to start having contractions soon after her water broke. Since she wasn’t, they started her on a low dose of Pitocin (a synthetic form of oxytocin, the hormone that – among other things – causes uterine contractions during labor). She labored like a champ for eight or nine hours on the Pitocin drip (which is somewhat infamous for sometimes causing contractions that can be much more intense than those that you might have normally), and finally had an epidural late that night, which allowed all of us to relax a little bit and actually dose off for a few minutes at a time here and there. Finally, at almost 6 am the next morning, our son was born, weighing a healthy 7 lb 14 oz.

As I sit here now and watch him sleep (which is really something I should be doing as well, since sleep has been a rare commodity over the past day and a half and things don’t look to get any better any time soon), it’s almost surreal to realize that he is our child. It’s really incredible to realize that this temporarily peaceful little human belongs to you and is your responsibility. It’s something that is hard to grasp from just interacting with other people’s babies or young children – this little guy is yours, and it’s your job to keep him alive and teach him about life and all that that entails. It’s also incredible how darn cute and little he is, but I digress. Things will be busy, I’m sure, particularly with medical school in the mix, but I wouldn’t have it any other way.

Thursday, March 13, 2014

Anki Q&A: Part 1

Since I've started using Anki and writing about it on this blog, I’ve received a few questions about how I use it on a daily basis. Because I think Anki is awesome (though certainly not the only way to study for medical school – or study anything else, for that matter), and because if one person has a question, then usually there are several others with the same question, I’ve decided to write up a brief “Anki Q&A” based off of questions that I’ve received or I've seen commonly asked online. It’s important to note, however, that Anki is an extremely versatile tool, and though I use it in certain ways, the way I use it is far from the only way to do so. There is no “right” and “wrong” here – there are certainly more or less optimal ways to use the program, but ultimately it comes down to what works best for you – and what is best for you may not even be using Anki in the first place, depending on your study style. So take everything below as more of a starting point than as Anki gospel. If you have any other questions, please feel free to post them below in the comments section and I may add them to the post later on.

Image politely stolen from here
Q: Why Anki?
A: I’ve written before about why I use Anki, and you can click here to read a more in-depth explanation of the program and how to navigate its nuts and bolts. Briefly, though, I use Anki as a systematic way to retain the information that I’ve worked so hard to learn for the long haul. Before starting medical school, I commonly heard or read the writings of medical students bemoaning the fact that they feel as though they had forgotten large amounts of information as time passed. Obviously, to some extent, that’s inevitable. Also, much of the information we learn, particularly early on in medical school, isn’t crucial to remember to “be a good doctor.” Nevertheless, I did the binge-and-purge method of studying throughout undergrad, and frankly only remember half of it all, if that. I didn’t want that to be true for medical school.
On a practical level, the process of making cards for Anki helps me to consolidate the information I am learning into discrete units of information that I can then tie together for a broader understanding of major concepts. Of course, simply staring at your notes after class or writing a summary page for each lecture or *insert method here* can do the same thing, so that’s not really unique. What is unique is that Anki then forces me to review that information precisely when I need to – I see it before I forget it but not until I need to, thereby helping me to avoid wasting my time by relearning information before a test that I had learned a few weeks ago in lecture and forgotten or by reviewing information that I already know.
Q: So you like flashcards. Why not something like Firecracker?
A: I’ve personally not used the Firecracker program, but I’ve heard great things about it. However, I personally find the process of creating flashcards to be helpful in terms of making sure that I truly understand a concept before I just start mindlessly memorizing it. Also, Anki is pretty much free (the iPhone/iPad version costs about $25, but the desktop and Android versions are completely free). So that’s cool. That said, if you’re someone who doesn’t want to make flashcards (which is certainly a time commitment) but you want the advantages of spaced-repetition, I could see Firecracker being a great option.
Q: How many cards do you make per lecture?
A: Depends on the lecture. I usually try to shoot for somewhere around 20-50 cards per lecture, but honestly that depends largely on the type of cards I’m making (cloze vs. image occlusion vs. basic, etc.) and the content of the lecture. On average, as of late anyway, I’ve probably been making closer to 70-100 cards/lecture for physiology and immunology – mostly image occlusion cards. While that might seem like a lot, they really go pretty fast when I’m reviewing them later, mostly because I really try to have a card for each discrete fact that I want to remember, rather than, say, 10 facts on one card.
Q: How long does it take you to make your cards each day, and how much time do you spend reviewing old cards?
A: On average, I’d say it takes about 1-1.5 hours to make cards for an hour-long lecture. Since I usually have about two lectures a day, I spend around 2-3 hours reviewing the lectures/clarifying concepts/making cards, and then maybe a half an hour reviewing them, depending on how many I made. Additionally, it takes anywhere from 30 minutes to an hour and a half or so to review old cards that are due that day, again depending on how many cards I made the previous day (and how focused I stay while reviewing them…). That said, the time spent reviewing old cards can be distributed throughout the day thanks to the Anki app that I have on my phone – that way, I can just knock out a few cards here and there throughout the day, so that by the time I’m ready to sit down and make new cards for the day, I’m done reviewing old cards or only have a few left.
Q: What type of cards do you make? What kind of stuff do you include?
A: Depends on the class/topic/how I'm feeling that day/etc. I started out making a lot of basic flashcards (e.g. "List the 4 steps of xzy," "What is abc?"). When anatomy hit, I found online textbooks to be very helpful because I could screen capture an image and use image occlusion to make cards out of it. For physiology, it's more conceptual so I've found myself using more cloze deletion cards. In fact (and this probably isn't the best way of doing things, but whatever), for long processes or complicated concepts where it's helpful to have a lot of information in one spot for future reviews, I'll make a really long card with all the relevant information I need and then the cloze the heck out of it, so that for some cards I have almost 20 individual clozes per card. You could also just put the relevant sentence or two on a card, and then put all of the excess stuff in the "extra" box so that it pops up for review when you answer the card, but putting it in the card makes it more likely for me to actually take the time to review stuff when I'm rushing to get through my cards.
You can also write up a paragraph or two of information (e.g. how sodium is handled in the nephron), throw in a few pictures, arrange things so it all fits within your screen, screen capture it all, and then use image occlusion to block out words or phrases within a sentence (basically cloze deletions). Heck, if you’ve got good slides, you can just use image occlusion on those to make a decent, quick card.
Q: Do you keep reviewing all of the cards you’ve made throughout the year? Or do you stop reviewing certain decks/cards after you’ve had an exam on that material?
A: So far I've kept reviewing all of my decks - I'm still reviewing some cards from our very first classes, and still reviewing things from anatomy last year. That, to me, is one of the major purposes of using Anki - a systematic way to review old material so that it's at least a little bit fresher when it comes time to take, for example, Step 1, or even if you just need to call upon the knowledge for whatever. That said, I do suspend certain cards that I wrote that contain details that really are irrelevant for anything but the test. However, I also only try to make cards for things that are worth remembering, so I really don't end up suspending a ton of cards.

That method isn't the only way to do it, obviously, but it is, for me at least, the method that is most consistent with what I want to get out of Anki - I view it not just as a way to do well on the next test (although it serves that purpose well), but as a way to review information that would otherwise slowly degrade over time, and using its spaced-repetition algorithm to eventually shift that information into my long-term memory. It's a commitment (I have around 12000 cards total now, and review anywhere from 200-400 old cards per day while making an additional 50-200 cards per day on most days - most of which is probably a bit excessive), but it's also my primary method of study, and no one ever said medical school would be easy. I personally would hate to have to tackle all of the information we learn without something like Anki to help me organize and process it. 
Anki might seem like a lot of work, and it can be, but it has been the best thing ever in medical school. It provides an organized way for me to integrate the information I'm learning, systematically review it, and retain that information for the long term. It can be a lot to keep up with on some days, but even though my weekdays are probably consistently busier than some of my classmates, my weekends are usually free, and I'm generally done by a reasonable time during the week anyway (usually, by the time I get home, review lectures for that day, make cards for those lectures, and review those cards, it’s around 5-7 pm). And it's paid off in terms of grades. Everybody learns differently, but this definitely has worked well for me.

Note: Anki Q&A: Part 2 can be found here.

Friday, February 21, 2014

A Terrible Day at the VA

Oh. My. Gosh. What a day.

For our Patient-Centered Medicine course, we are paired with a physician and an M3 student mentor, both of whom we have to shadow a couple of times over this semester. Since my wife is due in April, I figured it’d be best to get those out of the way now. So, today, I shadowed my M3 mentor. He was on an inpatient psych rotation at the VA hospital near Loyola. Which is probably the most terrible place in the world (ok, not really, but the events of today have left me rather ill-disposed towards it at the moment…).

After navigating my way to the main entrance, where I was supposed to meet my mentor, I discovered that, as it turns out, there are actually two main entrances. On opposite sides of the freaking building. So, I continued to navigate my way into the bowels of the VA and eventually found where I was supposed to be. I met up with my mentor, and he took me to a little psych consult room where a couple of other junior/senior medical students were working on stuff. After reviewing the past history of the patient we were about to go interview, we went and found the psychiatrist (whom we’ll call Dr. J) my mentor was working with and my mentor introduced me to him. He seemed nice enough, perhaps a little eccentric. We started walking back through the maze of hallways while talking about the next case. Dr. J asked if I had been here before, and I said no. They both smirked – in a friendly, yet knowing way – and said, almost in unison, “Welcome to the VA.”


As we were nearing the elevators, Dr. J turned back to me and said, “You’re welcome to take the elevators, but we take the stairs. We’re going to the 8th floor.”

Of course you are.

I went along with it though, like a good little medical student. After we huffed and puffed our way up to the 8th floor (I really need to do more cardio…) we stopped at the nurse’s station. “We always catch our breath before going into a patient’s room,” Dr. J said, in between breaths.

After recovering there for a bit, we finally knocked on the patient’s room. He was a male in his mid-thirties who was, at the end of the day, a pretty normal guy. He had had a tough few years, though, with family members dying, a divorce, and some tough luck. He had apparently had some chest pain recently (which he had experienced before) and presented to the VA seeking help. They had started to rule out a cardiac etiology, though they still wanted to do a stress test. Dr. J was here to investigate the possibility of generalized anxiety disorder and/or panic attacks causing his symptoms.

In the emergency department, where I worked for two years before medical school, a “long” interview was maybe 15-20 minutes. Today, though, we spent almost an hour interviewing and talking about the patient, which my mentor said was fairly average. We sorted out how best to get him some help in the form of outpatient counseling and a little Ativan for the odd anxiety attack, and went on our way to check on another patient, who was on the second floor. This time, mercifully, we took the elevator. This patient was in surgical ICU while recovering from abdominal surgery. He had apparently been a bit delirious, mostly at night. Last night, he had ripped out his ostomy bag, making a mess. He also apparently was telling people that he was actually dead and didn’t know how he was talking to them.

Today, though, he seemed mostly normal. Mostly. In talking to him, you could tell all of his oars weren’t in the water, so to speak, but he had apparently decided that he was in fact alive now. That’s good. But we’ll keep you here just a little longer. And give you something to sleep at night.

After that, I headed out. I had a bunch of stuff on my plate to do that afternoon, mostly in the form of actual school work I needed to get through. Before I left the VA campus, though, I wanted to pick up my ID card that had taken forever to sort out. Back when we first started, we had to fill out an hours-long set of forms online for a background check and then get fingerprinted (which took hours and hours of waiting in line at the ever-so-efficient VA HR department) so we could get a government-issued ID for our rotations at the VA hospital in third year.

Turns out, though, the person in charge of handling the paperwork for my entire class left the VA while it was processing, and somehow all of our applications were forgotten about. And after sitting in some electronic holding vat for too long, the VA system terminated some of ours, depending on how long they had been sitting there. Those of us who had gotten them done early, for example. Like me.  And, by the time they told us, our original fingerprints had expired. Lovely.

So I had gone back to HR a few weeks ago to get my fingerprints redone, and tried to figure out what was going on with the online forms. Someone took my name and said they’d figure it out and get back to me.

Which never happened.

I ended up calling the person in charge of “endorsing” us for our badges, who said don’t worry about it, we really didn't need that form anyway (so we spent hours filling it out then because…?). Your fingerprints are all you need for the background check. Go get your card.

Awesome. So, finally having a free moment from school, I thought that I’d run over to the ID card office and pick it up real quick. Hahahahahaha……

Turns out the office is in the middle of a seemingly mile-long building that stretches across the entire VA campus. And looks like it’s abandoned. And only has one entrance (that I could find) labeled “Suite C.”  I needed Suite E. I couldn't tell where along the mile-long expanse to park, so I called the office number and asked them for some type of landmark. “We’re in building 1.”

Yeah, I got that.

“Oh, we’re at the north side of the building.” Great. So I drove to the north side of the campus/building…no entrance. The frick.

Drove back to Suite C. Parked. Went in. Was told to walk up a long hallway to Suite E. So I did, and finally found the office. Then I found out I wasn’t actually going to be able to pick up my badge, I actually needed to start the process. Which means more fingerprints and pictures. Buuuut the fingerprint machine wasn’t working – its server is busy. Can you use the extensive fingerprinting that I had completed at HR? No, our systems aren’t connected like that. Fine. Let’s try again. And again. And again. Let’s wait and see if the system suddenly becomes not busy. I did some Anki while waiting. Try again. Wait again. More Anki. Try again. Wait again. Try again. Oh, let’s change this parameter – great, it’s fixed (an hour and a half later). Oh, remember those online forms you were told you didn't need? You actually do need it. We can’t give you a badge. Sorry.


So I walked back out of the building, toyed with going home and just doing the stuff I needed to get done, but decided that I’d better just go over to HR and sort out the online forms thing now and save myself a trip back to this dreadful place. So I walked over to HR, and actually ended up speaking to a lady there who was actually very helpful, which was a nice change of pace. She even stayed a little over her shift to sort things out, revived my forms from their electronic grave, dug some of my old paper forms that I had signed months ago out of some stack in a corner so I didn't have to go through them again, and got things moving again. I should be able to finally get my ID card in a few days.

I hope.

Monday, January 20, 2014


Anatomy is finally over.

Actually, it’s been over for about a month now. We finished the week before Christmas, and then went on a two-week break. Glorious break.

My wife and I flew home for Christmas to the West Coast (the best coast, in my humble opinion…) to spend it with our families. The flight there and the time we spent with them was pleasantly uneventful and relaxing. Then the effects of a so-called polar vortex hit the Midwest, wreaking havoc with our travel plans.

Image politely stolen from here
We were supposed to return home on an early-morning Friday flight. We pre-packed our stuff the night before, woke up at the rather ungodly hour of around 3 am, made our way to the airport, got our bags inside, made it half-way through the line to check our bags in… and then one of the airline employees made her way towards the line and started calling out, “If you are flying to Chicago, Denver, or New York, your flight has been cancelled due to weather. Please call the 1-800 number to reschedule.”

Well, darn.

I dialed the number while we were standing in line – the first of many times we would call this number over the next few days, as we would soon find out. I was answered by a machine and quickly put into an ever-growing queue.  My wife tried calling as well, and actually ended up getting through first. We were able to reschedule, but due to the treacherous weather our destination was experiencing, the earliest flight we could get on wasn’t till Sunday.

So we hung out for a few more days – sort of a forced vacation. At least we were able to be with family, but we were both ready to get home. On Sunday morning, we repeated our get-up-way-too-early-get-to-the-airport-get-in-line-check-to-see-if-the-flight-is-canceled-for-the-upteenth-time routine. We checked in, checked the flight status board on the way to security, made it through security, and were walking to our gate when we checked one of the flight status boards again, just to be sure.

Cancelled. Again.

We walked down to the gate just to see what was going on – the flight had literally been cancelled in the time it took for us to walk through security. This time we had to somehow get our baggage back, and apparently the airline didn’t have any standard procedure for this – one of the airline employees literally took a vote among the would-be passengers that were present at the gate about how they wanted their baggage returned (they ended up carting it to some office somewhere in the airport where we could go pick it up).

We again tried calling the 1-800 number, and when we finally got through, the earliest we could be rescheduled for was Wednesday afternoon – three days away. Argh. Also, it turns out the airline we were flying on was the one airline that wasn’t able to put their passengers on the flights of other airlines in case of situations like this.

By this point, we just wanted to get home. We found a place with WiFi access, took out one of our laptops, and searched for the soonest flight heading back home on another airline. We would have pay a bit more to switch our tickets, but whatever. We wanted to get back. We made the switch, but now we had to figure out how to get our baggage. It turns out that, normally, if you made a last-minute switch between airlines like this when you were already past security, the airlines will just switch your baggage for you as well. But the airline we were flying originally was, of course, the one airline that didn’t do this. So, we walked back out, tracked down our baggage, got back in line to check in our bags, went through security – again – and finally arrived at our new gate, tired and slightly ruffled but happy to be finally heading home.

Of course, this is all still at around 6 or 7 am in the morning. Our new flight didn't leave till around 10 am, so we had a few hours to kill. We hung out, got some food, read, and waited. Around 9:30, we were told that our flight would be delayed for another hour. Ok, fine. We just wanted to get home at some point.

We waited around some more, and as the promised time drew near, another announcement was made: we were delayed again. We ended up being delayed four times, but after spending about nine hours in the airport we finally were able to board the plane and make it home. Just in time for record-breaking subzero temperatures. At least school was cancelled that Monday, which was nice.

Our first day back, it was around -15 degrees Fahrenheit with a wind chill of around -30 to -40 degrees. We, of course, didn't get the memo and decided that we should go shopping before the week started. That was fun – particularly the part where I almost lost a couple of fingers (ok, not really, but I definitely reached the early stages of frostbite…) trying to uncover our buried cars, one of which didn't even start up for a couple of days (till it warmed up – relatively speaking – to around 25 degrees, anyway…). We had a pipe freeze, too, which thankfully didn't burst. That would have been a bummer.

School started up again that Tuesday. We started our physiology class, which will run for the rest of the semester. Now (a little over two weeks later), we've just finished our cardiac physiology section, which was really quite interesting. It’s quite the organ. We also learned how to interpret EKGs, and it’s amazing how much information can be derived from all of those bumps and squiggles. We also took our own EKGs, and apparently my heart is actually pointing almost straight down in my chest – most people’s hearts point down, left, and towards the front. The things we learn in medical school.

Oh, and apparently we have another cold front coming in tomorrow. Chicago, we love you too.