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 (bloggeradmin@dysgraphicmusings.com) or the comment section below. 

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.

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.

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.”

Huh.

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.

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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.

Frostbite

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.

My Personal Statement

Note: One of the more time-consuming and difficult things you must complete for your medical school application is a personal statement. It essentially provides an opportunity for you to tell admission committees who you are, what you value, why you want to be a doctor, what makes you different from the thousands of other applications, and anything else that doesn't really fit into the tidy little boxes on your AMCAS application. It’s an important part of the application for all schools, and a crucial part for some. Outside of your transcripts and whatnot, this is your only chance to convince the school to consider you for an interview.

I briefly wrote about how to formulate a personal statement here in the “How to Get into Medical School” series. One of the more difficult parts of writing it, for me, was not really knowing what it was even supposed to look like as a finished product. With that in mind, I've decided to post mine here – not that this is the only way to do it, by any means, but it’s one way. Whatever you end up writing, you'll most likely think it's the most amazing thing at the time, only to cringe when you look at it several years later (little heavy on the melodrama in mine, I think...). Regardless, I hope that it might help point some of you who are trying to compose your PS in the right direction. Good luck.

Death was no stranger to me. But this one was different--I knew her.  I was working in the patient transport department in a large hospital in Portland. I was new, and only had been working for about a month and a half. It was the middle of a moderately busy Friday evening shift. I sat down to rest my weary feet and to pick up a new job over the phone system. An automated voice came on the line, telling me to take a patient named Katie from the seventh floor to the morgue. My heart sank. I knew this woman. I had recently transported her, and even though she was in the hospital and obviously sick, she hadn't struck me as someone who was on death's doorstep. She was young--not even forty.  Yet here I was, picking up her morgue job. I hung up and reached for the morgue key.  The key was attached to a trapeze handle, apparently to make it easy to find. Most of the trapeze handles in the hospital were bright colors. This one was black. Fitting, I suppose. I left the transportation office, obtained a gurney and a blue tarp to place over the former patient, and began the long walk to the seventh floor of the hospital.  The seventh floor, by the way, was the Oncology unit. Katie had died of cancer.

Death hadn't really bothered me until Katie. But Katie was different. Cancer had struck her down when she had so much life left. And even though I had not really known her, I had cared for Katie and talked with her. She had, to me, been a real person, while the cadavers in anatomy lab and bodies of other patients had been anonymous. They had lived their lives, of course, but I had not been a part of that. With Katie, I had. Who could have known, on that day that I transported her just a few weeks ago, that I would later wheel her dead body to the hospital morgue? Sorry, Katie. We have failed you. Cancer has won this battle.

This was not the first time I had encountered this sense of helplessness.  A few years before Katie, I had the opportunity to travel to Africa.  While I was there, I was mentally wrestling with myself about the future.  When I was younger, I thought I would go into law.  The idea of being presented with an issue, thinking through all aspects and perspectives, and then using logic and argument to debate for one side appealed to me.  The thrill of the contest seemed to provide a rush like nothing else. However, in my first college English class, we were assigned to write the quotidian research paper.  I chose to focus on the medico-legal aspects of stem cells.  Although here again I found the excitement of laying out all sides and making my case, there was something new here.  The potential capabilities of stem cell applications in particular, and medicine in general, contained within themselves the possibility not only of captivating intellectual opportunities, but the real ability to radically change people's lives in a tangible way. It was then that this usurper of my attention, medicine, entered into my life.  I knew it had the potential to cause change, and in Africa, I saw the great need for just that. We spent some time in Kibera, the second largest slum in Africa. People were living in huts built from sticks and mud. Hygiene was poor--walking along the narrow roads between huts, it was generally best to not dwell on what was underfoot.  There was no running water, no formal sewage system. Disease, including HIV/AIDS, was widespread. Change was needed here.  These people needed social help, political help, economic help--but first, they deserve at least to live.  To not be plagued daily by easily preventable diseases. Medicine was necessary for this to become reality, to begin to effect lasting change--and I deeply desire to play a part in this.

A year later, I was working as a lifeguard back in the United States.  It was here that I experienced a rudimentary exposure to medical care, particularly emergency medicine.  The thrill I thought I had found in simple debate was exponentially replaced by the high that came from being presented with an acute problem, whether a simple injury or a drowning patron, accounting for a number of factors that play into the situation, and responding in a way that effected, often, a measurable relief.  I thoroughly enjoyed it.  To further explore this, I volunteered in a local emergency room, became trained as an EMT, and worked as an ED Scribe. The more I traveled into the realm of medicine, the more hooked I became.  But in all these positions, the limited level of care I was able to provide bothered me.  I wanted to be able to do more for those I cared for.

The majesty and brokenness of our inner workings have always intrigued me.  But what was crystallized for me in these experiences was a deepening of my desire for change; an urge to take up the weapons of medicine and join in this bittersweet war between life and death--the ultimate debate.  Death is sometimes an ally, but all too often an enemy. I want to fight for those like Katie, for those who live in Kibera, and for those whom Death strives to take too soon after they have lived lives of despair. This is a war that must be fought on many fronts, but one that I desire to fight as a doctor.

How to Study in Medical School

In an older post, I wrote a little bit about my search for efficient study tools for medical school, and how I eventually discovered Anki and OneNote. To briefly summarize, I spent part of the summer before school started trying to figure out how I was going to study. I knew it would be a different ballgame than undergrad (and that turned out to be true), so I figured my old methods wouldn't work so well (which would also be true...). In undergrad, I usually just went to class, took notes in a binder, read any assigned reading, and reviewed everything once or twice in the day or two before the exam, depending on the class. For medical school, though, I knew that I would need a way to take in more information, organize it, and review it more than once or twice.

After poking around the internet a bit, I settled on Microsoft’s OneNote to take notes (if you have a PC, I highly recommend this program. If you have a Mac, I don't think it's available. I have heard good things about Evernote, though, which is available on both platforms. That said, I prefer the organizational structure of OneNote over Evernote – both are good programs, however). This was a great way to 1) cut down on what I actually had to lug around 2) organize everything in one searchable, legible database (this latter point is important, as my handwriting is chicken-scratch) 3) and take more notes much more quickly than I could write them, while also incorporating various media as needed.

Below is a great video describing how one can use OneNote in medical school. Everyone might do things slightly differently, but this provides a good starting point. 

Note: These aren't my videos, but I think they give a great overview of how to use OneNote and Anki.

If you have a Mac, then I’d suggest checking out Evernote. Click here for a basic overview of how to navigate Evernote.

If you used paper in undergrad, like I did, you might think that you’d rather just keep doing that. And that’s fine. But if you can, I’d really recommend switching to a computer-based note-taking program. I have found it to be much faster and more efficient. It allows me to pretty much have access to every note that I have taken at all times, search the entire database, and sync it all in “the cloud” so that, if I were to lose my laptop, I could be up and running on any other computer in the time that it takes me to log in to SkyDrive. OneNote’s built in screen-capture feature is also a very helpful tool that I use on a daily basis.

So I had a good way of taking notes. Great. But how would I review them? It is a common refrain among medical students that you can expect to forget pretty much everything you learn in the first couple of years. That may be true, but that didn’t sit well with me. I’m sure most of what we learn is irrelevant, and that’s fine, but not all of it is, and a large chunk of what we are learning we’ll have to know for the boards. So I started to wonder if there was a way around that…and found Anki.

Anki is essentially a free flashcard program. You create the cards, review them, and then the program will use a spaced-repetition algorithm that makes certain cards due at various intervals, depending on how well you could recall the information. (Update: I've written a brief Anki Q&A here.)

So, for example, you make a card. Right after making the card, you review it. It’s pretty easy, and you answer it correctly. The next day, the card is due again. Again, you answered it pretty easily, so when Anki gives you the option of choosing how well you recalled the information (generally something along the lines of “again,” “hard,” “good,” or “easy,” with each option being associated with a certain default time interval, like “10 minutes,” “2 days,” “3 days,” or “4 days,” respectively), you select “good.” In three days, the card becomes due again. If you again select "good," this time the time interval might be “5 days,” and so on and so forth.

Taken from this random website

You can see in the graph how this works out over the long term. After we learn something, that knowledge immediately begins to decay. However, we can slow that knowledge decay by exposing ourselves to that information again within a specified window of time. Over time, this spaced review strengthens the memory of whatever it is we are trying to recall. Sounds great… but the trick is to figure out when we need to review the information. With physical flashcards, this quickly becomes tedious (especially when you accumulate thousands of flashcards...). With notes, we might review those a few times before a test, but then probably never really look at them again. With Anki, you don’t even have to think about it. Anki does all of the work, and uses your answers (whether the card is hard, good, or easy, for example) to create a personalized scheduling algorithm for you.

So how do you use this in school? There are many different ways to use it, but I’ll briefly walk through how I’ve been using it. After lecture, I review my notes and find important concepts, ideas, or minutia that I feel I need to know. It’s important here to distinguish between things that only the professor would ever ask, things that you might actually need to know for boards, and things that you simply find interesting and/or helpful. For the most part, you only want to make cards for things that fall into the last two categories. That said, you can make cards for things in the first category and “suspend” them after the test – that way, you reap the benefit, at least in the short term, of spaced repetition while avoiding making your daily reviews in the long term too long.

I would recommend trying to only make 20-50 cards a day (ideally), with an upper limit of 100 new cards per day. When making new cards, there are some rules that you should keep in mind about how to make efficient cards – you can (and should) read them here. If the cards that you make are junk, then Anki will not be beneficial for you. Right after you make the cards, be sure to review them. Additionally, it can be helpful to tag the cards as you make them – so, for example, if you are making cards about the upper extremity in anatomy, you can tag them all under “upper_extremity” so that you could pull all of those cards out later for a dedicated review, if you so desired. You can also tag by source – for example, if you wanted to check what you are learning in your classes against a gold-standard source like First Aid, you can tag any info that is in First Aid with an appropriate tag so that you can review it later or just to remind you not to suspend that card down the road. Again, while it would normally be a waste of time to look at a source like First Aid in your first year, with Anki this is no longer true, because you will actually remember the information. Ideally, this will help you later when you do begin to study for boards.

There are also different types of cards you can make. You can make straight flashcards (e.g. prompt on front, answer on back), you can use something called cloze deletions, or you can use image occlusions. There are many other types of cards, but these are the three types that I primarily use.

Cloze deletion and image occlusion are powerful tools, and are perhaps best illustrated by video. So below are some relevant videos that provide a short introduction to how to use Anki and create those types of cards. I highly recommend taking the time to watch them.

Now you’re ready to get started. Go here to download Anki, and here to see the user manual if you have any other questions – although, if you’ve watched the above videos, you should have a pretty good handle on things.

Finally, if you ever have any problems with Anki, following the instructions in the video below should fix them.

 

Once you’ve made the cards, make it a point to review them daily. Just get it done – you’ll be glad you did later. It might take a little more time up front to create the cards and spend time reviewing them, but when it comes time for a test, I think you’ll find that you’re a bit less stressed about it and are able to spend less time trying to cram information in your head. Usually for tests I just passively review my old notes once – quickly – just to get a “big picture” review and to go over anything I specifically marked as something I should review (for example, if I didn’t put something in Anki because it is important for the test but for absolutely nothing else in life).

Also, reviewing them can be done on the go. There is an Anki app for both Android (free) and iPhone (not free, but worth it). For example, I start reviewing cards in the morning while eating breakfast, while walking from the parking garage to school (which would otherwise be a waste of 5-10 minutes, and during which time I can get through a bunch of cards), in between classes, etc. This allows me to sometimes be completely finished with my daily review by the time I get home, or at least have a significant portion of it knocked out.

So that’s OneNote and Anki. These are very powerful tools. There are, of course, many ways to get through medical school, but, at least for me, these programs have single-handedly gotten me this far, and I plan on continuing to use them throughout the rest of school.