#1: How to study in medical school, residency and beyond…

February 1, 2016 | By Matthew Watto, MD

A procrastinator’s guide to continuing your medical education

Introduction
Studying and keeping up with the literature is not that hard and you shouldn’t be afraid to do it. Most people make the mistake of setting their expectations too high, which leads to procrastination, inaction and probably binge watching a Property Brothers marathon (or even worse, any show on Bravo). We live in an age where most people can’t keep their eyes off their iPhone (even while driving), so why do people say they are too busy for studying and continuing medical education? I say it’s time to either put down your phone or put it to good use, and I’m here to teach you how. If you’re more of a classics nerd like me (i.e. you prefer to read and highlight print journals and textbooks), then don’t fret because I have some suggestions for you too. Most of what I’ll share with you below are things that I figured out during the course of my medical education, things that I wish someone had told me along the way.

Creating a habit
Reading and studying are like exercise. There is a minimum effective dose to achieve and maintain results. Most people overestimate the amount of exercise (or reading) that they need to get and stay in shape. I utilize micro-habits whenever I am trying to change or adopt a behavior. Here’s how they work. Let’s say I want to create a daily reading habit to stay up-to-date on Internal Medicine. Instead of telling myself that I will read for one hour everyday, which is an unrealistic and intimidating goal for most people, then I will set a goal to read for five minutes every day (a total of 150 minutes per month). This is a much more manageable goal, and I will feel good about being able to achieve it. After four weeks of daily reading, I will have established this behavior as a habit. In addition, since I am unlikely to stop reading after only five minutes, I will probably have exceeded my goal of 150 minutes per month and be well ahead of my peers who are still watching a Real Housewives marathon. Once you’ve created a reading habit, it will be easier to read everyday than to skip this behavior.

Getting in the zone
Like placing a central line, the setup is everything. Pick a time of day where you can work without distractions. For most of us this means early morning or late in the evening. Turn off Push Notifications and set your phone to Do Not Disturb or Airplane Mode. I personally like to read in the evening while wearing headphones and listening to a single track or album on repeat (preferably one without words). This generates some background noise to keep me awake but won’t distract me from what I’m reading. Caffeine is not essential, but when used judiciously can help with focus. That’s all that I’ll say on the subject since I don’t want this to devolve into a discussion of “smart drugs” or “performance enhancing drugs”. If you want that debate then check out this podcast. (Intelligence2 Debates).

Where to start
Our challenge in learning medicine is an overflow of information and resources. Learners at every level have to decide how they will spend their time in an efficient manner. The good news is that you don’t have to sift through it yourself. I do not and cannot read, analyze and contextualize the thousands of articles in my specialty that come out each year. There are brilliant clinicians and academics who are paid to do this for us, and we can access these resources for free or at a low cost through our institutional affiliations (see “Continue your medical education” below). If you haven’t done so yet, then I recommend visiting your local medical library. Yes, I want you to physically go there! Chances are you will find a highly educated, tech savvy and underused librarian who commands an arsenal of print and digital resources. The librarian at my institution loaded my phone with apps such as DynaMed®, Uptodate®, John Hopkins Antibiotic Guide and taught me to use the powerful search tools available through the library’s website. Below I will detail my simplified approach that has successfully led me through medical school, residency and into my role as an academic clinician. If you are interested in developing your own strategy then I highly recommend checking out JAMAevidence Users’ Guide to the Medical Literature. You don’t have to read the whole thing, but the first few chapters give a great summary of how to prioritize your approach to medical literature.

Breeze through your clerkships
Here is a detailed strategy that proved itself effective as I aced my clinical rotations during medical school. The goal during this time period is to learn the language of medicine and how to interact with patients and other providers. I did most of my learning by asking questions on rounds to understand the rationale behind evaluation and management decisions for each patient. In addition, I recommend picking one good print or ebook to learn core concepts and evidence-based practices. For Internal Medicine, I prefer Pocket Medicine by Marc S. Sabatine, which I was able to get as a searchable PDF in iBooks along with a print copy that fit in my lab coat pocket (costs about $45). You should pick a comparable source for each specialty that facilitates on the fly learning and maybe even a few style points for “roundsmanship”. At home my focus was completing as many questions as possible from a Qbank like UWorld. Testing your knowledge is an active form of studying and will improve retention (Augustin M. Yale J of Biol and Med. 2014). Unless you are researching a specific clinical question, reading the primary literature should encompass about one percent of your time at this level. It is inefficient and low yield. You need to build up your textbook knowledge (which you will be tested on) before you start ingesting large amounts of primary literature. Doing so will probably just make you confused and overwhelmed.

Dominate residency
As a resident your life is chaos. Even if you have time to read, you probably don’t have the energy. As an Intern I absorbed as much as I could from being in the hospital and asking questions. My focus was survival and not reading. As a second and third year resident I became the primary decision maker for the team and an increased sense of fear and responsibility fueled my reading habit. Again, I picked one source, Pocket Medicine, and read it every night. Even if I was dead tired, I’d read a page or two that was relevant to what I had seen that day. By the end of my second year I knew that book from cover to cover and had a rolodex of high yield information on short recall. As a third year resident, it is time to study for boards and practice questions should be your focus. I used the micro-habit hack (see above) and set a goal of one question per day starting at the end of my 2nd year. This was quite easy to achieve. In reality, I’d usually end up doing five questions or more per day leading to excellent scores on the In-Training Exam and low stress when it came time to take boards. As in medical school, reading the primary literature will not be your primary focus during residency. The impetus should be to build medical knowledge in your respective field. This will enhance your daily practice and prepare you for boards. That being said, you need to spend some time reading primary journals to build your skills in evaluating and analyzing articles. The next section, although geared towards Staff physicians, will detail how this can be accomplished.

Continue your medical education
As an attending you should have mastered the basics in your field. Textbook knowledge won’t help when you have someone with 10 medical problems who has already exhausted 1st, 2nd and 3rd line treatments. Real world practice requires more obscure knowledge or at least a way to quickly access it. UptoDate® is sometimes a misnomer, and it doesn’t always qualify recommendations based on strength of evidence. I prefer using DynaMed® as a starting point since it provides strength of evidence and usefully links to guidelines and supporting articles. The problem is that even these sources, which rely heavily on guidelines, are months or years behind the literature. For this reason, I recommend signing up for email alerts from one or two premier journals in your field (e.g. New England Journal of Medicine or JAMA). Set an easy weekly goal like skimming the table of contents. This can be done on your phone during down time. Read the abstracts that interest you, and thoroughly read the few articles that are likely to change your practice. As an alternative you can follow the major journals on Twitter and casually browse the articles as they appear in your newsfeed. If you are still in residency, then make sure to attend Journal Club, Morning Report and Grand Rounds whenever possible. This will give you the chance to interact with seasoned clinicians who can help teach you how to deconstruct an article. If all of this still sounds like too much work, then subscribe to a publication like ACP Journal Club (free with ACP membership or print subscription to Annals of Internal Medicine) or NEJM Journal Watch ( $159 per year, but I bought mine for $55 on discount). Both publications are available in print or digital on a monthly or bi-monthly basis. Each includes practice changing articles in abstract form along with expert commentary to explain their clinical relevance and impact. I recommend reading on a daily basis (see “Creating a habit” above) but if you were to read only one thing per month then I’d recommend one of these sources, which cherry pick articles and spoon feed them to you. They’re a lazy man or woman’s best bet at keeping current.

Solidifying your knowledge
So now, you have conquered the seemingly insurmountable hurdle of turning off the TV. Maybe you even cracked a book or if you’re a millennial, you used your phone to crush some literature instead of some candy for a change. The last step of this process is making sure the information stays in your brain. Research shows that passive learning is much less effective than active learning (Augustin M. Yale J of Biol and Med. 2014). I recommend doing one of three things. One, create notes that summarize what you have read and review them in 24 hours, 7 days, 14 days and 30 days (spaced repetition). Two, complete the free CME questions offered by many journals where you can test your understanding of what you’ve just read. The third option, which I find easiest, is to teach others. I like to discuss what I’ve learned with a colleague, or better yet, teach it to a medical student or resident. People will often respond with questions that challenge your understanding of the material and quickly let you gauge your own retention.

The end
So that’s it. There’s my strategy. If you are interested in reading or hearing more about how others learn, then tune into The Curbsiders podcast. In addition to discussing topics in Internal Medicine, we ask all of our guests about their reading habits, how they learn and resources they find useful.