How to Learn Medicine in Residency

 

Learning during residency is very different from medical school. Medical school is where you are taught the basics of medicine – anatomy, pathology, terminology, physiology and a basic understanding of diagnostics and treatments of diseases. Residency is where you become a doctor and use your knowledge to treat patients.

You are no longer in the classroom. You are at the bedside making diagnoses and counselling patients. As a result, you have less time to learn. You are on call more and spend an enormous amount of time doing clinical work. In order to survive, I made changes to my learning. It’s still a work in process, but I’ve come up with several methods to learn more medicine with less time. I was able to go from average in my first year in-training exam to the top tenth percentile in my second year. I’m going to share with you ways I have been able to keep up with learning during residency.

Build Learning into your Routine

The last thing you want to do after a busy day on service is to crack open a textbook and read. Nothing will stick! It’s much better to build the learning into your day to day routine, so that it gets done without having to go out of the way to do it.

Here are the things I do almost everyday without fail

  1. Read Email
  2. Commute to work
  3. Use my phone during downtime
  4. Eat
  • Email: The key is to link learning with activities you are already doing. For example – NEJM as a great Resident e-Bulletin that sends you a short snippet of what’s important in each week’s issue. It takes about 5 minutes to read, and keeps me up to date in relevant topics. For a sample, take a look at this topic on Catheter-associated UTIs. All delivered to your inbox every Wednesday! There are similar email lists you can subscribe too – CMA’s POEM, Tools for Practice , and the list goes on and on.
  • Commuting: Similarly, listen to podcasts while commuting. You will be amazed how much you can turn an hour of lost time into studying time. Curbsiders, IMReasoning, Core IM are just a sample of some of the IM podcasts I listen too.
  • Downtime: countless phone apps are there, but I find question banks to be manageable to do throughout the day. Waiting for a page to be returned? Why not answer a few question from MKSAP?
  • Food: Often there are rounds that have free food too. Pick and choose good lectures. It’s a easy way to score lunch and a free lecture!

Prioritize Regular Studying

It’s easy to neglect hitting the books after working 80 hours a week, but early on, you have to make it a habit to read regularly and deliberately. I’ve been a long-time reader of StudyHacks, and one point Cal Newport emphasizes is developing career capital, skills and attributes that make you valuable. You have to be “So Good They Can’t Ignore You“.

The first step to being an excellent physician is competence and achieve that you need to know your stuff. No amount of communication skills, empathy and research ability can overcome a shortcoming of incompetence. You are first and foremost a medical expert. Realize that nothing having a strong medical knowledge will make you a valuable doctor in your community.

Choose and Read from a Primary Text

Each specialty has a recommended primary textbook or “Bible” that lays a strong foundation of knowledge. In internal medicine, I read from Harrison’s – an alternate would be Cecil’s. Similarly, if you’re in another specialty, find the Bible textbook for that specialty – emergency medicine (Tintinalli’s), pediatrics (Nelson’s), general surgery (Schwartz / Greenfield).

Set a goal to cover the main topics during your residency. You should plan to finish this textbook, from cover to cover, by the end of your residency to ensure a good foundation.

Some may say textbooks are dead with the number of electronic resources available like Medscape and UptoDate. However, I would argue that almost all the content covered in these textbooks are fundamentals that don’t change from year to year. Furthermore, they are important topics that were carefully selected by a group of authors as important. Working through a textbook ensures that you don’t have any glaring deficits in your knowledge and lays a strong foundation for any additional topics.

Start with the Foundation Topics

Hopefully, by the time you graduate from medical school you will already have a good foundation of medical knowledge. The next step in residency is to understand what are the core topics you need to know for your specialty. In your first year, don’t start off by reading the most recent literature on treatment of rare diseases. Start with the bread and butter topics that you will see over and over again.

In internal medicine, your first year should be focused on reading around common conditions – heart failure, pneumonia, obstructive lung disease, anemia, diabetes, acute kidney injury, etc. Worry about the atypical infections and rare inflammatory conditions afterwards. Make sure you have a mastery over the core topics, as they will be the cases you will see the most over your career.

Furthermore, once you have the basics down you will begin to notice the subtleties associated with these conditions. There are nuances with each disease condition that takes a while to grasp. I know that no matter how many times I’ve seen a certain presentation, there is always something to learn in each encounter. Make it a goal to find learning points from each case you see.

Be sure to add evidence to your understanding of these core topics. For COPD, I recommend going through the CTS guidelines. Similarly, for AFIB, you should read the CCS statements. CDA for Diabetes, etc.

See Lots and Lots of Patients

Nothing will teach you more clinical medicine faster than seeing lots and lots of patients. The more cases you see, the more “illness scripts” you will familiar with and the sharper you will be. That is why I never view new consults or patients to follow as more work to do. See them as learning opportunities.

Be enthusiastic about seeing consults. Ask and offer to cover your colleagues’ patients if they are busy or post-call. If there are patients with interesting clinical findings that other team members are looking after, ask if it’s ok for you to see them too for your own learning. Just be respectful of boundaries and don’t undermine your colleagues. For example, if a patient has a strange rash – it’s usually ok for you to examine the patient, it’s not ok for you to start making treatment plans for your colleague’s patient.

Keep Track and Follow Up on Your Patients

One thing I wished I did better during medical school was keeping track of the patient’s I saw. At the start of residency, I have diligently tracked all the patients I have seen, and this has turned out to be one of the most valuable activities I do.

A great reason to do this is to be able to recall specific cases for the future. The more patient encounters that you can remember, the better you’ll be able to draw from these experiences when you encounter them again. My system includes keeping a safe and secure list of patients I have seen. At first this was done in a notebook but has since moved onto a secure electronic format. On my list I include the age, gender, hospital number, admitting diagnosis, any procedures and learning points to remember. I usually add in a few particular comments – such as occupation, interesting history or physical appearance – to help me remember the case in the future.

I have found this activity of keeping track of my patients has helped me recall cases more accurately. This in turn has made me able to draw more on past experiences when making clinical decisions. I find looking at my list helps trigger me to recall my thinking process and clinical pearls I learned around the case.

Even better, I have found my diagnostic accuracy to be greatly improved because I can prospectively follow patients into the future. With current trends in medicine to decrease hospitalization time, patients often get admitted and discharged in a short span of time. For example, if you admit a patient on a Thursday call, the patient will likely to have been discharged before Monday when you get back. Similarly, you might be in clinic or”fly-in” to do a night coverage and see a patient only once.

As a result, there are a lot of open loops from patients that are never to be seen again. Was your diagnosis correct? What did the biopsy results show? With the help of the electronic health record (EHR), I can now follow up on cases to confirm whether my initial diagnosis was correct or not. This feedback helps refine my diagnostic accuracy.

Clinical Teachings – Insights and Pearls

Remember to draw on your preceptor’s experience to be a better clinician. Often there are “clinical pearls” short phrases that are memorable and contains an uncommon truth to help in clinical encounters. For example – “if there is a salt problem, the real problem is the water, and if it’s a volume problem, the problem is the salt.” This pearl helps remind trainees that if there is a case of hyponatremia (low salt levels), it’s much more important to look at the patient’s volume status (water).

Throughout your rotations, you will meet clinicians who are very sharp. Be sure to pick their brains and ask pointed questions to understand their thought process.

Then be sure to collect this information – usually in a notebook or a note-taking app. You will hard pressed to find these clinical pearls in a textbook, but I guarantee you will use them repeatedly over and over.

Dr. Brandt offers excellent advice on How to Study During Residency as she lays out a good foundation for learning during residency. She further elaborates on how using a peripheral brain like Evernote (referral link) can be make you more efficient with your learning, and how for clinical medicine she uses a 3×5 index card method.

Maintaining a Healthy Mind

In Barb Oakley’s Coursera MOOC “Learning How to Learn” (highly recommended) – she makes an emphasis on keeping a healthy mind to make sure your learning sticks.

For the large part this breaks down into three categories 1) getting enough sleep, 2) exercising, 3) eating healthy foods. I would add 4) is building relationships.

Unfortunately, sleep deprivation is entirely too common for residents, and looking after their own health is low on their priorities. It took 10 extra pounds during first year of residency, to motivate me to start exercising again and adopt healthier habits. I was surprised how much better my brain worked with a good night’s sleep and a 30 minute run.

Dr. Vineet Arora wrote a gem in 2011 on surviving residency by focusing on five F’s that reiterate the importance of balance during your career.

On Being the Best Doctor – Continue to Improve

Wellness Rounds is a blog I have followed for a few years now that offers excellent advice on all aspects of being a doctor. Dr. Brandt is a surgeon that shares her wisdom on how to balance personal and professional success. Particularly, her post on How to be the Best Intern in the Hospital offers practical advice for anyone just starting out.

If you’re in for a longer read, I would suggest Atul Gawande’s book Better: A Surgeon’s Note on Performance. One piece of advice that stuck with me all these years after reading it is to count something. He writes “If you count something you find interesting, you will learn something interesting.” For me right now, I have a system to keep track of the patients I have seen, the cases I have encountered and the procedures I have done. I can easily identify gaps in my knowledge and improve as a doctor because I have a system of keeping track of my progress.

Learning as a Lifelong Endeavor

Remember that medical knowledge is growing at a faster pace than any one person can learn. So continue to have a beginner’s mindset, and realize that this is a lifelong habit to build. Residency is a grueling time in a doctor’s medical career, but will only encompass a short duration. However, the habits you build will be with you for your entire career.

“To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all.”   William Osler.

N.B. I find it interesting that this post almost had no overlap with a previous post about learning in medical school. Writing this post initially started during PGY2 and was completed as an attending.

 

 

The Poor Historian

Credit Shelbyroot on Flickr

Last week, I was listening to the cases that were admitted by the overnight resident. By the time he presented the third case, I became annoyed after I repeatedly heard the dreaded phrase “poor historian.” This particular patient wasn’t forthcoming with his symptoms. He was vague with what was going on. “He couldn’t provide an accurate history.” The patient was a homeless man who came to the emergency room feeling unwell and coughing up blood. He had a rip-roaring pneumonia.

I stopped the resident and told him bluntly “the reason the patient can’t give a history is because he is very sick! You too would give a poor history, if you had strep pneumonia bacteria coursing in your blood. ”

The resident had also incorrectly used the term. The historian is the by definition, the one who takes the history. The resident had done a poor job and had blamed the patient for his own deficiencies.

In Jayshi’s Patel JAMA’s piece “The Things We Say” he recounts his own experience with this term.

Later, when I ignored the term and began to pay attention, I concluded encephalopathy, dementia, depression, frustration, anxiety, and anger were reasons why patients did not provide an accurate history. In fact, there was always a reason why the patient wouldn’t or couldn’t provide a history. I learned that a patient’s inability to provide a history should not limit my ability to correctly obtain one.

Whenever I hear the phrase poor historian, I try to teach that there are always ways to get a thorough history. There is collateral history we can take from a patient’s family and friends. There are written notes by the paramedics who are usually the first to the scene. There are old medical charts and electronic records we can peruse. We can examine the patients and phrase our questions in ways they can understand and respond to. Rather than grilling the patient, “we can use open-ended questions, pauses, silence, and active listening, to allow the patient to tell the whole story” writes Dr. Tiemstra. The historian isn’t just a scribe – they are the person who organizes the past events and details, and reorganizes the story in a way that makes sense.

When I went to see the patient in the emergency room, I saw a man who was lethargic and breathing hard. “I feel sick doc,” he said in a weak voice. There was nothing more needed to be said. He had given me an accurate history.

The Attending Life

I have been teaching a lot of medical students and residents lately as the “attending / staff” physician. It’s hard to remember what it was like ten years ago, when I was an undergraduate student and clueless about the world of medicine. I was naive and green. Optimistic and cautious. I didn’t even know how much I didn’t know. At least now, I know that I don’t know a lot.

A few afternoons, I went over some non-medical  topics that the students and residents really enjoyed, so over the next few months, I will try to find time to write and post them. One, so I have a reference I can use again and again, and second, maybe someone will find it useful too.

They include topics such as

  • Physician Finances – a topic I’ve been reading and learning a lot about
    • The most important rules for financial independence
    • Understanding lifestyle inflation / creep
    • Ways doctors can be smarter with their money
  • Building a Career
    • How to find and get a job successfully
    • Crafting your career into what you want
  • Studying – how to integrate into a busy rotation / residency / practice
    • how to build systems and confidence about your medical knowledge
    • Update on websites / apps / tools I use in my day to day

In other news – Life has been good. New city, new job, great opportunities, growing family. It’s been so fast that I haven’t had time to reflect. I will have to re-read some old posts as I start to revamp and clean up this blog.

New Chapter, New Beginnings

Life as an attending physician has been everything I had hoped it would be. I’ve been out of residency a year so far and I am loving my job – the autonomy, the colleagues, the patients, the medicine. As always, there are some aspects that aren’t as pleasant to deal with such as scheduling, overnight calls and difficult patient encounters, but on a whole, post-residency life has been good. However, there is one thing I had as a resident that I don’t quite have yet as an attending and that’s clear career goals.

Let me explain. Throughout medical education, there was always a clearly defined goal : graduation. I was willing to put in the effort in mastering my craft because I knew one day I would have to use these skills to help others.

Ten years ago, when I first received my medical school admission letter, I experienced a mixture of joy and relief. The relief was mainly from not worrying about what my future trajectory would look like, I knew more or less my 20s would be spent in medical school and residency to become a doctor.

Having finished those grueling years, I look forward and realize my career in medicine will be many times longer than my training. This leads me to the question, what do I want my career to look like and how will I get there?

There are aspects that I’ve already defined and shaped, with which I am happy about. I am practicing the specialty of my choice (internal medicine). I work in a blended academic and community hospital, having plenty of contact with medical trainees while getting my hands messy with front line care.  I am rewarded handsomely and will be financially secure.

Yet that same feeling of unease and uncertainty about the future that I felt as a pre-med, I feel now as an attending. In Daniel Pink’s book Drive, he argues that human motivation is largely intrinsic and consists of autonomy, mastery, and purpose. The first two aspects come easily in my day to day job. I have lots of control over my clinical work, and there are lots of skills I am continuing to master. However, tt’s the last aspect a purpose, or being part of something bigger, which is on my mind.

Don’t get me wrong, I find a lot of gratification and purpose in my clinical work. I love making the right diagnosis and having the right knowledge and abilities to alleviate suffering. But what I want to know is can I do more, and if so, how can I use my unique abilities to do so?

In my clinical work, I can improve or save a life one at a time, but my time and abilities aren’t scaleable. Would I be satisfied with Talmud’s quote “And whoever saves a life, it is considered as if he saved an entire world”, or do I believe I can affect more change.

Ultimately this is mixture of nervousness and excitement. No longer am I bound to a prescribed rigid timeline. I want my career to continue to evolve, what it will eventually look like, I’m not sure yet. But I know I would be extremely disappointed if the next ten years looked identical to my past year. I want to continue to grow, learn more and affect positive change. To keep pushing the boundary, and use my role as a doctor to be part of something bigger.