Getting Through the Semesters (or what if I fail something).

“The Thrill of Victory or the Agony of Defeat”

The Drama of Human Competition as the opening lines of ABCs “Wide World of Sports” promised. By now, many students have had their first blocks of exams in medical school. Some people have done very well and some people have “breathed a sigh of relief” that they passed and some people have not passed one or or more of their exams. To fail an exam at this stage can be a huge personal blow but your actions after discovering that you have not passed (I am going to avoid the word “failure” here) are critical to figuring out what you need to do to get “above the yellow line”. Sure you NEED to do a bit or mourning in terms of the loss of those wonderful feelings that infused during orientation week but don’t let the mourning phase go on longer than a couple of minutes. Replace mourning with a very objective strategical look at what might have gone wrong and how you are going to fix the situation.

There is something in medical school that will throw every person. It may be that first round of exams, that USMLE score or a patient contact that just did go well. The important thing is that out of every experience, good or bad, you learn something about yourself and what you are capable of achieving. It is out of experience that you will learn to treat your future patients so let your experience become your teacher and move forward from here. Not passing an exam just doesn’t feel good and can play with your “head” in terms of how your look at your future. My point here is that nothing except that round of exams is over at this point. You mourn a bit and then you push forward because (and I am not wrong on this), the material for the next round of exams is already upon you.

As soon as you know that anything has not gone well for you academically, ask for help. Your first action should be reviewing the test and trying to figure out where you went wrong. Do you need to rely on more detail? Did you move too fast and not answer the question that was asked? Did you neglect to read every answer choice with a more correct answer further down? Did you not fully understand the material? Were you distracted by something outside of school such as a relationship or illness and not put in enough time studying? In short, try to figure out what went wrong and take steps to make sure that you don’t repeat your mistakes.

What if I fail a whole course, like Biochemistry?

The consequences of failing an entire course in medical school are largely school-dependent. Some schools will want you to retake only the material that you did not pass while others will have you go through an entire summer remediation course. In any event, look at your remediation/retesting as an opportunity to hone this material well. You definitely want a strong knowledge base for your upcoming classes and you will have made some steps toward review in terms of preparation for USMLE. In this light, having to retake or remediate is not totally the worst situation that you can find yourself going through.

Plunge into your review with total concentration on the subject at hand. If you have one course or one area of subject matter, this is easier than if you have multiple subjects to remediate. Your only resolve in this situation is to not miss this golden opportunity to thoroughly master this material. You are not a “lesser person” because you need a second review and keep in mind, that you are reviewing at this point. In most cases, you have learned the material on the first shot but this review gives you insight into the material that you likely previously missed.

I am always more concerned about those students who “barely” passed than the students who failed and are re-mediating. In most cases, the student who re-mediates does not carry a knowledge gap forward while the student who barely passed likely has gaps in their knowledge base. It is those who barely pass that will need the most intensive review and preparation for board examinations.  I always encourage students who scored below an 80% to study for and take any optional shelf subject exams if offered by their school. These shelf exams can pinpoint knowledge gaps that can be filled in before taking Step I.

Class Attendance – Is this time well spent for me? 

In some medical schools, class attendance is not mandatory. If this is the case, and you ran out of study time, try figuring out if there is one day a week that you can stay home and study the material using note service/lecture tapes or vids/textbook and syllabus reading. Many students do not attend class and find that home (or away from school study) works best for them. This may work for you but be careful if you have too many distractions at home or find that not attending class puts you behind. (Getting behind in medical school is deadly.)

If your work is not detailed enough, figure out which classes do not require the detail and which ones DO require more detailed study. In short, give each course what it demands. Many schools have integrated courses that definitely demand loads of detailed work coupled with “professional-type” courses like Practice of Medicine that are more performance-based. Try to look at your coursework from this perspective and see if you can give your integrated course a bit more time and your performance course a bit less time.

Another problem is that in many first year courses, the load of information can seem overwhelming. Resist the urge to dwell on what seems overwhelming and nibble away a chunk at a time. I always remember that scene in the movie “Shawshank Redemption” where the protagonist chips away at the prison wall over the course of 17 years with a small rock hammer. Eventually, he gets through the wall and escapes. Extreme but I think you get my drift in terms of divide your work into manageable chunks and stay on course. Keep moving forward because you can only affect what is happening now and use that to impact the future. Weekends are your friend because you can breathe a bit, relax a bit and catch up if you have fallen a bit behind your class. In the middle of the week, go to where the class is and use the weekend to “catch up”.

Wasting time and less efficient practices

I discourage students from recopying notes as a means of study. When you have volumes of material and information, you can become more of an excellent clerk in terms of producing a beautiful set of notes that you have not mastered. Organizing your material is good (can be done with a highlighter or in the margins of your notebook) but total recopying of every word may be too time consuming and not as beneficial as when you were an undergraduate student with less volume. You may need to review the material and then constantly question yourself or recite the material back to yourself rather than a complete recopy. If you can recopy your work in an efficient manner while learning and your grades are good, then recopying is working for you and don’t change your strategy.

Another problem that can interfere with some freshman medical students is feeling that they “need” to study for boards. You don’t need to take time away from your coursework mastery to do board study at this point in your career. If you absolutely feel that you NEED to do some board study, then do it during the summer between your first and second year but the best preparation for boards is to thoroughly master your coursework and then study for boards at the end of your second year. You cannot “review” what you have not “learned” in the first place. Don’t take valuable coursework study time to do board study. Board review books are most useful because they summarize material but most medical school courses require the details and not summaries. Beware of the “I am going to use a review book to summarize” method of study because it might work against you in terms of you not getting enough of the details to pass your course. The other extreme is to attempt to memorize the textbook which is most likely too much detail. In short, strike a happy medium that will work for you.

Don’t be afraid (or ashamed) to consult your instructor or your dean if you are struggling. Not to reach out for help (especially because of the amount of money that you are paying for your school tuition) is not wise. It really looks great to a residency program director to see comments from your dean or professor that state that you were able to overcome a deficiency and excel. These types of comments indicate excellent problem-solving skills which are highly prized in a physician.

Finally, tune out the boasting of your classmates who say that they “didn’t study” and “aced” their exams. They are lying period. You have to do what you NEED to do for yourself. Congratulate them for being so “brilliant” and don’t waste a second of your precious time worrying that you are somehow deficient because you studied like a demon and didn’t do so well. There is nothing wrong with you that correcting your study strategy will not solve. Just don’t add “questioning your worth” to your list of things to overcome. It isn’t necessary and it won’t get the job done.

Striking a Balance

Finally, one key aspect of medical school, residency and the eventual practice of medicine is that you will have to constantly “strike a balance” between study, personal life and professional obligations. The first semester of medical school will definitely test your resolve to keep working away at your studies until you get them mastered but this should not be at the cost of your personal integrity or sanity. Try to find ways of incorporating some stress relief (physical exercise) and socialization (away from your classmates) into your life. Nothing, including the practice of medicine is one-dimensional and there needs to be balance.

For example, if you are studying in the library and know that you won’t make it to the gym, try to walk up at least 8 floors of steps on the days that you don’t get to the gym. Take 10 minutes and take a brisk walk around the corridors to get your brain relaxed before you keep “grinding” away at your study materials. Study and pace at the same time while reciting the material to yourself in your own words. Try making some study-drill tapes and drill yourself while you are on the elliptical trainer/treadmill in the gym. Finally, picture that professor’s head when you are doing your bicep curls or on the fly machine and pound things out. You will be more relaxed, less stressed and more efficient in your studies. In addition, you can enjoy eating without worrying about gaining weight.

Statistics (and odds) state that if you were accepted to medical school, you will get through the four years successfully. Some people make the adjustment to the rigors of medical school academics faster than others but trust yourself enough to know that you will get the job done. There is very little difference in intellect between the person who graduates first in their medical school class and last in their medical school class. Residency program directors know this which is why the person who graduates last in their class is still called “Doctor”. Run your own race and get what you need.

Academic Excellence

For many people in both medical school, graduate school and undergraduate school, this is the beginning of the second semester (or quarter). If you are new to your academics, then you finished the first semester/fall quarter with some academic achievements (good or bad) and learned some things about yourself. Since this blog is about strategies for success in medicine (getting into medical school, staying in medical school and other things associated with medical school), I though I would post a note or two about making changes that can enhance your Academic excellence.

Doing well in academics is something that can be mastered with practice. It comes out of having a strong and solid approach to what you have to master in terms of knowledge and it comes out of having a high comfort level with the learning process. If you always feel that you are somehow “not going to be able to get everything learned” or that ” the course is too hard”, then your beliefs can become a self-fulfilling prophecy. There is no task, no matter how great or how formidable, that cannot be approached by taking small steps every day until it is conquered. You have to be willing to “chip away” on a daily basis and note your progress on a daily basis in order to see that you are handling the larger task in smaller steps.

 Let’s take Organic Chemistry for as an example. At the beginning of the year, your professor hands you a syllabus that outlines the lecture schedule, laboratory schedule and exam dates in addition to what is expected in terms of how you will be graded in the course. Usually your grade is the result of your grades on some combination of exams and projects. Armed with this information, the first thing that you need to do is make a master subject calendar of lecture topics and test dates. Also include things like “one week to Exam 1 ” and “2 weeks to Exam 1″ along with “3, 2 and 1 week to project due”  so that when you look at your calendar daily, you know exactly how much time you have to master the knowledge for the material on your exams/projects.

The next thing to do is look at your reading and problem assignments each week for your lectures/topics. Some topics have many problems and some don’t have so many problems. Divide and conquer here by looking at the amount of time alloted for each topic. This should give you a good idea of the importance of each topic. Your textbook is a good resource in terms of looking at how much time and space it devotes to a particular topic. For example, look at functional groups of organic compounds. This is a topic that can be divided into families with the simpler families being presented first and the more complicated families being presented later. You can use your text to add upon your knowledge base.

The other thing that you want to do is be sure that you are prepared for each lecture. Don’t go to class with the idea that you can sit there, listen to the lecture and learn what you need for mastery. You need to know something about the topic before you hear the lecture. The best way to do this is to read about the topic before you hear the lecture so that you know something about the items that will be presented. Don’t every walk into a lecture “cold” as 50% of your actual studying can be done in your preparation for you upcoming lecture. The other 50% comes in your digestion of both the reading and lecture in addition to any problems that were assigned.

A point about problems and problem solving. With any problem that you are given, try to figure out what learning concept is behind the problem. For example, look at the wording of a problem and then review the concept that applies to that wording.  Consider the problem, in diabetic ketoacidosis, glycerol is primarily used for what? To answer this problem, you need to know something about the biochemical derangements that take place in diabetic ketoacidosis. In diabetic ketoacidosis, the patient is acidotic which implies that ketone bodies have been released and have lowered the pH of a patient’s blood. What else do you need to remember? You need to remember that while the blood sugar is high, the patient does not have adequate insulin which allows glucose to enter the cells and undergo glycolysis and be used for fuel. That leads you to thinking about why the ketone bodies are out in the blood stream in such high quantities in order to cause acidosis. This because the brain primarily, needs to have a constant fuel supply and in the face of a huge amount of glucose in the blood, none of it can be used by the brain because there is no insulin to allow the brain cells to take up the glucose. Now what do you need to know about diabetic ketoacidosis in addition to the above and that is that fat is being catabolized into acetyl Co-A that is being used to make the ketone bodies and that the fat comes from the breakdown of stored triglycerides into fatty acids and glycerol. The fatty acids can undergo beta oxidation to acetyl Co-A and then shunted into ketone bodies but the glycerol goes to the liver as a substrate for gluconeogenesis or the making of glucose. In the face of large amounts of glucose in the blood, the diabetic can’t use that glucose to feed their brain and thus they are making more glucose in addition to ketone bodies which are acidic. This is the concept behind this problem and why you need to approach problems like this or questions like this from many different angles rather than just memorize the answer.  You have to be able to master the concepts so that in any manner you are questioned, you can figure out the correct answer not attempt to rely on you memory.

The next thing that you must think about is that you have all of the tools that you need to master your coursework under the conditions that work best for you. Don’t compare yourself to anyone in your class. Some people are visual learners (tend to sit in the front of the class) and some folks are aural learners (tend to sit in the back to avoid aural distractions). Most folks use a combination of both visual and aural and thus learn best when they utilize both methods. If you are a visual learner, then make a brief outline of the material to be covered in lecture and take a note here and there. Don’t try to write down every word that the professor says but watch how the material is presented and fill in your notes later. If you are an aural learner, listen to the lecture and take a note here and there. Listen for inflections in the professor’s voice. Listen for key phrases such as “in summary” or lists of important topics. If you worry that you will miss something, take a small digital recorder with you and record the lecture. You can then upload it to your lap top and it’s there if you need to review concepts.

In short, if you have managed to get through first semester, you have every tool that you need to excel second semester. You may need to adjust some of your study habits or you may need to fine tune others. The important thing is not to dwell on what anyone else in your class does but to do what you need to get the results that you want. There is no class invented that could not be mastered because after all, someone had to come up with the facts and concepts for the professor to present. Don’t go into any of your courses with preconceived notions that the course is too “touch” or is a “weed-out” course. The coursework is there for you to master and you have to figure out how you will master it.

Another common mistake that many students make is relying on their perceptions of the professor’s like or dislike of them personally. No one who is lecturing actually cares about you as a person. They don’t have a personal relationship with you, and if they do, it doesn’t matter in terms of the presentation of the material to be mastered. The material is there and it doesn’t care about you or the professor or whether or not you “like” or ”dislike” the subject matter. If you spend the dollars in tuition, then that alone should be enough for you to have a vested interest in mastery of the material that is presented. In short, you need to get your tuition dollar’s worth out of this class for whatever reason. Whether you ”like” or “don’t like” the way the professor talks, looks, or anything else has no relationship to how you deal with the material that is presented. The professor is not your main source of knowledge but someone to help you navigate (by their experience) though mastery of this class.  

Finally, you can decide in this very instant, that you will change your “thinking” in terms of how you approach your coursework. You can approach your coursework from a point of fear and trepidation or you can approach your coursework from the standpoint of “hit me with your best shot because I can hit it back and score”. You can decide to toss old habits of trying to “cram” at the last minute and replace them with solid organization and daily study. You can decide that you will either adapt a lifestyle and study style that will allow you to become an excellent scholar or you will continue to do what you have been doing that doesn’t get the academic achievement that you want. The key point is that you are the complete master of your thoughts, actions and reactions.

Study Skills – Part IV

On the first day of your class, you will be issued a syllabus that outlines the professor’s grading policy, what will be expected of your in the class and a lecture/test schedule. Once you have that document in your hands, you can begin to set up your schedule for the rest of the semester. Ideally, you may want to purchase a very large desk blotter but the calender in MS Outlook (or something like it) will do just fine. On that calender, you want to place the date and time of every lecture, the topic,  and the required reading. You also want to place the dates of your exams and note the dates of 3 weeks to exam, 2 weeks to exam and 1 week to exam.  Any papers that are required should be treated like exams with 3 weeks to paper due, 2 weeks to paper due, 1 week to paper due.

 If you are taking a lab course, you need to add the dates and times of your various lab sessions to your calender along with the topics of each lab. If you list your labs by subject matter of each experiment, you can relate these to your lecture material for better integration of the course subject matter. If your course has a recitation section, be sure to list this too as you do not want to skip any recitation sections. These sections can be invaluable when it comes to test preparation time.

Once you have set your master schedule for the semester, fill in your schedule for the week. This means filling in how much time it takes for you to get to school, the times of your classes and labs, your study time – remember one hour of study for each hour of lecture and 45 minutes of study for each hour of lab-your meal times, your work out times and your bedtime. If you are using a computer-based program for your daily schedule, print out your next day’s schedule when you are studying the night before. Look at it and be sure that you have organized and prepared for the classes that are on this schedule.

Class preparation means look at the subject matter of the upcoming lecture. Review the assigned readings – pay close attention to any bold words, headings and topics-review the syllabus and do any assigned problems. If you have difficulty with any of the problems, put notes or checks where you had difficulty so that you can walk into your professor’s office during office hours and get your questions answered. Don’t wait until after the lecture to work pre-assigned problems. Most of the time, anything that you had difficulty with, can be answered in class. If you wait until after class, you will be behind. Attempt assigned problems before your lecture.

Listen to your lecture and take notes only on the things that you know are not in the syllabus or text book. (See my previous study skills posts for how I would cut my textbooks). Take notes on things that help you to understand the important points of the lecture or clarify concepts that you previously did not understand. As I have outlined in other study skills posts, I would take notes on the left side of my notebook only using the right 2/3rds of the page. The left 1/3 of the page would be left blank so that I could write in summaries of the notes or definitions of terms that were important. On the right pages of my notebook, I would recopy notes that were taken in a hurry so that they were legible. I would also place notes and information from my text book.

Most of the time, I took lecture notes on my laptop computer or on looseleaf notebook paper. I discovered the utility of using notebooks that were designed for law students (summary paper) and then resorted to making my own version of these summary pages. I would print out my notes and clip them into a looseleaf notebook so that I could highlight them or make notes to myself as I studied. I would review the previous lecture, study the current lecture and preview the upcoming lecture doing the text readings.

As I stated under Organic Chemistry, I never walked into any lab unprepared. My lab prep consisted of knowing the purpose of the experiment; how long each step would take; what data needed to be obtained and what conclusions/observations I would be expected to make. I kept a sticky note in my lab manual or notebook with the steps of the experiment briefly outlined so that I could refer to my note. This make any lab write-ups pretty easy to finish. If there were pre-lab exercises, these were done before I attended lab. I would also consult my textbook if the material covered in lab didn’t correspond with the lecture (most of the time the lab material was a bit ahead of the lecture).

For courses like English and Math, I made sure that I had a solid reading schedule that kept me ahead of the class. Again, I would have problems worked before coming to class. In English, I would make sure that I had thoroughly covered the readings taking notes as to tone, argument and subject matter as I moved along. Again, sticky notes were good for making extra notes in my reading books. I could past them in and add them to my professor’s notes after the lecture.

Soon after each lecture, I would quickly review the lectured material filling in any words that I had left out or drawing arrows to link materials. I would make any quick notes of things that needed to be clarified during office hours. In terms of Math and English, I would have circles around any problems that I had attempted but was not able to complete before class so that I could get my questions/problems taken care of. If these were not taken care of in the lecture, they would be taken care of during office hours.

My professors got to know me pretty well because I would attend office hours even if I was sure that I had mastered the material. It doesn’t hurt to have a “tune-up” and a “knowledge-check” even if you are sure that you are understanding everything. Sometimes these “tune-up” sessions would give me valuable insight as to what to emphasize for the exams and what to place less emphasis on. I figured that if I was paying thousands in tuition for each course, I was going to get every bit of instruction out of the course that was available. It also gave the professor a chance to get to know me which was good when I requested a letter of recommendation for graduate/medical school. I always received high praise for my business-like attitude and organization of my coursework.

Spending so much time preparing and previewing for each class made studying and review for each exam practically effortless. By the time the exam rolled around, I had been over each lecture a minimum of three times. I reviewed the previous weeks lectures on the weekend. By staying ahead of the professor and the class, I always had plenty of time to integrate the materials for every class. My attitude toward university coursework (honed by loads of experience in secondary school) was that my “job” was to master this material. I needed to thoroughly master my coursework because it was background for my graduate studies and I wanted the best undergraduate education that my university offered. 

Don’t get the idea that I spent every waking hour in front of a book. I used my university time to attend lectures and seminars on any subject matter that was of interest to me. I went to lectures on the Holocaust, aerospace engineering, mathematical theories, social theories, political science in addition to departmental seminars in biology, chemistry and physics. I obtained a departmental seminar listing during the first week of class and added these to my schedule. Even if you do not completely understand everything in a seminar, you can pick up valuable experience and broaden your knowledge base for free. These seminars are also a great opportunity to get to meet the faculty and learn their research interests.

As a medical student, I tried to attend grand rounds in Surgery, Medicine and Pathology as much as my schedule would permit. These grand rounds became invaluable for USMLE (all steps) as the speakers always presented both the basic and clinical science of their discipline. It was my interest in every aspect of medicine that lead me into academics and today, continues to allow me to keep up with basic science as well as clinical science.

As a student of science and medicine, you have to be quite proactive and a bit of a self-learner when it comes to the mastery of your craft. If you take the time to start keeping up with the literature and attending seminars/grand rounds while you are an undergraduate, you can carry those skills into graduate/medical school. You cannot afford to be a passive learner relying on the professor’s lectures for your entire education. I totally attribute my performance on the Medical College Admissions Test (MCAT), United States Medical Licensing Exam (USMLE) and my specialty board/in-training exams to my attendance at all of those seminars and grand rounds. By listening to the “cutting-edge” leaders in various subjects, you learn to analyze information and you learn to present information logically. These skills are free and the seminars are often free and easy to take advantage of.

Finally, approach your studies as you job. If you are working and attending class, you need to be organized but you need to do both well. I always recommend that students who work, need to take less hours. It is not useful to load up on semester hours only to do poorly or mediocre in the coursework. Take less hours in the first place, do well, and if you find that you have free time, use that time to attend seminars/grand rounds. If you are a full-time student with no employment, use some of your free time for seminars and experiences that widen your educational experience.  You only get once chance at your university experience and you need to be sure that you are getting the most out of every class for you money. Make your studies of prime importance and be proactive about getting your needs met.