Does 'The Checklist Manifesto' Apply To Medical Students?

This post is long overdue, but I finally got around to reading Atul Gawande's most recent book The Checklist Manifesto: How to Get Things Right. Longtime readers of Scrub Notes are likely aware that I'm a big fan of Gawande's writing. His first book Complications has practically become required reading for pre-med students. His second effort Better continues along the same vein. However, The Checklist Manifesto is Gawande's first major effort to move beyond merely an anecdotal descriptive text on the trials and tribulations of practicing medicine into the area of shaping policy and medical practice. And, to this reader, he makes a fairly convincing argument, utilizing extended examples from diverse fields such as piloting, building construction, and finance.

Gawande's argument primarily targets his fellow surgeons. However, what can medical students learn from his text? Can the humble checklist help a medical student succeed in learning the necessary knowledge to succeed in medical school? I doubt any serious study has been done in this area, but intuitively, the answer is yes. As Gawande suggests, try a checklist.

But, what does trying a checklist mean for a student? The checklist is meant to address a systemic problem, not an individual one. Gawande targets fellow surgeons because they run the ORs: they have primary responsibility for the patient's well-being as well as for insuring that the OR runs well. A trainee like a medical student typically simply plays their assigned role. However, therein lies the problem.

By simply playing an assigned role, the student learns from their environment in a haphazard way. Some ORs meticulously run through time-outs and other preparatory procedures; others perfunctorily mention them or even avoid them except for the most necessary ones. However, the student's responsibility ultimately is to the patient, not to maintaining a culture of complacency that he or she may find herself in. By creating and running through their own mental checklist prior to any patient encounter or procedure, you can ensure that you and your team avoid making unnecessary mistakes that may cause the patient harm. Even if you feel powerless on a team or service, your personal checklist can help ensure that you are doing your utmost to serve the patient. Although this may not be the 'heroic' side of medicine, as Gawande notes, the effects can be profound in terms of safety and patient care.

Beyond patient safety, taking the time to craft a checklist can help you break down a complex procedure into simple steps. As you are learning and practicing the procedure, focusing on these simple steps will make it easier to learn the procedure and learn to do it the right way in a safe manner. Gawande emphasizes this in his subtitle: How To Get Things Right. And that's what any student wants to do: get things right.

 

Updated 2015-12-20

Scrub Notes 2012 Med Student Holiday Gift Guide

Happy Thanksgiving! While this is a time to give thanks and count your blessings, tomorrow is a time to shop! However, most med students, residents, and other medical professionals may not be joining on these shopping trips: they're probably studying or on call! So, to celebrate their commitment to caring for others, here are a few ways to show them you care for them:

Kindle Fire by Amazon

The latest tablet from Amazon is quite a break from previous Kindles. Offering an Android-based operating system and full color, the Kindle Fire is Amazon's first foray into the competitive tablet space. While not as full-featured as the iPad, the one killer aspect of the Fire is the price: $199.

That's right, $199 - a full $300 cheaper than the iPad. For med students, the 7" form factor makes it much more portable than the iPad. While lacking 3G support, most students would likely use it in a library or lecture hall (or Starbucks), where Wifi hotspots are plentiful. And with access to Amazon's site well-integrated, it will be easy for them to purchase e-books... or TV shows whenever they need blow off some steam.

Giant Microbes White Blood Cell (Leukocyte)

A popular gift idea last year, the Giant Microbes are back! These stuffed toys are whimsical depictions of all things medical. From bacteria to neurons, check out all the options available. For the immunologically-minded, I put the white blood cell here. I can almost hear him saying, "Meep! A bacteria! Must defend!" Haha, almost like a Pokemon... but one that saves lives!

The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee

This book has been on my reading list all year long and hopefully I can get to it before the year is out. However, from all accounts, the book is well-written and lives up to its subtitle as a biography of cancer. Mukherjee details mankind's history in battling this scourage and how modern science has revolutionized the fight. However, with the great advances come new challenges and new concerns in how we deal with when our bodies fail us.

Looking for more gift ideas? Check out last year's med student gift guide. And if all else fails, you can't go wrong with a gift card =)

Updated 2015-12-20

How New Medical Students Should Learn To Learn

A confusing title, perhaps, but it's correct: newly minted medical students often have to reteach themselves the habit of learning medical knowledge in order to succeed in medical school. This guide from Wellness Rounds, originally intended for students entering Baylor College of Medicine, gives some good pointers for first year medical student study strategies: 

Your goals

1. Learn material for long term retention
2. Pass exams
3. Develop skills for lifelong education & studying (nope, it never stops but it can get faster!)

1. The Basics

• No magic formula for studying except for diligence and consistency
• Goal is to learn and apply pertinent material – NOT perfection
• Efficiency is a skill developed through practice, persistence, and reflection – not the result of drinking more caffeine or a genetic trait that skipped your generation
• Studying is not a competitive sport – some student take (much) less time to learn than you will, but some take (much) MORE time than you…that’s life! Good news – in the end, we are all doctors.
• Be gracious.  To yourself and your peers as you pass through the basic science crucible that brings out some less than pleasant coping mechanisms.  It’s normal and will pass.
• You will succeed!  Don’t believe us some days?  Ask any of the thousands of physicians, professors and mentors around you – we’ll be glad to remind you!

2. The Specifics

• Choose one way to study and stick with it for at at least 1 week
  • Switching study methods costs more time than it saves and there is a learning curve to all of them
• Start with the first lecture and go sequentially to be sure you don’t miss topics
• For all study techniques
  • Study reps: 45-50 min “on”, 10-15 min “off” (see below)
  • Skim before lecture (assigned readings, ppts, syllabus, etc)
    • SKIM to familiarize yourself with how to spell new words and the general outline/concept of the lecture – this is not learning time
  • Attend > stream lecture and actively listen by taking notes, drawing pics, writing qs, etc.
  • Take a lunch break after lectures to get good nutrition, socialization and to recharge
• Techniques for LEARNING
  • Mind maps
  • Review notes with ppts, syllabi and text book and create a condensed 1 page review
  • Rewatch the lecture while condensing notes and focusing on main points
  • Flash cards of high yield material
  • Single page flow chart of material
• Techniques for REVIEW
  • Practice questions (online, review BRS books)
  • Small group discussion, lecture by lecture (max 4 ppl)
  • Small group quizzing of lecture material
  • Peer or upperclassman tutoring

Study Reps: 45-50 min “on”, 10-15 min “off”

• “ON”
  • Close email, g-chat, FB, other distractions, put phone on vibrate/silent
  • Set an alarm and STOP studying when it goes off
  • Write down other tasks that come to mind on a sticky note but do NOT stop studying to do them (ex: reply to email, wash dishes, make a snack, look-up question from another lecture, chat with nearby friends, etc.)
    • These tasks can be done during your “off” period
    • You will be amazed at what distracts you and feels “urgent” while studying, but there is almost NOTHING that can’t be put off for <45 min, including perez hilton
  • Don’t be frustrated if the first 15-20 min (or more) feel “wasted” bc you can’t focus – this is NORMAL and the time from sitting to focused productivity will decrease as you adjust to a daily routine (the same as exercising)
• “OFF”
  • Set an alarm
  • Reward time! NO STUDY RELATED ACTIVITIES!
  • Grab a snack, read a NYT article, catch up on the FB developments (OMG, so much happened in 45 min!!!), chat with a friend, send off a quick email, check off the list you made during  your “ON” period
  • Get up and stretch, walk around for a couple min – it’ll wake you up, get you out of your “study zone” (wherever  you are working)
  • Congratulate yourself on sticking to your study schedule and breaks
  • Relax and don’t worry about how much time you have/not spent studying, let the alarm clock guide you rather than checking your watch constantly

3. The Refinement

• What works for others may or may not work for you – don’t be discouraged!
• Study methods evolve as you discover what sticks best in your own head
• New topics/blocks may require different approaches
• At the end of the week or block, reflect on what worked well (timing, setting, method)
  • Adjust study methods to what works best for you – but remember, DILIGENCE and CONSISTENCY are king & queen
• Exam results not reflective of your efforts?  Ask for help! Professors, upperclassmen, mentors and strong peers can enhance your study skills.
• STUDYING is STUDYING – it is never wasted.

4. The Balance

• All work and no play makes a miserable and burned out student, resident and physician
• Set aside at least 1 hour as sacred for meeting your personal needs (NOT chores)
  • Examples: exercise, cooking a nice meal, calling friends and family, reading a great book, prayer or meditation
• Sleep on a schedule: go to bed and get 7-9 hrs of sleep every night, your brain needs that time to literally build memory
• Eat well: again, your brain and body need good protein to build synapses for memory, carbohydrates for fuel to burn while studying, and plenty of water to keep you going in the Houston heat
• Break up your week: take Sat. afternoon/evening off for fun activities with friends/family (movies, restaurants, dancing, bars, parties…), sleep in Sunday morning and have time for yourself and your personal development (reading, writing/journaling, church, chats with significant other)
• Schedule it: if we write it, we do it.  Use your gmail calendar, phone app, planner, etc. and plot out your week including your studying, exercise, family/friends and other activities.  It will give you a sense of control over your life as you plan your days, rather than your days ruling you.

5. The Non-Science Major

• You’re not alone – great physicians come from a variety of backgrounds!
• You may play catch-up at first, but you undoubtedly can succeed
• Writing and theoretical dissection of literature/theory/philosophy/art will be applicable in medicine – but basic sciences throws you back to the forgotten days of multiple choice exams and memorization.  Dusting off those skills and learning to study for regurgitation/application rather than creation may take some time, so don’t despair if you are spending longer in the library than the Bio-E major.
• Link up with a science-major classmate who is good at identifying high-yield material AND explaining it.
• Contact the upperclassmen study tutors – many of us had limited science exposure starting med school (“Wait, is it 2 livers or 2 kidneys – I’m not really sure?” – General Surgery Bound MS 4) and more than succeeded — but we’d love to make that transition easier for you!

For more study strategies for first years, check out Wellness Rounds. 

When Should I Start Preparing For The 2012 USMLE Step 1?

How about... right now?

That's right: even though the exam is several months away for most students, the time to start preparing for the 2012 Step 1 is today! Why so early, you ask? Simple: USMLE Step 1 is an exam that tests your cumulative knowledge. The sooner you start accumulating this knowledge, the better. This is not crammable knowledge. I repeat, this is not crammable knowledge. Yes, I know, you're a medical student - you live off of cramming. It's worked so far, right? Why not keep pushing your luck? Trust me: this is *not* the test you want to cram for, nor is it the test to take chances with. Most residency programs heavily weight Step 1 scores when determining which applicants to interview, let alone rank. Remember, this test is a means to an end: getting into a great residency program.

Hippocrates

So, now that I've got you properly on edge, how do you start preparing for Step 1? The key is to gradually build up your knowledge in a Step 1-specific way while you are studying for your basic science exams. As I've mentioned before regarding Step 1 preparation, you should purchase a general USMLE Step 1 review book such as First Aid for the USMLE Step 1 2012 and annotate it with your own learning as you proceed through your basic science courses. Using this technique, when it comes time to study for Step 1, you are not reading some unknown professor's notes, but rather your own in a language you can understand. And, you will also become very, very familiar with the review book that you intend to use, which is quite helpful. You will start to notice certain topics end up being covered in multiple areas. For example: meningitis is both an infectious disease topic as well as a neurological topic. Both chapters will likely mention it but with a different focus. Knowing this well in advance can help you annotate one section with a note saying "Hey! Check out the other section for more info on this!" Remember, the body does not have chapters or sections. Disease is not neatly organized, so the key for your preparation for Step 1 is to be as organized as possible.

If annotating is not your thing, there are other options. You can purchase a USMLE Step 1 Qbank now and start looking at practice questions now. Simply take a section related to a topic you are working on and go through it. Figure out what your weak areas are and study them doubly hard. Whatever method works best for you is fine. It does not how you are reviewing for Step 1, but that you are doing something specific to prepare. Even doing as little as one hour per week can give you as much as a 30% head start over your peers in that final stretch before the exam. The key is to start doing something every week now so that when it is crunch time you feel prepared and confident to tackle the challenges that lie ahead. Good luck!

Updated 2015-12-20

What The Doctor Saw

I recently finished reading What the Dog Saw by Malcolm Gladwell. I enjoyed the book, although it's more a collection of essays rather a unified work like his prior works. Why mention it here? Well, one chapter/story heavily involves mammography. The chapter is actually two stories in one, but both basically relate to the premise that a picture is worth a thousand words... but are they the right thousand? The other story involves the use of satellite imagery by the U.S. military to assess foreign targets. Malcolm Gladwell compares this to a mammographer scanning for tumors on a mammogram. The analogy is reasonable... but like all analogies, it breaks down after a while.

So, what does Gladwell conclude? Honestly, it is kind of hard to tell. He notes the difficulties in mammographers being over- and under-sensitive, yet concludes by noting the benefit of mammography spread across the population. What I wish he had taken more time to address would have been the nature of a screening exam. What does it mean for an exam to be 'sensitive'? 'Specific'? I'm willing to bet the vast majority of people out there don't know. Heck, I imagine many people within medicine aren't 100% clear. The recent controversy over prostate screening guidelines highlights just how controversial this subject is. If healthcare professionals are not united in how such screening is presented to the public, how can we expect patients to choose the right course of action? Furthermore, in the long run, such revisions erode the public's trust in healthcare overall.

How do healthcare professionals strengthen this trust in an era of seemingly constant changes in recommendations? Simple: focus on the underlying reasoning behind getting screened. Explain to patients that such tests evolve over time as new technologies develop. Help patients make informed decisions on their own. Ultimately, the better we communicate the need for testing, the benefits *and* the risks, the better relationship we will have with our patients, and hopefully they will enjoy better health in the long run.

What do you think? Check out the book to see Gladwell's argument yourself... you might find yourself enjoying his other pieces as well!

Just want to read the chapter but not the whole book? Gladwell has it posted on his website here.

Site Note: Regular readers may have noticed the long pause in new posts. Apologies, but sometimes life comes at one fast... and the blog got pushed to the backburner. Again, thanks for sticking with us and we look forward to putting up lotsa great new Scrub Notes stuff shortly! Happy reading!


Updated 2015-12-20