How We Studied for the Boards

I love learning new ways to learn almost as much as I love learning new stuff.  A few weeks ago, I read and summarized A Mind for Numbers by Barbara Oakley. A quick read, it’s the companion book to “the #1 most popular MOOC (massive open online course) of all time,” Learning How to Learn, taught by Oakley, an engineering professor, and by Terrence Sejnowski, a computational neuroscientist.  I signed up for the course a long time ago but didn’t check it out until this month.

Why did I summarize it, you may ask?  Well, I got into the habit of distilling books into high-yield summaries when I observed my brilliant medical school classmates summarizing our textbooks, back in the day.  (When a bunch of smart kids study the same hard stuff over four years, they learn some things from each other.)  I still summarize practical books whenever I can, both to improve retention and to have a quick personal reference on hand for later use.  It’s great.

If you’re interested in learning strategies or in math, engineering, the mathematical sciences, or chess, I recommend you check out A Mind for Numbers.  It’s packed with research-supported insights about how best to learn such material.  A lot of it rings true with me from my computer science days.  I had to figure out many of these strategies on my own back then.  I wish there had been books like this!  It would have saved a lot of time.

However, for medical students, residents, and fellows, it’s not sufficient.  Medicine is less concept-heavy and more detail-heavy–at least until the most important details are memorized and understood–than math-related subjects are. In this article, I’ll discuss a medicine-specific strategy that many of my physician colleagues and I have used over the years to learn dense, complicated information quickly and effectively, and to do well on board exams.  I’ll follow this with specific, high-yield examples that worked for us in studying for Step 1–arguably the most important exam of a physician’s career besides his specialty-specific boards–and for the internal medicine and rheumatology boards.  Finally, I’ll end the article with general study tips that have worked for me.  Here we go:

The Two Most Important Tenets of Studying for a Medical Board Examination

1. Find the highest-yield information and memorize it cold–with active methods such as mnemonics, teaching others, lecturing “to the wall,” writing notes out from memory, writing your own multiple-choice questions, etc.–before moving on to information that’s less likely to be tested.

2. Identify the highest-yield question banks–the ones that best resemble the exam–and test yourself frequently while studying.  Look up every unfamiliar answer choice (even the wrong ones) following each question.  As Oakley explains in her book, testing practices retrieval of information–a critical aspect of learning.  Try to buy or obtain practice exams that closely resemble the actual test and take them after every few weeks of studying to gauge your progress. (You hit two birds with one stone by mastering question banks because board exams supposedly test your mastery of the subset of knowledge that’s most important to your clinical practice.  Whether or not board exams actually test this subset is a controversial topic that we won’t discuss here.)

Do both steps in parallel, not in sequence.  The better you execute these steps, the higher your score on a medical board examination.  That’s all there is to it.  The devil, however, is in the detail.

Example #1: USMLE Step 1

I attended Baylor College of Medicine (BCM) in the late 00s.  BCM’s average Step 1 score, compared with other medical schools, was rumored to be among the top few in the nation, if I remember correctly (a quick search failed to verify this, though).  And it has continued to rise.  There were several indirect reasons for our high scores.  We studied for and took Step 1 after we had completed several key clinical rotations (such as internal medicine, pediatrics, general surgery, etc.).  Also, BCM seemed to have a bias for admitting good test-takers (our average MCAT score was unusually high).  There were probably other indirect reasons, too.  However, these advantages aside, it remains the case that some study strategies are more effective than others.  The following was a popular Step 1 study strategy at our school (warning to current med students: this is from the late ’00s):

*Total study time: no longer than 8-10 hours daily for 8 weeks or less.  Many of us took weekends off.  Treat studying like a job:  get up at the same time, start studying at the same time, and finish studying at the same time each day.  Plan to stop studying a couple days before the exam so that you can “recharge” before you take it.

1. Memorize First Aid for the USMLE Step 1 cold.  This book was incredibly dense, disjointed, and painful to study.  But it was pure gold when it came to getting a high score on Step 1, especially when memorized as well as possible.  Some of us sort of memorized it by reading through it 4-5 times, each time more quickly than the last (e.g., 3 weeks for the 1st pass, 2 weeks for the 2nd pass, 1 week for the 3rd pass, etc.).  The pharmacology section was most critical.  First Aid required a lot of supplemental studying:

a. Rapid Review or Lippincott Biochemistry: I used RR Biochemistry as a reference, looking up any concepts I didn’t fully understand in the relevant section of First Aid and expanding that section with my own notes.

b. BRS or Rapid Review Pathology: read it twice.

c. BRS Physiology: read it twice, taking notes in First Aid.

d. BRS Behavioral Science: for those who didn’t take a psychiatry rotation before studying for Step 1.

e. Dr. Edward Goljan’s pathology audio lectures: best to take notes on these lectures while listening to them during the first month of studying.

f. Goljan’s High-Yield Review (~100 pages): best studied the week before the exam.

g. High-Yield Neuroanatomy: I remember really enjoying this book during med school, but I don’t recall how much I studied it for Step 1.

h. High-Yield Biostatistics: read it very quickly, taking notes in First Aid.

i. Skim the images in Robbins & Cotran Pathologic Basis of Disease.

2a. Kaplan Qbank or USMLEWorld.  The latter had recently debuted, back when I was studying.  With better explanations, diagrams, and a lower price point, it eventually became the “gold standard” question bank.  I don’t know if this is still the case.

2b. NBME practice exams.  These exams felt very different from Step 1, but word on the street was that one’s score supposedly correlated well with one’s actual Step 1 score.  Form #3 was considered most representative.

I first learned about the above strategy from an upperclassman who went into emergency medicine.  Later, one of my classmates who did very well on Step 1 told me that he used the same strategy.

In my own case, things didn’t unfold so neatly:  I read First Aid five times, took notes in First Aid while reading relevant parts of Rapid Review Biochemistry, then read BRS Physiology once and skimmed BRS Pathology and High-Yield Biostatistics quickly.  Also, and this scares me in retrospect, I only completed 36% of the Kaplan Qbank.  However, I took two NBME practice exams a few weeks apart during the second month of studying and did very well on them, predicting the great score that I got on the actual Step 1.  I think that in my particular case, knowing First Aid backward and forward was the key to doing well.

I shared this strategy with a friend who carried it out perfectly, then studied supplemental material–both question banks, other review books–and got an even higher score than I did.  We shared the strategy with other friends.  They all did well, too.  I told our preclinical directors about it.  The study strategy for Steps 2 and 3 is analogous.

Of course, other methods were also effective.  I’ve heard that at Caribbean medical schools, students are drilled with endless multiple-choice questions and mock Step exams for months, becoming expert at taking the test.  (There was, and may still be, a bias against Caribbean med students and foreign medical graduates when I was in residency.  They had to obtain high scores on the Step exams to have a fighting chance for an accredited residency slot in the US.)

There’s more than one way to eat a pomegranate.  And I’m sure the game has changed since 2008.  Spaced-repetition software is more popular now than it was back then.  There are medicine-specific, computer-based spaced-repetition systems like Firecracker (see below) that weren’t around when I was in medical school.  Optimal learning strategies are better-understood.  Every generation of students is savvier about learning and has better learning tools available to them.

Example #2: American Board of Internal Medicine

My internal medicine residency program had a very high ABIM pass rate.  Again, they preferred to accept medical students with high Step scores (the thought–whether or not it’s correct–was that this predicts internal medicine board pass rates).  However, there were other critical things about our program that set us up for easily passing the ABIM:

Continuous, Active Learning of High-Yield Material

Residents don’t have much time to study.  While seeing patients, we tested ourselves and learned actively by constantly questioning our treatment strategies.  We constantly looked up important points, asked ourselves why we were ordering, say, enoxaparin for one patient and not for another, or an echocardiogram for one patient with a certain condition and not for another with the same condition, etc.

Studying High-Yield Information and Practicing with a High-Yield Question Bank

We had already studied in-line with residency training, but for the ABIM, we had to round out our knowledge, which was done by studying the latest version of the ACP’s Medical Knowledge Self-Assessment Program (MKSAP), which our program director purchased for each of us.  MKSAP is a series of review books for every subject in internal medicine:  cardiology, pulmonology, nephrology, general medicine, etc.  It’s also a large question bank.  The wisdom passed down to us from prior generations was that knowing the question bank was enough to do well on the exam, and that knowing all of MKSAP by heart was sufficient for getting a high score.

This is all concordant with what we know now about learning any body of knowledge.

(Once again, there was more than one way to study. Some residents preferred other review series.)

Example #3: American Board of Internal Medicine – Rheumatology

Rheumatology is, in some ways, a difficult branch of medicine to study.  Many of the diseases we encounter (or must be able to recognize and treat but might never encounter) are at the case report level and could show up on, say, the popular television show, House, M.D.  Unlike the internal medicine boards, which mostly tests management of commonly-encountered diseases on the wards and in clinic, the rheumatology board exam has a large proportion of infrequently- (or never-) seen conditions, even by rheumatologists who trained in large, diverse cities.  It also has some basic science questions that never come up in clinical practice.  This is somewhat understandable because the field changed radically in prior decades by sophisticated new medications capable of putting previously-debilitating diseases into remission.

The general consensus is that the highest-yield review book is Rheumatology Secrets.  Thankfully, the third edition of Rheumatology Secrets came out just last year.  Until this edition was published, it was difficult to find an up-to-date, high-quality, concentrated review of rheumatology.  The second edition was published in 2002–not long ago–but rheumatology has exploded since then with new treatment options, better understanding of disease processes, new guidelines, etc.  I’m glad our program director bought each of us a copy last year.

The Rheumatology Image Library is also a critically high-yield source of information.  Memorize it cold, ideally using spaced-repetition.  It takes at least two weeks of part-time studying to get through this image bank the first time.

In rheumatology, the question banks to study are the CARE modules.  Use spaced-repetition to learn (at least) the most recent five years’ worth of CARE questions completely, looking up anything you don’t understand.

Some people swore by the UCSF Rheumatology Board Review.  Others didn’t find it useful.  My co-fellows and I didn’t go to it, so I can’t comment on its efficacy.

Following the advice of fellows who graduated before us and of young attendings who had recently taken the exam, I read Rheumatology Secrets twice, studied five years’ worth of CARE questions in the months leading up to the exam, went through the Image Library twice the month before the exam, and did very well on my rheumatology boards.

Here are other, more general tips for studying medicine that I’ve found particularly helpful:

*Distill bloated texts into high-yield summaries, then study those summaries.

*Concept-mapping might be even more effective than summarizing.  (Summaries were easy to type and store, so that’s what I got into the habit of doing, but in the age of tablet computers, concept maps might be digitalization-friendly, too.)

*(For residents, fellows, and attendings) Every day, study a bit of something you have not yet mastered or that you don’t know.  As with any other daily practice, it’ll amount to a lot over time.  Many physicians continue this habit–to the benefit of their patients–throughout their working lives.  (I picked up this tip from the chief of cardiology during my residency.)

*Don’t expect to outsmart medical exams.  They’re designed to prevent cleverness.  They often test how solid your knowledge base is by asking questions about “corner cases,” so you must have a strong working knowledge of the material.

*Master the high-yield information you’ve already learned, but don’t spend too much time on it before moving on to new material.  It’s comfortable to study familiar material, but focusing on important stuff you don’t know will make you much stronger.  (I adapted this tip from learning how to play guitar.)

*Study purposefully, with good, concrete reasons for why, how, and what you’re studying.  Don’t study on autopilot.  Don’t just reread stuff passively.  Change your study strategy if self-testing shows you it isn’t working well.  (I adapted this from a learning strategy that my guitar instructor emphasizes.  It worked well for me while studying for the rheumatology boards, too!)

*Cut out Facebook, Twitter, and other social media distractions in the months leading up to the exam. This will give you an immediate advantage because your attention will be less fragmented.

*Technology is a double-edged sword.  When used properly, it can help you learn more efficiently.  A friend of mine who recently reached the USCF National Master level in chess says that technology has helped today’s kids reach levels of chess skill unheard of before computer-assisted training became possible.  However, technology can also be a crutch that prevents you from learning what you need to know.  Don’t offload everything to your “other brain” (e.g., smartphone).

*Study mindfully–this is more subtle than it sounds and is another idea from learning a musical instrument.  I find that I can be stuck, for months, on a mediocre level of performance of a tricky piece for guitar if I don’t mindfully break the problems down into small pieces and find elegant solutions.  (This usually involves finding a different fingering sequence or pattern that eliminates the prior problems.)  As soon as I approach the issues mindfully, I move out of my plateau and begin to improve again.

*Interleave studying with seeing patients, when possible.  This gave us a large advantage to students at many other medical schools when it came to studying for Step 1.  Seeing patients will give your studying traction.  It solidifies what you’re learning by giving it context and making it practical.  It even helped, in a different way, while I was studying for my rheumatology board exam.  Since I was building my practice in an underserved area while studying for the boards, I saw patients with serious conditions who had been waiting for months or longer to be seen by a rheumatologist.  Seeing brand-new patients is very different from inheriting patients from other rheumatologists.  One has to think more carefully and catch on to more subtle clues.  This unique situation and my studying each informed the other.

*On practice tests and then on the actual exam, stay coldbloodedly focused on the relevant parts of questions.  Board exam questions are filled with distractors.  A technique that worked for me was to scroll down to the answer choices after reading the first couple sentences.  That helped me figure out what to look for as I read the rest of the question.

*Test yourself frequently in conditions as similar to the actual exam conditions as possible, to take advantage of unconscious cues.  If this isn’t possible, then study in multiple different settings so that you don’t set up unconscious cues tied to recall.  (E.g., studying in pink rooms but taking the test in a white room might really mess you up.)

*Keep your studying short and intense.  Approach it like a full-time job and then enjoy your afternoons and evenings.  Many of us studied for Step 1 full-time for no longer than 8 weeks.  The accepted wisdom was that one would begin to forget memorized material if one studied longer than 8 weeks, that it was more psychologically daunting to study hard for so long, and that it would be tempting to not study at full intensity.

*Spaced repetition:  there are general spaced-repetition programs like Anki and Mnemosyne that anyone can use and also dedicated spaced-repetition learning software, such as Firecracker, for pre-meds and med students.  (Firecracker wasn’t around when I was in med school.)  You can also just use your own spaced-repetition algorithm with paper and pencil.

*Mnemonics and mnemonic systems are useful both for short-term retention (e.g., long-enough to ace a test) and, in combination with long-term spaced repetition, for permanent retention.  There are entire books/websites on mnemonics, so I won’t go into detail here.  My favorite kind of mnemonic is the story mnemonic.  Read my next essay on how I used a giant story mnemonic to ace one of the hardest courses I’ve ever taken.

*Become a savvier strategist.  Consider learning chess or another strategy game.  Better yet, learn how to play many games.  This will increase your flexibility and effectiveness in everything you do.

*Try to get at least eight hours of sleep each night.  Try to exercise most days.

*Meditate daily for at least ten minutes.  Meditation is as old as the hills but research is only now beginning to discover its wonderful benefits.  A regular meditation practice will help you focus more easily when the big exam day arrives.  It will also help you avoid getting sidetracked when life (inevitably) tries to get in the way of your test preparation.

Do you use any of these approaches when learning new things?  If not, which learning strategies do you prefer?

Update 2/1/16: Dr. Oakley has graciously included this essay in the course material for Learning How to Learn!

Advertisements

How I Learned to Barre Cleanly, Without Buzzes, Squeaks, or Muted Notes

Barre chords are notoriously difficult for the beginning guitarist.  Now that I can finally, and to my own amazement, barre cleanly, I can tell you that it’s because barre chords are taught poorly.  There’s no reason I shouldn’t have been able to barre perfectly from the very beginning, except that the critical information I needed was found in only a single source:  Frederic Hand’s Classical Guitar Technique and Musicianship.  Hand recommends two things that instantly fixed my barring technique:  hyperextend the barring finger and place it straight down on the strings, without flexing it and without rolling or curving the finger to either side.  This works every time for me.

Before this revelation months ago, I was subject to all manner of confusing recommendations.  The Parkening Guitar Method recommends pressing “somewhat on the side of the finger” and stresses “position” of the finger over “pressure.”  Numerous internet resources also recommend pressing on the “bony side” (physicians call this the “lateral” or “medial” side) of the finger instead of “with the flesh” (volar side).  Pumping Nylon, the classical guitarist’s technique handbook par excellence, mentions various useful things like using the whole weight of the arm to barre instead of just squeezing with your finger and thumb (your fingers tire quickly if you don’t use your arm!).  It also mentions releasing tension whenever possible, squeezing only the strings necessary for the notes you want to produce, curving your barring finger for certain chords.  Et cetera.  Some resources style the difficulty of the barre as a rite of passage:  when you figure it out, things will progress more quickly, they promise.  Others recommend a tincture of time:  you’re a beginner, after all.  It’s okay if you squeak or buzz when you barre!  With more experience, you’ll get it…

But I still buzzed, squeaked, or muted notes occasionally when I barred.  None of the sources I reviewed mention the straightforward method Hand recommends and which worked instantly for me.  It worked because it stopped me from flexing my finger ever so slightly, which is what produced the buzz, squeak, or muted note.  It was a discrete leap, a 0/1, on/off thing, fueled by correct knowledge alone (not by strength, not by experience) to a new, satisfying level of skill.

The best way to learn is to have a personal instructor or coach.  Even one-on-one instructors, though, can’t identify every problem that arises.  They are only human.  One must supplement with other sources of information.  The bar of quality for these other, depersonalized educational strategies, such as books, articles, lectures, and videos, is so effectively low that syntopical browsing, as I did for barre chords, is often necessary to fill critical gaps in knowledge!

How to Learn New Things in Adulthood

image

1. Pick something you fear but secretly wish you knew or could do.

2. Be sure the activity you pick has an enjoyable process for you. Don’t think about end goals. Since you will fail many times on the way to mastery, the activity should have something fundamental about it that you enjoy regardless of success or failure. If you’re miserable all the time, you should find something else to do.

For me, the timbre of individual guitar notes and the unique sensation of holding and playing a guitar trump everything else about this instrument. This keeps me going when I’m not playing as well as I’d like, or when I think about how far I have yet to go before I can consider myself a guitar master.

IMG_3782

Likewise, drawing is satisfying on a deep, meditative level, while writing clarifies and organizes my thoughts.

3. Practice or learn every day. Stay focused on the process, not on end goals.  Don’t compare yourself to others.  Being goal- and comparison-oriented is one of the fastest ways to quit anything.

4. Find a good teacher or coach to guide your efforts. Constantly improve your practice/learning sessions by staying attuned to the process and by seeking out instructional material.  As you master your chosen activity, you’ll learn so much about yourself, and about learning, that can be applied to the rest of your life.

5. Find like-minded, nonjudgmental others to learn, practice, or share with.  They will surround your chosen activity with context; they will breathe meaning into it.  Without this, it can be difficult to keep going.