Old MacBook, Resurrected

Quick personal update:  This is my first blog post in quite a while.  In the past couple months, my girlfriend and I moved again, this time to be closer to each other.  Much has happened since then, including the following.  We’ve been very busy!

My “clamshell” unibody MacBook is about six-and-a-half years old.  Initially wooed by Apple with the lovely 12-inch PowerBook G4 from coffee-shop windows and the crooks of other people’s arms throughout my early twenties, I eventually succumbed to Apple’s charms and bought this MacBook–the only Apple computer I’ve ever owned other than my iPhone and iPad (and both of those were gifts from my dear mother).  I made a critical mistake when I first bought it, though, which is that I didn’t max out on RAM. I’ll never make that mistake again. You’d think I would have learned my lesson from the Lenovo laptop I purchased a few years before the MacBook.  I didn’t maximize the RAM on that one, either.  Soon hobbled by operating system updates that slowed everything down, I had to upgrade the RAM modules. (The upgrade was easy and effective.  The machine is still quite fast when running Linux or Windows.*)

Insufficient RAM was the Achilles’ heel of my MacBook for years.  Like the Lenovo, the MacBook was disabled by operating system updates soon after purchase, and, like a person with chronic, untreated inflammatory arthritis, I adapted to this impaired functionality by reducing the scope of my activities.  A few months ago, I installed cloud backup software, after which the computer’s performance degraded even further.  The coup de grâce was an OS X upgrade to El Capitan several weeks ago which rendered the machine practically unusable.

Suddenly desperate for a functional laptop, and realizing I had never gone so long without buying a new computer, I looked at the options at the online Apple Store and did some research.  I learned that the new MacBooks are clearly not targeted at my demographic:  they are ridiculously difficult to upgrade or repair (1, 2), have few ports, don’t have an optical drive, have relatively small storage space, and are becoming more dependent on Apple’s cloud-based services.  (Read this horror story by a blogger who had his entire personal music collection deleted from his hard drive by Apple when he signed up for Apple Music, along with his rare, cherished tracks being replaced by more popular versions in the cloud.)  As we all know, Little Brother has long since become Big Brother.

I wouldn’t buy this sort of computer unless I was absolutely forced to do so.

Curious about other options, I looked at PC laptops, then started looking at upgrade options for my current MacBook.  After a tiny bit of research, I learned that I can massively improve my current laptop’s performance to approximately that of the latest Apple MacBooks by spending at most 1/5 the price of the new MacBook Pro I was looking at a few days prior.  This gave me pause.  Why hadn’t I thought of such an easy solution in the years before my laptop came to a grinding halt?  A moment later, I realized it’s for the same reason so many new patients see me when they can no longer tolerate the pain of chronic arthritis: I was used to my laptop’s slow performance, just as many patients become used to chronic pain and to a smaller comfort zone until various treatments get them back up to speed.

The actual RAM/hard drive upgrade was easy.  I maxed out the RAM, replaced the hard drive with a solid state drive almost double the size of the old one, installed OS X El Capitan from a USB flash drive I had set up earlier, then used Migration Assistant and a USB drive adapter to transfer my old data over.  I didn’t replace the battery because after more than six years, it still has half of the maximum number of charge cycles left!  What this tells me is that I was so busy the first three years I owned the laptop–during internal medicine residency–that I hardly used it.

Anyone with a modicum of technical interest can upgrade or repair her old MacBook, too.  Here’s an excellent, minimally technical overview of the most common repairs.  Let me know if you’d like the step-by-step breakdown of my own approach.

My old MacBook is now the fastest computer I’ve ever used.  It’s quieter–the fan is basically never on–runs cooler, has a noticeably longer battery life, powers on and off more quickly, opens applications instantly, and doesn’t slow down.  I saved more than $1600 by upgrading this laptop instead of buying a new MacBook Pro.  A couple weeks post-upgrade, I’m still giddy, still amazed, that OS X can run so quickly.  This reminds me of some of my patients who are ecstatic for weeks or months after their debilitating conditions are treated because of how little pain they now have and by how much more they can do comfortably.  Perspective is only 20/20 in hindsight.

*Addendum 5/20/16: I’ve dual-booted Windows and Ubuntu Linux on my Lenovo laptop for years.  I use the Windows partition for Windows-specific applications and the Ubuntu side for a bit of programming, for writing, and for going online.  As I updated Ubuntu over time, it became more and more difficult for this ten-year-old computer to handle it.  I just reformatted the laptop and installed Windows alongside Lubuntu–a lightweight version of Ubuntu designed for netbooks and old computers–and am pleased to say that Lubuntu gives me what I like best about Ubuntu without all the graphics- and other resource-intensive frills.  I also bought a brand-new battery on eBay for only $17!  The laptop is highly usable once more.

*Update 8/28/16: I discovered today that my updated MacBook can videoconference smoothly.  I used it for an online guitar lesson via videoconference without any problems.  Previously, I used my iPad 4 for this purpose but it was slow, dropped and altered sounds and video, etc.  Before my MacBook was updated, I wasn’t able to videoconference with it because everything slowed down and the video and audio were of poor quality.

*Update 1/8/17: My MacBook and my Lenovo are still performing as well as they did post-upgrade! No problems so far.

Dr. Strangekidney, or How I Learned to Love Renal Pathophysiology

The year was 2006.  The class was renal pathophysiology, the bane of medical students everywhere.  Our text was from Harvard Medical School, and even Harvard admitted on the back cover that this is a “difficult subject for even the most advanced students.”  I don’t remember such a depressing statement–before or since–on any other textbook in my 30 years of studying all kinds of difficult subjects, including organic chemistry I and II, physical chemistry I and II, differential equations, formal languages and automata, advanced calculus/physics for engineers, and everything I’ve studied in medicine!

Certainly not the most advanced student in my class, I nevertheless resolved to somehow conquer this untamed beast of medical knowledge.   I don’t know what I was thinking.  Nephrology is, perhaps, the most difficult subject taught during the basic science years of medical school. The material is extremely complex, the time allotted to learn it too short, and the student finds it difficult to retain the numerous relationships between facts long-enough to place them into a top-level or conceptual context.  What made it more difficult was that there were several other subjects to learn during that block of basic science.

After seeing a fellow classmate use a story mnemonic for a set of facts in another class, I suddenly realized how I can use a giant story mnemonic to learn all the renal pathophysiology we had to learn.  By imposing a mnemonic system onto individual facts, and onto relations between them, a story arises, a concrete story that significantly facilitates retention of this abstract subject. Retention, in turn, facilitates reasoning about the subject on a higher level.

Even though I’ve never used any illicit drugs, nor even tried a cigarette, I began to spend bizarre, psychedelic afternoons and evenings learning renal pathophysiology while writing a very strange, nonlinear story in the margins of our textbook and printed PowerPoints.

For example, I represented sodium (Na) as a Morton salt container.  Since sodium moves into the renal tubular cell from the luminal membrane (the side that faces the tubule) and out of the cell from the basolateral membrane (faces away from the tubule), I visualized Morton moving toward the light (lumen ~ light) inside the cell. Once inside, Morton runs down a ladder to first base (“base-o-ladderal”).

We learned that charged particles can’t diffuse freely across lipid bilayers; they must use channels or transporters to move across cell membranes (which are lipid bilayers). Morton was charged with a crime, so he can’t move across a cell membrane without personal transporters or without showing up on a TV channel.

The loop of Henle is the portion of the nephron between the proximal and distal convoluted tubules.  I represented the loop of Henle as Don Henley, the famous singer-songwriter.  Na is reabsorbed in the loop of Henle via Na+-K+-2Cl- cotransporters. In my story, this became:  Don Henley eats salted (Na+) bananas (K+), then drinks swimming pool water (Cl-) to quench his thirst. (Mr. Henley himself never did this, of course, to my knowledge.  This was only a memorizational tool.)  The loop of Henle is regulated by the tubular flow rate: Henley flows, baby!

The distal tubule became the Orient.  Na is reabsorbed there via Na+-Cl- cotransporters.  This became: in the Orient, Morton salt containers float in pool water which empties into the Ganges river.  The distal tubule is regulated by the tubular fluid flow rate: the Ganges ebbs and flows, regulating life in the Orient.

I represented the collecting tubules of the nephron as museum collections.  Na is reabsorbed there via Na+ channels. The museum collections display televisions that show Morton salt containers 24/7!  The collecting tubules are regulated by aldosterone and atrial natiuretic peptide.  Aldosterone became Aldoster, the Spanish playboy, a collector of Morton salt containers, while atrial natriuretic peptide became an atrium filled with nature art: the collections include an atrium filled with nature paintings that pep you up.

And so on for hundreds of associations (including renal biopsies and other images, equations, etc.) in an ever-enlarging story involving the same “characters.”  I studied this mnemonic system twice before the exam:  once while building it, and once as a review.

The exam was a multiple-choice, Scantron-based affair.  We were under a lot of time pressure.  Halfway through, I suddenly realized the exam was misnumbered–it didn’t correspond to the Scantron!  I had misbubbled at least fifteen questions and felt I had no choice but to erase everything and start over.  Trying not to panic, I carefully erased everything, went back to the beginning, and quickly filled everything in again, question after question.  By the time I reached the point where I’d left off, I didn’t have much time left.  I picked up the pace significantly and still managed to finish.

Walking out of the examination room that day, one of my classmates (who was a bona fide “most advanced student”) told me she thought this was the hardest test she’d ever taken.

Some time later, we got the results.  I got one of the highest scores (if not the highest) on the exam–nearly a perfect score.  So, this crazy technique works.  Or it worked in that case.  I think it worked by imposing a concrete story onto abstract facts that are otherwise poorly associated (e.g., not intuitively associated) with other facts.

Years later, I discovered that Scott Young, the celebrated learner/self-improver, used an analogous strategy for learning new things.  He recommended practicing mnemonic techniques over and over until they become second-nature.  (I don’t know if he still recommends this because I haven’t kept up with his work.)

However, I didn’t ever use a giant story mnemonic again.  It was just too unwieldy for me.  I found that it’s more efficient to use a variety of learning techniques.

We moved on to the next block of material, I didn’t have any reason to practice my mnemonic system, and by the time I took a nephrology rotation during our clinical years of medical school, I found I had forgotten much of what I had learned and had to spend time relearning it.

How about you?  Do you use mnemonics on the fly while studying?  What’s your approach to learning subjects that are extremely rich in detail and in relationships between details?

My next essay was going to be on the following topics:  how I prepared for the SAT by myself and scored at the 99.9th percentile; scored 5 (highest) on multiple AP exams (Calculus AB, Literature and Composition, Biology, etc.); used the same pattern of preparation to study for the GRE in a month and got a similarly high score as on the SAT; and studied for the MCAT in less than two months and scored high-enough to impress any med school admissions committee.  However, I found this excellent article today that says much of what I wanted to say:  How to Get a Perfect SAT Score, by Allen Cheng.  Pair it with A Mind for Numbers and with How We Studied for the Boards and you have a complete top-level strategy for all of these exams.

If you’d like for me to publish my essay, let me know, and I’ll see if I can add to the excellent advice presented by Mr. Cheng.

Update 2/15/16: a friend read this essay and recommended that I check out Joshua Foer’s Moonwalking with Einstein.

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!

How I Lost Thirteen Pounds in Two Months

(Note:  the following is *not* health or fitness advice.  It is simply my personal account of how I lost extra weight.  You should consult your physician before starting any weight loss or exercise program.)

Earlier this year, I got a kick out of the fitness boost I got from interval training and decided to incorporate it into multiple runs each week. This was a terrible idea because after months of running too intensely, I injured my right hamstring and was forced to stop running for months.

I was fitter than ever at the time of injury.  I burned so many calories—or, so I thought—in the months leading up to the injury that I felt justified increasing my calorie intake to “maintain” my weight. (In reality, like many of us, I just liked to eat, so I came up with excuses to do so.  I’m reminded of a severely obese college roommate who enrolled in a jogging class and rewarded himself after each run with a large shake–containing more than a day’s worth of calories–from Smoothie King.)  I became used to a higher-calorie diet.

After the injury, I switched to cycling but didn’t change my diet. (It’s more difficult to burn as many calories cycling as running.)  A few months later, at my yearly physical, I saw that I weighed much more than I had ever weighed in my life!  (I’m convinced it was mostly fat weight because I paradoxically felt weaker over the prior few months despite strength training at least 3 days weekly.  My pants fit more tightly and my belt reached its final eyelet.)

By the standard body mass index (BMI) calculation, my weight was still within the “normal” range.  My family, friends, and coworkers also thought I was of normal weight. They didn’t understand why I thought I had a problem.  Did I have body dysmorphic disorder, perhaps?

However, Asians and Middle-Easterners have higher levels of body fat, a propensity for central obesity, and are at significantly higher risk for diabetes, heart disease, and other serious chronic illnesses related to weight gain, so a different BMI calculation, called the “South Asian BMI,” should be used for them.  According to my South Asian BMI, I was overweight.  What’s more, despite being fitter than ever, my hemoglobin A1c (a long-term measure of serum glucose levels), while still within the normal range, was higher than it was the previous year!

So, like many other Americans, I was both fit and fat, and I had just discovered that I can’t outrun a bad diet. (Calorie restriction is much more effective than exercise for weight loss.)  In America, we have an abundance of highly-processed, low-quality, easily-absorbed calories.  Sugar is the new tobacco.  We also don’t get enough sleep, which makes us crave fat and sugar.

I immediately cut out all stress-related and other surplus calorie intake.  This was difficult for the first two weeks; my thoughts repeatedly returned to food during this time.  After I became used to it, though, I was surprised by how infrequently I became hungry and by my enhanced focus on more important matters.  I refused high-glycemic treats brought over by drug reps at work.  I cut out eggs, decreased meat intake, started eating steel-cut oats* for breakfast, then switched to whole oat groats with mixed nuts and frozen blueberries.  I massively improved sleep quality by using blackout curtains at home and an eye mask during travel.  (I also benefit greatly from wearing soft foam earplugs during sleep.)  Also, and this is of critical importance, I bought a reliable scale and got back into the habit of weighing myself several times a week.

Two months later, despite working out less intensely than before the injury, I was thirteen pounds lighter (fifteen by now!), well within the normal South Asian BMI range, and had returned to my pre-fellowship weight.

I feel much better.

Update 1/3/16: I continued to lose weight until I dropped a total of 20-22 lbs.  Any more weight loss would threaten to make me underweight.  I’ve remained at this optimal weight by avoiding large amounts of refined or high-glycemic carbohydrates, by limiting total daily calorie intake to a normal amount for my size, by weighing myself several times a week, and by continuing to exercise regularly.

Update 7/4/16: Probably because of calorie creep, my weight slowly increases if I don’t practice intermittent fasting.  By skipping just one or two meals a week, my weight stays at goal.

Update 1/2/17: With the above strategy + intermittent fasting (see follow-up blog post here), I’ve remained > 20 lbs lighter–steady at ~23 lbs over the past few months–without any swings in weight at all.

*I was first introduced to steel-cut oats in the early 2000s upon reading Eat, Drink, and Be Healthy by Walter Willett.  That book changed the entire way I thought about food and health.  However, I didn’t make a regular habit of eating unrefined oatmeal for breakfast until this year!

Area Physicians View Cy Twombly Gallery

A group of area physicians visited the Cy Twombly Gallery in Houston, Texas on Sunday afternoon.

“We were walking around the block after viewing nineteenth-century French drawings at the Menil Collection next door when we noticed a tan building with a louvered roof next to a lovely oak tree.”

Intrigued by the building, they entered and saw works like Untitled (New York City), below, which sold for $29,976,448 at Christie’s on February 11, 2015, and Untitled, below, which sold for $69,605,000 on November 12, 2014:

Untitled (New York City), Cy Twombly, 1970
Untitled, Cy Twombly, 1970

“My three-year-old created something along those lines this morning,” said Ben Bovie, a general surgeon who once lifted the scrotum of a patient with Fournier’s gangrene for hours while his colleague skeletonized it, intermittently having drops of peppermint oil placed on their surgical masks by the scrub tech to mask the odor.

Ferragosto V, Cy Twombly, 1961

“So did my kid,” said Chris Ferrigno, an internist who spent two years after college designing a plumbing system for a rural town in Guatemala and who recently defaulted on his medical school loans.  As he gazed at the masterpiece above, he was reminded of his toddler’s breakfast-time wall painting using butter and various jams, including strawberry and grape.

As sunlight filtered tastefully through a ceiling of white-canvas sail cloth, they strolled past masterpiece after crowning achievement after masterpiece by the great post-Abstract-Expressionistic maestro who was born into privilege, became wealthy by dint of his undeniable artistic genius during his own lifetime, won the Praemium Imperiale, married into aristocracy, and lived in a 17th century palazzo in Rome built for the Borgia family while gracing humanity with a soul-expanding oeuvre that certainly could not have been created by, say, a blindfolded, autistic cat.

Cold Stream, Cy Twombly, 1966

“You know, these scribbles remind me of a schizophrenic patient I examined once in medical school. He tiled his bed and the floor all day and all night with sheets of paper filled with 0s and 1s.  He had to be put into isolation because he drove his roommate crazy,” said Dave Dalhousie, a cardiologist.  Dalhousie spent a year in college programming a Braille translation system for his local school for the blind while financially supporting his mother and five siblings.  He estimates he now spends 60% of his time on the phone, fighting insurance companies.

His five-year-old daughter, Sarah, tugged at his sleeve and said, “This is boring, Daddy! I wanna go home and watch Spirited Away [by Hayao Miyazaki].”

He took a few photos of the masterworks and sent them to his mother–she had dissuaded him from majoring in art because it isn’t “practical”–along with the link to Twombly’s Wikipedia page.  At press time, his mother refused commentary.

A Brief Report of Tragic Irony

I saw a patient today, a sweet elderly Hispanic woman of very limited means, and possessing of very limited education, who is lost in the maze of the convoluted Medicare system and cannot obtain her rheumatoid arthritis medications. She doesn’t qualify for Medicaid. Can’t afford other supplemental insurance. She signed up for Medicare parts A and B, but didn’t know she had to sign up for part D, and now she can’t obtain her TNF-inhibitor (for more than half a year now). What’s worse, she was recently told by her pharmacy that she won’t be able to get her methotrexate, prednisone, or quite frankly any of her medications. She’s been in a flare for many months, her disease gnawing away at her joints with irreversible damage.

This is tragic. What’s ironic is that the very system that should help people of her demographic (elderly, of limited means, etc.) has her lost instead in a complicated, confusing maze of complexity.

We tried to help her out as well as we could.  My attending spoke with a drug procurement specialist about her situation. I referred her to a case manager.

But it shouldn’t have even come to this. The system in place to help her demographic should make it easy for people like her to obtain the treatment they need. Sadly, ironically, tragically, many seniors find the system confusing.

A Witnessed Death

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“You live like this, sheltered, in a delicate world, and you believe you are living…And then some shock treatment takes place, a person, a book, a song and it awakens [you] and saves [you] from death.” – Anais Nin

On June 12, 2013, my driver and I were on our way to Sierpe, Costa Rica from Manuel Antonio when the road entered a palm tree plantation.  About 50 meters in front of us, a blue hatchback circled into view along a bend in the road, then lost control, veered off into the plantation, and hit a palm tree head-on, its front bumper popping out along a dramatic arc back onto the highway.

We were the only people who witnessed the accident, and we couldn’t believe our eyes.  My driver pulled to the side, rushed out, opened the trunk, and pulled out a fire extinguisher.  Flames licked the front of the wreck.  I was afraid the burning vehicle would explode.

He doused the fire, but then a little fire started up again near the front left tire.  His fire extinguisher was empty now, though, so he pulled out his cell phone and called an emergency number.

There was no way to pull the driver out of the car for CPR.  The young man was unconscious (likely died on impact, if not before), clamped tightly by the compressed right front seat.  His head lay to the right, out the passenger-side window.  An arm stuck out the window, too, and his face was bloody, with blood on the ground.

I checked his pulse through a blade of grass to avoid contact with his blood; his carotid and wrist pulses were absent.

We flagged down an eighteen-wheeler and other vehicles for assistance.  One of the drivers brought out a fire extinguisher but squeezed its lever with no effect, so he went back and produced a large container, previously for what seemed to be motor oil, and splashed what was probably water onto the remaining fire, dousing it.

More people had accumulated by this point.   Among other things, they looked at him and repeatedly checked for a pulse.  Then they put their hands on their heads and said “muerte,” one of the few Spanish words I understood.

If we could have pulled him out, if we could have cut away the car, we would have performed CPR.  I could have directed it.  But CPR was impossible.  Eventually, my driver and I got back into the car and drove to Sierpe.

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He dropped me off at a waterfront bar/cafe, “Las Vegas,” where I waited for a water taxi to the jungle town, Drake Bay.  The accident I witnessed earlier was on the Costa Rican national news.

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Sudden deaths are spooky.  Day in and day out, the most unusual thing about working in a hospital, relative to working elsewhere in a developed country, is that there are no illusions between you and the brutality of nature, which manifests most terribly as mortality. This is the most disturbing thing. Debility, deterioration, and death constantly force themselves into your view, such that there can be no illusions about what will happen to each of us, and indeed to all animals, everywhere (except, perhaps, the hydra).

I no longer spend a large amount of time in a hospital or acute-care setting.  Outpatient medicine is somewhat buffered from the three D’s above.  When I’m not dealing with the three D’s regularly, though, my wishful thinking begins to reconstruct itself: warm illusions of safety, stability, and longevity begin to envelop my perspective again.

The lesson in all of these experiences, for me, is to not take anyone in my life for granted.  It’s important to be fully present with yourself and others, to refrain from pettiness, to interact with others fully aware that you have no idea how long they’ll be around.

This essay was republished by KevinMD.com on 1/28/15.