MINDFUL OF MEDICINE

I spent the last month of internal medicine at the VA medical center. I had a wonderful team that made my time there a little more fun.  My team consisted of a senior resident, two interns, a podiatry resident rotating through, and two med students (myself included). Though having outpatient (clinic) hours at the end of my rotation would have made it easier to study for my shelf exam, having inpatient hours at the VA wasn’t bad at all. Things run a little slower at the VA and it made it a good place to get a lot of studying done when things got really slow. During my last week I picked an on-call day to keep track of so I could share what a day on the wards is like!

(Some details may have been changed to protect patient privacy)

6:00am. J and I wake up and start our day. He gets ready to go to the gym and I get Melo ready for his walk.

6:25am. I feed melo and start getting ready. I stare at my elliptical and yoga mat in my study room and regret not having time to exercise before work but console myself with the fact that tomorrow is post-call and I’ll get out early enough to get a great workout in.

6:45-7:00am. I grab my salad, overnight oats and apple out of the fridge and hop in my car. I’m lucky that it only takes me 6 minutes to get to work! When I arrive at the VA I stealthily find a parking spot close to my building (it’s a bit of a challenge avoiding security to be able to park in the lots closer to the hospital since students don’t have anywhere safe to park).

7:10-8:30am. When I arrive in the team room I get settled and check to see if both of my patients are stil on the board and they are. I check with my interns to see if they need me to see anyone else and they don’t. I grab my breakfast and go to the conference room where there are extra computers. I go through each patients' chart and check new labs, imaging results, and see if there are any notes from the night team. Once I’ve written down all of the pertinent results and have started a draft of my daily progress notes, I get ready to go see my patients - also known as pre-rounding.

8:30-9:00am. My first patient is asleep and I wake her up to do a focused physical exam that includes heart, lungs, abdomen and checking for edema. She looks much better today and I think she’ll get to go home soon. My second patient is doing well, too, but is having a hard time coming to terms with the changes that will come when he gets bilateral nephrostomy tubes. I spend some extra time with him and let him talk. At the same time I feel sad because I know that this year is the last time in my medical career that I will have time to chat with patients like this.

9:00-9:10am. After seeing my patients I go find my patients’ nurses to see if anything important happened overnight (sometimes even bowel movements are important overnight events!). Then I wait for my intern in the team room so we can discuss the plan for each of my patients. The plans are pretty straightforward and include routine labs and watchful waiting so I don’t have to make any phone calls today.

9:10-9:45am. Our attending is set to arrive around 9:45 for rounds which gives me a solid half-hour to get some UWorld questions done. My team understands that our shelf exam is coming up so they don’t mind us studying whenever we get a chance.

10:00-11:30am. The attending arrives and suggests we do “table rounds” today (we discuss each patient in the room instead of at bedside) since our team is on-call and will start admitting patients from the ED at 2pm. This gives the team some time to write notes and orders before we get really busy. After we finish table rounds me and the other med student eat our lunch and do more questions until we start admitting.

2:00pm. The day-call team drops off the admission pager exactly at 2’oclock and my team gets a new admit almost immediately. I volunteer to take this patient and proceed to do a chart review before going down to the ED to do a full H&P (history & physical exam). My patient’s chart history is extensive and I have to sort through hundreds of old notes to get a good picture of what my patient’s medical history is.

2:30pm. My intern and I have finished our chart review and we head down to the ED with our senior resident to talk to the patient. When my intern and resident have finished asking their questions they give me a chance to ask my own. We then go on to do a complete physical exam.

3:00pm. After the H&P, my intern and I sit down to talk about the plan for our patient. Since this is a new patient we have to have a holistic approach and do a comprehensive workup. I start to work on my admission note (at this VA medical student notes are considered valid and it really helps out the team workload) and it takes me a little over an hour to make sure I’ve written a good note.

4:30pm. A code blue comes through our teams “code pager” and we rush down to the chemo infusion suite (the team on call carries the code pager all day and responds to any code). By the time we arrive, the anesthesia and cardiology code teams have already arrived and there isn’t much for us to do. Once the patient is stabilized, my team heads back up to our team room.

5:00-6:45pm. I go over my note with my intern and get some feedback. Once my note is finished I ask my team if they need me to do anything. I go check on my patients before I sit down to do some UWorld questions.

7:00pm. This is technically the end of our call day and our resident lets me and my co-med student go home. I feel a little guilty knowing that the team will likely stay working at least a couple more hours but I’m really excited to go home, eat and spend time with J & Melo.

Hello!

I just finished my first clerkship of third year - internal medicine! It was 12 weeks long and thankfully every clerkship from now on will be 6 weeks, except for neurology, psych, and my surgical subspecialty elective (anesthesia) which are 3 weeks. Studying for the internal medicine shelf exam (we have national NBME exams at the end of each rotation) felt a lot like studying for step 1 and brought back a lot of memories. Now that it's been three months since I took step 1 I feel like I can share some honest study advice, particularly in terms of scheduling and what resources I used. I think that the emotional struggle of step 1 prep is worthy of a post of its own so I won't be focusing on that just yet.

There are many resources available and it really just depends on what works for you. Personally I used five:  1)  Firecracker, 2) Pathoma, 3) First Aid, 4) Picmonic, and of course 5) UWorld.  I used a combination of these during my first and second year. When I started second year I tried to be more proactive and began going through approximately 300 Firecracker questions every day when I started  to to supplement what I was learning in the current block and to help me remember older topics. By the time winter break of MSII rolled around I started to get nervous about the huge challenge of studying for step 1 even though the actual exam was 6 months away at the time. Making a schedule helped me plan my time and set goals for myself. I officially started studying for Step 1 at the beginning of my last semester of MSII. Since my dedicated 6-week study period started at the beginning of May, I had January through April to set a good foundation for myself. 

At the beginning of January, we took a practice NBME (NBME 12) through our school. I used my score as a starting point for my studying and as well as source of motivation for improvement. From January to the end of April I went through all of First Aid once. I did this by covering one section a week, which was tough since some were much longer than others! I would start by flagging all of the corresponding topics on Firecracker and reviewing them as I read through & annotated First Aid (annotating was really important since it helped me make a better mental map of the material!). I also watched the associated Pathoma videos for each section if there was one. As you might imagine, the Firecracker questions really piled up. I often struggled to get through my sometimes massive number of questions per day but I think it was worth it in the end. I have friends who stopped using Firecracker at this stage because it was too much, and they did just fine. I used Picmonic religiously for the microbiology section, particularly the bacteria and parasites.

In order to get through all of the studying I had to do during those three months I had to prioritize step 1 over my block studying. In order to do this I scheduled the First Aid sections that matched my block material a week before the block exam so I could multi-task. Personally I found that First Aid and my other resources highlighted what was actually important whereas block material can be more broad. In the end, I did better than my personal average on those last two blocks without even looking at class notes or listening to podcasts. This approach worked for me but remember to stick with whatever works for you!

By the end of April I had finished Pathoma, First Aid, Picmonic (the microbiology specifically) and Firecracker. I had also done about 693 UWorld questions sporadically throughout. Before I entered into my 6 week dedicated study period I re-evaluated by resources and made my official step 1 study schedule. Firecracker had been a foundation for my learning in the blocks and during my first pass review of everything. I decided to stop using it during by 6 weeks, however, because I didn't have time for it anymore. I also officially added UWorld to the mix. UWorld is indispensable as far as step 1 studying goes. Looking back, I learned more from it than anything else.  One of the most challenging topics for me was pharmacology - there are SO many drugs you need to know! - and I found the pharmacology flash cards by Lange to be extremely helpful. I got mine from an upperclassman and they had already written important additional information on them which was very useful.

Scheduling my 6 weeks seemed like a daunting task but thankfully there was an excel sheet circling around my class from a third year at the time. Using it as an example was so helpful and I was able to tailor it to fit my personal needs. I've linked it here and at the bottom of this post! Using this schedule I was able to get through approximately 1 section of First Aid with the associated Pathoma & pharm flash cards, and a few sets of 44 UWorld questions per day four the first four weeks.  One of my goals for the first four weeks was to get through all of UWorld once, so some days I did more questions than others. During this time I did questions according to what section I was reviewing. Overall, this was a time of heavy review and solidifying high-yield concepts. The last two weeks were dedicated to reviewing the material once more while getting through as many timed-tutor "random" sets of UWorld questions as a I could. I purposefully scheduled sections that I thought were difficult towards the end so that I would see them closer to my test date. For me, these were neuro, biochem and micro.

In terms of practice tests, I used four: NBME 13, 17 and the UWorld Self-Assessment Forms 1 & 2. I scheduled these at different points during my 6 weeks. The UWSA are famed for being difficult but having a very generous curve so UWSA 1 was the first one I took. It helped my confidence but also showed me my weaker areas. I took NBME 13 and NBME 17 next. These had a different question style than UWorld and had no curve. They were hard and definitely didn't give me confidence boost like UWSA 1, lol. I think NBME 13 and 12 (which I took in January) were a lot more realistic than NBME 17. I finished off with UWSA 2. Overall I think Step 1 was much more like UWorld in terms of question style and difficulty than the NBME exams.

Throughout my 6 weeks I kept a "UWorld Journal" in the form of a Google doc as well as handwritten notes. I would go through each completed quiz and write down the key facts that I was asked about. I think this was the single most helpful thing I did. I was able to review these notes throughout my study period and commit tons of high-yield material to memory.

Compared to my NBME 12 practice exam score in January, my actual step 1 score improved 68 points overall. Step 1 studying will be a very challenging time in your life but use it as an opportunity to grow and surprise yourself. It was honestly the hardest I've ever worked and it challenged me in ways that go beyond intellect. The only thing I would have changed about my approach is I would have started going through First Aid during first year.  If I could offer one piece of advice about this entire process from the bottom of my heart it would be to try your best every single day even if you feel like you can't because you want to be able to look back on this fragile time without any regrets.

Below is a dropbox link to my 6-week schedule complete with a sheet called "checklist" which helped me track what I was doing and what I needed to complete next. Feel free to download it, share it and edit it to fit your needs!

https://www.dropbox.com/s/ffv6f9qpnfsjid5/Step%201%20Study%20Schedule%20Blog.xlsx?dl=0

If you have any questions please leave a comment below or email me!

Hi everyone!

I've been pretty busy these days since I'm currently on my last few weeks of internal medicine. It honestly feels like I've been on this rotation forever and that's because it's a whopping 12 weeks long! I've learned a lot during medicine and as my knowledge base has grown, so have the contents of my white coat pockets. Now that might sound comical (it is) but it can also be really heavy on the shoulders. So to optimize my pocket contents I've narrowed it down to a few essential things!