If I were to do it all over again: Tips for Duke Med 1st Year (and elsewhere)

Update and Disclaimer: The recommendations below are for how to best learn key subjects in med school. In fact, any study advice I give on this blog or elsewhere is always with the aim of learning for the long term. For that should be the primary goal in my mind. One should hope that if you have learned anatomy, physiology or anything really well, then you should do well on any exam that is placed before you. However, I just want to be clear: my recommendations are not geared toward destroying class exams. If that is your goal, you need to really pay attention to lecture slides and class material and old exams and such. If you read the sources I suggest below and do a thorough job, I don't think there is anyway you could not do well on your exams. But if your goal is to get a 95+, you need to really focus on what the class wants. I'm not going to say what your goal should be, but I'll just say, the reason I'm even writing this post now a year later is because I focused too much on class material and test performance and my anatomy knowledge today suffers for it. Use class and lab as a way of focusing your attention when you study on your own. When you're new to a subject, it's tough to know what the salient and clinically relevant topics are. When you're in class or lab, take what is said and use that to focus your attention while you're reading or watching Acland's or doing cards. But I personally would not depend on a bunch of powerpoint slides to try to teach me anatomy. It's too fragmented and too incomplete, in my opinion.

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I often wish I had known certain things when I was a first year medical student. Now having completed that phase of my training, I know that if I had the chance, I would have done many things differently with regards to what and how I studied. For the new first years here at Duke, I want to share some recommendations.

Anatomy

Here is my recipe for how to really, truly learn anatomy well.

1. Watch Acland's

I wish I knew about these gems sooner in my anatomy studying. They are a series of high-quality, expertly narrated fresh dissections. Dr. Acland goes through key structures and landmarks in each region of the body. There are a lot of details missing, to be sure, but these videos give an excellent overview of the body's anatomy. I think anatomy is best studied by zooming in a couple of times from different levels. What I mean is, first, you want to get the 30,000 foot aerial view of the territory, just so you're familiar with the big stuff and the definitions and the overall plan. Then, you want to zoom in a little farther. This is where you want to crack out an excellent, clinically-relevant text like Moore's Essential Clinical Anatomy so you can appreciate the finer detail. Then, if you really want the nitty-gritty, you can go in even further with Big Gray's or Big Moore. I don't think this is necessary, but for those who love anatomy, this could be useful.

So, I think Aclands should be the first thing you do. Before you start a new body system, get a cup of coffee and some snacks and pull up Aclands on your laptop. Sit back, relax. No need to take notes at this point. Just absorb on the first pass. I DO recommend having a good atlas such as Netter's to consult if anything is unclear on Aclands (which it usually isn't).

2. Read... not too much at once, but a little each day.

After you've got that aerial view, now it's time to zoom in. There are a slew of anatomy texts out there. Gray's Anatomy for Students and Moore's Essential Clinical Anatomy are the most popular I think. Everyone will have their preferences. I used Gray's but I wish I had used Little Moore's. Time is limited in med school and you have to make a choice about how much you think you can reasonably learn and retain for the long term. I think it's better to have a complete albeit superficial understanding of a topic rather than a more detailed but fragmented or incomplete understanding. That's why so many medical students opt for review books; they don't have all the details, but you get the big picture, so that later on when you do need to get more detailed, you've got the intellectual infrastructure.

I think for learning anatomy, the review books like BRS Anatomy or High Yield are too little information. I don't think bullet points work terribly well with anatomy. Other subjects, outline form is great, but I think with anatomy, it's good to get more of a narrative. But not TOO much of a narrative such that you get overwhelmed by the details. It's kind of like Goldy Locks. You have to find the source that is just right. Gray's I thought was too much. BRS anatomy too little. Moore's Essential Clinical Anatomy is just right. It's got more than enough detail (at almost 900 pages) but has ton's of clinical correlates (blue boxes), good pictures and straightforward, approachable, intuitive text. I think a medical student can reasonably make it through this book with a dedicated schedule and get more than enough detail about clinical anatomy.

I think it's important to pace yourself when studying anything, but especially anatomy. Just like with food, information gluttony makes you feel sick and doesn't stay down. So making a reading schedule is key. 15-25 pages/day max. Less is better if you can get away with it.

3. Make Anki Flashcards while you read.. then crush them.

I've extolled the virtues of Anki before so, I'll just summarize here. Anki is a spaced repetition flashcard program. If you want to remember something - anything - Anki is the way to go. If you want to remember something, you need to be drilled on it multiple times and at increasingly longer intervals. This is true of all factual knowledge, but with anatomy, this is particularly so.

Unlike physiology or pathology, where you might use some conceptual knowledge to deduce something about a disease process, anatomy is largely a memorizatoin game. There is no getting around the fact that you just need to spend time with the material - lots of time. And if you want to have a chance of remembering most of the stuff you're learning as you slog through the texts and slice into you cadaver, you need something like Anki to keep reminding you.

Here is what I recommend (and I actually did this; I started Anki because I was looking for a way to help me retain all the anatomy info I was hit with):

Read. -> As you're reading, take note of salient facts and structures. Make a card for whatever fact you want to remember. Include an image. If you have your anatomy texts online, you can copy and paste with ease right into your card. This is one area where I will hand it to Gray's - the images are best in this book.

Here are some example cards.

So you make your cards as you go through your reading. Then after your reading, you immediately review your cards. It is essential to do this as soon as possible. Don't let any time lag between your reading and you reviewing. This process is critical for committing your hard-earned knowledge to memory. And remember, Anki will schedule these cards for future reviews.

You don't just see these cards once and move on. You need to continually review even while you're learning new stuff. That is why I say it's so important to pace yourself and set a reasonable schedule.

4. Repeat.

Do this same process for every body system. Watch Aclands -> read and make cards -> review cards -> read again the next day -> and so on and so forth.

5. Before you go to lab...

Anatomy lab is a rite of passage of medical school. When you're in there slicing through layers of fascia and fat and dissecting body parts, you really feel like a medical student. Some people find anatomy lab extremely helpful while others find it less so. I was in the latter camp, but I don't want to dissuade anyone from going to lab. You have to see what's best for you. What I will say, however, is that lab will be infinitely more meaningful if you know what you're looking for beforehand. Going in blind will make your time very low yield. You'll be picking blindly through a mess of parts that don't mean much to you. Your time would be better spent doing something else. On the other hand, if you've done your reading and watched Acland's before lab, you'll be ready to go - ready to be a rockstar.

At Duke, anatomy class usually precedes lab time. I generally found lecture to be pretty ineffective for the way I learned. I think a better way to prepare for lab would be to use the hour or so before lab to watch the relevant Acland's videos at 2x speed. Use the shiny new Duke Med Anatomy Website alongside so you can walk through the dissection before you get to lab. I think if you do this, your lab time will be very well spent and quite useful. I wish I had followed this advice last year. I would have learned a lot more.

Physiology

Physiology is, in my opinion, one of the most important things you'll learn. A deep understanding of how the body's organ systems work in harmony to maintain a constant internal mileu - homeostasis - is something every physician must have. Putting your time in now and learning physiology really well will reward you for the rest of your life. I did put a lot of time into learning physiology last year and I do indeed use that knowledge everyday on the wards in 2nd year. Here's an example. A kiddo came to the Peds floor after having an episode of Diabetic Ketoacidosis. One major component of management of such a patient is insulin. My resident asked me, "What electrolyte do we need to add to his fluids and what are we trying to prevent?" I said, "Potassium because insulin causes a shift of K+ into the cells because of increased Na-K ATPase activity. If we don't add K+, this kid will get severe hypokalemia." So you can see, physiology never goes away.

So how should you be studying physiology?

Here are my recommendations.

Get your hands on BRS Physiology. This book is widely regarded as one of the best, if not the best medical physiology review book around. It is a must-have for sure.

Like all the BRS books, the text is written in outline format. It's got all the information, but it's not written in prose. If you want to read more a story and get some finer detail - but not too much -then you should also get Physiology by Linda Costanzo (the same author of BRS Physiology). This pairing of Big Costanzo and Little Costanzo is great because they have almost exactly the same information, but with the former being more fleshed out and the latter more to the point.

So here is my recipe....

1. Read.

Make a reading schedule that overlaps with the system under study in class. So if the class is doing renal, try to have your reading overlap with class. Just as with anatomy, space your reading over a few days.

2. Make Anki cards as you read using BRS Physiology

You want to remember physiology, right? Well then you need some cards to help get that info in your head for the long term. I would read Big Costanzo as my primary source and follow alongside in BRS Physiology. Use the nice bulleted text in BRS to make your cards - the work is practically done for you already with the concise text of BRS. Then, after each reading session, review your cards.

3. Do some problems.

At the end of each chapter in BRS there are questions. Do them. There is another book called BRS Cases and Problems. Many students like this. I didn't use it myself, but I think it could have helped. You need to put the abstract knowledge you've gained into action to make it really stick. Doing problems helps.

At this point, you might be wondering, how should the material from class lectures figure into your studying?

I'll say this. If you study straight from Costanzo Physiology/BRS, you should know everything and more compared to what class will give you. There is actually great overlap here. I think some of the instructors even use BRS Physiology as a guide to make their own lectures. So don't fear that you'll be missing out. If anything, you'll be less confused because of the very clear presentation and accuracy of the books I'm recommending. I think with reading, you'll get 95% of what the class lectures go over. For the remaining small bit, if you feel so inclined, you might just do a quick weekly scan through the class notes (Notesgroup) and extract any information that didn't show up in your reading and make some cards for them. This shouldn't take too long since you've gotten most all you need from your reading, but in this way, you'll cover all your bases and feel confident in your physiology knowledge.

Lastly, I recommend using First Aid for Step 1 alongside your physiology reading. In fact, I recommend using First Aid alongside all the learning you do in first year. Sometimes, FA has stuff that no other source has. Everything in this book is high yield. You need to know it. So you might as well do it now while you're learning through the first pass. Make cards for anything in FA in the relevant physio section that doesn't show up in BRS/Physiology/Class stuff. Capture that in your Anki cards. There are some awesome mnemonics in FA that you'll find useful.

OK. Let me give you minute to breath and I'll talk about microanatomy and embryology in another post.