Dr.Willbe: Goljan

Update 2015-05-28: I've co-written a comprehensive guide to learning in medical school that incorporates Anki with a host of other evidence-backed study hacks. This book is an essential companion to the ideas in this post.

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. 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. I also want to be clear about my intentions and own abilities. I'm a regular med student who just likes to share ideas. I'm know there a lot smarter people in med school then me. In fact, I'm sure of it. But I think I've found things that work well and I want to share that information with anyone who will listen. Always be critical and always evaluate whether what I'm saying will suit your needs and abilities. Thanks for checking out Dr. WillBe.

I've been meaning to write this post for a while. With the first years at my school starting pathology last week, I thought now would be the right time.

Pathology is perhaps the most important preclinical subject. Pretty much, this is medicine. You've learned about how the body functions normally. Now it's time to see what happens when things go awry. Spending the time to learn pathology right will pay great dividends in your future clinical career. Having solid knowledge of the diseases that afflict people and their underlying mechanisms is a requisite to being an excellent physician, in my opinion. It's what separates doctors from technicians. We understand the why as much as the what. And with that understanding, physicians can push the boundaries of medicine rather than merely practicing it.

OK. Enough of my soapbox speech. Clearly I think Pathology has intrinsic value, but more practically, Pathology is the most heavily represented subject on the USMLE Step 1 exam. If you want to do well on Step 1, you need to know Path. And know it cold. There is no way around that. That's reason enough for most med students to take Path seriously.

How does one do that? Well, that's what I'm going to talk about today. As in my other posts, I'll discuss what I actually did and do in my own studying, and then I'll suggest what I would have done if I could do it again.

Methods
First, let's talk about methodology. I'm beginning to sound like a broken record, but I can't help singing the praises of Anki, a spaced-repetition flashcard program. I've benefitted so much from this tool that I want to tell everyone I know about it. You can read about the how and why of SR and Anki here and here. Needless to say, I think Anki is awesome for pathology and it has been the core method for my study of the subject. Actually, of all the subjects in med school, I think Anki is most important for Path because of the vast number of facts and ideas that one has to commit to memory.

For Path - and pretty much every other subject I study using Anki - the process goes like this.

Read - Make cards - Immediately review cards after reading - Repeat

It's that simple. What makes Anki challenging for many students, however, is the fact that you need to continue to review old cards even while you plow through copious amounts of new stuff. It's a struggle, I'll admit, but it's the only way to keep all the hard wrought information you learned already in your head. It get's better over time, and when you stop adding new material, the number of old cards you have to review gets smaller and smaller.

Before I go on, I want to clear up a misconception that people have about Anki. Flashcards ARE NOT A PRIMARY LEARNING TOOL! (sorry for the caps, but I feel like I need to scream this). I don't learn from looking at a bunch of disjointed flashcards. Nobody does. And if they do, they're probably doing a pretty poor job of learning. My primary learning tool is a book. I want a story. I need to see facts in context. We all do. That's not what Anki is for. Anki is for retention of information, not first-pass learning. You use it AFTER you've learned and understood something. This is one of the cardinal rules of SR best practices. Don't make a card for something until you understand it.

Many people will crush a 50 page chapter in Robbin's Pathology or something similar and then close the book, deluding themselves into thinking that just because they scanned their eyes over that much text, they actually are going to remember most of it. Then they go to take a test or something, and they find out that they only remember about 10-20% of what they read, if that.

Maybe there are 1 or 2 beasts in medical school who read massive texts without any other consolidation strategy, but for the rest of us, there needs to be some way to retain and maintain the knowledge we gleaned from our primary studies. Lots of cognitive research - and just good common sense- confirms that repetition and review is essential to long term retention. Moreover, the spacing of reviews over time with increasingly longer intervals is key. And that is what Anki gives us in a way that we could never do before. My personal path deck (see below) has over 6000 cards in it. Those facts are all pulled from the sources that all medical students use to learn path. If the number is daunting, that's because it is. There are just that many factoids to remember. Without a digital SR program like Anki, however, I could never make and manage that many physical flashcards. It's awesome to be a student in 2012 :)

So, bottom line. All my recommendations for studying path, and pretty much any other subject in medical school, depend on Anki. I don't believe in binge and purge. Slow and steady wins the race. Come time for Step 1, if you've used Anki diligently and continuously throughout medical school, there will be no need to have to go back and relearn most of 1st and 2nd year in the 4-6 weeks allotted to you for Step 1 study. Rather, all that knowledge you gained will be burned permanently in your mind, ready to access when needed. Then, instead of focusing on content review, you can spend your time mastering the information by doing tons of questions and problems. This is what I'm doing for my own Step 1 strategy. So that's the point of all this. To not forget. To master the material. To build a rock-solid foundation for rest of your clinical career. And to destroy Step 1.

Resources
This is the part that you've probably been waiting for. You're saying to yourself, "OK WillBe, I know you're an Anki zealot. I get it. I'll use it. But what should I make those cards from? What should I study?"

I'm glad you asked.

Because Pathology is such an important topic, there are a lot of resources to choose some. Some are better and more appropriate than others.

Let me first give a list of all the ones I know about and then we'll talk about which ones you should be using.

General
First Aid for the USMLE Step 1 - the gold standard for Step 1 review. Getting through FA should be the minimum goal you achieve in your studies. Everything in this book is high yield. This book might just seem like a litany of bulleted factoids (and it is), but it's surprisingly helpful. There are things in here that don't show up in any other source.

Textbooks
Robbins and Cotran Pathologic Basis of Disease, 8th ed ("Big Robbins") - the Bible of Pathology. This is the book that Pathologists learn from. Med students for decades have used Robbins as their go-to source for path. Most people use it now as a reference, but some students use it as their primary source. Depending on how much time you have and your willpower, you could slog through all of Robbins in your pathology course.

Robbin Basic Pathology 8th ed (9th coming out in April) ("Middle Robbins") - A pared down down version of Big Robbins. This book is more approachable, and more appropriate for medical students learning pathology. The core concepts are the same as in Big Robbins, but there is less information about the histopathology and sometimes less detail in the discussions of pathogenesis. Still, at 946 pages, Basic Pathology is no push over.

Review Books
Rapid Review Pathology 3ed ("Goljan") - In the last few years, this 'review' book (and I put review in quotes because this book is 600+ pages) has emerged as the favorite of medical students. The author, Edward Goljan, is sort of a legend amongst med students because of this text and the accompanying bootleg audio lectures. This book has everything one needs to crush the pathology on Step 1. It's written in bulleted format with high yield factoids in the margins. Many students bypass the above textbooks and learn directly from Rapid Review. This book has proven it's effectiveness over the years, and that's why it continues to be the favorite every year. I'm not so sure though that it's the best anymore (see below). Pathoma may have knocked the king off the hill.

Fundamentals of Pathology by Dr. Sattar (Pathoma) - Pathoma is a new resource that just came out in April 2011. It is a series of video lectures and a review book made by Dr. Hussain Sattar from the University of Chicago. In less than a year, Pathoma has become the hottest Pathology resource around. I learned about it after I was already done with Pathology, but I've been using it to fill in the blanks since then. There is 35 hours of extremely high-yield, high-quality videos and an accompanying textbook that is equally impressive. And all this comes at $100, which is an amazing deal when you think about it. Many have dubbed Pathoma 'the New Goljan'. I think this is correct. The book is more concise. The videos give more explanation. Dr. Sattar is just a gifted teacher. The difference between Pathoma and Goljan is that the latter has proven itself over the years as a tool for success. Students have used it for Step 1 and have done very well. Pathoma, on the other hand, has not had that kind of track record yet. Many med students rave about it on Student Doctor Network and some have used it for Step 1, but not as many as have used Goljan. So that's the downside. Using Pathoma is using an unproven tool. But that shouldn't deter you.

I've used all the canonical resources. I've read Robbins. I've read First Aid. I've read Goljan. And I've been reading Pathoma and using the videos. So I know them all. Pathoma has everything that First Aid has and more. So right there, Pathoma is already as good as First Aid, which people trust without a doubt. There is significantly less material in Pathoma than Goljan. But it is questionable whether that means much. I'd say everything in Pathoma is high yield. Goljan, despite being a review book, has lots of miscellaneous info that may or may not be useful on Step 1. In fact, I've heard it said that Goljan not merely for Step 1 (although that's how it's used) but also for Steps 2 and 3. So that explains some of the difference.

So while Pathoma hasn't stood the test of time yet, I think in a few years it will completely replace Rapid Review. Because Pathoma is higher yield, better written and more approachable than Goljan, I think one would be better served to use it. One stands a better chance of actually getting through all of Pathoma than Goljan too, which is significant. Better to have a complete view with good detail rather than an incomplete one with lots of detail in some areas but none in other. If one knew everything in Pathoma inside and out, I think he'd know more than enough pathology to excel in class and on the boards.

Plus the videos are excellent. Until now, everyone has used the bootleg audio from Goljan. I never did like these very much. The quality is poor. There are a lot of jokes and tangents. Plus, there is no visual component. And did I mention it's bootleg? Pathoma, on the other hand, is a whole library of video clips that one can watch as well as listen to. The visual component is key. And with the book, you can read along.

I am really enthusiastic about this new resource, in case you couldn't tell. I wish it was around when I was learning path the first time.

* Full disclosure. I have no ties to Pathoma. I've spoken to Dr. Sattar once just to tell him I loved his work and to keep it up. That's it. I want to support a good thing when I see it and so that's why I'm promoting it here.

Here is a sample video. Check it out and see if this style of teaching appeals to you.

BRS Pathology - This used to be the go-to source for Pathology review a couple of years ago, but it's since been replaced by Goljan. I really didn't use it, so I can't say much about it. Some people like it. The BRS format is familiar and effective. It's less dense than Goljan, bigger than Pathoma and First Aid. I think with Pathoma on the scene, BRS will become less popular even, but I don't think it's a bad book. If you like BRS books, check it out.

Question Banks
Robbins Review of Pathology - This is a companion book to Robbins. It's all questions testing your knowledge of path. My classmates used this book to study for our exams and we were well served. It's quite detailed, much more so than Step 1 level pathology. The nice thing about it is that every question references a section in the Robbins family of books so you can go read when you get a question wrong. I think this book is worth having.

USMLE World Step 1  - Does this even need an explanation? USMLE World is recognized as the best source for Step 1 prep questions. There is debate about whether or not you should use these questions while still learning material. Some people think you should save UWorld for when you're doing dedicated study for Step 1. I think this is a sound idea. There are plusses and minuses to both. The idea is that if you do UWorld too early, you'll forget what you learned and waste questions. That may be true if you do the binge-and-purge thing. But if you're using Anki, you could use UWorld and make cards for the explanations and thus remember everything. UWorld is as much a learning tool as a testing tool. There is stuff in here that might only show up in Big Robbins or maybe not even. So using UWorld and Anki together makes sense. This is what I do in fact. I've been going through the q's and making cards for things I didn't know so that they're in my review deck.

Kaplan Step 1 Qbank - Another USMLE q bank. I haven't used it. I might though. Word is that the questions can be esoteric at times. Not as high quality as UWorld but people use Kaplan while they're learning so that they don't waste the good stuff (UWorld) before they're Step 1 review time. This isn't a bad idea.

USMLERx  - Questions made by the First Aid authors. It's like being pimped on First Aid. I don't think it's bad. I haven't used it much.

Video and Audio Lectures
Pathoma  - See Above

Online, Free Resources
Web Path
WashingtonDeceit (the Shotgun Histo guy)
Pathology Guy

Putting It All Together - An Optimal Sequence
So we've covered the methods and the sources. Now how do we put it together? What is the optimal way to learn pathology?

As I've said before, I think learning complex subjects like Pathology is best done in layers.  What I mean is, first you want to get an aerial view and become familiar with the landscape. Then fly a little lower in see some detail. Then, zoom in even further and examine the nitty gritty. Studying this way makes the learning more meaningful and effective. If you zoom in to the little stuff right from the get-go, you tend to lose the forest for the trees. That's not good. The detailed stuff makes much more sense and sticks better once you've mastered the big ideas.

I'm recommending here my preferred sources. This is basically what I did. As I said before, when I was first learning, I didn't have the benefit of Pathoma. So my experience has been to back track. Everything that I'm suggesting I've done myself. I just didn't do it in that order. The order I'm giving is the ideal one that I would have followed if I had known better.

Step 1 - The Aerial View
- Watch the relevant Pathoma video(s) at 1x speed
- Follow along in Fundamentals of Pathology
- At the end of the video, make Anki cards for every nugget in Fundamentals
- Cross-reference with the corresponding section of First Aid and make a card for anything not covered in Pathoma
- After making cards, immediately review them

Step 2 - Zooming In
- Read the same material in Robbins Basic Pathology
- Capture any high-yield/relevant factoids that you didn't get from Pathoma. Use your judgment here. You need to decide what's worth remembering and what's not. This is an art that is learned from experience.
- After making cards, immediately review them.

Step 3 - The Microscope
This part is optional. If you're the sort of person who really likes fine detail (or perhaps your class exams require this), you can go a step further.
- Read corresponding section in Big Robbins
- Capture factoids that you didn't get from any other source
- After making cards, immediately review them

Step 4 - Refining
- After having completed an entire topic or chapter (say Cardiac Pathology), use USMLE World or Kaplan or USMLE Rx. Use the questions to help you integrate all the information you've learned.
- Make cards for the ones you get wrong and/or the factoids that you don't already have in your set

You might be wondering when you should be doing all this. My advice is to spread this out as much as you can. So for example, I would do Step 1 on Monday. This should take you the whole day. If it's a particularly large chapter, spread out Step 1 over two days.

On Day 3 do Step 2. Then on Day 4 do Step 3. Take a break on day 5 or catch up on any part of the prior steps that you didn't get to. Remember that you're going to have all of your prior Anki reviews from other subjects coming due too. So make time in your day for that.

Then on the weekend, you can do Step 4 and do some integration questions from UWorld or elsewhere.

How you carry out this sequence will depend a lot on your class requirements, your own learning pace and style and your time commitments. If you notice, I say nothing about studying from lecture slides. That's because I don't think class material is particularly good. If you go to a P/F school, you can follow my suggestions closely. If you don't do P/F, you'll need to figure out how to satisfy your class requirements. You might have required attendance or something like that. I want to be clear. PASSING YOUR CLASSES IS THE MOST IMPORTANT THING. This is just the reality of medical school. Although we'd all probably love for med school to get out of our way so we can learn medicine, the fact remains that passing your med school classes is necessary. So don't jeopardize that by completely disregarding class if you don't have that luxury. With that said, I'm certain that every medical school is in some way, shape or form covering the same material. Robbins is what your professors use to make their lectures. So if you do as I suggest, you're not going to miss anything. But what is emphasized by your class and what is emphasized by Step 1 are often not one and the same. Just keep that in mind.

Goal Setting

In all of this, you need to decide what you can handle and what you want out of your education. School is tough, and sometimes for all the wrong reasons. Mandatory classes, clinical skills classes(i.e. "tell me about your feelings"), busy work, and sundry other obstacles get in our way when trying to learn. That's just the way it is. So be realistic about what you can achieve.

I think a necessary, feasible and totally effective goal would be to cover First Aid and make cards for all of First Aid. That is the minimum goal. First Aid is not everything you need to know for Step 1, but it's a very large chunk of it. At the end of your preclinical courses, wouldn't it be great to have at least 50-60% of what you need to know down cold? If you aim for knowing 100% of everything, you'll get discouraged and likely quit this whole project and remember even less. Maybe like 20%. Be willing to compromise and be flexible.

My Pathology Deck and More
Disclaimer: I am sharing this deck because I want help other medical students learn pathology. I think making one's own cards is a valuable exercise and is superior to using someone else's, but I recognize that for a lot of people, this task is too much to handle. It's enough to turn people away from using Anki all together. So, I'm offering my cards as a compromise. If using my cards helps people learn Pathology and it encourages use of a system I really believe in (Anki), then I'm a happy man. I put hundreds of hours into building this deck but I see no reason why I should be the only one to benefit. I would have had to make these cards regardless, so why horde them all for myself? All I ask is that you give credit where it is due; if you share these cards with your classmates or anyone else, just let them know where they came from.

Also, I am almost certain that there will be some errors in these cards. There are over 6000 of them. I've done my best to ensure the accuracy and quality of my deck, but some errata have certainly slipped through the cracks. This is true of every learning resource, from First Aid, to Robbins. Please double check the material and I welcome you to post in the comments section any errata so I can fix my own deck. I'll periodically update the files with those improvements and any additions that I make.

A word on the content... This deck is nearly complete. It's covered all the pathology of First Aid. There are tidbits from Pathoma for things not covered by First Aid. There is a lot of Goljan. There is also material related to Big Robbins and from USMLE World. The only subject that needs a little more work is Female Pathology. That's about it.

Feel free to add your own cards to this deck once you take it down from Dropbox. If you feel so inclined, share those updates here by posting links so other people can benefit.

Happy Studying!

Update (04.24.13)
The Pathology deck has been revamped and updated, and is now for sale here on the site. You can find it here: DrWillBe Pathology Anki Deck

All other decks are still available for free. You can find them here

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