Saturday, February 7, 2015

Countless Hours: How to Become a Stellar Student and an Incredible Intern, Part 1: Domain Specific Knowledge

In his book Outliers, Malcolm Gladwell popularized the idea that to get really, really good at something, you need to work at it for 10,000 hours.  Some debate surrounds the validity of the 10000 hour rule, but I accept it because it dovetails with the theory of expert decision making in terms of prediction, which I think is representative of medical diagnosis.  (The rule would also seem to apply to fields that require technical skill such as surgery - the more Whipples you do, the better you become at doing Whipples.)  In order to become a good predictor (the best ones are weather forecasters, professional bridge players, and horse race handicappers, by the way, for reasons I will touch on below) you need three things (besides base intelligence)

  1. Domain Specific Knowledge
  2. Iterative practice, the more the better
  3. Immediate, accurate feedback
I will discuss each of these in three parts in this mini series, with critical commentary on how "the system" does either a good or a poor job of promoting them, and give suggestions on how to supplement the system to do even better.

Domain Specific Knowledge:  This is what you learn in the first two years of medical school in a structured way, and thereafter in a less structured way.  It is impossible to overemphasize how important most of this information is, with some variance depending on specialty (embryology did me absolutely no good, but if I had pursued OB/GYN it may have been crucial).  One of the best things you can do to foster basic knowledge and its retention during the first two years of medical school is to buy the board review books from the outset.  There are seven (give or take) sections of USMLE Step 1, and you can get a review book for each of them.  (BRS Pathology, BRS Physiology, BRS Behavioral Sciences, A&L Medical Microbiology and Immunology, A&L Pharmacology, A&L BioChemistry were my preferred ones.)  If you study these books while you first learn the material, they serve as an ongoing review of that material, and point out gaps in what they're teaching you in medical school lectures.  But more important, when you go to study for Step 1 after the second year, it will be a relative breeze because you're familiar with the review materials and their organization, and have made annotations and cross references in them and will have figured out anything that you would have struggled with the first time through the books.  Almost every person who has followed this recommendation after I gave it to them (it was given to me by a good friend a year ahead of me, bless him) has scored in the top decile on boards and many of them in the top percentile (scores over 250 - you know who you are).

But the studying does not end there.  You must continue to read through years 3 and 4, internship, residency, fellowship, and thereafter.  I am perhaps an extreme example, but my example can give you an idea of the upper limit that a person can take it to.  I read the 13th edition of Harrison's Principles of Internal Medicine from cover to cover during Med 3, again cover to cover during Med 4, and I read the 14th edition cover to cover during internship and almost made it through again during residency.  I also did the Harrison's and the Cecil's board question books during medical school, as well as any other question set I could get my hands on.  That's right, I was studying for Internal Medicine Boards as a medical student.  During Med 3 and Med 4 I also read Principles of Critical Care, Critical Care Medicine The Essentials, and about 70% of Braunwald's Textbook of Cardiovascular Medicine.  I even bought Principles and Practice of Infectious Disease, but I didn't make it very far through that, and sold it before parting for internship.  And this list is not comprehensive, there were many more books and study guides and reviews I read, basically anything I could get my hands on.  I studied day in and day out, weekends and evenings, on rotations, on vacations.  And it paid off in spades in many many ways.  There was hardly a disease, a syndrome, a drug, a device that I was not familiar with when I first encountered it, and any case I did encounter was a far richer learning experience because I was able to see so much more nuance, so much more subtlety because of the preparation I had done far ahead of time.

The system does a relatively good job of structured knowledge education for the first two years, but it largely falls apart after that, and during the 3rd and 4th years and thereafter, you are expected to just absorb knowledge and experience, or to read in an unstructured way "about your patients".  In my opinion, this unstructured approach does not work optimally, because if you're just reading about lupus on www.uptodate.com (a very good resource, by the way) when you see a lupus patient you will a.) not be able to competently handle your first case of anything; b.) only learn about what you have seen; c.) not be able to diagnose things on the fly.   Many things you will never see in your training or your career, but you must still be familiar with them.

In the next parts, I will segue to iterative practice and immediate, accurate feedback.

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