Medical student forums extensively discuss study for the USMLE exams. While this is important, because you need to pass the exam, there is a problem with spending a lot of time on rote memorization of numerous facts, since it steals time from understanding the subjects.
Understanding is key to practicing medicine; it enables the physician to provide better individualized patient care than relying on rote cookbook facts. Understanding also facilitates memory and retention. For those of you who have taken large subjects such as Biochemistry or Physiology, have you at the end acquired a broad understanding of the fields, or are you left with isolated points that never quite gelled into a coherent whole?
There is a better approach to medical education than rote memorization of an impossible number of facts. The medical school curriculum should instead insure that the student gains an overall picture and understanding of each subject, rather than cramming in an overbearing number of facts that will later be forgotten, even by the best physicians. These days, it is relatively easy to find isolated points on the Internet and elsewhere. It is not as necessary to remember everything; computers do a better job at that. The USMLE should also focus on understanding, but students are still required to memorize tons of information.
Over the past 32 years, Medmaster has tried to assist medical education by focusing on understanding, rather than rote memorization, through brief, clinically relevant books.
Since one has to study for the USMLE, it is important to maximize the efficiency of study, so that a great deal of material can be reviewed and retained in a short time. Andreas Carl has written Medmaster books for the USMLE Step 1, USMLE Step 2, USMLE Step 3, and NCLEX-RN exams using a unique approach. Rather than just presenting isolated and unrelated points, he has made extensive use of charts that compare one point with related ones; this saves study time. For instance, the chart below compares the most common causes of infection. Apart from having few words, the chart quickly allows the comparison of one disease with another. All his books do the same. His supplementary USMLE and NCLEX-RN Question Banks (available as free downloads from the Medmaster website), make review quicker by combining a number of questions into one, so that 4 or 5 facts can be covered in the time that it ordinarily would take to cover one.
While sometimes quackery is the product of deliberate deception on the part of the practitioner, at other times the practitioner is sincere but ignorant of the facts.
Robert Park described seven signs of quackery:
1. The claim about effectiveness of the alternative treatment is proclaimed to the media [rather than published in a reputable peer-reviewed journal].
2. The claim states that a powerful establishment [such as Big Pharma, or physicians who want patients to stay sick for monetary reasons] is trying to suppress the treatment.
3. The therapeutic effect is barely detectable scientifically.
4. Evidence for the effect is anecdotal, rather than based on properly designed experiments. [Improvement in one patient may not occur in another, or may be based on a spontaneous cure, the placebo effect, a mistaken diagnosis, or inaccurate reporting.]
5. The practitioner points to the treatment having been in use for centuries [which does not constitute evidence; bloodletting was used for thousands of years and killed many people, including George Washington].
6. The treatment was discovered in isolation by a lone genius who was laughed at by the establishment, as were so many great discoverers. [Science advocate Carl Sagan once commented, “They laughed at Columbus, they laughed at Fulton, they laughed at the Wright brothers. But they also laughed at Bozo the Clown.”]
7. The discoverer of the supposed treatment proposes new laws of nature to explain the claim.
I’d also add a few more:
8. The claim is made that the alternative treatment is the cutting edge of medicine and has just not been taught in medical school [when the reason it has not been taught is that there is insufficient evidence to teach it. I saw this personally when my grandson, who had a recurring inner ear infection, went with his mother to an alternative practitioner who spent a lot of time asking irrelevant questions and then, without examining him, prescribed an elixir of potassium, stating that conventional medicine had not caught up with this wonderful treatment. Regarding potassium, I once had a patient with renal failure who insisted on treating himself with potassium [a no-no in renal failure], because, as he stated, “potassium is the great healer.” He unfortunately died soon after].
9. The practitioner points to the toxic effects of conventional medicine, whereas their own treatment incurs no side effects. [Treating with nothing incurs no side effects either; maybe, then, it would be safer to not treat at all! Eating food can have side effects, too, but we don’t recommend not eating. Despite the potential side effects of many conventional medicines, you have to evaluate the risk of treating versus the risk of not treating. Also, many nonconventional “natural” medicines can have toxic effects, and may interact unfavorably with conventional medicines.]
10. The claim is made that the alternative treatment addresses the cause of the patient’s problem, whereas conventional medicine only treats symptoms. [This claim is untrue, since conventional medicine always looks first for the cause, e.g. infection, allergy, heredity, diet, trauma, emotional, etc., and treats symptomatically only when the cause is not apparent. Alternative practitioners, though, generally do not treat causes (unless you consider imbalances in a mystical vital energy life force as a cause) and frequently treat with only a placebo.]
A patient may say, “What difference does it make if it’s a placebo or not? I feel better and that’s all the matters.” It matters when reliance exclusively on placebo overlooks a more effective treatment. It also matters if the alternative treatment carries its own set of toxicities or a significant and unnecessary expense to the patient.
Quackery can exist in both conventional and alternative medicine. A previous blog post suggested reliable sources of information for evaluating alternative approaches to medicine. Another source is the Medmaster Search Engine page and the (free) downloadable Medsearcher app. It is very important for a practitioner to be able to evaluate the validity of research reports. It is for that reason that biostatistician Ann Weaver and I wrote Clinical Biostatistics Made Ridiculously Simple.
Medical practitioners have been respected for thousands of years, even when their medicines have been toxic. To a large degree (and this includes both conventional and non-conventional medicine), this success can be attributed to the spontaneous cure and the placebo effect. Most medical conditions improve by themselves; and the placebo effect can be significant; thus, the patient attributes improvement to the practitioner. Until the movement toward evidence-based medicine in the early to mid 20th century, there was great uncertainty as whether a claim for a treatment’s effectiveness was due to the intrinsic potency of the medicine or to the placebo effect and spontaneous cure. This uncertainty still exists, but to a lesser extent, due to the introduction of properly designed research.
The placebo effect, apart from the medication itself, also includes the bedside manner of the practitioner. The patient has confidence in the practitioner who spends time getting to know the patient, expresses concern about the patient, allays the patient’s fears, provides hope, and engages in laying on of the hands. Such bedside manner, or “grooming,” is an important part of medical practice, regardless of whether treatment is conventional or not. I learned this through 14 years of practicing Family Medicine with Lynn Carmichael, whom many consider to be the father of Family Medicine, having established the first Family Medicine residency in the U.S. and who was a strong advocate of grooming. Patients often go to an alternative practitioner rather than the conventional practitioner when the conventional doctor does not have the time to spend with the patient, a problem becoming increasing more common with the need to see more patients in a day. This problem will grow with future changes in the medical care system that may overwhelm doctors with more patients seeking care, with less time for grooming. Alternative practitioners often develop great skill in grooming the patient. It is important for conventional physicians to do the same.
Alternative medicine refers to medical approaches to diagnosis and treatment that lie outside the province of conventional medicine and are practiced instead of, rather than alongside, conventional medicine. Complementary medicine, which may consist of the same treatments as alternative medicine, is practiced in conjunction with conventional medicine, as a supplement.
CAM includes not only Acupuncture, Homeopathy, Chiropractic Therapy, and Herbal Medicine, but many other approaches to diagnosis and treatment, including (in alphabetical order) Alexander Technique, Alternative Diets, Alternative Exercise Therapies, Anthroposophic Medicine, Aromatherapy, Ayurvedic Medicine, Bach Flower Remedies, Cellular Therapy, Chelation Therapy, Colonic Irrigation, Craniosacral Therapy, Crystal Therapy, Cupping, Detoxification, Ear Candles, Feldenkrais Method, Feng Shui, Food Supplements, Hypnotherapy, Leech Therapy, Magnet Therapy, Massage Therapy, Meditation, Naturopathy, Neural Therapy, Orthomolecular Medicine, Oxygen Therapy, Reflexology, Reiki, Relaxation Therapies, Shiatsu, Spiritual Healing, and Traditional Chinese Medicine.
There is some difference in opinion as to what should or should be not classified as CAM. In a semantic sense, there really is no CAM that has been shown to work, since once a CAM treatment has been found effective it becomes adopted as a part of conventional medicine, so it is no longer “CAM.” Some CAM treatments have been shown to be ineffective, but for others there is insufficient evidence as yet to make the case one way or the other, and they might be useful.
While the same treatments can be used in alternative and complementary medicine, alternative medicine is more risky. By dismissing conventional medicine (e.g. many alternative practitioners advise patients not to immunize their children or use antibiotics), alternative medicine runs the risk of neglecting treatment for conditions that are highly treatable by the conventional approach. One plays Russian roulette with a child’s health by relying only on alternative medicine. Administering an ineffective remedy for a high fever in a child will be successful when the treater is lucky and there is a spontaneous cure, which usually occurs. But in the less common situation where there is a more serious illness, such as a meningitis or septicemia, the results may be disastrous. Hence, the importance of working together with the conventional system if one wants to try an unconventional approach.
You are taught conventional medicine in medical school rather than CAM. You will need to learn more about CAM on your own. You will be faced with patients who ask about or are using a variety of unconventional approaches. How do you sort through and evaluate all these options? The Internet is full of misleading information, as are many TV and radio shows, and tabloids that patients rely on from supermarket check-out counters. I suggest the following sites for trustworthy information:
Science-Based Medicine blog
Quackwatch, by Stephen Barrett
The SkepDoc by Harriet Hall, MD
New York’s Memorial Sloan Kettering Cancer Center’s herbal/botanical database
The Cochrane Summaries
There are also the following books:
Trick or Treatment: The Undeniable Facts about Alternative Medicine, by Edzard Ernst and Simon Singh
Snake Oil Science: The Truth about Complementary and Alternative Medicine, by R. Barker Bausell
Bad Science: Quacks, Hacks, and Big Pharma Flack, by Ben Goldacre
Do You Believe in Magic?: Vitamins, Supplements, and All Things Natural: A Look Behind the Curtain, by Paul A. Offit
Since so much of medical education involves reading, it is important to consider how eBooks compare with print books. Pros and cons of either method of reading have been presented in previous posts (A, B, C).
Which format do medical students prefer? Comparing medical student needs with those of general readers in other areas of interest is not necessarily useful. Someone reading a novel may have different preferences than a student who wants to underline, take notes, and study intensively for long periods.
The impression I have from medical students is that preferences differ considerably. Some prefer eBooks because they are easily portable and generally cost less than print books. Also, it is easier to acquire eBooks outside the country of publication, due to high costs of shipping print books. Ebooks also have an advantage of easy searchability and the ability to link to other areas. They can provide audio and video and are more easily updated.
Other students, however, prefer print books. Not every book requires audio and video. While an eBook can provide an impressive 3D rotation of the complex hemoglobin molecule, how important is it to know this structure? Is it educational or eye candy? While current eBooks allow for highlighting and note-taking, it is easier to do this directly in a print book, and one can easily just flip from one page to the next. Also, the screen glare is disturbing to some; it can be fatiguing looking at a screen for a long time, and there is a question as to whether reading speed and retention may be superior in print books. There is also an intangible; there is something “cozy” about a print book that is not found in an eBook.
In view of the differences in preferences, it would make sense for a publisher to publish the same book in both print and eBook format, so that readers can decide for themselves. Presently, several factors delay the publishing of eBooks: One is the different formats of eBooks; an eBook may be available on one type of reading tablet but not another, and even when books are available on a number of reading tablets, the interfaces may differ and the books may look different on one tablet as compared with another. Some books can be read on one’s computer desktop; others off the Internet, while others require a reading device. Also, some companies offer books using their proprietary reading applications, which are not available on Kindle, iPad, Nook, Android, or other reading tablets. This confusion is not the case with print books, where there is a single standard format; everyone knows how to use a print book and they are simple to use. If you want a print book, you can just go to a bookstore or major Internet distributor such as amazon.com or Barnes&Noble.com to purchase it. When the format and method of distributing eBooks become more standardized, this should increase the publication of eBooks, since a publisher can then develop an eBook in a single format and have it widely available, without having to prepare the book in a number of different formats for different eReading platforms.
Another factor holding up the production of eBooks is the evolving terms that eBook distributors such as amazon (Kindle), Apple (iPad), Barnes & Noble (Nook), etc. offer to publishers. These will need to be worked out and better standardized.
In addition, preparing an eBook that has many images and tables, particularly tables that spread across two pages in an 8.5″ x 11″ print book presents certain technical problems in trying to convert it to an eBook, since current eReaders offer a smaller viewing area, and there can be problems with the awkward reflow of text in tables.
Presently, Medmaster has begun developing a number of its titles in eBook format. These include Acid-Base, Fluids and Electrolytes Made Ridiculously Simple, The Four-Minute Neurologic Exam, Anatomy of the Soul, Med’Toons and Clinical Biostatistics Made Ridiculously Simple.
Another consideration has arisen. Does reading on an eBook interfere with the remembering of what was read?
Some studies suggest that remembering may be harder with eBook reading (see Healthland and The eBook Skeptic) than with print books. The associations one makes with landmarks in print reading (the relative positioning the text and figures, whether the information was at the top or middle of the page, on a left or right-hand page or column, etc.) is not set with eBook reading when there is shifting of text flow with resizing of the page or font size. This relates to a memory technique called the Memory Palace (the method of loci) discussed in a previous post, where the context of the information, such as the surrounding visual landmarks, plays a role in memory ( also see Brier Dudley’s Blog). Ebooks that have text reflow have fewer such landmarks, and remembering may be more difficult.
Another issue is whether reading may be slower with eBooks than print books. Some of the earlier studies suggested this, but were done years ago when the computer screen had lower resolution, so it is unclear whether this is still a source of concern. It is also a question as to whether linking all over the place slows down reading and makes it difficult for the reader to keep track of all the links.
The issues of remembering and reading speed with eBooks require more study. If you have used eBooks, do you have any personal observations regarding your ability to remember, or reading speed with eBooks? Do you prefer eBooks or print books?
As a medical student, which do you prefer, eBooks or print books?
A previous post summarized the pros and cons of eBooks versus print books in general. Do the particular needs of medical students tilt the preference one way or the other? I.e.:
Medical study is intense, involving a great deal of reading. Does the glare of reading on a screen for long periods outweigh the convenience of not carrying around heavy books and the generally decreased pricing of eBooks? While eBooks provide the opportunity for sound and video, many subjects do not need sound and video for effective presentation, or the sound and video could be presented as a separate program on your computer. Medmaster has done this for a number of its titles, with CDs that accompany the print books, the print books for the long stretches of reading, and the CD programs for additional interactivity.
Medical study often involves a great deal of text highlighting and page turning. While you can do this with both eBooks and print books, the process seems slower with eBooks than with print books. Is this enough of a problem to lead students to still prefer print books?
Another issue is the distraction that can occur when reading from an eReader. Do all the links to other areas, to YouTube, apps, games, the Web, music, and news steal time from the reading and study of the medical book, which should be the main object of focus?
What is your opinion? If you have used eBooks, do you find that you prefer them to print books? Would you use both? Please send your opinion. Your feedback is important.
Previous postings on this blog pointed to a number of different memory methods useful for rapid learning in medical school:
Of course, once you use one or more of these methods it helps to review the information. For certain subjects it also helps considerably to invest extra time to practice cases that put the information together into a clinically coherent whole.
For instance, in neuroanatomy, after learning particular structures in anatomy, it is important to practice clinical cases where you can combine this information to determine where in the nervous system a patient’s problem lies.
The subject of acid-base, fluids, and electrolytes contains a bewildering array of facts that have to be organized and put together in order to apply to a case. What is the diagnosis? What is the treatment? Which fluid bottles should you hang up? Case examples help consolidate this information for application to a patient.
In cardiology, it is not enough to just read a chapter on EKGs. The real learning comes on practicing the interpretation of EKGs with many examples.
In psychiatry, clinical cases help to fine-tune what medications and dosages to use for the individual psychiatric disorders.
In some medical curricula, students in the first two years of medical school do divide into groups that discuss individual case problems. This approach can be helpful for the particular case situation, but there is a drawback when a case takes up too much time in the group. There are so many case situations that have to be mastered, and spending too much time on just a bare few can be an inefficient use of time.
Try to use textbooks that include case problems in those subjects in which it is important to bring diverse facts together to diagnose and treat patients. Case problems alone, however, are insufficient to learn a subject. You also need a background in the subject before approaching the clinical problems.
MedMaster has a number of books that include case problems for those areas mentioned above:
Clinical Neuroanatomy Made Ridiculously Simple
Acid-Base, Fluids, and Electrolytes Made Ridiculously Simple
Clinical Cardiology Made Ridiculously Simple
Clinical Psychopharmacology Made Ridiculously Simple
Which do you prefer – eBooks or print books? MedMaster is considering converting a number of its titles to eBooks and is interested in your opinion as to the usefulness to medical students of eBooks, compared with print books.
When working in the hospital and medical office during the clinical years, it is common to receive pearls of wisdom from interns, residents, and attendings. How reliable is this information? And how reliable is the information we receive from lectures, journal articles, books, and drug reps?
A lot of information is passed around, and since some of it is wrong, it is important to rely on the best sources available. In the 1980’s, some of the best minds in medicine made a disastrous mistake. It was known that significant cardiac arrhythmias were correlated with death. A search was undertaken for drugs that would reduce such deaths. But rather than using reduction of deaths as an end point in the drug studies, it was easier to adopt a “surrogate” endpoint, namely whether the drug reduced arrhythmias. If a drug reduced arrhythmias, it presumably would also reduce deaths. It was not adequately considered that the drugs might have unexpected harmful side effects that would in fact worsen the problem and contribute to death. Antiarrhythmics became widely prescribed, even for non-life threatening arrhythmias, leading to many unnecessary deaths (which initially were felt to be due to the heart disease, rather than the drugs), until studies were properly done to assess whether the drugs actually saved lives. They didn’t; they killed thousands of people.
There is so little time to read and evaluate the medical literature, particularly the Materials and Methods sections of research articles, and there is an unfortunate tendency to rely on the word of physicians above us in the hierarchy, or on drug reps, or on research reports (particularly those funded by drug manufacturers) that may have biased and erroneous conclusions. It is necessary to know how to read and evaluate a research article. This requires some knowledge of biostatistics. For further information, see Ann Weaver’s brief and intuitive book, Clinical Biostatistics Made Ridiculously Simple, which focuses on the pitfalls of clinical research reports and how to evaluate them.
It is also important to use reliable medical search engines on the Internet, since the Internet contains lots of unreliable information. Such search engines are described on the MedMaster search engine page.
Do you prefer eBooks or print books? And why? Feel free to comment.
When I was in medical school, Pharmacology was taught by Alfred Gilman, a coauthor of Goodman and Gilman’s Manual of Pharmacology and Therapeutics, a superb reference text, both then and now.
However, I had great difficulty in grasping an overall picture of the subject through this reference text. It was too big; after reading one drug after another, the drugs soon started blending into one another, becoming difficult to sort out and remember.
What is the best way to learn Pharmacology? This goes to the question of what facts are important to memorize and which are not so important to memorize but can be looked up in a reference text or computer program.
In Clinical Pharmacology Made Ridiculously Simple, the author, James Olson, has sorted out the general characteristics of each drug group at the top of the page, for understanding and memory. Other details, particularly those contrasting the individual drugs in a given group with one another, are placed in a table for cross reference at the bottom of the page. Such information can be looked up rather than memorized, except for certain features that are highly characteristic of one drug in comparison with the others.
It is helpful to have a good reference text in addition to the small book that quickly enables the reader to grasp general principles.
What is your opinion about the usefulness of eBooks versus print books? Which do you prefer?
In 25 years of teaching medical students, I found that Biochemistry is the course that students have most difficulty relating to for clinical relevance. While Biochemistry has much clinically relevant information, the material students are taught often does not reflect this.
I think this is because there is a big difference in what is important to PhD students and what is important to medical students. For instance, ALT and AST are liver enzymes that are vitally important to the function of cells. Their detailed biochemical reactions are important to the PhD student, but not to the medical student. It is more important clinically to know that these enzymes leak out of damaged liver cells and are useful as markers for liver damage.
As another example, creatinine is a waste product of muscle biochemistry. It is not so important to the PhD student, but very important to the medical student as a marker of muscle and kidney damage.
It would help to have more clinicians teaching the basic sciences and providing a more clinical focus.
Of course, if your instructor emphasizes topics of greater interest to PhD students, you need to learn that, as well as facts that are asked on the USMLE. But teaching would be improved by emphasizing clinically important areas.
There is a problem with just rote-memorizing isolated facts. Somewhere along the line it would help to understand Biochemistry as an overall whole, particularly in a clinical context, for future practical use. For instance, there is much discussion about the value and side effects of HMG CoA reductase inhibitors (“statins”) in suppressing cholesterol synthesis. It helps to see this enzyme in the context of a broader Biochemistry map to understand the pathways involved in cholesterol synthesis and what may be affected by suppressing it.
In Clinical Biochemistry Made Ridiculously Simple, I have tried to do just that, present the clinically relevant points in Biochemistry (particularly the metabolic pathways and the diseases that affect it) on a single map that can be grasped as a whole. It is not a reference text, which disappoints some readers. I suggest that readers also acquire a good reference text, bearing in mind that it can be very difficult to see the overall picture in a reference book. The best way to study Biochemistry is to first grasp the overall picture in a small book, but also have a reference text and your class notes to fill in on other details.
What do you think about using eBooks versus print books?
The term “app” (application) generally refers to a small, specialized program that is downloaded onto a hand-held (mobile) device such as an iPhone or tablet, although the term is also used for laptop and desktop computers.
There are over 5,000 medical apps, which are continually evolving. There can be “app overload,” where many apps are downloaded, but few are used. What sort of apps should you look for?
Ideally, a medical app for a mobile device should provide rapid, useful information at the bedside or office visit (“point-of-care”) in such areas as:
Drugs (dosages, side effects, drug interactions)
Current workup and treatment
Calculation formulas and algorithms
Specialty items such as heart sounds, EKGs, dermatologic diagnosis, radiologic images, and vision testing, depending on your needs.
The top 5 applications that are favored by students at Harvard Medical School (http://mobihealthnews.com/10745/top-five-medical-apps-at-harvard-medical-school/) are:
- Epocrates:provides drug dosages, drug side effects and interactions, pill ID, lab values, calculation formulas, and algorithms.
- VisualDx Mobile: contains dermatologic images and diagnosis algorithms.
- Dynamed: provides up-to-date approaches to diagnosis and treatment.
- Unbound Medicine uCentral: has many apps that can be combined and customized for your particular needs and interests.
- iRadiology: shows a compendium of radiologic images.
I add a few more:
WebMD provides a rapid guide to symptoms, conditions, drugs and treatments, including first aid information.
Medscape provides information about drugs, including over-the-counter and herbal medications, diseases and conditions, procedures and protocols, and drug interactions.
MurmurPro offers a set of heart murmurs.
Vision Test provides vision tests.
Mediquations: While Epocrates offers calculation formulas, Mediquations provides more formulas and actually does the calculations.
In addition to the above apps, there are also Internet medical search engines that can look for reliable and specialized information, as opposed to the sometimes unreliable information that is found through general search engines, such as Google. A list of these search engines can be found at the MedMaster website, which also offers a downloadable app, called MedSearcher (free), which allows quick access to the major medical search engines. MedSearcher presently is only available for computer use on Mac and Windows.
All the above apps offer isolated point of information. Apart from individual facts, it is also important to have a general understanding of the subject and field. This requires a fair amount of reading, which for many students would be tedious on a small hand-held mobile device like an iPhone. It would require a print book or an eBook reading tablet. MedMaster specializes in books that promote understanding.
Do you have a favorite app that you would like to share? Please feel free to comment.