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New Medmaster Editions 2016

psychiatrist-evil.jpg

“And how long have you been, in my opinion, evil?” (From Med’Toons, by S. Goldberg, Medmaster)

Medmaster is pleased to announce the following new editions:

Nelson: Psychiatry Made Ridiculously Simple (Ed. 5). Includes the newer DSM-5 terminology in the diagnosis of psychiatric illnesses.

Board Reviews Books:
Carl: USMLE Step 1 Made Ridiculously Simple (Ed. 7)
Carl: USMLE Step 2 Made Ridiculously Simple (Ed. 6)
Carl: NCLEX-RN Made Ridiculously Simple (Ed. 4)

Each Board review book presents the material in a rapidly read chart format, plus Internet links to 1000+ review questions.

Information Overload x 2

primitive laser surgery

Primitive laser surgery
(From Med’Toons, by S. Goldberg, Medmaster)

Apart from the information overload of medical school study, modern technology adds to the problem.  While technology has made it easier to find information, its distractions can be time-consuming.

We depend on the Internet but sometimes it is down. There is the beloved “Error” message that punctuates computer illnesses of unknown origin. Email, texting, Facebook, Twitter, blogs, Google searches, the same news multiple times per day, and a zillion different apps compete for our attention. It is as if we have taken a step backwards in the way we read, switching from the centuries long efficient and easily grasped format of print books to the variable ways of reading books electronically, with smaller pages on mobile devices. Certain ebooks can only be read on certain tablets, and some tablets only allow certain reading apps, and certain ebooks are listed in only certain ebookstores.  This can be upsetting to students who would like their ebook library to be available in ebook format on a single tablet or computer and available from a single source.

Hopefully, the way we read electronic books will become standardized so we can purchase and read ebooks anywhere, and not depend on a particular reading tablet, ereading app, or ebookstore.  Personally, I think the optimal way to read ebooks in the future will evolve toward reading on the web.  In that way, ebooks can be read anywhere in the world by anyone who has internet access, on any computer or tablet, and will not depend on having a particular brand of reading tablet, a particular reading app, or a particular ebookstore.  There would be little concern about the time and expense of shipping print books, and books could be updated continually.  At Medmaster, we are looking into the most optimal ways we can offer our books in electronic format. Presently, the field is not yet ready for prime time, due to different format issues with complex books, publisher terms with ebookstores, and the great variety of competing, often mutually exclusive reading apps and tablets.  We receive inquiries from students as to when Medmaster will have all of its books in ebook format.  While we have done so for a few books, we are exploring the evolving ways of presenting them and hopefully we will shortly be able to offer the remainder of Medmaster titles in ebook format as an alternative to print for those who prefer that way of reading.

The Best Ebook Readers And Reading Apps For Med Students

Einstein's-x-ray-[Converted]

Einstein’s X-ray
(from Med’Toons, by S. Goldberg, Medmaster)

Previous posts discussed the pros and cons of print books versus ebooks.  This post discusses the pros and cons of the various eReading devices and eReading apps.  Which tablet (or computer) should you use to read ebooks?  Which reading apps?

Choosing the best way to read ebooks can be confusing.  There are many different reading tablets. Some ereading apps work with some tablets and not  others.  There is also  the growing ability to read books directly from the web, whether from a tablet or a computer.

While it may seem obvious that publishing companies should simply list all their books on every eBookstore (e.g. Amazon, Barnes & Noble, etc.), it is not that simple.  The particular ebookstore’s terms to a publisher may differ depending on the size of the publisher and the price of the book.  Thus, a publisher may opt to place certain titles  in only certain ebookstores.  Also, some books do not presently lend themselves well to ebook format.

Buying print books is relatively simple: buy them any place; no need to distinguish between reading tablets, apps or booksellers.  For ebooks, though,with time-consuming usernames, passwords, and wrestling with computers, mobile devices, and reading apps, it is a wonder that a medical student can get any reading done at all.  Time is at a premium for medical students, and we need the most efficient ways to read.

I still prefer print books.  But others prefer ebooks for their ease of acquisition, portability, searchability, hyperlinking and multimedia capability, and generally less cost than print books. If you want to read using an ebook, which is the best tablet to purchase, and which ebookstores and reading apps should you use?  I have summarized my current understanding of the matter in the chart below, along with some general observations that follow.

Reader-devices

1.  Of all the tablets, only the iPad supports reader apps from the all the various ebookstores (iBooks, Nook, Kindle, etc.).  I suspect that is because Apple, although having its own ebookstore, is mainly interested in selling iPads and wants its readers to know that with a single iPad they can read any ebookstore’s books.  On the other hand, Nook (Barnes & Noble) and Kindle (Amazon) are mainly bookstores, and are more resistant to having other eBookstore apps on their tablets.  Thus, their tablets do not support the broad range of reading apps as the iPad.

It is interesting that while the iPad has its own iBookstore, you cannot read iBookstore books on a Macintosh computer (!), or for that matter on any other tablet or computer.  So if you want to read books from Apple’s iBookstore, you presently need an iPad.

2.  Medical students’ needs differ from that of the general public in that medical students, in addition to studying a lot, commonly want to highlight, and to a lesser degree take notes when reading. I found highlighting more awkward on the Nook tablet than on iPad, Kindle, or Android. While the Nook tablet otherwise has excellent reading features,  its somewhat awkward highlighting and lack of support for reading apps other than its own is a drawback.

While the Nook app for Windows Vista works well, it appears the Nook for Windows 8 does not presently have a highlighting or notes feature.  I found Nook for Macintosh buggy in that sometimes its menu does not appear when the application is opened.

3.  In contrast to tablets, it seems easier and quicker to highlight using a computer, whether Mac or Windows, using a mouse or trackpad.  The availability of relatively large monitors for Mac or Windows computers makes them easier to study from than the smaller monitors of  mobile devices.  And the external keyboards of Mac and Windows computers make typing, as for notes and other functions, quicker than on a tablet.

4.  There is an increasing ability to read books on the web.  Kindle, in addition to its reading app for computers and tablets, also allows reading directly from the web via its Kindle Cloud Reader, which makes it easier for the student to log in anywhere, even without a tablet or a computer that has the Kindle app.  Kindle Cloud Reader has good highlighting and note-taking ability.  Google Play, Inkling and Vitalsource (VS) also have tablet readers as well as web-reading functionality with good highlighting and note-taking. Nook for web allows direct reading from the web, but at this time it does not appear to support highlighting or note-taking.    Of course, the drawback of relying on the web to read is that the web may be down, or you may be out of range of wi-fi.

5.  In addition to the specific ebookstores, such as Apple’s iBooks, Barnes & Noble’s Nook, and Amazon’s Kindle, there are also many independent bookstores that have their own reading apps (help!), or whose books readers can access with what I will call “generic” readers.  Two of the best generics are Adobe Digital Editions (ADE, especially the latest edition), for Mac and Windows computers, and BlueFire (BF) for tablets, both of which can read ePub and PDF files.

There is now a Windows 8 Surface Pro tablet, which, unlike the Windows Surface RT tablet, has the full range of Windows 8 function, just like a regular Windows 8 computer.  It, however, is thicker and heavier than most tablets and does not presently have a large screen.  It also does not support the full range of reading apps as the iPad.

The bottom line: I suggest that the student, where possible,  use a computer (Mac or Windows) for ereading because of the easier ability to highlight, the larger monitors, and the greater ease in typing on an external computer keyboard.   But if you want to use a tablet, the iPad offers the greatest range of ebookstores to choose from, good highlighting and note taking features, and an intuitive interface.

[Update Jan 16, 2014: Apple now has an iBook app for Macintosh computers, which appears to run very well.  However, at this time it is not available for Windows or other tablets except iPad. One would have to purchase books from the iBooks bookstore.  It seems to me that the wave of the future, for those who prefer eBooks to print books, will involve reading off the Internet.  In that way, books will be  accessible to everyone who has Internet access, not requiring a specific reader or computer.]

The field of ebooks is changing rapidly and these opinions may change as well. What do you think?

Study For The USMLE

“It’s the most comprehensive book for the Medical Boards. Unfortunately, no one can carry it out of the store.”

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.

Ebooks Or Print Books? Which Should You Use?

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 SoulMed’Toons and Clinical Biostatistics Made Ridiculously Simple.

Is Remembering Harder With eBooks?

Cinderella’s untimely episode of pedal edema.

Previous posts have presented the pros and cons of eBooks versus print books, with particular emphasis on the eBook needs of medical students.

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?

eBooks vs Print Books: Med Student Survey

"Easy, John, help will be here any day now."

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.

Learning Through Case Problems

"Continue the antibiotic ..... and remember to drink lots of toilet water."

Previous postings on this blog pointed to a number of different memory methods useful for rapid learning in medical school:

•  Understanding

•  Visualization

•  Ridiculous Associations

•  Substitute Words and Pictures

•  Ditties

•  The Linking Method

•  The Peg Method

•  The Memory Palace

•  Chunking

•  Acronyms

•  Hands-On

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.

How Reliable Is Your Medical Information?

Perhaps oxygen wasn't such a good idea!

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.

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Do you prefer  eBooks or print books?  And why?  Feel free to comment.

How To Study Pharmacology

The Seven Dwarves' Medicine Chest

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.

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What is your opinion about the usefulness of eBooks versus print books?  Which do you prefer?

How To Study Biochemistry

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 Best Medical Apps

Treatment that works for one patient does not necessarily work for another.

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)
Differential diagnosis
Current workup and treatment
Lab values
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:

  1. Epocrates:provides drug dosages, drug side effects and interactions, pill ID, lab values, calculation formulas, and algorithms.
  2. VisualDx Mobilecontains dermatologic images and diagnosis algorithms.
  3. Dynamedprovides up-to-date approaches to diagnosis and treatment.
  4. Unbound Medicine uCentralhas many apps that can be combined and customized for your particular needs and interests.
  5. iRadiologyshows 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.