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Should USMLE Step 1 Be Eliminated, Modified, Or Open-Book?

XBalloon-injection-[Converted]

“Now this shouldn’t hurt a bit!”
From Med’Toons, by S. Goldberg, Medmaster

At first glance, Step 1, which emphasizes basic science knowledge and is taken after the second year of medical school, would seem necessary to insure that medical students have achieved the proper level of knowledge to proceed in their education.  However, there is another consideration.

I cannot help but notice the great amount of time spent by students discussing how to pass the medical Boards; students are compelled to spend a great deal of time in rote memorization of esoteria for the exam; otherwise they may not pass.  In my view, this emphasis interferes with the need for students to acquire a proper understanding of the topics discussed in the first two years, understanding that is vital in taking care of patients.

Today, it is relatively easy to electronically search for isolated points of information through apps and the Internet; there is less need for rote memorization, which computers do best, and greater need for understanding, which humans do best.  Despite the information explosion, surely there is less need to memorize so much and greater need to promote understanding of the clinical material as a whole.

Even the best physicians may have trouble with questions on the Boards. We would like to gear medical education to turning out the best physicians.  But what constitutes an excellent physician?:

• Most cases a physician sees are common situations rather than zebras.  Good medicine is largely a matter of applying common knowledge and principles to diagnosis and treatment, without getting sloppy, rather than coming up with a roundsmanship coup. The excellent physician does not, to save time, routinely order, in a shotgun fashion, all manner of rare, invasive, and expensive low-yield tests.  Nor does the excellent physician hastily rush to decide on a diagnosis based on a too-quick, superficial initial impression. The best physician is not necessarily the one who has the greatest knowledge base, but the one who consistently and meticulously applies common knowledge.

• Patients do not care so much about the physician’s medical school or residency diplomas as they do care about how the physician responds to them as individuals, whether the physician is compassionate, and allots the patient the necessary time.  “Patients do not care how much you know, until they know how much you care.”  This aspect of medicine is also important, just as is the knowledge base.

• The good physician, unless there is an emergency, schedules reasonable office waiting times, promptly notifies patients of lab results, follows up on the patient’s progress, and adopts more than just a cookbook approach to diagnosis and treatment. Medical education needs to emphasize understanding of important concepts, as well as familiarity with where and how to search for isolated points of information, which have grown too large for anyone to remember.  This is not emphasized on the Boards.  Emphasizing understanding, something Medmaster has focused on for the past 34 years, may seem to be a minimalistic approach to education, but in fact it is a maximal approach, insuring that the student acquires the greatest degree of understanding. Every patient is different, and a cookbook approach may not work for all patients; understanding  what one is doing is critical to good patient care.

So, should Step 1 of the USMLE be eliminated, or modified? Perhaps Step 1 should be an open-book exam; this would more resemble everyday practice, where physicians now have ready access to point-of-care information. What do you think?

Student Preferences For Ebooks Versus Print Books

curses---120

Curses – the leading cause of death in patients age 120 years. (From Med’Toons, by S. Goldberg, Medmaster)

Previous posts (A, B, C) discussed the pros and cons of digital versus print books.  A survey of students by Bowker Market Research (June 11, 2013) indicates that only 3% of college students in the previous semester used a digital textbook as their main course material.  Publishing Business Today  (Jan 21, 2015) confirms the student preference of print books over ebooks.

The Bowker survey of 1,540 undergraduate college students found that students overwhelmingly prefer print, at both four-year and two-year institutions of higher education.  The reasons include students preferring “the look and feel of print,” the greater ease in highlighting and note-taking, and the fact that they can’t re-sell digital textbooks.

Among those few students who prefer digital textbooks, the reasons include price, ability to search the text, and ease in carrying around.

As of March 2013, laptop computers are by far the most popular device for students reading digital textbooks. The iPad is No. 2:

Laptop computer: 51%
iPad tablet: 21%
Desktop computer: 8%
Android tablet other than Kindle Fire: 6%
Kindle Fire tablet: 5%

The topic continues to evolve.  We welcome your continuing thoughts on the use of ebooks in medical student education. In the meantime, Medmaster is working on the best ways to present its books in both print and ebook formats.

Frustration In Medical School

Surgeon-divining

From Med’Toons by S. Goldberg, Medmaster.

The huge amount of studying that medical school demands can at times be so frustrating as to make one question medicine as a career.  The following illuminating story is reproduced with permission from the interesting blog WaitingForMd.

“It was a beautiful sunny day as everyone filed into the windowed room and took seats around a large, oblong table and scattered seats along the wall.  Medical students chit chatted about needing to get back to class and wondered when the main attraction, free Thai food, would finally arrive.  Meanwhile quietly in one corner a young woman sat with her hands neatly folded in her lap with a white lab coat.  She didn’t make conversation but smiled politely.”

“The meeting began after everyone was done scooping little heaps of pad Thai into their plates and shuffled back to their seats around the table.  Some introductions of board members were made and the general idea of the student organization was described.  At the close of the meeting they asked for any questions or comments and after some expected questions the young woman in the corner raised her hand and said ‘could I please share a story with the group’.”

“The club president smiled at her and replied ‘of course’.”

“‘I had always wanted to be a doctor; it was just something I never thought was possible for me.  I was married very young.  I spent most of my life in Africa and when I came to the United States I did not think that even going to medical school was an option for me.  I was always one of the brightest girls in my class and I even went to college but it all seemed so far away. By that time I was already a mother of two young children, which made a very busy schedule for me.  Somehow I managed to secure admission into a program that allowed me to do some coursework, and upon successful completion they would allow me to go to medical school.  I could not believe my eyes or ears and I worked hard, so hard to make sure I could do it.  My grades were all very good.  But then I started to notice that my youngest son was not speaking as he should be; he was not developing at a proper pace. The doctors said that he had autism.  He would need speech therapy and physical therapy.  Hours of individual attention were needed but my husband worked.  He told me he could not do anything; we needed the money; he had to go to work.  I was left with no choice and I had the acceptance letter in my hand and I declined my admission to medical school.  After all of that work, someone had to take care of my son.  I had to care for my child and I had to give up my dream for it.  I wish my husband had supported me more, so I could achieve my dream.  Even today when I walk on the sidewalk and I am walking in one direction and one of you, a medical student, is walking the opposite direction and passes by me in a white coat, I stop and I turn around and I look at you walking away. I see my dream that I had walking away from me.  I am so happy for each of you and I am so sad for myself that I did not find a way to make my dream.’”

“The entire room sat in silence. Sitting in that room with nothing on my mind besides needing to get back to class at the end of the lunch hour, this woman’s story really touched me.  I could feel tears welling up in my eyes.  This story just serves as a stark reminder that this is an opportunity that we were lucky to have been given.  It sucks sometimes.  It’s really hard.  It makes you want to punch the wall.  But no matter why you did it, there was something that drove you.  If you can keep a piece of that with you and remember back to the time when you would have traded anything to be where you are today, everything gets a whole lot easier.”

On a personal note, I was at the bottom half of my class in medical school and there were many frustrating times.  I was a slow reader.  What I have learned is that under such circumstances, it helps to simply keep going.  In the end, it will work out. Small steps each day add up.  When it appears that you are hopelessly behind, you are not as far behind as you think.  And just like a hiker cuts through the obstacles of a dense forest underbrush, but eventually arrives at a clearing with a brilliant panoramic view, there will be a time when you no longer have the continual pressure to pass exams.

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?

Revamping The Med School Curriculum

From Med'Toons, by Stephen Goldberg, Medmaster

From Med’Toons, by Stephen Goldberg, Medmaster

Having taught medical students for 25 years, practiced in several different medical fields, edited all the Medmaster titles in the basic and clinical sciences, and received feedback from many instructors and students through the years, here is how I would revamp the medical curriculum:

1.  I would continue learning the basic sciences in the first two years, followed by 2 years of clinical experience, as opposed to the idea of learning the basic sciences and seeing patients right from the start.  While one may want to see patients as soon as possible, it is better to first learn the basics, since you can then approach medicine with overall understanding, rather than scattered facts.  It is like the juggler, who needs to combine a number of different skills to perform, such as simultaneously juggling 6 balls, twirling 3 hoops around one foot, and balancing a stick on his head.  He would do better by first learning each skill separately and then putting them together, rather than trying to learn by practicing all of them together from the start.  The basic sciences, though, should not be taught without reference to clinical medicine; they should be taught with a clinical emphasis, showing the clinical relevance of each subject as it is taught.

2.  While small group discussions of clinical cases in the first two years can be an excellent source of learning for a given case, they tend to be an inefficient way to learn.  They are time-consuming and cannot get into the vast amount of medicine that has to be learned.  Also, when scheduled in the basic science years, they are presented too early for an adequate understanding of the topics, since the student has not yet learned the underlying basic science.  While case discussions in the basic science years provide a way to introduce clinicians into the discussion (as most basic science courses are taught by PhDs, rather than clinicians), clinical relevance can be introduced more efficiently through well-designed reading, audio, and video presentations.

3. There is an overload of information in the medical curriculum today.  We need to focus on general principles and understanding as opposed to numerous esoteric facts. People are much better at understanding than rote memorization, while computers excel at memorizing detail.   The game-changer in today’s education is that it is easy to search for facts as needed on electronic media such as the Internet, in contrast to the past, where one had to rely on the latest reference texts and printed journals or go to the library to search through tomes of Index Medicus for relevant articles.

By the end of medical school we forget many of the facts that we learned.  And we do not acquire an overall understanding of many topics because of the deluge of information that we are hit with over the four years; we do not see the forest through the trees.  It is better to acquire overall understanding and know where to search for further detail.  Learning general principles with understanding is in itself a fulltime job.

4.  I would, for the most part, eliminate classroom lectures.  Lecturers vary in quality, and even when there is an excellent lecturer, it can be difficult keeping up with note taking and grasping what is being said in a fast-talking delivery, especially when tired after staying up late.  Why sit through a classroom lecture when one can learn the same thing through a YouTube or other video venue, at one’s own time and pace, and stop and go back to review points for clarification? I think the best use of the future instructor will not be to deliver a lecture in a classroom, but as a facilitator in pointing to the best educational sources for the student and responding to student questions.  Where an instructor has something special to relay to the student that cannot be found elsewhere, it often would be better to present it as a personal reference video than as a classroom lecture.  The instructor should, however, be available for individual questions from students, whether in person or by electronic communication.  This will not only be better educationally for the student, but for the basic science instructor, who in many cases would prefer to spend more time in research activities. Rather than repeating the same lecture many times, the instructor can point to a well-designed video that can be accessed by different classes.

5.  There should be a detailed list that the student receives on entering medical school as to what material in the basic sciences to learn, with recommendations as to where to find the information.  The student should largely learn independently. There should be periodic tests to insure that studying is not crammed in toward the end, when the tests are given.

The same should apply in the clinical years. The student should have a list of the most important clinical conditions, with suggestions as to the most reliable learning resources to diagnose and treat them, whether they are books, apps, or videos. As is, education in the clinical years is often not organized, with the student left on his/her own to determine what is important to learn. As in the basic sciences, there should be periodic tests of knowledge.  Learning through direct patient care is also very important, perhaps the most important way of all to learn.  After seeing patients in the hospital each day, the student should seek out information as to differential diagnosis and treatment of the conditions seen that day.  The student cannot learn everything, but by focusing mainly on the illnesses of the day, at the end of the four years the student will have studied the most common diseases.

6.  Exams, including the Boards, should not present ‘gotcha’ questions, but basic information highly relevant to practice.  So what if the questions are so basic that nearly everyone can succeed at the tests.  They should be designed to confirm that the student has the necessary practical knowledge base. With the time saved by teaching general principles and promoting understanding in the basic sciences, rather than an overload of esoteria, the student will have more time to review for the Boards and study medical topics of personal interest.

7.  While this may seem to be a “minimalist” approach to education, it is not.  In the end it would maximize a student’s overall understanding of medicine, while inculcating a lifelong method of seeking out detailed information as needed.

What do you think?

Complementary And Alternative Medicine (CAM)

The first Medicare bankruptcy

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

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

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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.