Competency: Systems-Based Practice
From the day I put my white coat over my shoulders for the first time, I could barely contain my excitement and urgency to learn everything I could during my time a student.
And when I say everything, believe me—I tried to learn everything. It hadn’t even been a week before I was behind in completing lectures as I literally tried to absorb every fact that was presented to me. I spent so long making flashcards during my first pass through each lecture that I could barely get through each day’s material once (if that) before it was time to sleep. It wasn’t until Saturday that I had time to return to Monday’s material, and by that time I had forgotten much of it.
And then I found out that week 1 is an easy week.
I started to feel discouraged and began to look to my peers for help. Trevor, a fellow M1 introduced me to Anki—a flash card program that focuses on long term retention and fast creation of cards. Two weekend reviews of 1100 flashcards later, I felt ready for my first graded quiz—and then I got a 60%. Despite literally studying every waking hour of every day with the exception of meals, I hadn’t even scored well enough to pass. Now I was really discouraged.
This time I tried attending tutoring sessions from older students that could serve as role models. At each session, my flashcard technique was met with skepticism—which I ignored. But I did accept one important critique: I was trying to learn too much. The M2’s in the sessions taught me that it is not only impossible to learn every detail on every slide, but also unnecessary.
I learned that knowing how many angstroms each subunit of hemoglobin moves upon binding of oxygen isn’t nearly as important as knowing what conditions prevent oxygen binding in the first place. It made sense: if I find that I really need highly technical hemoglobin information in the future, I will have the tools and skills to look it up. But without knowing, at a critical moment, that low blood pH in a patient can lower hemoglobin’s ability to bind oxygen, I may fail to save a life.
So I hit the books again, but this time with a new focus in my learning on what was most important for my patients. When the next quiz came, I was able to score an 83% on Monday’s quiz. I was feeling better.
I decided to then take some advice from these older students to meet with OSU’s academic advisor at the time, Kelly-Ann. She advised me that spending nearly all day making hundreds flashcards just wasn’t a sustainable strategy. I was defensive because I had spent my entire life studying that way, but I listened to what she had to say.
And I’m so glad I did.
Kelly-Ann taught me a lesson that I believe changed my method of acquisition of medical knowledge forever. She taught me the importance of the big picture. While my method of cramming a thousand individual facts into my head might work for a weekly quiz, it would not work for a final when I had five thousand flash cards to review or Step 1 when I had a million. I learned that before I even made a flashcard I needed pour over the material a bit to gain the big picture—and then make a few cards if necessary.
So, after some experimentation, I completely overhauled my study. When it came time for Quiz 3 I felt better than ever and came out with a score to match: 100%. When it came time for the final exam using the study materials from earlier weeks was tough, but the confidence boost from my new found strategy helped me to push through. I benefited greatly by the practice tests provided by M2s and when the test came I walked out with a respectable 86%.
While I continued to hone my skills in acquiring medical knowledge throughout my first two years of medical school, OSCEs remained a difficult area. Despite the fact that they never represented more than 10% of my grade, nothing in medical school has set the hairs on the back of my neck standing quite like an OSCE.
That’s not to say that I wasn’t showing improvement over time. In the months leading up to Step 1, comments like these from OSCE examinations were suggesting that, after almost 2 years of practice at home, in clinic, and, occasionally, on my dog, I was finally getting the hang of efficiently and effectively moving through a patient history:
“You did well to gather information in an organized manner and deliberately move through each component of the history.”
“You were very organized and had a clear agenda for the visit. Nicely done.”
“Very good time management”
“Very good pace/tone, very good summary and closure.”
With comments like those, I was feeling at least a little better about OSCEs. It was almost 6 months before my next OSCE. This one was the first of 3 in Part 2 of OSU’s curriculum. While I was definitely still nervous, I thought that the worst of the OSCE learning curve was behind me. Based on the comments from that first Part 2 OSCE, turns out I was wrong:
“You asked repeatedly the same questions about timeline and quality of pain.”
“Work on time management to make sure you have time to do all the things needed during the encounter.”
“I think you could be more efficient and directed there to save some time. I almost felt like you were fishing mentally for what questions to ask.”
“Because you left yourself so little time for the physical exam and for the discussion, these were incomplete.”
And then there was the score report.
What had happened? Had I grown rusty after 6 months without an exam? How could that be when I had just spent the last 3 months seeing patients for real? Why was it so hard to think of questions to ask next and form a differential? I wrestled with these questions for a while before coming to the conclusion that I again needed to look to a role model, just as I had done with my study strategy during the pre-clinical years.
I met with what OSU calls an “expert educator”, an attending physician willing to provide one-on-one clinical help to students. It was enlightening to say the least. As we talked, we realized my difficulty obtaining a quick history stemmed from an inability to form a differential diagnosis in the moment. Digging further, the solution to my problems came down to one important skill: obtaining the review of systems. She suggested that instead of attempting to prepare and memorize an individualized review of systems before the visit as I had been, I should become proficient in moving quickly through a nonspecific review of systems that I could apply to a wide variety of patients. That way, I could rapidly form a “clinical vignette” that could serve as a spring-board to more questions and a preliminary differential diagnosis.
As I later put this plan into practice, my review of systems became quick and fluid. I became far more adept at quickly forming differential diagnoses which allowed me to not only follow up with additional questions, but also quickly determine the labs and treatments my patients needed.
These improvements paid dividends in every patient encounter I took part in–both real-world and practiced. My remaining OSCEs in medical school tangibly demonstrated this growth:
These experiences span the entirety of my medical school experience. As I reflect on them as a whole I see a common theme: while hard work is important, it is often reaching out to role models that catalyzes the greatest growth. In a few short weeks, I will have two big letters behind my name and students may start to look to me as a role model. My commitment now is to both seek out opportunities to be that resource while always maintaining the humility to ask for help from my own role models when I need it. Each rotation, I will try to identify a way that I can make a long-lasting impact on a student’s life. I feel it is through this repeating cycle that medicine has become the incredible field that it is and it is up to me to help the next generation reach its true potential.