Tag Archives: medicine

Going Paperless

In the 20 years that I have been a student, I have always had a backpack.  I was never in want of a place to stow a binder, pockets for extra pens and highlighters, and still more compartments for snacks, a laptop, umbrella, and the various tools, trinkets and gadgets that I might (never) need to use.

Well, I’m still a student, but now I have only two pockets in a short white coat to assume the place of my trusty pack.  Suddenly, I have become over-encumbered with what would have in the past only been only a moderate load.  It wasn’t too difficult to boot the umbrella and trinkets from my cargo manifest, but the nature of the true culprit quickly became obvious: paper.  I hate paper.  It has been only three weeks since I have been forced to accelerate the demise of this pulpy, archaic medium, but I am happy to declare that progress has been made.

Looking back, it’s scary how dependant I was on 19th century (and older) technology for organizing my life.  Because of its insidious creep into every nook of my routine, there was no single solution to ridding myself of those stacks of ugly scrawl, often labored over for hours only to be buried under an unstable tower of their brethren and forgotten.  Yet slowly I have succeeded in reducing – if not eliminating – my dependance on parchment.  Here is what I have used to accomplish the task:

Notepad / Scrap paper: Google Tasks

Google Tasks open in Gmail

Google Tasks open in Gmail

Google Tasks is the best tool for anyone integrated into the google ecosystem, as it is quickly accessible from gmail.  I leave it enabled in the bottom right corner of my screen, and have lists for To-Dos, personal notes, long term reminders, and tasks specific to certain occupations, organizations or activities.  These liste are instantly synced across all of my computers, as well as my android phone (app: GTasks) and iPad (app: GoTasks).  There is a checkbox to mark a task complete, and you can also set reminders and due dates.  Say goodbye to sticky notes and that pile of cut-up recycle paper you used to keep on your desk.

Filing Cabinet: Evernote

Evernote Web Clipper browser plugin

Evernote Web Clipper browser plugin

Evernote occupies that second tier of notes – those that aren’t tasks or items to be remembered for a short time later, but rather all of those pesky little details in life that need to be remembered.  That combination for the bike lock that you always forget in the spring?  You know, the one you wrote down….somewhere?  Yup, evernote will take care of it.  Along with longer items such as notes, pictures and even audio recordings.  You’re limited to 100MB of uploaded stuff per month, so plan on paying for the premium account if you do much of the latter.  For text and the occasional picture / scan, it’s plenty. The web clipper browser plugin is also essential for saving interesting/funny things you read online.  Storing them in evernote solves the issue of trying to find them later only to realize the content was pulled, the site offline, or you just plain forgot where to look.  Of course, like Google Tasks, Evernote is available on the desktop, web, and mobile platforms, so your filing cabinet is always with you.

Scrawl: Penultimate

penultimateI use this app on the iPad for those rare situations in which you simply need to write.  The resolution and accuracy of a capacitive stylus leaves much to be desired, but it works in a pinch.  Samsung’s Note line of phones/tablets, as well as many Windows tablets such as MS Surface, have Wacom digitizer hardware, allowing the use of a proper stylus for better accuracy and ease of use.  Still, my 9″ iPad mini is about as good as a 3×5 paper notecard as far as the amount I can fit on a page.  On the plus side, it syncs to Evernote – a feat that leaves the note card feeling quite resentful and unwanted.  Good riddance.


Binders: Dropbox

Dropbox or Google Drive, you can have your pick.  Either of these are great for storing vast archives of created content or school/work documents and keeping them synced across all your devices.

Flashcards: Anki

I already wrote in length about Anki.  In short, if you have a pile of things to memorize and retain for any significant amount of time, there’s nothing better.

Textbooks: PDF

It’s amazing how many things you can find online if you dig a bit.  And by digging, I actually mean a simple google search.  If you’re lucky enough to find a decent quality PDF of the textbook you need, I still think Adobe Reader is the best app for the job (perhaps with the exception of PDF X-Change Viewer on a Windows machine).  Sadly, the CHM format is still used frequently, and it necessities using apps that are generally more buggy and less polished.

Books / Novels: Calibre and ePub

Calibre is an awesome piece of software for managing an eBook library for use with dedicated eReaders, tablets or phones.  Not only will it organize and convert your library of digital books, but it can also act as a server to allow those books to be accessed from anywhere if you happen to have a computer you can leave running all the time.  My favorite apps that support the ODPS protocol that Calibre uses as well as the widely-used ePub format for eBooks are FBReader on Android and Marvin on the iPad.










With the above tools, as well as a capable PC, smartphone and tablet, you have all that’s needed to leave paper behind in the last century where it belongs.  If you still find yourself having to use it from time to time, I think you would be well served by adding two more items to that list: a scanner and document shredder.

Why Medicine?

Recently, a friend considering medicine as a career asked me for my perspective.   I actually had a bit too much fun with this, reflecting back on how I ended up here in this little cubicle with my First Aid and a computer screen taunting me with 2200 practice questions to be studied so that I could jump through the next of many academic hoops in the long progression toward becoming a productive member of society.   Well, I may know a bit less about biostatistics for STEP 1, but the time spent reflecting was valuable to my mental health.  The curse of being a very long-sighted, future-thinking individual is that you’re willing to accept almost any punishment in the short term if it is necessary to achieve your ultimate utopian dream life.  Despite being experts on the subject of delayed gratification, even us med students can get a bit weary of the grind.  So, the chance to be introspective for a bit and recall why all this hard work was supposed to be worth it turned out to be quite refreshing.

The Questions

 How did you know that this was what you wanted to do?

I can’t say I was that person who knew from birth that they wanted to be a Doctor when they grew up.  Nor did I have any one experience or revelation that this is what I wanted to do, despite what my elegant Personal Statement may have implied.  Honestly, I could have seen myself in any number of fields (medicine, engineering, IT, military, aviation, business, consulting, intelligence, game development…you name it) – it came down to Aerospace Engineering vs Medicine in high school, and Medicine won out.  There were many reasons for the ultimate decision, including both the rational (nature of the work, didn’t want to be constrained to a certain geographical location, lifestyle, pay, work/family balance) and personal (I didn’t want to be a cog in a wheel, wanted to directly and unquestionably be doing something good for the world and be helping people, didn’t want to work for a bean-counter, didn’t want to slave for years making a revolutionary trinket that would be obsolete and forgotten a decade later, wanted independence, etc…).  In the end, I wanted a career that I could look back on years down the road and be proud not only of my own accomplishments, but more importantly in what I had done for the world; the fact that I had made a significant and positive difference in the lives of my patients.  Above all else, this is why I chose medicine, and why, no matter how hard the daily struggle, the frustrations of politics, academia and bureaucracy, or the boredom of memorizing minute facts for an exam, I will always be satisfied with my choice.

How many schools did you apply to?

Just MSU CHM.  I fell in love with the school, the collaborative (vs competitive) atmosphere and our magnificent, $100M new campus in Grand Rapids, MI.  The fact that I wouldn’t have to move was also a plus.  I applied through my undergraduate university’s Early Admissions Program, which meant that I only applied (early) to MSU, took the MCAT early (in May vs July or Aug), and got a decision almost a year early (June after Junior year).  If I hadn’t been accepted, I could have still entered the normal application process without losing any time. I wanted to stay in state for med school – there is little reason to spend double the tuition going to an out of state or private school, unless you are either dead-set on getting into a highly prestigious residency or want to practice Academic Medicine at a prestigious university. Say your life goal is to do a Retina fellowship in Ophthalmology at Johns Hopkins’ Wilmer Eye Institute.  Are you going to get one of those 4 or so spots without being from a top-10 medical school — probably not.  Can you still go into Retina Ophtho – absolutely.  Just do well on STEP 1 and perform well during your 3rd year rotations and your choice of medical school (as long as it is an accredited MD school in the U.S.) is of little significance in what specialty you can attain.

How did you prepare for the MCAT?

I got suckered into taking the Kaplan course.  Fear is a powerful motivator, and the fear that I wasn’t doing everything I could to prepare for a test that would determine my life overcame my reservations (and the protests of my wallet) for taking said prep course.  Hindsight is 20/20, and if I had to do things again, I’d have followed my gut and just used the resources recommended by other students on SDN, made my own plan, and stuck to it.  Actually, this is what I mostly ended up doing anyways, albeit with the inferior Kaplan books, a class taught by a GVSU senior that was more distraction than a help, and $1800 less to my name.  If you’re the type that needs externally-imposed structure and guidance, a prep course may be worth it, but otherwise I’d recommend against it.  Get the best books, take a solid month or so off to study them, do lots of practice tests, and take the real deal when you’re fully ready.  In the end though, it all worked out, so I guess I can’t complain too much.

What kind of things did you do to make yourself look good to med schools?

I checked most of the important boxes for the “good med school applicant”.  In order from most to least important, they would be a good MCAT score, competitive GPA, personality / “fit” for the school based on the impressions made during your interview and your personal statement, service (not necessarily related to medicine) and work experiences in the field (I was Nurse Assistant for a few summers during undergrad), research and/or publications (dissecting pig hearts was actually pretty fun) and other leadership experiences / awards (president of bla bla bla organization, prestigious scholarship of awesomeness, and the ever illustrious Dean’s List) ,etc..  Unlike residencies, which care much more about the first two items (test scores and grades), it is very important to have a “balanced” application for medical school.  All of these items are important.

Is med school impossible?

Haha, probably not the best time to ask this question – I’m currently studying for USMLE STEP 1, our first licensing exam – which makes the MCAT look like a colorful, fun toddler toy in comparison.  We refer to it as the mKitty.  Seriously, though – it’s easy to become overwhelmed with the path ahead.  The best way to tackle med school is to focus on the now.  Take things day by day, break large tasks into smaller tasks, and don’t get caught in the trap of comparing yourself to others and fretting about the little things that don’t matter.  There may be some long days, but in retrospect, time flies by and you really get a sense of accomplishment looking back on how far you’ve come.

Do you get sleep?

lol, yes.  I’m ferociously protective of my sleep.  Actually, I can honestly say I had more late nights studying in undergrad vs med school.  You could cram for organic chemistry.  Cardiology?  Not so much.  With the amount of materiel we are fed, there is little to be gained by an all-nighter.  Even procrastinators like myself figure out real fast that their definition of procrastination must at least be…adjusted a bit.  I feel like I’m cramming for STEP 1, and I’ve been studying for 35 days straight, with several more to go until the big day.  This is as extreme as it gets, as like the MCAT, the impact of your score determines the career options that remain available to you.  That said, I’ve managed to get 7-8 hours of sleep each night, work out an hour each day, find time to eat, and even sneak in the occasional break for a bike ride, movie, or night with friends.  It’s not impossible – you just have to manage your time.

Are you going to specialize?

Well, everyone “specializes” in that you will have at least a 3-year residency after medical school in which you train and become certified in a particular field.  Family Medicine is no less a specialty than Neurosurgery in this respect.  You can then go on and do a Fellowship to sub-specialize in a particular niche within your specialty.  I begin my clinical rotations this summer, and I fully expect that the experiences I’ll have over the next year will have the greatest influence on what I end up going into – regardless of my current leanings.  Really, though, this is one of the coolest parts of medicine – you have so many options from which to choose a field that fits you and your interests / needs.

For those still in undergrad and considering medicine as a career, it is important to learn as much about what’s involved in this decision as you can.  Keep asking questions, shadow some Docs, get involved in pre-professional clubs, and most importantly – have fun!  Don’t waste those blissful undergrad days working yourself too hard just for the sake of it (read – don’t torture yourself with the waste of time and sanity that is analytical chemistry for a meaningless minor, unless you’re actually interested in…titrating colored water and writing lab reports…and stuff).

Anatomy of a Board Question

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In an attempt to displace some of the frustration of studying for boards, I decided to provide an insight into why USMLE STEP 1 is such a difficult exam for medical students – such that, on average, 5-6 weeks need to be dedicated solely to the task of preparation, in addition to the time spent throughout the course of second year.  The best way to illustrate the misery of this test is simply to describe the average question that may appear on it.  Multiply this by 322, and you have the 7-hour exam that is STEP 1.

To ease the pain ever so slightly, I’ll cast it tn the context of a history question:

In the 20th century, a prominent political figure became heavily involved in the production of a new automobile known as the “People’s Car.”  A few years later, this man’s favorite pet, “Blondi”, delivered several offspring.  He named one of them “Wolf.”  Of what species or breed was “Wolf”?
A)  Canis lupus
B)  Oryctolagus cuniculus
C)  Doberman Pinscher
D)  Felis catus
E)  Golden Retriever
F)  German Shepherd
G)  Thylacinus Cynocephalus
H)  Bradypus variegatus
I)  Bloodhound
J)  Chihuahua

Now, the first question you may have after attempting to answer this is “What does this have to do with history?”  Understandably, trivia is not a favorite pastime for most people.  If this is the case, the logical approach might be to try answering one or more of the separate components of this question, hoping that this would lead to the answer.  An automobile fan may recognize that “People’s Car” is actually an English translation for Volkswagen, and thus come at the question from this angle – who was behind the success of this company?  Sadly, there are no people in the answer choices.  “Well,” you say, “I can still get this.  After all, I know the genus and species of the Wolf – and Canis Lupus IS an answer choice.”  You would be right — and yet ultimately still wrong.  Who names their wolf “Wolf”?  At this point, you will probably throw up your hands in fury and, rather than continue attempting to answer the question, complain about why it was even asked.  Who cares about the pet of a car company owner?

Now, is the purpose of this question really to test your knowledge of cars or famous pets? Of course not.  Obviously, the question was testing your understanding of historical leaders, with the simple task of identifying Germany’s leader in the mid 1900s.  Because everyone knows that this was Adolf Hitler, it would be silly to have this be an answer choice – no one would get the question wrong, and the bell curve would be all nasty and skewed to the right.  Examiners worship the uniformity of the curve like a cult, and do everything in their power to maintain it – even if it means asking the name of Hitler’s pet dog, who happened to be a German Shepard.  What, you never learned that?  Clearly, you should have studied a couple more weeks.

With the example out of the way, one can begin to identify a structure; a method to the madness:

Diagram of a board question.

Anatomy of a board question.

Knowing the structure gives you some idea of what it takes to successfully work through a question, but it is even more useful if we distill this structure into a couple of High-Yield rules:

  1. The question and answer will rarely be what is explicitly asked.
  2. The obvious answer is almost always wrong.
  3. The seemingly logical answer is also generally wrong.
  4. On a rare occasion, the obvious or logical answer will be right.

Now, the first 3 rules can arguably be explained away as methods to test your critical thinking.  Of course, the 4th is there just to play with your mind.  Similar to the way your high school biology teacher would have 10 answers in a row be “C” on your multiple choice test, just to troll you.  Combine these rules with the multi-step nature of the question, in which you must jump through a series of mental hoops just to figure out what is being asked.  Now, add 6-10 answer choices and a time limit.  The result: a multiple-choice question in which a failure to successfully complete any one of the steps necessary to answer it results in failure.  Guessing doesn’t work out too well, either.

To prove that this isn’t all hyperbole, I actually have a real question to submit as evidence:

A sample USMLE STEP 1 question

A sample USMLE STEP 1 question

I hope you can see the resemblance to my example.  Perhaps the detailed analysis and rules actually allowed you to come to the correct answer.  Of course, knowing the rules only gets you part of the way there.  You still need to know that the Erythropoietin Receptor is a Type I cytokine receptor, meaning that it is associated with a non-receptor tyrosine kinase, and that a JAK2 mutation of this non-receptor tyrosine kinase will lead to a clonal proliferation of hematopoietic stem cells, the disease for which is called Polycythemia Vera.  No problem, right?  Or at least… nothing a few more weeks of studying First Aid can’t fix.

The problem I have with these questions, is that they’re essentially training us naive young physicians to miss the forest for the trees.  You spend so much time memorizing that the creator of the Volkswagen had a German Shepard named Blondi that you forget the fact that this individual was named Adolf Hitler and was responsible for the Second World War.  The goal of these so-called “Licensing Exams” has become badly warped.  Rather than asking questions that test knowledge a competent physician should have, similar to the way an FAA exam would ask student pilots about proper navigation techniques, the USMLE examiners have somehow decided that the purpose of their test is to stratify medical students into the most symmetric bell curve possible, regardless of the cost.  The intent behind many questions is “Let’s try to ask them something they might not know” instead of “Let’s ask something that they should know.”  I’m sure this approach makes residency directors happy, as they have a convenient 3-digit number available to sort applicants with, rather than relying on more subjective determinants of ability, such as clinical performance, letters of recommendation, and impressions made during interviews.  I suppose I don’t blame them – who in their right mind wants to read 1200 CVs, anyways?

Flashcards Like a BOSS…with Anki

When confronted with information overload on a daily basis, one quickly learns how to be efficient when it comes to memorization.  One of my favorite tools for this daunting task is Anki, a multi-platform flashcard application that uses the principle of Spaced Repetition  to maximize retention of information.  There’s nothing more frustrating to spend, say, a semester learning the intricacies of Biochemistry just to forget everything a year later when it comes time to review for an exam.  Sadly, I haven’t managed to solve this particular problem, but Anki is the closest to a solution I have come across.

There are plenty of tutorials out there on what Anki is and how to use it, so what I’d like to focus on is my setup for reviewing cards.


To maximize speed and comfort while reviewing 100s of cards in one sitting, I’ve found using the keyboard and mouse to be suboptimal.  Instead, I acquired one of these:

Microsoft Media Center IR Remote (A9O-00007)

Microsoft Media Center IR Remote (A9O-00007)

This is the first half of the equation.  The second is a nifty piece of software called LM Remote Keymap.  It allows you to assign any keystroke (or other function, such as launching programs etc…) to the button of your choosing on the remote.

By default, Anki is set up to use Enter (or the OK button) and the numbers 1-4 to advance and rate cards.  All I had to do was assign a button for Suspending (Hotkey: @), Marking (*) and Undoing (Ctrl-z).  I chose to use 3 of the 4 media buttons above the number pad (Recorded TV, Guide, and DVD Menu), because they had no other function outside Media Center.

With this setup, you can assume any number of postures while reviewing; you aren’t stuck in a chair, nor bound by a cord.  The next option improves on this idea even further…


Here’s the true breakthrough in efficient studying.  If you own a treadmill, the option exists to position it in such a way that allows it to work with the above setup.  At the gym, however, one must improvise…

1) Android Tablet, running AnkiDroid (free) – MUST Support Bluetooth

2) Wii Remote

3) Wiimote Controller App

Wiimote + Nook Color (CM7, Rooted) + AnkiDroid + Wiimote Controller App

Wiimote + Nook Color (CM7, Rooted) + AnkiDroid + Wiimote Controller App

The process is much like before.  You need to map the keys of the Wiimote to function in AnkiDroid.  I used the D-pad for rating cards (Left=1, Down=2, Right=3, Up=4) and the A button for advancing cards (Enter).  AnkiDroid didn’t have as many hotkeys as the desktop version when I last used it (an update may have fixed this), so I just used the touchscreen if I needed to mark, undo or suspend.  I also set the cards to auto-advance after 30sec in the options, marking the current card as failed.

iPad folk – sorry, I’ve had no luck finding a way to replicate this setup.  Even with a Jailbroken device, there are few options for Wiimote tethering over Bluetooth, and all of them are either tech demos or usable solely for games.  No app exists to map keys…yet?

With the proper setup in place, it’s surprising how much more efficient it is to review flashcards.  Mastering Anki’s many functions, such as filtering cards by tag, creating filtered decks, and most importantly – designing cards in a suitable fashion for memorizing – are things that come with time and practice.  With its growing popularity, multitudes of high quality, shared decks, and compatibility (with sync) for all of the major operating systems, Anki is unparalleled for reviewing flashcards in a digital format.

UPDATE: Well, what do you know, using Anki on a Treadmill actually has research to support its effectiveness.  Seth Roberts has an excellent post detailing the synergy of these two activities: Boring + Boring = Pleasant!?

USMLE Arms Race

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And so it begins.

Today marks the start of the dreaded ISP, or Intensive Study Period – that time when second year medical students attempt to refresh or re-learn everything from the past two years of their schooling.  We have just one month spend diligently cramming for the most important test of our lives.  The USMLE Step 1 is the first of three national licensing examinations for U.S. MD students, but its real importance lies in determining our career options.  Do well and the world is your oyster.  End up at the low end of the curve…well let’s just say your hopes of matching into a Dermatology or Plastic Surgery residency are rather stricken.  If you were planning to practice Family Medicine somewhere in BFE – well then it may just be your lucky day.


The real travesty of the high selection pressure imposed by STEP 1 is that it has come to resemble an information and economic arms-race not unlike the duel between the U.S. and U.S.S.R. during the Cold War – metaphorically, at least.  Medical students are some of the most competitive and hard-working people on the planet, but here this works against us.  A positive-feedback loop was created, in which students willing to pursue ever-more diminishing returns to memorize factoids that might appear on the boards slowly started to have an impact on average scores.  To compensate for this apparent grade inflation, the designers of the test had to find even more obscure, clinically irrelevant details to maintain their precious bell curve, and so forth.

Then the internet hit.  Now everyone has access to vast expanses of all these formerly secret and exclusive nuggets of trivia, carefully compiled by a host of new companies who have found themselves in the business equivalent of an all-you-can-eat buffet.  Desperate, anal-retentive med students represent the ultimate seller’s market.  $50 soft-cover test prep book?  Shut up and take my money.  $100 online pathology review lecture series?  Sign me up.  $300 question bank?  How could I hope to do well without it?  The list goes on.  I didn’t even mention the $1500-$3000 live prep courses available…ouch.


So now we are in a situation where an exam costing $560 requires an additional $400 at a minimum to prepare for.  I am unashamedly following the herd like a sheep in front of a cane, sporting my trusty 2013 edition First Aid ($40), Pathoma ($100) and USMLE WORLD question bank ($300).  Baaa.

I wish I could say it gets better, but sometime next year we’ll be taking STEP 2, an exam with both a written and practical portion (in Chicago, no less).  Cost?  Well, lets see – $1750.  Looks like the government will be making record returns on its 6.8% investment next year.  Pity it’s at my expense.

Category: Medicine | Tags: , , ,

Doctors Appointment of the Future?

I’ve stumbled across a number of articles and demonstrations this week that provide an interesting glimpse into the (near?) future of medicine. A lot of this is already possible today.

What will a Doctors Appointment in 2020 look like?

IBM Watson Demo: Oncology Diagnosis and Treatment

Motion and Color Amplification: Heart Rate from a Video

More than anything, these scenarios and new technologies depict what is possible with a high level of standardization in the healthcare environment, with universally available health records serving not only to benefit the patient, but also providing an extensive database for researchers and supercomputers to find trends and recommend evidence-based treatments.

It wouldn’t surprise me if Canada or the UK is able to implement something like this far before we do here in the U.S., at least outside of an academic setting.

It would also take a considerable up-front investment in infrastructural changes, as well as a re-balancing of the duties of primary care physicians vs specialists. In the scenario I linked, the PCP (with the aid of an expert system / “AI”) is also taking the role of radiologist and possibly cardiologist. However, this requires a much longer visit (a couple hours?) with the patient.

While I’m sure such an approach would ultimately be more efficient, the direction we seem to be heading is just the opposite, with PAs and NPs taking more of a role in primary care, and most complicated cases / procedures being referred to specialists.

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