The Modern Medical Student Manual is a book outlining some methods on how to learn faster, find fulfilling work, and how to make your mark in medicine. The author, Chris Lovejoy is a Cambridge medicine grad, works as a junior doctor in London, is passionate about machine learning in medicine, and also has a YouTube channel.
I wish I had read the book back when I was a first-year medical student, as a sort of guide for me to get started with. Reading this book gave me a perspective on medical school and the never-ending rat race. If you’d like to learn more about how to study effectively and how to do more in medicine, this book is for you.
This book provides insight on how to learn effectively, how to master clinical medicine, how to increase our impact in healthcare, why research is important, how to communicate better as a medical student, and the pitfall of working too hard in medical school.
Chapter 1: Medicine From Fifty Thousand Feet: Perspective, Targets and Limits
Studying medicine can be fantastic. There’s an endless amount of knowledge that can be obtained. Gradually ascending this mountain of information can be enjoyable and rewarding.
However, there is a common pitfall that this can create: Working too hard for the sake of it.
I began to assess my motives. For a long time, I had been telling myself “I need to study hard so that I can be the best doctor I can be” but I realised this didn’t hold up to scrutiny: the difference between a good and a great result wouldn’t make me a much better doctor, yet the reduced life experiences from living in the library may well make me a worse one.
Assessing your priorities and maintaining perspective can be a continuous journey, one that is facilitated by reflection. A lot of us reflect informally, but there can be additional benefit from certain methods of formal, structured reflection. Two such techniques are ‘Following the Trail of Whys’ and ‘Attending Your Own Funeral’.
Follow trails of why
The founder of Toyota, Sakichi Toyoda, is credited with advising people to “Ask why five times.” The exact number is not important, but continually asking why can be effective at finding new answers and uncovering flaws in previous assumptions.
If I had been honest and objective with myself during my first two years of university, the Trail of Whys may have produced something like this: Why do you study so hard? Because I want to get one of the highest marks. Why do you want to get one of the highest marks? Because I want to show everyone that I’m the best. Why do you want to show everyone that you’re the best? Because I derive some of my sense of self-worth from what others think of me. Why do you derive your sense of self-worth from what others think of you? Because my upbringing taught me to seek the approval of others. This was an adaptive response to my environment but is not serving me well while studying a competitive course at a competitive university. Therefore, the solution is to deliberately re-appraise how I evaluate myself, rather than to focus on how hard I am studying or working.
Attend your own funeral
This technique involves visualising your own funeral, imagining how it could go and how you want it to go. The aim is that, by doing so, you will appreciate what really matters and is most important to you.
Set limits, not targets
Learning medicine can consume your life. With clearer understanding of your priorities, you can set not only more appropriate targets but you can also set limits.
It may be that you still want to aim to finish top in your medical school, and that’s fine. However, you may be content with a more modest target. For example, after my summer of reflection I set my target as finishing in the top 25% of all exams alongside enjoying life, spending time with friends and family and investing time and energy into other pursuits.
One fear that some medical students have is that if they don’t study as much as they can, they won’t pass their exams. However, if you are intelligent enough to get into medical school then you are definitely smart enough to pass exams with the right approach.
Chapter 2: The Fundamentals of Fast Learning
One thing that I learnt is that it’s not the raw level of intelligence that determines success at medical school. It’s also not just how hard you work. I saw smart people do poorly and less smart people do exceptionally well. Rather, the most important thing is how you work.
At school we’re taught many things but we’re never really taught how to study. Yet there is a lot of research looking at the principles of memory formation and effective learning. Different people learn in different ways but many people go their whole lives without fully understanding how to maximise their personal capabilities.
Spaced repetition involves reviewing content at gradually increasing intervals. Research has shown that it dramatically increases the memory retention and thus efficiency of learning
A practical way to use this in medicine is as follows: when you learn some new information, recall it from memory and review your notes after about one hour, then one day, then one week, then one month, then six months and then one year.
One option for the micro level is to use electronic aids, such as Anki (where you can make your own flashcards) and Memrise (where you can use those created by others). These present you with flashcards and will re-present them at increasing intervals, based on your ease of recollection.
I created a Review System which is easily organised through a central document as shown below.
Learn for understanding
Learning for understanding leads to higher percentage retention and for longer periods of time. Abstract facts leak out of your brain, whereas understanding provides the context that will enable longer retention.
In medicine, it can feel like we don’t have time to develop a real understanding of a topic because there is so much to learn. We are often assessed in ways that directly test our factual recollection rather than our understanding, such as multiple-choice or true/false questions. As a result, it can be easy to focus on rote learning as many facts as possible. While it requires slightly more initial effort to develop the base understanding, the greater retention makes it much more efficient in the long-run. It also better serves the real aim of medical school which is to become good doctors rather than to pass exams.
The Feynman method is a useful way to identify any gaps in understanding of a concept and how to solve them
Another technique that facilitates learning for understanding is “Following the Trail of Whys”, as explored in Chapter 1.
Before you learn or review a topic, assess your current state of understanding by asking yourself the following questions: –
- What do you already know about the topic? (Write out as much as you can from memory)
- What don’t you know? What don’t you understand? The purpose of asking these questions is to highlight gaps in your knowledge or memory which you can then fill. Use them to write a set of questions to have in the back of your mind as you study, to act as a mental prompt and keep you on track. When you’re finished, check that you can now answer these questions from memory. Afterwards, to check whether you do truly understand the content you must actively test yourself. Useful ways to do so include:
- Recall the information from memory. For example, write a three-sentence summary of what you have learnt, write a short essay or make a poster or integrative diagram — you can be creative.
- Practise exam questions (if learning for an exam) — don’t wait until someone else sets them for you or for the exam itself; find your own and see which you can answer and which you can’t!
Create conditions for deep work
By fostering our ability to maintain focus, we can reach greater depths of understanding. When probing something intellectually, understanding is obtained gradually. Each answer raises another question to be answered. Becoming distracted disrupts this, inhibiting the depth of understanding you can reach.
Remove distractions. This may sound obvious, but distractions can be a huge hindrance to productivity. Five minutes spent checking emails or Facebook leads to far more than five minutes of time wasted as it takes time and effort for your mind to regain focus on the original task. Often, allowing yourself to be distracted is the easy way out of a doing a difficult task.
Use social media on your own terms
Social media can be a massive time-sink.
There are other side effects of social media not directly related to productivity which can be insidious. It can increase how much you care about what others think and it can cause you to compare yourself more with others. This may explain why some recent studies show that social media can have a negative effect on satisfaction.
One simple technique that can have a dramatic effect on study efficiency is the Pomodoro method. In short, it involves alternating 25 minutes of undisrupted work with 5-minute breaks.
Meditation is similar in that for a period of time you continually bringing your attention back to an object of focus. There is an increasing body of evidence to support that it can improve concentration.
Facilitate continual improvement
Learning to learn faster is an individualised process and is not as simple as just following a list of steps or using some techniques that someone tells you. This brings me on to the fourth fundamental principle which is to facilitate continual improvement. This involves continuous experimentation and evaluation.
Give yourself feedback by asking the following questions after each event: What worked well? Where could you improve? Ask other people for feedback.
Use objective assessment methods. For example, do past questions in timed conditions and then mark them.
Cal Newport has written about how a Weekly Review can increase short-term productivity and lead to long-term improvement. It involves setting aside some time each week (I usually spend an hour or two on Saturday morning) to assess how the previous week went, what you can try in the upcoming week and structuring your week.
There is an inexhaustible amount of information available on learning theory, study tips and techniques. Your aim is to find those that work best for you; cherry-pick from the information available and if they work, use them – if they don’t, discard them.
Chapter 3: Mastering Clinical Medicine
Making the most of clinical time
Unfortunately (for you), the clinical environment is designed to treat patients rather than to train medical students. This means it’s up to you to take the initiative. It is very easy to spend time on the ward, thinking that you’re a good student for being there, without learning very much at all. So much happens in a hospital on any given day. It’s easy to just go with the flow and hope that you passively absorb all the things you need to.
With this approach, you may have the occasional great clinical experience and will gradually pick up the required knowledge and skills with enough time. However, the more self-directed you are, the quicker you can learn and the better you can become. This is achieved by deciding your objective in advance. A great little book with suggestions for objectives is “101 things to do with spare moments on the ward” by Dason Evans and Nakul Patel. The title is self-explanatory.
Don’t be afraid to leave
That being said, there will be days where despite your objectives and your enthusiasm, there is just too little benefit to be gained from staying where you are. Perhaps the doctors are busy, you’ve seen all the patients with signs on examination and there’s not much else to do. Don’t feel an obligation to stay on the ward, in theatres or in clinics. Your time may be better spent elsewhere in the hospital or by going home and doing some study. Remember: you are not being paid and you are there for your own learning, so if you would learn more from leaving and doing something else then do so.
Tag on to good teachers
Sometimes you will have the good fortune of coming across a doctor who is (a) friendly, (b) keen to teach and (c) good at teaching. Tag on to them and milk them for all they are worth. One concern some students have is that they don’t want to distract doctors or waste their time. However, when doctors teach medical students it is mutually beneficial.
Link your experiences to your reading
It is often better to learn the academic and clinical components of medicine together, rather than in isolation. Aim to spend at least an hour each evening doing follow-up reading based on what you saw that day.
Deconstructing clinical skills
Any complex skill or activity can be broken down into parts. With more practice and experience, you become less conscious of the smaller parts and start to experience them as one whole integrated activity. This is true also in medicine. When someone starts learning medicine, they must learn the key subcomponents, such as ‘history-taking’ (asking the patient questions about what’s wrong) and the ‘physical examination’ (inspecting the patient’s body for signs related to disease). These subcomponents can be further broken down; a history includes exploring the patient’s main complaint, screening for other symptoms, exploring the patient’s medical background, their social situation and other elements. An experienced doctor has the ability to integrate these skills and draw on the appropriate combinations as required. When learning these skills, a useful approach is to deconstruct them into their smallest parts, analyse the best ways to learn each component and then re-integrate them.
Mastering the physical examination
I divided OSCE-style physical examinations into four components:
- The examination schema: The specific sequence used and signs looked for. For the major systems (cardiovascular, respiratory and abdominal examinations), you usually start in the hands, work up the arms to the face, then down the body via the chest and abdomen to the legs).
- Recognition of signs: In every patient, the schema followed is the same but different patients will have different patterns of signs present. A skilled clinician recognises these signs in combination to point towards a diagnosis, for example the combination of (i) nail clubbing, (ii) reduced chest expansion and (iii) fine crackles in the lungs is suggest of pulmonary fibrosis.
- Presenting the findings: After the examination, you must briefly summarise the signs (both positive signs and important negatives) and the possible diagnoses that they point towards.
- Viva: The examiner then asks follow-up questions about the possible conditions, distinguishing features and other information. For each of these aspects of the examinations, I devised a plan for practising them until they became second nature.
- The examination schema
As early as possible, create your own specific sequence for the examination.
In terms of the structure, it is useful to create ‘hooks’ that you can hang different parts of the examination off. For example, for the inspection part of the hand examination I have five hooks: (i) skin, (ii) nails, (iii) soft tissues, (iv) bones and (v) joints. Within each of these five there are a number of things to look for: e.g. when inspecting the (i) skin I’ll look for rashes, nodules, scars, etc.; then, when looking at the (ii) nails I’ll look for pitting, onycholysis, clubbing, etc. It is much easier to remember things in these domains than as a long separate list.
Think of as many useful ways for remembering different parts of the examination (rather than rote learning it all). Once you have created the schema and thought of useful ways to remember it, the more practice, the better to make the examination as automatic as possible. As the old adage goes “One examination a day keeps finals at bay”.
Not having patients is no excuse; practise with your friends, on a teddy bear or even on your pillow!
Recognition of signs
The key to getting good at recognising patterns of signs is to see as many patients as possible on the wards and trying to figure out what is wrong with them – there is no real substitute.
Initially, it is okay to know what condition the patient has before you see them so that you can see it and register “so that’s what spider naevi look like”. However, once you have a little experience you want to avoid as much as possible knowing what the patient’s condition is before you meet them. This way you actively have to try and work out what they have and you will learn much more. Another useful technique is to visualise the combination of signs you would expect to see in certain conditions.
There is no ‘right’ way to present findings after an examination, although certain approaches are more effective than others.
My advice is to experiment with different ways and find what works for you. The two most popular approaches are as follows.
Following the rough order of the examination
Present only the main positive findings then important negative findings.
Common questions in the viva include “what is the differential diagnosis for X?” (for example, a systolic murmur, jaundice, hepatomegaly), “what investigations would you like to perform?” and “what would your management be?”.
I prepared answers based on the most likely examination findings and the most common questions asked. For each, I thought of a logical structure for an answer and aimed for a top three or groups of three where possible. I created recordings where I would ask the question then leave a pause for me to answer before the recording gave the model answer that I prepared.
As well as practising separate components, it is important to continually practise integrating them together. This can be done by finding a colleague and practising on each other or on patients, each time following the full schema, presenting findings and giving each other a viva.
Chapter 4: Make Your Mark on Medicine (And The Power of Self-Education)
“… And that’s why my friend quit medicine and became a banker.” It wasn’t the conclusion I expected from a talk entitled ‘How doctors can do more good’, but I was intrigued. I’d never really questioned the positive impact of doctors before then. I’d always thought it was a given that medicine is a great career because you save loads of lives. Yet this talk suggested that it wasn’t quite that simple.
Why should we do more?
Medicine = mostly algorithms
There are optimum algorithms to follow in almost all situations, as determined by the existing evidence base and ‘best practice’ Becoming a better medical student and doctor involves becoming better at these algorithms. All medically-qualified doctors are, by definition, considered competent. They are deemed good enough at following the required protocols in order treat their patients.
The benefits of exerting effort to further exceed this ‘competency threshold’ are subject to the law of diminishing returns, as shown below.
Greater understanding of medicine beyond what is required for competency does not lead to a significantly better impact on patients for a number of reasons: There is extensive guidance on the different algorithms to follow, including NICE guidelines, trust guidelines and other resources. Greater knowledge doesn’t necessarily lead to better action. As a junior doctor, you can consult senior doctors if unsure. As a senior doctor, you can consult people with more specialist experience
The benefits of the competent-to-excellent progression faces a further restriction; you can only treat the patients directly in front of you. You are only one individual so no matter how much better you may be than your peers at clinical medicine, only the patients fortunate enough to interact with you directly will benefit from this. This is not the case in other fields or professions. For example, consider the public health researcher who devises a scheme that lowers the national smoking rate or the researcher who contributes to the discovery of a new anti-cancer drug. Even a relatively tiny contribution can lead to greater overall benefits due to the ability to scale up.
Therefore, the doctors who make the greatest positive contribution to the health of a population do so through things which can scale-up and affect more people. There are approaches that can be taken at medical school to maximise our ability of doing so.
How can we increase our impact?
Extending our work beyond our direct clinical practice can dramatically enhance our positive impact. Doing so requires motivation so it needs to be something that we enjoy. Therefore, one of the best ways to maximise our contribution to the medical field is to find something we love doing and work out how to use it to make a positive impact.
There is no one-size-fits-all approach to finding what we love. It often involves a wide exploration and a lot of trial-and-error. However, two principles that can facilitate it are undertaking extensive self-education and developing fundamental transferrable skills
In the short-term, pleasure and drive gained from working hard towards something you love has knock-on effects in other areas of your life. By increasing your mood and your drive it can lead to better performance in clinical practice. It also gives you motivation to study efficiently to make more time for what you love.
Incorporating our passion into medicine Some people will find deep interest in areas that can combine with medicine quite naturally, enabling them to have a positive impact. Mr Samer Nashef is a prominent cardiac surgeon who combined an interest in statistics with his medical expertise to create a risk model for cardiac surgery called the EuroSCORE. When exploring personal interests, try to avoid filtering things out based on how easily they may be applied to medicine. It’s better to explore things you are more genuinely passionate about, even if you have to work harder to incorporate it into medicine at a later date.
Self education: 21st century super-power
Self-education enables us to develop the understanding required for insight into our enjoyment of a particular area.
The first step is to identify what your potential areas of interest are. This can take any form; a subject area, a skill, an artform.
At a fundamental level, an approach for doing so is to:
- Identify good sources of input and methods of output.
- Incorporate them into daily life.
The three main domains by which we can learn are by auditory input, visual input and by output (thinking, making and doing).
Output is an essential stage in all learning. It may involve writing about something you’re learning; manipulating information that you have come across or forming your own opinions can highlight gaps in your knowledge and consolidate ideas. It may involve teaching others.
Incorporating them into daily life Our day provides a plethora of opportunities for different forms of information input or output. There will be gaps in your day when you could read something. There will be activities that you do regularly, during which you could listen to something. There will be certain times of day optimum for creating something. The benefits of self-education
The gains from this approach extend well beyond the content that you learn. It increases your ability to retain further information and to come up with new ideas.
Developing fundamental transferrable skills
The ability to think well and communicate well, both orally and through writing, are fundamental transferrable skills.
Chapter 5: A Scientific Approach to Research
Do your own work
Learning to think for yourself is one of the most valuable skills you can develop. Scientific research can be a great arena for developing this ability but only if the right approach is taken. It can also directly help your medical career as published scientific papers strengthen future job applications and can help you to establish connections. In short, the approach to take is think of your project idea first and then find the most suitable supervisor based on the idea.
We must learn to think for ourselves and train our brains to come up with good ideas. Active brainstorming is to our brains what regular exercise is to our bodies.
Create the right environment
Sit down with a sheet of paper, a pen and nothing else. In theory, a computer, phone or tablet would be fine to write on but make sure you won’t get any notifications or other distractions. Think of as many ideas as possible
Filter the ideas
Test the ideas
As a student, you will need a supervisor on board for the project.
The supervisor you choose can have a major impact on the quality of your project so it is worth investing a significant amount of time finding the right one. The ideal supervisor is someone with relevant experience of the field your study is in, a good record of publishing papers and who will be able to find the time to give you regular feedback and help with challenges that arise.
Contacting a renowned scientist to pitch your project idea can be daunting but it’s important not to be put off. Most researchers would love the prospect of an enthusiastic student pitching them
Writing the paper
A good supervisor will give advice on what information to include in each section. There are also many useful guides available on the internet.
Chapter 6: Commanding Clearer Communication
One of the best ways to develop oral communication at medical school is through teaching. The best way to develop writing skill is through goal-orientated writing and feedback. Ways to obtain this as a medical student include essay prizes, writing freelance articles and blogging.
Oral communication in healthcare
Developing the ability to communicate well with patients, relatives and other members of the team is an important part of becoming a great doctor. Communication can even have an impact on patient outcomes. However, as a medical student the opportunities to develop effective communication skills directly are limited. There are limits to how much can be learnt through observation and simulation.
Learning to teach well
As well as helping you to develop good oral communication, teaching others is an important role of a doctor
Regardless how you feel about teaching, I would highly recommend gaining at least ten hours of contact-time. Ten hours will enable you to understand the format, overcome initial anxieties and start to develop your own style. One easy way to acquire ten hours of experience is by finding a student to tutor. I consider the practicalities of this below. However, there are many alternatives, from teaching groups of medical students to volunteering at a local school.
Learning to write well
Some people find writing comes more naturally than others. However, writing ability is something that can be learnt. Doing so also increases clarity of thought more broadly. I always struggled with writing but, after hard work over many years, have reached the point where I can write this book.
Is Medicine Right For Me?
“Is medicine really for me?” is a question that a lot of medics ask at some point during their career.
It’s worth noting that whatever your source of dissatisfaction, no career change is going to immediately solve this.
It’s easy in a moment of frustration to think “screw this, my life would be so much easier if I became a (insert ‘dream job’ here). The reality is every profession will have its own upsides and downsides. Identify your fundamental sources of dissatisfaction and consider whether you can improve the situation or whether it will change in future as your career progresses.
The flip-side of this is that you mustn’t feel obliged to stay in medicine for fear of leaving.
The best approach to take is to do your research
Broadly, there are three routes you can take:
- Find a clinical practice that suit you.
- Find a non-clinical, medically-related job, such as scientific research, medico-legal work, teaching, public health, medical communications, medical entrepreneurship and medical management consultancy.
- Find a job unrelated to medicine
If Medicine Gets You Down
Here are some approaches that myself and colleagues use which have been helpful. Of course, nothing that we do will guarantee eternal happiness and contentment but I share them here in the hope that they may help:
- Make a central refuelling resource
- Mix it up
- Change your physical state (and your mind will follow)
- Write your way out
- Incorporate a new daily practice
- Other suggestions
Make a central refuelling resource.
“Dear Future Chris, I’ve compiled this resource for you. For when you feel drained of energy, disheartened or depressed, frustrated, confused or overwhelmed, with no apparent end in sight. Use this book to give you the strength and energy to push through. Past Chris”
Mix it up
A lack of variation can make us feel stuck in a rut. The best solution for this is to deliberately do something we’ve never done before. It can be anything that breaks up the normal pattern of things. Ask yourself ‘What’s one thing I could try that I’ve never done before?’
Change your physical state (and your mind will follow)
Science has shown that our body has a massive impact on our mind. If we smile, our mind starts to assume we are happy. If we walk with a confident posture, we start to feel confident.
Two useful ways to improve your state of mind are to:
Take an ice-cold shower
Write your way out
Writing can be a great way to process thoughts, feeling and emotions and can lift you out of a funk.
Incorporate a new daily practice
Certain things, when done on a consistent basis, can have a dramatic improvement on your mood. The best way to achieve this consistency is to incorporate it into your daily routine.
Tim Ferriss advises having at least one evening a week in the company of three or more friends.
- Letter and word mneumonics
- Method of loci and story associations
- Major System technique
- Synesthetic memory
Learning from others
Neurox, not xerox
After missing a teaching session, I emailed the consultant neurologist who had run the session asking for a summary of the supervision or some notes. His one-line email reply was the above. This simple phrase has stuck with me and helped me realise the benefit of committing things to memory rather than keeping comprehensive notes.
The first thing you prescribe to a patient is yourself
The power of observation
One GP emphasised how much can be gained from observation – of doctors, as both positive and negative role models, and of patients:
Always ask why
A cardiac surgeon explained that his habit of asking why was one reason for his successful career.
Never use ‘executed’ when you can use ‘did’
Keep it simple in the way you use your language as the purpose is to communicate a message.
Know the meaning of every word that you use
When a patient comes to you with a ‘functional’ problem, it’s because they have a problem which they can’t deal with on their own.
Medical Student Challenges
Here are some challenges from the author. I’m halfway through completing it!
- Self-educate in a topic that interests you. Set a goal to work towards and a deadline for achieving it.
- Undertake at least one research project based on an idea that you come up with.
- Get at least ten hours of teaching experience.
- Enter at least one essay prize. Select a title and commit to submitting an essay no matter what.
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