medicalschool

Successfully finishing undergrad on a pre-med track requires strategizing. When I first started taking science classes, I felt like medicine wasn’t for me. I had zero background in science and I was working a full-time job. I felt like I’d never catch up to my classmates, or better yet, pass the classes I was taking. That was when I earned my first C freshman year. I was taking Human Biology at a local college in my hometown and thought my horrendous high school study habits were sufficient to get me through college level classes. I was rudely awakened to the fact that my method of studying was no where near what was required for a successful run at a college level class.

The process of perfecting my study habit and finding a flow that worked best for me was a slow a strenuous one. I’d say it took the entirety of my freshman year, and maybe even some of sophomore year, for me to start to really get the hang of it and not feel like I was in a constant state of TRYING NOT TO DROWN!

First, before I get into the tips, I want to introduce you to my 5 phases of studying. I’ve realized over the years that I study best and learn best when I follow specific steps and study in a certain order. I divided the process into 5 phases and I go through each in the same order every time. I try to not skip phases unless I’m falling really behind or feel like the material is easy enough to where I can jump straight into practice. All of these phases are after lecture and after I have skimmed through the material either before or after class (depending on my availability). The phases are as follows:

Recall Phase: The first step in studying the material I am learning. This involves me using active learning practices such as brainstorming what I remember from lecture, drawings pictures, writing out ideas, creating a song/poem or creating a poster board. The best thing to do is review information from class after a break in between, not immediately after lecture. This may seem difficult at first because you realize there are gaps in what you can recall, but that’s OK! It means you need to retrieve information from memory which is what we want to master anyways.

Action phase: This is where what I’m learning is put into practice. I do as many practice problems, exams, quizzes and tests that I can get my hand on. In this phase, I am not yet testing myself. I am using my notes and videos to guide me through the problems. I mark down questions I am getting wrong and do them until I understand my error and corrected it.

Testing phase: This is where I do exactly what I was doing in the action phase, but I use no help at all. I do everything by myself and grade my own practice as if I had taken an exam. This phase is extremely important because you may be do extremely well in practice when you have an aid and realize you are still getting stuck when you have to critically think through problems on your own.

Review phase: The review phase includes going over any final topic or material that you are still struggling with. If you are struggling after the testing phase, seek help from your professor or a classmate that understands the material better than you. Don’t be afraid to use outside resources for your own benefit. They are there for a reason!!!

Elaborating phase: This phase isn’t always possible, but it’s my favorite because it really helps me solidify what I know and makes me feel like I’m a smart cookie. I try to teach the material to either someone else or myself. This literally means talking out loud and, FROM MEMORY, going over everything I know from the topic and explaining it as if I was teaching it to someone who never heard of it before.

One of my favorite resources for learning better studying techniques is the learning scientists blog. On their website, you can find more resources on what they consider to be the best six strategies for effective learning. I personally practice at least 4 of them during my studying sesh on any given day.

1. Ditch the flashcards

Don’t get me wrong, flashcards can work wonders when you are trying to simply memorize information short-term. As you all very well know, if you are trying to pursue a graduate career past your undergradhate degree, a lot of the information you are learning (especially core science or science related courses) will come back to haunt you. You will either have to know it for the MCAT or for the first year of medical, dental, pharmacology and vet school. Don’t underestimate the future need for the information you are learning. Merely getting an A in the class should not be your main priority. You want to really learn and understand the material. Instead of flashcards, consider incorporating active learning into your studying. Refer back to my initial phase of studying description to get an idea of what active learning may look like.

2. Space out your studying

The worst thing you can do to yourself is try to cram an entire week of material into one day of studying. It doesn’t work! 7 hours of studying on a Saturday is not the same as 1 hour of studying 7 days a week. The latter results in you not retaining the information and is exhausting. Work out a healthy balance between your work, personal and school schedule and ensure you give yourself personal time for hobbies and relaxing. Space out your work over several days or blocks throughout your day so that it adds up to your goal time. For example, wake up an hour earlier and spend 45 minutes in the morning reviewing for course A. Then, at lunch from work, review what you did in the morning. After work, don’t do anything related to course A. Focus on a different course and swap the schedule the next day so that course A is your evening focus.

3. Make connections

Memorizing words, formulas or basic ideas can be fairly easy, but what is required for you to really learn and understand the material so that you never forget it again? How do you master a subject? My favorite technique for mastery involves making meaningful connections between what I am learning and something that is engraved in my brain. I read a book once about the mastery of memorization (click here to buy it on amazon) and I learned a thing or two about how to make things stick. One trick I found interesting in the book was making absurd connections to what you are trying to learn. So, when I say “meaningful” I mean something out of proportion, unreal or exaggerated. For example, mnemonics work best when they are funny or even slightly inappropriate. Mnemonics are not very useful unless you can memorize the phrase, right?

4. Condense information

I am a big visual learner and I believe most people are too. For me, fitting all of the information that was being taught (even if it was 70+ slides on a powerpoint) into ONE sole typed out sheet of paper helped me visually see the information in my head during exams. Sometimes, I have to make my letters really small, but I color coordinate the information and add tables or small figures to help. Adding figures is most effective when you are drawing them yourself and personalize them to what your understanding of the material looks like. I add the most important information from the entire powerpoint or chapter and study only this one sheet of paper. This helps the information not seem so daunting and you don’t have to flip through pages and pages of scribbled notes or useless information. You don’t feel as overwhelmed and when exam time comes, you are able to visualize what was written on that page to use either process of elimination or recall to answer the question. DO NOT READ THROUGH NOTES OR READ THROUGH THE POWERPOINT FOR REVIEW. I promise you, this is a waste of your time! The information will go in one eye and out any other hole you have except stay in your brain like it’s supposed to. Like I said, active studying is the most effective form of studying there is.

Here’s an example of a poster I made for organic chemistry to help me understand functional groups better:

5. Get a planner. Yes, like middle school

Remember when you were in middle school and you would get personalized planners for the school year? Your teachers would have you write down your homework for the day or assignments that were due in your planner so that you wouldn’t forget? I know it sounds childish but there is nothing better than being organized. Even if your brain is moving at 100 mph all of the time, you can still learn to slow down buy using a calendar. There is no task too small for planning. I like to plan out my entire week on Sunday evenings. I sit down at my desk at home and I write down everything that is due that week on a sheet of paper. Then, I write down things I want to accomplish that week that are not associated with school such as gym time, personal time, mediation, grocery shopping, errands… literally ANYTHING else.

I divide my tasks into blocks on my schedule and don’t ever schedule over 2 hours of studying in one sitting. We think we get more accomplished based on the time we spend doing it, but that’s not necessarily true. I decided that my max time was 2 hours but every person’s stop time may be different. A good way to know when it’s time to stop is when you no longer feel focused on the material and are just reading through or trying to rush through the information to finish the task or assignment. The extra time you spend doing that is ineffective and wasteful. You could be spending that time doing something for yourself like going for a run or playing with your dog. Take breaks and make time for healthy habits in your life. You will never be a good doctor if you are not in good health. Personalize your calendar to best fit your sleep schedule, life and goals. Being organized is important in every aspect of life. Remember: the only way to not get behind is to stay ahead!

As I’ve mentioned before, I am currently working as a medical assistant in pain management. It’s now been almost a month that I started my new job and I love it! I get to work alongside the best pain management doctors in my area and have learned so much in a short amount of time. Last week, I had the privilege of shadowing several Epidural Steroid procedures as well as a Kyphoplasty procedure. It was the coolest thing I’ve seen since tori removal back in my oral surgery days. If you don’t know what a Kyphoplasty is, keep reading because this post is all about it!

What’s a Kyphoplasty?

A Kyphoplasty is a procedure performed to correct vertebral compression fractures (VCF) through the use of polymethylmethacrylate (PMMA) aka bone cement. The leading cause of VCFs is osteoporosis (Cooper et al, 1992), but falling or high risk activities like lifting heavy weights could also lead to a fracture. Due to the nature of the fracture, VCFs can be very painful; the vertebral body collapses causing the patient to lose height in their spine. During the procedure, a hollow needle is inserted into the body of the vertebra through the pedicle. An inflatable balloon is then placed inside, inflated to restore the vertebral height and to create a working channel for the cement to flow into. The entire procedure is guided through a fluoroscope and contrast medium.

Why a Kyphoplasty?

Other treatment options for patients with painful VCFs include non-surgical management (NSM) and a Vertebroplasty procedure. A Vertebroplasty is very similar to a Kyphoplasty. The primary difference is that a balloon is not used to create a working space for the cement to flow into and the cement used tends to have a lower viscosity. Both of these factors increase the most pertinent risk associated with the procedure: bone cement extravasating into the epidural space. Without a working space, the physician doesn’t have as much control of where the cement is flowing into. Also, bone cement viscosity is identified as a decisive guideline influencing leakage in a Vertebroplasty, so using a cement with a higher viscosity reduces the risk of extravasation (Giannitsios et al, 2005). In fact, the incidence of leakage during a Vertebroplasty ranges between 2-67% compared to 0-13.5% for a Kyphoplasty (Denaro et al, 2009). Other risks to consider include heart attack, cardiac arrest and stroke. In addition to surgical procedures, there are also NSM options for patients with VCFs. These include bed rest, pain relief medication and back bracing. Compared to patients who undergo a Kyphoplasty procedure, patients following a NSM treatment plan for VCFs experience less pain relief and improvement (Meirhaeghe, 2013). For these reasons, if a non-surgical treatment is insufficient, a Kyphoplasty is often the preferred treatment option for VCFs.

What are the main indications for the procedure?

Patients with Osteoporosis
Patients experiencing intense pain adjacent to the level of the fracture
Patients diagnosed with a fracture by an MRI, CT or X-Ray
Patients who failed non-surgical management for at least 4 weeks
Patients with lesion causing benign and metastatic tumors

Which patients are not candidates for the procedure?

Patients who did not fail non-surgical management for at least 4 weeks
Patients with asymptomatic vertebral compression fractures
Patients with allergies to materials used in the procedure such as PMMA or barium contrast
Patients with bleeding disorders that are unmanageable

How is the procedure performed?

The patient is placed on the table, face down with a gown open to the back. The patient’s skin where the needle will be inserted is prepped with an antiseptic solution. Most patients are sedated for comfort and since the procedure is minimally invasive, local anesthetic is primarily used.
The provider starts by inserting a bone access needle into the area affected to determine the trajectory of the working cannula. Once it’s confirmed through the fluoroscope that the access needle is at the correct location (on pedicle of vertebra), a bone drill is used to create a pathway through the pedicle into the vertebral body.
Once the pathway is created, a curved-tip osteotome is inserted into the vertebral body and manually curved/directed towards the fracture.
The balloon is inserted through the hollow needle and inflated to compact the soft porous bone inside of the vertebral body. Doing this not only restores the natural height of the vertebra but also creates a working channel for the cement to flow into. This decreases the chances of the cement flowing to places it shouldn’t flow into and gives the doctor more control of the cement’s trajectory. A contrast is used to visualize the inflation of the balloon and its location through the fluoroscope.
Finally, the balloon can be removed and cement is injected into the working channel under pressure using a special cement filler cannula. The pressure and quantity of cement being injected is strictly controlled to prevent leakage. The needle is removed slowly and carefully, ensuring the cement is not following the needle forming a “tail.” This is done by waiting for the cement to slightly harden and monitoring its progress through the fluoroscope.
The needle is removed and the incision is closed with either steri-strips or skin glue. Once the remaining cement on the table hardens, the patient is ready to be moved to the recovery room.

Pictures from the procedure I shadowed:

Works Cited

Giannitsios, D., Ferguson, S., Heini, P., Baroud, G. & Steffen, T. (2005). “High cement viscosity reduces leakage risk in vertebroplasty”. European Cells & Mat 10, Poster No. 314. http://www.ors.org/Transactions/5thCombinedMeeting/0314.pdf

McCall, T., Cole, C., Dailey, A. (2008). “Vertebroplasty and kyphoplasty: A comparative review of efficacy and adverse events.” Current Reviews in Musculoskeletal Medicine, Vol. 1: 17-23, doi: 10.1007/s12178-007-9013-0. https://link.springer.com/article/10.1007/s12178-007-9013-0

Meirhaeghe, J., Leonard, B., Steven, B., Jonas, R. & John, T. (2013). A randomized trial of balloon kyphoplasty and nonsurgical management for treating acute vertebral compression fractures. Spine, Vol. 38(12): 971-983, doi: 10.1097/BRS.0b013e31828e8e22. https://pubmed.ncbi.nlm.nih.gov/23446769/

Denaro, V., Longo, U., Nicola, M. & Denaro, L. (2009). Vertebroplasty and kyphoplasty. Clinical Cases in Mineral And Bone Metabolism: The Official Journal of the Italian Society of Osteoporosis, Mineral Metabolism, and Skeletal Diseases, Vol. 6(2): 125-130. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2781232/