John Oliver turns his incisive gaze on scientific studies:
Fantastic as always, with some great “TODD” talks too.
From the NYTimes piece about a new synthetic polymer that could be used medically to keep topical medications on the skin, maintain moisture in conditions like eczema, and—of course—to temporarily reduce wrinkles:
A Harvard colleague, Dr. Mathew Avram, who was not associated with the company or its product, said he had tried second skin, putting it under his eyes.
“It does work,” he said.
“But it was a little depressing,” he added. “I didn’t realize I had those bags.”
Is this going to replace some surgeries, make us all feel worse about the superficial effects of aging, or both?
Despite the rave reviews from family, friends, and readers on Amazon, I thought David Larson’s Medical School 2.0: An Unconventional Guide to Learn Faster, Ace the USMLE, and Get into Your Top Choice Residency overall falls prey to the common trap of the self-help genre: overpromise and underdeliver.
It’s unapologetically the approach to medical school as if written by Tim Ferriss (of the 4-Hour Workweek fame), which is fine I suppose, but therefore it harkens from the same spiritual family of life hackers that purport to teach you how to make six figures while banging the best-looking people in every city as you travel the world with two pairs of pants and some merino wool socks in a small Tom Bihn backpack. Even though the content is usually fine, the constant hyper-selling (you too can be like me!) sort of makes your eyeballs feel cheap.
On the whole, the book is clearly self-published. The first 13% is all introductory fluff. Larson repeatedly and irritatingly uses ALL CAPS to signify emphasis. There are a lot of grammatical, typographic, and miscellaneous errors (e.g. using “deep-seeded” instead of “deep-seated,” using “I.E.” when he meant “E.G.,” “your” vs. “you’re” etc). But most of all, it just needs an editor. It’s too long and fluffy. It plays the typical self-help book game of giving you a few pages of information with ten times more verbiage in an attempt to convince you of how great and revolutionary the plan is and how it will benefit you.
Much of the self-help/life-hacking genre is a silly follow the leader game, whereby an individual makes money by trying to sell their success methods to other people (a fraction of which then try to do the same). The real problem is that while success may be sexy, achieving it almost never is. Anyone who purports to teach you the secret to achieving your dreams is mostly selling snake oil (or a book or a pricey online e-course). The good thing is that many of these books, this particular book included, actually have reasonable advice buried beneath the hype. It’s not earth-shattering, but it is solid. The bottom line is something I used to tell my students all the time: You can’t learn everything. No matter what, you will have to pick and choose what to learn, and it might as will be the stuff that matters. Limit your resources. Don’t let your overachieving peers drag you down. If it’s not high yield for step one and you don’t otherwise know that it’s going to be on your unit exams, then you probably don’t need to know it. How Larson thinks you should study finally makes an appearance at the 48% mark (hint: it’s flashcards and spaced repetition, such as many students do with Anki). In catchphrase parlance, that’s “study smarter, not harder.”
So, other than discussing how to study, the book includes exactly 0% of the other parts of medical school: any real specifics about study resources, what to do with the summer after first year, anything specific to the boards, anything about clerkships, anything about applying for residency, etc etc. This is just about how to study, which means in many ways it’s not really about medical school at all. If you want to know about medical school itself, you’ll have to look elsewhere.
There’s also a bunch nutritional pseudoscience and wellness stuff, which is +/-. Maybe I’m too cynical.
If you need someone to help you orient your mindset as you begin medical school, then this book will do the trick. The study methods are fine. Although, while the “typical” med student Larson refers to does exist (the “gunner”), it’s a bit of a straw man to compare his method against. Most people I knew in med school where nothing like what he describes.
All that griping aside, I do think Larson genuinely thinks medical students are making themselves miserable and is trying to offer his perspective of a reasonable approach to prevent throwing four years of your life away, and for that, I do applaud him. The mindset aspect of the book may very well be the most helpful thing about it.
Overall: If you want an in-depth discussion of how to stay sane making flashcards, go for it.
From FiveThirtyEight’s article, What Would Happen If We Just Gave People Money?, discussing the results of the MINCOME experiment in Canada in the 1970s where families received a basic income, no strings attached:
Families receiving MINCOME had fewer hospitalizations, accidents and injuries, Forget found. Mental health hospitalizations fell dramatically. And the high school completion rate ticked up during the years of the experiment, with 16-to-18-year-old boys, in particular, more likely to finish school. Younger adolescent girls were less likely to give birth before age 25, and when they did, they had fewer kids.
The program brought most recipients above Canada’s poverty line. And the employment effects in Dauphin were modest. “For primary earners — those with full-time jobs — there was virtually no decline” in work, Forget said. “Nobody was quitting their jobs.” Cash from the government eased families’ economic anxiety, allowing them to invest in their health and plan over a longer horizon.
The idea of a basic income (instead of means tested “welfare”) is gaining traction. Several countries (Canada, Finland, Switzerland, Kenya, etc) are planning modern experiments of their own. Politics and logistics aside, how else will our economies function when much of the conventional labor force is inevitably replaced by machines?
If you’ve seen the headlines, then you know that this open letter to the CDC from three medical students and Martin Makary at Johns Hopkins has gained a lot of media attention. In it, they argue that the CDC should allow doctors to list medical error as a cause of death. So far so good.
Then they argue, through the power of contrivance, that medical error is the third leading cause of death after heart disease and cancer but above COPD (emphasis mine):
We define death due to medical error as death due to 1) an error in judgment, skill, or coordination of care, 2) a diagnostic error, 3) a system defect resulting in death or a failure to rescue a patient from death, or 4) a preventable adverse event. The prevalence of death due to medical error leading to patient deaths has been established in the literature. From studies that analyzed documented health records, we calculated a pooled incidence rate of 251,454 deaths per year.(1) If we project this quantity into the total number of deaths in the year 2013 (2,596,993 deaths), they would account for 9.7% of all deaths in the nation.
Wait, what? All of the medical error data is slightly bullshitty, and doubling down on it to “calculate a pooled incidence rate” for this purpose is no different. Medical errors that occur before death do not necessary cause that death (correlation and causation). Some patients who die “due” to medical error are so sick that the medical error is not the prime (or even secondary) culprit. Perhaps being on death’s door and requiring high level and Herculean care is a risk factor to experiencing medical error. Not all bad surgical outcomes, hospital acquired or postoperative infections are “errors” even if someone labels them as “preventable.”
The accompanying article in BMJ is longer but doesn’t help with the underlying math (emphasis mine):
A literature review by James estimated preventable adverse events using a weighted analysis and described an incidence range of 210 000-400 000 deaths a year associated with medical errors among hospital patients.16 We calculated a mean rate of death from medical error of 251 454 a year using the studies reported since the 1999 IOM report and extrapolating to the total number of US hospital admissions in 2013.
Associated. I have to imagine that this “analysis” is for dramatic effect, to spur popular outrage and official (re)action. It’s like projecting the cancer risk of CT scans based on the atomic bomb survivors exposures, dividing to estimate the risk of a single CT, and then multiplying to get the total risk of all CTs. Sure, it could be right by coincidence, but it’s certainly not rigorous or even definitely based in reality.
The premise that we should actually know if we kill someone is important and makes sense (though telling people to actually put down “medical error” on a death certificate for their patients given the malpractice climate might be a tough sell and means that I imagine in real life it would often be reserved for egregious cases). I personally think that while this sort of presentation may generate discussion, it actually cheapens an important topic within medicine. Medical error is important and we must do more to track it, but tying a number to it in this manner is almost arbitrary.
In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.
If 1 in 3 seems low to you (and it certainly does to me), that’s because it almost certainly is. The data were acquired from normal ambulatory care visits with physicians. Not included? Midlevels and urgent care centers (as well as dentists and over-the-phone call-ins). I bet it’s at least half taking all things into account.
The study’s lead author, Katherine Fleming-Dutra, quoted in the Washington Post (emphasis mine):
Clinicians are concerned about patient satisfaction and the patient demand for antibiotics. But the majority of individuals do trust their doctors to make the right diagnosis, and better communication by doctors about the dangers of antibiotic overuse can lead to more appropriate prescribing.
This is an important statement, but I’m not sure it’s true. For acute complaints, many people seek medical attention precisely because they want/feel/think they need antibiotics. Anything else they can get over the counter. Even if they are aware of the likelihood of a viral illness, many still want an antibiotic due to the possibility/notion of a superimposed infection or because they’re miserable and/or not getting better quickly. Even if the majority of individuals do trust their doctors, I would love to see data on the percentage of inappropriate antibiotic receivers that do!
The popular press has been all over a new study out of McMaster University in PLOS One that demonstrated that 1 minute of intense exercise in the midst of 10 minutes of lesser activity had similar cardiovascular benefits to 45 minutes of moderate exercise (in otherwise sedentary men).
The major novel finding from the present study was that 12 weeks of SIT in previously inactive men improved insulin sensitivity, cardiorespiratory fitness, and skeletal muscle mitochondrial content to the same extent as MICT, despite a five-fold lower exercise volume and training time commitment. SIT involved 1 minute of intense intermittent exercise, within a time commitment of 10 minutes per session, whereas MICT consisted of 50 minutes of continuous exercise at a moderate pace.
Which is neat, but the press headlines are all about the 1 minute part. Sadly. I would love to be convinced that exactly 1 minute of high knees could assuage my guilt of being sedentary and loving Cinnabon. But it’s not a 1-minute workout. It’s a ten-minute workout of which 1 minute hurts. That’s actually longer than the 7-min workout (app) that made the circuit a couple years ago.
This does dovetail nicely with this rundown in Vox summarizing the research demonstrating that, overall, exercise doesn’t help you lose much weight. This comes up all the time, and people are wrong about this all the time. Exercise is fantastic for you in so many ways, but its benefits aren’t primarily related to weight loss.
One 2009 study shows that people seemed to increase their food intake after exercise — either because they thought they burned off a lot of calories or because they were hungrier. Another review of studies from 2012 found people generally overestimated how much energy exercise burned and ate more when they worked out.
The popularization of nutritional science in general has led to a number of pervasive myths due to a conflation of correlation and causation (as well as bad science), like how millions of people still think that eating breakfast will magically make you skinnier.1
The overestimation of weight loss due to exercise is so pervasive in part because it’s so ostensibly logical. Exercise burns calories, therefore I should lose weight if I exercise. But even ignoring the hormonal and behavior/consumption reactions to exercise that can erase the calorie losses, I always just tell people the same thing when it comes to weight loss in the real world:
What you eat matters more. Which takes longer, eating the Cinnabon, or working it off?
Newly minted orthopod Daniel Paull MD’s So You Got Into Medical School….Now What? came out last year. The book attempts to be a one-stop shop of medical school advice with a big focus on how to study. I bet the idea of a detailed how-to guide for medical school seems compelling to a lot of people (particularly the anxious type A variety), but I find it odd how specific authors and various internet people attempt to be for study advice given how variable the coursework and grading are for the basic sciences nationwide.
Chapter 1 (“Conceptual Learning and Detail Worrying”) is 7% of the book, extremely dry, and could be summarized by saying medical school is hard, there is a lot of information to learn, and given that, you should try to really understand material and not cram. I’d argue that the argument that studying over time leads to better long-term retention over cramming requires no argument at all. It’s self-evident. Even people who cram (and I’m one of them) know that it is a test taking strategy of procrastination/weakness and not a good method for truly learning the material or preventing self-hatred and sabotage.
Paull also advocates strongly for reviewing the material before lecture. Conversely, many students would argue that avoiding lectures altogether when possible is a more time-efficient solution. His discussion of anatomy is pretty old school without any discussion of how anatomy instruction has changed at many institutions around the country (with many schools placing a greater emphasis on prosections, virtual dissections, etc instead of lots and lots of hours in the lab).
I did really like one bit of counterintuitive advice: keeping a study schedule can help you prevent the feeling that you should always be studying more. The schedule as a means to say “you’ve done enough” sounds like a great idea! Everyone needs balance.2
When it comes to specific test advice like Step 1, he again focuses on the idea of the magical schedule (without supplying an example himself). He doesn’t mention anything specific about book recommendations, question banks, or any recommendations on how to structure your review. I wonder if he avoids mentioning any books by name so that his book doesn’t become outdated? Either way, all the conceptual writing about studying then falls short without any specific advice when it might count. Paull falls prey to thinking his own specific experiences and school set-up are totally generalizable (because they’re not). His take:
Review books and question banks are equally important in preparing for the Step 1, and just about every study schedule will dictate the use of both.
Again, the best approach is to ask upperclass students which materials they found most helpful. Usually you’ll get a consensus on this.
Which is a huge cop-out! You’re the upper classman in this context! People are reading the book because they want your thoughts! If there is really a “consensus,” then give it. You ask enough people, especially completionists, and you won’t get a consensus. In reality, ask enough people and you’ll eventually get a list of more good/reasonable resources than you can handle. (I’d also personally argue that the question banks are generally more important than books in preparing for Step 1, but that’s just my take.)
Regarding shelf exams:
Another mistake students make is not reading the books they select in their entirety; too often students rely entirely on practice questions. Despite their usefulness, practice questions often do not cover all the necessary details of a topic and are designed simply to test the base of knowledge you will gain from books.
Agree that you need to read the entire book, but I’ve never met anyone who really relied too much on practice questions; I have however met a lot of people who haven’t done enough.
Regarding clerkship evaluations:
The subjective component can comprise up to 50 percent of your clerkship grade.
Up to but not more than? Really? 50% of your grade from evaluations is the maximum cut off nationwide?
Regarding Step 2 CK:
In fact, most medical schools simply require students to take this test before graduation.
On average, students study for two to three weeks for the Step 2 CK
Second, find someone who did well on the Step 2 CK and ask how that person studied.
The appeal to authority fallacy is really a terrible way to live your life. Many (most? who knows?) schools require Step 2 CK long before graduation, and more importantly, a growing number of programs require passage before ranking.
Regarding Step 2 CS:
Most nonnative English speakers will have a more-than-sufficient clinical skill set to pass those aspects of the test, but the spoken English proficiency section can be a challenge.
The data don’t necessarily demonstrate that. Spoken English Proficiency (SEP) is the least likely cause of failure in all groups (US and IMG). International students (which doesn’t distinguish between native and non-native English speakers) fail ICE > CIS > SEP, the same order as US students. I wrote about this here (with actual data).
Regarding The Match:
A personal statement won’t make or break your application.
A great personal statement can only “make” an application in extreme circumstances, but truly terrible personal statements absolutely can and do break applications.
Either way, if an institution doesn’t have a majority of residency positions filled by people who rotated there (this includes students from the program’s home institution), consider that a bad sign.
This is highly field-dependent. Small surgical subspecialities like Ortho and Urology differ greatly from typically larger residencies like Medicine or even Radiology.
Anyway, you get the idea.
Ultimately, the book falls prey to the obvious limitation: Paull is a single author who hasn’t made a huge effort to see how his medical school experience might differ from other students across the country.2 The general advice is reasonable but not mandatable. Study hard but not too hard, over time instead of overtime. The specific advice is occasionally way too narrow,. and of course, the whole thing is mostly common sense. That’s the nature of these things.
Overall: If it would make you feel better to have a solid road-map of medical school to keep you grounded, give it a spin (especially if you have a free trial or subscription to Kindle Unlimited, making it free to read). I know that during med school I was always wanting to know more about what happened next and felt that the class meeting that discussed it was inevitably further away than I wanted. If you want specific advice though, you’ll still have to (and should) look elsewhere.
The Scope is a new free weekly medicine newsletter that distills down some highlights from the major journals (NEJM, JAMA, etc) in plain English with a dose of context and light analysis. I’ve added it to my newsletter subscriptions, which also includes The New Yorker Minute (which reads the New Yorker so you don’t have to, recommending which parts are worth your time, and which I also love). The Scope is published on Fridays by a group of Columbia medicine residents and makes a great 2-minute light read for medical students, residents, and anyone who wants something in between reading journals all the time and waiting for something to be misinterpreted by the mainstream media.
My very short and very well received book (26 all 5-star reviews and counting, hooray!), The Texas Medical Jurisprudence Exam: A Concise Review, is now available on iTunes/iBooks and Kobo in addition to Amazon. Additional ebook formats and the print version are forthcoming. 
While I personally use Amazon for just about everything, I know some people prefer to use other ebook vendors or non-Kindle readers. While the book was part of the KDP Select program (Kindle Unlimited etc), it was exclusive to Amazon. I’ve decided to not renew that program membership (more on that later), which allows me to open up the book to other markets for those so inclined.
For the time being, Kobo is offering a $5 credit for your first ebook purchase, which means that if you’ve never gotten an ebook from them before, my book would be half price.3