James Malcolm2024-03-29T02:25:52+00:00http://jgmalcolm.com/James Malcolmme@jgmalcolm.comDo research backwards2023-06-02T00:00:00+00:00http://jgmalcolm.com/do-research-backwards<p>Research experience is highly valued in competitive graduate programs, medical
schools, and surgical residency programs. Engaging in research demonstrates
your commitment to learning and advancing your field. However, getting started
with research can feel overwhelming, especially as a trainee when you don’t
have perspective to know what’s important. In this blog post, I propose a
unique approach to conducting research by starting with your goal in mind and
working backwards to fill in the necessary pieces. This approach will help you
navigate the research process more effectively and increase your chances of
success.</p>
<p><em>Target A Journal.</em> To begin your research journey, choose a journal that
aligns with your field of interest. Let’s say you are a neurosurgical
resident. You might explore the latest issue of the Journal of Neurosurgery
(JNS) or Neurosurgery journal. Skim through the articles and identify one that
catches your attention.</p>
<p>Suppose you come across a study on the use of functional magnetic resonance
imaging (fMRI) in preoperative planning for brain tumor resection. Study this
article diligently, either in digital format or by printing it out and marking
it up. Take notes, highlight important points, and pay attention to the study
design, methodology, and results.</p>
<p>While studying the chosen article, resist the temptation to immediately chase
down every citation mentioned in the text. Instead, mark the citations that
you believe are important but hold off diving into them right away. At the
end, select the three most crucial citations and study them with slightly less
intensity. This approach allows you to focus on the most relevant and
impactful references.</p>
<p><em>Copy structure.</em> Create a new document and use the outline from the article
you are studying as a starting point. Include sections such as abstract,
introduction, methods, results, discussion, and any figures or tables. By
adopting the structure of a published article, you gain insight into how to
structure your own research. Additionally, for each figure or table, start a
spreadsheet to organize the corresponding data. This step ensures that you can
easily reference and analyze the data during the research process.</p>
<p>Remember, you can accomplish all of these steps without a mentor initially.
Once you have completed these tasks, approach a mentor and seek their guidance
on the topic. Ask them if they have encountered the subject matter, possess
relevant data, or consider it important. Their expertise can provide valuable
insights and direction for your research.</p>
<p><em>Target A Conference.</em> Conferences provide an excellent platform to showcase
your research and network with professionals in your field. Start a document
where you compile a list of upcoming conferences along with their dates for
the next 12 months. Websites like
<a href="https://conferencealerts.com/">ConferenceAlerts.com</a> or the official websites
of neurosurgery professional organizations can help you find relevant
conferences.</p>
<p>For each conference, create bullet points outlining the abstract or project
you intend to submit. As your research progresses, you can modify and
rearrange these bullet points accordingly. Sharing this document with your
advisor keeps them informed of your research direction and enables them to
provide feedback and guidance.</p>
<p>To stay organized, hyperlink the document to the current version of your
submission. You can use cloud storage platforms like Google Drive or Dropbox
to store your research documents and easily share them with collaborators or
mentors.</p>
<p><em>TBD.</em> At the bottom of the document, create a section labeled “To Be
Determined” where you can jot down long-term ideas and plans for future
research projects. This section serves as a repository for potential research
directions that may not be fully developed yet. It allows you to brainstorm
and revisit these ideas as your knowledge and skills grow. In MS Word, I
created an autocomplete so that anytime I type “###” it automatically changes
it to be highlighted in yellow so these spots stand out.</p>
<p><em>Identify mentors.</em> Finding influential individuals in your program or field
who are working in areas that align with your interests can be immensely
beneficial. Stay updated on their latest work by following their publications
and attending any seminars or presentations they give. For example, if you are
a neurosurgical resident interested in neuro-oncology, you might identify a
senior attending who has published extensively in that area.</p>
<p>Approach these individuals and express your interest in their work. Share your
thoughts and insights on their latest research findings or innovations. By
showing genuine interest and knowledge, you demonstrate your commitment to the
field and create a foundation for collaboration. Consider proposing a research
project or asking if you can assist them with their ongoing studies.</p>
<p><em>Peer collaboration.</em> Build connections with peers who have similar research
interests. They may be excellent collaborators and co-authors for your
projects. Attend departmental meetings, conferences, and research seminars to
meet and network with like-minded individuals. Engaging in research with your
peers not only enhances the quality of your work but also fosters a supportive
and collaborative environment.</p>
<p>Embarking on a research journey can be a daunting task, especially for
graduate students, medical students, surgical residents, and early career
attendings. By adopting the “do research backwards” approach, you can navigate
the research process more effectively. Start by targeting a journal, study an
article that interests you, and create a structured outline based on the
article. Then, set your sights on conferences and begin outlining potential
abstracts or projects for submission. Finally, identify influential
individuals in your field and establish connections. Remember, research is a
continuous learning process, and your persistence and dedication will propel
you toward success in your academic and professional pursuits.</p>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutNegotiations2023-01-18T00:00:00+00:00http://jgmalcolm.com/negotiations<p>Negotiating can be a daunting task, but with the right preparation and
approach, you can increase your chances of success. One of the key elements to
successful negotiation is taking the time to prepare before the actual
meeting.</p>
<p>The more time you put into pre-negotiations, the better. By preparing in
advance, you’ll be able to calmly evaluate trade-offs and have pre-formulated
responses ready. It’s important to know what’s important to you and what you
can give away for leverage. Additionally, try to figure out what’s important
to the other party and where you two might run into conflict.</p>
<p>One effective way to prepare is to conduct research on the other party and the
industry. This could include researching their past deals, understanding their
business model, and identifying any potential pain points or areas where they
may be more flexible. By understanding the other party’s perspective and
priorities, you can tailor your approach and make more effective arguments
during the negotiation.</p>
<p>For example, let’s say you are negotiating with a company that prioritizes
cost savings. In this case, you may want to emphasize how your product or
service can help them reduce costs in the long run. Additionally, you may want
to be prepared to discuss any discounts or flexible pricing options that you
can offer to help them meet their cost-saving goals.</p>
<p>When preparing, it’s also important to determine what’s reasonable and what’s
your max and min range around that. One way to estimate what’s reasonable is
to compare to a similar good or service, or use another industry or product
for proxy numbers. It’s also important to determine your maximum and minimum
price without offending the other party.</p>
<p>During the negotiation, don’t be afraid to ask for the other party’s
reasoning. Asking questions like “Why do you think that’s a reasonable price?”
or “How did you come up with that timeline?” can provide valuable insight and
help you make informed decisions.</p>
<p>Another important aspect of negotiation is determining what’s important and
what’s giveaway. Make a list of the things that are non-negotiable from your
perspective and rank them in order of importance. Additionally, make a list of
things you can give/take on to sweeten the deal for the other party. Examples
of things you might be flexible on include payment terms, dates, quality, or
product features..</p>
<p>When thinking of your priorities and non-negotiables, it’s important to have a
clear understanding of what you want to achieve and what you are willing to
give up in order to reach a deal. One way to do this is to make three lists:
Must Have, Nice to Have, and Give Away. This will help you prioritize your
goals and make it clear to the other party what you are looking for.</p>
<p>For example, let’s say you are negotiating the terms of a contract with a
client. Your Must Have list might include a specific payment schedule, a
certain level of quality, certain features, or a specific delivery date. Your
Nice to Have list might include additional services or a longer contract
term. And your Give Away list might include things like discounts or a more
flexible delivery schedule. By identifying your priorities in advance, you can
be more effective in the negotiation and make sure that you get what you want
out of the deal.</p>
<p>In addition to preparing, it is also important to be aware of your own
emotional state during the negotiation. It’s easy to get caught up in the heat
of the moment and make decisions based on emotions rather than logic. Try to
stay calm and composed during the negotiation and avoid getting into a power
struggle with the other party. Instead, focus on finding common ground and
working towards a mutually beneficial solution. Don’t be afraid to pause,
suggest circle back to a point, or even recommend reconvening later. Tell the
other party you’ll need to check with your boss before discussing further.</p>
<p>Incentives and penalties are also important to consider. Think about what
you’re likely to mess up and how you can minimize those
penalties. Additionally, think about what outcomes or assets are most
important to you and how you can protect those interests.</p>
<p>When discussing price, it’s important to consider the effect of
anchoring. This technique involves establishing a starting point for the
discussion, typically by being the first to mention a price. This can be a
powerful tool because it sets the reference point for all subsequent offers
and counter-offers, influencing the other party’s perception of what is
considered a fair or reasonable price.</p>
<p>If you have a strong preference on a price, you may want to consider being the
first to mention a number. However, be aware that this can be a double-edged
sword as it can put off the other party if they feel it is unreasonable. On
the other hand, if the other party is the first to mention a price that is
lower than what you desire, you can try to re-anchor at a higher number by
using other pricing examples or highlighting features that differentiate you
from the anchor they established.</p>
<p>When it comes to signaling a price, it’s important to remember that the goal
is to arrive at maximum utility for all parties. Emphasize this throughout the
discussion to assure the other parties that you’re trying to work with them.</p>
<p>In conclusion, negotiation is an art form that requires preparation and a
thoughtful approach. By taking the time to prepare beforehand, determining
what’s important and what’s giveaway, and focusing on incentives and
penalties, you can increase your chances of success. Remember, every time you
walk away from a negotiation, you may feel like you could have driven a harder
deal, but it’s important to remember that building a long-term working
relationship is often more important than winning a single negotiation.</p>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutQuantum Error Correction2018-02-16T00:00:00+00:00http://jgmalcolm.com/quantum-error-correction<script type="text/x-mathjax-config">
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<p>Quantum computers promise to solve many problems considered practically
impossible using today’s classical computers. However, in constructing such
devices, errors are introduced into the system as the unstable subatomic
components interact with their environment. Careful encoding of quantum
data protects against such errors.</p>
<h2 id="introduction">Introduction</h2>
<p>Computers have revolutionized society. This much is obvious. They are
everywhere from controlling traffic signals to controlling nuclear reactors.
They help us compose email and run the stock market. They calculate explosive
forces in video games and satellite trajectories. However, there are still
many problems just beyond the reach of feasible computation.</p>
<p>One such problem that is difficult on classical computers is simulating
quantum systems where the dimensionality of such systems is enormous compared
to classical systems. The state of a classical $n$-bit system has dimension
$n$ and size $2^n$; however, a quantum $n$-qubit system already has dimension
$2^n$ because of complex interactions between quantum states. Simulation of
such quantum systems with all these state interactions is largely intractable
\cite{Gottesman1997}. If such a system is so hard for us to model on
computers, how does Nature seem to do it so easily? This led noted physicist
Richard Feynman in 1982 to conjecture that a computer using quantum mechanical
processes for computation might be more efficient at such simulations.</p>
<p>A distant possibility in 1982, physical realizations of such quantum
computations are now reported every year. However, major hurdles still lay on
the path. One of the largest is that of errors creeping into computations:
quantum systems are extremely sensitive to their environment. Suppose each
computation on a quantum computer introduced some $\epsilon$ of error, then
after $N$ computations, the chance of producing an error free result is
$(1-\epsilon)^N$ which gets exponentially worse with each further computation.</p>
<p>Digital computers are free from such problems. After each computation, the
state is reset to either 0 or 1 and so any small error is corrected. However,
a similar problem of error arises in the use of unreliable media. For
example, radio transmission in a thunderstorm or reading a scratched compact
disc. For these and other such systems, robust encoding schemes have been
developed to correct for such errors.</p>
<p>In this report we will briefly cover the development of classical error
correcting codes defining several concepts that will lead us to the
development of analogous techniques for quantum systems. Included is a survey
of several advanced codes and discussion of future directions for fault
tolerant quantum computation.</p>
<h2 id="quantum-channels">Quantum Channels</h2>
<h3 id="quantum-noise-entanglement-and-decoherence">Quantum noise, entanglement, and decoherence</h3>
<p>Quantum computers are much more sensitive than their classical counterparts,
and so errors arise as they interact with their environment while performing
computations. While robust advances are announced every year, it is unlikely
quantum computers will reach the reliability of classical computers. As such,
methods are needed to reliably represent data during storage, computation, and
transmission.</p>
<h3 id="the-bottom-line">The bottom line</h3>
<p>Three problems present themselves when designing quantum codes \cite{QCQI}.</p>
<ul>
<li>We are unable to replicate an arbitrary state as per the
<a href="https://en.wikipedia.org/wiki/No-cloning_theorem">No-Cloning Theorem</a>,
hence we cannot simply use replicating an arbitrary qubit to then send. We
can however deterministically spread the information contained in some
arbitrary state over a larger state space.</li>
<li>There is a continuum of possible states and hence a continuum of
possible errors, and so it is not so simple as detecting which error
occurred as some errors could have occurred to greater or lesser extent.
Care must be taken in designing a finite set of corrective operations to
account for the infinite number of possible errors.</li>
<li>Directly measurement of qubit states destroys quantum information.
While classical coding theory may examine the state of the system and then
choose appropriate corrections, quantum coding must be more careful in
determining the character of error present. We must measure the error, not
the stored information.</li>
</ul>
<h2 id="classical-coding-theory">Classical Coding Theory</h2>
<h3 id="linear-codes">Linear codes</h3>
<p>Classical coding theory arose out of the need to communicate data in the
presence of noise. Following the pattern of most texts, we consider a unit of
data to be a <em>bit</em>, that is, an element of the set $\B=\{0,1\}$, and so
all arithmetic is modulo two, i.e. $0+0=1+1=0$ and $0+1=1+0=1$. In this
scenario, it is convenient to think of arithmetic as simply bitwise XOR.</p>
<p>A common approach begins by grouping data into uniformly sized blocks of bits.
Suppose we wish to encode $k$ bits using $n$ bits where $k<n$. We denote such
a scheme as an $[n,k]$ code. In other words, we have a pool of codewords $\C$
of size $2^k$ that we wish to embed in the set $\B^n$ representing $2^n$
possible binary words. If we represent these codewords as binary vectors $v
\in \B^k$, it follows naturally to define this encoding as a matrix $G$ called
the <em>generator matrix</em> representing the linear transformation $\B^k
\rightarrow \B^n$. The original codeword $v$ is now encoded as $Gv \in \B^n$.
In effect, this matrix $G$ spreads these codewords out in the higher
dimensional space.</p>
<p>Can we now formulate a quick test to see if an arbitrary word $s$ is a
codeword? Note that the $k$ columns of $G$ form a basis for the
$k$-dimensional subspace of codewords embedded in the $n$-dimensional space of
possible words $\B^n$. Let $\C$ denote this embedded codeword subspace. By
definition, valid codewords are found strictly within this subspace as a
linear combination of these $k$ basis vectors, while invalid codewords will
are found at least partly outside this subspace. With this observation, it is
interesting to examine this remaining $(n-k)$-dimensional space. Given a
generator matrix $G$, we can find the matrix $P$ of maximal rank, the rows of
which span this remaining subspace. Then by definition, for codeword $v$, its
encoded form $s=Gv$ must be in the null space of $P$, or equivalently $Ps=0$.
We now have a quick test to see if arbitrary word $s$ is a valid codeword:</p>
<div class="theorem">
$Ps=0$ iff $s$ represents a valid encoded codeword, that is, $s \in \C$.
</div>
<p>The matrix $P$ is called the <em>parity check matrix</em>.</p>
<p>With this notion of a binary vector space in hand, let’s talk of the nature of
errors. Let us define an error $e$ as a contamination of encoded codeword $s
\in \C$ to produce $s’ = s + e$. If we perform a parity check on this new
word $s’$, we find</p>
\[Ps' = P(s + e) = Ps + Pe = 0 + Pe = Pe .\]
<p>The value $Pe$ is called the <em>syndrome</em> of error $e$. Note that if $Pe$
is unique for every possible error $e$, then given arbitrary word $s’$ we can
determine and fix whichever error is present. In fact, this is a sufficient
condition for error recovery:</p>
<div class="theorem" text="Classical Syndrome">
Error recovery is possible iff every error has a unique syndrome.
</div>
<p>Since the value of $Ps’$ depends only on $e$, if $Pe$ is different for all
possible errors $e$, then we can uniquely determine which error occurred and
fix it.</p>
<p>Another useful way to examine the space of words to look at its topology
induced by a norm. Let us now look at such norm, that of Richard Hamming.</p>
<div class="theorem" text="The Hamming distance">
For a word $s \in \B^n$, its <i>weight</i> is defined as the number of
nonzero entries, and is denoted as $w(s)$. The <i>Hamming distance</i>
between two words $s,t \in \B^n$ is then defined as $d(s,t)=w(s+t)$. This
distance is a metric. The <i>minimum Hamming distance</i> of a code is the
minimum distance between any two codewords and is defined as
$d(\C)=\min \{ d(s,t) : s,t \in \C \text{ and } s \ne t \}$.
</div>
<p>Another description of the Hamming distance is the minimum number of bits that
must be flipped to convert one word to another. A simpler definition for the
minimum Hamming distance is revealed when we remember that since $\C$ is a
linear space, $s+t \in \C$ and so $d(s,t)=w(s+t)=w(z)$ for some $z \in \C$.
Now the minimum Hamming distance is defined simply as $d(\C)=\min \{ w(s) : s
\in \C \}$.</p>
<p>With this notion of distance, we may now quantify the amount of error as the
distance between an encoded codeword $s$ and the contaminated version
$s’=s+e$. Specifically, the number of errors is</p>
\[d(s',s) = w(s' + s) = w(s + e + s) = w(e) .\]
<p>In this sense, errors move a codeword away from its original position. If we
assume all errors on to be equally likely, the this perturbation can move the
original codeword in any direction. The process of recovering the original
codeword is now one of determining the closest codeword. It is often useful
to include this minimum distance in the description. Setting $d \equiv d(\C)$
we denote a code now as $[n,k,d]$.</p>
<figure class="thumb">
<img src="/images/qec/fig1-code-words.png" />
<figcaption>
A space with three codewords (black dots) spread in an
embedding space. Shaded circles indicate the Hamming sphere of each
codeword. We can only recover contaminated codewords that are within
these Hamming spheres. For example, the blue words are recoverable while
the red words are not.
</figcaption>
</figure>
<p>So what does the space of codewords look like? Remember again that the set of
valid codewords is spread out in the space of all possible words, any two code
words $s,t \in \C$ being a distance of $d(s,t)$ from each other.
The figure to the right illustrates a space containing three codewords. In
order for us to recover a contaminated codeword, we must be able to trace it
back to a unique codeword. This gives rise to the idea that, for a given
code, only errors in certain regions are guaranteed to be recoverable.
The figure indicates such regions, called <em>Hamming spheres</em>,
with shaded circles. For a given code $\C$, all such spheres have radius
$r=\tfrac{d(\C)-1}{2}$. In other words, we can correct errors up to size $t$
if $d(\C) \ge 2t+1$. More formally,</p>
<div class="theorem">
For code $\C$ with $d(\C) > 2t$ for some $t \in \mathbb{N}$, any
contaminated codeword $s'=s+e$ with error $e$ satisfying $w(e) \le t$ is
uniquely recoverable.
<br />Proof: Suppose we have some other codeword in $t \in \C$ that is at least as close
to $s'$ as $s$ is, and so may be confused with $s$. In other words $s \ne t$
yet both $d(s,s') = w(e)$ and $d(t,s') \le w(e)$. Then we have
$$
2t < d(\C) \le d(s,t) \le d(s,s') + d(s',t) \le 2w(e) \le 2t
$$
implying $2t < 2t$ which is a contradiction. Therefore $s$ is closest to
$s'$.
</div>
<p>Here our triplet notation $[n,k,d]$ comes in handy. For a code to correct up
to $t$ errors, $d > 2t+1$.</p>
<p>One last important concept to define is that of the <em>dual</em> of a code
is defined to be the set of all words orthogonal to the code. We denote the dual
as $\C^\perp = \{s \in \B^n : s\cdot t=0,\ \forall t \in \C\}$.</p>
<p>We conclude this summary of classical coding theory by mentioning that, in
general, the task of finding the original codeword $s$ in an arbitrarily
structured space is called the <em>decoding problem</em> and is considered of
class NP. Classic coding theory sets out to carefully construct codes with a
structure that allows both efficient encoding and decoding. The linear codes
described above in terms of generator matrices represent one such class of
efficient codes. Along similar lines other methods draw upon abstract algebra
using structured groups. And still other approaches use more exotic
substrate.</p>
<h3 id="classic_3bit">A simple redundant code</h3>
<p>The essence of error correction is to encode the data with enough redundancy
to ensure recovery in the presence of noise. A straightforward application of
this idea is to simply replicate the data. This happens commonly in real
life: if you didn’t quite catch what someone just said, you might ask them to
repeat it. Let’s now design such a system that encodes a single bit with
three copies of itself:</p>
\[\begin{eqnarray*}
0 & \rightarrow & 000 \\
1 & \rightarrow & 111 .
\end{eqnarray*}\]
<p>With this setup, we decode the result as the bit with majority presence:</p>
\[\begin{eqnarray*}
000, 100, 010, 001 & \rightarrow & 0 \\
110, 011, 101, 111 & \rightarrow & 1 .
\end{eqnarray*}\]
<p>How robust is this system? Suppose we know our noisy channel to flip bits
with probability $p > 0$. Majority voting here fails if two or more bits are
flipped in error. This system failure occurs with probability $p_f =
3p^2(1-p) + p^3 = 3p^2 - 2p^3$. Compared against the original unprotected
version that fails with probability $p$, we want $p_f < p$ which holds if $p <
1/2$.</p>
<h2 id="quantum-codes">Quantum Codes</h2>
<h3 id="the-quantum-analogue-to-linear-codes">The quantum analogue to linear codes</h3>
<p>Here we recast this linear vector space formulation in a manner suitable for
addressing quantum systems. In the linear formation, words were considered
points in a high dimensional space. In the quantum version, words represent
points on the Bloch sphere, i.e. the state of the system. We begin by adopting
the <a href="https://en.wikipedia.org/wiki/Bra%E2%80%93ket_notation"><em>bra</em> and <em>ket</em> notation</a>
to denote words: $s$ becomes
$\ket{s}$. Since bits become qubits, an $n$-bit word $s \in \B^n$ now becomes
a $n$-qubit word $\psi \in \Q^{\otimes n}$, the complex Bloch hypersphere. We
denote the Pauli operators as $I$, $X=\X$, $Y=\Y$, and $Z=\Z$.</p>
<p>Let us develop a notion of quantum error now. Like any physical quantum
process, error is a unitary transformation. Possible such errors may include
bit flips, phase flips, or some combination thereof. With the addition of
identity $I$ representing no error, these correspond nicely with the Pauli
operators: $X$ represents a bit flip, $Z$ represents a phase flip, and $Y$ a
combination.</p>
<p>For illustrative purposes, let us begin to design quantum codes for specific
errors, the first to address bit flips and the second to address sign changes.
Here, as in classic codes, codewords are embedded in a higher dimensional
space with special structure.</p>
<h3 id="three-qubit-bit-flip-code">Three-qubit bit flip code</h3>
<p>Let’s design
our first quantum code following the pattern of the classic three bit
repetition code described in <a href="#classic_3bit">Classic 3bit</a>. In doing so,
maybe we can correct for bit flip errors analogous to those of the classical.
Remember that we are unable to observe the state of our quantum system
directly, so our goal is to reformulate the results from Section
\ref{sec:linear_codes} in terms of inner products.</p>
<p>Given arbitrary initial state $\ket{\psi} = a\ket{0} + b\ket{1}$ on the
computational basis, where $a,b \in \C$, we first transform it to a new
redundant basis $\ket{\psi} = a\ket{000} + b\ket{111}$. This repetition has
the effect of spreading the original single qubit state over these three
qubits. So as not to destroy the contained information, we must be careful
not to perform any direct measurements that would perturb the state. Instead,
we carefully measure certain aspects of this augmented state while retaining
the original state. Specifically, we measure the <em>difference</em> between
certain pairs of qubits.</p>
<p>Recall that errors, like all physical transformations, are unitary operators,
hence their action on a system can be undone.
Theorem Classical Syndrome tells us that if we can uniquely
determine which error syndrome occurred, we can recover the error. Here, as
in the classical version, we decode based on which qubit has majority
presence, and so here again we assume at most one qubit is in error. In this
three qubit encoding, there are the possible errors are: no error, first qubit
flipped, second qubit flipped, third qubit flipped. There are four projection
operators to detect for these syndromes:</p>
\[\begin{eqnarray*}
P_0 \equiv \ket{000}\bra{000} + \ket{111}\bra{111} & \text{no error} \\
P_1 \equiv \ket{100}\bra{100} + \ket{011}\bra{011} & \text{error in first qubit} \\
P_2 \equiv \ket{101}\bra{101} + \ket{101}\bra{101} & \text{error in second qubit} \\
P_3 \equiv \ket{001}\bra{001} + \ket{110}\bra{110} & \text{error in third qubit}
\end{eqnarray*}\]
<p>Now we must convince ourselves that measuring to test for these error
syndromes does not disturb the state of the system. As an example, suppose
the first bit was corrupted so that now $\ket{\psi} = a\ket{100} +
b\ket{011}$. We then have the following result for syndrome measurement with
$P_1$:</p>
\[\begin{align*}
\ip{\psi|P_1|\psi}
&= \ip{\left(a\bra{100} + b\bra{011}\right)
\ket{100}\bra{100} + \ket{011}\bra{011}
\left(a\ket{100} + b\ket{011}\right)} \\
&= a^2\ip{100|100} + 2ab\ip{100|011}^2 + b^2\ip{011|011} \\
&= a^2 + b^2 \\
&= 1 .
\end{align*}\]
<p>Further, $\ip{\psi|P_0|\psi}$, $\ip{\psi|P_2|\psi}$, and $\ip{\psi|P_3|\psi}$
are all zero. Notice that measurement with the syndrome operator $P_1$ does
not perturb the state of this corrupted system. This is further confirmed in
that the measurement $\ip{\psi|P_1|\psi}$ contains no information as to the
$a$ and $b$ of the superimposed state.</p>
<p>Armed with these tests for specific errors, we can design a circuit to apply
the appropriate inverse error operation, e.g. $X \otimes I \otimes I$ to
un-flip the first qubit.</p>
<table>
<tr>
<th>Error</th>
<th>$\ip{\psi|Z_{12}|\psi}$</th>
<th>$\ip{\psi|Z_{12}|\psi}$</th>
</tr>
<tr><td>None</td> <td>$+1$</td> <td>$+1$</td> </tr>
<tr><td>First qubit</td> <td>$-1$</td> <td>$+1$</td> </tr>
<tr><td>Second qubit</td> <td>$-1$</td> <td>$-1$</td> </tr>
<tr><td>Third qubit</td> <td>$+1$</td> <td>$-1$</td> </tr>
</table>
<p>With further work, we can reduce the number of necessary syndrome measurements
from four to two. We define two new operators: the first operation compares
the first and second qubits, the second operation compares the second and
third qubits.</p>
<p>What operators perform this comparison? Remember that the $Z$ operator has
spectral decomposition $Z = \op{0}{0} - \op{1}{1}$. Used in a tensor product
we get a resulting decomposition that has positive eigenvalues iff the two
qubits are the same sign:</p>
\[\begin{align*}
Z \otimes Z &= \left( \op{0}{0} - \op{1}{1} \right) \otimes
\left( \op{0}{0} - \op{1}{1} \right) \\
&= \op{00}{00} - \op{01}{01} - \op{10}{10} + \op{11}{11} \\
&= \left( \op{00}{00} + \op{11}{11} \right)
- \left( \op{01}{01} + \op{10}{10} \right)
\end{align*}\]
<p>For simplicity of notation involving multi-qubit operators, define an operator
$U_i$ to be the tensor product of one qubit operators $U$ acting on qubit $i$
and $I$ acting on the remaining qubits, with analogous extension to
multi-qubit operations $U_{ij}$, $U_{ijk}$, etc.. In this notation,</p>
\[Z_{12} = Z \otimes Z \otimes I , \qquad
Z_{23} = I \otimes Z \otimes Z ,\]
<p>compare the first two qubits and the second two qubits, respectively.
Combining the results of these two measurements, we can determine if and where
a bit flip occurred. The four possible cases are laid out in
the table above. As with the projectors originally defined,
measurement with $Z_{12}$ and $Z_{23}$ does not perturb the state. This is an
intuitive result as two binary values can form four possible combinations.</p>
<h3 id="three-qubit-phase-flip-code">Three qubit phase flip code</h3>
<p>We now define a quantum code to detect and correct for phase flips, an error
that takes $a\ket{0}+b\ket{1}$ to $a\ket{0}-b\ket{1}$. While classical
systems do not have a notion of a phase channel, it is interesting that with
an appropriate change of basis the phase flip encoding and decoding can simply
use the three qubit bit flip code just described. Recall that in the three
qubit phase flip code, the error was the $X$ operator performing a bit flip:
$\ket{0} \rightarrow \ket{1}$. Notice that if we rotate our computational
basis via the Hadamard gate $H$,</p>
\[\begin{eqnarray*}
\ket{0} & \rightarrow & \ket{\downarrow} \equiv (\ket{0} + \ket{1})/\sqrt{2} \\
\ket{1} & \rightarrow & \ket{\uparrow} \equiv (\ket{0} - \ket{1})/\sqrt{2} ,
\end{eqnarray*}\]
<p>the phase flip error will analogously be the $HXH$ operation flipping
$\ket{\downarrow}$ to $\ket{\uparrow}$ and vice versa. Recall that $H^2=I$,
so a second application of the Hadamard operator returns us to the original
computational basis. In other words, we can use the three qubit code as a
black box by simply rotating before encoding and rotating again after
decoding. Where the syndrome measurements were $Z_{ij}$, they are now
$H^{\otimes3}~Z_{ij}~H^{\otimes3}$. The transformed syndrome measurements are
laid out in the table below. These two codes are said to be
<em>unitarily equivalent</em> since the action of one is the same as the other
under a unitary change of basis.</p>
<table>
<tr>
<th>Error</th>
<th>$\ip{\psi|H^{\otimes3}Z_{12}H^{\otimes3}|\psi}$</th>
<th>$\ip{\psi|H^{\otimes3}Z_{12}H^{\otimes3}|\psi}$</th>
</tr>
<tr><td>None </td><td> $+1$ </td><td> $+1$ </td></tr>
<tr><td>Phase of first qubit </td><td> $-1$ </td><td> $+1$ </td></tr>
<tr><td>Phase of second qubit </td><td> $-1$ </td><td> $-1$ </td></tr>
<tr><td>Phase of third qubit </td><td> $+1$ </td><td> $-1$ </td></tr>
</table>
<h3 id="shor">The Shor code</h3>
<p>Named for its inventor Peter Shor, the <em>Shor code</em> detecting and
correcting for both bit flips and phase flips \cite{Shor1995}. In what
follows, we outline the technique for a system of one qubit. This scheme is a
clever combination of both the bit flip and the phase flip codes described
above.</p>
<p>Shor proposed mapping the computational qubit basis into a new basis of two
nine-qubit elements. This mapping is broken down into two parts. First we
map the computational basis to the phase flip basis,</p>
\[\begin{eqnarray*}
\ket{0} & \rightarrow & \ket{\downarrow\downarrow\downarrow} \\
\ket{1} & \rightarrow & \ket{\uparrow\uparrow\uparrow} ,
\end{eqnarray*}\]
<p>then we map each of these qubits to the phase flip code,</p>
\[\begin{eqnarray*}
\ket{\downarrow} & \rightarrow & (\ket{000} + \ket{111})/\sqrt{2} \\
\ket{\uparrow} & \rightarrow & (\ket{000} - \ket{111})/\sqrt{2} .
\end{eqnarray*}\]
<p>The full mapping is then factored as</p>
\[\begin{eqnarray*}
\ket{0} & \rightarrow & \frac{(\ket{000} + \ket{111})
(\ket{000} + \ket{111})
(\ket{000} + \ket{111})}{2\sqrt{2}} \\
\ket{1} & \rightarrow & \frac{(\ket{000} - \ket{111})
(\ket{000} - \ket{111})
(\ket{000} - \ket{111})}{2\sqrt{2}} .
\end{eqnarray*}\]
<p>Before performing some analysis on this representation, let’s first examine a
few examples of possible errors and their detection to develop an intuition.
Suppose the first qubit is flipped in error, switching $\ket{0…}$ to
$\ket{1…}$ and vice versa. For notational While we now have more qubits to
test, we still follow the same procedures for checking bit flips and phase
flips as in the introductory codes. In this case, we test the sign of the
first and second qubits and find $Z_{12}=-1$ indicating one of them flipped.
We then check the second two bits and find $Z_{23}=1$ indicating they are of
the same sign, and so we conclude that the first bit is flipped and correct it
with $X_1$. In the same manner we test for and correct bit flips on the
remaining qubits.</p>
<p>As a second example, suppose the first qubit phase was flipped via $Z_1$.
Notice that such a phase flip would change the sign of the second element in
the first block of three qubits in each factored mapping changing
$\ket{000}+\ket{111}$ to $\ket{000}-\ket{111}$ and vice versa. As such, a
phase flip in any of the first three qubits would have this affect. Our
syndrome test then compares the phase of the first block with the second via
$X_{123456}$ and reverses the phase flip via $Z_{123}$. Analogous
computations address phase errors in the remaining blocks.</p>
<p>As a final example, suppose the first qubit has both bit flip and phase flip
errors, the corrupted state being $Z_1X_1\ket{\psi}$. We show that detection
and correction of the bit flip error and the phase flip error may be performed
sequentially. Our first syndrome measurement to detect the bit flip error
leaves the state untouched, but correcting the bit flip transforms the
corrupted state</p>
\[\begin{align*}
Z_1X_1\ket{\psi} \rightarrow X_1 Z_1X_1\ket{\psi} &= -Z_1X_1X_1\ket{\psi} \\
&= -Z_1\ket{\psi} ,
\end{align*}\]
<p>since the Pauli operators anti-commute, i.e. $\{X,Z\} = XZ + ZX = 0$. Now
notice that our syndrome measurement to detect the phase error on this new
state $\ket{\psi’}\equiv -Z_1\ket{\psi}$ is equivalent to detecting the phase
error on the original corrupted state:</p>
\[\begin{align*}
\ip{\psi'|X_{123456}|\psi'} &= \ip{\psi|Z_1^\dagger X_{123456}Z_1|\psi} \\
&= \ip{\psi|Z_1^\dagger X_1 Z_1 X_{23456}|\psi} \\
&= -\ip{\psi|Z_1^\dagger Z_1 X_1 X_{23456}|\psi} \\
&= -\ip{\psi|Z_1^\dagger X_{23456} Z_1 X_1 |\psi} \\
&= -\ip{\psi|Z_1^\dagger X_1^\dagger X_{123456} Z_1 X_1 |\psi} \\
&= -\ip{\psi|(X_1Z_1)^\dagger X_{123456} (Z_1 X_1) |\psi} \\
&= \ip{\psi|(Z_1X_1)^\dagger X_{123456} (Z_1 X_1) |\psi} .
\end{align*}\]
<p>Upon detection, the phase is fixed by applying the operator $Z_{123}$.</p>
<p>How robust is this code? Since we compare neighboring qubits to see if their
sign is different, the code breaks down if more than one qubit in this 9-qubit
tuple is in err. If each qubit decoheres with probability $p$, then the
probability that one or zero qubits decohere is $9p(1-p)^8 + (1-p)^9 =
(1-p)^8(8p+1)$ and so the probability that two or more qubits decohere leading
to erroneous decoding is $1-(1-p)^8(8p+1)~\approx~36p^2$. So, for a $k$-qubit
message that we encoded into $9k$-qubits, our chance of successfully decoding
the original message is $(1-36p^2)^k$.</p>
<h3 id="some-generalizations">Some generalizations</h3>
<p>Here we generalize the notion of error and show that the Shor code can correct
arbitrary error. Errors, like any action on a quantum system, are unitary
operations and as such they can be represented as a linear combination of the
Pauli operators operating on the Bloch sphere. Recall that the state of an
arbitrary operation has Bloch representation as the density matrix</p>
\[\begin{equation}
\rho = \frac{I + \vec{r} \cdot \vec{\sigma}}{2}
\end{equation}\]
<p>where $\vec{r}$ is a real vector weighting the contribution of each Pauli
operator. Now, for an arbitrary error corrupting qubit $i$, we may write</p>
\[\begin{equation}
E_i = e_{i0}I + e_{i1}X + e_{i2}Y + e_{i3}Z .
\end{equation}\]
<p>This leads the transformation that corrupts qubit $i$</p>
\[\begin{equation*}
\ket{\psi} = a\ket{0} + b\ket{1}
\rightarrow e_{i0}\ket{\psi} + e_{i1}X_i\ket{\psi}
+ e_{i2}Y_i\ket{\psi} + e_{i3}Z_i\ket{\psi} .
\end{equation*}\]
<p>With this corrupted state, we begin testing for the presence of the various
syndromes on each qubit. For all tests on qubits other than the $i$-th,
measurements return zero. Notice that in the previous scenarios, our syndrome
measurements leave the state of the system unharmed because each error was
either present or not resulting in either 1 or 0 for the measurement. Here,
the linear transformation leads to our system collapsing to the measured value
with some probability. We measure our system to be</p>
\[\begin{eqnarray*}
X_i\ket{\psi} & \text{with probability } |a|^2, \\
Y_i\ket{\psi} & \text{with probability } |b|^2, \\
Z_i\ket{\psi} & \text{with probability } |c|^2, \text{ or } \\
\ket{\psi} & \text{with probability } |d|^2 .
\end{eqnarray*}\]
<p>The collapsed system is then corrected appropriately \cite{Gottesman1997}.</p>
<h2 id="example-codes">Example Codes</h2>
<p>In this section we document several proposed quantum coding schemes in an
effort to illustrate the landscape of such methods. Where appropriate we will
document similarities and contrasts between the techniques.</p>
<h3 id="calderbank-shor-steane">Calderbank-Shor-Steane</h3>
<p>Drawing upon classic algebraic coding theory, CSS codes were invented by
Calderbank and Shor and simultaneously by Steane. They provide a general
formulation for constructing quantum codes from the linear codes readily
available \cite{QCQI}. Suppose we have two classic linear codes
$\C_1=[n,k_1]$ and $\C_2=[n,k_2]$ where $\C_2 \subset \C_1$ and both $\C_1$
and $\C_2^\perp$ correct for errors of weight $t$, as judged by the Hamming
distance. We will now construct an $[n,k_1-k_2]$ quantum code denoted
$CSS(\C_1,\C_2)$ capable of correcting $t$ qubit errors.</p>
<p>Recall that in classic codes, each codeword lives in its own subspace. A
basis can then be formed for codewords, each codeword then is formed from a
linear combination of these basis elements. We can think of these basis
elements as cosets with generator words. $\C_2$ then generates cosets for
elements $x \in \C_1$:</p>
\[\begin{equation*}
\ket{x + \C_2} \equiv \frac{1}{\sqrt{\C_2}} \sum_{y \in \C_2} \ket{x + y} .
\end{equation*}\]
<p>These cosets are orthonormal. To see this, suppose $x$ and $x’$ are in
different cosets of $\C_2$, then by definition, $\nexists y \in \C_2$ such that
$x+y=x’+y’$ for any $y’ \in \C_2$. In other words, we can not form linear
combinations to equate elements from the two sets, hence they are orthonormal
sets.</p>
<p>Now we begin to define the quantum code. Define our new code $CSS(\C_1,\C_2)$
to be spanned by the cosets $\ket{x + \C_2}$. The number of such cosets is
$\frac{|\C_1|}{|\C_2|} = \frac{2^{k_1}}{2^{k_2}} = 2^{k_1 - k_2}$, thus our code
may be denoted as $[n,k_1-k_2]$.</p>
<p>We now step through examples using this code to correct for both bit flip and
phase flip errors, each in turn. Following the classic formulation, an error
is a vector that perturbs elements of our codeword. We only need to show that
we correct for basis codewords (cosets) since all other codewords are formed
as linear combinations. Denote a basis codeword as</p>
\[\begin{equation*}
\ket{x+\C_2} = \frac{1}{\sqrt{|\C_2|}} \sum_{y \in \C_2} \ket{x+y} .
\end{equation*}\]
<p>Suppose this is corrupted by a bit flip error $e_1$. It then becomes,</p>
\[\begin{equation*}
\ket{x+\C_2+e_1} = \frac{1}{\sqrt{|\C_2|}} \sum_{y \in \C_2} \ket{x+y+e_1} .
\end{equation*}\]
<p>If $H_1$ is the parity check matrix for $\C_1$, we can construct a quantum
circuit with zero ancilla to perform</p>
\[\begin{eqnarray*}
\ket{x+y+e_1}\ket{0} & \rightarrow & \ket{x+y+e_1}\ket{H_1(x+y+e_1)} \\
& & \ket{x+y+e_1}\ket{H_1e_1} ,
\end{eqnarray*}\]
<p>since $x,y \in \C_1$ so $H_1x=H_1y=0$. We measure the ancilla to find
$\ket{H_1e_1}$ telling us which error is present and the remaining state is
now</p>
\[\begin{equation*}
\frac{1}{\sqrt{|\C_2|}} \sum_{y \in \C_2} \ket{x+y+e_1}
\end{equation*}\]
<p>which can be corrected with appropriate bit flip operations to leave our
original state,</p>
\[\begin{equation*}
\frac{1}{\sqrt{|\C_2|}} \sum_{y \in \C_2} \ket{x+y} = \ket{x+\C_2} .
\end{equation*}\]
<p>Suppose now instead that we had a phase flip error. Similar to the Shor’s
algorithm \ref{sec:shor}, we rotate our state via Hadamard gates, treat the
problem again as a bit flip error, and rotate back after correction.</p>
<p>Before beginning, let’s prove two equalities that will come in handy during
the reductions. Recall from our discussion of classical codes that a code
$\C$ and its dual $\C^\perp$ are orthogonal spaces. Suppose $y \in \C$ and $z
\in \C^\perp$. Then $y\cdot z=0$, and so consequently, $\sum_{y \in
\C}(-1)^{z\cdot y} = |\C|$. Alternatively suppose $y \in \C$ and $z \in
\C^\perp$ implying that $z \in \C$, so $y\cdot z \ne 0$. In the binary
formulation, $y\cdot z$ is either an even or odd integer. When summing over
the entire set $\C$, for every element $y$ there is its ``compliment’’ $y’\in
\C$ with all bits flipped such that $y\cdot z + y’\cdot z = 1.$ Therefore,
summing over the entire set $\C$ with modular arithmetic produces terms that
cancel each other: $\sum_{y \in \C}(-1)^{y\cdot z} = 0 .$</p>
<p>A phase corrupted state may be expanded as</p>
\[\begin{equation*}
\frac{1}{\sqrt{|\C_2|}} \sum_{y \in \C_2} (-1)^{(x+y)\cdot e_2} \ket{x+y} .
\end{equation*}\]
<p>We begin by rotating each qubit via $H^{\otimes n}$ to form</p>
\[\begin{equation*}
\frac{1}{\sqrt{|\C_2|}} \sum_{y \in \C_2}
\left( \frac{1}{\sqrt{2^n}} \sum_{z} (-1)^{(x+y)\cdot (e_2+z)} \ket{z} \right) ,
\end{equation*}\]
<p>where $z$ runs over all words.</p>
<p>Notice that if we perform change of variable over the inner summation via $z’
\equiv z + e_2$, this looks like a bit flip error. In this new form, we may
equivalently sum over $z’$ since in either case we are summing over all the
elements of the space.</p>
\[\begin{equation*}
\frac{1}{\sqrt{|\C_2|}} \sum_{y \in \C_2}
\left( \frac{1}{\sqrt{2^n}} \sum_{z'} (-1)^{(x+y)\cdot z'} \ket{z'+e_2} \right) ,
\end{equation*}\]
<p>since $z’ + e_2 = z+e_2+e_2=z$ under modular arithmetic. This can be
simplified using the equalities we just proved:</p>
\[\begin{align*}
\frac{1}{\sqrt{|\C_2|}} &\sum_{y \in \C_2}
\left( \frac{1}{\sqrt{2^n}} \sum_{z'} (-1)^{(x+y)\cdot z'} \ket{z'+e_2} \right) \\
= \frac{1}{\sqrt{|\C_2|2^n}} &\sum_{y \in \C_2}
\left( \sum_{z' \in \C_2^\perp} (-1)^{(x+y)\cdot z'} \ket{z'+e_2}
+ \sum_{z' \not\in \C_2^\perp} (-1)^{(x+y)\cdot z'} \ket{z'+e_2} \right) \\
= \frac{1}{\sqrt{|\C_2|2^n}} &\sum_{y \in \C_2}
\left( \sum_{z' \in \C_2^\perp} (-1)^{(x+y)\cdot z'} \ket{z'+e_2} \right) \\
= \frac{1}{\sqrt{|\C_2|2^n}} &\sum_{y \in \C_2}
\left( \sum_{z' \in \C_2^\perp} (-1)^{x\cdot z'}(-1)^{y\cdot z'} \ket{z'+e_2} \right) \\
= \frac{1}{\sqrt{|\C_2|2^n}} &\sum_{z' \in \C_2^\perp} (-1)^{x\cdot z'}|\C_2| \ket{z'+e_2} \\
= \sqrt{\frac{|\C_2|}{2^n}} &\sum_{z' \in \C_2^\perp} (-1)^{x\cdot z'} \ket{z'+e_2} .
\end{align*}\]
<p>We now detect and correct for the bit flip using the parity matrix $H_2$
constructed from the generator of $\C_2^\perp$. This produces:</p>
\[\begin{equation*}
\sqrt{\frac{|\C_2|}{2^n}} \sum_{z' \in \C_2^\perp} (-1)^{x\cdot z'} \ket{z'} .
\end{equation*}\]
<p>Finally we rotate back via $H^{\otimes n}$. Since this is an orthogonal
rotation, we change the summation from $\C_2^\perp$ back to $\C_2$.
Additionally the dot products are all now zero yielding $(-1)^0=1$. This
produces our final error free result:</p>
\[\begin{equation*}
\frac{1}{\sqrt{|\C_2|}} \sum_{y \in \C_2} \ket{x+y} .
\end{equation*}\]
<p>As we demonstrated for the Shor algorithm, in cases of both bit flip and phase
flip errors, both syndromes can be detected and corrected sequentially.</p>
<p>Recall that the Shor code corrected for at most one error per every nine
qubits for a correction rate of 1/9. CSS codes correct for $t$ errors across
$n$ qubits which can be made higher than 1/9 \cite{Calderbank1996}. By
measuring for information equivalent to $t$ qubits, we recover errors in the
remaining $k$ qubits representing the message.</p>
<h3 id="a-seven-qubit-css-code">A seven qubit CSS code</h3>
<p>We now look at a specific example of a CSS code showing increased capacity
compared to the original Shor algorithm. With the introduction of CSS codes
in 1996, Andrew Steane gave as an example one such code \cite{Steane1996b}.
It was well known that a simple repetition code producing a superimposed state
$\ket{\psi}=\ket{000}+e^{i\phi}\ket{111}$ is highly sensitive to sign changes
because it represents the superposition of two states representing vary
different positions. Measuring for the $\ket{111}$ basis element in this
state involves measuring $\phi$ which is sensitive in experiments.</p>
<p>Steane suggested a different basis pair where the measurement of interference
between the superimposed parts is less sensitive. He proposed using
$\C_1=[7,4,3]$ and its dual $\C_2=[7,3,4]$ to produce $CSS(\C_1,\C_2)=[7,1]$.
First we show that $\C_2 \subset \C_1$, then we look at the quantum
representation.</p>
<p>The parity matrices for $\C_1=[7,4,3]$ and $\C_2=[7,3,4]$ are</p>
\[\begin{equation*}
H_1 = \m{0 & 0 & 0 & 1 & 1 & 1 & 1 \\
0 & 1 & 1 & 0 & 0 & 1 & 1 \\
1 & 0 & 1 & 0 & 1 & 0 & 1} ,
\quad
H_2 = \m{1 & 0 & 0 & 0 & 0 & 1 & 1 \\
0 & 1 & 0 & 0 & 1 & 0 & 1 \\
0 & 0 & 1 & 0 & 1 & 1 & 0 \\
0 & 0 & 0 & 1 & 1 & 1 & 1} .
\end{equation*}\]
<p>Notice that the rows of $H_1$ are spanned by those of $H_2$: row 1 is row 4 of
$H_2$, row 2 is rows 2+3, and the last row is rows 1+3. Since these parity
matrices are kernels of the space, the inverse relation holds on the codeword
spaces: $\ker(H_1) \subset \ker(H_2) \Leftrightarrow \C_2 \subset \C_1$. Since
$\C_2^\perp=\C$, both codes correct for $t=1$ error.</p>
<p>The corresponding quantum basis elements are $\ket{0+\C_2}$ and
$\ket{1+\C_2}\equiv X_{1234567}\ket{0+\C_2}$ which expand out to:</p>
\[\begin{eqnarray*}
\ket{a}=\ket{0+\C_2}
\equiv &\ket{0000000} + \ket{1010101} + \ket{0110011} + \ket{1100110} + \\
&\ket{0001111} + \ket{1011010} + \ket{0111100} + \ket{1101001} \\
\ket{b}=\ket{1+\C_2}
\equiv &\ket{1111111} + \ket{0101010} + \ket{1001100} + \ket{0011001} + \\
&\ket{1110000} + \ket{0100101} + \ket{1000011} + \ket{0010110} .
\end{eqnarray*}\]
<p>By direct inspection, we confirm that $\ket{a}$ and $\ket{b}$ form a code of
$d(\C)=3$. It has been proven under the Hamming distance that this is the
minimal number of qubits required for borrowing classical linear codes
\cite{Laflamme1996}.</p>
<h3 id="a-perfect-five-qubit-code">A perfect five qubit code</h3>
<p>Before we talk of a perfect code, we should generalize the minimal
characteristics of an quantum error correcting code. Every quantum code must
entangle the original basis pair $\ket{0}$,$\ket{1}$ in some $n$-qubit space.
Any transform, including errors, on this basis may be expressed as a linear
combination of the Pauli operators:</p>
\[\begin{equation*}
\ket{E} = \ket{e_{I}}I + \ket{e_{X}}X + \ket{e_{Z}}Z - i\ket{e_{Y}}Y
\end{equation*}\]
<p>This produces one of four possible outcomes: unchanged, bit flip ($X$), phase
flip ($Z$), or a combination of both bit and phase flip ($Y$). Therefore, an
error correcting code must be able to determine which of these possible four
outcomes occurred. To do this, the dimension of the code basis must provide a
subspace for each of the three errors that can occur on each of the $n$
qubits, plus one for the unperturbed state. Double this to account for
superpositions: $2(3n+1)$. Now this must be accommodated in the total space
provided by the $n$ qubit code. Therefore,</p>
\[\begin{equation*}
2(3n+1) \le 2^n .
\end{equation*}\]
<p>This inequality was satisfied for the 9-qubit code of Shor and the 7-bit CSS
code of Steane; however, its minimum of $n=5$ indicates that as few as five
qubits is all that is necessary.</p>
<p>Motivated by this insight, \cite{Laflamme1996} produced a code found with
constrained search on coefficients of each five-qubit basis producing the
(unnormalized) mapping:</p>
\[\begin{eqnarray*}
\ket{0} &\rightarrow& \ket{b_1}\ket{00} - \ket{b_3}\ket{11}
+ \ket{b_7}\ket{10} + \ket{b_5}\ket{01} \\
\ket{1} &\rightarrow& \ket{b_0}\ket{11} - \ket{b_3}\ket{00}
+ \ket{b_7}\ket{01} + \ket{b_5}\ket{10}
\end{eqnarray*}\]
<p>where the $b_i$ indicate (unnormalized) Bell states:
$\ket{b_{1/2}}=\ket{000}\pm\ket{111}$, $\ket{b_{3/4}}=\ket{100}\pm\ket{011}$,
$\ket{b_{5/6}}=\ket{010}\pm\ket{101}$, and
$\ket{b_{7/8}}=\ket{110}\pm\ket{001}$. Another such code was proposed
simultaneously \cite{Bennett1996}, and still others can be formed from
permutations.</p>
<h3 id="stabilizer-codes">Stabilizer codes</h3>
<p>While optimally sized codes have been found, work has been done to develop
codes that are easier to work with. Stabilizer codes offer just such an
easier to manipulate formulation having arisen out of insights from abstract
algebra. Notice that the set of Pauli operators together with $\pm1$ and $\pm
i$ eigenvalues form a group called the <em>Pauli group</em>:</p>
\[\begin{equation*}
\P \equiv \{\pm I, \pm iI, \pm X, \pm iX, \pm Y, \pm iY, \pm Z, \pm iZ \} .
\end{equation*}\]
<p>Let $\P_n$ denote the group defined over $n$ qubits, each element acting on
one qubit.</p>
<p>A <em>stabilizer</em> is an Abelian (self commuting) subgroup $\S \subset
\P_n$ containing only the positive eigenvalue elements. For example, recall
our observables to compare the parity of qubits. They happen to form such a
group: $\{I, Z_{12}, Z_{13}, Z_{23}\}$. Suppose we define a code making use
of the positive nature of the subgroup’s eigenvalues:
$\C(\S) = \{\ket{\psi} : M\ket{\psi} = \ket{\psi}\ \forall M \in \S \}$.
Codeword by construction
reside in the real positive eigenspace of each stabilizer element; however,
errors $E$ leave codewords into the negative eigenspace when projected on any
stabilizer element $M \in \S$ that anticommutes with $E$ \cite{Gottesman2005}:</p>
\[\begin{equation*}
M(E\ket{\psi}) = -EM\ket{\psi} = -E\ket{\psi} .
\end{equation*}\]
<p>A more compact representation for a group is its list of <em>generators</em>,
those elements of the group that the products of which form the remaining
elements. In our example of $\{I, Z_{12}, Z_{13}, Z_{23}\}$, notice that
$Z_{12}Z_{23}=Z_{13}$ and $Z_{12}Z_{12}=I$. Hence, each element of the group
can be written as a product of two elements $Z_{12}$ and $Z_{23}$. We can
then unique represent the group as $\langle Z_{12}, Z_{23} \rangle$. We have
only to project against this reduced set. Further, in a group of size $n$,
there are at most $\log n$ such generators, indicating that generators
affording far fewer computations in constructing codes.</p>
<p>What subgroups can form nontrivial stabilizer codes? By trivial code we mean
a code containing only $\ket{0}$. Two conditions are necessary for a
stabilizer $\S$ generating a nontrivial code \cite{QCQI}:</p>
<ul>
<li>Elements of $\S$ commute: $MN=NM$ for $M,N \in \S$. Since $M,N$ are
Pauli operators, we know they either commute or anticommute. Suppose we
were to allow them to anticommute: $MN=-NM$. Now by construction of $\S$,
$MN\ket{\psi}=-NM\ket{\psi} \Rightarrow \ket{\psi}=-\ket{\psi}$ which holds
implies $\S$ must be trivial. Therefore, we only allow elements of $\S$ to
commute.</li>
<li>$-I$ must not be a member of $\S$. Suppose it were a member, then
$-I\ket{\psi}=\ket{\psi} \Rightarrow -\ket{\psi}=\ket{\psi}$, which again
holds only if $\S$ only generates $\ket{0}$. Therefore, we exclude $-I$
from membership in $\S$.</li>
</ul>
<p>To illustrate the generality of such codes, a stabilizer of a five qubit code
would be generated by \cite{Gottesman2005}</p>
\[\begin{align*}
&X \otimes Z \otimes Z \otimes X \otimes I \\
&I \otimes X \otimes Z \otimes Z \otimes X \\
&X \otimes I \otimes X \otimes Z \otimes Z \\
&Z \otimes X \otimes I \otimes X \otimes Z .
\end{align*}\]
<h2 id="the-future">The Future</h2>
<p>Quantum error coding has seen impressive advances in the past decade.
Lowering the number of qubits necessary has meant fewer resources for storage.
Lowering the number of computations necessary for syndrome analysis has meant
simpler coding circuits. We now have fundamental results on error bounds,
limits of robust coding, and thresholds for which reliable quantum computing
can succeed. Work continues to design, build, and scale physical
realizations of such systems.</p>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutSurgical sub-intern2016-09-02T00:00:00+00:00http://jgmalcolm.com/surgical-subintern<div class="series no-print">
<b>clinical:</b>
<a href="/clerkships">
Clerkships
</a>
//
<a href="/how-to-be-a-good-sub-intern">
How to be a good sub-intern
</a>
//
Surgical sub-intern
</div>
<p>The general surgery program director at my school said they look for three
things in any potential resident: integrity, compassion, and passion. I
completely agree that success or failure depends on those qualities.</p>
<h2 id="prep-before-surgery">Prep before surgery</h2>
<ul>
<li>
<p><strong>Know anatomy.</strong> Flip through your text or google images for some quick
refresher. Know major arteries, nerves, and veins. If for every case you
spend not even five minutes reviewing, you will soon have seen the relevant
anatomy repeatedly and it will no longer be as necessary to review.</p>
</li>
<li>
<p><strong>Know the indication for surgery.</strong> Know why this patient is on the
table. If it’s a biopsy, what is the differential diagnosis? Know 2-3 items
and some interesting fact about each. Example: from imaging alone
meningiomas also look like hemangiopericytomas.</p>
</li>
<li>
<p><strong>Prepare for pimping.</strong> <a href="http://amzn.to/1LLV9tD">Surgical Recall</a> has classic responses for pimping</p>
</li>
</ul>
<h2 id="case-setup">Case setup</h2>
<ul>
<li>
<p><strong>Introduce yourself until it gets ridiculous.</strong> Keep introducing yourself
to every new team member – circulators, anesthesia, scrub techs,
attendings, etc. – until it’s almost laughable. You want everyone to be
crystal clear on who you are and what your level is (medical student), so
they know what to expect and what you’re capable of. Remember everyone’s
name, be humble and quiet. Work “from the edges inward” – meaning as you
find yourself working with someone new at the periphery of the room,
introduce yourself. If you’re walking into a room and don’t know anyone,
start by introducing yourself to the circulator (who records your presence
in the computer). Knowing people and saying hello in the morning pays
dividends: everyone feels more comfortable, everyone remembers who you are,
what you’re capable of, and it simply adds to a more friendly environment.</p>
</li>
<li>
<p><strong>Watch what the circulator does.</strong> They do a hundred small tasks that you
can help with. Bair-hugger, foley, bovie ground pad, SCDs, etc. Watch and
learn so you can start taking these on one by one. The circulator will love
you and sing your praises, but more importantly he will look out for you and
do anything he can to help you in the OR. Life is easier for everyone if
everyone helps.</p>
</li>
<li>
<p><strong>Put in the Foley.</strong> This is a time consuming task – only minutes but
longer than most simple equipment tasks that the circulating nurse handles.
You can place the foley while she completes other tasks in parallel. If
it’s the first time you’ve worked with her, ask permission and also invite
her to supervise. It’s her neck if there’s a UTI. Better yet, watch her do
it and mimic her steps. Nothing will make her more comfortable than you
doing exactly what she does, quirks and all.</p>
</li>
<li>
<p><strong>Placing the foley.</strong> Adequately unwrap the sterile package so your field
is wide and doesn’t fall back on itself. Take time to unwrap/uncap every
item before touching the patient: hook up the sterile flush syringe very
tight so it doesn’t pop when you start pushing, unwrap the catheter and
stick it into the gel, loosen up the Foley bag and tubing so it doesn’t get
caught as you’re advancing. Once your “dirty hand” touches the genitals,
there’s little your sterile hand can do except start advancing the catheter.
Be sure your clean hand does not contact anything dirty as you advance the
catheter: your dirty hand stays on the genitalia, your clean hand stays on
the sterile catheter, and never shall these two cross.</p>
</li>
<li>
<p><strong>Keep the Foley bag clean.</strong> After inserting the Foley catheter, use your
sterile hand to hold the Foley canister off the field while your dirty hand
(the one holding the genitalia) gathers up all the trash and drapes. Do
everyone a favor who comes behind you and handles it: don’t touch the
canister with your dirty hand.</p>
</li>
<li>
<p><strong>Get gloves, for you and the resident.</strong> Always get your own gloves and
gown. The scrub tech likely has enough gowns for you, but never hurts to
walk over to the table with gloves and gown. After handing those off in a
sterile manner, ask if you can get anything else. Often the scrub tech has
been busily organizing the back table while scrubbed in and there’s one or
two items on his mind to pull from the stock room; you can fetch things.
Memorize your resident’s gloves and offer to pull those.</p>
</li>
<li>
<p><strong>Setup the bair hugger warmer.</strong> Drag it into position, plug it into power,
plug it into the blanket (do not turn it on yet). Same with the sequential
compression devices: put them on (if not already on from pre-op), plug them
in, but go ahead and turn them on.</p>
</li>
<li>
<p><strong>Position the patient.</strong> Hold the head while resident pins, remove the head
of bed and place the Mayfield frame, while resident holds the head you
tighten to ensure teeth lock as you go in order from head to bed. At end of
case, undue first from head then just drop the handle (skip middle lock). If
“tucking the arms”, then start gelpadding the arms while using 4x4 gauze to
pad any plastic IV attachments that might hurt. Tape the arms, but put some
folded excess that can be popped if there’s too much inspiratory resistance.
When done, you yourself go along the entire body (head to toes) and ensure
pressure points are relieved, joints are not extended, fingers are relaxed,
breasts are not smashed, etc.</p>
</li>
<li>
<p><strong>Tie and spin gowns.</strong> Before you scrub in, stand ready in the wings to
help tie the scrub tech’s or resident’s gown and spin them.</p>
</li>
<li>
<p><strong>Streamline the prep.</strong> Whatever you can do to help speed prep, do it.
Each institution and attending has their own preferences and protocols, but
watch and learn to anticipate. Get the electric razor ready. Get tape to
pick up stray hairs. When the resident reaches for the razor, you ready
some tape. Soak some cotton in alcohol. Whatever you observe being doing
routinely, get it primed. Tie the resident’s gown and spin them. Prime the
chloraprep sticks so when the resident is ready they are already soaking.
Get a kick bucket under the head for drip; consider tossing down a temporary
blue towel over the Mayfield frame. I often wait to be the last person
scrubbed in and in the mean time do everything I can to speed up the work of
scrub tech and resident. Do everything you can to help setup and start
prepping. Do everything you can to streamline their process.</p>
</li>
<li>
<p><strong>Do not contaminate anyone.</strong> Do not contaminate yourself, but more
importantly do not contaminate the attending, resident, or scrub tech. Watch
what you touch. Don’t back up; your back is not sterile.</p>
</li>
<li>
<p><strong>Move slow around the sterile field.</strong> Don’t jump quickly to help reach for
something; you’ll unnerve everyone with sudden unpredictable movements, even
if you’re just trying to be helpful. Think before you act.</p>
</li>
<li>
<p><strong>Don’t reach over someone’s head while gowned.</strong> You’ll likely hit their
head. They’ll look up to see what’s going on above them. Don’t put on the
light covers until the field is setup.</p>
</li>
<li>
<p><strong>Build your sterile field from incision outward.</strong> Don’t skip steps,
e.g. don’t reach to put on light covers until field underneath is ready,
otherwise you might hit someone’s head or the bed with your gown as you’re
reaching. Go in the same order every time.</p>
</li>
<li>
<p><strong>Watch the scrub tech.</strong> Watch how they gown and glove people. There will
come a time when they are busy and another surgeon wants to be gowned and
gloved. Be ready to confidently step up to bat when that day comes.</p>
</li>
<li>
<p><strong>Learn to gown and glove yourself.</strong> When things are busy, you can’t always
expect the scrub tech to help you gown and glove. If the scrub tech has
bloody gloves, they need to get a fresh pair (ie. waste). Grab an unused
area of table to setup your gown and gloves so you can do it all yourself.
Go very slow and deliberate so you don’t contaminate. Scrub techs gown and
glove themselves all the time; watch and learn.</p>
</li>
</ul>
<h2 id="during-surgery">During surgery</h2>
<ul>
<li>
<p><strong>Know what’s next.</strong> They ask for suture, you ask for scissors; they finish
opening incision, you get the bovie and raytec ready; they are wrapping up
galea stitches, you get scissors ready to cut; after galea stitches, you
wipe the wound with raytec and hand them the monocryl for skin closure; for
a biopsy when they finish opening galea, you get navigation ready for them
to reorient trajectory. If they ask for flowseal, you use the bayonet to
ready a cotton pad. If they pick up a leksell, rongeur, kerrison punch,
etc., then you pick up a raytec to grab scraps and clean tips. If they put
away the bovie after charring some tissue, you pull it back out briefly so
you can clean off the tips for next use.</p>
</li>
<li>
<p><strong>Guess what’s next.</strong> While you’re watching what they are doing, always ask
yourself ‘What is next?’ If you keep checking your predictions against what
actually happens then you will evolve quickly; actively guessing wrong will
teach you faster than passively watching. The emotional flash of getting it
wrong will help your amygdala enhance the memory.</p>
</li>
<li>
<p><strong>Don’t touch what you can’t see.</strong> If you can’t see into a hole, don’t
stick the suction or irrigate. Always be able to see the tip of your
instruments or the effect of your action.</p>
</li>
<li>
<p><strong>Give the surgeon elbow room.</strong> Never stand or lean where you might fall
into their arm and push their instrument into the brain. Don’t balance on
your tippy toes or lean over to get a better view. Don’t do anything
unnatural. Make sure you are firmly planted.</p>
</li>
<li>
<p><strong>Respect the scrub tech and his domain.</strong> When you start a case with a
scrub tech with whom you’ve not yet worked, don’t be too helpful from the
start. Observe his routine, layout, methods, and quirks. The mayo stand is
their domain and responsibility. Don’t assume you can touch, hand
instruments, rearrange, etc. start slow by watching. If the surgeon asks for
something and the tech is at the back table, go ahead and help, but
slowly. A few small successful helpful moments will build trust. By the end
of the case the tech will relax and let you handle instruments and
more. Subsequent cases will go smoothly. But start by building trust and
showing respect.</p>
</li>
<li>
<p><strong>Always be thinking of the anatomy.</strong> Keep yourself oriented. What’s in
view? What’s nearby? This will keep you engaged but more importantly safe.</p>
</li>
<li>
<p><strong>Recognize when it’s a crowd.</strong> When there’s not much elbow room, step away
and watch. When the scrub tech, attending, and one or two residents are
present, you likely need to just step way back and watch until someone
scrubs out.</p>
</li>
<li>
<p><strong>Don’t bovie the skin.</strong> After opening incision, you’ll use a bovie to stop
any superficial bleeding. If you bovie the epidermis, the wound will not
heal properly in that spot. There are no vessels right up under the dermis
that need cautery–only under the subcutaneous–so you shouldn’t need to
bovie that close anyway. If you’re coming close to skin, switch to “cut”
mode (not “coag”) for less charge dispersal. Some people use this setting
to extend the skin incision, but it’s poor form because it causes
unnecessary scarring. In those cases, just ask for the knife back.</p>
</li>
<li>
<p><strong>Active bleeding means shut up.</strong> When there is active bleeding in the
field, keep quiet. Pause conversation; let the surgeons work.</p>
</li>
<li>
<p><strong>Watch what the surgeons are watching.</strong> Can you see what they are doing?
If there is blood or other fluid obscuring their view of a tissue edge or a
screw head, you should suction or dab with raytec. If there is bone dust,
you irrigate.</p>
</li>
<li>
<p><strong>Suction.</strong> Keep the important things visible. If everyone has their hands
full and there’s a suction unused, pick it up and be ready. Early on I would
suck up any blood I noticed anywhere on the field, but eventually I realized
that I shouldn’t waste time sucking up clots randomly. Focus on the area
where the surgeons are working, ignore everything else unless there is
active arterial bleeding (ignore oozing). If you keep sucking up every
random clot and puddle, you’ll distract the surgeons and keep agitating
those areas to keep them from clotting off.</p>
</li>
<li>
<p><strong>Avoid knee jerk answers to pimping.</strong> In my eagerness to answer a
question, I often speak before thinking. The surgeon points to some basic
anatomy asking what is it, I respond in knee-jerk fashion, and as soon as
the words are out I realize I’m wrong. If only I had taken a breath and
slowly processed before answering. Train yourself: when asked a question,
take a full breath, then answer. No one is going to jump in to answer
before you. Slow down and think.</p>
</li>
</ul>
<h2 id="closing">Closing</h2>
<p>This is the time when you will likely get the opportunity at bat. After a
long case, the resident is tired and they will appreciate that you patiently
watched and helped along the way. They tell you to close. Here are tips for
doing this right. I <strong>highly recommend</strong> this
<a href="https://www.youtube.com/watch?v=TFwFMav_cpE">video from Duke on various knots</a>.</p>
<ul>
<li>
<p><strong>Good suturing starts with watching.</strong> Obsessively watch the senior
residents and attendings stitch. Watch where they place galea stitches: how
much galea do they grab, at what depth, how many times they grab the needle
with each stitch, where they grab the needle in each phase of stitch, how
they pop off the needle, how they hand back the driver with spent needle,
etc. Mimic them.</p>
</li>
<li>
<p><strong>Practicing tying knots during lectures.</strong> Carry some silk suture around.
Remove needles or use the multi-pack of silk ties. After a surgery, ask the
scrub tech if you can keep any left over clean suture. You can do all tying
with either one-handed or instrument technique. Pick some fixed or heavy
object and keep tying back and forth so you get the flow. This has the
added benefit of keeping you awake.</p>
</li>
<li>
<p><strong>Consistency in placement.</strong> Watch carefully that you enter and exit the
skin at the same depth and inset on both sides of the incision. For running
sutures, use the same run length on both sides.</p>
</li>
<li>
<p><strong>Closing galea.</strong> Make sure you actually grab galea. Give the suture a
little tug: subcutaneous tissue rips out, galea is firm. Start the stitch
from deep under the galea, then cross the incision superficial, and pierce
down through the galea on the other side. Make sure to have consistent
depth on both sides. Only grab 3-4 mm of galea inset on each side: more and
you’ll pucker up the skin and subcutaneous fat will stick out, too little
and it risks ripping out.</p>
</li>
<li>
<p><strong>Avoid a stitch abscess.</strong> Each stitch increases your chances of an
abscess. You want to balance having enough stitches to hold and not so many
that you necrose the skin or too superficial that it erodes through and
spits out of the dermis.</p>
</li>
<li>
<p><strong>Don’t button-hole the skin.</strong> That’s where you come out the back side of
the skin.</p>
</li>
<li>
<p><strong>Subcutaneous.</strong> Learn to start and end with the stitch buried. Open with
a deeper anchor stitch, bury the knot as you come back to the apex, then
start your run. Use an Aberdeen to bury the knot at the end.</p>
</li>
<li>
<p><strong>Start and end with short runs.</strong> At the start and end corners of the
incision, travel only a short distance with each stitch. This way takes
more time but does better at keeping the incision smooth. In the middle is
where you travel longer to make up time.</p>
</li>
<li>
<p><strong>Watching your suture tail.</strong> Avoid getting tangled. If the resident is
already supervising you place each stitch, ask her to “follow you” (they
hold the tail out of your way while you stick the needle).</p>
</li>
<li>
<p><strong>Use fewer touches for speed.</strong> Use the driver to run the needle through
tissue, use the pickups to pull it out on other side and immediately reload
on the driver at proper angle/position. Reload the driver while still near
the incision, right after you came through the tissue; do not pull stitch
through and then load it with your hands by your face. Keep it down by the
wound. When coming out on last side you use the pickup to load onto needle
driver in such a way that you can pull up and pop off in one swoop. The
fewer touches, the faster you go.</p>
</li>
<li>
<p><strong>Breaking stitches.</strong> Be careful as you tie that you don’t cause too much
friction as the knot comes together; if there is friction then the suture
will cut itself as you cinch it down. Be gentle but make sure the knot is
firmly seated.</p>
</li>
<li>
<p><strong>Cut out bad knots immediately.</strong> Don’t sheepishly move on. Your resident
will notice any bad stitch. Better you see it first, cut it out, and
repeat. Do not ignore it and sheepishly move on. These will haunt you.</p>
</li>
<li>
<p><strong>Evert the dermis.</strong> This maximizes the amount of dermis in apposition
which enhances granulation and healing.</p>
</li>
</ul>
<h2 id="after-surgery">After surgery</h2>
<ul>
<li>
<p><strong>Drapes in the trash.</strong> As the medical student, while gowned you move the
dirty drapes to the trash. The scrub tech is packing up instruments and
moving away the back tables. The resident is breaking scrub to write
orders. You take down the dripping drapes and carefully gather all cords.
Tie a knot in any distal suction lines so they don’t leak as you take down
drapes, carefully pop the bovie and bipolar plugs out, ensure you don’t dump
the cranial drainage bag, etc. Do this dirty work while still gowned and
<em>after</em> you’ve helped apply bandages. You’re dirty now, so don’t return to
bandaging the patient – go ungown.</p>
</li>
<li>
<p><strong>Don’t check your phone.</strong> Look for ways to help wrap up and get the
patient out of the room sooner. Help unwrap and move the patient.</p>
</li>
<li>
<p><strong>Warm blankets.</strong> Learn where these are and grab them as soon as the
patient is settled and waiting to wake up – this might be after moving to
the new bed. There should be a natural lull where the patient is being
unwrapped and when you can grab warm blankets.</p>
</li>
<li>
<p><strong>Mask on while extubating.</strong> Often patients cough when the tube is coming
out, don’t get hit in the face.</p>
</li>
<li>
<p><strong>Help cleanup.</strong> After the patient is warming and waking, start tearing
down and cleaning up. Put bed linens in the laundry, pick up any trash on
the floor, use any remaining blue towels or linens to sop up any floor
spillage.</p>
</li>
</ul>
<h2 id="hours">Hours</h2>
<ul>
<li>
<p><strong>Arrive 5-10 minutes early.</strong> Whatever time they tell you to be there,
arrive at least five minutes before that. Ten is comfortable.</p>
</li>
<li>
<p><strong>Leave when dismissed.</strong> When the resident directly tells you that you may
go home, thank them and leave. If there is clearly something going on that
you want to watch or that you might be able to help with, offer that you
stay to the end of that and then leave. The resident likely has a lot of
paperwork or crap to do that you can only hinder by making small chat.
Leave them to work in peace. Don’t be that idiot who overstays your
welcome. They are dismissing you for a reason: either you’re so incompetent
that you’re only holding them up, or they genuinely believe you’re better
off going home.</p>
</li>
<li>
<p><strong>Never ever ask “Can I go home?”</strong> You can ask the alternate “Is there
anything I can help with?” That might prompt the resident to suggest you go
home.</p>
</li>
<li>
<p><strong>Falling asleep.</strong> Do not be seen dozing off to sleep. Activity is key to
staying awake. Keep moving in very small, unseen ways: bounce your foot,
gently tap out a beat with your finger, pinch yourself so hard you flinch.
Stand up; if you need to be less obvious, excuse yourself to the restroom,
and when you come back just stand in the background instead of resuming your
seat. Drink water. Chew gum. Write notes, anything that is being said,
whatever comes to mind, just keep scribbling words. Anything to force you to
move and stay engaged.</p>
</li>
</ul>
<h2 id="call-room-etiquette">Call room etiquette</h2>
<ul>
<li>
<p><strong>Never sit while a resident stands.</strong> You are the last person to relax in a
chair. If they haven’t taken the chair after several minutes, then you might
have it.</p>
</li>
<li>
<p><strong>Study when there’s a lull.</strong> There is likely a decent neurosurgery atlas
or textbook laying around that you can thumb through during down moments.
Instead of randomly flipping it to a new chapter each time you pick it up
for a minute or two, toss a bookmark in it so you can make actual progress
through chapters. An atlas is better than a dense textbook; always a good
idea to freshen up on anatomy.</p>
</li>
<li>
<p><strong>Know when to keep quiet.</strong> If the residents are busily writing notes or
doing any kind of work that involves thought, use conversation sparingly so
you don’t distract. Know when it’s a bad time to tell that new joke you
learned.</p>
</li>
</ul>
<blockquote>
<p><a href="https://forums.studentdoctor.net/threads/away-rotations-excelling.1028285/">Excelling During an Away Rotation</a>,
<a href="https://www.reddit.com/r/medicalschool/comments/27e977/prepping_for_a_subi_neurosurg/ci09nwv">Reddit: Preparing for a sub-i in neurosurgery</a></p>
</blockquote>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutJunior resident tips and tricks2016-09-02T00:00:00+00:00http://jgmalcolm.com/junior-resident<h2 id="your-relationship-with-scrub-tech-and-circulator">Your relationship with scrub tech and circulator</h2>
<p><strong>Enunciate.</strong> Don’t mumble. State clearly what you want. Also state clearly
what you will want soon. Be consistent in how you ask for each category: “may
I have 3 punch please”, “we will need a 3 punch soon”. Whatever feels
natural, keep doing it that way so that the scrub tech can recognize the key
phrase even when they are turned to the back table.</p>
<p><strong>Please and thank you.</strong> When things are slow and smooth, adding these little
niceties now and then keeps things pleasant. When things are moving fast,
it’s understandable there is no time and these phrases should be dropped for
efficiency, or simply when it seems excessive. It’s all about respect and
appreciation.</p>
<p><strong>Gently state your preference.</strong> Scrub techs are obsessive about clearing the
instruments off the near field and putting them back on the mayo stand or back
table. If you’re going to be going between two instruments over and over, ask
“may I place this here for a moment” to indicate you want an instrument to
remain nearby and not be cleared right away. Follow up soon to “release” the
instrument back to the tech, and thank them for allowing you to hang onto it
longer. It’s just good to show deference here. They are doing their best to
keep an orderly environment. Don’t make it a power struggle.</p>
<h2 id="functional--stereotactic">Functional & Stereotactic</h2>
<ul>
<li><strong>Hemostasis before proceeding.</strong> When working through a stereotactic burr
hole, don’t place your stabilizing plate or cover until you have
hemostasis. Same for any procedure where you’re operating down a deep dark
hole. Control even a trickle hemorrhage from the galea before moving
forward. Otherwise you’ll be fighting for visibility.</li>
</ul>
<h2 id="emergency-craniotomy">Emergency craniotomy</h2>
<p><strong>Which side?</strong> While everyone is scrambling to setup, you need to be
repeating to yourself which side you’re operating on (left or right), because
if you screw that up, you will be famous. Let everyone do their job while you
calmly confirm imaging and mentally rehearse.</p>
<h2 id="pulling-drains">Pulling drains</h2>
<p><strong>JP</strong> Pull slowly so you can be sure you’re not getting caught by a stitch or
causing a bleed. Leave open the small wound. Grab and pull as proximal (to
patient) to reduce risk of breaking. If oozing or trickle bleed, then consider
placing a small gauze bandage. Preferable to place in red environmental
hazard bag since non-trivial blood.</p>
<p><strong>EVD</strong> The drain should already have been clamped before the decision was
made to withdraw. CloraPrep the area. Under sterile conditions, place a 3-0
monocryl stitch to close the opening in a figure-eight. Withdraw the catheter
slowly–it’s the brain! Tie off your stitch. Place catheter and bedside drain
in red hazard bag.</p>
<h2 id="closing">Closing</h2>
<p><strong>Closing the dura.</strong> If using pericardial implant for decompressive
craniectomy, lay it down so that later cranioplasty dissection doesn’t go into
brain. Fit the inlay around the temporal angle before worrying about
frontal/parietal layout. Don’t cheat yourself.</p>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutHow to write and publish a scientific paper2016-05-18T00:00:00+00:00http://jgmalcolm.com/writing-science<p>Writing your first scientific paper for publication can be daunting. In this
post, I go through my general process for what to consider in each section,
pitfalls to avoid, and how to handle the review process.</p>
<p>This all assumes you’ve got the bulk of the results done. It’s normal that as
you’re writing, you come up with new experiments to prove out a point. The
manuscript evolves.</p>
<p><img src="/images/calvin.gif" /></p>
<p><strong>New project, new document.</strong> Whenever a new project is taking shape, I
create a blank document with headings for abstract, methods, results, and
discussion. As the project evolves, I keep adding to this outline.
Interesting papers get a quick summary in the discussion for later. Ideas for
experiments and figures get sketched in the methods and results.
Inclusion/exclusion criteria in the methods. Very fast and loose, but
something you can share with co-authors to update on project status.</p>
<p><strong>Identify your building blocks.</strong> For every study, there are probably only
2-4 key clinical studies you’re directly building off. Print out those papers
and really study them. Those should be referenced in the introduction as part
of your motivation and in the first two paragraphs of your discussion to show
tie in. Everything else is just a distraction that probably deserves mention
at best. Discuss these papers with your senior authors.</p>
<h2 id="write-in-order">Write in order</h2>
<p><strong>Start by drafting the abstract.</strong> This will define the general trajectory:
research question, basic methods, highlighted result, conclusion. The actual
paper of course has many details, and may include experiments and results not
mentioned in the abstract. As you start out, much of the abstract is unknown
and vague but still you should try to articulate in broad strokes what the
paper will set out to accomplish, how you intend to do it, and even speculate
about what you expect to find. This abstract will evolve as the rest of the
manuscript does. At this point, it should be enough that anyone coming to the
manuscript later – coauthor or yourself – can quickly come up to speed on
the project.</p>
<p><strong>Finish by polishing the abstract.</strong> You’ll return to this abstract time and
again, each time making sure it is in line with the rest of the paper.</p>
<p><strong>Follow the reader’s eyes.</strong> Always keep your reader in mind. The first
thing they read is the title and abstract, so those need to be the most
polished pieces. Between drafting the abstract and its final touches, write
in the order that they will read: right after reading the abstract, most
people skim the figures and tables. From there, the methods, results, and
discussion. For people familiar with a field, the conclusion and introduction
are of lesser importance. Conclusions are often redundant and low quality
summaries, introductions are often filled with history you already know, and
both are of less importance than the abstract, methods, and results.</p>
<ol>
<li>abstract (draft)</li>
<li>figures and tables</li>
<li>methods, results, discussion</li>
<li>conclusions and introduction</li>
<li>abstract (polish) and title</li>
</ol>
<h2 id="title">Title</h2>
<p><strong>Put your main conclusion in the title.</strong> This is truly the first thing
anyone sees, so make it count. If they remember nothing from your paper, they
at least know the main finding.</p>
<ul>
<li>Bad: “The effect of Tylenol on headache symptoms”</li>
<li>Good: “Tylenol decreases headache symptoms”</li>
</ul>
<p><strong>Title: Subtitle.</strong> Take the liberty of breaking your title up to squeeze in
more information. You could use the subtitle to describe the type of study.</p>
<ul>
<li>Good: “Tylenol decreases headache symptoms”</li>
<li>Better: “Tylenol decreases headache symptoms: A randomized controlled trial”</li>
</ul>
<p><strong>Avoid technical jargon.</strong> Try to avoid acronyms where possible, unless it’s
truly understood through the vast majority of your readership. You want a
wide reader catchment.</p>
<p><strong>Gut check.</strong> After reading just your title, reviewers will already have a
gut feeling of whether they are interested in a paper, and maybe even a bias
to accept/reject.</p>
<h2 id="abstract">Abstract</h2>
<p><strong>It should stand alone.</strong> Give some context, state the objective, summarize
the basic methods, relate the most important results, and draw conclusions.
Don’t speculate. Don’t be vacuous and hint at what the article contains.
This abstract should contain the most juicy pieces without requiring the
casual reader to have to fetch the full document.</p>
<p><strong>Interested?</strong> The abstract can either solidify or dissolve the reviewer’s
interest. By the end, a reviewer might already lean toward rejecting or
requesting re-submission with further details.</p>
<h2 id="introduction">Introduction</h2>
<p><strong>Remember your readers.</strong> Your readers are not students like yourself. They
have been practicing science and performing surgery since you were in diapers.
Don’t start at square one. Imagine as a graduate science major reading a paper
where the intro sentence talks about how “addition and subtraction are common
processes in mathematics” – you’d roll your eyes and skim right past it. A
wasted sentence. Don’t start your neurosurgery article telling the readers
that cranioplasty is putting back together the skull. Don’t start your
internal medicine paper telling the reader how diabetes involves the
pancreatic islet cells. Jump right into the meat with your first two
sentences.</p>
<p><strong>Don’t discuss.</strong> This is the introduction, not the discussion. Don’t be
exhaustive and cite everything. Just cite a few (2-3) major studies that
you’re going to springboard off. The discussion later can be a more
exhaustive literature review. Similarly, leave the conclusion and results for
the conclusion and results sections.</p>
<p><strong>Too many citations.</strong> The intro should be very basic and merely introduce
the topic. You should even get away with making basic statements that don’t
need citation. You don’t want to overwhelm the reader with references they
need to screen.</p>
<p><strong>Why should we care?</strong> You need to quickly justify the importance of your
project. How many people are affected? How bad is the disease on quality of
life? Has there been some recent change in methods or studies you are
exploiting?</p>
<p><strong>Give perspective.</strong> How has this area evolved? What were some major changes
in the past decade? Don’t go back more than a decade though – that’s for a
history review, not a clinical article.</p>
<p><strong>Two paragraphs.</strong> That’s all you need. The first paragraph introduces the
problem and some perspective on the past decade. The second paragraph is even
shorter, maybe two-three sentences, where you clearly state the clinical
questions that form the goal of this present study. Sometimes you can insert
a paragraph between these giving a review 2-3 studies you’re comparing against
or building from.</p>
<p><strong>Don’t oversell.</strong> Avoid cliche terms like “novel”, “unique”, or “first
ever”. It’s all been done before in some form or fashion. You don’t want some
tenured professor who’s seen it all to pull a muscle after rolling her eyes.</p>
<h2 id="methods">Methods</h2>
<p><strong>Write for a knowledgeable reader.</strong> Your audience should be familiar with
your research area. They will likely have done similar projects, worked with
similar substances, done the procedure themselves, used the same statistical
tools. This reader should be able to reproduce your experiments.</p>
<p><strong>Provide details.</strong> You can almost never have too much. This goes back to
reproducibility: any constants, thresholds, or tuning parameters must be
included. Every inclusion/exclusion decision you made. How long you waited to
check something. If it’s a very new procedure you’re proposing with important
details you want people to reproduce, then consider submitting a supplemental
methods document.</p>
<h2 id="results">Results</h2>
<p><strong>Only include the key results.</strong> You don’t need to detail every experiment
you did. What you include needs to follow a logical progression and build
toward clear conclusions. You don’t just want a catalog of things you tried.
If you have more you think might be interesting to others, ie. inconclusive
experiments others could build off, consider supplementary materials.</p>
<p><strong>Supplementary materials.</strong> Any data that you want to share but don’t want to
bog down the manuscript. Others may pick up from where you left off.</p>
<p><strong>Use subheadings to group.</strong> Organize your results. This also helps later
because you can organize your discussion around those exact subheadings.</p>
<p><strong>Clearly address your goals.</strong> Keep going back and re-reading the abstract
and intro. Make sure everything is inline. Make sure your abstract doesn’t
overstate your actual results.</p>
<p><strong>Keep a consistent order.</strong> The organization of your results should be mirror
your abstract and methods. If you stray from this symmetric structure, you
risk muddling the message.</p>
<h2 id="figures--tables">Figures & Tables</h2>
<p><strong>Use color sparingly.</strong> Use it to emphasize key portions of a figure or
graph; not everything has to be in awesome colors and shading. Not everyone
prints out on a color printer. Shading can turn out crappy on a bad printer.
For graphs, use different line styles that will show up on black and white
printers.</p>
<p><strong>Include scale.</strong> Every graph needs x/y-axis labels and units. Color
intensity needs a labeled bar. Run your figures by someone completely
unfamiliar with the project to see if they understand.</p>
<p><strong>Two sentence captions: what it is, what it means.</strong> First sentence describes
what you’re looking at, second sentence tells you what you should take
away. If you use several figures of the same style, your first caption can
include some extra details to familiarize the reader with symbols/layout, but
then subsequent captions can omit this.</p>
<p><strong>Tables report data, figures show trends.</strong> What type of information are you
trying to communicate? Use the appropriate tool.</p>
<h2 id="discussion">Discussion</h2>
<p><strong>Talk to the audience.</strong> Here is where you switch voice a little. You’ve
just laid out all the facts. Now you get to take a deep breath and help the
reader make sense of it all.</p>
<p><strong>One intro paragraph.</strong> Begin the discussion with one paragraph
contextualizing and summarizing the results. Very briefly connect your
results with one or two other references.</p>
<p><strong>Nothing new.</strong> Do not introduce any new results. You should make summary
references to the results already documented and draw connections.</p>
<p><strong>Compare your result with published results.</strong> Make connections. Are your
findings in line with those of other groups? Did you come up with wildly
different results? How did your work specifically extend that of others?</p>
<p><strong>Address differences.</strong> Reference papers with different conclusions. As long
as you were careful in your methods, it’s okay. It is what it is. Someone
else may come later and figure out why there is a difference, but go ahead and
take a crack at what you think explains the situation.</p>
<p><strong>Make notes throughout your project.</strong> Every time you read a relevant paper,
make a 2-3 sentence note on it. I record these in the tentative “Discussion”
section of my developing manuscript, even before I have results. A good body
of these will start to take form and it’ll be easy later to string these
bullet points together into sentences and paragraphs.</p>
<p><strong>What do you suggest?</strong> You are now the expert. Let your voice come through.
What do you think is the best way of handling the topic? What do you suggest
future studies look into? You have freedom here to vent a little. If it’s a
systematic review and you found the literature a mess, tactfully suggest ways
future studies can be more consistent. After all your experimental work, did
you realize you screwed up and future studies should do it differently?
Suggesting clear lines of future work is a great way to inspire others to
follow the trail. Nothing is ever done and done. You shouldn’t worry if it’s
something you yourself plan to do – getting scooped is rare in practice, and
you already have a massive advantage with just having the present manuscript
out.</p>
<h2 id="conclusions">Conclusions</h2>
<p><strong>What did you contribute?</strong> How did you advance the field? Be very specific
but brief. Rank order your contributions, briefly state them, and don’t feel
like you need to rehash every result.</p>
<p><strong>Avoid numbers.</strong> The abstract is where you have the quantitative details.
The conclusion is just to summarize the basic trends.</p>
<p><strong>Suggestions?</strong> If there is one or two important suggestions buried in your
discussion, give one last shout out. Be brief; your paper has all the
details. Avoid the pithy ‘future work is needed’ – that much should always
be obvious. Stating this adds zero value and eats printer ink.</p>
<h2 id="acknowledgments">Acknowledgments</h2>
<p>While not everyone deserves a co-author spot, you have the liberty to show
your appreciation with a small mention. Did someone help review your stats?
Did someone do a lot of specimen preparation early in the project? Anyone who
helped conduct experiments but may not have been justified a co-author spot.</p>
<h2 id="references">References</h2>
<p><strong>Software.</strong> Mendeley, EndNote, Zotero – lots of options, but often it’s
best to use what everyone else in your group is using. At any given time, I’m
often using each of them for different projects. They all have pros and cons.
I prefer Mendeley over EndNote over Zotero. EndNote has given me many problems
when upgrading Word and/or EndNote.</p>
<p><strong>Don’t futz around.</strong> While writing, don’t get bogged down searching and
including references as you go. Simply cite with name/year and keep typing
(Smith2002, Johnson2010). While drafting – right up until submission – I
keep references in LastNameYear style for easier reading.</p>
<p><strong>Show some judgment.</strong> Too many references means you’re unfocused. Don’t go
overboard trying to cite everything that’s ever been done and is loosely
connected. Focus on the few papers you were most impressed with. For a
review article you need to extend a wider net, but for a research article you
can show judgment. I’ve never had a reviewer kick back my papers because I
didn’t cite something. They may make suggestions, but never is that a make it
or break it.</p>
<p><strong>Too few and you haven’t done homework.</strong> Nearly everything’s been done under
the sun. You should easily be able to find a few key papers you’re building
from.</p>
<p><strong>Look at other papers to judge count.</strong> If the key papers you’re extending
have ~20 citations, then aim for that. If yours turns out to have 40+, then
maybe you need to show some judgment.</p>
<h2 id="when-stuck">When stuck</h2>
<p><strong>###</strong> When I know I need to come back to something, this is what I drop in
the text. It’s an unique tag that is easily searchable. Keep moving forward,
don’t lose momentum. One of my biggest weaknesses is that I agonize over
text, getting bogged laying down each sentence in final form. I’ve learned to
relax more and just get it all out on paper by sprinkling these in wherever I
know I need to come back later. Like an embedded TODO list.</p>
<p><strong>Copy/paste.</strong> When I’m a little unsure about how to present something, my
typical trick is to look at 3-5 example papers and pick the one or two I like
the most. Often I will literally copy/paste from another article, and then go
sentence by sentence using the same structure but rewriting completely using
my own data. In the end there is zero plagiarism but you borrowed a structure
to get started. As I continue revisiting and revising, eventually the text
becomes all my own and turns out completely unique from the initial
copy/paste.</p>
<h2 id="responding-to-reviewers">Responding to reviewers</h2>
<p><strong>Respond quickly.</strong> Reviewers fatigue and their attention wains. Best to get
it back to them quick while it’s still fresh in their head.</p>
<p><strong>Create a response document.</strong> Start by pasting the reviews verbatim. I tend
to reformat them in bold/italic with each paragraph prefixed by “>”. I then
embed my responses in plain text after each reviewer’s point. This way, if
you have to paste your whole response into a plain text form, the difference
between reviewers and your comments will still be clear.</p>
<p><strong>Triage.</strong> Make a separate checklist for you and co-authors, ordered by
importance. Keep going down that list until you judge items not important.
Then justify everything below that line.</p>
<p><strong>Start by thanking the reviewer.</strong> Highlight any specific ideas you
appreciated. Thank them for their time.</p>
<p><strong>Never argue.</strong> Guarantees failure. Be tactful in your responses. Reviewers
may be quick/sloppy but they are never stupid and they are always “right”.</p>
<p><strong>Address everything.</strong> You might get away with glossing over minor
suggestions, but best to acknowledge and give your thoughts. Better to say
you considered something and, while you didn’t do exactly what is suggested,
you did something similar.</p>
<blockquote>
<p>Michael Ernst (University of Washington) on
<a href="https://homes.cs.washington.edu/~mernst/advice/write-technical-paper.html">“How to write a technical paper”</a></p>
</blockquote>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutUSMLE Step 22016-04-29T00:00:00+00:00http://jgmalcolm.com/step2<p>I’ve written elsewhere about <a href="/tags/?q=studying">studying</a> and <a href="/tags/?q=Step1">Step 1</a> strategy. Here are some
lessons I learned while preparing for Step 2.</p>
<h2 id="questions">Questions</h2>
<p><strong>Don’t read too much into things.</strong> They will give you all the relevant
positives and negatives. If a finding is not present and you know it’s
critical, then that’s probably a clue. Don’t assume anything that’s not
written. There is no wasted sentence.</p>
<p><strong>Syndromes.</strong> Given all the positive symptoms, does it resemble a syndrome?
When you feel overwhelmed because a question listed a bunch of findings, take
a step back and just look at the dominant positive symptoms. Do those add up
to anything found among the answer choices?</p>
<p><strong>Look for excesses.</strong> If the person is a 2 pack per day smoker for 40 years,
then you better be thinking lung cancer. If the person is just a half pack
for the last ten years, then while still a possibility, it’s less dramatic.</p>
<p><strong>Question stems.</strong> These are important clues that frame how you should triage
the answers. <em>“Most common cause…”</em> there may be multiple possible but less
likely distractors. <em>“Next step…”</em> or <em>“Initial management”</em> Patient has a
lump in their thyroid. Yes it might be cancer and might have metastasized,
but before you order that full body PET scan, do a needle aspiration to first
diagnose it.</p>
<p><strong>Dominant symptoms.</strong> What’s the chief complaint? Never forget that and
don’t get distracted by minor symptoms four sentences in.</p>
<h2 id="test-bank-strategy">Test Bank Strategy</h2>
<p><strong>First pass: topical.</strong> While you went through your clerkship rotations, you
likely already did select UWorld questions. Now as you begin your dedicated
study time, start by creating blocks all from the same topic, eg. Surgery,
Medicine/Renal, Micro. The purpose is so in the same stream of questions you
will keep hitting the same topics and start to see the similarities and clues.
You’ll keep reinforcing things. After you’ve completed the question bank this
way, then start doing random. If you had started random, it would have felt
like you were getting punched from a dozen directions at once, and you’ll
retain less. The goal at this stage is not to simulate test day; the goal is
to learn.</p>
<p><strong>Prioritize your weaknesses.</strong> Go where the money is at. Given any UWorld
performance data you gathered while going through clerkships, first do
questions on your weakest areas. Keep going until you’ve completed the qbank.</p>
<p><strong>Second pass: random.</strong> Now that you’ve completed all questions once during
clerkships and the start of this dedicated period, you should now begin random
blocks.</p>
<p><strong>Timing.</strong> Learning should be done in Tutor mode up until the last week or
so. The NBME and UWorld self-assessments are timed, and those alone may
provide enough timing practice. I did all of UWorld in Tutor mode and relied
on those self-assessments for timing practice.</p>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutHow to write a systematic review and meta-analysis2016-01-24T00:00:00+00:00http://jgmalcolm.com/systematic-reviews<p>Reviews are a great way to learn about a topic as a new student but also
contribute by bringing clarity when multiple studies cloud the topic. This
article talks about getting organized, narrowing your scope, and tips for
writing the paper.</p>
<h2 id="get-organized">Get organized</h2>
<p>Organizing and <a href="https://github.com/jtleek/datasharing">sharing data</a> with
collaborators heavily influences the efficiency of your progress. Use
<a href="//drive.google.com">Google Docs</a> for real-time collaboration on spreadsheets
and comments to keep in sync. Use <a href="//mendeley.com">Mendeley</a> for citations
and integrating with Microsoft Word. <a href="//www.zotero.org/styles">Zotero</a> has
thousand of journal style templates to download for Mendeley. Turn off the
feature that pushes your PDFs to the cloud; it’s unnecessary, seems to cause
duplication, and this way you’ll always stay within the free pricing tier.</p>
<p>Familiarize yourself with the <a href="https://en.wikipedia.org/wiki/Preferred_Reporting_Items_for_Systematic_Reviews_and_Meta-Analyses">PRISMA</a> guidelines. Journals now tend to
expect that level of rigor and documentation. Hit everything on the
checklist.</p>
<p>Create a document for your research notebook. Record every query, date
performed, and result counts. Once you’re happy with a query, export the
results to a spreadsheet (PubMed and Scopus let you export CSV which imports
into Google Spreadsheets). For each row in this spreadsheet of results,
you’ll want to have columns annotating how the article was handled at each
stage in the PRISMA screening process. There are really three stages you need
to document, so you can probably setup three columns: is it a duplicate paper
(if combining results from multiple databases), result of reading
title/abstract, result of reading full text. Plus a column for free-text
notes: variables assessed, outcomes assessed, or why you rejected. Setup
formulas that keep counts of each column.</p>
<h2 id="narrow-the-scope">Narrow the scope</h2>
<p>If you’re finding a lot of papers attempting to answer a question, then you’re
likely on a valuable topic. Look at previous systematic reviews in your
target journal: how many articles do they initially screen and how many do
they ultimately include? Usually it’s something like 100-500 initially
screened to ultimately include 10-20 articles. If your query is returning
1000+ articles, then do yourself a favor and narrow it. This will take some
time playing with the query, and be sure to document this evolution in your
research notebook document.</p>
<p><strong>Narrow your date range.</strong> If you’re looking at complications for a surgical
technique, maybe you don’t want to include articles from 1980 when many other
factors in a patient’s care were different from today.</p>
<p><strong>Lumpers and splitters.</strong> If you’re still overwhelmed by the search results
or have multiple questions swirling in your head, look for a way to split up
the topic. Aim for the most important question and set aside secondary
questions for a separate study. Take notes so you can discuss with your
colleagues and come back later.</p>
<p><strong>Quality over quantity.</strong> Do not try to include every single article that
even tangentially relates to your question because you’ll end up with a lot of
poor quality studies that will degrade your findings. Use something like the
<a href="http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp">Newcastle-Ottawa Scale</a> to assess for quality. Consider tightening your
inclusion criteria in ways that weed out low quality studies, eg. well defined
cases/controls, adequate followup, etc. More studies does not mean stronger
conclusions; more studies often means more variation, bigger confidence
interval, lower p-value.</p>
<h2 id="avoid-getting-bogged-down">Avoid getting bogged down</h2>
<p><strong>Don’t read into things too much.</strong> Not every paper will report on every
variable you’re interested in. If the paper doesn’t record an outcome measure
that you’re looking for, then move on. You don’t have time to wade through
their raw data and make your own interpretations. Only record what they
record so you stay unbiased. There’s always a balance, but as much as
possible, you need to “delegate” and rely on their clinical assessment.</p>
<p><strong>Focus on one thing at a time.</strong> After you skim a few related papers on your
topic, you should have an idea on what are the main risk factors,
complications, or whatever else all the papers make a fuss about. Take a pass
through all papers and just focus on this one variable so you develop
judgment. You’ll flounder if you try to go through every paper and record
every single detail into twenty different columns. You’ll quickly get lost in
the minutia. As you’re reading papers, it’s easy to go down rabbit trails
with new references you’ve not yet seen; you should put those in a separate
list for later.</p>
<h2 id="data-analysis">Data analysis</h2>
<figure class="thumb">
<img src="http://imgs.xkcd.com/comics/p_values.png" />
<figcaption>xkcd.com/1478</figcaption>
</figure>
<p>Simple descriptive statistics (mean, std) can be done in a spreadsheet.</p>
<p>The Cochrane Collaboration provides <a href="http://tech.cochrane.org/revman">RevMan</a>
for you to produce <a href="https://en.wikipedia.org/wiki/Forest_plot">Forest plots</a>
that visually depict the pooled analysis. For the highest quality images,
export to EPS and then <a href="http://www.zamzar.com/convert/eps-to-tiff">convert to TIFF</a> if the journal requires that
format.</p>
<p>Before you really get too far into things, read the chapter on meta analyses
from the <a href="http://www.biostathandbook.com/metaanalysis.html">Biostat Handbook</a>
online. It has a nice illustrative example of garbage-in-garbage-out. In
fact, read all of the articles on that site.</p>
<p><strong>Blinded by significance.</strong> As you’re sorting through studies, avoid the urge
to only hunt for significant findings. Your job is to report the facts. It
may seem sexy to report that some procedure has significant complications, but
if your data turns out to show no significance then it’s okay to report that
there was no significant difference. It’s okay for your systematic review to
simply report that you found no significant results. That’s still a
contribution. As you’re gathering data, it’s important you don’t
unintentionally start to filter results.</p>
<p><strong>Meta-analysis.</strong> While you can rely on RevMan to handle your pooling, you
should read about the Mantel-Haenszel method it uses. I highly recommend
setting up some toy problems in a spreadsheet so you know each step of
calculating your effect measure (odds ratio, risk ratio) or difference measure
(mean difference, standard mean difference), confidence intervals, weights,
and pooled results along with p-values, Chi<sup>2</sup>, heterogeneity
(I<sup>2</sup>) (see
<a href="http://www.ncbi.nlm.nih.gov/pubmed/12958120">Higgins 2003</a>). This is
important because many times your data is not in a form that RevMan accepts.
For example, to pool correlation coefficients (Pearson, Spearman) you have to
first z-transform them to a normal distribution so you can get a standard
error, run through the MH calculations, and then reverse z-transform to get
back to a correlation coefficient.</p>
<p><strong>Random-effects vs fixed-effects models.</strong> Try to get a sense of these two
and when to use which one. Here’s my best shot at explaining… Fixed-effects
is for when you have several consistent studies and you think the real answer
is something like a blend of these. Random-effects is for when you have a
more heterogeneous set of studies and you think these represent a sampling of
all possible studies. Fixed-effects tends to have a tighter confidence
interval while random is wider because you’re less sure. In practice, look at
your heterogeneity measure (I<sup>2</sup>) and whether it is significant
(Chi<sup>2</sup>); if significant (p < 0.05) then use random-effects,
otherwise use fixed-effects. I’m sure the statisticians in the audience are
cringing but this should be enough to get you started. Most universities have
some library or department staff available to help you navigate this, or get
someone on board who’s done these before.</p>
<h2 id="writing">Writing</h2>
<p><strong>Don’t get bogged down.</strong> Staring at a blank document can be overwhelming.
Where do you start? Start by reading the instructions to authors for your
target journal. Lay out the headings it requires.</p>
<p><strong>XXX.</strong> As you write, if there’s something you’re unsure how to word or what
to cite, put “XXX” and keep going. Come back later. Write whatever you can
and move on to the next thing you can write. Over time, the paper will evolve
as you hammer out a paragraph here, a
paragraph there.</p>
<p><strong>Copy and modify.</strong> Look to existing papers for how you can word things or
what to mention where. Sometimes when I have writer’s block, I’ll literally
type out a paragraph from a paper that says what I want to say; then I will
tear that to pieces as I go through and rewrite in my own words using my own
findings. I’m not advocating plagiarism here; I’m suggesting you copy
sentence and paragraph structure. Whenever you get stuck in your paper, jump
over to read a few other papers to see how they handled this particular spot.
But don’t go down the rabbit trail of reading for an hour; you can always
write “XXX” and come back.</p>
<p><strong>Methods.</strong> Write this section first. It should be the most straight
forward: you’re just documenting what you did. Look at other papers to see
what is important to document and in what order. Follow the <a href="https://en.wikipedia.org/wiki/Preferred_Reporting_Items_for_Systematic_Reviews_and_Meta-Analyses">PRISMA</a> formula,
but don’t get too bogged down with all the details; do as much as you can and
move on.</p>
<p><strong>Introduction.</strong> Make this brief, like two paragraphs. First paragraph is
broad strokes introducing the topic and a few notable works. This is not a
discussion; it is merely an introduction of topics. Second paragraph
motivates your work: what question are you seeking to answer? You must have
a good motivation, not simply “Previous studies suck. I could do better.”</p>
<p><strong>Discussion.</strong> Break it into sections for each of the topics. From most
studies, you’ll generally only be including information that’s mentioned in
the abstract; anything else buried inside a paper is not likely important.
For each topic, highlight the papers where that topic was a primary outcome.
You don’t need to wring every nugget from each paper; just highlight one
takeaway for each. When citing another paper’s finding, don’t include their
p-value; that <a href="http://fivethirtyeight.com/features/statisticians-found-one-thing-they-can-agree-on-its-time-to-stop-misusing-p-values/">lacks sufficient context</a>. If the reader is interested,
they can follow the citation to read the full paper.</p>
<p><strong>Citations.</strong> Don’t get caught up in citations; it can distract from your
communication. Focus first on saying what you want to say in the order you
want to say it; then later integrate citations. In my first pass, I might
manually put a citation in parenthesis (Smith), and later worry about fussing
with the plugin.</p>
<blockquote>
<p>See also <a href="http://goo.gl/A0PBq">Guide to executing and writing a systematic review</a></p>
</blockquote>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutCo-founders2015-05-27T00:00:00+00:00http://jgmalcolm.com/co-founders<p>Building a new business is exciting, but there are important things to
consider as you form the founding team, whether with friends, existing
business partners, or a significant other. Here I share some tips based on
experience creating <a href="//arrayfire.com">AccelerEyes</a>.</p>
<h2 id="summary">Summary</h2>
<ol>
<li><a href="#personal">Personal</a>: work with a responsible person you like
and share values with.</li>
<li><a href="#equity">Equity</a>: split equally, earn it out, and maximize
value for all.</li>
<li><a href="#competencies">Competencies</a>: think what is needed and what you
can get better at.</li>
<li><a href="#run-through-scenarios">Scenarios</a>: plan for inevitable
contingencies and fights.</li>
<li><a href="#your-worst-enemy">Your worst enemy</a>: pre-emptively and
explicitly plan for the worst.</li>
</ol>
<h2 id="personal">Personal</h2>
<p><strong>Is this someone you like working with?</strong> Can you see yourself working
together at 3 am under a deadline? Do they annoy you? These are probably
some of the most important questions that will determine your happiness.
While having an annoying partner is not a deal breaker, the baseline
aggravation can trigger bigger issues later.</p>
<p><strong>Is this person responsible?</strong> Is this someone you trust to work hard and get
the job done? The nature of forming a partnership is because you need to
spread work out, so you need to be able to trust that your partner will
execute on their fair share.</p>
<p><strong>Do you share the same sense of values?</strong> Do you question their judgment?
Have you witnessed or heard about them doing anything ethically questionable?
If so, be blunt and ask them about it. Better to air the matter now rather
than after you’ve formed a joint bank account.</p>
<p>It’s been said that business partnerships are like a marriage without the
benefits. You will be very close to your partners - as close as family.
Choose your associates wisely.</p>
<h2 id="equity">Equity</h2>
<blockquote>
<p>A beginning is the time for taking the most delicate care that the balances
are correct. <em>(Dune, book 1)</em></p>
</blockquote>
<p><strong>Equal split is best, unless you have a strong reason otherwise.</strong> Anything
other than equal will create a subtle imbalance. The minor partners will feel
less responsibility and show less initiative. Some days you’ll be the slug,
and on those days you want to know that your partners are picking up the
slack.</p>
<p>Even if one partner clearly brings more to the venture, think long and hard
about tipping this balance. You never know what the future holds, and likely
you’ll all end up growing in your rolls.</p>
<p>Instead of creating an imbalance from the start, look at the core competences
and areas of the business and come up with a rough split that allows the
would-be minor members to grow.</p>
<p><strong>When to consider unequal splits.</strong> There are good reasons to consider an
unequal split. One partner might bring significant industry and operational
experience, financial resources and capitalization, or simply putting more
time into the project.</p>
<p><strong>Earn out.</strong> Avoid granting all equity up front. Instead, equity should be
granted over years (4-5 years is common because it typically takes about that
long to prove out a venture). I’ve seen companies trapped in an equity
arrangement with a partner who abandons the project while keeping the original
equity locked; these typically end in a dissolution of assets and
re-incorporation. What a waste of time and energy. Bake in an agreement that
<a href="http://notonlyluck.com/2014/05/21/founder-vesting/">rewards partners for sticking around</a>, leaves open the option for
fairly compensating partners that decide to walk away, and protects the
corporation through all of this.</p>
<p><strong>Equity alternatives.</strong> Maybe you want to avoid equity altogether. One
option is for the minor partner to be paid hourly while the major partner
retains equity. If things are pre-revenue, maybe the minor partner could be
guaranteed hourly pay from the first profits that roll in. Maybe the minor
partner could “earn” equity over time.</p>
<p><strong>Maximize value for all partners.</strong> Whatever you do, the goal is to ensure
that all partners can contribute as much as possible to the venture while
feeling fairly compensated for those efforts.</p>
<h2 id="competencies">Competencies</h2>
<p><strong>What core competencies are needed for the venture?</strong> Make a list. Who
brings what? Who’s responsible for what? Think through the entire pipeline
of your business, from sales and marketing to back end production and
operations. Also consider ancillary tasks such as taxes and pay roll.</p>
<p><strong>What do you need to get better at?</strong> Some things you stink at, can’t (yet)
outsource, or will need to learn yourself. Make a plan for how that will
happen.</p>
<h2 id="run-through-scenarios">Run through scenarios</h2>
<figure class="thumb">
<a href="http://amzn.to/1WS3Ck2"><img src="/images/founder-dilemmas.jpg" /></a>
<figcaption>"Founder Dilemmas" is a collection of stories and lessons about
when things go wrong, should you go it alone, or when to bring in
cofounders, hires, and investors to help build a business.</figcaption>
</figure>
<p><strong>What happens if one partner walks?</strong> Who gets what? What if it’s after one
year, two, or four? Consider specific scenarios if you can: if you’re both in
school, what happens after graduation? What if you stay and the other partner
leaves for a big fancy job? What about continuing work remotely? What if
you are both balancing school or a job?</p>
<p><strong>What level of involvement is required to remain a partner?</strong> How and when
will you evaluate? What’s the process for pushing a partner out?</p>
<p><strong>What happens when we don’t agree?</strong> Do you have a respected mentor or
arbiter? <a href="http://www.aaronkharris.com/cofounder-management">Disagreements and fights are inevitable</a>, so start a
conversation early about how you’d like to handle when the inevitable happens.
A few gentle, proactive discussions can significantly reduce the pain if things go off the rails.</p>
<blockquote>
<p>John Melonakos, my co-founder at ArrayFire/AccelerEyes writes about our some
of early experiences in <a href="http://notonlyluck.com/2014/05/21/respecting-our-student-commitments/">“Respecting our student commitments”</a>,
<a href="http://notonlyluck.com/2014/05/21/founder-vesting/">“Founder Vesting”</a>, and
<a href="http://notonlyluck.com/2014/05/30/cofounder-relationship-struggles-are-the-most-volatile/">“Cofounder Relationship Struggles Are The Most Volatile”</a>.</p>
</blockquote>
<h2 id="your-worst-enemy">Your worst enemy</h2>
<p>Ask yourself these questions:</p>
<ul>
<li>what if this partner was your worst enemy?</li>
<li>how would you split up assets if you needed to divorce?</li>
<li>what about assets you brought to capitalize the business?</li>
<li>how would profits be disbursed?</li>
<li>if you left early, how can you get your money back?</li>
<li>if you caught them cheating, how would you deal with it?</li>
</ul>
<p>Don’t just gloss over holes in the contract and assume you both understand
what it means. Make things explicit where you can.</p>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutHow to be a good sub-intern2015-05-03T00:00:00+00:00http://jgmalcolm.com/how-to-be-a-good-sub-intern<div class="series no-print">
<b>clinical:</b>
<a href="/clerkships">
Clerkships
</a>
//
How to be a good sub-intern
//
<a href="/surgical-subintern">
Surgical sub-intern
</a>
</div>
<h2 id="every-rotation">Every rotation</h2>
<p><strong>Equipment</strong></p>
<figure class="thumb">
<a href="http://amzn.to/1KH0btu"><img src="/images/penlight.jpg" /></a>
<figcaption>You need a penlight that's small, light, and has a focused beam.</figcaption>
</figure>
<ul>
<li><strong>Two pens.</strong> Be prepared to give one away.</li>
<li><strong>Pen light.</strong> Small, lightweight, and with a strong focused beam. Useful
not just for pupil exams but also examining a patient in a dim room. Don’t
fumble around with the flashlight app on your phone.</li>
<li><strong>Stethoscope.</strong> Nearly every specialty will use this except psych. Instead
of draping around your neck or tangling in your pocket, get a <a href="http://amzn.to/1M3H9xZ">belt clip</a> to keep it secure and out of the
way.</li>
<li><strong>Notecards.</strong> A small stack of blanks in your top pocket that you can whip
out to write down anything at a moment’s notice. Often you’re asked on the
spot to call a number for a consult; you don’t want to be fumbling for your
phone to take down the number. I often have one card per patient to write
down details like meds or important H&P details. For ICU rotations and more
complicated patients, you may need larger blank paper or
<a href="http://www.medfools.com/downloads.php">scutsheets</a>, but still keep some
notecards handy for little things.</li>
<li><strong>Insoles.</strong> You’re on your feet for hours on end, and those hospital floors
are hard. You can join the cool kids and get some <a href="http://www.amazon.com/s/ref=as_li_ss_tl?_encoding=UTF8&camp=1789&creative=390957&field-keywords=dansko&index=blended&linkCode=ur2&tag=jgmalcolm-20&linkId=ZEZ3BOYLBLXFR6K3">Dansko’s</a>, but a
far cheaper option is a <a href="http://amzn.to/1DhoXxY">simple gel
insole</a> in your existing shoes. While Dansko’s are great for standing,
people tell me they stink for regular walking. I far prefer the insole
because the Dansko’s look ridiculous with anything other than scrubs, and
even then they look a bit odd…</li>
<li>
<p><strong>Rubber gloves.</strong> Always carry 1-2 pairs in your pocket. I often find
myself in a situation requiring gloves but none are nearby.</p>
</li>
</ul>
<p>Surgery likely doesn’t need your stethoscope. Psych probably doesn’t need
anything beyond pens; leave your tie and white coat at home so a patient
doesn’t strangle you or get intimidated. An ophthalmoscope is handy on
consult services where you’re unlikely to have tools handy.</p>
<p><strong>UpToDate.</strong> Graduate from Wikipedia to <a href="//uptodate.com">UpToDate.com</a>. This
is the most well-organized resource I’ve found for efficient, practical, and
comprehensive research on topics encountered in clinical medicine. Hopefully
your school provides you with a subscription.</p>
<p><strong>Set some goals.</strong> Before you hit the floors on day #1, come up with a list
of 2-3 things you want to get better at on this rotation. For example, if
you’re interested in cardiology, you can always say you want to get better at
listening to hearts whether it’s a pediatrics or adult medicine. Having a
ready answer shows you’re a self starter, and it primes you to get more out of
the opportunities that come up.</p>
<p><strong>Have the calendar in your head.</strong> Someone is invariably going to ask you how
long you’re rotating with them, or what you’re doing next. Replying “I don’t
know” makes you look aimless. Know your dates. What’s more, I like to
solicit feedback at the halfway point so I have room to improve on anything
attendings note. The day before the halfway point, I’ll mention to the
attending that I’d appreciate if there was an opportunity for some feedback
the next day.</p>
<h2 id="get-comfortable-with-chaos">Get comfortable with chaos</h2>
<p>No longer are you lumped in with hundreds of other students all going through
lectures and exercises in lock step. You’ll often be adrift, alone on a ward
somewhere. For much of this year you’ll spend your time wondering if you’re
where you’re supposed to be. The second half of medical school is much less
organized than the first half.</p>
<p><strong>Get used to messing up on your first swing.</strong> You’ll daily feel fumbling and
incompetent. The important thing is that you learn quickly. Attendings and
residents expect that you’ll fumble the first day or so, but if you’re making
the same mistakes day after day, expect low ratings.</p>
<p><strong>Prioritize your time.</strong> You no longer have infinite time to study at your
own pace. You must now more than ever prioritize what to cover and how deeply
to cover it.</p>
<p><strong>Know your nurses.</strong> For each patient, introduce yourself to his or her
nurse. If they carry a ward cellphone, write down that number. A quick phone
call can save you lots of walking. Go one step further and write down the
number to the patient’s bedside for quick questions and updates. Obviously
not all patients will be able to pick up the phone, but for some it is
efficient.</p>
<h2 id="morning-rounds">Morning rounds</h2>
<p><strong>The List.</strong> Every morning, print a fresh copy of your team’s patient list.
As your team goes around, you’ll build a todo list of things that need to be
done for each patient: consults to call, records to request, lab values to
hunt down, etc. It’s a given you do everything you can for your patient, but
for other patients without a medical student helping, step in and offer to
help. To do this, you need to make note of todo items on patients that aren’t
even yours.</p>
<h2 id="examining-patients">Examining patients</h2>
<p><strong>Always introduce yourself.</strong> For inpatients, introduce yourself again each
day until it’s clear they know you. Address them as Mr X or Mrs Y, and only
use first names if they insist. Always knock before entering. Recognize that
patients have lost control or privacy, so knocking and requesting to enter is
one way to give some of that back. When leaving the room, repeat your name
again so you’re not just some random “doctor” coming to examine them; I’ve
found that this in particular makes you memorable.</p>
<p><strong>Minimal exposure.</strong> While you need to examine head to toe, you don’t have to
expose them all at once. Keep as much covered as possible as you’re going
along.</p>
<p><strong>Think about why they’re here.</strong> What organ systems are the most important to
report on? What are complications to keep an eye on? What other medical
conditions do they have that you need to watch out for? If someone has
myasthenia gravis and just had anesthesia, are they feeling weak?</p>
<h2 id="presenting-on-rounds">Presenting on rounds</h2>
<p><strong>Gather the information.</strong> Before diving into the digital records, ask the
night staff if there were any updates. I tend to check the medical records
before examining the patient; this might provide overnight clues that will
guide my physical exam. Sometimes you might want to briefly glance at the
patient to get basic vitals and then come back later for a thorough exam.
When examining a patient in the wee hours of the morning, be nice: use your
penlight as much as possible instead of flipping on the overhead lights.</p>
<p><strong>Put together the story.</strong> Use only 50% of the data, but be prepared if asked
about the other 50%. Giving 100% of the details in an unorganized fashion
forces the attending to work at making sense of the situation. Don’t fall
into the trap of being proud of yourself that you were able to spew out all
kinds of detailed data rapid fire. Better to tell a logical story at normal
rate. Figure out what you think is most likely and tailor the story to that.
List other possibilities and what you’re doing to rule them out.</p>
<p><strong>H&P versus SOAP.</strong> On inpatient services, you present new patients
differently than ones that have been on your service a night or two. New
patients need a full H&P that includes the history of how they got to your
service so everyone’s on the same page (eg. emergency department course).
From the second day onward, you report using a SOAP note only highlighting
overnight events, new lab values, and plan changes.</p>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutClerkships2015-03-28T00:00:00+00:00http://jgmalcolm.com/clerkships<div class="series no-print">
<b>clinical:</b>
Clerkships
//
<a href="/how-to-be-a-good-sub-intern">
How to be a good sub-intern
</a>
//
<a href="/surgical-subintern">
Surgical sub-intern
</a>
</div>
<h2 id="surgery">Surgery</h2>
<figure class="thumb">
<a href="http://amzn.to/1SsYvrZ"><img src="/images/pestana.jpg" /></a>
<figcaption><b>Pestana</b> is simple, comprehensive, portable, and has
accompanying audio that walks you through hundreds of vignettes. Great for
the shelf exam.</figcaption>
</figure>
<p><strong>Pre-game.</strong> This is nothing like your other rotations. Read the first
section of <a href="http://amzn.to/1LLV9tD">Surgical Recall</a> to orient yourself to what’s expected, what to
touch, names of instruments, and answers for all the classic pimping questions
you’ll get on rounds or in the OR. Doing a gallbladder? Know Calot’s
triangle. Review abdominal anatomy: arteries, muscles, abdominal fascial
layers; nerves and veins are less important. Create a notecard with the list
of things to check on morning rounds (overnight events, IVs, tubes/drains,
I/Os, wound healing, etc.).</p>
<p><strong>Shelf.</strong> Similar to the medicine shelf, but focused on management more so
than pathophysiology. For the bread and butter, you’ll need to know when to
manage conservatively and when to head to the OR. Do all the UWorld questions
for Surgery, GI, Renal, and Electrolytes, and do them twice. Consider taking
one or both of the NBME Self Assessments. <a href="http://amzn.to/1SsYvrZ">Pestana</a> is an excellent, concise
book covering the bread and butter general surgery, but also all the
specialties included on the shelf: ortho, neuro, urology, pediatrics, burns,
etc. Find the audio that accompanied an earlier version. It walks through
several hundred very simple vignettes, each with a slight variation from the
previous to emphasize teaching points on differences in management. This is
about 13 hours, so listen to it while exercising or on the commute.</p>
<figure class="thumb">
<a href="http://amzn.to/1LLV9tD"><img src="/images/surgical-recall.jpg" /></a>
<figcaption><b>Surgical Recall</b> is comprehensive, concise, and has
answers for all the classic pimping questions. Great for day to day
procedures.</figcaption>
</figure>
<p>A more detailed post on <a href="/surgical-subintern">Making the most of your surgical sub-internship</a>.</p>
<p>More great advice:
<a href="https://redd.it/2vcroj">Tips & Tricks for the Surgery Clerkship</a>,
<a href="https://redd.it/2vanpe">FAQ for Matching into General Surgery</a>,
<a href="https://www.med.unc.edu/surclerk/overview/guide">UNC Clerkship Guide</a>,
<a href="http://surgery.med.umich.edu/portal/education/mse/Residency_GuideBooklet_2015.pdf">U Mich: Applying To Residency</a></p>
<h2 id="medicine">Medicine</h2>
<p><strong>Pre-game.</strong> Understand how to read an EKG; plenty of great online videos:
<a href="http://zapt.io/tqyjd4ju">basics</a>, <a href="http://zapt.io/tfxkvx9d">rate & rhythm</a>,
<a href="http://zapt.io/t4cubvtk">intervals</a>. Brush up on
<a href="http://www.blaufuss.org/">heart sounds</a>. <a href="http://amzn.to/1OahqBv">Pocket Medicine</a> has been
invaluable. Whenever I’m about to examine a patient for a chief complaint I’m
not as familiar with, I hit that page and this gives me questions for my
history, physical exam findings to look for, differential diagnosis to
consider, and tests to order. Look like a rock star because you covered all
the bases. Consider getting a digital copy for your phone/tablet instead of
lugging around the little notebook.</p>
<figure class="thumb">
<a href="http://amzn.to/1OahqBv">
<img src="/images/pocket-medicine.jpg" />
</a>
<figcaption><b>Pocket Medicine</b> has been invaluable in getting a thorough
history and physical for common chief complaints.</figcaption>
</figure>
<p><strong>Shelf.</strong> UWorld is all you need to do well. Absolutely do all 1300
questions. <a href="http://www.amazon.com/gp/product/1934465542/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=1934465542&linkCode=as2&tag=jgmalcolm-20&linkId=5LTX75SLT7D62FSF">MKSAP</a> is great but extra.</p>
<h2 id="ob-gyn">Ob-Gyn</h2>
<p><strong>Pregame.</strong> Download an app for calculating gestational age based on LMP, US,
EDD, etc. There are free ones but <a href="https://itunes.apple.com/us/app/perfect-ob-wheel/id293656711?mt=8">Perfect OB Wheel</a> was a cheap one I found
to have a great interface.</p>
<p><strong>Outpatient.</strong> Drill on your gyn/ob history template questions and speculum
exam. I ultimately preferred to perform the bimanual exam before placing the
speculum because then I knew what I was aiming for. Position and get
everything ready before you put on your gloves to begin touching the patient’s
anatomy. Practice your bimanual and speculum exam so it’s no longer awkward
and you start to focus on fine tuning comfort for the patient.</p>
<p><strong>Labor and Delivery.</strong> Wear shoe covers. Always. At the start of every
shift, get a copy of the roster and go around briefly meeting every patient
who might be delivering. No patient wants to meet and greet during active
labor.</p>
<p><strong>Surgery.</strong> Review pelvic anatomy: ovarian artery comes off the aorta,
branches of the internal iliac, genitofemoral/iliohypogastric/ilioinguinal
nerve paths and cutaneous distributions (watch your retraction), ligaments
holding up the uterus and ovaries, etc. Get used to looking at the pelvis
from a laparoscopic viewpoint. Perform a bimanual exam before prepping so you
get an appreciation for uterus size/position, ovaries, fibroids, etc. If
you’re assigned “down below” during the procedure, don’t contaminate “up
above”.</p>
<p><strong>Shelf.</strong> <a href="http://amzn.to/1RNqT5i">Blueprints</a> covers everything in perfectly
simple detail. Skim this early in your rotation, and then reread topics in
detail as you go through the rotation. <a href="https://www.apgo.org/student.html">UWise</a> is an excellent free question
banks (542 questions) organized into topics plus additional comprehensive
self-assessments. Do appropriate topics before rotating on LND, surgery,
outpatient, etc. UWorld has about 250 questions you need to hit.</p>
<h2 id="neurology">Neurology</h2>
<p><strong>Pregame.</strong> Specific equipment for the physical exam: reflex hammer, tuning
fork, safety pins, ophthalmoscope. Practice your complete neuro exam. Review
anti-epileptic drugs for seizure control and pain management, calcium channel
blockers for treating vasospasm, beta blockers for lowing blood pressure, and
anesthetics. Get familiar with one of the <a href="https://itunes.apple.com/us/app/10-second-stroke-scale/id478624302?mt=8">NIH Stroke Scale apps</a>.</p>
<p><strong>Shelf.</strong> About 220 questions in UWorld covering Neurology and Ophthalmology,
plus the two <a href="https://nsas.nbme.org/home">NBME</a> subject tests which were quite similar to the real deal.
<a href="http://www.amazon.com/gp/product/0071761144/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=0071761144&linkCode=as2&tag=jgmalcolm-20&linkId=ZYVMQGEVHO36UUO3">Neurology Pre-Test</a> is okay if you want more practice, but only if you’ve
finished UW and NBME. I’ve heard <a href="http://www.amazon.com/gp/product/0071761705/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=0071761705&linkCode=as2&tag=jgmalcolm-20&linkId=HHAGQO35U4AM2TYM">Neurology Clinical Cases</a> is good but I
had my hands full already.</p>
<h2 id="pediatrics">Pediatrics</h2>
<p><strong>Pre-game.</strong> Kids are not like adults, so print out some reference material
for developmental milestones, a <a href="http://www.utmb.edu/pedi_ed/CORE/Neonatology/page_02.htm">template review of systems</a> so you
hit on pediatric-specific questions during your H&Ps, and watch some videos of
the <a href="http://www.utmb.edu/pedi_ed/CORE/Neonatology/page_11.htm">pediatric physical exam</a>, carry around a template
<a href="http://www.meddean.luc.edu/lumen/MedEd/peds/newborn_pe_exercise.pdf">checklist</a> and try to hit more of it with each new exam.
Newborns labs have their own range of normal; get familiar with heart rate,
respiratory rate, febrile thresholds in neonates, infants, and toddlers. Get
a basic outline of how to workup common problems: respiratory distress,
<a href="http://www.meddean.luc.edu/lumen/MedEd/peds/newborn_pe_exercise.pdf">neonatal jaundice</a>, fever of unknown origin, etc.</p>
<p><strong>Pediatric H&Ps are not adult H&Ps.</strong> If a child is in the first decade of
life, you should ask about birth history, feeding, development. Carry a
reference sheet with developmental milestones and, for their age, ask about
the four areas.</p>
<p><strong>CLIPP Cases.</strong> Available from <a href="//www.med-u.org/clipp">MedU</a>. These cover
about 30 basic scenarios you’ll encounter daily. Do a quick pass in the first
week of your rotations so you’re familiar with the content. Then do a
subsequent slower pass to truly study the material before the shelf.</p>
<p><strong>Handle with care.</strong> You’ll find they’re pretty resilient. I doubt you’ll
drop a child, but another important aspect of handling with care involves
diaper mishaps. During your physical exam, always position the diaper over a
little boy’s private parts. The time when you have them fully exposed should
be on the order of seconds. When checking femoral pulses, shields up.
Further, before picking a child up to coddle, check the diaper. Your clothes
will quickly soak up a wet diaper. This is experience talking. For Peds,
OB/Gyn, and Surgery you’ll want to have a full change of scrubs in your locker
or car.</p>
<p><strong>Nursery.</strong> The newborn physical exam looks for specific physical findings
from the birth process: birth trauma and deformities from in utero
positioning, skin findings such as umbilical site, jaundice, rashes, etc.
Your history will need to assess this pregnancy and delivery as well as
previous pregnancies. Know jaundice and respiratory distress cold. Normal
vitals are unique in the first few days.</p>
<h2 id="psychiatry">Psychiatry</h2>
<p><strong>Interviewing.</strong> Be nosy. This isn’t regular society where you tip-toe
around issues. Patients don’t always volunteer, so always be digging. Screen
for everything kind of thought or behavior: mania, depression, auditory/visual
hallucinations, etc. Several times I was embarrassed when after a relative
normal interview I would read a chart and realize I had been talking to a
patient with some crazy back story I didn’t elicit.</p>
<p><strong>Shelf.</strong> UWorld (all 150q) + <a href="http://amzn.to/21y1eRT">Lange</a> (most of 750q). Know where general
medicine and surgery meet psychiatry: delirium, liver/renal/cardiac
co-morbidities to psychiatric drugs.</p>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutTravel Hacks2015-03-09T00:00:00+00:00http://jgmalcolm.com/travel-hacks<p>I’m fortunate to have had many opportunities to travel under various
circumstances, packing everything from business suits to backpacking gear,
sleeping anywhere from luxury hotels to a rental car, cleaning up under a
trailer park hose or out of a train car sink. Here are some practical tips I
picked up along the way.</p>
<h2 id="basics">Basics</h2>
<p><strong>Plastic bags</strong> for dirty clothes or a wet bathing suit.</p>
<p><strong><a href="http://www.amazon.com/gp/product/B00IOY8XWQ/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B00IOY8XWQ&linkCode=as2&tag=jgmalcolm-20&linkId=DKOWV2R7PBCJ6EFV">Kindle</a></strong> <a href="http://www.amazon.com/gp/product/B00IOY8XWQ/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B00IOY8XWQ&linkCode=as2&tag=jgmalcolm-20&linkId=DKOWV2R7PBCJ6EFV"><img class="thumb" src="/images/kindle.jpg" /></a> because books just get beat up, plus you’ll always have more
books than you can possibly read. I also setup
<a href="https://www.instapaper.com/apps">Instapaper article delivery</a>.</p>
<p><strong>Ear plugs and head phones</strong> because you never know when you’ll be seated
next to a crying two-year-old. I really like the
<a href="http://www.amazon.com/gp/product/B00JAAJ1F6/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B00JAAJ1F6&linkCode=as2&tag=jgmalcolm-20&linkId=MC3Y54SMJGTYZ5Q3">Jarv NMotion Sport Wireless Bluetooth</a> headphones to avoid cords getting
caught.</p>
<p><strong><a href="http://www.amazon.com/gp/product/B0092ECRLA/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B0092ECRLA&linkCode=as2&tag=jgmalcolm-20&linkId=N65XMV7K3UGT5KGU">Day pack</a></strong> that stuffs down. Ditch your big travel backpack and carry
just the essentials while you’re out and about.</p>
<p><strong>Two pens and scratch paper.</strong> Use pens that won’t leak. Folded computer
paper is good, but notecards might be more durable.</p>
<p><strong>Granola bars, almonds, and other TSA-friendly snacks</strong> for when you’re
caught between meals, tired of airplane food, or not interested in a $12
sandwich in the terminal.</p>
<p><strong><a href="http://www.amazon.com/gp/product/B00ITILPZ4/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B00ITILPZ4&linkCode=as2&tag=jgmalcolm-20&linkId=3WTM7NSD7S7XTNCF">Portable battery</a></strong> <a href="http://www.amazon.com/gp/product/B00ITILPZ4/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B00ITILPZ4&linkCode=as2&tag=jgmalcolm-20&linkId=3WTM7NSD7S7XTNCF"><img class="thumb" src="http://ecx.images-amazon.com/images/I/412NAqrHJ%2BL._SL110_.jpg" /></a> for when you’re stuck without an outlet and need a few
watts.</p>
<p><strong><a href="http://www.amazon.com/Outlets-Go-Power-Strip-USB/dp/B0018MEBNG/">Power strip</a></strong> with multiple ports, USB, and ground. Never again feel
sheepish asking if you can bump someone off the only outlet available because
your phone is about to die but you’re so close to a new high score on Candy
Crush. Nevermind, you should feel sheepish.</p>
<h2 id="clothes">Clothes</h2>
<p><strong>Drier sheets.</strong> Stuff a few fresh ones throughout your clothes to keep your
laundry smelling fresh throughout the trip.</p>
<p><strong>Rolling a bundle of clothes to avoid wrinkles.</strong> When shirts and pants are
individually folded and packed, wrinkles are inevitable. Stack several dress
shirts on top of each other, toss some t-shirts in the center, and fold the
dress shirts around the bulky t-shirts to avoid sharp fold creases.</p>
<p><strong>Pack loose.</strong> Even if you folded your dress clothes neatly, squishing them
down can still leave wrinkles. Pack everything else tight and put your dress
clothes in last and loose.</p>
<p><strong>Dirty laundry bag.</strong> Preferably one that’s water and smell proof. Don’t
rely on plastic grocery bags; get something a little more sturdy.</p>
<p><strong>Take care of your fancy dress shoes.</strong> To avoid scuff marks, stuff them into
large socks or wrap them in old t-shirts. To avoid smashing them or causing
creases in the leather, stuff them full of socks and underwear for some
internal support.</p>
<p><a href="http://www.amazon.com/gp/product/B002VS8H3G/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B002VS8H3G&linkCode=as2&tag=jgmalcolm-20&linkId=74DZ3RHLRTSDNKQM"><img class="thumb" src="https://images-na.ssl-images-amazon.com/images/I/4173D1gyb4L._SL250_.jpg" /></a></p>
<p><strong>A duplicate set of all your toiletries.</strong> When you travel regularly, it gets
stupid to continually pack and unload your toiletries. You’ll soon forget
something. Stock a travel kit that you know to be complete and ready every
time. Restock it after every trip. Instead of using some generic
travel-sized shampoo and soap, buy <a href="http://www.amazon.com/gp/product/B002VS8H3G/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B002VS8H3G&linkCode=as2&tag=jgmalcolm-20&linkId=74DZ3RHLRTSDNKQM">reusable 3oz travel containers</a>
and fill them with the shampoo and soap you’re hair and body are used to.
When you find a brand you like, always stock up on extras; running out of
something you knowingly use daily is just a sign of poor planning. Consider
putting these all in a heavy duty zip-lock in case something leaks or is still
wet when you have to rush to the airport. For razors, put a large black
binder clip around the blade portion to keep it from getting dulled.</p>
<h2 id="international">International</h2>
<p><strong>Hit up the airport ATM.</strong> Before you leave the destination airport, get some
local cash. Fees from your home bank and the local ATM are likely fixed (not
percentage), so withdraw enough to make these fees a trivial fraction. Avoid
the currency exchanges with their ridiculous rates.</p>
<p><strong>Notify credit/debit card companies in advance.</strong> Ask for an increase in your
daily withdrawal limit. You don’t want to be stuck on day one. Don’t assume
it’ll work because you have a pin. Do this online or by phone a day or two in
advance.</p>
<p><strong>Split up your cards and cash.</strong> Keep a small amount of cash and one card in
easily accessible pockets. The bulk of your cash should be either safely
locked in the hotel or in a hard to access internal pocket. Consider for a
moment if you get robbed; while you’ll likely be quickly let go, you may be
searched for additional money and valuables. For the small amount of easily
accessible money, consider that sticking your hand in and out of your pocket
all day might cause the money to fall out. Partition your assets.</p>
<p><strong>Eye patch and inflatable pillow.</strong> Catch some rest whenever and wherever.</p>
<p><strong>Photocopy your passport.</strong> Put copies in all your luggage and carry-on.
Write your contact information on these copies. Besides this backup copy, you
want at least two forms of identification, and you want to store them in two
separate locations.</p>
<p><strong>Plan on doing laundry.</strong> Only pack clothes for 5-7 days. Even when
traveling on some remote islands, I’ve always been able to find local services
to do my laundry.</p>
<p><strong>Band aids, neosporin, sunscreen, needle, & thread.</strong> For any trip with the
potential for adventure.</p>
<h1 id="miscellaneous">Miscellaneous</h1>
<p><strong>Hijack hotel TVs</strong> When staying in a hotel, skip the annoying local network
and TV guide and instead plug in your Chromecast/Fire/equivalent for full
control.</p>
<p><strong>Packing list.</strong> I tend to pack last minute, but to minimize the risk of
forgetting something on a new adventure I will start days ahead creating a
packing list of anything that comes to mind.</p>
<blockquote>
<p>For more tips on everything from packing lists, planning adventure, and
exercising on the road, I recommend posts from two friends:</p>
<ul>
<li>Shawn Lankton: <a href="http://www.shawnlankton.com/2011/02/become-a-super-packer/">“Become A Super-Packer”</a>,
<a href="http://www.shawnlankton.com/2007/05/lessons-from-a-traveler/">“Lessons From A Traveler”</a>, and
<a href="http://www.shawnlankton.com/2012/07/best-travel-power-strip/">“Best Travel Power Strip”</a></li>
<li>Matt Might: <a href="http://matt.might.net/articles/travel-hacks/">“Travel Hacks”</a></li>
</ul>
</blockquote>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutUSMLE Step 12015-02-15T00:00:00+00:00http://jgmalcolm.com/step1<p>I’ve written elsewhere about <a href="/tags/?q=studying">studying and test strategy</a>,
but this post contains some specifics for Step 1 including how to plan your
schedule, what resources to use, where to focus, and the days leading up to
Test Day.</p>
<p><strong>It’s important, but not everything.</strong> You’ve heard so much about this test
from older students. While the anxiety is building, it’s important to keep
some perspective. Your STEP1 score is not a make-or-break score. Do your
best and move on to the next set of hurdles. Your residency application is a
combination of board scores, letters, grades, and research. You probably only
need two of those to be great to get an interview, and after that it’s
absolutely more about personality than raw numbers. Ultimately keep in mind
that this test doesn’t define who you are. It’s ridiculous how much pressure
is placed on this one test value and faculty I talk with say it’s only one
piece of a small puzzle.</p>
<p><strong>It’s a marathon.</strong> If you know what you want to do, it’s the things you do
week after week after week that get you there. Research, relationships, work
ethic on sub-internships, etc that get you in. Step1 is just one number they
might use to screen. They don’t compare people like “student A is 225 versus
Student B who is 235”….no. The competitive programs compare based on letters
and research and relationships.</p>
<p>Now on to what you probably came for…</p>
<p><strong>Do questions.</strong> That’s the biggest thing you can do now that will effect
your grade. Stop just straight reading First Aid. Switch from this
inefficient undirected review to only spot review based on the questions you
encounter. By now you should have a pretty good idea of what you’re weak
in. Spend time there so you stop bleeding points.</p>
<p><strong>Question banks: Rx … UW.</strong> UWorld is by far the best. Rx is lower
quality, but is an excellent stepping stone earlier in your study. I started
off my early studying with Rx, and once complete moved on to UWorld. I found
Kaplan too detailed and a little out of touch with UW. Absolutely finish
UWorld and the two self assessments. Mark good questions and come back for a
fast second pass on those marked ones. I think UWorld and Rx are the best
bang for your buck; Kaplan is just nice additional coverage. You would be
fine not even using Kaplan. More on my resources page on <a href="/medschool-resources#uworld">UWorld</a> and
<a href="/medschool-resources#question-banks">question banks</a>.</p>
<p><strong>Spreadsheet your schedule.</strong> Track daily progress, see when you are falling
behind your goals, make notes, keep motivated. You can see
<a href="https://drive.google.com/open?id=1WSxMoeXs_5UY1b8mdUqSL7oG0VN1KEsXzK0wCAu90Nc">my spreadsheet here</a>.</p>
<p><strong>Use Kaplan for extra questions in your weak areas.</strong> Even then, probably
best to repeat UW questions in those areas. But if you find you’ve memorized
the UW answers for those, then try Kaplan.</p>
<p><strong>Accuracy before speed.</strong> Keep the question banks in un-timed tutor mode.
Only switch to timed blocks and practice tests in the last 10-14 days leading
up until Test Day. While in un-timed tutor mode go slowly and really think
through questions and work on your technique and thoroughly flesh out a
process that works for you.</p>
<p><strong>Practice tests in the home stretch.</strong> Save these for the end. Taking one
early to “see where you stand” is absolutely a waste. You should already know
your weak areas from your grades thus far. If you do poorly, you’ll freak
out. If you do well, you’ll have a false sense of security. I did five
NBMEs; the higher numbers mean it’s more recent. Pay to get the
correct/incorrect. They don’t offer explanations, but you can search online
forums for help. Save the two UW SAs until the last 2-3 days before Test Day.</p>
<p><strong>Why did I get that wrong?</strong> For every question, really try to parse that
out. Did you misread? Did you over think? Were you able to see what the test
writers were going for? Did you narrow it down and guess wrong? Were you
jumping at a distractor? Did you narrow it down and give up and just guess?
Did you simply not have the requisite knowledge to answer? Did you rule out
the correct answer and, if so, why? Or was the correct answer still among the
ones you did not cross out?</p>
<p><strong>If you lack base knowledge…</strong> then it’s rote study time that’s
needed. Practice questions themselves can beat the information into you. But
if you’re consistently missing because of inadequate content, then best to
pause and really dig into that area…instead of continuing to bleed points.</p>
<p><strong>If you’re second guessing yourself…</strong> then maybe you’re over-thinking
it. Try asking yourself a different question: what is the tester trying to get
after? What are they trying to test me on? It might make the question unfold
simpler than it seems. Maybe you’re overthinking to make it more complicated.</p>
<p><strong>Triage your block time.</strong> For the questions about study bias and such,
probably simply doing lots of questions would be good. You’ll get familiar
with the tested aspects. For example, time on calculation questions was an
issue for me, so I liked to leave these questions till the end of the block
when I didn’t feel as much pressure to move along and didn’t fall into the
trap of blowing a lot of time. Just straight skipped them when I hit
them. Don’t even guess. Come back when you have time. As you get really good
in the last week or so, you’ll start having more time at the end to review and
do those. Leave them to the end when you have less feeling of pressure like
you need to move on.</p>
<p><strong>Only use Pathoma where you need review.</strong> Don’t simply plod through
it. Goljan however is really good to listen. I hit the treadmill an hour each
day for <em>focused</em> listening to one Goljan session each day. I swear, nearly
every day I got a question correct only because I had just heard that man talk
about it. For more tips on how to use this, see my <a href="/medschool-resources#pathoma">resources page</a>.</p>
<p><strong>Anatomy is always in context.</strong> You only need First Aid and UWorld. BRS is
too dense at this point. I recall that most questions centered around the
following:</p>
<ul>
<li>Innervation of the lower extremity (tibial, common peroneal/fibular,
anterior compartment, typically a tackle or injury just below the knee).</li>
<li>Brachial plexus. Know this cold. Draw that diagram repeatedly at moderate
detail. Know a few muscle innervations off that, winged scapula,
thoracodorsal.</li>
<li>Collateral blood supply of the stomach. In an emergency, if you had to cut
an artery, which would be okay? Would the spleen still get blood supply?</li>
<li>Portal hypertension anastomoses. There are only three so make a simple
table and memorize. Most often it was the esophageal varices.</li>
<li>Rotator cuff muscles. SItS and their movement. Innervations not very
important.</li>
</ul>
<p>Online videos are a great way to learn. More tips on my
<a href="/medschool-resources#anatomy">resources page</a>.</p>
<p><strong>Eat well and exercise daily.</strong> Take care of yourself. De-stress by
exercising. Spend time preparing nutritious foods (leafy greens, veggies, low
carbs, lots of water, low sugar).</p>
<p><strong>In your last week, focus on timing and routine.</strong> Get closer to simulating
the full test experience. Start doing questions at the same time your exam
will begin on test day. Practice the marathon portion. Aim for 150-200
questions per day so you start to understand your personal psychology when
fatigued. Get some experience working through that.</p>
<p><strong>Practice tests under real conditions.</strong> Start at 8am. Consider doing 8-10
warm up questions before. Take the appropriate breaks. Get to know yourself
and how you’re going to work through fatigue when it hits you. Better to learn
how to handle yourself now than wrestle with this on test day.</p>
<p><strong>Do nothing the day before Test Day.</strong> Something I wished I had allowed more
time for: rest before the exam. Maybe do ten questions the day before the exam
just to keep some focus, but you really need to restore your energy before
walking in there. You want to be busting with energy to tackle The Test, not
worn out from a forced march. Watch a movie. Exercise so you’re tired and
sleep well. Go to bed ridiculously early.</p>
<p>Always keep in mind that this one test does not define you and that, if you
have dreams, you can always find a way to achieve them.</p>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutMemorize Anything2015-02-13T00:00:00+00:00http://jgmalcolm.com/memorize-anything<p>Did you ever need to memorize a table of facts for some test? Tired of
reading and rereading through the table hoping the information will somehow
stick? This article outlines simple steps for using your imagination to build
“memory scenes” that leverage your visual, spatial, and emotional memory.</p>
<div class="series no-print">
<b>STEP1:</b>
<a href="/tactical-test-taking-skills">
Tactical Test-Taking Strategies
</a>
//
<a href="/medschool-resources">
Med School Resources
</a>
//
<a href="/medschool-strategy">
Med School Study Strategy
</a>
//
Memorize Anything
</div>
<h2 id="simple">Simple</h2>
<p><strong>Start with a unifying theme.</strong> Come up with a consistent theme for all your
objects in the scene that relates to your overall topic. For example, a
period in time (Renaissance) or a location (local diner). This common theme
will reinforce the connections binding all your symbols together. Setting a
scene also makes it easier to come up with individual symbols.</p>
<p>For example, if you recall that the entire scene was set in a farm field but
you’re forgetting one area, you have a better chance of narrowing it down as
you try to recall common farm objects likely present. If the scene had been
too ridiculous and involved completely unrelated objects, then good luck.
You’re screwed. It’s very easy to forget a symbol that’s unattached to
anything else.</p>
<p>If you’re having trouble coming up with a theme, go work on a few key objects
to get a feel for the elements, and then return to the overall theme and
figure out how these objects will come together.</p>
<p><strong>What immediately pops into your head?</strong> When you repeat the word or fact to
yourself, what is the first thing that comes to mind? Run with that natural
association.</p>
<p><strong>Stew on it.</strong> If nothing immediately comes to mind, don’t be afraid to mull
around for a while until you find something that really fits. Play with the
word some. Roll it around in your mouth. Pronounce it in various ways. Look
for a synonym. Use a dictionary to find other words that begin with the same
first few letters. Instead of representing the word directly, represent a key
fact about the concept. For example, to represent Calcium, you could use Milk
or a Cow.</p>
<p><strong>Trigger off most characteristic syllable.</strong> Unless every syllable is
important, just use the one with most emphasis. For example, for the
medication alendronate (a-len-DRONE-ate), the most characteristic syllable
sounds like “drone”, and you could represent it with a robot drone.</p>
<p><strong>Use easily recognizable objects.</strong> If the object is too complicated or
unusually decorated, it might get blurred in your visual memory. Use dynamic
action to make things memorable.</p>
<p><strong>Stark contrasts.</strong> Avoid weak or qualitative differences between contrasting
objects. Symbols should be either huge or tiny, incredibly strong or
laughably scrawny. Contrasting objects should be near enough that the
differences are obvious.</p>
<p><strong>Only include salient features.</strong> Ignore details in the initial stages. As
you become an expert in a topic, the details just naturally associate with the
topic in your mind. There is less need to fit them in at the beginning of
scene formation.</p>
<p><strong>Avoid multiple associations per object.</strong> Aim for a 1-to-1 mapping between
symbols and facts. You may think you’re clever with one object representing
three facts, but it’s easy to forget when there’s a list.</p>
<p><strong>Consistency.</strong> Aim for all your facts to be roughly the same size. If some
of your objects are huge and some are tiny, your mind’s eye may be overwhelmed
by the huge objects and forget all the tiny details.</p>
<p><strong>Avoid clutter.</strong> Too many symbols and they’ll mush together. Spread them
out. Split it up into multiple scenes, and reuse some symbols to link the
scenes. Also avoid putting in unnecessary detail: don’t put anything in the
scene that doesn’t actually represent a fact.</p>
<h2 id="vivid-pictures">Vivid pictures</h2>
<p><strong>Visceral and emotional.</strong> In order to get as many brain cells firing as
possible, you need to evoke visceral or emotional reactions. Gross blood,
smelly fish, painful wounds, a deflated ego, a guilty conscience, an
attractive person.</p>
<p><strong>Dynamic scenes.</strong> Use action to get your attention. A bunch of independent,
static objects can become a fragmented blur. A bunch of interactive objects
and moving actors will stick.</p>
<p><strong>Positioning.</strong> An object high up on a shelf might indicate a high value;
conversely, an object on the ground might indicate a low value. An object
falling down off a table might indicate a falling value.</p>
<p><strong>Make it real to you.</strong> Walk around it to see it from all sides. Push
something around. Focus on details. Smell, taste, and touch.</p>
<h2 id="getting-faster">Getting faster</h2>
<p>There is an up-front cost of time spent generating a scene, but I’ve found
that I don’t have to restudy material which saves me time overall. Even more,
as I’ve practiced constructing scenes, the process has become faster. I’m
faster now at coming up with symbols, associations, and an integrated scene.
Reusing symbols from previous scenes reinforces those same associations.</p>
<p>Spaced repetition is an efficient algorithm for scheduling when to revisit a
weak topic, but it does nothing to help you when you’re actually trying to
absorb the specific topic material. Sometimes I felt like I was getting hit
in head with a hammer repeatedly every time I encountered the same topic day
after day, each time unable to actually absorb and assimilate the details for
any meaningful retention.</p>
<p>Spend time reviewing and interacting with your mental scenes. Close your eyes
and walk through them. As you review, reach out to touch every object to make
it real, as if you’re there in the scene.</p>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutMed School Study Strategy2015-02-05T00:00:00+00:00http://jgmalcolm.com/medschool-strategy<div class="series no-print">
<b>STEP1:</b>
<a href="/tactical-test-taking-skills">
Tactical Test-Taking Strategies
</a>
//
<a href="/medschool-resources">
Med School Resources
</a>
//
Med School Study Strategy
//
<a href="/memorize-anything">
Memorize Anything
</a>
</div>
<h2 id="studying-takes-energy">Studying takes energy</h2>
<p>It’s often obvious what needs to be done and how best to do it. Sometimes all
that’s really needed is the energy (and motivation) to carry through. So part
of studying is managing your energy.</p>
<p>It takes a long time to truly build up the discipline and tolerance to sustain
consistent long hours for days on end. As you stretch yourself, you will do a
lot of studying when you really don’t want to. It’s critical you figure out
ways to manage your energy and stretch your <a href="http://www.amazon.com/gp/product/0143122231/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=0143122231&linkCode=as2&tag=jgmalcolm-20&linkId=RUYFTLGPIX7E62OL">willpower</a>.</p>
<div class="gallery">
<figure class="thumb">
<a href="/images/cascade.jpg" data-gallery="cascade" title="Repeatedly redrawing a table or chart is a way to memorize on autopilot.">
<img src="/images/cascade.jpg" /></a>
<figcaption>A chicken scratch diagram of the coagulation cascade. Lacking
some details and not something I'd put on the refrigerator, but at least I
now know the basic cascade.</figcaption>
</figure>
</div>
<p>Does your mind wandering while studying a diagram or memorizing a table?
Recopy it by hand multiple times. It requires only determination to keep
copying while you’re brain is (mostly) on autopilot. I’m always amazed at how
effective this can be. I usually pull this out when I’ve repeatedly gotten a
topic wrong, and I just channel that frustration into recopying a diagram or
table. Each iteration, add a new detail to the diagram, simplify a part you
already know, go faster.</p>
<p><strong>Break the problem down into easier pieces.</strong> Is the entire combined
glycolytic, TCA, Urea pathway too daunting? Then just pick one to redraw for
now. Work on another later. Similarly, if you’re getting worn down with full
blocks of 46 questions, do smaller blocks so you get more immediate feedback.
If your worn down by low performance, smaller blocks might show an actual
score improvement for some positive feedback to keep you motivated.</p>
<p><strong>Switch tactics to boost energy.</strong> If you’re getting bored of answering
questions, switch over to watch a video lecture.</p>
<p><strong>Optimize your procrastination equation.</strong> What’s keeping you from doing what
you know you need to be doing? Do you not think the pay off is worth it? The
payoff is too far away? The energy required is too much? Whatever it is,
figure out a way to optimize that part of the
<a href="http://lesswrong.com/lw/9wr/my_algorithm_for_beating_procrastination/">procrastination equation</a>.</p>
<h2 id="personal-traps">Personal traps</h2>
<p>Here are personal mistakes I’ve struggled against.</p>
<p><strong>Glossing over big words.</strong> I have a tendency to gloss over big words which
leaves it all a blur. For example, I might come across this sentence from
biochemistry: “Phenylketonuria is due to a decrease in phenylalanine
hydroxylase or decreased tetrahydrobiopterin cofactor”. I would wrongly gloss
over the unfamiliar words, so I end up reading something more like “Phenyl—
is due to a decrease in phenyl— — or decreased — cofactor”. It’s no
wonder that a lot of biochemistry was just a blur to me. I now to force
myself to slow down and parse every syllable, and slowly those hard words have
become more natural.</p>
<p><strong>Doing what’s easiest.</strong> Passively reading and nodding along because it all
seems familiar and I believe I know the material. The harder road is to
actively do questions that test recall. If material looks familiar but you’re
having trouble recalling details necessary to answer questions, then you can
probably blame passive review. As a corollary, with so many topics to study,
I often found myself avoiding some daunting topic by distracting myself with
more interesting (easier) topics. Thinking about the
<a href="http://lesswrong.com/lw/9wr/my_algorithm_for_beating_procrastination/">procrastination equation</a> often helped me find a way out of
the situation.</p>
<p><strong>Punting down field.</strong> Often when I was going through question banks, tired,
and hit a topic I didn’t know, I would mark the question and just tell myself
I’d come back to study it later. The truth: I never would come back. Fix:
Study the material immediately while the emotion of a wrong answer is still
present and you’ve got the question context in mind. If you’re too tired to
study the explanations, then you’re too tired to do questions. Either pack it
in, take a break, or switch to something else like watching Pathoma videos,
but don’t get in the habit of telling yourself you’ll do it tomorrow.
Tomorrow is always a day away.</p>
<p><strong>Tunnel vision.</strong> When a patient has presents with systems involving multiple
systems (renal, muscular, pulmonary), I tended to mistakenly jump at answer
choices that might explain one or two findings perfectly, but ultimately
didn’t explain all the physical exam or lab findings. Now I know my answer
choices need to <a href="/tactical-test-taking-skills#abnormal-findings">account for every abnormal finding</a>.
There are no wasted words in these vignettes.</p>
<p><strong>Going too fast.</strong> The more <a href="/tactical-test-taking-skills#qbanks">practice questions</a> I did, the quicker I
would get, but I also got sloppy. When I noticed myself not improving and
making stupid mistakes, I had to slow myself down. Read. Slower.</p>
<p><strong>Mistaking ‘activity’ for ‘active learning’.</strong> I often caught myself writing
everything down furiously so I can study it later. The truth is, you’ll
always be busy and never return to sort out the material. This is a form of
autopilot, passive learning. Always think critically about information
instead of just passively transcribing.</p>
<h2 id="organize-information-the-way-it-gets-tested">Organize information the way it gets tested</h2>
<p>Questions typically present a clinical vignette with chief complaint and then
some secondary information to narrow down the diagnosis.</p>
<p>For example, consider a patient presenting with osteomyelitis. With no clues,
<em>S aureus</em> is most likely overall, but the vignette will likely give some
history or physical exam findings that point to other causes. You want to put
to put together a table like the following.</p>
<table>
<thead>
<tr>
<th>Clue</th>
<th>Cause</th>
</tr>
</thead>
<tbody>
<tr>
<td>none</td>
<td><em>S aureus</em></td>
</tr>
<tr>
<td>Sexually active</td>
<td>septic arthritis, <em>Neisseria gonorrhea</em></td>
</tr>
<tr>
<td>Sickle cell</td>
<td><em>Salmonella</em></td>
</tr>
<tr>
<td>Diabetic</td>
<td><em>Pseudomonas</em></td>
</tr>
<tr>
<td>Prosthetic joint</td>
<td><em>S aureus</em> > <em>S epidermidis</em></td>
</tr>
<tr>
<td>Vertebra</td>
<td><em>M tuberculosis</em></td>
</tr>
<tr>
<td>Cat/Dog bite</td>
<td><em>Pasteurella</em></td>
</tr>
</tbody>
</table>
<p><strong>Make your own tables.</strong> Don’t simply reply on those in your textbooks or
First Aid. Work out your own versions that start out simpler and only list
and compare one or two of the most important features.</p>
<p>Some dimensions you can compare and contrast along:</p>
<ul>
<li>epidemiology
<ul>
<li>younger or older patients?</li>
<li>risk factors: sex, drugs, smoking</li>
</ul>
</li>
<li>onset
<ul>
<li>slow, insidious, progressive</li>
<li>acute, emergent</li>
<li>congenital, shortly after birth</li>
</ul>
</li>
</ul>
<p><strong>Look for contrasts to distinguish diseases.</strong></p>
<ul>
<li>Pernicious anemia (autoimmune destruction) vs. B12 insufficiency (diet)</li>
<li>Follicular adenoma (encapsulated) vs. follicular carcinoma (capsular breech)</li>
<li>21-beta-hydroxylase (hypotensive) vs. 11-beta-hydroxylase (hypertensive)</li>
<li>Liddle’s Syndrome (hypokalemia) vs. Georges Syndrome (hyperkalemia)</li>
<li>Thalassemia (defective synthesis of globin) vs. Sickle Cell (defective
structure of globin)</li>
</ul>
<h2 id="to-type-or-write">To type or write?</h2>
<p>Typing is fast. Writing is slow, but it forces you to think critically about
what’s important to record.</p>
<p>Typing lets you copy and paste previous notes. Writing forces you to be
economical in what you choose to record. Typing lets you copy and paste a
figure into your notes. Writing forces you to recopy the figure from scratch.
Writing ultimately forces you to work with the information slowly and
deliberately, and hence you’re more likely to remember.</p>
<p>Typing lulls you into a false security of being able to quickly search and
look up information. Writing forces you to scan manually, and so you end up
reviewing more ancillary information while searching for what you really want.</p>
<p>I started out typing to record the deluge of information, but ultimately I
ended up writing so I’d exercise my memory every time I had to rewrite a fact.</p>
<h2 id="scratch-work">Scratch work</h2>
<p>Draw diagrams and simple tables. Don’t transcribe everything; these notes
should be much simpler than your textbooks and review. Only record 1-2 key
distinguishing facts. Those key facts will jog your memory of additional
ancillary facts.</p>
<p>When you revisit a topic, try to reproduce (redraw) as much as you can from
memory. Resist the urge to immediately flip back in your notes. Every time
you stretch your recall, it strengthens those neurons. Every time you redraw
a diagram, you’ll get faster. I was dumb as bricks when it came to metabolic
biochemistry. Repeatedly redrawing metabolic pathways was the only way I
could get it through my thick skull.</p>
<p>Keep this all bound, in order (dated) in a notebook so you can flip back (“Oh,
I remember that from last week … let me find that …”). At the start of
each day’s study session, skim your pages from yesterday or the day before.
Since these notes are all the things you got wrong or want to remember, this
is like a poor man’s version of <a href="/top-students#spaced-repetition">spaced repetition</a>.</p>
<p>No figure or table is sacred. I often fall into the trap of trying to make
things pretty, or shying away from even starting a table or figure because I
think it’ll be a mess. Go fast and loose, and repeat frequently.</p>
<h2 id="daily-review">Daily Review</h2>
<p>Every day during my Step 1 & 2 study blocks I would start with a blank sheet
of paper and record scratch notes on anything I got wrong or lessons learned
– mostly just two or three word associations or small lists. What was a key
fact I should know? This was very fast, loose, and cursory. It wasn’t meant
to be saved. What did I do with this? At the start of every new day I would
scan that list to refresh my brain. It typically took less than five minutes.
No need to look stuff up, just read what the page has. I filed these away in
a stack but rarely looked at them again. Afterward, I was warmed up and would
begin with a fresh sheet of paper.</p>
<h2 id="when-studying">When studying</h2>
<p><strong>Control your environment, or it will control you.</strong> If there’s something
distracting, get rid of it. If you are at a coffee shop distracted by
someone nearby, move your table or move to a different area. If you’re
attention keeps drifting to something outside the window, draw the shades or
move locations. If you keep getting the impulse to check the news,
<a href="/top-students#focus">block the website</a>. Move to a high traffic location where fellow
students can see over your shoulder that you’re goofing off. Erect whatever
barriers are necessary to make studying the easy road.</p>
<p><strong>Unload distractions.</strong> If you realize you need to do laundry, don’t.
Instead, write that on a piece of paper for something to do during your
upcoming break. Anything that is on your mind that’s not about studying,
simply write it on this list to think about later. The simple act of
writing something down and pushing that aside helps me de-clutter my mind.
When a distracting urge rises up, learn to say “No” to yourself.</p>
<p><strong>Set timers.</strong> This will force you to be conscious of time and not simply let
study time fill all your time. During the first half of medical school you
have plenty of time so you can study for hours, but during the clinical years
you have very little time and you need to get faster at covering material.
Use the clock to up your game.</p>
<p><strong>Be disciplined about short breaks.</strong> Many times my 15min break would
easily stretch to 30, 45min. Set a timer to kick you back in to gear when
the time comes.</p>
<p><strong>Use your breaks to re-energize.</strong> While studying, make a list of what you
are looking forward to doing during your next break. Plan fun things to
look forward to. When I get really worn down and start dragging in my
studies, one remedy I use it to plan something super fun for the next break
or that evening.</p>
<p><strong>When Not Studying.</strong> What you do outside your study time will affect what
you do during your study time.</p>
<ul>
<li><strong>Sleep.</strong> Decrease stress and let your brain process the info you’ve fed it.</li>
<li>
<p><strong>Exercise.</strong> Decrease stress, release energy.</p>
</li>
</ul>
<h2 id="step1">STEP1</h2>
<p>It will punish those who do not put in the time. As a cumulative exam,
anything you failed to learn during your modules will show up here and cost
you points again. If you didn’t learn something the first time, now is your
last chance.</p>
<p>It is a test of endurance and discipline. I’m not talking about test day.
I’m talking about endurance and discipline in the weeks leading up to test
day. If you fail to work diligently during your dedicated period, you will be
punished.</p>
<p>It is also a very straight forward test for anyone willing to dedicate the
energy to working through question banks.</p>
<p><strong>How badly do you want it?</strong> All the tactics in the world are not going to
work if you don’t have the motivation to push forward. Strong motivation
energizes and fully engages your senses. Step back and think about what you
want in a career and what you’re willing to trade for it. Do you want that
subspecialty residency so much that you’re willing to prioritize weekend study
over social outings?</p>
<p>It’s not just about a test score and getting into a top residency. It’s about
becoming the best physician possible. It’s about being able to answer patient
questions, explaining to them what’s happening to their bodies. It’s about
being able to notice a disease pattern that others might have missed.</p>
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James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutWashington: A Life2015-01-01T00:00:00+00:00http://jgmalcolm.com/washington-a-life<figure class="thumb">
<img src="/images/books/washington.jpg" />
<figcaption>'Washington: A Life' by Ron Chernow</figcaption>
</figure>
<p>George Washington was a British officer, the commanding general in the
American Colonial Revolution, reluctant political figure, and by his actions
defined the role of President of the United States.</p>
<p><strong>British Officer.</strong> Before the revolution, Washington rose to the rank of
Major in the colonial branch of the British army. Since he was not part of
the core British regiments, he was always treated as a second class soldier
and hit a glass ceiling for promotion. His frustration over this likely
helped tip him toward revolution.</p>
<p><strong>Discipline and routine.</strong> He rose at dawn to survey his land during his days
as a farmer or troops as a general.</p>
<p>Several times early in the war he jumped into battle to turn the course of
events. This risk to self both worried his generals and inspired his troops.
With time, he came to realize the risk to his army if he were to be lost and
he relied more on his generals.</p>
<p><strong>Chronic debt.</strong> With the war and presidency consuming his attention, his
farm crops were chronically unsuccessful and often ran at a loss. On top of
that, he liked nice things: shopping sprees whenever he traveled, ordering the
latest fashions from Europe. After assuming the presidency, he ceased to
purchase from Europe and instead focused one wearing “Made in the USA”
clothing to show his support.</p>
<p><strong>Honored his personal debt.</strong> Even though many colonists used the successful
ending of the revolution as an excuse to not repay debts owed to British,
Washington made a point to pay down his personal debts. Unfortunately,
hyper-inflation of the colonial currency made it more difficult for him to
collect on the debts he was owed by land tenants and such.</p>
<p><strong>Assumed state debt to bind the union.</strong> During the revolution, each state
went into debt, both domestic and foreign. Alexander Hamilton, the first
Treasury Secretary, proposed the federal government assume all state debt.
Having just thrown off one tyrannical government, many states feared now being
indebted to a new master, but ultimately the plan prevailed. The most
important effect of pooling debt in this new government was to bind the states
into a union under one bank.</p>
<h2 id="discipline">Discipline</h2>
<blockquote>
<p>As president, he lectured a young relative about to enter college that
“every hour misspent is lost forever” and that “future years cannot
compensate for lost days at this period of your life.”</p>
</blockquote>
<p>Corollary: Waste a dollar and you can always later earn a dollar to replace
it, but waste an hour and it’s gone forever.</p>
<blockquote>
<p>A master of the profitable use of time, Washington listed his monthly doings
in his diary under the rubric “Where and how my time is spent.” Whether for
business or social occasions, his punctuality was legendary, and he expected
everyone to be on time. In his business dealings, he boasted that “no man
discharges the demand of wages or fulfills agreements with more punctuality
than I do.”</p>
</blockquote>
<blockquote>
<p>His love of ritual, habit, and order enabled him to sustain the long,
involved tasks that distinguished his life. “System in all things is the
soul of business,” he liked to say. “To deliberate maturely and execute
promptly is the way to conduct it to advantage.”</p>
</blockquote>
<blockquote>
<p>Washington benefited from the unvarying regularity of his daily routine and
found nothing monotonous about it. Like many thrifty farmers, he rose before
sunrise and accomplished much work while others still slept. Prior to
breakfast, he shuffled about in dressing gown and slippers and passed an
hour or two in his library, reading and handling correspondence. He also
devoted time to private prayers before Billy Lee laid out his clothes,
brushed his hair, and tied it in a queue. Washington liked to examine his
stables before breakfast, inspect his horses, and issue instructions to the
grooms. Then he had an unchanging breakfast of corn cakes, tea, and honey.</p>
</blockquote>
<blockquote>
<p>Washington couldn’t bear anything slovenly. “I shall begrudge no reasonable
expense that will contribute to the improvement and neatness of my farms,
for nothing pleases me better than to see them in good order and everything
trim, handsome, and thriving about them,” he advised one estate
manager. “Nor nothing hurts me more than to find them otherwise and the
tools and implements laying wherever they were last used, exposed to
injuries from rain, sun, etc.” No detail was too trivial to escape his
notice, and he often spouted the Scottish adage “Many mickles make a
muckle”—that is, tiny things add up.</p>
</blockquote>
<h2 id="revolution">Revolution</h2>
<p>If Britain had treated colonists as first class citizens, the revolution might
have never have reached critical mass, and America might still be a colony.</p>
<blockquote>
<p>Washington’s first stirrings of anti-British fervor had arisen from his
failure to receive a royal commission, but they were now joined by
disenchantment over pocketbook issues. Great Britain was simply bad for
local business, a fact that would soon foster the historical anomaly of a
revolution inaugurated by affluent, conservative leaders. As potentates of
vast estates, lords of every acre they saw, George Washington and other
planters didn’t care to truckle to a distant, unseen power.</p>
</blockquote>
<p>I had always pictured the Founding Fathers all being roughly the same age, but
of course they were all in different stages of life. Franklin was the elderly
grandfatherly figure. Washington was not much younger. Jefferson was just a
student.</p>
<blockquote>
<p>In the House of Burgesses, a young rabble-rouser, Patrick Henry, rose amid
the dark wooden benches and brandished fiery resolutions. “Resolved,” he
announced, “that the taxation of the people by themselves or by persons
chosen by themselves to represent them . . . is the distinguishing
characteristic of British freedom.” For a young law student standing in the
rear of the hushed chamber, these words sounded with a thrilling
resonance. “He appeared to me to speak as Homer wrote,” Thomas Jefferson
remembered.</p>
</blockquote>
<p>Washington’s personal debt burden weighted heavily on his shoulders and
factored keenly into his thoughts on secession. His insight here into the
psychology of debt is as true today as it was then.</p>
<blockquote>
<p>On April 5, 1769, Washington sent Mason a remarkable letter that gave both
his private and his public reasons for supporting a boycott of British
goods. Doubtless thinking of his own plight, he said a boycott would break
the onerous cycle of debt that trapped many colonists, purging their
extravagant spending. Before this the average colonial debtor was too weak
to break this habit, “for how can I, says he, who have lived in such and
such a manner, change my method? . . . besides, such an alteration in the
system of my living will create suspicions of a decay in my fortune and such
a thought the world must not harbor.” <strong>Washington provided here a key
insight into the psychology of debt: fear that any attempt at a more frugal
existence would disclose the truth about a person’s actual wealth.</strong></p>
</blockquote>
<p>Declaring an official revolt was dangerous. For these colonists, it was an
all or nothing decision. If they failed, they knew what fate awaited them.
They risked everything.</p>
<blockquote>
<p>The Declaration made the rebels’ treason official and reminded them of the
unspeakable punishments the British government meted out for this
offense. Only recently a British judge had handed down this grisly sentence
to Irish revolutionaries: “You are to be drawn on hurdles to the place of
execution, where you are to be hanged by the neck, but not until you are
dead, for while you are still living your bodies are to be taken down, your
bowels torn out and burned before your faces, your heads then cut off, and
your bodies divided each into four quarters.”</p>
</blockquote>
<p>The French revolution came soon after the American revolution, but both were
founded on very different ideals.</p>
<blockquote>
<p>An essential difference between the American and French revolutions was that
the American version allowed a search for many truths, while French zealots
tried to impose a single sacred truth that allowed no deviation.</p>
</blockquote>
<h2 id="personal">Personal</h2>
<p>Washington was chronically in debt.</p>
<blockquote>
<p>Money was the one area where Washington tended to dodge personal
responsibility and blame force majeure.</p>
</blockquote>
<blockquote>
<p>While public life forced Washington into expenditures beyond his control,
during his entire adult life he had exhibited an inability to live within
his means.</p>
</blockquote>
<p>Throughout the war, Washington was torn between the crumbling colonial army
and his crumbling personal property.</p>
<blockquote>
<p>Washington must have been distressed by the creeping signs of decay
everywhere. Whatever the war’s outcome, he would be left a poorer man, which
weighed heavily on his mind. That June, in a letter to William Crawford, the
steward of his western lands, he broke down and confided his concern about
his wealth withering away as the war progressed: “My whole time is . . . so
much engrossed by the public duties of my station that I have totally
neglected all my private concerns, which are declining every day, and may
possibly end in capital losses, if not absolute ruin, before I am at liberty
to look after them.”</p>
</blockquote>
<div class="gallery">
<figure class="thumb">
<a href="/images/washington.jpg">
<img title="Washington during his second term started to show the physical
signs of fatigue from the presidency." src="/images/washington.jpg" />
</a>
<figcaption>Washington during his second term started to show the physical
signs of fatigue from the presidency.</figcaption>
</figure>
</div>
<blockquote>
<p>The pastel portrait that Williams executed on September 18, 1794, shows a
particularly dour, cranky Washington, with a tightly turned-down
mouth. Posing in a black coat, he wears Masonic symbols on a blue sash that
slants diagonally across his chest. His face is neither friendly nor heroic
but looks like that of a bad-tempered relative, suggesting that the
presidency was now a trial he endured only for the public good. Unsparing in
its accuracy, the Williams portrait shows various blemishes on Washington’s
face—a scar that curves under the pouch of his left eye; a mole below his
right earlobe; smallpox scars on both his nose and cheeks—ordinarily edited
out of highly sanitized portraits.</p>
</blockquote>
<h2 id="government">Government</h2>
<p>Washington presided over a rabble citizenry that just toppled its previous
government. Always conscious of its populist tendencies, he tried to shepherd
gently.</p>
<blockquote>
<p>One virtue of a war that dragged on for so many years was that it gave the
patriots a long gestation period in which to work out the rudiments of a
federal government, financial mechanisms, diplomatic alliances, and other
elements of a modern nation-state.</p>
</blockquote>
<blockquote>
<p>Try though he might, Washington couldn’t completely extricate his thoughts
from politics and feared that the still immature country would blunder into
errors before arriving at true wisdom. As he affirmed, “all things will come
right at last. But, like a young heir come a little prematurely to a large
inheritance, we shall wanton and run riot until we have brought our
reputation to the brink of ruin.” Only when a crisis materialized would the
country be “compelled perhaps to do what prudence and common policy pointed
out as plain as any problem in Euclid in the first instance.” This statement
tallied with Washington’s often expressed view that citizens had to feel
before they saw—that is, they couldn’t react to abstract problems, only to
tangible ones.</p>
</blockquote>
<blockquote>
<p>The long fight against British tyranny, paradoxically, only strengthened his
view that the foremost political danger came not from an overly powerful
central government but from an enfeebled one—“a half-starved, limping
government that appears to be always moving upon crutches and tottering at
every step.”</p>
</blockquote>
<blockquote>
<p>Shays’s Rebellion crystallized for him the need to overhaul the Articles of
Confederation. “What stronger evidence can be given of the want of energy in
our governments than these disorders?” he asked Madison. “If there exists
not a power to check them, what security has a man of life, liberty, or
property?”</p>
</blockquote>
<blockquote>
<p>He also knew that the American public needed to contribute its share; the
Constitution “can only lay the foundation—the community at large must raise
the edifice.”</p>
</blockquote>
<blockquote>
<p>Closer in tone to future inaugural speeches was his ringing expression of
faith in the American people. He devised a perfect formulation of popular
sovereignty, writing that the Constitution had brought forth “a government
of the people: that is to say, a government in which all power is derived
from, and at stated periods reverts to, them—and that, in its operation
. . . is purely a government of laws made and executed by the fair
substitutes of the people alone.”</p>
</blockquote>
<blockquote>
<p>A whirlwind of energy, Madison would seem omnipresent in the early days of
Washington’s administration. He drafted not only the inaugural address but
also the official response by Congress and then Washington’s response to
Congress, completing the circle.</p>
</blockquote>
<blockquote>
<p>Although Washington seemed unaware of it, Hamilton had been training for the
Treasury post throughout the war, boning up on subjects as diverse as
foreign exchange and central banks. Like Washington, Knox, and other
Continental Army officers, Hamilton had perceived an urgent need for an
active central government, and he grasped the reins of power with a
sure-handed gusto that set the tenor for the administration. He headed a
Treasury Department that, with thirty-nine employees, instantly surpassed
the rest of the government in size. Of particular importance, he presided
over an army of customs inspectors whose import duties served as the
government’s main revenue source.</p>
</blockquote>
<blockquote>
<p>In its sparsely worded style, the Constitution mandated that the president,
from time to time, should give Congress information about the state of the
Union, but it was Washington who turned this amorphous injunction into a
formal speech before both houses of Congress, establishing another
precedent. Trailing him in his entourage were the chief justice and members
of his cabinet, leading to yet another tradition: that the State of the
Union speech (then called the annual address) would feature leading figures
from all three branches of government. Everything about the new government
still had an improvised feel, and Washington’s advent occasioned some
last-minute scurrying in the Senate chamber.</p>
</blockquote>
<blockquote>
<p>Hamilton was also persuaded that, since the debt had been raised to finance
a national war, the federal government should assume responsibility for the
states’ debts as well. Such an act of “assumption” would have
extraordinarily potent political effects, for holders of state debt would
transfer their loyalty to the new central government, binding the country
together. It would also reinforce the federal government’s claim to future
tax revenues in any controversies with the states.</p>
</blockquote>
<blockquote>
<p>Washington had ten days to sign or veto the bank bill and stalled in making
up his mind. Perhaps by design, Hamilton delivered, and Washington accepted,
the argument in favor of the bill right before that deadline expired,
leaving no time for an appeal inside the cabinet. When Washington signed the
bill on February 25, 1791, it was a courageous act, for he defied the legal
acumen of Madison, Jefferson, and Randolph. Unlike his fellow planters, who
tended to regard banks and stock exchanges as sinister devices, Washington
grasped the need for these instruments of modern finance. It was also a
decisive moment legally for Washington, who had felt more bound than
Hamilton by the literal words of the Constitution. With this stroke, he
endorsed an expansive view of the presidency and made the Constitution a
living, open-ended document. The importance of his decision is hard to
overstate, for had Washington rigidly adhered to the letter of the
Constitution, the federal government might have been stillborn. Chief
Justice John Marshall later seized upon the doctrine of “implied powers” and
incorporated it into seminal Supreme Court cases that upheld the power of
the federal government.</p>
</blockquote>
<blockquote>
<p>Washington and other founders entertained the fanciful hope that America
would be spared the bane of political parties, which they called “factions”
and associated with parochial self-interest. The first president did not see
that parties might someday clarify choices for the electorate, organize
opinion, and enlist people in the political process; rather he feared that
parties could blight a still fragile republic. He was hardly alone. “If I
could not go to heaven but with a party,” Jefferson opined, “I would not go
there at all.” Yet the first factions arose from Jefferson’s extreme
displeasure with Hamilton’s mounting influence. They were not political
parties in the modern sense so much as clashing coteries of intellectual
elites, who operated through letters and conversations instead of meetings,
platforms, and conventions. Nonetheless these groups solidified into parties
during the decade and, notwithstanding the founders’ fears, formed an
enduring cornerstone of American democratic politics.</p>
</blockquote>
<blockquote>
<p>However trying he often found the press, Washington understood its
importance in a democracy and voraciously devoured gazettes. Before becoming
president, he had lauded newspapers and magazines as “easy vehicles of
knowledge, more happily calculated than any other to preserve the liberty
. . . and meliorate the morals of an enlightened and free people.” In his
unused first inaugural address, he had gone so far as to advocate free
postal service for periodicals. As press criticism mounted, however,
Washington struggled to retain his faith in an independent press. In October
1792 he told Gouverneur Morris that he regretted that newspapers exaggerated
political discontent in the country, but added that “this kind of
representation is an evil w[hi]ch must be placed in opposition to the
infinite benefits resulting from a free press.” A month later, in a more
somber mood, he warned Jefferson that Freneau’s invective would yield
pernicious results: “These articles tend to produce a separation of the
Union, the most dreadful of calamities; and whatever tends to produce
anarchy, tends, of course, to produce a resort to monarchical government.”</p>
</blockquote>
<blockquote>
<p>At the end he struck a note of serenity, a faith that the American
experiment, if sometimes threatened, would prevail. While fearful of
machinations, he told Trumbull, “I trust . . . that the good sense of our
countrymen will guard the public weal against this and every other
innovation and that, altho[ugh] we may be a little wrong now and then, we
shall return to the right path with more avidity.” 15 It was an accurate
forecast of American history, both its tragic lapses and its miraculous
redemptions.</p>
</blockquote>
<blockquote>
<p>The presidential legacy he left behind in Philadelphia was a towering
one. As Gordon Wood has observed, “The presidency is the powerful office it
is in large part because of Washington’s initial behavior.” Washington had
forged the executive branch of the federal government, appointed outstanding
department heads, and set a benchmark for fairness, efficiency, and
integrity that future administrations would aspire to match. “A new
government, constructed on free principles, is always weak and must stand in
need of the props of a firm and good administration till time shall have
rendered its authority venerable and fortified it by habits of obedience,”
Hamilton wrote. Washington had endowed the country with exactly such a firm
and good administration, guaranteeing the survival of the Constitution. He
had taken the new national charter and converted it into a viable, elastic
document. In a wide variety of areas, from inaugural addresses to
presidential protocol to executive privilege, he had set a host of
precedents that endured because of the high quality and honesty of his
decisions. Washington’s catalog of accomplishments was simply
breathtaking. He had restored American credit and assumed state debt;
created a bank, a mint, a coast guard, a customs service, and a diplomatic
corps; introduced the first accounting, tax, and budgetary procedures;
maintained peace at home and abroad; inaugurated a navy, bolstered the army,
and shored up coastal defenses and infrastructure; proved that the country
could regulate commerce and negotiate binding treaties; protected frontier
settlers, subdued Indian uprisings, and established law and order amid
rebellion, scrupulously adhering all the while to the letter of the
Constitution. During his successful presidency, exports had soared, shipping
had boomed, and state taxes had declined dramatically. Washington had also
opened the Mississippi to commerce, negotiated treaties with the Barbary
states, and forced the British to evacuate their northwestern forts. Most of
all he had shown a disbelieving world that republican government could
prosper without being spineless or disorderly or reverting to authoritarian
rule. In surrendering the presidency after two terms and overseeing a smooth
transition of power, Washington had demonstrated that the president was
merely the servant of the people.</p>
</blockquote>
<p>The political climate of the day was acrimonious and this was a constant
scourge on Washington. As time went on, his early confidants Jefferson and
Madison turned on him. Political parties sprang up and discourse was often
vitriolic:</p>
<blockquote>
<p>Washington never achieved the national unity he desired and, by the end,
presided over a deeply riven country. John Adams made a telling point when
he later noted that Washington, an apostle of unity, “had unanimous votes as
president, but the two houses of Congress and the great body of the people
were more equally divided under him than they ever have been since.” This
may have been unavoidable as the new government implemented the new
Constitution, which provoked deep splits over its meaning and the country’s
future direction. But whatever his chagrin about the partisan strife,
Washington never sought to suppress debate or clamp down on his shrill
opponents in the press who had hounded him mercilessly. To his everlasting
credit, he showed that the American political system could manage tensions
without abridging civil liberties. His most flagrant failings remained those
of the country as a whole—the inability to deal forthrightly with the
injustice of slavery or to figure out an equitable solution in the ongoing
clashes with Native Americans.</p>
</blockquote>
<h2 id="martha">Martha</h2>
<p>The Presidency clearly took its toll on Washington and his family, as I’m sure
every Presidency since then has.</p>
<blockquote>
<p>To the end of her life, Martha Washington would speak forlornly of the
presidential years as her “lost days.”</p>
</blockquote>
<blockquote>
<p>Martha Washington had sacrificed so much privacy during her married life
that after her husband died, she evened the score by burning their personal
correspondence—to the everlasting chagrin of historians.</p>
</blockquote>
<h2 id="leadership">Leadership</h2>
<blockquote>
<p>Whether on the plantation, in the army, or in government, he stressed the
need to inspire respect rather than affection in subordinates, a common
thread running through his vastly disparate managerial activities.</p>
</blockquote>
<blockquote>
<p>When General Howe herded 300 destitute Bostonians, riddled with disease,
onto boats and dumped them near American lines, Washington feared that they
carried smallpox; he sent them humanitarian provisions while carefully
insulating them from his troops. After a second wave of 150 sickly
Bostonians was expelled, Washington grew convinced that Howe had stooped to
using smallpox as a “weapon of defense” against his army. By January 1777 he
ordered Dr. William Shippen to inoculate every soldier who had never had the
disease. “Necessity not only authorizes but seems to require the measure,”
he wrote, “for should the disorder infect the army in the natural way and
rage with its usual virulence, we should have more to dread from it than the
sword of the enemy.” This enlightened decision was as important as any
military measure Washington adopted during the war.</p>
</blockquote>
<blockquote>
<p>Washington tried to rouse his untried men with impassioned words. He had a
genius for exalting the mission of his army and enabling the men to see
themselves, not as lowly grunts, but as actors on the stage of history. “The
time is now near at hand which must probably determine whether Americans are
to be free men or slaves . . . The fate of unborn millions will now depend,
under God, on the courage . . . of this army.”</p>
</blockquote>
<blockquote>
<p>Finally he was stranded alone on the battlefield with his aides, his troops
having fled in fright. Most astonishingly, Washington on horseback stared
frozen as fifty British soldiers started to dash toward him from eighty
yards away. Seeing his strangely catatonic state, his aides rode up beside
him, grabbed the reins of his horse, and hustled him out of danger. In this
bizarre conduct, Nathanael Greene saw a suicidal impulse, contending that
Washington was “so vexed at the infamous conduct of his troops that he
sought death rather than life.” Weedon added the compelling detail that only
with difficulty did Washington’s colleagues “get him to quit the field, so
great was his emotions.” It was a moment unlike any other in Washington’s
career, a fleeting emotional breakdown amid battle.</p>
</blockquote>
<blockquote>
<p>He seemed to know implicitly that no loyalty surpassed that of a man
forgiven for his faults who vowed never to make them again.</p>
</blockquote>
<blockquote>
<p>Yet despite the calamities at Forts Washington and Lee, the British had done
Washington an inadvertent favor. They had shown him the futility of trying
to defend heavily fortified positions along the seaboard and forced him out
into the countryside, where he had mobility and where the British Army,
deprived of the Royal Navy, operated at a disadvantage. For political
reasons, Washington hadn’t been able to countermand the congressional
decision to defend New York City and the Hudson River, but now that he had
done so and suffered predictable defeats, he would have more freedom to pick
and choose his targets. With his drastically diminished army and depleted
supplies, it was no longer a question of standing and confronting the
British with their vastly superior troops and firepower.</p>
</blockquote>
<blockquote>
<p>English poet Edward Young: “ ‘Affliction is the good man’s shining time.’”</p>
</blockquote>
<blockquote>
<p>Washington demanded self-sacrifice from aides, who had to follow his
schedule uncomplainingly. If he slept in the open air before a battle, so
did they. “When I joined His Excellency’s suite,” wrote James McHenry, “I
gave up soft beds, undisturbed repose, and the habits of ease and indulgence
. . . for a single blanket, the hard floor or the softer sod of the fields,
early rising, and almost perpetual duty.”</p>
</blockquote>
<blockquote>
<p>Washington was adept at identifying young talent. He wanted eager young men
who worked well together, pitched in with alacrity, and showed esprit de
corps. His own personality forbade backslapping familiarity or easy
joviality. Beneath his reserve, however, he had an excellent capacity for
reading people and adapting his personality to them. As before the war, he
remained wary in relationships and lowered his emotional barriers only
slowly, but he was trusting once colleagues earned his confidence.</p>
</blockquote>
<blockquote>
<p>Since the Battle of Monmouth, Washington had soldiered on for more than two
years without a major battle, and Lafayette told him of impatience at
Versailles with his supposed passivity. Washington replied that this
inactivity was involuntary: “It is impossible, my dear Marquis, to desire
more ardently than I do to terminate the campaign by some happy stroke, but
we must consult our means rather than our wishes.”</p>
</blockquote>
<blockquote>
<p>Washington surrounded himself with a small but decidedly stellar group. With
his own renown secure, he had no fear that subordinates would upstage him
and never wanted subservient courtiers whom he could overshadow. Aware of
his defective education, he felt secure in having the best minds at his
disposal. He excelled as a leader precisely because he was able to choose
and orchestrate bright, strong personalities. As Gouverneur Morris observed,
Washington knew “how best to use the rays” given off by the sparkling
geniuses at his command. 9 As the first president, Washington assembled a
group of luminaries without equal in American history; his first cabinet
more than made up in intellectual fire-power what it lacked in numbers.</p>
</blockquote>
<blockquote>
<p>Washington’s accomplishments as president were no less groundbreaking than
his deeds in the Continental Army. It is a grave error to think of George
Washington as a noble figurehead presiding over a group of prima donnas who
performed the real work of government. As a former commander in chief, he
was accustomed to a chain of command and delegating important duties, but he
was also accustomed to having the final say. As president, he enjoyed
unparalleled power without being autocratic. He set out less to implement a
revolutionary agenda than to construct a sturdy, well-run government, and in
the process he performed many revolutionary acts.</p>
</blockquote>
<blockquote>
<p>Washington grew as a leader because he engaged in searching
self-criticism. “I can bear to hear of imputed or real errors,” he once
wrote. “The man who wishes to stand well in the opinion of others must do
this, because he is thereby enabled to correct his faults or remove
prejudices which are imbibed against him.” The one thing Washington could
not abide was when people published criticisms of him without first giving
him a chance to respond privately.</p>
</blockquote>
<p>Henry Knox was one of his most trusted generals, until Knox chose his family
over the war efforts. Washington may have begrudged him, because he himself
was constantly submitting his personal affairs to those of the nation:</p>
<blockquote>
<p>While Washington was at Carlisle, Henry Knox belatedly returned to
Philadelphia. It must have dawned on him just how annoyed Washington was by
his protracted absence, for he sent him a letter awash with “inexpressible
regret that an extraordinary course of contrary winds” had delayed his
return. Knox volunteered to join Washington at Carlisle and must have been
shocked by his curt reply: “It would have given me pleasure to have had you
with me on my present tour and advantages might have resulted from it, if
your return in time would have allowed it. It is now too late.” This was a
remarkable message: the president was banishing the secretary of war from
the largest military operation to unfold since the Revolutionary War. In
addition to giving Knox a stinging rap on the knuckles, Washington must also
have seen that Hamilton had assumed a commanding posture and would have
yielded to Knox only with reluctance.</p>
</blockquote>
<blockquote>
<p>[H]e summed up his executive style: “Much was to be done by prudence, much
by conciliation, much by firmness.”</p>
</blockquote>
<p>Hamilton nicely sums up Washington’s approach to major decisions:</p>
<blockquote>
<p>Hamilton concurred that the president “consulted much, pondered much;
resolved slowly, resolved surely.”</p>
</blockquote>
<blockquote>
<p>Well aware of his own executive style, Washington once instructed a cabinet
member “to deliberate maturely, but to execute promptly and vigorously.”</p>
</blockquote>
<blockquote>
<p>Washington once advised his adopted grandson that “where there is no
occasion for expressing an opinion, it is best to be silent, for there is
nothing more certain than that it is at all times more easy to make enemies
than friends.”</p>
</blockquote>
<blockquote>
<p>A taciturn man, Washington never issued opinions promiscuously. A
disciplined politician, he never had to retract things uttered in a
thoughtless moment. “Never be agitated by more than a decent warmth and
offer your sentiments with modest diffidence,” he told his nephew Bushrod,
noting that “opinions thus given are listened to with more attention than
when delivered in a dictatorial style.” He worried about committing an error
more than missing a brilliant stroke. Washington also hated boasting.</p>
</blockquote>
<blockquote>
<p>By the time of his death, Washington had poured his last ounce of passion
into the creation of his country. Never a perfect man, he always had a
normal quota of human frailty, including a craving for money, status, and
fame. Ambitious and self-promoting in his formative years, he had remained a
tightfisted, sharp-elbowed businessman and a hard-driving slave master. But
over the years, this man of deep emotions and strong opinions had learned to
subordinate his personal dreams and aspirations to the service of a larger
cause, evolving into a statesman with a prodigious mastery of political
skills and an unwavering sense of America’s future greatness. In the things
that mattered most for his country, he had shown himself capable of constant
growth and self-improvement. George Washington possessed the gift of
inspired simplicity, a clarity and purity of vision that never failed
him. Whatever petty partisan disputes swirled around him, he kept his eyes
fixed on the transcendent goals that motivated his quest. As sensitive to
criticism as any other man, he never allowed personal attacks or threats to
distract him, following an inner compass that charted the way ahead. For a
quarter century, he had stuck to an undeviating path that led straight to
the creation of an independent republic, the enactment of the Constitution,
and the formation of the federal government. History records few examples of
a leader who so earnestly wanted to do the right thing, not just for himself
but for his country. Avoiding moral shortcuts, he consistently upheld such
high ethical standards that he seemed larger than any other figure on the
political scene. Again and again the American people had entrusted him with
power, secure in the knowledge that he would exercise it fairly and ably and
surrender it when his term of office was up. He had shown that the president
and commander in chief of a republic could possess a grandeur surpassing
that of all the crowned heads of Europe. He brought maturity, sobriety,
judgment, and integrity to a political experiment that could easily have
grown giddy with its own vaunted success, and he avoided the backbiting,
envy, and intrigue that detracted from the achievements of other
founders. He had indeed been the indispensable man of the American
Revolution.</p>
</blockquote>
<h2 id="anti-slavery">Anti-slavery</h2>
<blockquote>
<p>Whatever his motivations, it was a water-shed moment in American history,
opening the way for approximately five thousand blacks to serve in the
Continental Army, making it the most integrated American fighting force
before the Vietnam War. At various times, blacks would make up anywhere from
6 to 12 percent of Washington’s army.</p>
</blockquote>
<blockquote>
<p>That winter the projected shortage of soldiers led Washington to introduce
another significant change in policy. In January 1778 Brigadier General
James Mitchell Varnum of Rhode Island asked the unthinkable of the Virginia
planter: the right to augment his state’s forces by recruiting black
troops. “It is imagined that a battalion of Negroes can be easily raised
there,” he assured Washington. Washington knew this was an incendiary idea
for many southerners. Nevertheless, desperate to recruit more manpower, he
gave his stamp of approval, telling Rhode Island’s governor “that you will
give the officers employed in this business all the assistance in your
power.” The state promised to free any slaves willing to join an all-black
battalion that soon numbered 130 men. Massachusetts followed Rhode Island’s
lead in enlisting black soldiers, and in Connecticut, slave masters were
exempt from military service if they sent slaves in their stead. That August
a census listed 755 blacks as part of the Continental Army, or nearly 5
percent of the total force.</p>
</blockquote>
<blockquote>
<p>By freeing his slaves, Washington accomplished something more glorious than
any battlefield victory as a general or legislative act as a president. He
did what no other founding father dared to do, although all proclaimed a
theoretical revulsion at slavery. He brought the American experience that
much closer to the ideals of the American Revolution and brought his own
behavior in line with his troubled conscience.</p>
</blockquote>
<h2 id="governance">Governance</h2>
<blockquote>
<p>In early January, amid rumors of mass resignations, a three-man delegation
of officers went to Philadelphia to lay before Congress a petition that
catalogued their pent-up grievances: “We have borne all that men can
bear—our property is expended—our private resources are at an end.” This
delegation met with two dynamic young members of Congress: James Madison of
Virginia, a member since 1780, and Alexander Hamilton of New York, who had
joined Congress a little more than a month earlier. However alarmed by the
prospect of an officer mutiny, Hamilton believed it might represent a handy
lever with which to budge a lethargic Congress from inaction, leading to
expanded federal powers. On February 13 Hamilton wrote to Washington in a
candid tone that presupposed that a profound understanding still existed
between them. He talked of the critical state of American finances and
suggested that the officer revolt could be helpful: “The claims of the army,
urged with moderation but with firmness, may operate on those weak minds
which are influenced by their apprehensions rather than their judgment
. . . But the difficulty will be to keep a complaining and suffering army
within the bounds of moderation.” In suggesting that Washington exploit the
situation to influence Congress, Hamilton toyed with combustible
chemicals. He also tried to awaken anxiety in Washington by telling him that
officers were whispering that he didn’t stand up for their rights with
sufficient zeal. “The falsehood of this opinion no one can be better
acquainted with than myself,” Hamilton emphasized, “but it is not the less
mischievous for being false.” On March 4 Washington sent Hamilton a
thoughtful response and disclosed grave premonitions about the crisis. “It
has been the subject of many contemplative hours,” he told Hamilton. “The
sufferings of a complaining army, on one hand, and the inability of Congress
and tardiness of the states on the other, are the forebodings of evil.” He
voiced concern at America’s financial plight and told of his periodic
frustration at being excluded from congressional decisions. If Congress
didn’t receive enlarged powers, he maintained, revolutionary blood would
have been spilled in vain. After spelling out areas of agreement with
Hamilton, however, Washington said he refused to deviate from the “steady
line of conduct” he had pursued and insisted that the “sensible and
discerning” officers would listen to reason. He also asserted that any
attempt to exploit officer discontent might only “excite jealousy and bring
on its concomitants.” It was a noble letter: Washington refused to pander to
any political agenda, even one he agreed with, and he would never encroach
upon the civilian prerogatives of Congress. In a later letter Washington was
even blunter with Hamilton, warning him that soldiers weren’t “mere puppets”
and that the army was “a dangerous instrument to play with.” The officers
continued to believe that Philadelphia politicians remained deaf to their
pleas, and Washington had no inkling that they would soon resort to more
muscular measures. In his general orders for March 10, he dwelt on a mundane
topic, the need for uniform haircuts among the troops. Then he learned of an
anonymous paper percolating through the camp, summoning officers to a mass
meeting the next day to air their grievances—a brazen affront to
Washington’s authority and, to his mind, little short of outright
mutiny. Then a second paper made the rounds, further stoking a sense of
injustice. Its anonymous author was, in all likelihood, John Armstrong, Jr.,
an aide-de-camp to Horatio Gates, who mocked the peaceful petitions drawn up
by the officers and warned that, come peace, they might “grow old in
poverty, wretchedness, and contempt.” Before being stripped of their weapons
by an armistice, they should now take direct action: “Change the milk and
water style of your last memorial—assume a bolder tone . . . And suspect the
man who would advise to more moderation and…</p>
</blockquote>
<p>On political parties:</p>
<blockquote>
<p>While he acknowledged their right to protest, he was persuaded that the new
societies constituted a menace because their permanence > showed a settled
hostility to the government.</p>
</blockquote>
<h2 id="foreign-policy">Foreign Policy</h2>
<blockquote>
<p>His skepticism about French motives would harden into a corner-stone of his
foreign policy. His fellow citizens, he thought, were too ready to glorify
France, which had entered the war to damage Britain, not to aid the
Americans. “Men are very apt to run into extremes,” he warned Henry
Laurens. “Hatred to England may carry some into an excess of confidence in
France, especially when motives of gratitude are thrown into the scale.”
John Adams summed up the situation memorably when he said that the French
foreign minister kept “his hand under our chin to prevent us from drowning,
but not to lift our heads out of water.” In yet another sign of his growing
political acumen, Washington generalized this perception into an enduring
truth of foreign policy, noting that “it is a maxim founded on the universal
experience of mankind that no nation is to be trusted farther than it is
bound by its interest.”</p>
</blockquote>
<blockquote>
<p>Because the states had refused to collect their quota of taxes, Morris
couldn’t service the sizable debt raised to finance the war. He warned that
creditors “who trusted us in the hour of distress are defrauded” and that it
was pure “madness” to “expect that foreigners will trust a government which
has no credit with its own citizens.”</p>
</blockquote>
<blockquote>
<p>While Washington grew increasingly apprehensive about the violent events in
Paris, Jefferson viewed them with philosophical serenity, lecturing
Lafayette that one couldn’t travel “from despotism to liberty in a
feather-bed.”</p>
</blockquote>
<blockquote>
<p>In August 1792, to Lafayette’s horror, the Jacobins incited a popular
insurrection that included the storming of the Tuileries in Paris and the
butchery of the Swiss Guards defending the palace. The king was abruptly
dethroned. Refusing to swear an oath of allegiance to the civil
constitution, nearly 25,000 priests fled the country amid a horrifying wave
of anticlerical violence. A month later Parisian mobs engineered the
September Massacres, slaughtering more than fourteen hundred prisoners, many
of them aristocrats or royalist priests. Ejected from his military command
and charged with treason, Lafayette fled to Belgium. “What safety is there
in a country where Robespierre is a sage, Danton is an honest man, and Marat
a God?” he wondered. Arrested by Austrian forces, he spent the next five
years languishing in ghastly Prussian and Austrian prisons. With cruel
irony, he was charged with having clapped the French king in irons and kept
him in captivity. While claiming the rights of an honorary American citizen,
Lafayette was confined in a small, filthy, vermin-infested cell.</p>
</blockquote>
<blockquote>
<p>On January 21, 1793, the former King Louis XVI, who had helped win American
independence, was decapitated before a crowd of twenty thousand people
intoxicated with a lust for revenge. After stuffing the king’s head between
his legs, the executioner flung his remains into a rude cart piled with
corpses, while bystanders dipped souvenirs into the royal blood pooled under
the guillotine. Vendors soon hawked patches of the king’s clothing and locks
of bloodstained hair, in a spectacle of sadistic glee that shocked many
people inside and outside France. On February 1 France declared war on Great
Britain and Holland.</p>
</blockquote>
<blockquote>
<p>On the Jay Treaty: “As it happened, four days later the document sat on his
desk. Washington must have quietly gagged as he pored over its provisions,
which seemed heavily slanted toward Great Britain. The treaty failed to stem
the odious British practice of seizing American sailors on the high
seas. Shockingly, it granted British imports most-favored-nation status,
even though England did not reciprocate for American imports. Once the
treaty was revealed, it would seem to many as if Jay had groveled before his
British counterparts in a demeaning throwback to colonial times. The treaty
would strike southerners as further damning proof that Washington was a
traitor to his heritage, for Jay had failed to win compensation for American
slaves carted off at the end of the war. For all that, the treaty had
several redeeming features. England finally consented to evacuate the forts
on the Great Lakes; it opened the British West Indies to small American
ships; and it agreed to compensate American merchants whose freight had been
confiscated. And these concessions paled in comparison to the treaty’s
overriding achievement: it arrested the fatal drift toward war with
England. On balance, despite misgivings, Washington thought the flawed
treaty the best one feasible at the moment.</p>
</blockquote>
<blockquote>
<p>The uproar was overwhelming, tagging Jay as the chief monster in the
Republicans’ bestiary. In the treaty, Republicans saw a blatant partiality
for England and equally barefaced hostility toward France. Critics gave way
to full-blown paranoid fantasies that Jay, in the pay of British gold, had
suborned other politicians to introduce a monarchical cabal. Some protests
bordered on the obscene, especially a bawdy poem in the Republican press
about Jay’s servility to the British king: “May it please your highness, I
John Jay / Have traveled all this mighty way, / To inquire if you, good
Lord, will please, / to suffer me while on my knees, / to show all others I
surpass / In love, by kissing of your———.” 5 By the July Fourth
celebrations, Jay had been burned in effigy in so many towns that he
declared he could have traversed the entire country by the glare of his own
flaming figure.</p>
</blockquote>
<blockquote>
<p>Tacitly railing against Republican support for France, he expounded a
foreign policy based on practical interests instead of political passions:
“The nation which indulges towards another an habitual hatred, or an
habitual fondness, is in some degree a slave.” Sympathy with a foreign
nation for purely ideological reasons, he said, could lead America into “the
quarrels and wars of the latter without adequate inducement or
justification.” He clearly had Jefferson and Madison in mind as he took
issue with “ambitious, corrupted or deluded citizens (who devote themselves
to the favorite nation)” and “sacrifice the interests of their own country.”
Restating his neutrality policy, he underlined the desirability of
commercial rather than political ties with other nations: “ ‘Tis our true
policy to steer clear of permanent alliances with any portion of the foreign
world.” It was Jefferson, not Washington, who warned against “entangling
alliances,” although the concept was clearly present in Washington’s
message.</p>
</blockquote>
<h2 id="behavior">Behavior</h2>
<blockquote>
<p>While Washington cultivated friendships throughout his life, he didn’t have
many true intimates and his relationships were seldom of the candid or
confessional type. His reserve, if not impenetrable, was by no means lightly
surrendered. He was habitually cautious with new people and only gradually
opened up as they passed a series of loyalty tests. “Be courteous to all but
intimate with few,” he advised his nephew, “and let those few be well tried
before you give them your confidence. True friendship is a plant of slow
growth.”</p>
</blockquote>
<blockquote>
<p>In trying to form himself as an English country gentleman, the self-invented
young Washington practiced the classic strategy of outsiders: he studied
closely his social betters and tried to imitate their behavior in polite
society. Whether to improve his penmanship or perhaps as a school
assignment, he submitted to the drudgery of copying out 110 social maxims
from The Rules of Civility and Decent Behavior in Company and Conversation,</p>
</blockquote>
<blockquote>
<p>Washington believed that ambitious men should hide their true selves,
retreat into silence, and not tip people off to their ambition. To sound out
people, you had to feign indifference and proceed only when convinced that
they were sympathetic and like-minded. The objective was to learn the
maximum about other people’s thoughts while revealing the minimum about your
own. Always fearful of failure, Washington wanted to push ahead only if he
was armed with detailed knowledge and enjoyed a high likelihood of
success. This cautious, disciplined political style would persist long after
the original insecurity that had prompted it had disappeared.</p>
</blockquote>
<blockquote>
<p>The taciturn Washington wasn’t the kind of glib burgess who sprang to his
feet and orated extemporaneously. He practiced a minimalist art in politics,
learning how to exert maximum leverage with the least force. Thomas
Jefferson, who was to serve with Washington and Franklin in the Continental
Congress, spotted their economical approach to power. “I never heard either
of them speak ten minutes at a time, nor to any but the main point,” he
later said of the two statesmen. “They laid their shoulders to the great
points, knowing that the little ones would follow of themselves.” Later on
Washington coached his stepson on how to be a Virginia legislator, reminding
him to be punctual in attendance and “hear dispassionately and determine
coolly all great questions.”</p>
</blockquote>
<h2 id="relationship-with-his-mother-mary-washington">Relationship with his mother Mary Washington</h2>
<blockquote>
<p>There would always be a cool, quiet antagonism between Washington and his
mother. The hypercritical mother produced a son who was overly sensitive to
criticism and suffered from a lifelong need for approval. One suspects that,
in dealing with this querulous woman, George became an overly controlled
personality and learned to master his temper and curb his tongue.</p>
</blockquote>
<p>In modern psych, Washington’s mother had
<a href="http://psychcentral.com/disorders/histrionic-personality-disorder-symptoms/">histrionic personality disorder</a>.
Everything was always about her and she was always acting out to get the
attention and sympathy of others.</p>
<blockquote>
<p>As best we can tell, Mary Ball Washington boycotted the wedding and,
according to Martha’s biographer Patricia Brady, may not have met the bride
until the year after the wedding.</p>
</blockquote>
<p>Not happy that little George had another lady in his life.</p>
<h2 id="was-washington-a-christian">Was Washington a Christian?</h2>
<p>If he was, then he didn’t make that clear in the least. He seems more like a
deist.</p>
<blockquote>
<p>A stalwart member of two congregations, Washington attended church
throughout his life and devoted substantial time to church activities. His
major rites of passage—baptism, marriage, burial—all took place within the
fold of the church. What has mystified posterity and puzzled some of his
contemporaries was that Washington’s church attendance was irregular; that
he recited prayers standing instead of kneeling; that, unlike Martha, he
never took communion; and that he almost never referred to Jesus Christ,
preferring such vague locutions as “Providence,” “Destiny,” the “Author of
our Being,” or simply “Heaven.” Outwardly at least, his Christianity seemed
rational, shorn of mysteries and miracles, and nowhere did he directly
affirm the divinity of Jesus Christ.</p>
</blockquote>
<blockquote>
<p>Numerous historians, viewing Washington as imbued with the spirit of the
Enlightenment, have portrayed him as a deist. Eighteenth-century deists
thought of God as a “prime mover” who had created the universe, then left it
to its own devices, much as a watchmaker wound up a clock and walked
away. God had established immutable laws of nature that could be fathomed by
human reason instead of revelation. Washington never conformed to such
deism, however, for he resided in a universe saturated with religious
meaning. Even if his God was impersonal, with scant interest in individual
salvation, He seemed to evince a keen interest in North American
politics. Indeed, in Washington’s view, He hovered over many battlefields in
the French and Indian War and the Revolutionary War.</p>
</blockquote>
<h2 id="random">Random</h2>
<p>When the British surrendered New York City back to the Americans, one
anonymous British officer was still gathering his belongings after the British
had departed, and he noted that the Americans were peacefully reentering the
city compared to the relatively less peaceful camp-life during the British
occupation. He noted:</p>
<blockquote>
<p>The Americans are a curious, original people. They know how to govern
themselves, but nobody else can govern them.</p>
</blockquote>
<blockquote>
<p>Unable to tell a lie, Washington admitted in his diary that he had “cut down
the two cherry trees in the courtyard.”</p>
</blockquote>
<p>That’s where that saying comes from. This was from his own courtyard once the
Mount Vernon property was his; not when he was a child.</p>
<blockquote>
<p>In addition to his better-known title of Father of His Country, Washington
is also revered in certain circles as the Father of the American Mule.</p>
</blockquote>
<p>Washington always sought to experiment in better agricultural methods and more
hardy livestock.</p>
<p>On Thomas Jefferson’s often duplicitous actions:</p>
<blockquote>
<p>The letter gave the world a peek into a very different Thomas Jefferson:
not the political savant but the crafty, partisan operative marked by
unrelenting zeal.</p>
</blockquote>
<blockquote>
<p>Prior to leaving New York, Washington also
<a href="http://www.huffingtonpost.com/2013/11/28/thanksgiving-proclamation_n_4078958.html">signed a proclamation</a> for the first Thanksgiving on November
26, declaring that “Almighty God” should be thanked for the abundant
blessings bestowed on the American people, including victory in the war
against England, creation of the Constitution, establishment of the new
government, and the “tranquillity, union, and plenty” that the country now
enjoyed.</p>
</blockquote>
<p>While Washington set the date for one of the first Thanksgiving celebrations,
it was not until
<a href="https://en.wikipedia.org/wiki/Thanksgiving_(United_States)">Lincoln</a> that it
became an official federal holiday.</p>
<blockquote>
<p>Joined at last by Dr. Brown, they took two more pints from Washington’s
depleted body. It has been estimated that Washington surrendered five pints
of blood altogether, or about half of his body’s total supply.</p>
</blockquote>
<p>Washington would have died either way from his upper respiratory infection,
but the multiple rounds of blood letting sure
<a href="https://en.wikipedia.org/wiki/George_Washington#Death">hastened things</a>.</p>
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James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutMed School Resources2014-11-29T00:00:00+00:00http://jgmalcolm.com/medschool-resources<p>There are hundreds of resources available to help you study with new ones
popping up every year, so it’s important to narrow in on the best. Here is a
short list of the best resources I used during the didactic portion of med
school. I cover various approaches to learning: review texts, memory palaces,
video lectures, spaced repetition software, physical note cards, and more.</p>
<div class="series no-print">
<b>STEP1:</b>
<a href="/tactical-test-taking-skills">
Tactical Test-Taking Strategies
</a>
//
Med School Resources
//
<a href="/medschool-strategy">
Med School Study Strategy
</a>
//
<a href="/memorize-anything">
Memorize Anything
</a>
</div>
<h2 id="every-student-uses">Every student uses</h2>
<p>There is no resource that will cover 100% of the NBME STEP1 exam, so you’ll
pull from various sources. Don’t fall into the trap of thinking your grades
will improve if you have more resources; you’ll get spread thin. Better to
focus on knowing a few good resources thoroughly, and then picking pieces from
other resources as needed. That said, here are three resources every medical
student uses for the boards.</p>
<h3 id="first-aid-for-step1"><a href="http://www.amazon.com/s/?_encoding=UTF8&camp=1789&creative=390957&field-keywords=first%20aid%20for%20step%201&linkCode=ur2&rh=i%3Aaps%2Ck%3Afirst%20aid%20for%20step%201&tag=jgmalcolm-20&url=search-alias%3Daps&linkId=65ZSHFLD65LXYPVO">First Aid for STEP1</a></h3>
<ul>
<li>Content review for entire exam</li>
<li>Everyone taking STEP1 purchases a copy of this.</li>
<li>Everything you need to know to pass. Not a good primary learning tool, but
an excellent outline review.</li>
<li>Often referred to simply as First Aid or FA</li>
<li>New editions come out every January. This is the book you will likely spend
the most time with in the months leading up to STEP1.</li>
<li>Consolidate resources: annotate other resources (Pathoma, Firecracker, etc)
into this so you’re not spread among five review books.
<ul>
<li>Don’t write every random fact or you’ll clutter out the important things.
This book is already distilled down to high concentration; only add a fact
if it really helps clarify or was a key to some practice question.</li>
</ul>
</li>
<li>You’ll definitely want a hard copy to annotate, but also a digital copy for
text search</li>
<li>You’re going to spend a lot of time with this book and carry it everywhere
you go. Consider cutting off the binding so you can put it into a 3-ring
binder for protection and to easily lay flat. Staples/OfficeMax will punch
holes for $3, but be sure to ask them to slice very close to the binding,
otherwise you lose some of the inner marginal text.
<ul>
<li>For each module in school, pull out only the relevant section and use a
slim folder.</li>
<li>Since I had a PDF of the original, anything that wasn’t actual study
material was thrown away: all pages from front cover until Behavioral
Science, all pages after Rapid Review. This cut out over a hundred pages.</li>
</ul>
</li>
</ul>
<h3 id="pathoma"><a href="//www.pathoma.com">Pathoma</a></h3>
<figure class="thumb">
<a href="http://google.com/trends/explore#q=pathoma%2C%20Goljan">
<img src="/images/goljan-pathoma-trend.png" alt="Pathoma (blue) is overtaking Goljan (red)" />
</a>
<figcaption>Google Trends shows Pathoma (blue) overtaking Goljan's Rapid Review Pathology (red).</figcaption>
</figure>
<ul>
<li>Concise video lectures covering all relevant pathology along with a slim
review text
<ul>
<li>About 1.5 - 2.5 hours of video per organ system</li>
</ul>
</li>
<li>Highly, highly recommend (you’ll also see it highly recommended in First Aid
resource recommendations appendix)</li>
<li>Purchase the longest possible subscription (eg. 21 months) because you’ll
keep coming back to these videos during your modules and especially in the
run up to STEP1.</li>
<li><a href="#record-audio">Record audio</a> so you can listen while you commute or exercise</li>
<li>Combine with <a href="#goljan-step1-audio">Goljan’s lectures</a> to get multiple views of key
topics. Sometimes one explains it better than the other. Goljan gives
great cross-cutting explanations, particularly with respect to nutrition and
biochemistry, topics Pathoma does not cover.</li>
<li><strong>During each block, watch each video three times.</strong> Watch at 1x to learn,
and then a week later at 1.3x or 1.7x to review, and finally once more
before the exam. Whenever I get tired of doing questions, popping up a
Pathoma video is an easy step down that still keeps me productive.</li>
<li>In your 1x pass, underline in your book the things Sattar emphasizes in his
slides. If he draws a diagram, draw it in your book’s margin. For
subsequent passes at 1.3x and 1.7x, just sit back and absorb the slides.</li>
<li>Read more on <a href="#other-pathology-resources">other pathology resources</a>.</li>
</ul>
<h3 id="uworld"><a href="//www.usmleworld.com/purchase.aspx">USMLE World</a></h3>
<ul>
<li>The official practice question bank of USMLE</li>
<li>2618 questions total
<ul>
<li>bank of 2250 questions</li>
<li>two self assessment exams (184 questions each for a total of 368 questions)</li>
</ul>
</li>
<li>Explanations are of the highest quality</li>
<li>various purchase options
<ul>
<li>Purchase about 30-90 days out from your STEP1 date</li>
<li>Organize your classmates to get a group discount</li>
</ul>
</li>
<li>When you hit dedicated STEP1 study time, you must do every question in this
qbank at least once. Many students go through twice.</li>
<li>For your modules, you’ll want to purchase the
<a href="#question-banks">USMLE-Rx or Kaplan qbanks</a></li>
<li>Tips:
<ul>
<li>Under “Utilities → Preferences”, set your defaults to “Tutor”, “Unused”,
and pick a font.</li>
<li>It’s a buggy Java app, so be sure to close and restart every day. If you
leave it open for days in a row it’ll start bogging down.</li>
</ul>
</li>
</ul>
<h2 id="most-students-use">Most students use</h2>
<p>The three resources above will provide the most comprehensive coverage in the
fewest number of resources. You should be spending the vast majority of your
dedicated STEP1 study time focused on those three. Everything else here is to
learn throughout your regular curriculum or hit your hot spots during your
dedicated period.</p>
<p>Beyond those, nearly all students pull from a few additional resources
throughout their coursework. The following is a survey of resources. Choices
depend on your weaknesses and learning style.</p>
<h3 id="firecracker"><a href="https://firecracker.me">Firecracker</a></h3>
<ul>
<li>Flashcard software prepoplated with STEP1 material (a combination of First
Aid, Goljan, etc.)</li>
<li><a href="http://www.gwern.net/Spaced%20repetition">Spaced repetition</a> algorithm to optimize when to review
what information. Simply reviewing your books and notes from the first page
onward is terribly inefficient; spaced repetition algorithms optimize your
review schedule.</li>
<li>As you cover material (daily) you add it to the question pool (flag it).</li>
<li>The “practice simulations” are very low quality; stick to Rx/Kaplan/UWorld</li>
<li>Learn the keyboard shortcuts (when you’re doing a quiz, there’s a little
laptop icon on the bottom right)</li>
<li><a href="#anki">Anki</a> is a similar and better tool for its design and feedback metrics, but
Firecracker is better overall for medical students because it is
prepopulated saving you hundreds of hours of reinventing the wheel by making
your own cards or hassling with those from others.</li>
<li>A big downside to Firecracker is the <strong>lack of figures and images</strong>:
everything is text-based. This makes it especially hard when it comes to
biochemical pathways or anything in First Aid with a diagram. Think of all
the figures First Aid has; Firecracker has none of those. Any figures they
have are picked off random websites, likely to avoid copyright fees.</li>
<li>While comprehensive, another downside of Firecracker is moderate quality,
relative to some of the more highly edited resources like First Aid, UWorld,
Kaplan, Rx, Goljan, etc. Firecracker is written by senior students and
residents, and as such it uses inconsistent formatting and very often
includes extraneous detail. I was often frustrated by what seemed like its
focus on pedantic details. The <em>spaced repetition algorithm</em> is absolutely
the best strategy; however, the content of Firecracker needs improvement.
That said, Firecracker appears to be evolving and improving faster than any
other resources in this list. They listen to customer feedback and daily
make edits and improvements.</li>
<li>I probably spent half of my pre-boards time in medical school learning with
Firecracker, although for various reasons, I would not spend that much time
if I had to do it again. Read more on
<a href="#how-i-use-firecracker">how I use Firecracker</a>.</li>
<li>Ken Noguchi writes about <a href="http://sidenotelife.tumblr.com/post/88788673049/ken-explains-studying-in-med-school-a-year-long">his use of Firecracker</a>.
The Firecracker blog has a lot of (biased?)
<a href="http://blog.firecracker.me/2013/06/18/how-to-score-a-266-on-usmle-step-1">case</a>
<a href="http://blog.firecracker.me/2013/12/10/how-this-firecracker-scored-a-270-on-usmle-step-1">studies</a>
from
<a href="http://blog.firecracker.me/2014/08/01/firecrackers-averaged-a-245-on-step-1">customers</a>.</li>
</ul>
<h3 id="lippincotts-microcards"><a href="http://www.amazon.com/s/?_encoding=UTF8&camp=1789&creative=390957&field-keywords=lippincott%20microcards&linkCode=ur2&rh=i%3Aaps%2Ck%3Alippincott%20microcards&tag=jgmalcolm-20&url=search-alias%3Daps&linkId=TQOYT6JCPI3PE5HR">Lippincott’s Microcards</a></h3>
<div class="gallery">
<figure class="thumb">
<a href="/images/micro-flashcards.jpg" data-gallery="microcards" title="Simple annotations to highlight tested facts. Think critically 'What is testable?' so you only emphasize a few things per card.">
<img src="/images/micro-flashcards.jpg" />
</a>
<figcaption>Simple annotations</figcaption>
</figure>
</div>
<ul>
<li>Flashcards that show a vignette, key symptoms, diagnosis, treatment, and
high yield facts.</li>
<li>Covers about 140 bacteria, viruses, fungi, protozoa, and helminths.
Everything is relevant for STEP1.</li>
<li>Underline and annotate to emphasize key facts. As with adding to any review
resource, be careful not to add too much. It’s okay to add a small table
contrasting against other bugs, but be careful to not add low-yield random
facts that will clutter the card.</li>
<li>Combine these with <a href="#picmonic">Picmonic</a></li>
</ul>
<div style="display:none">
### [Sketchy Micro](http://sketchymicro.com) {#sketchy-micro}
[Sketchy Micro]: #sketchy-micro
* Re-branded to [Sketchy Medical](http://sketchymedical.com)
* video [memory scenes] of 47 bacteria, dynamically drawn while narrated with
teaching points
* create free account to get *Staph*, *Strep*, and *Enterococcus*, and
[free samples on YouTube](https://www.youtube.com/channel/UC1BRRTxAdlQCy2Tq8YfHX0w)
* $40/6mo
* Focused only on bacteria (as of Fall 2014)
* [record the audio][record audio] to listen while you commute, exercise, or
do chores
* After the "required" First Aid, Pathoma, and UWorld, I would say that
**Sketchy Micro was the best money I spent** on learning materials.
</div>
<h3 id="picmonic"><a href="http://picmonic.com">Picmonic</a></h3>
<ul>
<li>~800 static <a href="http://www.ted.com/talks/joshua_foer_feats_of_memory_anyone_can_do">memory scenes</a> with audio tutorials</li>
<li>$250 for 12 months, or $25/month</li>
<li>I use this only for spot memorization (eg. pharm, vasculitides, micro,
viral) rather than conceptual material (eg. pathophysiology)</li>
<li>Whenever I hit something I have trouble recalling, I skim the picture in
Picmonic or queue it up in a review play list.</li>
<li>I only use the <em>Learn</em> feature (not <em>Explore</em> or <em>Quiz</em>)</li>
<li><a href="#record-audio">record the audio</a></li>
</ul>
<div id="pharm" class="message no-print" style="overflow:hidden">
<a href="//pharm450.com">
<img src="/images/artist_studio-characters.png" style="border:none; max-width: 30%; float:right" />
</a>
My newest project is <a href="//pharm450.com">Pharm450.com</a>, the easiest
way to learn pharmacology for USMLE Step 1. Pharm450 packs an entire course
on medical pharmacology into a set of entertaining videos that leverage your
visual, spatial, and emotional memory so you learn faster and retain more.
</div>
<h2 id="videos">Videos</h2>
<ul>
<li>YouTube is a treasure trove of focused topical videos.
<ul>
<li>Each module, create a playlist and add videos as you come across them.
<a href="http://www.youtube.com/channel/UCJJNCT5F3nhtAT0vWvdGVJA/playlists">Here are ones I collected</a>.</li>
<li>Browse and subscribe to various channels and playlists out there:
<ul>
<li><a href="https://www.youtube.com/channel/UCesNt4_Z-Pm41RzpAClfVcg">Armando Hasudungan</a></li>
<li><a href="https://www.youtube.com/user/DoctorNajeeb/playlists">DoctorNajeeb</a></li>
<li><a href="https://www.youtube.com/playlist?list=PLYojB5NEEakWCoWLnx0F1OxY6PXVaBkVT">Antibiotics</a></li>
</ul>
</li>
<li>These were especially useful for anatomy:
<ul>
<li><a href="https://www.youtube.com/playlist?list=PL6F5A027100A37163">Human Anatomy Dissections</a></li>
<li><a href="https://www.youtube.com/playlist?list=PLNdgkaw0fFGRODIAe2ZiGeIE216CgIRk0">James Preddy @ U Touro Nevada</a></li>
</ul>
</li>
</ul>
</li>
<li><a href="//handwrittentutorials.com">Handwritten Tutorials</a>
(<a href="https://www.youtube.com/user/harpinmartin">YouTube</a>) - Excellent, simple
videos of key topics in anatomy, biochem, immunology, neuroscience, pharm,
and physiology.</li>
<li>Khan Academy has been building up a great collection of videos in <a href="https://www.khanacademy.org/science/biology">biology</a>,
<a href="https://www.khanacademy.org/test-prep/mcat/cells">cells</a>, <a href="https://www.khanacademy.org/science/biology/cellular-respiration">cellular respiration</a>, <a href="https://www.khanacademy.org/science/biology/immunology">immunology</a>, <a href="https://www.khanacademy.org/science/biology/human-biology">human biology</a>,
<a href="https://www.khanacademy.org/science/health-and-medicine">physiology</a>, and more.</li>
<li><a href="https://www.youtube.com/watch?v=AdYaTa_lOf4">Teddy Has An Operation</a> for
those interested in going into surgical specialties</li>
</ul>
<h2 id="question-banks">Question Banks</h2>
<p><a href="#uworld">USMLE World</a> is the best choice for STEP1 dedicated study, but you
want to save it until that time. Throughout the year and even at the start of
your dedicated study period, you’ll want to work through either of the
following standard question banks.</p>
<p>Until you get close to STEP1, <strong>do questions in <em>Un-timed Tutor Mode</em></strong>. This
allows you to take your time, look up things if you choose, and get immediate
feedback. When you get a few weeks out from STEP1, then you want to do timed
tests to work in endurance and pacing. Several times I accidentally created
blocks that were timed; Rx lets you delete them from the web interface, but
you have to email Kaplan to delete these tests.</p>
<h3 id="usmle-rx-qmax"><a href="https://www.usmle-rx.com/content/step-1-qmax">USMLE-Rx Qmax</a></h3>
<ul>
<li>2524 total questions</li>
<li>Written by the authors of First Aid, answer explanations show pages from
First Aid so consider this a companion qbank</li>
<li>12mo subscription is $149 with <a href="https://www.usmle-rx.com/amsa">$50 discount</a>
after free
<a href="http://www.amsa.org/AMSA/Homepage/MemberCenter/JoinAMSA.aspx">AMSA membership</a>
(regularly $199)</li>
</ul>
<h3 id="kaplan"><a href="http://www.kaptest.com/Medical-Licensing/Step1/s1-qbank.html">Kaplan</a></h3>
<ul>
<li>2006 total questions</li>
<li>$210 with AMA membership ($20) for a total of $230
<ul>
<li>regularly $300 without AMA membership)</li>
</ul>
</li>
<li>answer explanations contain links to video and other media, as well as scans
from pages in <a href="http://www.amazon.com/s/?_encoding=UTF8&camp=1789&creative=390957&field-keywords=medessentials%20for%20usmle%20step%201&linkCode=ur2&tag=jgmalcolm-20&url=search-alias%3Dstripbooks&linkId=FQNEWPBM3VIQJQ2U">medEssentials for USMLE Step 1</a></li>
<li>terrible customer support</li>
</ul>
<h3 id="comparing-kaplan-and-usmle-rx">Comparing Kaplan and USMLE-Rx</h3>
<ul>
<li><strong>Kaplan has the best explanations. Rx is more straight forward for learning
First Aid.</strong>
<ul>
<li>Kaplan’s explanations tend to teach broad lessons about the question
topic, including details and links to
<a href="http://www.amazon.com/s/?_encoding=UTF8&camp=1789&creative=390957&field-keywords=medessentials%20for%20usmle%20step%201&linkCode=ur2&tag=jgmalcolm-20&url=search-alias%3Dstripbooks&linkId=FQNEWPBM3VIQJQ2U">medEssentials for USMLE STEP1</a>, occasional videos, and
better explanations of why answers were wrong relative to the correct
answer. Best of all, Kaplan often takes the opportunity to review a
larger portion of the relevant pathophysiology. Rx tends to just state
facts relevant to the immediate question. Don’t skip the Kaplan “ReKaps &
Refs”; they’re golden.</li>
<li><strong>Kaplan is harder than Rx.</strong> Kaplan often seems pedantic, uses
descriptive terms not in First Aid, and uses images of histology/culture
that look very different from First Aid, but if you get good at Kaplan,
you’ll probably know the material nuances better than with Rx. I found my
Kaplan scores slightly lower than my Rx scores, but <strong>I always felt like I
knew the material better after Kaplan</strong>. Avoid favoring Rx over Kaplan
simply because your scores are better with Rx. Read another student’s
<a href="http://forums.studentdoctor.net/threads/just-finished-kaplan-qbank-my-brief-thoughts-on-it.943957/">review on Kaplan</a>.</li>
<li>Kaplan regularly uses second-order questions, and some are even
third-order. Rarely will you find a straight recall question in Kaplan
(first-order). In contrast, Rx is full of first- and second-order
questions, but no third-order. In this way, one Kaplan question covers
2-3 layers of information while an Rx question only covers 1-2. UWorld
has zero first-order questions, so its complexity is more like that of
Kaplan.</li>
<li>Rx ties directly into FA (the explanations literally show you the relevant
FA pages). Use it as a way to learn FA, but it’s lacking those broad
lessons that Kaplan explanations often emphasize.</li>
<li>Both provide about the same level of post-test analysis.</li>
</ul>
</li>
<li><strong>Rx has a better user interface.</strong>
<ul>
<li>Rx is a clear winner here: smooth web interface (HTML), but poor iOS app.</li>
<li>Kaplan has a terrible interface (Flash) and even worse iOS app. If I had
a nickle for every time Kaplan froze or logged me out, I’d have bought a
lot of coffees.</li>
</ul>
</li>
</ul>
<p>Ultimately, I ended up using both qbanks a lot because I found it great to see
information from multiple perspectives. I used Rx mostly during the school
year to learn FA, and I used Kaplan mostly during the dedicated STEP1 study
period before switching to UWorld. Whenever pressed for time, I used the
Kaplan bank to cover more material per question.</p>
<h3 id="first-aid-qa-for-usmle-step-1"><a href="http://www.amazon.com/gp/product/0071744029/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=0071744029&linkCode=as2&tag=jgmalcolm-20&linkId=QRNMRPTNGRDQXWFL">First Aid Q&A for USMLE Step 1</a></h3>
<ul>
<li>1000 questions organized into basic principles and organ systems, plus a
full length exam.</li>
<li>Consider buying a paper-based question bank because sometimes it’s nice to
study without your computer or outside on a sunny day.</li>
<li>I’ve found maybe 10% of these questions duplicated in USMLE-Rx Qmax</li>
<li>I sometimes use these as throwaway <a href="http://www.nytimes.com/2014/09/07/magazine/why-flunking-exams-is-actually-a-good-thing.html">pretest questions</a> early on
in a module to “prime” my brain for key concepts to be on the lookout for.</li>
<li>Much like USMLE-Rx, but great for when you want to put your computer aside
and knock out extra questions.</li>
</ul>
<h2 id="anatomy">Anatomy</h2>
<ul>
<li><a href="http://www.amazon.com/gp/product/1455704180/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=1455704180&linkCode=as2&tag=jgmalcolm-20&linkId=MBQR5BOPKEMNCZH4">Netter</a> is the gold standard and has all the classic diagrams you’ll see in
lectures, eg. cervical plexus. <a href="http://www.amazon.com/gp/product/1604067454/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=1604067454&linkCode=as2&tag=jgmalcolm-20&linkId=FAG7IGVPT2EBXLIW">Atlas of Anatomy 2e</a> is also great, but
probably best to stick with Netter.</li>
<li>To learn anatomy, skip anatomy lectures. They go too fast to actually
learn. Instead drill with <a href="http://www.amazon.com/gp/product/0323185959/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=0323185959&linkCode=as2&tag=jgmalcolm-20&linkId=TVGDMDJL366QWFXE">Netter Flashcards</a> and <a href="#videos">online videos</a>
so you can pause and memorize as needed. For each exam, put all the
relevant cards on the ring and flip through those as you can.
<ul>
<li><strong>The educational value of stabbing yourself.</strong> I found that using my own
body to learn made the experience more vivid. If I stabbed myself in the
back below the floating rib, what would I hit? Trace the pathway of
nerves/arteries/veins on your own body. Watch as you flex specific
muscles. All the while imagine what’s going on under the hood. (Don’t
actually stab yourself, but just use your imagination.)</li>
</ul>
</li>
<li><a href="http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/INDEX.html">U Michigan</a>
has detailed explanations of various dissections along with relevant quizzes.</li>
<li>Buy the recommended Clemente dissector and Netter atlas, same edition
recommended. This way you match the lecture slide references.
<ul>
<li>As a table, buy two dissectors and two atlases to leave in the lab.</li>
<li>Personally buy Netter for home study (keep it for life).</li>
<li>Consider getting a second copy of the dissector for personal prep (not a
gooey lab copy)</li>
</ul>
</li>
<li>Only buy two (2) dissecting kits for your entire table and share. Make sure
you have two of everything: scalpel, small & large scissors, small & large
hemostats, small & large toothed & non-toothed tweezers (pickups).</li>
<li>Consider buying your own
<a href="http://www.amazon.com/gp/product/B0072IHTIO/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B0072IHTIO&linkCode=as2&tag=jgmalcolm-20&linkId=SYCNZHTAV32IKRGV">fresh lab coat</a>
instead of using the stained used ones. Write your name prominently on the
collar or front. Personalize as inspired.</li>
<li>
<p>Buy
<a href="http://www.amazon.com/gp/product/B001CE8J9C/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B001CE8J9C&linkCode=as2&tag=jgmalcolm-20&linkId=57VJNMQMWTKABLL2">thick multi-colored friendship bracelet string</a>
to tag arteries, veins, nerves, muscle, etc. Regular sewing thread is too
thin and you’ll want multiple colors. Keep it in a ziplock bag.</p>
</li>
</ul>
<h2 id="studying">Studying</h2>
<p>Here are a few blog posts from others that influenced my thinking about
studying and productivity in med school.</p>
<blockquote>
<p>Find more tips and tricks in <a href="/medschool-strategy">“Med School Strategy”</a></p>
</blockquote>
<h3 id="step-1">Step 1</h3>
<ul>
<li><a href="https://members.aamc.org/eweb/upload/Are%20Questions%20the%20Answer%20PPT%2011-6-12%2010PM.pdf">Effect of Popular Study Resources on USMLE Step 1 Performance</a> - tl;dr: question banks are the most effective and efficient study method</li>
<li><a href="http://meded.ucsd.edu/index.cfm//ugme/oess/study_skills_and_exam_strategies//how_to_study_actively/">How To Study Effectively</a> -
comprehensive guide from UC San Diego on an organized and active approach to
studying in med school</li>
<li><a href="http://erikreinertsen.com/prep-for-step-1-usmle/">Erik Reinertsen</a> describes his approach in the weeks leading up</li>
<li><a href="http://sidenotelife.tumblr.com/post/88788673049/ken-explains-studying-in-med-school-a-year-long">Ken Noguchi on STEP1</a> -
covering his experience with Firecracker, Pathoma, and UWorld</li>
<li><a href="http://managingmedicine.wordpress.com/2013/08/17/my-guide-to-the-usmle-step-1">A Guide to the USMLE STEP1</a></li>
<li><a href="http://www.dysgraphicmusings.com/2013/11/how-to-study-in-medical-school.html">How To Study in Medical School</a></li>
<li><a href="http://www.usmlegunner.com">USMLE Gunner</a></li>
<li><a href="http://www.hopefuldoc.com/step-1-usmle-study-secrets/">Sample study schedule</a></li>
<li><a href="http://www.reddit.com/r/medicalschool/comments/2hbssw/what_do_your_class_top_10_do_differently/">What do your class top 10% do differently?</a> (r/medicalschool)</li>
<li><a href="http://usmle-score-correlation.blogspot.com/">Score correlation</a></li>
</ul>
<h3 id="general-study-methods">General study methods</h3>
<ul>
<li><a href="http://www.lexisnexis.com/lextalk/industry-trends/f/5/t/1343.aspx">25 Things Skilled Learners Do Differently</a></li>
<li><a href="http://calnewport.com/blog">Cal Newport</a></li>
<li><a href="http://www.scottyoung.com">Scott Young</a>:
<a href="http://www.scotthyoung.com/blog/2007/03/25/how-to-ace-your-finals-without-studying">How to ace your finals</a>,
<a href="http://www.scotthyoung.com/blog/2011/01/11/learn-faster-and-better">Learn Faster and Better</a></li>
<li><a href="/top-students">What Do Top Students Do Differently</a> (from me)</li>
<li><a href="http://www.danielwillingham.com/articles.html">Daniel Willingham</a></li>
<li><a href="http://www.effectivestudy.org/">EffectiveStudy</a></li>
</ul>
<h3 id="beyond-medical-school">Beyond Medical school</h3>
<ul>
<li><a href="http://whitecoatinvestor.com/new-to-the-blog-start-here">White Coat Investor</a> -
about managing student debt, investing, insurance, budgeting (not about studying)</li>
</ul>
<h2 id="anki"><a href="http://ankisrs.net">Anki</a></h2>
<ul>
<li>Excellent software and performance feedback graphs, but you have to spend
time populating. Firecracker is prepopulated.</li>
<li>Good for hot spot memorization of tables/charts (eg. drugs, cytokines,
vitamins) but not recommended for general use since pre-populated resources
exist</li>
<li>Excellent advice on how to make the best cards:
<a href="http://rs.io/2014/04/05/anki-10000-cards-later.html">Anki: 10,000 cards later</a>
and
<a href="http://www.supermemo.com/articles/20rules.htm">20 Rules of Formulating Knowledge</a>.</li>
<li>Some prepopulated <a href="https://ankiweb.net/shared/info/3641619405">decks</a>
<a href="https://ankiweb.net/shared/info/1656465381">already</a>
<a href="https://ankiweb.net/shared/info/2445310057">exist</a> for the
<a href="https://ankiweb.net/shared/info/1014441642">“Rapid Review” tables</a> in First
Aid.
<a href="http://www.yousmle.com/how-to-master-pharmacology-for-the-usmle-step-1-over-a-glass-of-wine/">Pharmacology</a>
is one great use for this.</li>
<li>Better graphs than Firecracker to chart progress</li>
<li>Downside: Lacks good methods for sharing/updating decks with classmates</li>
<li>Everyone I know who used this eventually abandoned because of time involved
in creating and curating decks</li>
</ul>
<h2 id="goljan-step1-audio">Goljan STEP1 audio</h2>
<ul>
<li>A series of lectures as part of a boards review course he conducted</li>
<li>These lectures were delivered with the first edition of
<a href="http://www.amazon.com/gp/product/0323087876/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=0323087876&linkCode=as2&tag=jgmalcolm-20&linkId=W27RBR7TKB2ATXIM">Rapid Review Pathology</a> text, but you can still follow along in the latest
edition. The slides and a scan of the original textbook can be found
online.</li>
<li>Full of board pearls since he helps edit the USMLE questions. While most of
the pathognomonic stuff is outdated and boards questions rarely use such
classic tip-offs, the concepts are still valid and tested in similar ways.</li>
<li>It’s thorough but not well organized, but makes for good background
listening while running errands, doing chores, or exercising.</li>
<li>Comparing against Pathoma:
<ul>
<li>Pathoma is more updated, organized, and focused.</li>
<li>Goljan covers biochemistry, fluids, nutrition, and other important STEP1
concepts not included in Pathoma.</li>
<li>Goljan often makes cross cutting connections between topics which provides
more context than Pathoma.</li>
<li>While studying for STEP1, I regularly would get a question only because I
had heard it in a Goljan lecture while working out earlier that same day.</li>
<li>I highly recommend watching Pathoma at your desk at high speed and
listening to Goljan while you’re working out.</li>
</ul>
</li>
</ul>
<h2 id="first-aid-basic-sciences"><a href="http://www.amazon.com/gp/product/0071785744/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=0071785744&linkCode=as2&tag=jgmalcolm-20&linkId=7CLFIS3XQTFUNYJW">First Aid Basic Sciences</a></h2>
<ul>
<li>A companion to First Aid for STEP1, but this is a learning tool.</li>
<li>Covers all basic science in First Aid, but is due for an update compared to FA.</li>
<li>You could probably get by purchasing this instead of the random specialized
and overly-detailed books that professors recommend. The exception is
Lilly’s <a href="http://www.amazon.com/gp/product/1605477230/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=1605477230&linkCode=as2&tag=jgmalcolm-20&linkId=PMW3LS2CV3N2VRDV">Pathophysiology of Heart Disease</a>, an absolutely fantastic
text for your cardiology module.</li>
</ul>
<h3 id="other-pathology-resources">Other pathology resources</h3>
<ul>
<li><a href="http://www.amazon.com/gp/product/1451115873/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=1451115873&linkCode=as2&tag=jgmalcolm-20&linkId=A3ED6I7JXGH55IUM">BRS Pathology</a>
<ul>
<li>Concise and well-organized review</li>
<li>Simpler than Pathoma</li>
<li>Each chapter has about 20 solid questions</li>
</ul>
</li>
<li>Goljan’s <a href="http://www.amazon.com/gp/product/0323087876/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=0323087876&linkCode=as2&tag=jgmalcolm-20&linkId=W27RBR7TKB2ATXIM">Rapid Review Pathology</a>
<ul>
<li>The same topic sequence as Pathoma but much more detail, especially when
it comes to microbiology, but not as much as <a href="http://www.amazon.com/dp/1455726133">Robbins & Cotran</a> (aka “The
Bible of Pathology”, get this if you’re interested in Pathology as a
residency).</li>
<li>Further on in the curriculum, I realized I wanted more details and a
alternative view on pathology so I started skimming chapters from this but
Pathoma is sufficient for a good foundation.</li>
<li>The first edition of this text is what his <a href="#goljan-step1-audio">audio lectures</a> are
based on</li>
</ul>
</li>
</ul>
<p>If you had to rank order the complexity of these resources: BRS < Pathoma <
Goljan’s < Robbins & Cotran. Pathoma is more than enough for STEP1.</p>
<h2 id="how-i-use-firecracker">How I use Firecracker</h2>
<h3 id="when-you-fall-behind">When you fall behind</h3>
<p>Sometimes I fall behind and the question load can be overwhelming. Here are
some strategies:</p>
<ul>
<li><strong>Put in the time.</strong> There’s no substitute to just putting in the time.
Glancing at the info and rating it a 1 is better than ignoring it forever.
Try to just remember one bit of info and then move on.</li>
<li><strong>Do Fewer questions.</strong> Narrow the scope of a quiz. Otherwise, you might
feel like you’re getting punched from every direction as random topics hit
you.
<ul>
<li>Above the calendar, click “More Options” > “Do Fewer Questions”.</li>
</ul>
</li>
<li><strong>Spread out questions.</strong> Spread over the coming days/weeks.
<ul>
<li>You can only spread Review and Catchup questions (not Study).</li>
<li>Above the calendar, click “More Options” > “Spread Out Questions”.</li>
</ul>
</li>
<li><strong>Switch to Normal Mode.</strong> Focus on a smaller set of the highest yield
material.
<ul>
<li><em>Normal</em> mode contains about half the number of questions.</li>
<li>You still get the benefit of reviewing topics according to how strong you
are, and you can always take a moment to review the full topic and all its
sub-topic details that you might have been tested on in <em>Legendary Mode</em>.</li>
<li>To switch learning modes, click the doctor icon in the top-right >
“Account & Settings” > “Settings” > “Normal Mode” (default is “Legendary”)</li>
<li>Your flagged topics, notes, and history will all remain.</li>
<li>In the months <strong>leading up to STEP1, I switched to Normal mode</strong> so I
could hit the high points but start spending more time with qbanks and
other resources.</li>
</ul>
</li>
<li><strong>Check STEP1 only.</strong> No need to include STEP2 (3rd year) questions.
There’s a lot of overlapping coverage and you’ll be fine with just STEP1.
This is also under “Account & Settings”.</li>
<li><strong>Uncheck topics covered better elsewhere.</strong> Pathoma is better at pathology
than Firecracker, so I ended up un-checking many of these topics
post-module. Physiology was also another item I unchecked. Firecracker was
best at brute memorization of micro and pharm.</li>
</ul>
<h3 id="long-term-value-proposition">Long term value proposition</h3>
<p>The real value of Firecracker comes after months of use. It surprised me how
much I retained from past modules because Firecracker forced me to touch on
things now and then. I’d say that half its value can be realized for learning
in your present module, but half its value is longitudinal over all your
blocks. Put in the time to review old material.</p>
<h3 id="put-in-the-time">Put in the time</h3>
<p>There are no short cuts to simply putting in the time to actually learn.
Merely owning Firecracker or any resource won’t make you a better student.
The hard reality is that you have to put in the time.</p>
<p>With Firecracker, there’s a lot of upfront work of slogging through questions
before you start to reach steady state maintenance mode. As long as you’re
flagging new topics a few times a week (as you’re going through new material),
it’ll be a battle to keep that number down.</p>
<p>You need to spend time on weekends and vacations chipping away at questions,
or they pile up.</p>
<h2 id="record-audio">Recording audio from video</h2>
<p>As I watched <a href="#pathoma">Pathoma</a> and <a href="#picmonic">Picmonic</a>, I recorded the audio
to mp3 so that I could listen to it while commuting, exercising, or doing
chores. While lacking the visual experience it’s a way to eek out a little
extra learning as you exercise your visual recall. The audio will make little
sense unless you’ve spent time watching the videos to pick up the mental
imagery.</p>
<ul>
<li>Install <a href="http://audacity.sourceforge.net">Audacity</a> to record and export audio</li>
<li>Install <a href="https://code.google.com/p/soundflower/downloads/list">Soundflower</a>
to channel audio from your browser to Audacity</li>
</ul>
<p>For listening on the go, I recommend <a href="http://www.amazon.com/gp/product/B00JAAJ1F6/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B00JAAJ1F6&linkCode=as2&tag=jgmalcolm-20&linkId=MC3Y54SMJGTYZ5Q3">Jarv NMotion Sport Wireless Bluetooth</a>
headset. They’re inexpensive and it’s super convenient to not have cords
getting tangled while you’re on the go. For listening at your computer, I
recommend <a href="http://www.amazon.com/gp/product/B003V9QDXK/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B003V9QDXK&linkCode=as2&tag=jgmalcolm-20&linkId=MDT4Q76B4IQOY4BF">Audéo earbuds</a> - expensive, but excellent quality and snug fit.</p>
<p><a href="http://codepen.io/jon-walstedt/pen/jsIup">Convert your mp3s into a podcast</a>
to use the podcast apps which often have the feature to rewind 15 seconds so
you can hear a key fact repeated. This is especially true for iOS where the
default Music app is not designed to listen to tedious hour long lectures. If
you use Dropbox to host all the files, be sure to change the
<a href="http://theaudacitytopodcast.com/can-you-host-your-podcast-with-dropbox/">download link ending</a> to <code>?dl=1</code>.
<a href="http://castfeedvalidator.com/">Validate</a> your feed to troubleshoot.</p>
<h3 id="record-settings">Record settings</h3>
<ul>
<li><a href="http://www.wikihow.com/Record-Application-Audio-With-Soundflower">Screenshots showing the process</a></li>
<li>Audacity
<ul>
<li>Set the microphone to Soundflower (2ch), Mono</li>
</ul>
</li>
<li>Enable ‘Sound activated recording’ so you won’t have to start/stop/trim;
it’ll just start when the video starts, and stop when the video stops.
<ul>
<li>Audacity: Preferences > Recording > enable ‘Sound activated recording’</li>
</ul>
</li>
</ul>
<h3 id="mp3-export-settings">MP3 export settings</h3>
<ul>
<li>How I name MP3s from each service (ID3 info): Artist / Album / Track
<ul>
<li>Pathoma / chapter / topic</li>
<li>Picmonic / organ system play list / vignette</li>
</ul>
</li>
<li>Encoding settings
<ul>
<li>Install either LAME or FFmpeg</li>
<li>22 KHz sampling, (fast) variable 65-105 kbps, mono</li>
<li><a href="http://manual.audacityteam.org/index.php?title=MP3_Export_Options">advanced details</a></li>
</ul>
</li>
</ul>
<p><img class="thumb" src="/images/soundflower.png" alt="Ensure Built-in Output is checked" />Sometimes when I pull my headphones out, this setup gets in a
weird state where I have no sound. When this happens, ensure the
Soundflower icon in menu bar is set for 2ch output to be “Built-in Output”.
Usually this fixes the situation.</p>
<p><em>Thanks to classmates Evan McClure and Giacomo Waller for tips on recording
MP3s</em></p>
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James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutTactical Test-Taking Strategies2014-09-29T00:00:00+00:00http://jgmalcolm.com/tactical-test-taking-skills<p>Med school is all test after test after test, and so a little over a year into
it and I’m noticing some patterns. Here are simple strategies that brought
order to chaos. While most of this is from med-school tests, the principles
apply to nearly all multiple choice exams.</p>
<div class="series no-print">
<b>STEP1:</b>
Tactical Test-Taking Strategies
//
<a href="/medschool-resources">
Med School Resources
</a>
//
<a href="/medschool-strategy">
Med School Study Strategy
</a>
//
<a href="/memorize-anything">
Memorize Anything
</a>
</div>
<h2 id="qbanks">Practice questions</h2>
<p>Only through practice on questions will you improve your technique, accuracy,
endurance, and learn what’s important. Do not passively read your review
books and notes.
<a href="https://members.aamc.org/eweb/upload/Are%20Questions%20the%20Answer%20PPT%2011-6-12%2010PM.pdf">Question banks are the most effective and efficient study method</a>.</p>
<p>You should jump into doing questions <a href="http://www.sciencemag.org/content/331/6018/772.full">before you feel ready</a>. If
you wait until you feel ready, you’re too late. Questions sharpen contrasts,
a key part of learning to differentiate diseases and disorders. Don’t wait
until you’ve reviewed to start questions; consider the questions and working
through the explanations as part of the learning process. There is only one
score that matters: what you get on the exam. Practice problem scores don’t
count for anything. In fact, you probably remember better after the small
emotional jolt of getting the answer wrong. I find that if I guess correctly,
I’m relieved and may not pay as close attention to the explanation versus if I
had gotten the answer wrong. If you’re learning, you’re headed in the right
direction.</p>
<p>Reviewing and accumulating all the random facts is just part of studying for
an exam; another big part is learning how to make sense of all those facts and
how they relate, an experience that you only get from working through
questions that put these random facts in context and draw contrasts.</p>
<p><strong>Read slowly.</strong> Don’t just read and nod along but parse the meaning of each
and every single sentence. Make sure you understand each step of the
pathophysiology or mechanism of action. Even take the time to parse out each
syllable in long words. In medicine and science, a lot of meaning is packed
into each syllable of words like <em>choledocolithiasis</em>. This may all feel
slow, but it’s reinforcing neural pathways and ultimately to speed up your
future reading comprehension. Seek to understand on the first pass. If you
go fast, you’ll cheat yourself and likely end up re-reading the material
anyway. If you’re reading fast to cram more in to your study time, consider
simply budgeting more study time. Take a shorter lunch break. <strong>First gain
accuracy, then gain speed.</strong></p>
<p><strong>Pay attention.</strong> There are two types of questions you miss. First, there
are those where you simply don’t know the facts needed, so you
<a href="#guessing">guess intelligently</a>. Second, and likely the majority of
questions I miss, the ones where I misread the question. I either skimmed
quickly past a phrase or I didn’t understand the significance of some fact.
These are the ones where you’re reading the explanation and smack your
forehead. This goes along with “Read slowly”: parse every piece of data for
its significance. There are no wasted words in high quality question banks.</p>
<p><strong>Emotional reactions have a lasting effect on memory.</strong> Wrestling with a
question and the immediate emotional and intellectual feedback of seeing the
answer helps solidify the knowledge. It’s important that you commit to an
answer so you increase the emotional charge in the event you’re wrong. Giving
up and guessing is less emotional; it’s better to convince yourself of one
answer, commit, and click submit. One trap I stumbled into is that even when I
got a question right but just barely, I found I got sloppy in reading through
the explanation. In many cases it would have been better had I got the answer
wrong to grab my attention and drive me to achieve understanding.</p>
<p><strong>Commit to an answer before looking anything up.</strong> I often find myself
wanting to look up a fact in the textbook before clicking submit, but that
lessens the emotional payoff. It’s better to think of what specific
information you want to look up and how that factors into the answer choices.
That way, when you do get to see the explanation, you really drive home the
critical details you were missing. It’s best to commit to an answer, let the
chips fall, and use that energy to understand the correct answer. Don’t worry
about getting a low score from wrong answers: <em>the only score that matters is
the real exam</em>.</p>
<p>There’s some evidence that if you take a pretest before you’ve even been
exposed to material, <a href="http://www.nytimes.com/2014/09/07/magazine/why-flunking-exams-is-actually-a-good-thing.html">you’ll do better</a> when it comes to the actual
test afterward. If your scores are not improving or you are just guessing,
you might not be ready. Consider stepping back to review more.</p>
<p><strong>Drilling on questions also helps you understand your own psychology.</strong>
Recognize the signs that you’re tiring or getting sloppy, and learn to
refocus. Recognize your proclivities to jump toward certain answers and not
read the question fully. One odd thing I noticed is that, for questions where
two answers are very close, I tended to prefer the first of the two. Once I
recognized this tendency, I started catching myself and instead focus on those
choices without bias. If you’re consistently choosing the second best answer,
ask yourself what is it that distracted you or tipped you the wrong way? Are
you over-thinking the question, ie. adding unnecessary “logical” steps to
justify the wrong answer? Critically investigate what you are missing and
where you went off track.</p>
<p><strong>Doing more questions can also perpetuate bad habits.</strong> If you stop improving
or regress in performance, it’s a sign you’re developing sloppy habits like
<a href="#read">not reading the entire question</a> or
<a href="#abnormal-findings">not paying attention to every lab value mentioned</a>. Investigate
why you’re choosing wrong answers to see a pattern emerges.</p>
<p><strong>Mark questions valuable to see again.</strong> Doing an entire question bank again
from scratch is probably not the best use of your time, but some questions
teach valuable lessons and are worth returning to down the road. Flag/mark
such questions for later studies. But be sure to get everything you can out
of the explanation in the moment. Don’t mark a question telling yourself
you’ll come back to study it later. There never is a “later” as the pace of
life only picks up.</p>
<p><strong>Start easy.</strong> Consider doing a test with all easy questions so you can start
easing into concepts and get some positive vibes going. However, don’t be
fooled into thinking this is your actual performance until you’ve cut your
teeth on some harder questions.</p>
<p>Practice until these techniques are second nature and you’ve killed bad
habits. Techniques will only incrementally improve your performance. There
are no true shortcuts on these exams and these techniques only work when you
already have the core knowledge.</p>
<h2 id="first-sentence-last-sentence">First sentence, last sentence</h2>
<p>Read the first sentence and then the last sentence. Skip everything in
between for the moment. Skim the answer choices. Now you’ve got your
context. You know what topics are going to be relevant. You know what type
of answer is expected. As you go through the rest of the scenario and answer
choices, your brain is already working quietly to connect the dots. You’re
primed to pay close attention to key information as you continue reading.</p>
<p>At this point, you can skim the answer choices and probably immediately rule
out one or two. In some cases, the answer is obvious (but don’t jump until
you’ve read everything).</p>
<p>Now go back to read the rest of the scenario and attack the remaining answer
choices.</p>
<p>You’ll avoid the situation where you’re reading along thinking you know
exactly the diagnosis, only to come to the end and realize the prompt is
asking you something different like a side effect of the treatment for that
obvious disease (second-order sequence instead of first-order recall). If you
had known the prompt, you could have been reading the scenario and already
thinking of how to make a connection to the prompt. Wasted time and energy.</p>
<p>If there’s an image, look at it before reading the full question to see if you
recognize anything. Often, after only reading the final prompt and glancing
at the answer choices, you can already rule out one or more wrong choices in
seconds. Classic histology or gram staining is “classic” for a reason.</p>
<h2 id="study-the-answer-explanations">Study the answer explanations</h2>
<p>Always review explanations. First for the correct answer, second for your
wrong answer, but also for all the other answers. Specifically look for how
you could have ruled out each incorrect answer. The point of the question
isn’t just the information limited to the correct choice; the point of the
question is the integration and contrasts between all answer choices. A good
rule of thumb is that you should spend more time studying the explanation than
you just spent completing the question.</p>
<p><strong>Markup your notes/textbook.</strong> Find the topic in your notes, underline the
most important physical or lab findings, etc. Put a small dot next to the
tested fact. Over time, the highly tested material becomes apparent. Not all
information is weighted equally, and you’ll soon start to see which topics are
most important. Avoid cluttering your notes and only do this for things you
got wrong. I used a different dedicated color for each question bank.</p>
<p>Some topics are not that important or not substantial enough to merit their
own question, so instead they will be frequently used as distracting (wrong)
answers. Becoming familiar with these <em>secondary distracting topics</em> is as
important as familiarity with <em>primary tested topics</em>. Don’t skimp on
studying wrong answers.</p>
<p>How do you know when you’re read to move on to the next question? Ask
yourself: <strong>If I saw this again, would I be able to rule out all the wrong
answers?</strong></p>
<p><strong>Review topics, not isolated details.</strong> If you get a question wrong, don’t
just memorize the specific fact you missed. Go and skim over the entire
disease or pathway in context. If the answer stems were all a cluster of
related diseases, skim those and understand how to compare and contrast. If
it was a bone tumor question and the answer was a particular bone cancer,
review the specifics of that cancer, but also do a quick recap of the other
ones. If the answer was a particular enzyme in the purine salvage pathway,
review the entire pathway. Take every opportunity to learn in context.</p>
<h2 id="record-learning-points">Record learning points</h2>
<p>Whenever you have an “Ah, ha!” moment, write it down. Keep this very simple
and low-friction. You don’t want to complicate this because you probably
<em>will not</em> come back and review. <strong>Just the simple act of recording the
learning point forces you to synthesize a precise factoid suitable for
cerebral storage.</strong> If you got a question right but just barely, consider
recording the learning point to solidify your thinking. Just as you take
notes while you’re studying lectures, treat question banks as study time and
take a few <em>simple</em> notes. Don’t waste time making these notes pretty. Every
day you start with a new page and blank slate.</p>
<figure class="gallery thumb">
<a href="/images/scratch.jpg" data-gallery="scratch" title="Quick, simple scratch notes on key facts. No time for pretty.">
<img src="/images/scratch.jpg" />
</a>
<figcaption>Quick, simple scratch notes on key facts. No time for pretty.</figcaption>
</figure>
<p>Instead of simply stating the correct answer or tested fact, put it in
contrast with the wrong answer you picked, eg. differential diagnosis.</p>
<p>This process will seem to slow you down, but it’ll quickly pay dividends as
you speed up. As your knowledge base grows you’ll pick up speed because
you’ll record fewer learning points and you’ll answer questions faster.</p>
<p>To avoid clutter and save time, avoid writing things you already solidly know.
Instead, just let your mind stew on the concept for a moment to reinforce
those neurons before moving along.</p>
<blockquote>
<p>Read more:
<a href="http://www.medschooltutors.com/blog/the-uworld-journal-how-i-scored-a-263-on-the-usmle-step-1">MedSchoolTutors: Creating a UWorld Journal</a></p>
</blockquote>
<h2 id="chief-complaint">Chief complaint</h2>
<p>The first sentence likely contains the most important clue and sets the
context. Here are a few classic tip-offs.</p>
<ul>
<li>chief complaint - your diagnosis must absolutely explain this
<ul>
<li>whatever the patient came in complaining of is the most important thing to address</li>
</ul>
</li>
<li>race - anytime race is mentioned, it’s a clue
<ul>
<li>African-American - HTN, sickle cell, autoimmune</li>
<li>white - cystic fibrosis, membranous nephropathy</li>
<li>Greek, Italian - classic Mediterranean patients - B-thalassemia</li>
</ul>
</li>
<li>sex - female autoimmune</li>
<li>age - diseases sometimes target a rough age range: childhood, middle age, elderly
<ul>
<li>1-2 yo boy - x-linked</li>
</ul>
</li>
<li>obese - DM2</li>
<li>occupation, home environment - environmental exposure
<ul>
<li>farmer, veterinarian - animal exposure, hypersensitivity to moldy hay</li>
<li>construction worker, old apartment, painter - lead poisoning</li>
<li>college student - Neisseria, mono</li>
</ul>
</li>
<li>exotic environment
<ul>
<li>an emergency department in the third world - think of old drugs not used anymore in the US
<ul>
<li>Chloramphenicol causing aplastic anemia (no longer used in US but might encounter in third world)</li>
</ul>
</li>
</ul>
</li>
<li>immigrant or foreigner visiting who recently became ill
<ul>
<li>unvaccinated, endemic disease (late manifestations), lack of newborn screening</li>
</ul>
</li>
</ul>
<h2 id="beyond-buzzwords">Beyond Buzzwords</h2>
<p>Initially you’ll get really good at recognizing pathognomonic phrases for
symptoms. These buzzwords are concise ways of communicating often complicated
pathophysiology. But learning buzzwords will only get you so far, and soon
you’ll plateau when you hit questions without these classic phrases.</p>
<p><strong>Alternative descriptions.</strong> Instead of telling you “patient complains of
dyspnea”, the question indirectly describe that the “patient is winded during
regular daily activities.” As you do more and more questions, you’ll learn
all these alternative descriptions for common findings.</p>
<p><strong>Understand what they’re telling you.</strong> To go to the next level, you need to
recognize what the question is trying to tell you. You need to categorize
multiple physical findings into their underlying pathophysiology so you see
through the buzzwords.</p>
<blockquote>
<p>Patient presents with history of dyspnea, orthopnea, and ankle swelling.</p>
</blockquote>
<p>What that means:</p>
<blockquote>
<p>Patient presents with signs of both left-sided heart failure (dyspnea,
orthopnea) and right-sided heart failure (ankle swelling).</p>
</blockquote>
<h2 id="ruling-out">Ruling out answers</h2>
<p>Never commit to an answer without ruling out other choices. This will make
sure you’re not just jumping for a distractor. Once you rule out a choice,
you can completely forget about it and focus your attention on comparing the
remaining choices.</p>
<p>Multiple choice tests are as much about knowing the right answer as being able
to rule out all the wrong answers. Sometimes you arrive at the right answer
only because you ruled out all the other choices.</p>
<p>A single phrase can rule out an answer choice. The question prompt may
mention an ancillary test that was performed whose only purpose is to rule out
one specific answer choice.</p>
<blockquote>
<p>Patient presents with X, Y, Z that appear to be some form of anemia. In the
course of workup, <u>direct Coombs test was negative</u>.</p>
<ul>
<li>A</li>
<li>B</li>
<li>
<strike>Autoimmune hemolysis</strike>
</li>
<li>D</li>
</ul>
</blockquote>
<p>Every answer choice was included for a reason. Don’t just rule something out
because it simply seems odd. As I got faster, I had the tendency to sometimes
rule out answer choices quickly because they seemed unrelated. This was a bad
habit because often what seemed immediately unrelated was in fact related in
an indirect way. I now force myself to consider what each answer choice means
and why it was included before crossing it out. I can catch myself going down
this path now: when I’ve ruled out several choices but the remaining choices
all seem a muddle. That alerts me to the possibility that I’ve ruled out the
correct answer, and so I backtrack a little to reevaluate anything I didn’t
carefully consider before crossing it out. If you’re finding that you’re
often ruling out the correct answer, you need to slow down and be more sure
before ruling things out.</p>
<p>If you’re unsure, skip that choice for a moment and continue evaluating the
other choices. Sometimes the other choices will shed light on the one you
didn’t immediately understand.</p>
<p>I often found myself picking the second best answer, and this was typically
because I was over thinking the question and second guessing the test writers.</p>
<p>Once you’ve narrowed down to two answers, ask yourself <strong>“What is different
between these choices?”</strong> and then look back in the scenario for specific
clues.</p>
<p><strong>When faced with an unfamiliar answer choice.</strong> Forget about it for the
moment, and focus only on the answer choices you do know, the ones that you
are capable of ruling out with your knowledge base. Only pick that unfamiliar
choice if you can be reasonably confident in ruling out the other choices you
know about. Suppose you’ve ruled out all but the unfamiliar and one that is
familiar, but you’re uncomfortable with that familiar one. Resist the urge to
simply guess the unfamiliar one as a way out; that’s a baseless guess. Think
critically about the one you do know and use that as the basis of your
decision to rule that known answer in or out. Be careful that you don’t <em>read
meaning</em> into the unknown answer, i.e. project onto it what you think it might
mean when you truly have no basis.</p>
<p><strong>Practice good habits.</strong> Practicing good habits will see your score continue
to rise as you accumulate the information and learn better how to apply it.
If your score has plateaued, then you need to take a close look at what habits
you’re practicing. Don’t rush: start slow to gain accuracy and build
execution speed later.</p>
<h2 id="guessing">Guessing intelligently</h2>
<p>If you have to guess, do so intelligently:</p>
<ul>
<li><a href="#ruling-out">Rule out</a> as many wrong choices as possible.</li>
<li>If there are multiple answers that are equivalent and one that is different,
then it’s likely the equivalent group is all wrong together.</li>
<li>If two answers are the opposite of each other, then the answer is likely one
of those. Ignore the other choices.</li>
<li>Use epidemiology to pick the most likely. The most common disease
(<a href="https://en.wikipedia.org/wiki/Zebra_(medicine)">avoid zebras</a>). An adult patient with no mention of chronic or
childhood issues, then rule out congenital diseases that would have shown up
in early childhood (e.g. hemophilia, sickle cell). Anything that occurs
suddenly without any history, think acquired instead of congenital.</li>
<li>Avoid costly or invasive diagnostic tests.</li>
<li>Don’t go for something you’ve never heard of until you’ve ruled out all
other options.</li>
</ul>
<h2 id="histology">Histology</h2>
<p>Most histology looks like a mess at first, but you should always start at the
center and try to identify what you’re seeing. The “area of interest” will
not be on the periphery; it will be near the center. Literally put your
finger in the exact center and scan that square centimeter for what is of
interest. If you see something funny in the periphery that’s not also found
in the center, then ignore it. Ask yourself what you expect to see, eg. the
esophagus is nonkeratinized (stratified) squamous epithelium.</p>
<p>Look for characteristic features:</p>
<ul>
<li>Eosinophils (bilobed)</li>
<li>Neutrophils (3-5 lobes)</li>
<li>Macrophages (large, multiple nuclei)</li>
<li>Auer rods (acute myelogenous leukemia)</li>
<li>Granulomatas (pink)</li>
</ul>
<h2 id="avoid-outliers">Avoid outliers</h2>
<p>When one answer is totally different than the others, it’s likely a distractor.</p>
<blockquote>
<ul>
<li>Oxygen curve is shifted to the right because of B.</li>
<li>Oxygen curve is shifted to the right because of C.</li>
<li>Oxygen curve is shifted to the right because of D.</li>
<li>
<strike>Oxygen curve is shifted to the left because A.</strike>
</li>
</ul>
</blockquote>
<p>Boards questions almost always give you enough information to make a
diagnosis, and rarely is a patient without risk. So avoid those answer
choices:</p>
<blockquote>
<ul>
<li>The patient is at risk because of X.</li>
<li>
<strike>The patient has no risk because of Y.</strike>
</li>
<li>
<strike>Not enough information is provided to make a diagnosis.</strike>
</li>
</ul>
</blockquote>
<h2 id="abnormal-findings">Account for every abnormal finding</h2>
<p>Your answer needs to explain every given lab value and physical finding. If
there’s some seemingly completely unrelated lab value that’s wildly abnormal
and you cannot explain it with your answer, then think harder about the other
choices. There are no wasted words in a question prompt.</p>
<p><strong>Tunnel vision.</strong> This is especially true in disorders involving multiple
systems. Individual answer choices may address individual system
dysfunctions, but you need to make sure that your chosen answer explains all
abnormalities. For example, a patient presents with renal dysfunction, joint
pain, and hematologic abnormalities. The individual answer choices might be
nephritic syndrome, rheumatoid arthritis, and myelodysplastic syndrome. Each
of those answer choices correspond to a chief complaint, but none answer the
whole picture. Be careful not to jump at a single physical finding. If
multiple systems are involved, you need to tie as many together as you can.
This patient has lupus.</p>
<h2 id="classic-clues">Classic clues</h2>
<p>There are some triggers that should either perk your ears to a likely
diagnosis or rule out specific answer choices:</p>
<ul>
<li>African-American female → autoimmune</li>
<li>20-40yo female → autoimmune, multiple sclerosis</li>
<li>“Patient presents to emergency room…” → unlikely a chronic issue,
acute often means vascular</li>
<li>“Complaining of progressive symptoms for several months” → tumors can
develop over months</li>
<li>Infant or first few weeks of birth → genetic
<ul>
<li>no family history → recessive</li>
</ul>
</li>
<li>female → ignore x-linked</li>
<li>“multiple rounds of antibiotics” → no gut flora causing Vitamin K
deficiency (bleeding), C diff</li>
<li>medication that was recently prescribed → side effects causing chief
complaint</li>
<li>multiple sexual partners, IV drug use → consider STDs or HIV/AIDS and
opportunistic infections</li>
<li>“Family history of <symptoms/disease>” → this always factors into the
diagnosis</li>
<li>aspiring athlete → anabolic steroid use</li>
</ul>
<h2 id="tip-offs">Tip offs</h2>
<p>Specific constructs can help clue you in to what they’re trying to get at.</p>
<ul>
<li>“What is most likely?” - forget about rare diseases, just think what is most
prevalent. <a href="https://en.wikipedia.org/wiki/Zebra_(medicine)">Avoid zebras</a>. It’s likely more than one answer is
possible, but you’re being tested on epidemiological prevalence to determine
the most likely.</li>
<li>“What is the next step in management?” - There might be an overall treatment
goal, but this question is likely asking about immediate next steps.</li>
</ul>
<p>If most of the questions (3-4) have the same base phrase but differ in the
second half, look to choose among those if you have to guess.</p>
<blockquote>
<p>Patient is having a reaction to heparin.</p>
<ul>
<li>Discontinue heparin, do X.</li>
<li>Discontinue heparin, do Y.</li>
<li>Discontinue heparin, do Z.</li>
<li>
<strike>Do something completely different.</strike>
</li>
</ul>
</blockquote>
<p>Examine the answer choices together. If several choices are equivalent, then
they might be ruled out together as a block.</p>
<blockquote>
<p>Question, blah, blah, blah.</p>
<ul>
<li>
<strike>Decreased pH</strike>
</li>
<li>
<strike>Increased hydrogen ion concentration</strike>
</li>
<li>
<strike>Decreased bicarbonate</strike>
</li>
<li>Something else</li>
</ul>
</blockquote>
<p>One answer may refer to a combination of others. Often you can ignore the
other choices not involved in that combination. This shows up more so on
lower quality tests.</p>
<blockquote>
<p>Question, blah, blah, blah.</p>
<ul>
<li>Dog</li>
<li>Cat</li>
<li>
<strike>Tiger</strike>
</li>
<li>Dog & Cat</li>
</ul>
</blockquote>
<h2 id="three-types-of-questions">Three types of questions</h2>
<p>There are three types of questions: those you know immediately, those you
don’t have the knowledge to answer, and those that you’ll end up pondering.
Every question is worth the same as every other question, so you can be
strategic about how you spend your time and energy.</p>
<p>First calculate your benchmark time per question: test is X minutes with Y
questions, so you need to average (X/Y) per question.</p>
<p>For the easy bread-and-butter questions, answer them immediately to lock in
the majority of your points.</p>
<p>Some questions you simply won’t have a clue about because you’re lacking the
requisite knowledge. It’s a death trap to fritter away your time on these.
Narrow it down to 2-3 choices and guess. You want to avoid the situation
where you’ve got 10 minutes left but 20 questions, and so you make sloppy
mistakes on easy ones.</p>
<p>For these marked questions, go carefully and spend the time. These questions
will make the difference between pass and high pass.</p>
<h2 id="read">Read the entire question carefully.</h2>
<p>Your middle school teacher was right. As you’ve gotten used to banging
through questions, sometimes a question will seem so easy that you jump right
to the answers looking for what you already have in mind. Test-writers know
this too and can create a dead obvious question except for one small detail
that totally changes. And they know exactly the trap answer to put for those
zipping through.</p>
<p>Make sure you’ve taken into consideration every single symptom and avoid the
knee jerk choice. The first sentence here sounds like lupus, but reading the
entire question guides us to dermatomyositis.</p>
<blockquote>
<p>Patient presents with malar rash and signs of chronic inflammation and a
positive ANA … Patient also complains of <strong>proximal muscle weakness</strong>.
The ANA shows anti-Jo-1 antibody.</p>
<ul>
<li>
<strike>Lupus</strike>
</li>
<li><strong>Dermatomyositis</strong></li>
</ul>
</blockquote>
<p>I can’t count the number of times I’ve jumped to an answer after reading the
first sentence or two only to be wrong. Unless you’re clearly committed to
guessing, you better have a reason for ruling out all other answer choices
before you click submit. Forcing yourself to address each (incorrect) answer
choice in turn will help you squeeze out these sloppy errors.</p>
<p>NBME has released their <a href="http://www.nbme.org/PDF/ItemWriting_2003/2003IWGwhole.pdf">guidelines for writing questions</a> which go into
great detail on how they choose and format their standard exam questions.</p>
<p><em>Many thanks to my classmates Ming Lee,
<a href="//erikreinertsen.com">Erik Reinertsen</a>,
<a href="//twitter.com/evan_mcclure">Evan McClure</a>, Juan-Manuel Duran, Jason Boulter,
and LeslieAnn Kao for discussions.</em></p>
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James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutMac OS X Tweaks2014-09-01T00:00:00+00:00http://jgmalcolm.com/osx-tweaks<p>Some tweaks to get rid of a few Mac OSX window animations for a snappier feel.
Copy and paste these into your terminal (<code class="language-plaintext highlighter-rouge">#</code> lines are ignored comments).</p>
<figure class="highlight"><pre><code class="language-bash" data-lang="bash"><span class="c"># disable new window animation</span>
defaults write <span class="nt">-g</span> NSAutomaticWindowAnimationsEnabled <span class="nt">-bool</span> NO<span class="p">;</span> killall Dock
<span class="c"># disable toolbar in fullscreen</span>
defaults write <span class="nt">-g</span> NSToolbarFullScreenAnimationDuration <span class="nt">-float</span> 0
<span class="c"># scrolling Finder column view</span>
defaults write <span class="nt">-g</span> NSBrowserColumnAnimiationSpeedMultiplier <span class="nt">-float</span> 0
<span class="c"># rubber band effect when scrolling</span>
defaults write <span class="nt">-g</span> NSScrollViewRubberbanding <span class="nt">-int</span> 0
<span class="c"># Dock animations</span>
defaults write com.apple.dock expose-animation-duration <span class="nt">-float</span> 0
defaults write com.apple.dock autohide-time-modifer <span class="nt">-float</span> 0
defaults write com.apple.dock autohide-delay <span class="nt">-float</span> 0
<span class="c"># hide sidebar when opening PDFs</span>
defaults write com.apple.Preview PVPDFSuppressSidebarOnOpening <span class="nb">true</span></code></pre></figure>
<p>These and more can be found on
<a href="http://apple.stackexchange.com/questions/14001/how-to-turn-off-all-animations-on-os-x/">StackExchange</a>.</p>
<p>The <a href="https://github.com/drduh/OS-X-Yosemite-Security-and-Privacy-Guide">OS X Yosemite Security & Privacy Guide</a> has an extensive list
of tweaks to disable some unnecessary background services that can save some
CPU.</p>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutGrad School: What I Wish I Did2014-07-31T00:00:00+00:00http://jgmalcolm.com/grad-school<p>I should admit from the start that I didn’t do all of these. If you could
manage to do them all, you would be a rock star. These are things I wish I
did, in some cases saw others do. Some ideas might resonate with you, others
might fall flat. Grad school is a time to find your own path.</p>
<h2 id="work-on-important-projects">Work on important projects</h2>
<p>Whatever you do, make sure it’s worth it. You want your time and energy to
make a difference. It’s so easy to work on projects that are technically
feasible but have no consequence on the world. These will be some of the most
focused and productive years of your life, so make them count.</p>
<p>At the start, you’re likely to get swept up in some “awesome” project your
advisor or a senior student dreams up. This may seem like a grind and you
might not be able to step out. If that’s the case, then keep at it and keep
your eyes open for opportunities to breakout in new interesting directions.
Use the experience to learn your tools.</p>
<p><a href="https://en.wikipedia.org/wiki/Richard_Hamming">Richard Hamming</a> gave a famous lecture entitled
<a href="http://www.cs.virginia.edu/~robins/YouAndYourResearch.html" title="Richard Hamming: You and Your Research (text)">“You and your research”</a> (<a href="https://www.youtube.com/watch?v=a1zDuOPkMSw" title="Richard Hamming: You and Your Research (video)">video</a>). I highly
recommend pouring over his advice. Among the gems in there, one I want to
highlight here is how he would have lunch with people from other departments.
Often he would raise the question “What are the important problems in your
field?” And soon after that he would prod by asking why they weren’t working
on the important problems? Questions like this get under your skin. He
wasn’t welcomed at the lunch table anymore. <a href="http://paulgraham.com/procrastination.html">Paul Graham</a>
has a good discussion of this.</p>
<p>Elon Musk is another a fascinating individual with wildly ambitious goals.
<a href="https://en.wikipedia.org/wiki/Elon_Musk#Early_life_and_education">The story goes</a> that he dropped out of the Stanford robotics PhD
and ultimately came to focus his energy on the biggest problems facing Earth’s
limited resources: energy (<a href="https://en.wikipedia.org/wiki/SolarCity">solar</a>, <a href="https://en.wikipedia.org/wiki/Tesla_Motors">electric cars</a>) and
<a href="https://en.wikipedia.org/wiki/SpaceX">space exploration</a>.</p>
<h2 id="follow-rockstars">Follow rockstars</h2>
<p>Study their techniques and writing. Try to distill why they are successful.
Maybe you can find a way to relate your work to theirs and forge a joint
project. Have a list of rockstars both inside and outside your field.</p>
<p>Every year when the <a href="https://en.wikipedia.org/wiki/Nobel_Prize">Nobel Prize</a> is announced, understand the technique it
highlights enough that you can explain its significance to friends and family.
Same goes for the <a href="https://en.wikipedia.org/wiki/Breakthrough_Prize_in_Life_Sciences">Breakthrough Prize</a>, <a href="https://en.wikipedia.org/wiki/Fields_Medal">Fields Medal</a>, <a href="http://amturing.acm.org/">Turing Award</a>,
<a href="https://en.wikipedia.org/wiki/Lasker_Award">Lasker Award</a>, etc.</p>
<h2 id="choose-your-advisor-carefully">Choose your advisor carefully</h2>
<p>This will in large part determine what you work on, how stable funding is, and
overall how friendly the lab will be. Your advisor can control a lot of
factors outside your control.</p>
<p>Find a young and hungry advisor. It’s good for the advisor to have a few
years at your school already so you can ask around for others’ impressions and
enjoy the benefit of an established pipeline of projects already up and
running. It’s also good for the advisor to be a few years out from tenure so
they are hungry for work and willing to roll up their sleeves to help.</p>
<p>Probably above all else, you want an advisor you get along with, one you’d
enjoy grabbing beers with. Ask their students and other faculty for
impressions. If your advisor picks up the tab, that’s a good sign that
funding is secure.</p>
<p>Review their publication record. Do the topics interest you? Does the
quality match your expectations?</p>
<p>Later, when it comes to your committee, that’s the opportunity to get more
seasoned professors involved to help make introductions.</p>
<p>Don’t just jump at the first professor offering funding. Take your time here
and seek the advice of others.</p>
<h2 id="consult-your-advisor">Consult your advisor</h2>
<p>Read all of their major works. Ask them where to start and what to read.
You’ll find that a few key papers keep coming up, especially as you prepare
background citations in your work and go on to meet former students at
conference.</p>
<p>Ask your advisor to sketch out her view of the entire field and how her work
fits within it. Which topics should you master and which should you only be
familiar? What are new hot areas? Any related fields to pay attention to?</p>
<h2 id="create-a-blog">Create a blog</h2>
<p>You’re now a knowledge worker and your personal website is your brand. Treat
it like an investment: early work pays dividends as you build up a valuable
resources for those following in your footsteps. Don’t wait until your final
years to advertise yourself.</p>
<p>More important than building a public image, writing is a great way to evolve
your thinking, to vet ideas, and practice effective communication. It’s also
a great way to show your advisor what you’ve been up to.</p>
<p>In some fields, there’s of course the need to not give away your ideas to
competitors, but I wager you can still put valuable information in the public.</p>
<h2 id="avoid-classes">Avoid classes</h2>
<p>You’ll have some minimal requirements. Get those out of the way as fast as
possible. You will be way more productive once you can spend 100% of your
brainpower on research, instead of breaking to go to some random class. At
this point, with all that’s available online, top students can teach
themselves anything necessary. Your advisor can point out most of your
deficiencies; ask her what you should take classes in, and what to avoid.</p>
<p>It’s fine to “drop in” on a few lectures here and there that you enjoy, but
don’t delude yourself into actually taking the course to learn. Classes,
especially those at the grad level, have you jumping through hoops to complete
ethereal homework assignments and cramming for exams when you could be putting
that energy into a publication that will advance your career. To broaden your
horizons, attend some seminar lectures, drop in on some specific classes, have
lunch with a particular professor, ask your advisor to point you in the right
direction, let yourself wander on the internet for a few hours. But don’t
consign yourself to a static lecture every Wednesday afternoon.</p>
<p>If you’re really interested in something, approach the professor personally
and ask for any lecture notes or a book recommendation, and then block off
several days to work through the first few chapters and associated problems –
no research, just working through the book and <a href="/wikipedia-tricks">Wikipedia</a>. Come
back to their office for help. I would wager that a professor watching you do
this would be ecstatic to see a student with such diligence and true interest.
You’ll likely learn more out of a few focused days rather than some sprinkled
one hour lectures and a final.</p>
<p>Invest in yourself and understanding how you learn, so that you can forever
after teach yourself anything you want.</p>
<h2 id="put-everything-under-version-control">Put everything under version control</h2>
<p>Version control is like today’s version of the lab notebook: a record of
everything tried. Version control both code and data. This way every
experiment is repeatable: every experiment is uniquely identified by a
<a href="http://git-scm.com/book/ch6-1.html#A-SHORT-NOTE-ABOUT-SHA-1">SHA</a> indicating
a specific version of the code and data. If you’re using a database,
<a href="http://blog.codinghorror.com/get-your-database-under-version-control/">get your database under version control</a>.
Put your papers in source control. Don’t put source code in Dropbox.</p>
<p>This is a great way to show your advisor you’re working: point him to the
commit log. But of course, just making commits do not mean you’re being
productive.</p>
<p>Get your research group collaborating this way. It’s a great way to ensure
proper hand-offs of code and projects between students. If you need private
repos to keep work confidential (pre-publication?), then ask your advisor to
spring for it.
<a href="https://github.com/blog/1840-improving-github-for-science">GitHub</a> is making
strides to support academics.</p>
<p>Other great ways to collaborate may include using Google docs for real-time
collaboration between coauthors or drafting. You can now track changes and
accept/reject suggested edits.
<a href="http://tex.stackexchange.com/a/1654">Several platforms</a> exist for
collaborating with LaTeX documents. <a href="http://mendeley.com/">Mendeley</a> lets you
share papers among colleagues and quickly assemble bibliographies in MS Word.
<a href="https://authorea.com/users/3/articles/3904/_show_article">Authorea</a> is a
project to make it easier to interact and share scientific ideas.</p>
<p>Any time you’re dealing with code – your own or from a colleague – you want
to get that done in source control. Suppose an older grad student hands you a
bunch of code. If it wasn’t through github or such, you should start by
putting the files into a fresh repo, before you make any edits. Unzip and
make that the initial commit. Only after that initial commit should you make
any changes to get the code to run, e.g. changing hard coded
values/parameters.</p>
<p>More: <a href="https://da-data.blogspot.com/2016/04/stealing-googles-coding-practices-for.html">Stealing Google’s Coding Practices for Academia</a></p>
<h2 id="every-project-needs-its-own-page">Every project needs its own page</h2>
<p>Every project should have its own online page where people can learn more. At
a minimum this should have the paper itself, but consider making available
code/data for those wishing to replicate/extend your work, high resolution
figures, any slides or poster you created, full citation already formated for
BibTeX or similar, etc. Make it easy for those wishing to learn more and
extend your work. Maybe some student wants to present your work to his/her
lab group, so having a ready-made slide deck makes this easy. This is a great
way to <a href="https://hacks.mozilla.org/2013/05/how-to-spread-the-word-about-your-code">spread the word about your code</a> and there are many benefits
to <a href="http://tom.preston-werner.com/2011/11/22/open-source-everything.html">open sourcing everything</a>. You’re more likely to get
cited and for others to build upon your results. When you package up code,
set it up so it runs right out of the box on some sample image/data.</p>
<p>Make it accessible to the non-technical readers too. Your research was likely
funded by taxpayers, so make some effort to cut out jargon. Make it easy for
anyone to quickly grasp the importance of your result and the basic technique.</p>
<h2 id="contribute-to-wikipedia">Contribute to Wikipedia</h2>
<p>Evangelize about your research area. Link it into other relevant topics.
Link to seminal research and online resources. Provide a road map for newbies
and generations to come. This will help you organize your own thoughts and
mental map of the research landscape. If you’re going to be spending a lot of
time on Wikipedia, <a href="/wikipedia-tricks">customize the user interface</a> for efficiency.</p>
<h2 id="papers-and-publishing">Papers and publishing</h2>
<p>Figure out your target conferences and journals, and then obsess over those.
Skim the last few years proceedings to get an idea of where the bar is at and
what’s hot. Some journals have <a href="http://www.shawnlankton.com/2009/07/rss-feeds-for-scientific-journals" title="RSS Feeds for Scientific Journals">RSS feeds</a> so you can keep up.</p>
<p>Pick some target conferences and workshops (ones with great locations!) and
work backward from those submission dates. Put them on your calendar. Map
out the Program Committee members, and be sure you’re familiar with their
interests and cite their papers where relevant. A PC member will easily frown
upon a paper that fails to mention their relevant work.</p>
<p>Increase your network and chance of publication by teaming up with colleagues.
Each of you submits as a primary author but have the other as coauthor (with
appropriate contribution). Hopefully at least one of you gets a paper
accepted.</p>
<p>Know what a “Win” looks like to your advisor. Where do they want to publish?
What do they need to move their own career forward?</p>
<p>Good scholarship is the difference between
<a href="http://togelius.blogspot.com/2016/04/the-differences-between-tinkering-and.html">tinkering on a project</a>
and pushing the boundaries of knowledge.</p>
<blockquote>
<p>Read more:
<a href="/writing-science">“How to write and publish a scientific paper”</a>,
<a href="/systematic-reviews">“How to write a systematic review and meta-analysis”</a>,
<a href="http://blogs.lse.ac.uk/impactofsocialsciences/2012/11/28/lupton-30-tips-writing/">“30 Tips on writing”</a>,
and <a href="/tags/?q=writing">more posts on writing</a>.</p>
</blockquote>
<h2 id="conferences">Conferences</h2>
<p><strong>Build your network.</strong> Look through the attendee list (if available) and
email anyone whose work you build on to see if you can grab coffee or sit
together at a session. It’s a conference, not a vacation.</p>
<p><strong>Read through the program.</strong> Circle anything interesting. For anything
related to your work, reach out those authors. They put as much time into the
topic as you did so there will definitely be something to talk about, and you
will likely want to cite each other if relevant. Maybe you can coauthor
something.</p>
<p><strong>Poster sessions.</strong> Print copies of your poster and paper/abstract, and pin
these up in a folder underneath your poster for anyone to take for later.
Print like 30 copies of the poster/abstract, fewer of a multi-page paper; lots
will be wasted but people will be less sheepish about taking one if there are
plenty. Double-sided. Balance time in front of your poster and time walking
around to interact with other presenters.</p>
<h2 id="what-can-i-say-i-learned-from-it-all">What can I say I learned from it all?</h2>
<p>I learned how to frame and solve problems. I no longer fear a research paper
or get intimidated by big fancy science. When faced with the uncertainty of
new topic, I can come up with a research plan and milestones. I can develop
convincing experiments. And I can craft an efficient and comprehensive
writeup.</p>
<h2 id="my-story">My story</h2>
<p>I completed a PhD in medical imaging and computer vision with the Department
of <a href="http://ece.gatech.edu">Electrical & Computer Engineering</a> at Georgia Tech.
My advisors provided excellent guidance and support in both life and academia:
<a href="http://pnl.bwh.harvard.edu/yogesh-rathi-ph-d/">Yogesh Rathi</a> and <a href="https://en.wikipedia.org/wiki/Allen_Tannenbaum">Allen Tannenbaum</a>. My committee included some of the
most superb scientists I have ever worked with: <a href="http://www.ece.gatech.edu/faculty-staff/fac_profiles/bio.php?id=116">Tony Yezzi</a>,
<a href="http://www.ece.gatech.edu/faculty-staff/fac_profiles/bio.php?id=139">Patricio Vela</a>, and <a href="http://pnl.bwh.harvard.edu/people/profiles/bouix.html">Sylvain Bouix</a>. I worked and shared an office with
some amazing friends: <a href="http://thecrontab.net">Gallagher Pryor</a>, <a href="http://notonlyluck.com">John Melonakos</a>,
<a href="http://shawnlankton.com">Shawn Lankton</a>, <a href="http://romeilsandhu.com">Rome Sandhu</a>, <a href="http://matt.might.net">Matt Might</a>, and more. Afterward I had the
opportunity to focus on diffusion MRI as a research fellow at
<a href="http://pnl.bwh.harvard.edu">Brigham and Women’s Hospital</a>. You can see more about the
<a href="/pubs/research.html">techniques</a> and <a href="/pubs">papers</a> we developed.</p>
<p>During the course of all of that, I worked with fellow students
<a href="http://thecrontab.net">Gallagher Pryor</a> and <a href="http://notonlyluck.com">John Melonakos</a> to build <a href="https://en.wikipedia.org/wiki/Jacket_(software)">Jacket</a> and
<a href="http://www.arrayfire.com">ArrayFire</a>, both software libraries for high performance technical
computing.</p>
<p>After all that, I’m now pursuing a lifelong dream as a medical student in
Atlanta.</p>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutWhat do I use?2014-05-10T00:00:00+00:00http://jgmalcolm.com/what-do-i-use<p>The right mix of tools can save you hours a week, or cost you hours. I’m
always looking for better ways of doing things and new ways of getting
leverage. Here are lists of the hardware, software, and services I use daily.</p>
<h2 id="hardware">Hardware</h2>
<ul>
<li><a href="http://www.apple.com/macbook-air">Macbook Air 11”</a> with
<a href="http://www.amazon.com/gp/product/B007AK6QBA/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B007AK6QBA&linkCode=as2&tag=jgmalcolm-20&linkId=PDK4MX2ZIQ6RCJTY">thin padded case</a> and <a href="http://amzn.to/2gBaSVQ">power cord protector</a></li>
<li><a href="https://www.apple.com/iphone">iPhone</a> with <a href="http://amzn.to/2bKM2AE">Tech21 case</a> and apps:
<ul>
<li><a href="http://instapaper.com">Instapaper</a> – instead of reading everything at the moment, I queue up
articles to read later using their <a href="https://www.instapaper.com/save">bookmarklet</a> and
<a href="https://www.instapaper.com/apps">Kindle integration</a>.</li>
<li><a href="http://www.sleepcycle.com">Sleep Cycle</a> to wake me up gently at just the right time</li>
<li>for Facebook and news, I just use Safari. I want to use Chrome, but Apple
insists on Safari as the default browser
(<a href="https://en.wikipedia.org/wiki/United_States_v._Microsoft_Corp.">reminiscent of Internet Explorer bundling</a>).</li>
</ul>
</li>
<li><a href="http://www.amazon.com/gp/product/B00IOY8XWQ/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B00IOY8XWQ&linkCode=as2&tag=jgmalcolm-20&linkId=DKOWV2R7PBCJ6EFV">Kindle Paperwhite</a> <a href="http://www.amazon.com/gp/product/B00IOY8XWQ/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B00IOY8XWQ&linkCode=as2&tag=jgmalcolm-20&linkId=DKOWV2R7PBCJ6EFV"><img class="thumb" src="/images/kindle.jpg" /></a> for carrying around a small
library of interesting books and articles. The backlit screen is fantastic
in low light. I got the 3G model which has come in handy fetching new books
while traveling in the US and abroad, but Wifi-only is sufficient.
Integrates with <a href="http://instapaper.com">Instapaper</a>.</li>
<li><a href="http://www.amazon.com/gp/product/B003V9QDXK/ref=as_li_tl?ie=UTF8&camp=1789&creative=390957&creativeASIN=B003V9QDXK&linkCode=as2&tag=jgmalcolm-20&linkId=MDT4Q76B4IQOY4BF">Audéo earbuds</a> while working at the computer, expensive but superb sound
and snug fit</li>
<li>
<p><a href="http://amzn.to/2qRjSdA">TaoTronics Bluetooth Headphones</a> for listening on the go. Good sound,
excellent price, great for commute and cordless jogging</p>
</li>
</ul>
<h2 id="software">Software</h2>
<ul>
<li><a href="https://www.google.com/intl/en_US/chrome/browser/">Chrome</a> web browser with extensions:
<ul>
<li><a href="https://chrome.google.com/webstore/detail/adblock/gighmmpiobklfepjocnamgkkbiglidom">AdBlock</a> to knock out advertisements</li>
<li><a href="https://chrome.google.com/webstore/detail/lastpass-free-password-ma/hdokiejnpimakedhajhdlcegeplioahd">LastPass</a> to keep all my passwords safe, quickly log me into sites, and fill out tedious forms</li>
<li><a href="https://chrome.google.com/webstore/detail/vimium/dbepggeogbaibhgnhhndojpepiihcmeb">Vimium</a> to quickly navigate and search pages without moving to the mouse</li>
<li><a href="https://chrome.google.com/webstore/detail/the-great-suspender/klbibkeccnjlkjkiokjodocebajanakg">The Great Suspender</a> to suspend and save inactive tabs, saves CPU cycles and memory and battery</li>
<li><a href="https://chrome.google.com/webstore/detail/fkomnceojfhfkgjgcijfahmgeljomcfk">Overwrite Downloads</a> to avoid accumulating downloads Foo (1), Foo (2), Foo (3), … instead overwrite Foo</li>
</ul>
</li>
<li><a href="http://spectacleapp.com">Spectacle</a> to move and resize windows with hot keys</li>
<li><a href="https://github.com/yujitach/MenuMeters">MenuMeters</a> to keep an eye on CPU, memory, internet speed, etc.</li>
<li><a href="https://alt-tab-macos.netlify.app/">AltTab</a> to switch between the individual windows of an application (Mac OSX
only lets you switch between full applications with Command+Tab, and
Command+` between windows within one application; Witch lets you switch
between individual windows in separate applications, just like Windows)</li>
<li><a href="http://lightheadsw.com/caffeine">Caffeine</a> to keep my Mac from going to sleep while I’m presenting or surfing</li>
<li><a href="https://justgetflux.com">F.lux</a> to alter my laptop’s screen colors to the time of day (blue light is
bad at night). If you’re on a Chromebook then use <a href="https://chrome.google.com/webstore/detail/glux/hinolicfmhnjadpggledmhnffommefaf">G.lux</a>.</li>
<li><a href="http://selfcontrolapp.com">SelfControl</a> (Mac) and <a href="http://getcoldturkey.com">ColdTurkey</a> (Win) to keep me off facebook, email, and the news when I need to be productive</li>
<li>Emacs/vim/bash/screen/git. Copy my
<a href="https://github.com/jgmalcolm/dotfiles">dot files</a>.</li>
<li><a href="https://ingmarstein.github.io/Monolingual/">Monolingual</a> to remove unused language files and object code
(architectures), eg. you only use English and use a 64-bit Mac so get rid of
Russian language files and PowerPC libraries</li>
<li><a href="https://github.com/sbmpost/AutoRaise">AutoRaise</a> moving the mouse over a window gives it focus (no need to click)</li>
</ul>
<h2 id="services">Services</h2>
<ul>
<li><a href="http://www.google.com/enterprise/apps/business">Google Apps</a> - get Gmail, Calendar, Drive, etc all using my own domain (jgmalcolm.com)
<ul>
<li><a href="javascript:(function(){var a=encodeURIComponent(location.href)+escape('\x0A'+'\x0A')+encodeURIComponent((!!document.getSelection)?document.getSelection():(!!window.getSelection)?window.getSelection():document.selection.createRange().text);var u='http://mail.google.com/mail/?view=cm&ui=2&tf=0&fs=1&su='+encodeURIComponent(document.title)+'&body='+a;if(u.length >= 2048){window.alert('Please select less text');return;}window.open(u,'gmail','height=640,width=840');console.debug(a)})();void(0);">send the current page/quote</a></li>
<li>learn shortcuts to <a href="https://support.google.com/calendar/answer/36604">quickly add events</a></li>
<li>find out which company has sold your email address with this <a href="http://gmailblog.blogspot.com/2008/03/2-hidden-ways-to-get-more-from-your.html">Gmail trick</a></li>
</ul>
</li>
<li><a href="https://developers.google.com/apps-script/">Google Apps Scripting</a> lets you write powerful scripts to manage Gmail, Drive, Calendar, etc.
<ul>
<li><a href="http://lifehacker.com/5825634/how-to-add-a-snooze-button-to-gmail-no-extensions-required">Gmail Snooze</a> lets you push an email out of your inbox for a few days, <strong>highly recommend</strong></li>
<li><a href="https://code.google.com/archive/p/gmail-delay-send/">Gmail Schedule Send</a> lets you draft an email and specify a time for it to be sent</li>
</ul>
</li>
<li><a href="/wikipedia-tricks">Wikipedia interface tricks</a> to navigate and view images more efficiently</li>
<li><a href="http://ifttt.com">IFTTT</a> - I use facebook and twitter to share articles with friends and
family. IFTTT records all my <a href="https://ifttt.com/recipes/175480-all-your-tweets-in-a-google-spreadsheet">tweets</a> and
<a href="https://ifttt.com/recipes/175481-save-links-i-share-on-facebook-to-a-google-drive-spreadsheet">facebook posts</a> so I can keep track of interesting articles.
It’s also setup to <a href="https://ifttt.com/recipes/175482-new-link-post-by-you-then-you-tweet-the-link">cross post</a> facebook article shares over to
twitter, so I don’t have to post to both accounts. I use the
<a href="https://www.facebook.com/share_options.php">Facebook bookmarklet</a> to quickly post.</li>
</ul>
<h2 id="bookmarklets">Bookmarklets</h2>
<p>Instead of installing browser extensions that constantly chew up resources,
bookmarklets are efficient for simple tasks. Each of these is a little
<a href="https://www.mattcutts.com/blog/javascript-bookmarklet-basics/">snippet of JavaScript</a>.
To use one, drag it to your Bookmarks (toolbar).</p>
<ul>
<li>post the current page on <a href="javascript:var d=document,f='https://www.facebook.com/share',l=d.location,e=encodeURIComponent,p='.php?src=bm&v=4&i=1367542561&u='+e(l.href)+'&t='+e(d.title);1;try{if (!/^(.*\.)?facebook\.[^.]*$/.test(l.host))throw(0);share_internal_bookmarklet(p)}catch(z) {a=function() {if (!window.open(f+'r'+p,'sharer','toolbar=0,status=0,resizable=1,width=726,height=536'))l.href=f+p};if (/Firefox/.test(navigator.userAgent))setTimeout(a,0);else{a()}}void(0)">Facebook</a> or <a href="javascript:(function()%7Bwindow.twttr%3Dwindow.twttr%7C%7C%7B%7D%3Bvar D%3D550,A%3D450,C%3Dscreen.height,B%3Dscreen.width,H%3DMath.round((B/2)-(D/2)),G%3D0,F%3Ddocument,E%3Bif(C>A)%7BG%3DMath.round((C/2)-(A/2))%7Dwindow.twttr.shareWin%3Dwindow.open(%27http://twitter.com/share%27,%27%27,%27left%3D%27%2BH%2B%27,top%3D%27%2BG%2B%27,width%3D%27%2BD%2B%27,height%3D%27%2BA%2B%27,personalbar%3D0,toolbar%3D0,scrollbars%3D1,resizable%3D1%27)%3BE%3DF.createElement(%27script%27)%3BE.src%3D%27http://platform.twitter.com/bookmarklets/share.js%3Fv%3D1%27%3BF.getElementsByTagName(%27head%27)%5B0%5D.appendChild(E)%7D())%3B">Twitter</a> or send via <a href="javascript:(function(){var a=encodeURIComponent(location.href)+escape('\x0A'+'\x0A')+encodeURIComponent((!!document.getSelection)?document.getSelection():(!!window.getSelection)?window.getSelection():document.selection.createRange().text);var u='http://mail.google.com/mail/?view=cm&ui=2&tf=0&fs=1&su='+encodeURIComponent(document.title)+'&body='+a;if(u.length >= 2048){window.alert('Please select less text');return;}window.open(u,'gmail','height=640,width=840');console.debug(a)})();void(0);">Gmail</a></li>
<li>send this page to <a href="javascript:function iprl5()%7Bvar d%3Ddocument,z%3Dd.createElement(%27scr%27%2B%27ipt%27),b%3Dd.body,l%3Dd.location%3Btry%7Bif(!b)throw(0)%3Bd.title%3D%27(Saving...) %27%2Bd.title%3Bz.setAttribute(%27src%27,l.protocol%2B%27//www.instapaper.com/j/gFzynNNmWmlP%3Fa%3Dread-later%26u%3D%27%2BencodeURIComponent(l.href)%2B%27%26t%3D%27%2B(new Date().getTime()))%3Bb.appendChild(z)%3B%7Dcatch(e)%7Balert(%27Please wait until the page has loaded.%27)%3B%7D%7Diprl5()%3Bvoid(0)">Instapaper</a></li>
<li>create a blank <a href="javascript:(function(){ window.open(‘https://docs.google.com/document/create?hl=en')})();">Google Doc</a> or <a href="javascript:(function(){ window.open(‘https://spreadsheets.google.com/ccc?new&hl=en')})();">Sheet</a> in a new tab</li>
</ul>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutTop Students: What do they do differently?2014-05-07T00:00:00+00:00http://jgmalcolm.com/top-students<p>True story: Two students go to the library Saturday morning right when it
opens. Instead of enjoying the beautiful weather, both students work hard
until the library closes. Here’s the kicker: they put in the <em>same amount of
time but I bet they likely each learned very different amounts of material</em>.
Same input but very different output.</p>
<p>We live in unprecedented times. This generation more than ever has the
opportunity to delay entering the workforce in order to develop skills. The
tools and technology at our fingertips blow away anything available 20 years
ago: laptops, mobile, online tutorials, search. Human potential is boundless,
and it’s a shame when anyone squanders the opportunity to learn.</p>
<p>This is a big topic, and these are just some cursory thoughts. There’s a lot
of “right” ways to study, but there are even more “wrong” ways, so if your
grades suck, then you’re probably doing it the “wrong” way.</p>
<h2 id="excuses">Excuses</h2>
<p>We often look at high achievers and see them as different. We rationalize why
they’re doing so well: they were a Bio major so they’ve already seen this med
school stuff before, all they do is study so they won’t have anything cool on
their resume, they’ve just got more brains, etc. These are all excuses and do
nothing to improve your own personal performance. Recognize them as simple
excuses and instead turn them into inspiration. So what if they are better?
That’s got nothing to do with your success but relying on excuses is one way
to guarantee failure.</p>
<h2 id="focus">Focus</h2>
<p>Top students don’t endlessly peruse their Facebook feed several times an hour.
Your job is to learn. Your job is not to check email. You’re not going to
get an A because you checked email a lot or had the most pithy tweets. Your
job is not to carry on text message conversations throughout the day. All of
those things are secondary to learning. All of those things in fact take away
from learning. They cause you to break focus, and then it takes time to get
back in the zone. Your output is a function of both time and <a href="http://calnewport.com/blog/2014/04/08/work-accomplished-time-spent-x-intensity">intensity</a>.
Instead of checking your phone between classes, put your phone in your locker
and only check it during lunch.</p>
<p>Another secret weapon of mine is software that simply blocks internet
connection to certain sites (<a href="http://selfcontrolapp.com">SelfControl</a> for Mac OSX, <a href="http://getcoldturkey.com/">ColdTurkey</a> for
Windows, or <a href="https://chrome.google.com/webstore/detail/stayfocusd/laankejkbhbdhmipfmgcngdelahlfoji">StayFocusd</a> Chrome extension). Facebook, Twitter, Gmail,
Buzzfeed, Upworthy, ICanHasCheezburger … whatever is your thing…block it.</p>
<p>I often whine that these are ways I relax and it’s all justified distraction.
It’s mostly an excuse. If that were all true, is this really how I want to
spend my free time? After a month of regular Facebook, Twitter, news, etc.,
add that all up into one big lump and what do I have to show for it? In the
end, these are all distractions. They truly add nothing and each of them
consumes 100% of your attention when you are giving it to them. Block them
and reclaim this time for other non-studying activities that will bring you
lasting happiness.</p>
<p>Personally, I’ve found that blocking social media and batching up all my
consumption has made me realize how much time it really consumes. A few
minutes here and there throughout the day feels like nothing, but if you put
all those together in one block, you notice an hour fly by.</p>
<h2 id="time">Time</h2>
<p>Top students simply put in the time. There are no shortcuts here. They
consistently schedule and prioritize blocks of study time. Not just 30min
here and 1hr there, but big chunks of time. They treat it like a job
consistently starting in the morning and continuing the full day. Taking off
an afternoon or a long lunch here and there is important, but not the norm.</p>
<h2 id="synthesis">Synthesis</h2>
<p>Top students have a knack for understanding what is important, and what is
just context. Their study time is active learning. Creating your own study
guide will force you to wrestle with the material in a way that passively
reading doesn’t achieve. Underlining key words or phrases focuses your
attention. Studies show that
<a href="http://www.theatlantic.com/technology/archive/2014/05/to-remember-a-lecture-better-take-notes-by-hand/361478">hand written notes are more effective than typed</a>.</p>
<p>In addition to knowing what’s important,
<a href="http://www.reddit.com/r/medicalschool/comments/2hbssw/what_do_your_class_top_10_do_differently">top students seek to understand</a>. Memorizing only provides
short-term results. You’ve probably heard that knowledge is like a tree: you
fill in the branches, then the leaves. Taking the time to understand <em>Why</em>
something is the way it is will last much longer than simply <em>What</em> something
is.</p>
<h2 id="testing">Testing</h2>
<p>Reading the same material over and over bores me. My mind often drifts and my
energy wanes. I’ve found that I’m most engaged when I’m doing practice
questions. Instead of passively reading and nodding along, doing a few
practice questions and getting stuff <em>wrong</em> gets my attention. There’s
plenty of research into this <a href="https://en.wikipedia.org/wiki/Testing_effect">testing effect</a>.</p>
<p>Doing practice problems also helps me keep clear on what’s important. What’s
important testable material and what’s just context. While doing these
practice sets, I try to refer to the study guides I created and make marks to
indicate what material came up in questions. Put a small dot in the margin
every time a question hit on a concept, and then you’ll quickly start to see
what are the high yield topics.</p>
<blockquote>
<p>Read more on <a href="/tactical-test-taking-skills">Tactical Test-Taking Skills</a> and <a href="http://www.reddit.com/r/medicalschool/comments/2hbssw/what_do_your_class_top_10_do_differently/">r/medicalschool</a></p>
</blockquote>
<h2 id="spaced-repetition">Spaced repetition</h2>
<p>Making a study guide is a good start, but you need to circle back to study
that study guide. Not only that, when you circle back matters. Knowledge
tends to drop off on a curve: 1hr spent reviewing 24hrs after lecture is more
effective than 1hr spent 5 days later.</p>
<p><a href="https://en.wikipedia.org/wiki/Spaced_repetition">Spaced Repetition</a> is a technique that attempts to model this timing
to queue up review items when most effective. Simply reviewing your books and
notes from the first page onward is terribly inefficient; spaced repetition
algorithms optimize your review schedule.</p>
<p>There are great flashcard systems like <a href="http://ankisrs.net">Anki</a> that implement these models and
provide cute graphs and numbers so you can <a href="http://lifehacker.com/the-psychology-of-gamification-can-apps-keep-you-motiv-1521754385">gamify learning</a>. For
standardized classes, chances are someone <a href="https://ankiweb.net/shared/decks">already created the deck</a>
you want to study, e.g. <a href="https://ankiweb.net/shared/decks/usmle">med school boards</a>. Read more about
<a href="http://www.super-memory.com/help/il_full.htm">incremental learning</a>, <a href="http://www.gwern.net/Spaced%20repetition">spaced repetition</a>, and
<a href="http://www.supermemo.com/articles/20rules.htm">best practices</a> for making notecards.</p>
<h2 id="balance">Balance</h2>
<p>School isn’t everything, and you’ll be punished if you try to make it so.
Find what balance means for you. What makes you happy? I found that I like
to leave all my books at school and do all my studying there. Now I feel so
relaxed when I get home. I make work/school a distraction-free environment,
and home is my personal space. Having strong barriers defining zones of study
and relaxation helps me <a href="http://www.scotthyoung.com/blog/2014/04/01/study-hard-no-burnout">avoid burnout</a>.</p>
<h2 id="manage-your-energy">Manage Your Energy</h2>
<p>All the tips in the world won’t help you if you don’t have the energy to
execute. I often find that I know what the best way to study is, but because
I don’t want to put in the energy, I go with an inferior study method because
it’s easier.</p>
<p>Get good <a href="http://www.super-memory.com/articles/sleep.htm">sleep</a>. Figure out personally how much sleep you need to
consistently feel 100%. I’m not impressed when I hear people brag about
running on X hours of sleep. I’ve done that plenty myself, and I’ve found my
mood and energy sub par for a day or two after. A few extra hours of cramming
often affects an entire day or two after.</p>
<blockquote>
<p>Read more on <a href="/medschool-strategy">Med School Strategy</a> about managing your energy and
study time.</p>
</blockquote>
<h2 id="parting-thoughts">Parting thoughts</h2>
<p>Don’t expect to become a top student over night, but you should be better than
you were yesterday. Pick a few of the tips above and run with it. Stop
wasting your Saturdays, and start studying hard so you can play hard.</p>
<p>Lots more could be written on the topic, and I’m sure I’ll come back to it.
I’m constantly trying new things, borrowing from the best, mixing and matching
to suit my personality, always trying to become better.</p>
<blockquote>
<p>Read more:
<a href="http://www.artofmanliness.com/2012/01/03/ace-your-exams-study-tactics-of-the-successful-gentleman-scholar/">Ace Your Exams: Study Tactics of the Successful Gentleman Scholar</a></p>
</blockquote>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutWhat drugs are you on?2014-04-30T00:00:00+00:00http://jgmalcolm.com/what-drugs-are-you-on<p>While I never say it the way the title has it, here’s some tips and tricks
I’ve learned to get all the facts.</p>
<p>I typically start with:</p>
<blockquote>
<p>“What medications are you currently taking?”</p>
</blockquote>
<p>Meds often give you a list of the patient’s diseases, but often meds become so
routine that patients omit one or two when you ask. For example, synthroid,
aspirin, and statins are often left off the list because a patient has been
taking them for as long as they can remember. Patients are more apt to report
something they started taking a few months ago, not the med they’ve been
taking for 10 years.</p>
<p>It’s also good to fish for any drugs they recently stopped taking or ran out
of refills.</p>
<p>So this is often just a good start, but the next three questions will help
make sure you have all the information.</p>
<blockquote>
<p>“What pills do you put in your mouth every day?”</p>
</blockquote>
<p>Restating it this way often shakes out one or two loose meds. Also go beyond
pills and prescriptions: herbals, over the counter, vitamins, supplements.</p>
<!-- Sidebar: pre-natal vitamins pack a powerful punch of vitamins and minerals -->
<!-- which can interfere with the absorption of other medications like insulin, so -->
<!-- taking them at the same time could bind the insulin rendering it ineffective. -->
<!-- Solution: take one in the morning and the other at night. -->
<p>Just having the list is not enough. For every med on that list, you need two
more things: why are they taking the pill, are they actually taking the pill.</p>
<blockquote>
<p>“Why are you taking that?”</p>
</blockquote>
<p>Meds have off-label uses or can be used to treat multiple disorders. Don’t
just assume that because the patient is on synthroid that they have
hypothyroidism – they could have had a thyroid removed due to cancer.</p>
<blockquote>
<p>“How often do you miss a dose?”</p>
</blockquote>
<p>So many patients are ill simply because they’re skipping doses. Other
variants: Are you actually taking it? How many doses have you missed in the
last month? A common scenario is for a hypertensive patient on medication to
show up with high blood pressure because they forgot to take their meds that
morning or ran out a week ago.</p>
<p>Often patients simply forget, so walk them through some strategies to
remember: pill boxes, rituals (at breakfast, when setting alarm at night, in
car while commuting), or multiple pill caches for when you forgot and you’ve
already left the house.</p>
<p>Any tips you use?</p>
<p>For some levity, watch <a href="http://www.youtube.com/watch?v=Ed99IkTKtPY">how to get a thorough history</a>.</p>
<p class="message"><i>You should know that I am not an expert. These posts in
no way constitute medical, legal, or financial advice, nor is their validity,
accuracy, currentess, or completeness guaranteed.</i></p>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutWikipedia Tricks2014-04-26T00:00:00+00:00http://jgmalcolm.com/wikipedia-tricks<p><img class="thumb" src="/images/wikipedia.png" /> <a href="//wikipedia.org">Wikipedia</a>
can be a little clumsy to navigate. These three tricks will enable you to
read articles more efficiently by simplifying the interface, streamlining
image viewing, and enabling pop-up link previews.</p>
<p>These tips are especially useful if you view Wikipedia images or find yourself
bouncing among linked articles. The tips below streamline both of those
processes, in addition to giving you more reading space.</p>
<h2 id="creating-an-account-to-store-your-preferences">Creating an account to store your preferences</h2>
<p>To get started, you’ll need to <a href="https://en.wikipedia.org/w/index.php?title=Special:UserLogin&type=signup&returnto=Main+Page">create a Wikipedia account</a> so you can
save settings to your profile. It’s quick and it just lets you save
preferences between visits to the site (<a href="https://en.wikipedia.org/wiki/Wikipedia:Why_create_an_account%3F">among other benefits</a>).</p>
<h2 id="pop-up-link-previews">Pop-up link previews</h2>
<p>Exploring any new topic on Wikipedia can be a chasing a dozen rabbits: every
new and unfamiliar sub-topic gets its own tab, and so I’m often left with a
dozen new tabs open to other Wikipedia pages. The cluttered tabs are not
really necessary because often I just could have read the first paragraph to
get an idea before continuing on with the original article.</p>
<p>Enter <a href="https://www.mediawiki.org/wiki/Beta_Features/Hovercards">Hovercards</a>. Hover the mouse over any link to another
Wikipedia article and a small pop-up appears with the first few sentences.
I’ve found this lets me move more quickly through articles. Enable Hovercards
from the <a href="https://en.wikipedia.org/wiki/Special:Preferences#mw-prefsection-betafeatures">Beta Preferences page</a>. This is the simplest of the tricks
and only involves checking that box to enable the feature.</p>
<div class="gallery"> <a href="/images/wikipedia-tricks-hover.png" data-gallery="wiki" title="Hovering over any link to another Wikipedia
article creates a popup with the first few sentences and key image."> <img src="/images/wikipedia-tricks-hover.png" /></a> </div>
<h2 id="simplify-the-interface">Simplify the interface</h2>
<p>The default Wikipedia page layout has a sidebar that takes up a good chunk of
the screen and that means less room for the important stuff: text and images.</p>
<p><a href="https://en.wikipedia.org/wiki/User:Blue-Haired_Lawyer/Wide_Skin">WideSkin</a> moves the left sidebar panel into the toolbar. WideSkin
only works with the Vector theme (the default).</p>
<p>This trick will have you pasting a few lines of code into your preference
files. Then you can brag to friends you coded
<a href="http://www.guru99.com/interactive-javascript-tutorials.html">JavaScript</a> and
<a href="https://en.wikipedia.org/wiki/Css">CSS</a>.</p>
<p>Wikipedia also lets you directly modify source files for both the global site
(regardless of theme selected) and source files for the particular theme
selected. These files are either
<a href="http://www.guru99.com/interactive-javascript-tutorials.html">JavaScript</a> for code or
<a href="https://en.wikipedia.org/wiki/Css">CSS</a> for color/font settings.</p>
<ul>
<li>global <a href="https://en.wikipedia.org/wiki/Special:MyPage/common.js">common.js</a> and <a href="https://en.wikipedia.org/wiki/Special:MyPage/common.css">common.css</a></li>
<li>
<p>theme-specific <a href="https://en.wikipedia.org/wiki/Special:MyPage/vector.js">vector.js</a> and <a href="https://en.wikipedia.org/wiki/Special:MyPage/vector.css">vector.css</a></p>
</li>
</ul>
<p>Follow the instructions on the <a href="https://en.wikipedia.org/wiki/User:Blue-Haired_Lawyer/Wide_Skin">WideSkin page</a> to make two
modifications to your user theme files: adding an import statement to your
custom <a href="https://en.wikipedia.org/wiki/Special:MyPage/vector.js">vector.js</a>, and adding a few new CSS tags to your custom <a href="https://en.wikipedia.org/wiki/Special:MyPage/vector.css">vector.css</a>
file.</p>
<div class="gallery">
<a href="/images/wikipedia-tricks-full.png" data-gallery="wiki" title="Using the WideSkin theme reclaims the wasted space on the left. Those rarely used links are now in a toolbar dropdown.">
<img src="/images/wikipedia-tricks-full.png" /></a>
<a href="/images/wikipedia-tricks-full-before.png" data-gallery="wiki" title="Default Wikipedia has a sidebar on the left that takes up valuable screen real estate."></a>
</div>
<h2 id="streamline-image-viewing">Streamline image viewing</h2>
<p>With the default Wikipedia, images always require two hops: clicking on the
image brings up the File page where you click again to see the full resolution
image. Then you have to click the Back button to return to your page.</p>
<p>Skip all of that by setting up <a href="https://en.wikipedia.org/wiki/User:JGMalcolm/SimpleLightbox">LightBox</a> so a single click brings
up the image full resolution, and clicking or hitting any key will close it.</p>
<div class="gallery">
<a href="/images/wikipedia-tricks-image.png" data-gallery="wiki" title="With LighbBox enabled, clicking on an image immediately brings it up full screen. Any keypress or click returns you to the article.">
<img src="/images/wikipedia-tricks-image.png" /></a>
<a href="/images/wikipedia-tricks-image-before.png" data-gallery="wiki" title="With default Wikipedia, clicking on an image takes you to a separate page for that file. You have to click a second time to see the full image."></a>
</div>
<p>Wikipedia also has its own built-in alternative <a href="https://www.mediawiki.org/wiki/Multimedia/About_Media_Viewer">MediaViewer</a> but
I’ve found it to be clunky.</p>
<p>Any other tips and tricks you find useful?</p>
<h2 id="more-tips-and-tricks">More tips and tricks</h2>
<p><a href="https://en.wikipedia.org/wiki/Wikipedia:Keyboard_shortcuts">Keyboard shortcuts</a>,
<a href="https://en.wikipedia.org/wiki/Wikipedia:Customisation">Wikipedia customizations</a>,
<a href="https://www.mediawiki.org/wiki/User:Remember_the_dot/Syntax_highlighter">syntax highlighting</a> while editing</p>
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James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutFree medical dictionary for Microsoft Office2014-04-24T00:00:00+00:00http://jgmalcolm.com/medical-dictionary<p>Getting tired of seeing red squiggly marks under your diverticula and
granulomas? Install a free medical dictionary for Microsoft Office.</p>
<p>This one change handles all the Office tools: Word, PowerPoint, Outlook,
Excel.</p>
<h2 id="mac-osx">Mac OSX</h2>
<ol>
<li>
<p>Download the <a href="http://rajn.co/free-medical-spell-checker-for-microsoft-word-custom-dictionary/">free dictionary</a> and save the unzipped file <code class="language-plaintext highlighter-rouge">*.dic</code>
where Office puts all its own dictionaries: /User/ <user>/ Library/
Application Support/ Microsoft/ Office/ Preferences/ Office 2011/</p>
</li>
<li>
<p>Open up Word and any document (blank or existing).</p>
</li>
<li>
<p>Add the dictionary:
Preferences →
Spelling and Grammar →
Custom dictionary →
Dictionaries … →
Add …</p>
<p>Note, if the dictionary is grayed out, use the ‘Enable’ dropdown to filter
‘All files’.</p>
</li>
<li>
<p>Quit and restart any Office programs.</p>
</li>
</ol>
<h2 id="windows">Windows</h2>
<p>For Word 2013,
<a href="http://www.howtogeek.com/142069/how-to-use-custom-dictionaries-in-word-2013/">follow these steps</a>.</p>
<p><a href="https://www.youtube.com/watch?v=JZnvgAJ2SXg">Watch a video</a> following these
the steps.</p>
<p>For earlier versions of Word, follow the steps below:</p>
<ol>
<li>
<p>Download the <a href="http://rajn.co/free-medical-spell-checker-for-microsoft-word-custom-dictionary/">free dictionary</a> and save the unzipped file
<code class="language-plaintext highlighter-rouge">Raj&Co-MedSpelChek.dic</code> where Office puts all its own dictionaries: C:<br />
Users \ <user> \ AppData \ Roaming \ Microsoft \ UProof</p>
</li>
<li>
<p>Add the dictionary:
Tools menu →
Options →
Spelling & Grammar →
Click Custom Dictionaries →
Add</p>
</li>
<li>
<p>Activate the custom dictionary. In the Custom Dictionaries dialog box,
make sure the check box beside the dictionary’s name is selected. On the
Spelling & Grammar tab, clear the Suggest from main dictionary only check
box.</p>
</li>
<li>
<p>Quit and restart any Office programs.</p>
</li>
</ol>
<p>If the above didn’t work for you, please use the comments below to post issues
or fixes.</p>
<p>Adapted from
<a href="http://office.microsoft.com/en-us/word-help/create-and-use-custom-dictionaries-HP005189558.aspx">Microsoft Help</a>.</p>
James Malcolmme@jgmalcolm.comhttp://jgmalcolm/aboutHide the side panel in Google Slides2014-04-20T00:00:00+00:00http://jgmalcolm.com/hide-side-panel<p>Ever want to close that slide panel in Google Slides so you can get more screen space? This
bookmarklet will do the trick.</p>
<p>Drag the bookmarklet below to your bookmarks. When you’re working on your
presentation, simply click it to hide (or show) the slide panel:</p>
<p><a class="button" href="javascript:(function (){var e=document.getElementById('filmstrip');e.style.display=(e.style.display=='')?'none':'';})();void(0)" onclick="void(0)">Toggle Slide Panel</a> ← drag this button to your bookmarks</p>
<div class="gallery">
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<img src="/images/slides-before.png" /></a>
<a href="/images/slides-after.png" data-gallery="slides" title="Hiding the side panel gives more room."></a>
</div>
<p>You’ll notice that it simply hides the panel but doesn’t refresh the screen
layout to reclaim that space previously filled by the side panel. Adjust the
window or the notes tray and it’ll immediately fill in. Do you know a good
way to fix this or force a refresh?</p>
<p>If you refresh the page, the panel will reappear. This bookmarklet doesn’t do
anything permanent to Google Slides.</p>
<p>I’ve also found the text format reset keyboard shortcut useful: “Ctrl + \”.
Since a lot of my presentations are imported Microsoft PowerPoint, the notes
text is often all wonky. “Ctrl + A” followed by “Ctrl + \” selects all the
text and resets it to baseline. Note: Ctrl → Cmd for Mac OSX</p>
<p>When you’re writing notes you can hit Esc a couple of times to back out from
edit mode to navigation mode where you can use the arrow keys to move between
slides.</p>
<p>Any tips you’d like to add?</p>
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James Malcolmme@jgmalcolm.comhttp://jgmalcolm/about