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Many medical schools are in the “thick” of the process of screening applicants and selecting those applicants that they wish to invite for interview. This process generally falls along the lines of first, making sure that the applicant meets the minimum requirements for said medical school in terms of undergraduate grade point average (undergraduate GPA) and scores on the Medical College Admissions Test (MCAT).  While most medical schools will review the entire application, in terms of figuring out how to get 8,000 -10,000 applications pared down to a workable number for closer scrutiny, we screen by undergraduate GPA and MCAT scores.  There just is not a better way to make the preliminary cut than these two factors. 

In the case of those who do not make the preliminary cut, we generally send these applications for a secondary screen by administrative staff who are looking for criteria that we have flagged so that many of those cut by the undergraduate GPA /MCAT screen might make it back into the secondary screen if our administrative staff keys in on something in the personal statement, coursework or letters of recommendation that we should discuss in the admissions committee.

Those applications who DO make the preliminary screen are divided among the admissions committee members who read every work on the application and decide if we want to invite the applicant for interview. In short, do we want to meet this applicant? Would they be a good fit for our medical school? Do they show promise of being able to get through our very demanding curriculum? Do we want to know more about this applicant? In short, we invite applicants that we strongly feel will make good physicians based on the material that is present in their AMCAS applications.

That being said, as applicants are filling out those AMCAS applications, they need to be sure that the information in the AMCAS is as accurate as possible and as clear as possible. Many people have been rejected for interview based on a poorly written personal statement. These rejected applicant may have had the GPA/MCAT score but neglecting to write a strong personal statement is like heading out on a long automobile trip and draining the oil out of your engine. You  are just not going to get very far even if your engine appeared to be in great shape. You need to have a well-written and coherent personal statement.

On the other hand, a great personal statement/letters of recommendation will not make up for very poor academics. If your academics are poor, take the time to get them as high as possible keeping in mind that the average undergraduate GPA for medical school matriculants is 3.6/4  and the average MCAT score is 30 with no single score less than 8.  Some schools may have considerable variation around their means but my medical school does not.

Are schools “forgiving” of a poor undergraduate start but a very strong finish? To a certain extent this is true but there are academic “holes” that can be too deep to climb out of without years of “damage control”. In short, if medicine is your goal, work diligently and consistently at a high level. Don’t count of anything being “forgiven” and keep in mind that no allopathic medical school in this country is searching for applicants. We have far more applications than we need. We try to make sure that every application is screened at least twice before sending out that dreaded rejection letter. This is a monumental task that seems to take longer and longer each year.  Again, keep in mind that one of my medical schools received more than 10,000 applications for 110 spots in the entering freshman class last year. This year, we have already broken last years numbers. There are just too many good applicants out there.

As I read through the applications, I always look at how many hours of coursework an applicant has taken in any given year as well as the grades earned. In addition, I look at the content of those hours. If a student took three laboratory courses in one year and managed to earn a 4.0 GPA versus a student who took one lab course along with general education requirements and barely managed a 3.0, I tend to look more favorably on the first student.  We also make allowances for things like full-time employment versus full-time student.

We look at the age of academic work. A student may have earned high grades 10 years ago but without recent academic work or a recent MCAT score, we generally will not offer admission. Many things change over the course of ten years including the ability to jump into a very demanding academic challenge. In most cases, we ask for some recent coursework in addition to MCAT scores not more than three years old.

In terms of multiple MCAT attempts, we tend not to accept students who have more than three attempts. If a student retakes, we expect the score to go up. If not, that is usually a signal that the student wasn’t prepared on any of the attempts. To keep taking that exam and scoring mediocre scores is generally a very bad idea. If your first score is not what you wanted, do a thorough analysis of your performance and correct your deficiencies. To just keep taking that test without doing additional preparation or changing your method of preparation, is not using sound judgment no matter what your undergraduate GPA.

Graduate school GPA does not overcome a poor undergraduate GPA. As a graduate student, you are expected to maintain a minimum GPA and you are expected to do well. While earning a graduate degree can enhance your application, there are huge differences between graduate school and medical school.  In the case of special masters programs that are specifically designed for pre-medical students who need application enhancement, you need to do very well in these programs. Just taking the coursework will not work, you have to take the coursework and make yourself “stand out” from the rest of your classmates in these programs. It goes without saying that we scrutinize the performance of special masters students very carefully and take into consideration strongly, your letters of recommendation from your SM professors.

I have written the above so that those folks who are in the process of contemplating application to medical school might definitely understand how important it is to have a complete and strong entire application. You are considered within the context of how competitive you are with the rest of our applicant pool and how competitive you are with the national applicant pool. We are given AMCAS data as it becomes available and we adjust our standards according to the data that we receive. For the past five years, undergraduate GPAs and MCAT scores have been increasing. We don’t expect that this trend will reverse.

The number of applicants had increased slightly this year. We don’t’ know if this is a national trend or just a trend for our school. In general, many people look at medicine as a very lucrative career and seek out admission to medical school for this reason especially when the national economy is not as strong as in previous years.

Most medical students take a Physical Diagnosis class during their second year. This course teaches history taking and the skills necessary for performing a complete physical examination. Back in my second year of medical school, I found this course a bit intimidating in terms of what the syllabus outlined for us to accomplish in a few short weeks. Little did I realize that I had most of the tools that I needed to do well in this class, namely, an insatiable curiosity, a good ear, two good hands and total interest in my patients. The first lecturer emphasized that we would get 90% of what we needed to make a diagnosis from a good patient history. “Good” was the operative word here because as one sits and reads the “how-to” of taking a medical history, it seems that there is an abundance of information that we must obtain in the patient interview while writing a couple of notes here and there. How would I remember every detail? What happens if I forget something important? What if the patient lies to me? How am I going to figure out what a comatose patient needs? Those were just a few of my concerns in addition to looking at my opthalmoscope and trying to figure out how I would ever get the “hang” of making this forbidding tool useful in my practice. One day of the week, we would spend the afternoon in the hospital with our preceptors. My upperclassmen friends looked at the name on my paper and said that I had “hit the jackpot” with my preceptor assignment. My preceptor was a master diagnostician and an excellent teacher too. He was an endocrinologist who specialized in metabolic syndrome, a disorder that runs largely unchecked in most medically under-served populations because of poor diet and lack of physical activity. I was excited to get my practical knowledge underway with my new preceptor. My preceptor had two medical students assigned to his service at the same time. It turned out later that the other student rotating with me was my rotation partner for all of third year so we were great friends and become even closer. We met our preceptor in his office and he led us to one of the medicine floors in the hospital. He had made a short list of his patients who were willing to have us use them for our history-taking practice. I entered the room of a middle-aged gentleman who was hospitalized for jaundice. I quickly went thorough my script of questioning this very soft spoken man who lay quietly in bed. I came to find out that he was a physician who had been diagnosed with a biliary disorder that would kill him without a liver transplant in the next two weeks. He was kind and patient as I asked all of those questions about family history, social history, medications and the like. He asked me to stop by later that evening and read my historical write-up back to him. When I stopped by, he helped me organize the information and provided invaluable assistance in thinking about how to question patients. We chatted off and on for a week, until he received the word that he was being transferred for his liver transplant. I saw him three weeks later when he was ready to leave the hospital with a new liver, a new life and such joy! I practiced with my stethoscope on my own chest. It became very satisfying to lie in bed at night and listen to my own heart sounds. I listened to each sound appreciating the tones and timing. I also listened to my breath sounds, over the trachea, over the bronchi and over the lung parenchyma. I practiced listening to each heart valve and learned to appreciate the subtle differences between the sounds a the pulmonic site versus the sounds at the mitral site. I appreciated the split in my second heart sound with my respiratory cycle. If I could appreciate the subtleties of my own chest, I would be able to pick out abnormalities on my patients. That pesky opthalmoscope was the biggest hurdle that I had to cross. The first thing that I did was learn to operate the light and aperture. Since I have no visual defects, I always start with the diopter setting on 0. I also quickly learned the utility of performing this examination in a dim room as bright light makes the patient’s pupils quite constricted. A dilated pupil is easier to examine. The other useful piece of information is to start with the opthalmoscope light dim so that you don’t blind the patient while you are attempting to examine the retina. At first, I could just pick out the “red reflex”. Soon, I found a vessel and later, I learned to focus sharply on those vessels and follow them to the optic disks. In short, there is a learning curve that is most quickly overcome if you force yourself to examine the retinas of every patient that comes into your office. If you don’t practice, you won’t learn to do an adequate examination. I would wager that most physicians out in practice today, other than the ophthalmologists and neurologists, do not perform an adequate retinal exam. When it came to learning the rectal, pelvic and breast exams, we were taught by professional “patients”. These people knew the exams and used their own bodies to teach medical students. On the pelvic exam demonstrations, one of the demonstrators indicated that she was in the middle of her menstrual cycle. One of the male students in my group, left the room and never returned. I never found out how or if he learned to perform a pelvic examination but those demonstrators were excellent. They allowed us to practice and pointed out landmarks and hints that were invaluable. I found myself thinking about the type of person who is willing to become a professional demonstrator of breast, pelvic and rectal exams. While the job pays well, I would have to cross it off of my list of things to do if I needed loads of money quickly. The neurological examination is the most fun to perform and write up. I found myself collecting an odd assortment of instruments to test sensations of hot and cold (I used capped test tubes filled with tap water); vibration (tuning fork), smell (alcohol pads, nail polish remover pads); color sensation (photos); light touch (feathers of various colors) and sharp versus dull (paper clip). I had a small bell and a small stuffed kitten as objects for my patients to name. I also collected a tape measure for lesions and an assortment of cotton swabs and tongue blades for cranial nerve testing. I learned to perform my history while I was performing my physical examination. I would start with the head and ask about problems with headache, earache and vision. I would examine the eyes and nose while asking about sinus problems. I went from head to toe asking questions as I moved along. I always save invasive exams like pelvic and rectal for the end of the exam. While the patient is getting dressed, I would jot down my pertinent positive findings and spend the rest of the time chatting with the patient and explaining my findings. At this point, my preceptor would usually join me and we would discuss the treatment plans for the patient together. The most important thing that I learned in this class was the value of communicating with your patient. I probably learned more from my patients than they learned from me. I learned to listen to their words and put their words and my physical findings into a cogent clinical plan for treatment. I also learned the importance of just getting to my patient’s fears, concerns, likes and dislikes. When a physician touches a patient, there is a relationship of trust that is begun. Your patient trusts that you will use everything that you have learned in biochemistry, anatomy, pathology, pharmacology and physiology to figure out what you can do to get them healthy and keep them healthy. There is a puzzle and the pieces must be fit together for the good of the patient. I also came to appreciate the sanctity of the apprentice-mentor relationship that I had developed with my preceptor. In no other profession is that relationship so important than the attending physician/medical student. My preceptor was indeed a master and I was a very willing student. He led me through the maze of various patient encounters and kept me coming back for more. It was truly magical in many ways. Finally, I mastered that opthalmoscope during the last week of my Physical Diagnosis class. I was quite comfortable with my exam and I appreciate the art of being able to make a diagnosis. While this class seemed to be quite intimidating at first, it became one the the sentinel courses in my medical school experience. After five plus years of practice and thousands of patients later, I wonder if my preceptor knows how many thousands of patients he has touched through all of his students.

This is the last in my series about surgical clerkship. In this essay, I thought I would address some of the things that can go wrong and present some strategies to fix them or do “damage control”.

Misunderstandings or Miscommunication - Communication is medicine - any specialty- is a key component. Learning to listen carefully to your patients, your colleagues and your teachers is of paramount importance. Sometimes anxiety or time prevents you from actually “hearing” the message. This happens to everyone and especially to people who are trying to juggle several tasks at the same time. If you make a mistake, own up to it, apologize and move on. Don’t internalize and don’t personalize anything on any clinical rotation. It is very easy to miscommunicate when you are under pressure and in unfamiliar territory. When you find that you have misunderstood something or that someone has misunderstood you, acknowledge the mistake and keep moving forward. Forgive yourself, forgive others and move on as misunderstandings/mis-communications are part of being human.

Not telling the Truth - This goes along with miscommunication and mistakes. Don’t lie about anything. If you didn’t check something, acknowledge your mistake and let it go. Make a note to yourself not to repeat the mistake and leave it at that. Many times, especially when you are tired, you will forget something. Again, make notes to yourself if you forget something or did not do something but don’t lie about anything that you did or did not accomplish. Your ”word”  in medicine is golden and your career, your patients’ lives  and you colleagues trust all depend on your word and its truthfulness.

Grave errors - I remember an incident when I was an intern. A fourth-year medical student was attempting to re-wire a central line and made a fatal error that caused the death of a patient. In the defense of the fourth-year student, he/she was not supervised and wasn’t familiar with central line rewiring. In defense of the resident on whose service this student was rotating, he/she did not know that the student had not performed the procedure unsupervised. In this case, the student and resident was reprimanded but both owned up to this grave error. The worst problem is that this student will carry this incident for the rest of his/her life.

In short, never ever perform a task or procedure unsupervised unless you are sure of what you are doing. In any procedure, especially the invasive ones, you should be able to explain the procedure to the person who is supervising you along with any complications that can arise and how you will handle them. When you are learning procedures, learn them from preparation, performance, complications and management of complications. The learning curve for things like central lines is usually 10 supervised before you do the procedure unsupervised.

Personality Conflicts - There will be people on your team (nursing personnel, fellow students, interns, attending physicians) that you will not get along with. In my opinion, personality conflicts have no role in medicine as they are counterproductive to good patient care. When I have encountered a personality conflict, I will defer my feelings as long as the care of my patient is not compromised. In short, my business and my job is to be able to work with each member of the team as professionally as possible for the benefit of the patient. As I have said in other essays, the clock ticks and you will not be around this person for the rest of your life. Be sure that you don’t burn any bridges behind you.

Another rule of mine is that I never discuss my colleagues with anyone except the person that I am having the conflict with. I don’t have time for gossip and I never allow negative comments about my colleagues from nursing or other people. One of my jobs as I have moved through residency has been to evaluate others. In these evaluations, I have readily admitted when I have a personality conflict and tried not to allow this to interfere with my evaluation. If I place something negative on an evaluation, I always cite the reason and what I believe the person can do to improve the situation. I also do not place negative information on an evaluation unless I have warned the person and asked them to correct the behavior which is the object of an evaluation in the first place. In short, check your ego at the door when it comes to patient care.

Time Management - There are 24-hours in a day and you do need rest at some point. Don’t try to ignore your body’s signals when you are tired. Manage your time so that you get some rest (it’s never going to be enough) and take care of your physical needs (eating, hydration). When you start a new rotation, you won’t be as efficient as when you end the rotation because you don’t know the procedures. Pay close attention to your interns and residents and ask for help. Never be too proud or too afraid to admit when you are overwhelmed. Also, avoid drugs to “keep you going” as these often bring on personality changes that can cause problems.

Most chief residents and interns will allow you to rest when there is nothing of educational value going on. If you are told to leave (go home), do what you are told to do. Don’t hang around the hospital but leave. If you are not tired, go to the library and study or go home and study but don’t hang around. You won’t get too many opportunities to “leave early” on most surgery rotations. If something is going on that you want to observe, ask your intern or resident before you go off and observe. Don’t ever leave one service to “hang out” with another without permission from your intern/resident and the agreement of the intern/resident of the service that you are “hanging out” with.

Helping Your Fellow Students - If your are efficient at getting your work done, help your fellow students if they need it. Your fellow students are your colleagues and sometimes they just need a hand at some small chore. If you are able to lend this hand, do so.  Share information with your fellow students if you have something that is useful to the team.  Your fellow students are not your competition at this point. Try to do what you can for the good of everyone. If someone has an emergency, offer to switch their call (let your chief resident know) and do so if you can. You never know when you might need the favor returned.

If one of your fellow students mistakenly keeps trying to manage your patients, show off to the residents and attendings, speak to this person about their behavior. If they continue in this aggressive behavior, let the intern/resident know what is going on. I can tell you from experience that quite often, the chief resident is aware of what is happening and will deal with the problem. Your job on any clerkship is to learn as much as you can. If someone, fellow student or resident, is interfering with this process, the clerkship manager/dean should be made aware of the situation. Ask for a meeting and come prepared with examples of how your education is being compromised. Offer solutions to the problem too. As I said above, personality conflicts have no role in medicine but nothing should interfere with your learning. Make sure that you outline that problem and depersonalize it before you present it. Most of the time, learning interference problems can be solved by good and honest communication as opposed to “running to the clerkship manager/dean”. Reserve going outside the team for things that you cannot solve within the team.

Beware of the fellow student who is “going into surgery” and feels the need to scrub any cases that he/she deems interesting. Do the cases that are assigned to you and don’t let your fellow students take your cases. If this is happening on a regular basis, that is, you have scrubbed 15 hernias and nothing else while your colleagues are getting all of the interesting cases, check with your chief resident. On the other hand, if you are just scrubbing the “easier cases” so that your inpatient list is short, your grade may suffer. Don’t be afraid to tackle a complex patient and a complex case. You will be surprised at how much you can learn by digging in and taking on the assignment.

Attitude - I have said that attitude is everything in clinical medicine. Approach each rotation with the attitude that you will master what you need. You don’t have to “love” everything that you are doing but you do need to be able to give your patients your best work regardless of whether or not you love the rotation or anticipate entering the specialty.

Ask for feedback early and often. No one was born knowing how to perform on a rotation. A five-minute “how am I doing conference” with your intern and resident is not a bad idea early in the rotation. Listen to what they have to say and make notes of what you need to improve. Practice your skills and add to them. Keep a running list of procedures that you have done complete with the names of patients, date of procedure and supervising physician.

Problems in the OR - Don’t get into a ”pissing match” with any of the Operating Room personnel. If a scrub person tells you that you are contaminated, step away from the field and take care of it with a “thanks for pointing this out” attitude. I can tell you from personal experience that some OR personnel will try to ”get to you” because you are male, female, human, and other characteristics. Let this stuff go as long as they are not interfering with your knowledge. As an assigned medical student, you have a role in every case that you scrub. You are not to be ”pushed out of the way” by anyone. If this happens, discuss it with your attending or chief resident after the case but don’t get into a shoving match during a case. This rotation is part of your medical school education and you are paying good money for this experience. Don’t allow anyone to compromise your learning experience.

If you feel “faint” in the OR, step back from the table. You can just say, “I need step back” and everyone knows what is happening. The circulator will usually stick a stool under your before you fall. It also goes without saying that you should never go into a case with a full bladder or an empty stomach. Keep some kind of a snack in your coat pocket and keep hydrated too. If you are feeling ill, don’t scrub especially if you have a fever. Explain the situation to your resident/attending and don’t scrub the case. If you are “sick” for every case, your grade may suffer but on at least one occasion, students DO get sick and should not be in the OR.

Remember that too much caffeine will make your hands shake. I have found from experience that caffeine doesn’t alleviate fatigue and doesn’t make you more alert if you are exhausted. Things that help me fight fatigue are rest, hydration, good physical conditioning and fresh air. A cup or two of coffee/tea is not going to hurt you but downing cases of cola or pots of coffee/tea will not help you and may compromise your health, not to mention the diuretic effect of caffeine. Use this drug with caution and avoid overuse.

Grades - You should know ahead of time, how your grade is going to be calculated for any rotation. Be sure that you are not neglecting the projects and performance objectives of your rotation. Go back and look at your clerkship objectives weekly to be sure that you are accomplishing what you need to accomplish. If you have been assigned to a Cardiothoracic team, be sure that you are not neglecting your reading when it comes to hepatobiliary conditions. Your shelf exam is going to cover all aspects of general surgery, trauma, critical care, orthopedics and cardiothoracic surgery. Be sure that you neglect nothing.

Be sure that you continue to hone your diagnostic skills. Even if you are going into primary care, you need to be thoroughly familiar with the diagnosis and treatment of the acute abdomen. In short, you need to be totally familiar with the instances where you need to “consult” surgery. Every case of abdominal pain does not require a surgical consult and you will quickly lose the respect of your surgical colleagues if you consult them before you have done a complete work-up. Be sure that you know why and what you need from any consultant and are not using them to do your work.

Physical Limitations - If you have physical limitations that do not permit you to scrub the longer cases, the let you chief resident know ahead of time. If you have a chronic condition such as diabetes, multiple sclerosis, cerebral palsy or other physical limitations, these should have been discussed with your clerkship preceptors and the residents should have been made aware of your condition. These should not be done in front of the rest of the team but you should make sure that the people who need to be aware of your condition are aware. This is especially true if you are pregnant and are having complications. If you become pregnant during your surgical rotation, be sure that your preceptors knows what is happening and is made aware of any problems that encounter. Again, this rotation should not place you (or your/your unborn child’s health) in jeopardy. I have had medical students who were physically challenged who contributed more to the success of my surgical team than some students who didn’t have these limitations. In these cases, I didn’t run the stairs with the team or make that person scrub the ten-hour cases without a break.  In the end, it all evens out.

Remember that your chief resident and attending physician preceptor are not your enemies. You need to have a good working relationship with them and good communication with them. You also need to be proactive about your learning by keeping up with your reading and adding to your skills whenever possible. General Surgery often moves very quickly and decisions must be made with incomplete data gathering. If you don’t understand how a decision was reached, ask the resident to go through this with you.

Have the attitude that you are going to be a valued team player because you are. You are not the “scut person” and you are not on a team to be the “butt of jokes” by your residents or fellow students. Pitch in and refuse to be alienated by things like occasional “locker room humor”. Don’t personalize anything and learn from your mistakes.

I thought I would write a short essay about my experience with Gross Anatomy class when I was in medical school. This class can cause some angst and turmoil for some freshman medical students because it generally requires the greatest adjustment in terms of study skills and habits.

First of all, Gross Anatomy does not require any great feats of intellectual insight. The material to be mastered takes diligent and systematic study. In short, there is NO substitute for just grinding through the process and taking the time to organize the material for study. At my school, Gross Anatomy also included Embryology which, made Gross Anatomy (GA) far easier to organize in my opinion.

During orientation, we were given a huge syllabus complete with objectives, lecture schedule and lab schedule arranged by topic. We were also given an exam schedule which allowed us to know exactly how much material each exam would cover and when the exams would be given. The breakdown was along the lines of Exam 1 - Extremities and Back Muscles, Exam 2- Thorax, Abdomen and Pelvis, Exam 3 - Head and Neck. This division made sense because dissection and study of the Back Muscles and Extremities requires far less manual precision than dissection of Head and Neck Structures. By the time we reached study of Head and Neck, we were old “pros” at dissection and finding structures.

My best tools for study of Back Muscles and Extremities were my embryology book and one of the skeletons. Our anatomy department had loads of bones and skeletons everywhere in the gross lab. My first approach was to sit down with the syllabus and look over what would be covered in lab and lecture. My next approach was to skim the material in the syllabus looking carefully at the objectives. This usually took less than 15 minutes tops and I was on to the reading making notes in the margins of the text that corresponded to material that was mentioned in the objectives.

My GA textbook was Moore’s Clinical Anatomy for Medical students. I had the binding removed from this book so that I could place the reading pages in a three ring binder. I always had something readily available for reading. My next step was to photocopy or scan the Netter plates that corresponded to the lecture that we would be covering. I would note with a pink highlighter, any structures that were mentioned in the syllabus. That was my prep for each lecture. After hearing the lecture, I would study my notes (or the noteservice notes) and do the same prep for the next lecture.

In prep for lab, I would take out my dissector and make a check sheet of every structure that were expected to observe in lab. I would organize them according to superficial, deep, nerve supply and blood supply. When it came to the muscles, I would list every origin and insertion and action on a sheet with a check list. Before I began dissection, I would visualize them on a skeleton and visualize the actions. I learned the nerve and blood supply at this point too. For example, let’s say that I was looking at the muscles of the back. My first task was to organize them into extrinsic back muscles (associated with the movement of limbs) and intrinsic back muscles (associated with movement of the spine). I would then organize them into superficial and deep layers.

My coverage of the anatomy of the back would have started with organizing the anatomy into surface anatomy (my fiance was a willing model for this stuff), bony anatomy (learning all of the vertebral bones), spinal cord anatomy and then the back muscles. Associated with all of these lectures were embryology lectures on development of the muscles, bones and nerves. But back to the my organization scheme. The embryology lectures took place before dissection so that we had that background before moving into the lab.

Let’s say that today’s lecture included the muscles of the back. I would have my Netter plates (with annotations) and my key words from the objectives in my folder for that lecture (the material that I had prepared the evening before). I would listen to the lecture taking notes as I needed them and adding notes to my plates or on paper. We would then head off to the lab where I would look at the skeleton and trace out every origin (medial attachement) and insertion (lateral attachement) for each of the back muscles. Lets look at the Latissimus dorsi for a specific example. The medial attachement is the spinous processes of the six most inferior thoracic vertebrae and the lumbar vertebrae, inferiorly: the iliac crest and the thoracolumbar fascia and the inferior 3 to 4 ribs. This muscle inserts on the floor of the intertubercular groove of the humerus. By locating the origins and insertions of a muscle, I would be able to picture the action of that muscle as it contracts. In the case of the latissimus dorsi, I knew for sure that this muscle was not an intrinsic back muscle but functioned primarily on the humerus (an arm bone).

I would also learn the blood and nerve supply as I studied the skeleton. The nerve supply is the Thoracodorsal nerve which can be found heading through the axilla and to this muscle. One of my instructors like to say that the extrinsic back muscles “crawled out onto the back and took their blood and nerve supply with them”. This statement easily explains why the thoracodorsal artery is a distal branch of the axillary artery and that I could trace the small branches on the anterior surface of the latissimus dorsi muscle back to the distal part of the axillary artery which is a continuation of the subclavian artery. The nerve system is the same as the thoracodorsal nerve is a branch off the posterior cord of the bracheal plexus which travels to the LD muscle that is located on the posterior, inferior portion of the superfical back. In short, by organizing the material before heading into the dissection lab, I knew where to look for nerves and vessels; the actions of the muscle and bony landmarks all at the same time.

My GA class also required that we study radiographs, CTs and MRIs in addition to our dissection. I studied the available materials along with my dissections. When I came to the dissection lab, I had a checklist of all of the materials that I wanted to review and master. I can tell you that I was in the dissection lab at least 10 hours per week outside of the dissection lab times. On the weekends, I would review the week’s materials which usually took three or so hours. This study was done with my study group. I also looked at every cadaver in the lab weekly in addition to my own. We kept a running list of excellent dissections (more likely to be tested) at different tanks. We always asked permission before entering another group”s tank.

Another thing my study group did was ask one of the instructors (usually the course director) to spend 30 minutes quizzing us a week before the lab practical. He was totally willing to work with a five-student group. We asked him to be picky and brutal. Usually these sessions made us go back and work a bit more on our identification of structures. Our instructor was very good about telling us how to identify structures on a lab practical. He always liked to show us great landmarks.

The most important aspect of GA study (any course study) in medical school, is not to get behind. If you miss something (illness) you need to go immediately to where the class in and catch up on the weekend. Some students get behind and attempt to catch up and never get there. Again, catch up on weekends (they don’t lecture on Saturdays and Sundays). Also, don’t underestimate how much your classmates can be great resources for you. I never found a classmate who wasn’t willing to review structures with me in the lab. The biggest gunner gets an extra boost by helping classmates who are struggling. Everytime I reviewed something, I learned it that much better.

Some caveats: You cannot organize the material for your classmates. Each person has to find their own system and each person has to learn the material for themselves. Working with a study group helps to reinforce the material but each person is responsible for their own learning. Don’t even try to work with a group until you have done a thorough mastery of the material for yourself. If you are isolated, you lose out on the great reinforcement so don’t isolate yourself. If you have a family and other outside obligations, schedule some study group time even if it is minimal. Medicine is not a solo activity and you will have to rely on your colleagues when you are in practice. Medical school is good practice for learning to work as a group.

Well, the above is the essence of my system for GA and embrylogy. I can tell you that I spent plenty of time in the Gross lab and working on GA. It was interesting and it helped me appreciate my classmates even more. We all worked together and we all learned together. GA is not a course that you can sit down, memorize and master in a vacuum. You need feedback and your instructors/classmates are great resources. While there is much to learn and master, it’s not all rote memorization. My classmates that were great rote memorizers did fine on the tests but crashed on USMLE Step I in most cases. The understanders and intergrator (like me) did equally well on the exams and on USMLE Step I. It takes both.

I would also say that GA is not a course to be feared but a course to be mastered. A full 75% of my class failed the first GA lecture exam but only about 2 people failed the course itself. In most schools, you are not penalized for getting off to a slow start as long as you figure out what you need to do to get your information mastered. For me, GA was daily study, preparation and mastery. I also forged a great relationship with the GA instruction staff (I was the class rep for this course) so that we all could do our best. The instructors were not there to “fail” us but to help us master this neat course. In the end, it worked out fine.

On the first day of your class, you will be issued a syllabus that outlines the professor’s grading policy, what will be expected of your in the class and a lecture/test schedule. Once you have that document in your hands, you can begin to set up your schedule for the rest of the semester. Ideally, you may want to purchase a very large desk blotter but the calender in MS Outlook (or something like it) will do just fine. On that calender, you want to place the date and time of every lecture, the topic,  and the required reading. You also want to place the dates of your exams and note the dates of 3 weeks to exam, 2 weeks to exam and 1 week to exam.  Any papers that are required should be treated like exams with 3 weeks to paper due, 2 weeks to paper due, 1 week to paper due.

 If you are taking a lab course, you need to add the dates and times of your various lab sessions to your calender along with the topics of each lab. If you list your labs by subject matter of each experiment, you can relate these to your lecture material for better integration of the course subject matter. If your course has a recitation section, be sure to list this too as you do not want to skip any recitation sections. These sections can be invaluable when it comes to test preparation time.

Once you have set your master schedule for the semester, fill in your schedule for the week. This means filling in how much time it takes for you to get to school, the times of your classes and labs, your study time - remember one hour of study for each hour of lecture and 45 minutes of study for each hour of lab-your meal times, your work out times and your bedtime. If you are using a computer-based program for your daily schedule, print out your next day’s schedule when you are studying the night before. Look at it and be sure that you have organized and prepared for the classes that are on this schedule.

Class preparation means look at the subject matter of the upcoming lecture. Review the assigned readings - pay close attention to any bold words, headings and topics-review the syllabus and do any assigned problems. If you have difficulty with any of the problems, put notes or checks where you had difficulty so that you can walk into your professor’s office during office hours and get your questions answered. Don’t wait until after the lecture to work pre-assigned problems. Most of the time, anything that you had difficulty with, can be answered in class. If you wait until after class, you will be behind. Attempt assigned problems before your lecture.

Listen to your lecture and take notes only on the things that you know are not in the syllabus or text book. (See my previous study skills posts for how I would cut my textbooks). Take notes on things that help you to understand the important points of the lecture or clarify concepts that you previously did not understand. As I have outlined in other study skills posts, I would take notes on the left side of my notebook only using the right 2/3rds of the page. The left 1/3 of the page would be left blank so that I could write in summaries of the notes or definitions of terms that were important. On the right pages of my notebook, I would recopy notes that were taken in a hurry so that they were legible. I would also place notes and information from my text book.

Most of the time, I took lecture notes on my laptop computer or on looseleaf notebook paper. I discovered the utility of using notebooks that were designed for law students (summary paper) and then resorted to making my own version of these summary pages. I would print out my notes and clip them into a looseleaf notebook so that I could highlight them or make notes to myself as I studied. I would review the previous lecture, study the current lecture and preview the upcoming lecture doing the text readings.

As I stated under Organic Chemistry, I never walked into any lab unprepared. My lab prep consisted of knowing the purpose of the experiment how long each step would take; what data needed to be obtained and what conclusions/observations I would be expected to make. I kept a sticky note in my lab manual or notebook with the steps of the experiment briefly outlined so that I could refer to my note. This make any lab write-ups pretty easy to finish. If there were pre-lab exercises, these were done before I attended lab. I would also consult my textbook if the material covered in lab didn’t correspond with the lecture (most of the time the lab material was a bit ahead of the lecture).

For courses like English and Math, I made sure that I had a solid reading schedule that kept me ahead of the class. Again, I would have problems worked before coming to class. In English, I would make sure that I had thoroughly covered the readings taking notes as to tone, argument and subject matter as I moved along. Again, sticky notes were good for making extra notes in my reading books. I could past them in and add them to my professor’s notes after the lecture.

Soon after each lecture, I would quickly review the lectured material filling in any words that I had left out or drawing arrows to link materials. I would make any quick notes of things that needed to be clarified during office hours. In terms of Math and English, I would have circles around any problems that I had attempted but was not able to complete before class so that I could get my questions/problems taken care of. If these were not taken care of in the lecture, they would be taken care of during office hours.

My professors got to know me pretty well because I would attend office hours even if I was sure that I had mastered the material. It doesn’t hurt to have a “tune-up” and a “knowledge-check” even if you are sure that you are understanding everything. Sometimes these “tune-up” sessions would give me valuable insight as to what to emphasize for the exams and what to place less emphasis on. I figured that if I was paying thousands in tuition for each course, I was going to get every bit of instruction out of the course that was available. It also gave the professor a chance to get to know me which was good when I requested a letter of recommendation for graduate/medical school. I always received high praise for my business-like attitude and organization of my coursework.

Spending so much time preparing and previewing for each class made studying and review for each exam practically effortless. By the time the exam rolled around, I had been over each lecture a minimum of three times. I reviewed the previous weeks lectures on the weekend. By staying ahead of the professor and the class, I always had plenty of time to integrate the materials for every class. My attitude toward university coursework (honed by loads of experience in secondary school) was that my “job” was to master this material. I needed to thoroughly master my coursework because it was background for my graduate studies and I wanted the best undergraduate education that my university offered. 

Don’t get the idea that I spent every waking hour in front of a book. I used my university time to attend lectures and seminars on any subject matter that was of interest to me. I went to lectures on the Holocaust, aerospace engineering, mathematical theories, social theories, political science in addition to departmental seminars in biology, chemistry and physics. I obtained a departmental seminar listing during the first week of class and added these to my schedule. Even if you do not completely understand everything in a seminar, you can pick up valuable experience and broaden your knowledge base for free. These seminars are also a great opportunity to get to meet the faculty and learn their research interests.

As a medical student, I tried to attend grand rounds in Surgery, Medicine and Pathology as much as my schedule would permit. These grand rounds became invaluable for USMLE (all steps) as the speakers always presented both the basic and clinical science of their discipline. It was my interest in every aspect of medicine that lead me into academics and today, continues to allow me to keep up with basic science as well as clinical science.

As a student of science and medicine, you have to be quite proactive and a bit of a self-learner when it comes to the mastery of your craft. If you take the time to start keeping up with the literature and attending seminars/grand rounds while you are an undergraduate, you can carry those skills into graduate/medical school. You cannot afford to be a passive learner relying on the professor’s lectures for your entire education. I totally attribute my performance on the Medical College Admissions Test (MCAT), United States Medical Licensing Exam (USMLE) and my specialty board/in-training exams to my attendance at all of those seminars and grand rounds. By listening to the “cutting-edge” leaders in various subjects, you learn to analyze information and you learn to present information logically. These skills are free and the seminars are often free and easy to take advantage of.

Finally, approach your studies as you job. If you are working and attending class, you need to be organized but you need to do both well. I always recommend that students who work, need to take less hours. It is not useful to load up on semester hours only to do poorly or mediocre in the coursework. Take less hours in the first place, do well, and if you find that you have free time, use that time to attend seminars/grand rounds. If you are a full-time student with no employment, use some of your free time for seminars and experiences that widen your educational experience.  You only get once chance at your university experience and you need to be sure that you are getting the most out of every class for you money. Make your studies of prime importance and be proactive about getting your needs met.