Rite of Spring

Hours ago I finished up the 4th exam for my core course of my second semester of PA School. I’ve been trying to write a blog post since the second week of class but things have been that busy. Spring Semester has been intense. With just days until Spring Break, let’s take a look back at the last two months.

This morning’s exam tested my ability to distinguish among the following: 

  • Primary, Secondary, and Subclinical Hypothyroidism

  • Primary, Secondary and Ectopic Hyperthyroidism

  • Primary Hypoparathyroidism

  • Secondary Hyperparathyroidism

  • Primary Hyperparathyroidism

  • Pseudohypoparathyroidism, which is still sort of Secondary Hyperparathyroidism

  • Pseudopseudohypoparathyroidism

I swear all of those things are real medical conditions. The mental gymnastics I had to employ to keep all of that straight was quite absurd. That content is also just scratching the surface of three PowerPoints (PPT) of a seven PPT exam on Endocrinology.

I actually wrote a blog in May of 2023 called “Diabetes Medications: Quick and Dirty.” Fast forward almost a year, and I created this:

The Endocrine system has always been interesting to me. In March of 2021 while I was studying Biology for my Post-Bac, I uploaded a video outlining a mnemonic for the hormones of the Pituitary Gland. And now, 3 years later, I used the same mnemonic, but made this:

The exam this morning was pretty high stakes for me because my blog has started to gain some attention and I’ve started to recommend my study strategies. So employing them for this exam… and not doing well would have been disheartening and pretty embarrassing. But luckily, I did well. What I’m doing is working. It’s important for me to mention that on here because I talk about so many different study techniques and as a reader you might be wondering, “Okay, yea but does any of this actually work?” ’ll reiterate again: I’m no genius. I’ve had average grades almost my entire life. But in returning to school at 34, I’ve re-entered academics with a fresh perspective and I think I’ve stumbled upon some pretty big revelations and started to get this down to a science. Am I getting 100s? Hardly. But a perfect score should never be the goal in PA School. Perfection isn’t sustainable nor worth the effort for most students. The goal is passing with wiggle room, or “Passing with style.” It’s about doing well enough and still being a functioning human being.

The Feynman Technique

I haven’t talked about the Feynman Technique much, but it deserves special mention. I wrote a 97 page “Study Guide” from seven PPTs of content for this exam, a process I’ve been repeating since September. And the format I follow for my writing is grounded in the Feynman Technique: taking a complex topic and putting it in language that a child could understand. And the idea isn’t to “dumb down” concepts and present them in a condescending way. The idea here is that in order to teach something complex in simple terms, you have to understand it very, very well. That’s huge.

How much of your study time do you spend teaching? The answer should be “yes.”

I’ll share an example of this technique in action mixed with my own personal spin of “StoryNoting”. My favorite example of this has to do with Calcium’s relationship to Albumin:

🧮  Correcting Serum Calcium Based on Albumin

Well a normal calcium is: 8.5-10.5 mg/dL. 85-105mm is a really nice portrait lens if you’re into photography. Here’s the deal, remember that half of that 1% of serum calcium (0.5%) are chilling on proteins like 🛟Albumin. So if 🛟Albumin is low… calcium might be artificially low. Wait, but where does the 0.5% go… it just doesn’t exist I guess? Wouldn’t it just also be in the serum with that other 0.5%? I guess not. So where is it, still in the bones waiting to hop off the bone into the lazy river of blood but it needs an 🛟Albumin float or something cause the water is cold? Yea let’s go with that.

…

Okay, but BEFORE we waste the hospital’s money on a calcium panel, we need to do some math. This is important so let’s nail this. First, remember that:

99% of this bad boy Calcium is in our bones and teeth. The other 1% is in the blood:

  • 0.5% bound to proteins, like 🛟Albumin

  • 0.5% is free and BIOACTIVE. 

Yes, so that albumin is important. If that’s low, we need to account for it. We want albumin to be 4.1, like the GPA we’ll never have. If it’s low, remember that means less lazy river 🛟Albumin pool floats for Calcium to jump onto. We need to count how many Calciums are standing on the edge of the river (the blood stream) because there aren’t enough floaties.

We need 4.1 albumin, but let’s say we only have 2, so we are 2 shy of a full pool. So, we add back in to our Calcium, 0.8 for every 1 float of albumin we are missing. How are you going to remember that it’s 0.8? If you can’t remember, picture someone coming into the classroom while you’re taking this exam with an 🎱 8-Ball, POINTING to it, so there’s your decimal, telling you it’s full of calcium, and then promptly shoving it down your throat. Sorry if that’s too much, but now we won’t forget it.

Back to our patient… Normal Calcium is: 8.5-10.5 mg/dL.

The patient has a total calcium of 8 mg/dL and a serum albumin concentration of 2 g/dL. Oof, Calcium is an 8? We need 8.5 to be normal. So do we pull our labs…. NOT YET! Look at that albumin! Missing two pool floaties (2 under 4.1); so we need to account for the fish out of water. So add in 0.8 X2 = 1.6 units of calcium giving our adjusted calcium a new value of 9.6 mg/dL. Very nicely in that 8.5-10.5 range. Send em home!

It might seem absolutely absurd to write things like: “Yes, so that albumin is important” or “Sorry if that’s too much, but now we won’t forget it” or interrupt a thought process with a comment about photography, but I’m not just going to re-type what’s on the slides. That’s a tremendous waste of time. I like writing as a stream of consciousness. If I misunderstand something, I keep it in and just make the clarification. You might also think that writing in “flavor text” is a waste of time. I’d argue that slowing things down and spending more time with topics make them stick; you might as well have some fun while you’re doing that. I’ve spent two hours on 11 slides before because I really want to understand those 11 slides before I move forward. As much as I promote the usefulness of memory, understanding is critical.

The key with Feynman is to write notes for an audience, not for yourself. This forces you to be really clear and break things down. Other students do read my content, but even before they didn’t, I wrote in this fashion.

Taking a concept like Calcium & Albumin and turning it into a conversation about lazy rivers and pool floaties? That’s not studying. That’s just plain fun.

Anki Live

Something new I’ve been doing this semester is recording myself studying and then uploading it to YouTube. This is effective for me for a couple of reasons.

When the camera is on… I’m “on.” I find I never pick up my phone, get distracted, or browse away from what I’m studying. I’m staring at myself on screen and keeping myself accountable. It also gives me the opportunity to kind of “perform” while studying. I make commentary, get animated, get frustrated, and get excited when I get things correct. And even better, I can watch/listen to these videos while I’m doing laundry or driving to campus. A fellow student told me she was searching for resources on YouTube and my video came up. “I listened to it on a bike ride. Can you make more of these?” I mean, sure.

I’m very productive in the morning but once the afternoon comes around, I’d rather watch paint dry or go to the dentist than study another hour. Anki Live is my way of forcing myself into productivity. I get to create content, I get to populate my YouTube channel. It’s different. It works.

What Works

My recipe for success at the moment is the following:

  • Get a good night’s sleep every single night. Zero exceptions. If you want to maximize your sleep even more, go to bed and wake up at the same time every day, seven days a week. If you’re not sleeping well, you’re shooting yourself in both feet.

  • Protect your mental health at all costs. After an exam, avoid people. Suppress that urge to ask, “What did you put for…?” The best case scenario is you feel lucky, the worst case scenario is you feel stupid, and the even worse scenario is you make someone else feel stupid. I think that last part is very important to realize. If you want to look things up and see what you got right/wrong, do it in your own time. Make the acceptance of a failure a personal experience. It’s better to laugh at your own mistakes alone than try to argue your reasoning for why you chose an incorrect answer to a crowd. I almost always get defensive when everyone said A but I put B so I’ve taken myself out of that equation. It’s human nature to not want to look stupid. It’s human nature to want to be the person that saw something that no one else did. It works wonders for mental health to let all of that go.

  • Spend time with the content that you’re studying. Just you and the slides. Take your time, limit interruptions, and go over every single word and bullet. Don’t move forward to the next slide until you understand the one before it. Teach every slide in simple terms before moving on, whether you want to handwrite or type. Make it into a story and don’t take it too seriously.

  • You need to zoom out. 115 slides means nothing if you don’t understand the big picture. How many categories are here? How do they relate to each other? How many “Players” are there? You have to look at the entire cast before you can understand each character. Then… don’t just write an outline or massive never-ending spreadsheet! Put all of the players together in a scene and make something beautiful. Make your notes an invigorating episodic TV-show, not a drawn out, boring documentary.

  • Utilize spatial memory. The research says handwriting notes is superior but it’s critical to understand why. It’s not because they’re slower; it’s because they utilize spatial memory. Google Docs tables also utilize spatial memory. Also, do you know what technique the Official USA Memory Championship Record Holders use? Memory Palaces, a form of spatial memory.

  • Stop using Quizlet and start using Anki. You need to spend less time with the flashcards you know and more time with the ones you don’t. Also seeing a flashcard once doesn’t mean you know it. And when you get one wrong, Quizlet just shows it to you immediately again. With Anki, I have to see a card three times, spaced out, before it goes away.

  • If you really want to pick up extra exam points, study at least a few hours per exam with a group of people. What the group as a whole thinks is important is usually on the exam. Words of fellow students are very memorable.

  • Put interconnected topics all on one page and study little pieces of the larger whole, but never look away from that larger whole. Give the information you’re studying a permanent home rather than a fleeting short-term neuron. Put 100 slides into a single table and image occlude 150 words and keep running through it until you can almost recite the entire table from memory. I use Anki for this. If you were memorizing a map of the United States would you just look at one state, or even one region, at a time?

Here’s an example:

This goes into Anki and all but one occluded yellow box will appear at a time. That’s one flashcard. Let’s say it’s the one in the middle-right blue box surrounded by the purple asterisks. It reads “ETOH.” Once I get that right, I need to get it right two more times before the card goes away. In about 45 minutes, I’ll have weeded out the easier stuff. ETOH is pretty easy to remember but a lot of these others aren’t. I might have to try them 5 or 6 times before getting them correct. Then, the next day, I need to get the right once; this helps even more to see what I know and what I thought I knew.

The other massive benefit to this strategy is you can pick up trends. Oh… this class is good for ASCVD… where else did I see that. Oh it’s literally right here. I don’t have to go searching for connections.

In PA School we get whiteboards and wax pencils with each exam to use however we’d like. This morning, I took about 10 minutes after the exam began to fill the whiteboard. Each PPT had key tables that I created so I then drew out each one, whether that was a 3X3 or a 2X1 or a 3X2 and put the title of each box where it belonged. Just the title! I just need to know what goes where and the contents of each box just appear in my head. This allowed me to harness the short term memory of everything I had been studying, without the interference of the exam. I also noticed it calmed my nerves immensely. Staring at a blank whiteboard and having to draw something out mid-exam while your brain is already fuzzy isn’t ideal. The moment right before you dive into that first question is the moment on the exam when your head is the clearest. Utilize it.

Staring at a whiteboard loaded with the most high yield parts of your 97-page study guide that you wrote over the past two weeks, organized by spatial memory? In the words of Chazz Reinhold from Wedding Crashers: it’s like fishing with dynamite.

Freedom

Having spent over 10 years in Corporate America, you get used to hearing the words “No” and “You can’t do that” and “We’ve always done it this way!” I realized the life of a student is so incredibly liberating. It doesn’t matter how you study. You’re in complete control of how you get to your destination. I’m really grateful for that.

This last exam was a true test of my methods. I was terrified that I’d created so many tables that I’d confuse them all and I’d have to walk into remediation with my tail between my legs and have to admit that my silly rainbow-colored Google Docs charts had finally failed me and I’d have to resort to re-reading notes and typing out outlines. “Maybe stop spending so much time on choosing pleasing color palettes and emojis for your notes. Maybe stop writing out your notes like a blog post and just outline them like students have done for centuries. Put down your silly Nintendo controller and start taking this seriously. You’re going to have to start missing a little bit of sleep. This is a grind. This is a sacrifice. It’s not supposed to be fun. It’s supposed to be hard or else everyone would be doing it.”

Maybe one day I’ll hear those words… but it wasn’t today.

Studying in PA School: The Tools of the Trade

There are many tools I’ve used this past semester to study and help remember content to pass exams. With one week (now one day as I edit this) to next semester, let’s crack open the toolbox and see what worked. There’s a science to science but there’s also a science to studying, remembering, learning, and passing exams. So let’s tear apart note-taking, what makes a bad mnemonic, and the logic behind flashcards. Maybe I can uncover some new and insane way to help remember information (spoiler: I have).

Let’s talk.

StoryNotes

So here’s what I call StoryNotes: I take a PowerPoint deck (or any information) and process it. As a whole, how many sections does it include, what is going to fit nicely into a table, what is going to need some mnemonics to remember, etc. And then I just type it into plain language and try to maintain it like a stream of consciousness. It’s informal, self-aware, full of jokes, mnemonics, and observations. Even though I make these mainly for myself, I type like I’m teaching the information which is the best way to learn. If PA school is harnessing water from a firehose with a coffee straw, this is my way of getting rid of that water as fast as possible in bite size chunks, and using the fire hose to water the plants, if you will.

StoryNotes have another big benefit. The creation of something I can refer back to in the future if really valuable and has paid off already. You can’t really revisit Anki cards in the field. Here’s an example of StoryNotes.

The gold standard for me would be to create my notes before class so it’s like “Okay, this is my take from this content, now let’s reconcile it with what the professor has to say and maybe, just maybe, I can participate in class a little more and understand more.” Because that’s my biggest weak point: really understanding what is in front of me and being able to talk about disease processes as a whole. So that’s my #1 goal for the Spring. I don’t think I can pull this off for every single class, but I’ll try my best to do it for CMPP (my main class).

So StoryNotes are sort of the first pass of studying. What comes next, the real crux is the actual studying which for me is Anki. At the core it’s really just free recall and spaced repetition.

Enter the Matrix

Probably the most profound tool I’ve come across are tables within Google Docs, what I call Matrices. Now, I don’t handwrite my notes, but a powerful benefit of handwritten notes is spatial recall; you remember where and how large on the page the information is. Matrices work in a similar way. If you are comparing some disease processes, putting them all in a table so they can compare and contrast and live next to each other just works wonders. It helps narrow down multiple choice questions. If you don’t remember “What is” you might remember “What’s not” and that could get you the point.

Upon studying for finals, when going over Acute Bronchitis, Bronchiolitis, and RDS of the Newborn, my mind traveled right back to the matrix I made weeks and weeks ago. I didn’t remember everything but I remembered the big picture stuff. Just like with a Memory Palace, I can’t think about some of these concepts without thinking about the location in the tables. It’s pretty wild stuff. Here are some examples of Matrices from this semester:

Acronyms

I think the most infamous acronym mnemonic I’ve come across is: CLUBBING, which “spells” out the causes of digital clubbing:

  • Cyanotic Heart Disease, Cystic Fibrosis

  • Lung Cancer, Lung Abscess

  • Ulcerative Colitis

  • Bronchiectasis

  • Benign Mesothelioma

  • Infectious endocarditis, idiopathic pulmonary fibrosis, idiopathic, inherited

  • Neurogenic Tumors

  • GI Diseases: Cirrhosis, Regional Enteritis (Crohn’s)

At first glance… it looks like an absolute mess, but it’s actually not as chaotic as it appears. The second B meaning “Benign Mesothelioma” is so bad it’s good and actually quite memorable. The cool thing about acronyms is that you can encode whatever you want in each letter. “B” could make you think of honey which could lead to an H word.

The most important question here is… well how do you learn this acronym? You can either learn the entire thing all at once, learn each of the 8 terms separately, or put it into bursts or runs. The problem with learning the entire thing all at once, is I can master 6/8, but if I keep getting caught up on “Benign Mesothelioma” I have to keep repeating the entire flashcard, and that’s wasteful. Learning 8 separately is probably the best: “Hey, here’s the other 7, but one is missing, what’s missing and how does that fit into the other 8?” I opted for a hybrid approach and broke it runs of 3, 3, and 2. The value to an acronym, besides telling you there’s 8 in total and giving you the first letter, is to always present and recall the information in the same order. So this process worked and I got the exam question correct. Here’s what the Anki card looked like:

One acronym mnemonic I created that I’m particularly proud of is for the functions of the liver. The liver does… a lot. At first I had a bunch of image occlusions on the slide of the functions, but it just wasn’t working because I wasn’t reciting the functions in the same order every time. I could have tried doing it in sequential runs, like with CLUBBING, but I realized this was really important to know long-term, so I did something else.

I created both an acronym and a memory palace / story to go with it and I even embedded mnemonics within mnemonics. So my “cardinal” acronym was: ABUStIES. I’ll see if I can recall what they all stand for right now, months after I’ve seen this content:

  • A = Angiotensinogen

  • B = Bile & Bilirubin

  • U = Urea Cycle

  • St = Storage of CV-GIF

    • C - Copper

    • V - Vitamins? Yes, but A, D, K, B12

    • G - Glucose (as Glycogen?)

    • I - Iron

    • F - Fiber Fats

  • I = Immune Factors

  • E = Excretes Waste

  • S = Synthesizes ACT

    • A - Albumin

    • C - Clotting Factors

    • T - Thrombopoietin

Okay so I recalled almost all of that, just mistaking Fiber for Fats, and missing which vitamins. I recalled part of the memory palace to complete it. Adding in CV-GIF and ACT also didn’t slow me down at all. This is pretty powerful stuff. It’s worth noting that I included “St” along with “S” to not confuse the two S words. This does create the possibility that I might think the the “t” of “St” could mean another item starting with “T” but I’ve never gotten tripped up on that.

So this is like a “super mnemonic” because it combines two methods and I think it’s almost completely full-proof and obviously long lasting.

Acrostics

I talked about acrostics a bit in my last blog but they’re worth mentioning here. Notable examples I’ve encountered:

  • She Always Likes Friends Over Papa, Sister and Mama, the branches of the external carotid artery

  • TOSS My Gravy Spoon, Darling, the infra and suprahyoid muscles of the neck

  • Ooh, ooh, ooh to touch and feel very good velvet, such heaven (or any of the dirty variations), for the cranial nerves

With infinite respect to their authors, these are all… really bad. EDIT: I’ve been thinking about my wording here. My phrasing admittedly is a bit sensationalist. I think it’s important to make a clarification here (and I also feel bad and don’t want to offend anyone). I don’t have a problem with these mnemonics, and if you Google them you can find them all over the place. What’s most interesting to me is how often do we evaluate silly mnemonics like this? Who wrote them? Who cares? To me, the science of mnemonics is incredibly interesting but also incredibly niche. So I think there’s a lot of value to take a step back and say “Hey, is there a way to rewrite these mnemonics to make them more effective?” Anyways:

During this semester I rewrote the first two:

  • I changed this first one to ST-AP FA-LING Out-Of PA, St. Max, which is kind of a hybrid acronym/acrostic. ST: Superior Thyroid, AP: Ascending Pharyngeal, FA: Facial, LING: Lingual (this and facial are “switched”), Out Of: Occipital (Two Os make me think of eyes = occipital), PA: Posterior Auricular, St: Superficial Temporal, Max: Maxillary.

  • I kept TOSS which stands for Thyrohyoid, Omohyoid, Sternothyroid, Sternohyoid but pictured the first two sitting on top of two Sterno burners. The second part stands for: Mylohyoid, Geniohyoid, Stylohyoid, Digastric which I turned into: My Genie’s Stylin’ Digs or My Genie’s Stylist Digs Bellies (because digastric has two bellies). Notice how similar those words are to what they are representing. Swapping “Gravy” for “Genie” to stand for Geniohyoid is a no-brainer.

  • I hate the cranial nerve mnemonic so much. The first three words are the exact same! The cranial nerves are so important to remember, I created a memory palace using the layout of Dunder Mifflin from The Office. Even six months after its creation, I remembered almost all of it.

  • There’s one I created for the hormones of the Anterior Pituitary that I’m proud of: The Flute Lute Theater Act Professionally to Grow to Milan.

As you can see, the secret with acrostics is to make the words as similar as possible to the words they represent. That’s huge.

Term vs. Definition

When making a flashcard, there are two big questions: Do I answer the term or the definition or both? For example: Side 1: A localized suppurative staphylococcal skin infection originating in a gland or hair follicle. Side 2: Furuncle. I usually keep it in that fashion, and answer the term instead of reciting the definition. But what about this one: Side 1: Early varicella, herpes, poison ivy. Side 2: Examples of Vesicles. For that one, it’s probably in my best interest to list the three examples of vesicles. I might just start associating “poison ivy” with vesicles and miss “early varicella” on an exam question. However, I think that takes up too much processing power. As long as I read the entire question and definition, it should be fine.

Here’s another example. Side 1: Pt presents to the clinic with abnormally deep, regular, "sighing" respirations. What kind of breathing is this? What could they have? Side 2: This is classic Kussmaul. Causes are DUMP: Diabetic Ketoacidosis (DKA), Uremia, Metabolic Acidosis (Three acidic conditions) Pneumonia Which actually can cause respiratory alkalosis, along with Sepsis. Sick = fever = tachypneic = blowing off CO2. Again, it would be easier to list the causes first and answer with the term, but I chose the hard way. I think the important thing here is to try and make connections and not make the seemingly arbitrary list not so arbitrary.

Cloze Clues

There’s another really interesting question that I’ve been playing with, and that’s “How much of a hint can I get away with?” Here’s an example:

ABX indication for pts with acute cholecystitis:

  • {{c1::Elevated WBCs: If WBC >12.5}}

  • {{c1::Fever: Clinical findings of Temp >101.3}}

  • {{c2::Air in GB or GB wall - Perforation!}}

  • {{c2::Elderly or Immunocompromised}}

So I see that I need four different things (and risk recalling them in a different order each time) But what if I rewrote this card as:

  • {{c1::Elevated WBCs: If WBC >12.5}} (LAB VALUE)

  • {{c1::Fever: Clinical findings of Temp >101.3}} (VITAL SIGN)

  • {{c2::Air in GB or GB wall - Perforation!}} (RADIOLOGY FINDING)

  • {{c2::Elderly or Immunocompromised}} (AGE / PATIENT POPULATION [2])

Is this going to inhibit my learning? My hypothesis is… probably not. I’m still recalling the answers but I think I’m cutting out the unneeded brain power. I actually think every Cloze should have an associated context or hint.

Here’s another example I’ve been playing with:

Within the context of Acute Liver Failure: So the cause of thrombocytopenia is due to something called {{c1::splenic}} sequestering OR: splenic {{c1::sequestering}}.

“Due to something called” is very generic. If I left it at that and had to recall “Splenic Sequestering” as a whole I’d probably have to look at that card quite a few times. Why not just present half of the answer? I think as long as I am recalling part of the answer, I’ll still remember it.

Memory Palaces / Roman Rooms

For the record, I’m editing this blog on vacation in Rome. Today’s my off day as I spent yesterday hiking the 200 steps of the Petraio in Naples, a neighborhood built around a massive staircase, up to Castel Sant'Elmo where I was met with an incredible view of Naples, Mount Vesuvius, and the Tyrrhenian Sea. I’m in my hotel room now, a Roman room, blogging about the Roman Room. That’s pretty neat.

I spent a lot of time in the year prior to my PA studies on memorizing the Top 300 prescribed medications. I did this more as an experiment in memory rather than to prepare for school, but it’s paid off in spades. I haven’t tried recalling the entire thing since the Summer, but I still remember almost every single one whenever one presents itself in class. And the other thing is that it’s impossible for me to think of a medication and not think about the location where I last left it. They’ve now become one in the same. My memory palace has helped me with quite a few exam questions and has helped me learn the context of these medications quite a bit. The other amazing thing is that I can add to it… now that I’ve learned more about Lisinopril (Zestril, Prinivil) which is the desk in the front room of my parents’ house. This desk is now in my apartment, but I think about the location that it used to be, rather than where the desk is now when I recall Lisinopril. I was able to mentally put a stack of bananas on the desk and think about a person swelling up as well to remember that the medication causes hyperkalemia and angioedema.

I’ve only created a couple of fully baked Memory Palaces in PA school, but they’re still handy when I need them. The most infamous for me is for the entirety of what we needed to know for vaccines. I used the layout of our PA studies building. The best part about it was that it was fun. It was active. I looked at the slides of what we needed to know and was filled with existential dread. There’s a lot of power in pulling out the Uno reverse card and saying “You know what, I’m going to make you the most fun thing to learn ever.”

I have the layout of my apartment in my back pocket in case a particularly nasty concept presents itself. You can encode in insane amount of information in the place where you live.

Numbers

The greatest challenge and barrier to memory so far in PA School is arbitrary numbers. Luckily, my program doesn’t make us memorize medication dosing (since they can be looked up) but there are a bunch of numbers we still need to know:

  • Years (vaccinations, houses for asbestos, etc.)

  • Volume, like the amount of CSF in the brain, in mL

  • Length, like the size of the aorta

  • Scales such as BMI and hypertension

  • Age ranges like for screenings, childhood development, etc.

  • Time, like the amount of time that has to elapse for hospital acquired pneumonia, post-op ileus, DVT risks, etc.

  • Frequency, like how often to get a mammogram, colonoscopy, etc.

  • Amounts like salt, alcohol, calories, fat, etc.

It’s… a lot and really tough to remember.

I’ve heard some people create an image for every number from 1-100. So if 35 was a camera lens, and 70 was my grandfather, I’d associate my grandfather and a camera lens for the ages of a diabetes screening. But you need 100 images, and have to memorize all of them before you can start applying it.

There’s another system called the Major System that converts numbers into sounds. The general idea is:

  • 1 = t,d (both letters have 1 downstroke)

  • 2 = n (has two downstrokes)

  • 3 = m (three downstrokes)

  • 4 = r (R kind of looks like 4 backwards, is the last letter of fouR)

  • 5 = l (roman numeral for 50)

  • 6 = soft g/j (looks like an upside down 6), sh, ch

  • 7 = k/c (looks like two sevens stuck together), q, hard G

  • 8 = f (cursive f looks like 8) or v

  • 9 = p/b (mirror image of 9)

This one sounds insane, but requires much less up-front effort. Let’s see if we can apply it. So let’s say I need to remember 18-79 for the ages for Hepatitis C screenings. I would create the sentence Taffy Cup, maybe you get Hep C from licking a bunch of taffies in a cup. The first two consonants of Taffy are T and F, which is 18 and the first two of Cup are C and P which is 79. That’s… actually very cool. This is absolutely the kind of insane stuff I’d be into.

HIV screening ages are 15-65. Tall Jill. So I’d just remember Tall Jill or think of a tall person named Jill with HIV. I really, really like this. The cool thing too is 15 can just now become “Tall” every time. I can come up with a library of words so I don’t have to think of new ones. I mean, unless that becomes too unwieldy. Like anything with 15 would be Tall Jill, Tall Mike, Tall Golf, Tall Chip, etc.

I think this is a fascinating technique and one worth trying.

Memorizing the 9 sounds would be absolutely cake. I could even test myself with creating words and asking what number they would be. I definitely want to research this some more.

There are actually quite a few resources that generate words for you:

In looking over the slides for class tomorrow, I gave the major system a try. To remember the values for hemoglobin for men and women, I came up with: Men: Tear Tequila and Women: Denim Dilemma. Tear is 14 and tequila is 17.5. Denim is 12.3 and dilemma is 15.3. Oh man. It’s so stupid but it’s already working. Do you know how long it would take to memorize those numbers alone? Probably days, especially because they have decimals.

Can You Have Too Many Mnemonics?

You might be skeptical of all of the ridiculousness of these memory techniques. Is this even learning at this point? Can you have too many mnemonics that you don’t even remember the actual information anymore? The answer to this question is a resounding no. If I don’t have some sort of harebrained, humorous way to remember something, I have a much lower chance to remember it.

If at least one exam question doesn’t make me laugh out loud because of some absurd conversation I had about a topic, I’m not trying hard enough. Actually, I’m probably trying too hard and taking things a little bit too seriously.

I see mnemonics like shortcuts on your desktop. Sure they take up more memory, but they are kilobytes to the megabytes and gigabytes they lead to. Efficiency has an upfront cost but saves time and reduces errors in the long run.

Anyway, that’s it for now. Happy 2024! Catch you in the next one.

Looking Back: One Semester of PA School

After each academic milestone I hit, I do two things: I listen to Explosions In The Sky’s 12 minute, “With Tired Eyes, Tired Minds, Tired Souls, We Slept” and I write. The song itself is instrumental but the title is enough to capture the feeling of finishing my first semester of PA school.

So what was it like going back to school at 34? What worked? What didn’t? Did I fulfill my goal of not missing an hour of sleep? Why was the final night of finals a highlight of my entire semester? Let’s talk.

What Worked

It’s an interesting feeling for sure: to feel “done” yet know this is just the beginning. I know Winter Break is going to fly by at lightspeed and I’ll be right back at it again soon. I think back to my time in my accelerated post-bac, feeling completely overwhelmed with organic chemistry thinking to myself, “I can’t imagine anything more challenging than this.” I’m thankful for my post-bac which gave me the mettle and grit I’ve employed this semester. The first four months of PA school were certainly challenging, but so very possible.

I spent a lot of time before PA school just thinking about the meta of learning. In fact that was the subject of some of my very first blogs. What even is studying? I learned that you need sleep for neurons to grow and solidify. I stumbled upon this Wikipedia page and learned about the importance of things like Brain-derived neurotrophic factor (BDNF). I learned about the Feynman Technique, the idea of taking complex topics and putting them into simple terms. And probably most importantly, I discovered the Memory Palace technique and sort of retro-fitted that into Google Docs Tables. The one piece of advice that I didn’t follow is handwriting my notes. As much as the research suggests that handwriting is better, typing just works better for me.

During school I stumbled upon a lot of little discoveries. It can be uncomfortable to study with other people because you feel like a dope, but you learn so much by surrounding yourself with people who are better than you at things. If you’re the smartest person in the room, you’ll never grow. Feeling stupid is the first step of feeling smart. You can hit a flashcard until your eyes bleed but hearing it once from a classmate sticks instantly.

I also tried my best to turn studying into a game, something to look forward to. I use a Nintendo Switch controller and blast music while I run through Anki. I try my best to translate PowerPoint slides into a story, typing out a stream of consciousness filled with jokes, memes, and absurd mnemonics. If I don’t make it fun, I can’t do it. I think a big mistake in academics is to take it much too seriously. Speaking of Anki, I really can’t stress how much of a game changer it is. It weeds out what you already know and makes you focus on harder content. It saves so. much. time.

I learned quickly that I don’t need to learn and memorize every single slide to succeed. Also, perfection is not sustainable and should not be a goal. You have to be happy with a 90 and be ecstatic with an 80 on an extremely hard test. Don’t beat yourself up if you fail an exam; just make sure you course correct for the future. I’ll take a 90 and a full night’s sleep over a 100 and an all-nighter, every single time. Don’t get angry because a question was written ambiguously. Learning to let go is so important. If your professor says to avoid the weeds, get out of there. If they reiterate time and time again that losing sleep is detrimental, then go to sleep. If they say focus on the new content for finals, then focus on the new stuff! The person who knows what’s best for you is rarely yourself.

Let’s talk about finals week.

Finals Week: The Lows

Finals week was tough. We had 6 cumulative exams and 2 practicals. It’s so much information, that you just become numb to it all. The most important offense to the invasion of information is simply time. If you put the time in, you’ll be okay. Just make sure you don’t lose any sleep!

The first final was our bread and butter 8-credit class; a four hour, 230 question exam. I spend the majority of my time working on that class so I felt fine and appreciated that it was up first. The second exam, History & Physical, is more about the practical part of medicine. I felt okay for that one too. The remaining 6 exams, however, I felt not so good. It’s really hard to forecast and balance out your time for 8 different classes.

After the third exam Tuesday afternoon, I returned to a home-base campus conference room where a group of us were studying. Even four months in, you still can’t help but compare yourself to your peers. It stings when someone explains a concept so matter of factly when you’re still struggling; you constantly feel like you know so little. And even the things you “know” do you really understand? I woke up the next morning and just felt deflated. I had poured everything I had into the first three exams and I wasn’t sure I had anything left.

I think Wednesday was the closest thing I had to a mental breakdown all semester. I wondered if I had what it took to be an ER PA one day or would I have to settle for something I was less interested in. Would I even get that far? I grappled with the struggle of trying to fit in as an older student. I had one of those moments where you just open the door to every doubt and insecurity that exists.

An hour or so later I headed to campus, still in a funk. Wednesday was a “break” of sorts as it had two practicals, one which was an SP or “Standardized Patient” encounter with a live patient, and the other which was an anatomy practical with a handful of… not so live patients. I enjoy the former quite a bit. After staring at PowerPoint slides for an eternity, it’s nice to interact with a human being.

After the SP encounter I headed to the anatomy practical. As grateful as I am to get the opportunity to study in an anatomy lab, it’s my least favorite part of my studies. There’s something so raw and visceral about that experience; it’s a stark reminder that medicine is gruesome and that life is temporary. The practical is timed and everyone is guarding their clipboards as to say “Yea, I know which gluteal artery that is. Maybe study a little harder next time.” It’s a torture chamber of anxious energy. As I continued around the room approaching a pinned structure, I leaned forward to get a closer look. I notably shrugged and chuckled, indicating I had no idea what structure I was looking at. My fellow classmate laughed as well as to say “Yea dude, I have no idea either.” It was a nice moment of camaraderie and levity, especially as I banged my head into the lamp that was shining onto what I think was the remnants of a piriformis muscle. It’s nice to smile and laugh, especially when you’re hopelessly overwhelmed and stressed.

Finals Week: The Highs

And then all of a sudden it was Thursday evening, the night before the final final: Anatomy.

So anatomy lab is its own class. There’s an entirely different lecture-based class on anatomy which was the subject of this final. It was cumulative (like every final), an exam on literally the entire human body. Every single nerve, muscle, blood vessel, bone, lymph vessel, and associated “Clinical Pearl” was fair game. Okay, it’s not as bad as it sounds. Sixty percent of the exam was on new material (the head and neck), so focusing there and then praying you remember some of the old stuff sounded like a solid strategy (and it was).

Luckily I had started grinding anatomy Anki the week before, mindlessly clicking through the flashcards I had made in class weeks ago. Usually dinner for me was reheated meal-prep and an episode of Workaholics, but dinners leading up to finals week became trying to figure out what the heck Scaphocephaly and Phantogeusia were. It sucked; I was taking a break from studying one subject by studying another. I realized, though, that Anki alone wasn’t working for this material so I put them on pause. I decided to start writing out what I call “StoryNotes” for the class. I had worked on these notes a bit every day leading up to Thursday night.

That night I still wasn’t feeling great. I won’t lie, I was worried that I wouldn’t do well the next day. But I always tell myself that I’m just one person and I can only do so much. Is this one exam going to be what stops me from being a great PA one day? No way. Also, I hadn’t lost a single hour of sleep all semester and I wasn’t going to make the final night the first night I lost sleep. That would seriously put a damper on the blog I was planning to write.

Some of the PowerPoint decks I was working with were… a little chaotic: a hodgepodge of wall-to-wall Arial text, Netter pictures with 50 labeled structures, overlaid text boxes, bright yellow font on this slide, bright red on that one, paragraphs of text hiding in the notes section. I can’t imagine it’s easy to put together an Anatomy deck, especially for neurology. It’s a lot.

So I pored over all of the slides. I asked myself: “Okay, they have 30 questions to ask here? Let’s find them. If I was writing this exam, what would I ask?” I translated and organized every slide into what I hoped was clearly understandable language (The Feynman Technique). As Thursday evening rolled on and I was entering into the last of the six decks and the final hours of the night, I realized an increasing number of viewers in my Google Doc (I usually share my notes with the class).

At one point, nearly half the class was in there with me; I had an audience. I received a GroupMe notification and saw that some students had some really nice words (read: some of the nicest compliments I’ve ever received) about the work I was doing. And honestly, that was a complete game changer for me; it didn’t just change my whole week, it changed my entire semester.

I cranked up Judah & the Lion’s “Over My Head” and proceeded into the most frenetic yet focused study sprint of my life. That song is the most fitting for the night before a final: “While I hydrate, caffeinate, medicate, repeat… all these thoughts are an ocean that I’m drowning in, I’m in over my, I’m in over my head.” I was a mad man typing away to the sound of a mandolin and a kick drum.

I think my favorite moment was when I discovered a mnemonic that was given to us for the branches of the External Carotid Artery: “She Always Likes Friends Over Papa, Sister and Mama.” This one… deserved a makeover. This is called an acrostic mnemonic and what I’ve learned is you should make the mnemonic as close as possible to the actual words. S for “Superior Thyroid Artery” is quite a stretch. I converted it to a hybrid acronym: ST-AP FA-LING Out-Of PA, St. Max. I don’t know who St. Max is, but nailing that mnemonic got me a point on the final. Bless up, St. Max.

Another mnemonic I was quite proud of was for Huntingdon’s Disease: It was “I wanna cauDATE Olivia Wilde,” whose character in the TV show House had Huntington’s (and a defect in the Caudate Nucleus causes it). Here’s a collection of resources I created for this exam, along with a photo of me and my messy locker on Wednesday (practical day; I needed three sets of clothes).

And then all of a sudden it was 9PM. There was a great amount I didn’t feel even close to confident in. There were entire prior exams I hadn’t even looked at. But I didn’t care. It was time for bed and not enough sleep would destroy all of the hard work I just poured out. That’s huge; after a focused study session you need a full night’s sleep or it all won’t stick. I powered down and hit the lights.

I woke up briskly at 5AM, shot out of bed, grabbed a coffee and dove right into Anki. What I learned is that after I type out my notes, it multiplies Anki’s effect because I can now anchor this information into my own writing and resources. I can now spatially recall the information I’ve organized. I hit 634 cards that morning. The exam was at 9:30AM. I drew the brachial plexus on a giant post-it on my bathroom wall while I brushed my teeth with the other hand.

I have a tradition that during my commute on the morning of an exam, I blast pop-punk and sing at the top of my lungs. It’s an exhilarating way to get the adrenaline pumping. Whichever song I choose, it’s usually stuck in my head during the entire exam and it helps me focus. This time it was “Try” by The Menzingers which was a rallying anthem for me that week. I sat in the car for a bit and quickly reviewed content from old exams; a load up on short-term memory for old content works pretty well.

I walked in to the classroom and took my seat. Our professor congratulated us on making it this far. This was it. We were 110 questions away from completing the first semester of PA School. I’ll never forget the deep breath I took before the first exam. I took another deep breath and began.

I was grinding through the questions at a steady pace, realizing I had forgotten to look over the entire unit on the abdomen. Oops. And then, boom, there it was: a question on Huntingdon’s Disease and my mnemonic was staring me right in the face. I answered the question instantly and let out a huge grin. Next question.

As the classroom emptied behind me I stuck with my strategy of going back over the exam and reviewing every question; it takes a lot of patience but I think it’s worth it. I finished up, hit submit, and walked out of the room for the last time that semester.

About five people told me they got the Huntington’s question right because of my silly mnemonic.

Two Things

If there are two things you need to succeed in PA school, I’d say it’s a consistent sleep schedule and motivation.

What I’m most proud of this semester is that I didn’t lose a single hour of sleep. For an entire semester, I went to bed by 10PM and woke up at 4:55AM every single morning, including most weekends and including all five days of finals.

I’m not saying this to boast nor am I saying I’m the only one to ever pull this off. Expressing that achievement as a proud moment is important to me. I think I just want people to know that it’s possible. For the record, I’m not some insanely disciplined person who meal preps and exercises all of the time. Despite my age, my life is next to a mess. I’m a very average and flawed human being. I’m not a genius. Never in my life have I been anywhere near the top of my class, including in PA School. To me, I’m just smart enough to know that I’m not crazy smart; I’m smart enough to know that I need to look for some tools and hacks to heighten the intelligence that I do have.

I look at my colleagues in my class and think, “Wow, they must really have their life together.” I have no idea if anyone thinks the same about me. But if they do, it’s certainly not the case. And that makes me feel better because despite outward appearances, we all have stuff going on.

Let’s talk sleep.

I’m fortunate enough to have a 1-bedroom apartment so I never once studied in my bedroom. That room was for sleep and that was it. I think it really helps you disconnect from the day and clear your mind so you can fall asleep. I don’t wake up to a phone alarm, I wake up to my favorite music. I have a different playlist that plays every morning. And it’s fully charged pop-punk we’re talking here. Every morning is like waking up in a new scene of my own movie. Life’s too short to not feel like the Main Character as you start your own day. I set my lamps to slowly turn on around 4:30 AM, the music starts playing at 4:55 AM, and then my annoying phone alarm finally goes off at 5:00AM, which is plugged in outside of my bedroom so I need to leave the room to retrieve it. Charging my phone in another room also means I can’t use it in bed. I think the big piece to this whole thing is that I try to stick to this sleep schedule on the weekends. Waking up at 5AM on Sunday, a day before the week begins, works absolute wonders.

Let’s talk motivation.

Motivation is certainly hard to find and even harder to maintain. For me, I’ve found it in writing study guides. People find the content I create useful. Two students told me they sat down over a glass of wine and watched a YouTube video I created. That’s pretty awesome. So as I study, I can help and teach other people. I’ve found an unlimited source of motivation.

The underlying theme here is that I’d love to teach one day. There’s a science to… science, but there’s also a science to learning and I feel like we vastly overlook the latter.

So that’s my secret. If my way of studying means another student can get another 1-2 hours of sleep, because they don’t have to dig through a deck looking for useful information, or can pick up a couple of points on an exam because of my stupid mnemonics, then I’ll keep doing that for the next two years.

That’s it for now. I’ll see you in the Spring!


100 Days: The Anatomy of the Night Before an Exam

“There are two things that people from Philly love: the Birds, and being weirdly aggressive,” Hot Mulligan singer Tades Sanville explained to the sold out crowd from the stage of Philly’s Fillmore. I was in that crowd and felt lucky to be there. The rigors of PA school have made my favorite hobby of attending shows few and far between. Luckily this one fell on a Friday and I wasn’t going to miss it, even with two brutal exams just on the other side of the weekend. Even at 34 there’s almost nowhere I’d rather be than in a pit full of strangers shoving each other as Heart Attack Man plays “Like a Kennedy,” my #1 song this year according to Spotify Wrapped.

PA school is all about sacrifice. I had to miss out on quite a few shows this semester because I’ve been so busy. There’s really not much time for anything else. I took my 23rd exam just this morning, and that doesn’t count 3 quizzes and 5 practicals this semester. Final exams are in a week and a half. So what have the first 100 days of PA school been like? Let’s talk.

Let’s walk through the anatomy of the night before an exam. This morning’s exam was particularly grueling and my head is still spinning. We call the class CMPP; it’s three classes in one, 8 credits altogether of Clinical Medicine, Pharmacology, and Pathophysiology. It’s the bread and butter and meat and potatoes of PA school. This exam was the beefiest to date, clocking in at nine PowerPoints and 580 slides. The content was entirely GI related and relied on my ability to the tell the difference between Alcoholic Fatty Liver Disease, Alcoholic Hepatitis, Acute Liver Failure, Viral Hepatitis (A through E, mind you), Ischemic Hepatitis, Cirrhosis… and the list goes on. And that’s barely a third of the content! I wrote a 67 page study-guide, went through 621 flashcards, listened to Cram the Pance, rewatched lectures, studied alone, studied as a group, AND recorded over two hours of YouTube videos… for one exam!

I think one of the biggest problems with material like this is that you start to forget what goes where. You memorize entire clinical vignettes… but forget the name of the actual disease process. You recite a triad, but forget the name of it, or what it’s even related to. I know you run a Lille score on day 7 to continue treatment… wait but for what? Which one can have an elevated INR? Wait but which one needs an elevated INR to be called this? I had to spend a lot of time with studying just reminding myself what PowerPoint I was even in and what was the name of what I was studying. It’s hard to put a face to the disease processes you’re studying.

This exam was unique for me because I ran out of study time. Usually my study group will set aside at least an entire night to review, but the night before, there were entire presentations some of us hadn’t even looked at yet. I had gone through 7/9 of them (also, “gone through” does not = master), the exam was in 14 hours, and I was still missing nearly 30% of the entire exam’s content. I ended up skipping a two hour class to make up some time.

Then I had a decision to make… do I go home and just grind Anki, or do I do some group study. I decided to do some group study and go over things I was familiar with. I sat down and a few of us just talked through things, one topic at a time. In the back of my head I was thinking “I shouldn’t be reviewing what I already know.” However, the power of group study continues to show it’s strength. When recalling information on the exam, what’s most memorable, time and time again, are the words of a fellow student. There were multiple nuances that I had overlooked as not important, but other students thought they were important and lo and behold, they were exam questions. It happens every time.

PA school is sifting through hundreds of slides of soil and dirt just looking for something that you think might be valuable. Don’t do it alone. Sometimes one student’s weeds are another student’s treasure.

After the group study, I went home, still with two entire slide decks that were foreign to me. So I made a plan: I’d tackle one at night, and the other the next morning, without losing any sleep in between. I’m determined that losing sleep is the most detrimental thing to my academics. I hadn’t lost an hour yet and wasn’t going to start then. Whatever material I didn’t get to, I didn’t get to. It’s not the end of the world. I did have a brief period of panic, but I took a deep breath and kept grinding.

There were two topics in particular: Primary Sclerosing Cholangitis (PSC), and Primary Biliary Cholangitis (PBC) that I needed to tackle. These two were like a master class in compare and contrast. One is more common in men, the other women. One has negative antibodies, the other positive. One has a buzz word histology finding, the other has a buzzword medication. You don’t hear the word Primary Sclerosing Cholangitis every day so just familiarizing myself with the words in front of me was difficult.

So I made a table, what I call a matrix, comparing and contrasting Primary Sclerosing Cholangitis (PSC) and Primary Biliary Cholangitis (PBC). I made PSC blue (more common in men) and PBC pink (more common in women). I put a big 90s 6-line letter “S” on the left. If you’re in my age bracket and have ever held a #2 pencil, you’ve drawn this. I put a big letter “B” that had a woman’s face in it on the right. And then I just dumped everything that had to do with each in their respective columns; it was either left or right, entirely binary. I think there were at least 7 or 8 questions in total on these topics, and I felt confident for every single one. Every time there was a question, the table would appear in my head. And when I read a buzzword like “Ulcerative Colitis” I could just feel that it belonged on the left, because that’s where I last left that information. That’s where it was literally sitting inside of my brain. And I knew the left side was blue, and had a huge S, so the answer was PSC. Then “T cells” came up. And I knew I had left that on the right side. “Ursodiol?” I left a picture of Ursa Major on the right side, so it’s PBC. Of the bajillion topics on this exam, PSC and PBC were what I spent the least time with, yet I felt the most confident with them. And yea, maybe because I reviewed them not long before the exam, I remembered them more, but I recall almost every facet about both now as I edit this blog now days after the exam. Spatial memory has become such a powerful tool for recall.

One of the funny things with this exam was a question regarding Alcoholic Hepatitis. I made a very elaborate mnemonic story set in the Harry Potter Universe: Mad Eye Moody (Maddrey) & Lilly Potter are setting out to help people with alcoholic hepatitis. Mad Eye is like, hey, Billy Rubin needs some Physical Therapy (Maddrey’s Function measures total bilirubin and PT). Then, McGonagall and five of her clean feline friends (PENT-OXI-FYLLINE, like five clean felines = Pentoxifylline (Trental). Lilly is like, I’m going to come back for book 7 (run a Lille score on day 7).

This med, pentoxifylline, had never been mentioned before, so it had to be a question, or so I thought. Upon reviewing this mnemonic with another student, I realized you could use either pentoxifylline or a steroid. I wrote it out on the white board and made a point of mentioning the steroid. If I hadn’t done that, I would have gotten the answer incorrect, and my entire elaborate mnemonic would have led me astray. Again, group study saved me.

So finals are around the corner. My strategy is just to do what I’ve been doing: transcribe the slide decks into plain language, make mnemonics that make me laugh, use spatial memory and memory palaces where needed, trust Anki, and lean on and rely on the bright minds around me. Am I going to go back and painstakingly review 23 exams-worth of content? No shot, bro. Finals in PA school are a numbers game. Both graduates of the program and my own professors have said to focus on new content, and that’s exactly what I’m going to do. If I don’t get to something, I don’t get to it. It’s not worth panicking or losing sleep over.

That’s it for now. Back to studying for finals. I’ll see you in the next one… after having finished my first semester as a physician assistant student.



What Even Is Learning: Two Weeks To Go

Two weeks until I start PA school. Yikes! Anxious, nervous, excited, terrified… these are just some of the emotions I’m feeling at the moment. I turn 34 next week and start graduate school the week after. The next two years will teach me how to be responsible for the lives and well-being of other people. Sounds simple enough to me.

I think the one thing I’d like to nail down before schools starts is how I’m going to, well, actually learn and study. And one of the big questions is what will I be doing while I’m actually sitting in class. I have class from 8-5 every day with an hour break in between. Now, I know eventually the structure won’t just be lecture; I’ll be in the anatomy lab, learning clinical skills, in the simulation labs etc. So that’s good. Still, that’s a long time to even be sitting down and I think my attention span has been absolutely zapped by technology.

So, what’s the best way to learn and study? Beats me. Does anyone, really?

I came across a video called “The Biggest Myth in Education” by YouTube channel Veritasium. It states that learning styles traditionally have been broken up into four types: visual, auditory, reading/writing, and kinesthetic. Basically the conclusion was… these are all bogus. Everyone learns basically the same way, and the answer is our learning styles are a combination of all of these and in fact, the best way to learn is to use multiple learning approaches.

Before even delving into debunking those learning styles, I found that what works for me is to stand up, grab a marker by a whiteboard, turn on a video camera (or have an audience of fellow students) and do my best to push information outward, rather than focus on cramming it inward.

There’s this idea behind the flipped classroom which, to me, just meant that the student now has to do work before class, in class, and after class. In all of my pre-med studies, I was able to fully prepare for a lecture, one time. In Biology 1, there is one chapter, on viruses, that I was able to read the entire chapter, and go through an entire flashcard deck by the book publisher, before going into the lecture. I think that’s the ultimate, having not only seen the material once, but testing myself on the concepts before hearing the information in lecture format; apparently you learn more from taking tests than any other form of studying .

For most of my studies, lectures have almost been just a thing that exists… at the end of the day the exam is what you need to tackle. Whether or not you find the lecture helpful is up to you, but do you really need it? It appears that most of the learning, which really is just retention to pass an exam, happens outside of the classroom. I think the real benefit of showing up to class is to get to know your professor, a real person, the person who is writing your exam. It’s developing that relationship so you can go to them with questions; is this going to be on the exam or not? Whether you are actually gathering and retaining information from that lecture is another thing. And whether or not you are remembering anything from that exam before you cram your head full of the next exam’s material is another problem entirely.

I made dozens of videos in pre-med, just grinding through topics and trying to quickly turn learning into teaching. The more props, models, etc. I can use, the better. I call it physical learning. I enjoyed recording myself as well, as evidenced in my YouTube channel. It’s not just about turning learning into teaching, it’s about turning teaching into performing. There’s also magic behind, “Hey, I understand this topic right now. Let me capture the magic of what I understand now. When it comes time to study before the test, the best way to refresh your memory is to learn it from a past version of yourself.

The most surprising and powerful study technique I’ve discovered is clearly the Memory Palace. Not only have I used this to memorize the Top 300 Prescribed US Medications, but now the 12 cranial nerves as well, using the Dunder Mifflin layout from The Office. I had been trying to memorize those for years, and committed them to long term memory in 23 minutes. The big question, is how to apply the memory palace to more complex topics. For me, it’s very binary right now. I’m essentially encoding two words + their function/class, but a lot of times I’m getting that from the suffix. The other thing, is I can recall the entire list, from scratch. Using a flashcard is already giving me half of the information, which I don’t think is bad particularly, as long as I go back and do the reverse. But doing an entire recall is much more powerful. I recently made just a simple set of mnemonics for white blood cells. After working on this, I immediately recalled it, and then recalled it the day after. Honestly, I think that’s plenty for an exam. I probably don’t have time for a memory palace so unfortunately I need to rely on short-term memory techniques. If I make videos, though, I can refresh my memory for the long-term!

How would I memorize the steps of Glycolysis, for example, using a memory palace? Well, each step would be planted in a spot. But how would I memorize… the blood vessels of the body, or the symptoms, presentation, medications, etc. for a certain illness? Would an entire room be… pneumonia, and each location would be one of the parameters? I mean, I guess that would work fine. I will see what I can do and report back!

Through all of my research, the ideal study structure would look like this:

  • Wake up at 5AM, hydrate, and get some exercise before you start the day; wait an hour before any caffeine intake.

  • Stick to your sleep schedule religiously, 7 days a week and get 7.5 hours of sleep per night.

  • Preview any information before you encounter it in full form, whether that be reading something, or listening to it in a lecture. This can be as easy as glancing through the slides, reading chapter headings, bolded terms, etc.

  • Read the information on paper when possible.

  • Handwrite notes on paper when possible.

  • As you are writing down key notes, look away from the page and try and recall what you wrote.

  • Sit in the front center of the class.

  • Recall information later in the day.

  • Recall information the day after.

  • Recall information the week after.

  • Teach the material and record your teaching or do it live in front of other students.

  • Test yourself above all other aspects of studying.

  • Interleave with other topics or other activities; if something isn’t sticking or you hit a road block, switch to something entirely different.

  • Study in different areas, alone, and with a group. Mix it up.

  • Use the Pomodoro method and be strict about it.

  • Exercise. I mean just glance at this Wikipedia page.

  • Eat BDNF foods, which stands for brain-derived neurotrophic factor, a protein involved in memory and learning. Berries, dark chocolate, and coffee are some examples.

  • Succeed.

Sounds pretty simple to me ;)

To Write or Type: Revisited

One of the areas I initially started looking into was whether to hand write on paper, tablet, or type notes. In fact, it was the topic of one of my very first blogs. The ultimate conclusion there was that handwriting was superior, but I didn’t necessarily compare pen and paper to pen and tablet.

I follow a TikTok channel run by two Harvard Law students and they posted a video about study tips. The first tip they mention is that you should handwrite your notes at least once (the others are find a good location to study, and get a good night’s sleep). I did some more digging here, especially at looking at the difference between writing on a tablet vs. writing in a notebook. It appears that if you’re going to handwrite, do it in a notebook. The reason is that when you are recalling this information, you will more likely remember the location on the page and size of that information. In a tablet, there is no front of the page, back of the page, etc. Also despite a hefty search function in the GoodNotes app, I forget about documents or folders I created all the time; you could have 1000 nested folders but there is no spatial awareness of scale or size on a computer or tablet. Think 10 gigabytes vs. 10 notebooks on your desk; one is much easier to grasp. The actual size of the information is lost as well with a tablet, as I am constantly zooming in and out, and resizing the window. On paper, you would remember that this topic took up half of a page.

The paper mentioned in the video, titled Paper Notebooks vs. Mobile Devices: Brain Activation Differences During Memory Retrieval was published in Frontiers of Behavioral Neuroscience in March of 2021 by researchers at the University of Tokyo. The PDF is here. The abstract states: “The significant superiority in both accuracy and activations for the Note group suggested that the use of a paper notebook promoted the acquisition of rich encoding information and/or spatial information of real papers and that this information could be utilized as effective retrieval clues, leading to higher activations in these specific regions.”

The paper also mentions retrieval processes and encoding procedures. Because on an exam, it’s all about retrieving; it just depends on how you encoded that information. There is a study I’ve heard a lot about by Mueller and Oppenheimer in 2014 that “...showed that students who took longhand notes performed better on conceptual questions than those who took notes on laptop computers.” That paper, titled The Pen Is Mightier Than the Keyboard: Advantages of Longhand Over Laptop Note Taking is here.

An excerpt from that paper is as follows: “A reasonable explanation for this interesting finding would be that the use of a paper notebook enables users to summarize and reframe information in their own words for encoding, while the use of a laptop tends to encourage them to write down information more passively (i.e., more nearly verbatim). The former processes thus naturally ensure deeper and more solid encoding via the active process of making notes. Moreover, it has been reported that longhand note-taking enhanced the performance of students on recognition of memorized words, even though typing on a computer keyboard allowed for greater speed.”

And that’s the thing, speed doesn’t really matter unless your lecturer is talking at the speed of sound, but then I’d question the purpose of the lecture in the first place. You’re not a court stenographer, you’re a student. I think likely I’ll have slides to annotate. I think I do learn the best by reading a textbook and then going to class, and from what I’ve heard from some students is that there are technically books that go along with each class, but the slides are better because the professor pulls out the pertinent information that you need for the exam. I sort of want to do as little reading as possible and get right to quizzing myself or writing a tutorial. Write, draw, record, and teach more instead of reading or typing. I think the key is that you want to push the information out, not cram it in.

The paper continues: “We hypothesized that the use of a paper notebook, together with longhand note-taking, would enhance both memory encoding and later retrieval processes that could then be investigated at the brain level. More specifically, the utilization of the paper likely enhances the processes of associating episodic (what) and spatial (where) information, especially in the hippocampus, given its well-established role in the integration of what/where/when information.”

What the paper doesn’t say, however, is if I should be taking handwritten notes during class, summarizing information afterward, or if it doesn’t matter.

In terms of comparing typed notes to tablet notes, I reference my typed notes almost exclusively (I haven’t handwritten notes on paper in my pre-med studies but plan on doing it during my physician assistant studies). I rarely go into my GoodNotes files and look for handwritten notes; they are just very messy and not well organized. So I’ve come to the conclusion that I am never handwriting notes on a tablet again, unless I’m in a lab or something.

I also have all of my textbooks on my iPad but might stop doing that. It’s been shown that reading on paper vs. a screen enhances reading comprehension. “Main findings show that students who read texts in print scored significantly better on the reading comprehension test than students who read the texts digitally” sourced from this study. So I should be printing out slides for sure and reading papers books whenever possible.

So that’s it! Just more reasons to break out the pen and paper and understand the limitations of technology.

The Final Five Live

I’m about to finish encoding the final five medications of the ClinCalc Top 300 List using the Memory Palace Technique so I figured I would walk through the process in real time and maybe touch upon how it has evolved since that first 25.

Right now my process is to pick a location that I’m relatively familiar with, or that I can walk to and view. Then I look through the five medications I want to encode and see if any words fit well into an object or scenario of some sort. For example, I placed Sennosides (Senna, Ex-Lax) - Laxative into a portable toilet in my local park. Sometimes the word fits the object like Dorzolamide (Trusopt) - Glaucoma which I encoded into a door. I also encoded Dorzolamide; Timolol (Cosopt), another glaucoma medication into a door in another location. I had encoded Risperidone (Risperdal) - Antipsychotic on the roof of my house so I used roofs in my neighborhood to do the same for Olanzapine (Zyprexa), Lurasidone (Latuda), and Ziprasidone (Geodon). This wasn’t the case for all medications of a similar type, but I was able to link together medications here and there to help me remember.

The location I am picking for the final five medications is a path in my local park that passes a baseball field and leads to a pond. Those five medicines, in order (296-300) are:

  • 296. Sotalol - Betapace - Beta Blocker

  • 297. Potassium Citrate - Urocit K - Urinary pH Modifier for Kidney Stones

  • 298. Melatonin - Hormone - Sleep Aid (Insomnia) / Sedative

  • 299. Isosorbide Dinitrate - Isordil - Nitrate / Antianginal

  • 300. Guanfacine - Intuniv or Tenex - Centrally Acting Adrenergic Agent (Hypertension) - Intuniv is for ADHD

Sotalol is just too similar to soda, so that’s an easy connection. And Betapace is a similar last name to a friend of mine so I’m going to visualize walking down this path and my friend has a cooler full of ice cold soda and is handing me one; it’s been a long journey and I’m thirsty. Sotalol ends in -alol so I know it’s a beta blocker already. The next isn’t as easy; a banana is a good way to visualize anything with potassium in it and we also have citrate which sounds like citrus. And Urocit sounds like sit. So maybe there is a folding camping chair with a banana and an orange on it. And I can picture it soaked in urine. By the way, explicit scenarios are encouraged. Okay, so my friend with soda, and a urine-soaked fruit chair. I move on from this chair and maybe I see my sister on a picnic blanket taking a nap (Melatonin). She’s taken that before so that’s easy to remember. Next I am going to picture a giant stone with a sword in it, maybe two swords (Di-Nitrate), and my picture is being taken. Isosorbide was already on the list and I visualized a camera (a setting of which is ISO). So the camera is Isosorbide and the sword is Isordil. I already know Isosorbides are nitrates. And then last, which I already have memorized just because it’s 300 and so very meaningful, is Guanfacine. I don’t know that I need a specific scenario for that one, just that there is one more after I take the sword out of the stone! Maybe Guanfacine is a dragon I slay with the sword.

The cool thing here is that I didn’t even need to use the baseball field or the pond; I can save those for more medications if I want. Sometimes you can use a pretty small space to fit a lot of information into. For example I’ve encoded 15 medications using my car as a memory palace.

So what I will usually do is type these into a spreadsheet I have to track the mnemonics along with the drug class and any other details I uncover. Then I look away and try to immediately recall it all from memory. I can usually get 75%-100% right away but I may need time to practice spelling and brand new words. After that I write them down a second time, but this time I draw out the scenario. This allows me to better visualize that group of five, in order, and also any particular medication individually. That’s why handwriting is so superior to any other form of note taking. You can visualize the space and size of a piece of information. And if you drew a little picture, it just strengthens the connection even more.

This is what one of those drawings look like, on the back of an index card.

The last 50 or so are on a route I take every morning with my dog. So as I walk I recall them all. So I will do that tomorrow to reinforce these.

I made a preliminary attempt on the first 200 or so and did pretty good. My goal is to nail down the entire list of 300 and then repeat it after 1 day, 7 days, 2 weeks, 1 month, and then 3 months. I think the real magic of this method is that you are using free real estate in your head. You already have a memory of the places you’ve been taking up space in your head. You are just storing more information in the spaces, in the neurons, that already exist around that memory.


Roman Room / Memory Palace Update

Every time I try to write about the Roman Room / Memory Palace, the information becomes obsolete. As of December 22nd, I reached the milestone of memorizing 100 of the ClinCalc Top 300 Drugs of 2020. As of January 15th, I’m at 215 in total memorized! I forecast I’ll be at 300 by the middle of February! The discovery of this memorization technique is by far the most significant academic discovery of my career.

I was able to fit 100 items inside my house, 15 in my car, and 35 in my yard. Once I hit 150, I experimented with reusing locations for the next 10, using the original locations from 1-10. The idea was I could just reuse 150 locations rather than create 150 new ones. I decided to abandon this strategy, as using existing locations was actually slower. It was less fun as well because as I continue the journey to 300, it’s fun to ask “Okay, where am I going next?” I’m now using my neighbor’s houses, placing 5-10 items in each.

The benefit of using a location that I see every day is that my mind just quizzes itself. Every time I take a shower, for example, I’m standing in Insulin Lispro / Humalog, and then I go through the other four medications I have planted in the bathroom. I’m starting to get better at recognizing suffixes as well, such as -ipine for calcium channel blockers, and -sartan for angiotensin II receptor blockers.

The technique is working incredibly well; I’ve already recalled several medications in real time in the ER to help nurses or patients. It’s made the project worth it already.

There was a minor hiccup because I was using the 2019 list and the 2020 list just launched and the orders changed, but I’ve created a hybrid list of sorts and can now match the 2020 list. I won’t lie, the process is definitely time consuming, but I mean, memorizing anything is time consuming. A lot of the lists and things I’ve memorized in the past rely on groups, for example to memorize the presidents I really need to list all of them and see where the holes are. I’ve built mnemonics into “runs” of presidents. With the memory palace, however, each individual medication can be recalled on its own within seconds. It’s pretty powerful stuff.

What I noticed also is that the mnemonics are like a scaffolding and fade away over time. One word instantly transports me to a location and the other word is sitting there waiting for me. The crazy and insane mnemonics die off after a while, which is fine. As that scaffolding folds, I can feel the information being cemented into my long-term memory.

The other thing I did, was to create a Quizlet. As I master another 5-10 medications, I add them to the Quizlet, so I can study the list out of order. The other day at work I asked a friend to quiz me. As I recited a list of 150 from memory, some of the nearby nurses took notice and said they were quite impressed. This actually inspired me to push toward 300. The other day, I ran through the deck, which then had 200, and got nearly all of them. What was especially cool was at 199, I could actually cycle through the entire memory palace and I knew that 200 was Sitagliptin / Januvia because I hadn’t done that one yet. That was a cool moment.

I’m not the first to attempt this. I actually found a video of a pharmacy student talking about how she learned the Top 300. Her strategy was just to use flashcards… rote memorization. What I’m learning is that flashcards are really only for short term memory. You need to intentionally store information somewhere. Flashcards just help with recall of that information.

I’m also learning a ton about the health of the entire country; this list is a snapshot, well probably more like a collage of the health of the entire population. My observations are as follows:

  • Our blood pressure is through the roof

  • We’re all very sad and anxious

  • A lot of us have asthma

  • A lot of us have diabetes

I say this because almost every other medication is to reduce blood pressure in some way, either as an ACE inhibitor (Lisinopril), calcium channel blocker (Amlodipine, Diltiazem, Nifedipine), diuretic (HCT, Furosemide), Angiotensin II receptor blocker (Losartan, Valsartan, Irbesartan), or a beta blocker (Metoprolol, Carvedolol, Labetalol). There are some other interesting ones like Clonidine which affects the nervous system and even combinations like HCT+ Lisinopril (Zestoretic) and HCT+Losartan (Hyzaar).

There are also too many antidepressants to count including SSRIs, SNRIs, NDRIs, and SARIs.

After the first 150, new medications started to emerge. New to the list are glaucoma medications (Timolol / Blocadren) medications for Crohn’s Disease (Mesalamine / Pentasa) and antifungals (Ketoconazole / Nizoral) to name a few.

So the goal now is to push to 300. I’m also trying to expand a bit, classifying the diuretics by type (loop, thiazide) for example or the antibiotics (macrolide, beta-lactam, etc.) or the insulins (fast-acting, long-acting). I’ll make a post when I hit 300!

So This Is The New Year

So that’s a wrap for 2022, the year that held the lowest point of my life, and potentially the highest point of my life. The lowest being the sudden loss of my father, and the highest being my acceptance into PA school. I don’t want to dwell too much on the pain that was most of this year. I do want to focus on what I’m walking away with. I’m walking away with fond memories of my father and all of the time we did get to spend together, especially over the past couple years since I moved back home. My acceptance of the loss of him his complicated and a constant rollercoaster that I will be processing for the rest of my life.

Life just isn’t the same, and not just because he’s not around. Life feels so incredibly temporary and fragile now. I realized I was taking absolutely everything for granted. I was very ignorant and truly in a clueless bliss. The other side of losing a loved one is terrifying, knowing that life can exist one second and cease existing another, or even worse be suspended in some sort of minimally conscious state. Life can truly be horrifying. I struggled desperately to find some sort of positive, some sort of lesson following this tragedy. And I think the best I could come up with is that this was some sort of dark wake-up call to make sure I don’t waste my life. Life and awareness is so incredibly rare and valuable. I have so many existential moments where I wonder what the purpose of life is. My own awareness, thought, the music I enjoy, the purpose of it all. I’m still coming to terms with it all.

This year was still full of some positives. I feel like for the first time in my life I finally have a substantial social life which I truly treasure. Working in an emergency room is a great chance for an introvert to find his place. This year I was accepted into physician assistant school. I honestly couldn’t be more excited to start in August. It will be bittersweet; I’ll be trading my first solid social life for a life as a student, but I know in that a new social life will be born. And that’s not to say I can’t keep my current social life intact. This time next year, my life will be entirely different from so many perspectives. I’ll have my own place to live again; I’ll be living in another county for the first time in… 25 years? I’ll be a quarter of the way through a master’s degree to practice medicine. Wow.

I’ve given a lot of thought to how I want to spend the next 7 months before school starts. I still want to work a bit and save up some money. This year I finished a side-hustle career of being a wedding photographer for nearly 7 years; what a ride that was. Not doing weddings definitely opened up some bandwidth for me which I am looking forward to. I want to spend my time doing independent study. I’ve been independently studying pharmacology, biochemistry, organic chemistry, and anatomy and physiology, and plan to continue doing that. This spring I plan to have a semester of study all to myself.

I also want to spend time having fun. I just bought a new bass guitar, returning to my roots of the first musical instrument I picked up. I plan on playing video games. I plan on listening to music and going to concerts. I plan on spending time with friends. And I plan on doing some type of travel but I haven’t yet decided yet.

My dating life has been… non existent and to be honest I’m completely fine with that. Life can be lonely, but there are so many benefits to being single and I am reaping all of those. For all of the time to be my own is truly a blessing. I think there will be a benefit to going away to school single. I want every single chance to excel in my studies. With that said… if my soulmate finds her way to me in the next seven months, then so be it. I’m ready to meet her.

I’ve been going to the gym more consistently than ever before and I want to keep that up to and through school since exercise is such an important part of keeping a sharp mind. A huge thanks to the movie theater cardio room at Edge Fitness for allowing me to rock out to pop punk music on the elliptical. I also plan on making some social changes, and trying my best to be more grateful, spend my time more purposefully, and even gossip and judge people less. Overall, I just want to strive to be a better person in all aspects of my life.

So that’s really it. I’m glad that this year is finally behind me and my family. And I hope and pray that we can move forward and grow and flourish over the next year. See you in the next one.

The Roman Room

So I wrote a blog recently all about memory. And the most prominent memory technique that I’ve found was the Memory Palace / Method of Loci / Roman Room. Every memory champion uses it so I had to see for myself. Over the past six months or so, I’ve created a Quizlet deck on pharmacology. I currently work as an ER tech and I’m constantly hearing medications so I when I hear a new one, I add it to the deck. I’ll go through the flashcards occasionally, trying to come up with some mnemonics here and there. But after a while, nothing was really sticking; I didn’t really have a system. I then came across this, a list of the 300 top prescribed drugs in the US in 2019. Well, that would certainly be a good list to become familiar with, I thought. And familiar with it I have become.

So okay, I wanted to give the Memory Palace a try. So I discovered Ron White, a national memory champion. He outlines the strategy here. So I gave it a try… and it worked. It actually worked! I memorized the top 25 most prescribed medications, in a single day. And not just the generic names in order, but their trade names, and their class. I was just as shocked as you are. So I pushed it a bit further, and now I’m up to 50, within a week. I used rooms in my house and the objects within, just as Ron had suggested. I picked 5 objects per room, and placed 25 on my first floor, and 25 in my basement. My plan is to do 25 in the upstairs and the remaining 25 of the top 100 outside. Here are some examples.

As I enter my house and go to the left, there is the door to our front room. And the first medication I had to memorize was Atorvastatin (Lipitor), which is a statin (lowers LDL cholesterol). So I pictured giving A Tour where I wanted those I’m touring to be quiet and button their Lips, and I was touring around Stannis from Game of Thrones. Next I moved to my TV where I pictured my friend (who takes thyroid medicine) wearing Levy jeans, playing a synthesizer. And for that I remember Levothyroxine (Synthroid), which is a thyroid medication. So that’s the idea there. Next was my sister Lisa cleaning with lemon zest, an ace playing card. Lisinopril (Zestril), which is an ACE inhibitor. So yes, I did this 50 times, with objects throughout my house like couches, printers, the fridge, toilets, and a mounted deer head.

The other day I was in triage at the ER where I work and as I was taking a patient’s vitals, the nurse was going through their medications. “Do you take Lexapro?” she asked. “Umm… what’s another name for that?” he replied. My heart started beating out of my chest; this was my chance to shine. I immediately thought of Lex from Survivor, in front of my microwave, nuking a bowl of escape keys. Of course, I said none of this out loud. Oh! “Escitalopram?” I replied. “Yes, that’s it!” the patient said. Oh man you should have seen the smile on my face. I also picture Lex as being depressed because he was betrayed by Boston Rob; Lexapro is an antidepressant / SSRI. I had learned that mnemonic just days ago and to be able to use it in real time was amazing.

My progress has definitely slowed a bit as I encounter medication names I’ve never heard of, like methylphenidate, or allopurinol and similar sounding names, like Coreg, Zocor (my friend Cory is my reminder for Zocor, so I have to be careful not to think of Coreg, where my reminder is an egg), Zoloft, Zolpidem, etc. I’ve also found that remembering the function is a bit harder; some I know just because of their name, like the statins. However, if I could do the first 50 in a week, I plan to do the next 50. Memorizing the top 100 medications prescribed in the US… imagine.

The question now is, what’s the limit? And my house is only so big. Do I “restart” the walkthrough for the second 100? Or do I have to pick another walkthrough? Do I pick 5 different items in each room now, or maybe start the walkthrough from a different room? The only other familiar locations I can think of is a walk around my block, a walk through the hospital, my commute to work, and my college campus. Okay, I guess that’s plenty to work with. I’m really excited to push this to the limit.

It’s August 25th now, a couple of weeks since I started this, and I have the first 75 committed to memory. I actually filmed myself walking around my house, recalling each medication as I encountered the object. I was quite amazed. I learned that typing out the mnemonic, then recalling it and writing it down helps the mnemonic stick. Through random times in the day I’ll either recall some, or jot them down. I had to do some “micro-corrections” to iron out some details, like keeping the antidepressants straight: SSRI vs. SARI vs. NDRI, vs. SNRI, by adding an additional image/mnemonic to my scenario, but they are sticking. I estimated that I can get to 150 by finishing the rest of my house, using my entire yard, and then placing 5 medications each in my neighbors’ houses as I walk down the street. 75 down. 75 to go!

On Being a PA

Paul Kubin, MS, MFT, PA-C, writing for Inside PA Training, 5 Reasons a Physician Assistant Career is Wrong for You:

Your interest in medicine is more about the science than about caring for patients. Don’t get me wrong – as a PA, you’ll need to know and work with plenty of science.  And PAs aren’t the only medical providers who care about their patients.  But as a PA, your patients are a larger focus.  Your communication with them and your ability to educate and counsel them about their health and treatment are your “magic bullets,” not your specialized knowledge of biochemical pathways or fluid dynamics.

This speaks to me. To be honest, I’m not the biggest fan of science. I wasn’t a science geek in grade school. I didn’t participate in the science fair. Don’t get me wrong: I respect science and can enjoy it. I actually look forward to learning biology and chemistry after having worked in healthcare for nearly ten years. I can finally see the application of it all. My end result though is exactly what Paul is talking about above. I’m all about people. And I’ve always enjoyed teaching; I’m just not knowledgeable enough on many subjects to get the ability to teach often. I’ve always enjoyed translating ideas into layman’s terms. I’ve always felt I’ve done a good job at not assuming any knowledge of an end user. Back when first learned Adobe Photoshop, I created a tutorial aptly titled So Easy a Caveman Can Do It. I had many comments on how easy it was to follow. You can still view it on my Deviant Art page 12 years later.

Stephen Pasquini, PA-C, writing for The Physician Assistant Life:

I honestly believe you can be better at compassion when you are more grounded. Having a life outside of work justifies life, it makes for a happy person which translates to better patient care.

I realized after quite a bit of soul-searching that I never really needed to be a Doctor, but I wanted to feel like one.

If you are on this journey to being a health care provider, just know that life exists beyond MD. It is a beautiful life, and it has fulfilled every single one of my dreams of being an excellent health care provider.

“PA is the sweet spot! Where life and medicine meet in the middle.”
— Stephen Pasquini, PA-C

Why PA School?

I’ve found myself in two situations in life where a career I’d never thought once about was introduced to me. Around 2010, I joined the Philadelphia Police Explorers, a youth program run by the Philadelphia Police Department, with assistance of the US Army, that taught discipline and hands on training. It was one of the most rewarding and enjoyable years of my life. Unfortunately, I aged out of the program because I joined when I was 20; I often wonder if my career path would have changed had I been allowed to continue. Through the program, we were trained by US Army drill sergeants, Philly police, and PA state police, to name a few. We learned how to conduct traffic stops, investigate and deescalate domestic disputes, handle firearms, how to march and drill, and much more. I had never seen the allure of a career in the military or law enforcement, but that mindset was quickly changed. I found all of it fascinating: marching as a unit, learning how to detain a suspect, entering into a building to find a criminal (actor) who was hiding inside. It was thrilling. The camaraderie, brotherhood, and sisterhood that I had with my fellow cadets was outstanding. I decided not to pursue such a career, but it’s always been in the back of mind even ten years later.

The second was in 2014 when I found myself in charge of the Undergraduate Medical Education (UGME) Program at Abington - Jefferson Health. I managed orientations for hundreds of medical and physician assistant students. Never once in my life had I considered a career in any aspect of medicine but now I was starting to see the appeal. I also worked alongside the Graduate Medical Education (GME) office. We had tons of foreign medical graduates coming to the US for the first time to complete their residencies. It was pretty inspiring to see. There were so many types of people coming through our doors. From the new batch of 50 residents per year to the 40 or so students per month that I was orienting, everyone had a story. They were all different ages. Many were married and had families. Many were older, non-traditional students who were non-science majors in undergrad. To add to this, I also assisted with Abington’s pre-med program. So from a college junior to a fifth year surgery resident, I was seeing the entire medical school journey unfold in front of me. There are medical students I’ve oriented who are now chief residents at the hospital, and others are practicing physicians.

In 2015, a close mentor of mine, one of the internal medicine physicians had said to me, “You know, you would make a great physician.” For the past few years people have been complimenting me on my people and customer service skills. And not just anyone; the former CEO of the hospital told me this in 2018. I’m not trying to sound pompous here; but when people like that compliment you, it’s incredibly meaningful. It’s these skills that landed me a job as a patient advocate in an emergency room. And that’s where I’ve been the past year and a half. I’ve been in hospital rooms. I’ve watched surgeries. I’ve shadowed physicians in the areas of family medicine, OB/GYN & internal medicine, even witnessed an autopsy; never though did one of those experiences make me say “Hey, THIS is what I want to do.” That all changed once I started working in an emergency room.

The camaraderie I found in the ER reminded me of my time in the Police Explorers. There was this way everyone blended into one big team; everyone had each other’s backs. The “always on” atmosphere of the ER is electric. Ever since it opened over 100 years ago, there has been a constant flow of patients. First responders, ambulances, traumas, it was all really exciting. I enjoyed spending time there and getting to know the staff but quickly I realized I wanted more. I wanted to be on the clinical side of things. As a patient advocate, you can only do so much. I realized I wanted to learn how to heal patients directly. The ER employed around 25 physician assistants. I was able to watch closely at how they worked, how they interacted with physicians and nurses. It seemed perfect for what I was looking for. They had ownership for their patients, but they weren’t at the top of of the ladder. They sat at a nice place in the hierarchy which I could appreciate.

I had never even heard of a physician assistant until 2014. It seemed like a pretty sweet gig. Two years of schooling to then have the freedom to go into whichever specialty that would take you. PA just sounded cool. I like interesting jobs that fit into special roles, and that seemed to be exactly what a PA was. It was a little bit mysterious. What exactly do they do?

Then there is the question… why not a physician? People have asked me that. I’ve heard of tales of PA students switching to medical school. I just can’t see myself as a doctor. I think visualization is an important part of life. There’s a certain level of pomp, glamour and stature that comes with being a physician and nothing about that seems appealing to me. Don’t get me wrong, I revere and respect physicians immensely. I often see though how intermingled life and career can become and that’s not something I’m looking for. I want to work to live, not live to work.

I like the idea of being a healer, but something a bit more involved than a nurse. I like the mechanics of making diagnoses and figuring out what is causing a patient’s problems. Waiting for lab results or radiology results to come back to find out what to do next is very exciting. I also like the “generalist / jack of all trades, master of none” dynamic that comes with emergency medicine or primary care. I can’t see myself getting into a specialty. But who knows? Life is full of surprises.