Busting Myths of Didactic Year in Physician Assistant School

There are multiple sayings, myths, and tropes that are associated with PA school so I wanted to unpack them a bit. All of what I’m about to share should be taken with a grain of salt. These observations are from my experience through didactic year of PA school as a 35 year old second-career student. Some of these tips might appear against the grain but that’s intentional. This is a list to make you rethink what it means to be a student. Your mileage may vary.

So without further adieu, and in no particular order:

You should go over what you learned in class when you get home.

So there’s this idea of being in class all day and then getting home and reviewing / studying everything you learned to help make it stick. On the worst days, you’re in class from 8-5. So what, you’re supposed to go home after and review an entire day’s worth of content? What does it even mean to “review?” Read it? Quiz yourself? Flashcards? You likely had 4-5 classes of differing, sometimes related, content. You’re supposed to go over all of it, regardless of when the next exam is?

Here’s my take. Likely you always have an exam coming up in the next couple of days, often multiple. So in my opinion your time is better spent on that content. Focus on short-term testable material that’s going to keep your GPA afloat. Besides, unless you’re planning to then review that same information from the day again at spaced intervals, it might not be worth your time to review content from earlier in the day because you’re probably going to forget most of it if the exam is more than seven days away. I think this is really critical to understand; there’s an illusion to feeling “caught up.”

Remember that you’re constantly battling the forgetting curve and when you start to fight that uphill battle matters. It might feel like you’re staying ahead, but you’re going to have to revisit information regardless. You might think, “Oh, but I’ll fall behind.” Well, welcome to PA School! You’re always behind, never catch up, and then you graduate. So in some instances, it’s actually to your benefit to delay when you start studying for an exam to maximize your memory and fight the forgetting curve. And when I say delay, I mean prioritize testable material that’s coming up sooner instead. For my big eight credit class, I would try to study a little bit every day, regardless of when the exam was, but it wasn’t in line with the class schedule. It was just my own personal pace which would then ramp up as the exam got closer. And a lot of that time I spent was just outlining, organizing concepts into tables, and creating Anki flashcards. That’s the stuff you want to have done ahead of time so that when it comes time for that crunch 3-5 days before a massive exam, you have plenty of filtered content already to study from.

What you do in class also matters. For me, what was helpful in class was to be working and doing something active; not just passively listening and jotting down notes. That way I didn’t get home and felt like I had to get started. Read more about that here (Tip #3): https://anthonysorendino.com/blog/2024/8/27/p1-p2-amp-the-top-5-tips-for-surviving-didactic-year

Final verdict: If you have the time to go over content daily, certainly go for it, but plan to revisit the information again at spaced intervals. Your immediate time might be better spent studying for exams you have within the next few days. 

You should outline the PowerPoints before class.

I think outlines are valuable. Most of the time, however, I would outline in class because I simply didn’t have time (or energy) to do it beforehand. It’s important to not get slide fatigue. A quantity of 50, 100, 200 slides, etc. doesn’t really tell you much. You need to know what’s inside of them (I would actually use PowerPoint’s word count feature to see how dense the deck was). The third image below shows the deck spread for our women’s health exam. The first number in parentheses is the slide count with the following number being the amount of words within. Included are comparisons to some famous books… for fun.

So make yourself a table of contents. How many “characters/diseases” are here? How many families of diseases/how do they relate? How can you organize all of this? Don’t just make an exact outline; make it work for you and organize it! Information is often presented in a linear fashion, with no real comparison or contrast to surrounding topics. 

An outline for me looked like the first image below which I would then turn into a spatially-oriented table (second image) of highlights:

This is why tables/matrices are so valuable as you flesh out your notes. It’s about transforming a linear outline like the above into something more visual. The most important benefit of using a table like this is that your brain will remember where the information was. Oh! I know I wrote Group A Strep on the upper right and that was Guttate Psoriasis. Done.

The reason they say writing with pen and paper is better is misunderstood. It’s not because it slows you down, it’s because you can’t pinch to zoom on a piece of paper. Your brain remembers the scale and weight of information on a physical piece of media. You can zoom into a Google Doc table, but upper right will always be upper right; it’s a digital format that retains the benefit from a printed page. See the section “Enter The Matrix” here: https://anthonysorendino.com/blog/2024/1/1/studying-pa-school-the-tools-of-the-tradein

Final verdict: It’s good to get a glance at what’s upcoming and reorganize the content to your liking. Use tables!

Most students study 4-5 hours after class.

The “time” you spend studying isn’t a good metric at all; it’s how you study and whether it was focused or full of distractions. I think giving students time-based study goals can actually be detrimental because it traps students into thinking longer is better and that they should be staying up later and sacrificing sleep to hit an arbitrary benchmark. Two hours of laser-focused, spaced repetition, spatial-based memory studying beats 4-5 hours of unfocused, passive, interrupted studying every time. I’d also argue that the last thing your brain and body want to do after being in class all day is to study/learn even more. Efficiency of your time is important. How much are you really going to retain when you’re exhausted? I’d recommend waking up early and doing some solid studying before you even get to school. This allows you to take it easier when you get home and actually unwind and recharge your batteries so that you can get a full night’s sleep. I would try to study from 5AM-7AM every morning, seven days a week. When most of your family and friends are still sleeping, you’re not getting texts, you have no new Instagram messages coming in, etc., It’s much easier to lock in during the peaceful early morning hours.

I truly believe that how you study is the biggest oversight in academics because it’s simply not taught. Here’s the process I came up with: https://anthonysorendino.com/blog/2024/6/5/summer-semester-amp-the-problem-with-memorization-in-pa-school

Final verdict: Never measure your progress by time. “I spent 20 hours studying.” Okay, 20 hours studying…. how? Studying what? Quality beats quantity every time.

You have to lose sleep / pull all-nighters.

This one is easier said than done but it’s possible to never sacrifice sleep during your didactic year. Probably my greatest achievement in didactic year was that I was able to get a full night’s sleep for an entire year, including all three weeks of finals. Not a single all-nighter. Not a single late night. Never once did I have more than one cup of coffee per day. Rarely do I flex, but this is my nerdiest weird flex and I’m proud of it. My sacrifice in humility here is worth it to show you that it’s possible. My goal here isn’t to gloat, it’s to inspire. And for the record, I’m no savant. I’ve always been a pretty average student from grade school into undergrad. I was never an honor student, in a gifted class, nor have I ever won an academic achievement award. So if I can do it, so can you.

It’s not rocket science. Going into an exam on little sleep weakens and dilutes all of the hard work you did earlier that day and that week. It’s pretty well documented that quality sleep helps strengthen and build neurons overnight. Sure your all-nighter might have yielded you a passing score, but at what cost?

It’s important to note that sometimes lack of sleep is a deliberate choice and that’s okay. Maybe you had an important family event or a concert the night before an exam. Maybe it was your birthday last night. Striking a work-life balance comes with a price; you just have to decide on a budget. It’s certainly preferable to have a social life in PA school for your general well-being. I’m 35 and live alone with no children. My social life is slightly different than a 22 year old college student or a student supporting a family. Self awareness of the author giving you all of this advice matters; nothing I’m offering here is a one-size-fits-all approach. I’m fortunate for my situation, but I still think with discipline it’s possible to maintain a steady sleep schedule no matter what your situation is. It’s my #1 tip for surviving didactic year: https://anthonysorendino.com/blog/2024/8/27/p1-p2-amp-the-top-5-tips-for-surviving-didactic-year

Final verdict: It’s entirely possible to maintain a consistent and healthy sleep schedule in PA school and I believe sleep should be your #1 priority. 

PA School is like drinking from a fire hose with a straw.

Drinking from a fire hose with a straw means that inevitably most of the water is going to go… I don’t know, on the street and into the sewers, instead of into your straw. I always thought of this metaphor as “Okay, I drank as much as I could, I guess that’s good enough.” But the problem is, you need most of the water that spilled out onto the street so you have to get down and dirty and go sewer diving. I don’t know that there is a true metaphor for PA School. It’s sort of like juggling fruit and you have to pick and choose what you want to add into your juggle. A banana? Nah. An orange? Sure, I’ll take that. It’s about sacrifice of content that you don’t think is that important and understanding your limits. You have to let some fruit go and splatter on the pavement. Juggle enough fruit for an exam, finish your routine, and then start a new juggle. And often you need to split your focus and juggle with both hands and sometimes a foot.

Final verdict: This saying simply means “PA school is hard” and really isn’t useful. You already know it’s hard. 

PA School is all memorization / regurgitation onto an exam.

This one honestly isn’t far from the truth, but that’s far from a bad thing. I spent most of my later blog posts talking about memory so I won’t repeat everything here. Read more here: https://anthonysorendino.com/blog/2024/6/5/summer-semester-amp-the-problem-with-memorization-in-pa-school I think it’s important to trust the process. The PANCE and Arc-PA have created a giant PA-C creating machine, and you’re a part of that and you have to buckle up and enjoy the ride. You’re not just a student, you’re also a paying customer but in a business model that works.

Over time, the constant smattering of information means that things will begin to stick. You won’t necessarily need mnemonics or charts; you’ll just know it. Minutes after the exam, you start to forget information at an alarming rate. At times, you might not feel like you’re learning much at all. This is all okay. This is normal. Trust the PANCE rates of your program. Trust the numbers. Trust the process! Also, keep in mind that most of your training as a PA is going to depend on your specialty and is going to happen on the job, just like any other job. Your #1 goal is to simply get to that point and pass your exams. 

Final verdict: Mostly true, but there’s nothing wrong with that. Capitalizing on memory techniques is one of the most understated “hacks” of PA school.

Don’t triage your studying.

To advise future healthcare providers not to triage was always interesting to me as triaging is the lifeblood of an emergency room, the front door of every hospital. You absolutely should triage and play the numbers. See tip #4: https://anthonysorendino.com/blog/2024/8/27/p1-p2-amp-the-top-5-tips-for-surviving-didactic-year

Be okay not studying as much for the quiz tomorrow in the 1 credit class so that you can study more for the exam in the 4 credit class three days from now. Be okay not being perfect. You’re not going to be able to put a triage “green tag” on every single exam. Sometimes you have to be happy with a yellow and keep moving. Survive any way that you can and constantly re-prioritize based on what’s coming up in the next few days.

Final verdict: Prioritizing and triaging is an important skill in PA school and in life in general. Be okay making sacrifices and playing the numbers.

You should make your own study guides.

As someone who made study guides most of his personality in the first year, this is a spicy one. I think the actual value you get from the process of creating a study guide itself is over-exaggerated. It’s the actual “studying,” the spaced repetition, the free-recall, the deep-dive, the grind, the using of said study-guide where you get the full benefit and start retaining information. I’d make 100+ page study guides with accompanying videos but still needed to “study” it to retain information. The creation process only got me maybe 15% of the way there. It’s not the short-term value of creating a study guide, but actually its long-term use that makes creating your own content a good idea. More on that in a bit.

But should you use other students’ resources? I rarely used anyone else’s study materials for a few reasons. I was already putting so much effort into my own study materials, not just from a content perspective, but from a formatting perspective. I probably spent the same amount of time on color-coding, font-size, and finding that perfect emoji as I did with the actual content itself. I’m a stickler when it comes to format; I find that aesthetically pleasing content is much easier and more enjoyable to consume. Color-coding is incredibly slept on as a study tool. I can tell you gram positive from gram negative bugs in an instant because every time it’s mentioned in my notes, I color GPs purple and GNs pink (I also have them in very different memory palaces which make them impossible to forget). Penicillins are orange, macrolides are yellow, fluoroquinolones red. Even now when antibiotics or bugs are mentioned in clinical year, I can feel the color of the medication and instantly know the class. I’ve developed an entire custom color-palette that I carry over into every new Google Doc. Here are some of my proudest examples:

I also tend to have a higher-threshold for what’s important (meaning I would ignore a lot of information). I don’t mean that to sound pretentious. It’s a game to guess what’s going to be asked on the exam, and I feel like I got pretty good at playing. I ignored almost every single lab-based diagnostic workup, not because it’s not clinically relevant, but because it’s not high value for an exam. I cut a lot of corners and just focused on the big picture stuff, plus a few unique things that make a disease process stand out. If your study guides are an exact copy of the source material, just reorganized differently, that’s probably not the best use of your time. I’d really recommend paring it down and using your judgement to just take what’s important. The process of actively filtering out important information is a great way to actively learn. 

The value I’ve seen with creating my own study materials is that I constantly referenced them throughout the remainder of my first year and constantly reference them during my second year. It’s very rare that I actually open up a PowerPoint deck and check on the “source” material. To have something meticulously color-coded and filtered, in my own words is so nice to look back on. I also use my notes much more often than Up To Date when initially looking something up during my rotations; I get the big picture from my own notes and can then dive into the recommendations on UTD or a hospital’s preset pathway.

With all of that said, if someone already painstakingly made a flashcard deck for the anatomy practical, by all means thank them for their service and use it. If someone made a nice chart of triads, use it. If someone made a 100-page fully color-coded study guide (ahem) go ahead and use it but try not to become completely reliant on the resources of others.

Final verdict: You can use any study material that you want, however there’s value as a long-term investment to creating your own content to your liking that you can utilize in the future.

This will be the most miserable year of your life.

I’ve heard this more than you might think and I’m sort of mystified by it. Sure there are times where you’re like “Man, this sucks” but I was never miserable. And that’s not even unique to me as an older student; everyone around me seemed to be pretty relaxed and having a great time throughout the entire year. PA school is only miserable if you let it get the best of you; it’s all about your mindset. You were vetted through one of the most competitive application processes in the country. You’re sitting in a seat that thousands in the country didn’t get to sit in. You’re surrounded by people who want you to succeed. You’re learning how to save lives. You’re learning practical, hands-on, skills. What’s remotely miserable about any of that!?

Final verdict: No shot.

You have to make social and personal sacrifices / won’t ever see your friends and family.

This is partly true but not nearly as dramatic as it sounds. I definitely had to make sacrifices like quitting video games, canceling concerts I had tickets to, etc. But I was still able to go to a couple of shows, still saw my family regularly, etc. It comes in waves though. Sometimes you have a crazy week coming up, so you really need that preceding weekend cleared. Then you get a few days to breathe and a weekend where you can squeeze some family time in. Your life certainly will revolve around school, but if you budget out your time, you can carve out time for yourself and others. This is another reason why efficiency in studying, not time spent, is important. Because I was efficient with my studying I was able to take multiple nights off per week.

The video games thing for me is interesting. They’re still one of my favorite pastimes but I knew they would be a time-suck, so I cut them out completely during most of didactic year. I sort of rewired my brain by using video game-like addons for Anki and a Nintendo Switch controller for the Anki cards to make studying as close to gaming as possible. What’s funny is that when you don’t feel like studying, it doesn’t matter what distractions are around you, you’re just going to do something else if you’re really not feeling it. I realized instead of gaming, I’d just be doom-scrolling / brain-rotting on social media, which is much, much worse than a couple hours of Borderlands or Warcraft. So I actually started gaming again late in my last semester. I realized it made me much happier; I felt human again. 

Final verdict: Anything worth doing that’s going to create a great career for yourself will come with sacrifice. Carve out time for what matters most. Do what makes you feel like a human.

Your grades matter.

This one might be controversial so buckle up. Do you need to pass your program to graduate? Yes. Does it matter what your GPA is? Not at all (as long as it’s above your program’s requirement). Shoot for 90s and strike a balance between grades and being a human being. Patients don’t care about your GPA or grades if you don’t know how to relate to them on a human level. So don’t be a robot! Some of the most academically brilliant providers I’ve worked with over the past 10 years have a poor bedside manner, and poor relationships with the nursing staff and cost their organization time and money through patient complaints and poor reviews. So in the end, how much did their 4.0 GPA really help them in practice?

I actually think GPAs and awards for high ones are outdated and can be detrimental. Because it forces you to sacrifice to “achieve” a number that’s meaningless in clinical practice. Are we rewarding someone who made unnecessary sacrifices and holed up in their room for an entire year, just to achieve a relatively arbitrary score, one that has no relation to patient safety and satisfaction? It also makes those that didn’t receive an award feel sort of inferior. Does this mean I’m not going to be as good of a provider? (No).

At the end of the day, as long as you pass, you’re all going to be a PA-C. I constantly grapple with that personal reflection of “Am I lazy and doing the bare minimum, or am I striking that school-life balance?” And I don’t necessarily think that’s a bad place to be as long as I am self-aware. I did really well in my didactic year and had a ton of fun while doing it. Am I going to win any GPA awards for being on the bleeding edge of a 4.0? Not a chance, and I’m perfectly happy with that.

Final verdict: Grades matter to no one else but yourself. Your grades and your patient safety and satisfaction scores have little correlation. Patients care about how you make them feel, not your GPA. Find a balance!

Final thoughts.

So that’s all I have for you! If you have any thoughts, please feel free to share!

For this post’s song, I chose one with the word “myth” in the title. “The Myth of Youth” by Geographer is a song I discovered while working in medical education and was actually one I had on a playlist I would play before medical/PA student orientations. It’s so bouncy and catchy and one of those songs where the verses are actually more of a hook than the chorus itself. That first post-chorus around 1:45 is just a symphony of sound that leads into a second verse accompanied by a driving synth and then the second half of the second verse kicks in with that main guitar riff. It’s just a fantastic song.

See you in the next one.

P1 ➡ P2 & The Top 5 Tips for Surviving Didactic Year

Just minutes ago I finished my second to last exam for my entire first year of PA school. My last exam tomorrow isn’t worth much so, all things considered, I’ve completed my first year of PA school. It doesn’t feel too long ago when I was grinding away at general chemistry in my post-bac. And now here I am, halfway to being a physician assistant. Whoa.

I’m really curious to see what it’s like as a second year PA student. It’s finally time to see all of the things we’ve been learning. And obviously there’s that pervasive feeling that I still know so little. But I think the goal of P1 year is to know just enough to be a part of the conversation. It’s about “Hey, I remember learning about this and maybe I remember a thing or two, but let me go refresh my memory.” We know the basics of a new language and now it’s time for the immersion to make it all stick.

I think now is the time for a mindset change. This past year, patients really aren’t a driving force behind the why of everything you have to do to study and prepare for these exams. Coming up with wild mnemonics just to survive exams is a far-cry from real patient care and decision making. Now it’s time to change that and start to bridge that gap. I’m likely less than 18 months away from having a job as a licensed PA, responsible for the lives of other human beings. That’s a serious undertaking and a true privilege. It’s now about making things practical, being able to pick up on potentially life-threatening underlying conditions, and having those worst case scenarios in mind in case things go south.

P1 year was a lot of fun but I want to shift gears from student to professional. I think that’s the goal of P2 year. It’s going to be a lot of self-directed learning but if I’m honest, P1 year was also a lot of self-directed learning. But you had 3-5 exams per week to keep a healthy flame under your tail. Now I have just a single end of rotation exam (EOR) every 5 weeks so self discipline is going to be important.

The realm of healthcare isn’t new to me, but being on the clinical side of things, wearing a white coat, well that’s new to me. It used to be my job to be at the podium in an orientation classroom with a bunch of medical and PA students in front of me, on the first day of their rotation. Now I’ll be sitting in that classroom. That’s pretty wild. Here’s a photo of me (the only one not in a white coat) with a group of Drexel medical students I managed for 12 months during their 3rd year.

What’s cool is that I actually shot a video interviewing some of these students on tips to survive their clinical year. The fact that their tips now apply to me is pretty cool and I’m really grateful for that.

So the first year of PA School… How was it?

The First Year

I had an incoming student recently ask me “So how crazy is this going to be, really?” I think that’s a really tough question to answer. My experience at 34 (now 35) is going to be different than my colleagues completing a 3+2 program.

I will tell you that I felt more stressed in my pre-med post-bac than I ever did in PA School. My post-bac was a perfect storm of sorts, however:

In October of 2019 I was engaged, had a full-time well-paying job, and was a homeowner. Less than 6 months later, I was unemployed, living in my parent’s basement, single, and officially a full-time accelerated pre-med student taking classes online in the midst of a pandemic. All by choice, mind you. So it’s hard to compare just the academic portion of that without all of the environmental factors, to the academic load of PA School. But I would take any class in PA School over general chemistry, organic chemistry, biochemistry, etc. in a heartbeat. Classes in PA school are so much more useful and practical and less abstract. And the beautiful thing about PA school is that the pre-reqs are so rigorous; you’re not entering into it and learning things that are completely foreign. To go from a past career in business (albeit in healthcare, but still) into pre-med was a brutal learning curve. Despite my pre-med experience being so rough it really did give me the discipline and grit required to get through didactic year. Shout out to all of my colleagues in the Jefferson P4 program who were in the trenches with me.

Didactic year certainly isn’t easy, but it’s entirely manageable. Everyone around me, including myself, never seemed to be overly stressed or miserable. I’m sure we all had our moments behind closed doors, but we all kept such a positive attitude throughout the entire year.

Enough self reflection. Here are some practical tips to survive didactic year.

Top 5 Tips for Surviving Didactic Year of PA School

#1: Master your sleep schedule. Above all else, including eating healthy, exercising, and even how you study, a solid sleep schedule is the most important factor to a successful didactic year and I will die on that hill. You need to be able to sit in a classroom from 8-5PM, and still have as much focus at 4PM as you did at 8AM. No amount of caffeine can compete with a full night’s sleep. To maximize your sleep even further, go to sleep and wake up at the same time, 7 days a week. (+/- 2 or 3 hours is doable on the weekends if you want to stay up later). Waking up early on Sunday at 5AM to then wake up at Monday at 5AM makes for a very energizing Monday morning. I’ve historically been a student who has fallen asleep in class because my sleep hygiene was horrid. Because I’ve followed the strategy I’m outlining here, I haven’t nodded off in class a single time. A consistent sleep schedule has been a life-changing game changer for me.

Here are some other tips for better sleep:

• Use Night Shift / Night Light on Apple / Android devices (removes the blue light from your screen). Set it up for 30-60 minutes before when you want to go to bed, or even longer.

• iPhones have a “Wind Down / Sleep Focus” where you can limit notifications from only specific apps. I have this turn on 15 minutes before I plan on going to bed.

• Don’t study where you sleep. That should help clear your head when it’s time to go to bed. If you have a studio apartment/dorm, try to have a dedicated desk / study space and only use it for studying. Don’t bring your studying into your bed! That way when you are in bed, your brain won’t try to think about studying and you should be able to fall asleep faster without your mind racing.

• Using Sunrise Lamps / Hatch / Smart Lights to turn on 30 minutes before your alarm goes off will help you wake up. It’s peaceful waking up in the light instead of a dark room.

• Instead of using an iPhone alarm to wake up, try an app with music. Or even better, if you have an Amazon Alexa device, you can set it up to play an Apple Music or Spotify playlist for you instead of a jarring alarm sound. Your favorite songs are infinitely more preferable to an instantaneous fight or flight response from an alarm. Oh, and use multiple devices for alarms. Never rely on a single device (your phone). And really you should have a battery-operated alarm in case your power goes out during the night. This is how I wake up:

  • My lights fade on with a warm light at 4:30AM

  • My Alexa plays a Spotify playlist at 4:55AM (I have a different playlist for every day of the week)

  • My iPhone alarm goes off at 5AM

  • On days where I have exams, I set an additional alarm on Alexa for 5:05AM

• Charge your phone across the room so when you wake up you have to get out of bed. Don’t use the snooze function, ever, iPhone’s sleep schedule lets you disable snooze.

#2 Use a study management system / dashboard. The amount of information you’re going to be met with and responsible for is… insane. You need a system to manage and track everything. PA School is like suddenly being responsible for a start-up company. You need to manage payroll, employees, funding, or else you’ll go bankrupt. For me, this management system was a simple spaced repetition dashboard. It allowed me to take an “Exam” and convert it into 20-50+ topics and be able to see at a glance where I was from a 50,000 foot view. In PA School, when it’s effortless to become lost in the weeds, having a macro-view of what you’re up against is a godsend. Does it take extra time to manage your management system? Yes, of course but the organization and peace of mind it will offer you is invaluable. As the days approach closer to an exam it’s easy to enter into a frenzy/panic because you’re so overwhelmed. It’s always better to know what you don’t know so that you can triage and decide what topics are most worth your time. I’ve adopted my dashboard from Ali Abdaal; you can read about it here. Find the part that says “My ‘Magic’ Spaced Repetition Spreadsheet System.” Mine looks like this:

#3 Utilize the time you spend in class. Unless you plan on reviewing content before you enter class to then listen passively, I’d argue there’s almost zero reason to sit in class and just listen; that’s far too passive. I’d also argue that it’s a waste of time to take “notes.” Every test question is taken from the text on the slides. Extremely rarely a question will pop up that was only said out loud. The only reason to write anything down in class is when a professor says “This will or will not be on the exam” or just to add some extra context to a slide. So what should you do in class? I think the best way to spend time in class is to be working. Whether that’s making flash cards or organizing information into tables, it’s valuable to leave class with a resource you didn’t have when you walked in. For me, sitting and only participating in class meant I wasn’t really walking out with anything tangible. There’s so much information that I’d rarely remember what had occurred in class with the exam anywhere from 1-2 weeks away. I just don’t learn from listening. Even our Clinical Reasoning classes where we’re encouraged to close our laptops and participate, I just don’t retain much from a “live” session. With the exam weeks away and a host of exams in between that, there’s just no way to retain all of that. I have to sit down with content and manage it on my own time to be able to grasp it. So I might as well use my time in class to work on study materials. PowerPoint slides are easy to teach from but hard to learn from so sadly most of our time is used re-organizing information from those slides. That time isn’t always wasted, however. You should never just take all of the information from slides and transpose them to flash cards or tables. This is a tremendous waste of time and leads to the pitfall of overstudying. You have to use your judgment and just take what’s important; you should be using critical thinking to sift through what you think will be tested on. Your study material should be filtered so you aren’t overwhelmed. You retain some information just from that filtering. You never want to get home and have that feeling of “Okay, I need to get started on what was went over in class today.” You want to come home and already have material ready to go.

#4 Play the numbers. If it’s a low-credit class, don’t lose sleep over it if you got an 80. Take topics like the structures of the iliac arteries and be okay saying “Yea, I’ll pass.” Sometimes you don’t have time to learn everything, so you have to make some cuts. Is it worth 1-2 hours of time for 1 question on the exam? I mean, if you have the time, go for it. But if it’s between 1 question and 1-2 hours of sleep, take the sleep. The goal of P1 year isn’t to learn everything. It’s to pass exams. Period. I know that sounds sort of cold, but PA School is a business, you’re a customer, and you have to play along. If you feel good enough about that H&P exam which is 3 credits, but still have some content to go over for it, just move on. Your 8 credit exam is 10 days away so you better get a move on. Put your ego aside, take the 90, and put your time into something more valuable. Don’t overstudy! I often overlooked entire workups for diseases. My focus was: What does it look like? How do I treat it? What’s unique? Done, moving on. I talk a lot more about this here.

#5 Use your exam time wisely. As soon as the exam begins, feel free to write out some tables and mnemonics on your whiteboard. Yes, you don’t have to “start” the exam the same time as everyone else. I mean you have to see the first question, but it’s totally okay to go for your whiteboard and then memory dump. You’d be shocked at how powerful it is to have some resources to refer to as you’re taking the exam. During the exam, read the last sentence of the question, and read every answer. There are multiple times I’ve tunneled into an answer but saw that there was a better answer hiding in the choices. Use your highlighter! If you choose to review the questions again, seeing the highlights will save time and make your review far less painful. If you look at a question and literally shrug because you have no idea what they’re asking, think again. There’s something you’re missing. Why would they include this in the question? There’s a reason! Think outside of the box.

The time after your exam is some of the most important in your entire didactic year. My advice is to avoid people at all costs, find a quiet corner, and use the time you have left to look through and start highlighting what was tested on. Studying for finals begins the minute you walk out that door with your first ExamSoft green screen. Going over questions with classmates, for me, was very detrimental to my mental health so I chose not to do it. I got too often into that fight or flight mode, defending my answers. When you were between A or B and everyone else put C, that’s pretty disheartening and harmful to your mental health. You want to be that student that picked up on something that everyone else missed, but that’s so unhealthy for yourself and everyone around you. Don’t do that. I talk more about that in one of my first blogs of didactic year.

Test review was rarely a surprise for me because I had gone over all of the content to do highlights and had already reconciled most of the content I got wrong. It can take hours to pore over and highlight 12 decks, but it’s always time well spent because it makes studying for finals so much easier.

After you complete your first pass of the exam, go over it again. The room is more empty and you have a new environment to focus in. You’ve seen the entire exam so now you can look through it with a new lens. This also helps when you do your highlights after the exam because now you’ve seen every question twice, not just the ones you had flagged so this makes the content on the slide jump out: “Oh, yea they asked a question about this!” You spent hours of time studying, so you can put it an extra 30 minutes to protect your investment!

#6 Master your memory. Okay, there’s one more tip, and that’s to become a master of your memory. I’d put this at #1, but I feel this one isn’t as accessible to the masses. If you’d read up to this point and want to really know how to get an edge over didactic year, it’s mastering memory. Many of my past blogs are devoted to this topic, so start here: https://anthonysorendino.com/blog/2024/6/5/summer-semester-amp-the-problem-with-memorization-in-pa-school A great place to start would be to look up the Memory Palace / Method of Loci / Roman Room technique. It’s the single most powerful study tool I’ve ever used and it’s not even close. The process saved me hours of time and afforded me a level of confidence unmatched by other study techniques. Here’s a video of me using this process for a clinical skills checklist.

What’s Next

I have more to unpack from year one, including common myths and tropes, and also just general tips on how to study. So stay tuned for that!

I include songs at the end of each blog so I wanted to mention why I chose each song. “Aside” from The Weakerthans was the credits song from Wedding Crashers and it’s a perfect song to play over the credits for my first year.

I’ll see you in the next one.

Disrupting The DSM-5 & How to Memorize Numbers

For someone who blogs a lot about memory, a post on the DSM-5-TR was inevitable. For the uninitiated, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) is a 1050-page guide published by the American Psychiatric Association outlining the criteria for around 300 psychiatric diagnoses.

Part of the PA school curriculum in my final semester of didactic year is to memorize the criteria for each disorder, little by little, week by week.

Here’s an example of one:

Now, we don’t technically need to memorize it word for word, but anything there is fair game to test on. We’ve been responsible for anywhere from 3-10 of these a week for the past three months.

With a healthy mix of distinguishing features, time frames, age-ranges, and number of criteria needed, the DSM-5 is the purest test of raw memory that I’ve encountered so far in PA School. And without a solid memory strategy, it can become a grueling slog of time-consuming repetition.

And this challenge is largely because it involves the memorization of a lot of numbers. It’s tough to keep each disorder separate. “Oh, did this one need three criteria or two criteria, and was it 3 months, 6 months, twice weekly, or no time frame at all?”

And I firmly believe that numbers are the most abstract and arguably the most difficult thing to remember, ever. There are countless posts and tricks online to help memorize numbers. I talked about this problem back in January when I trialed the Major System (which didn’t end up working out because that’s better suited for long strings of numbers). Think about how hard it is to remember a simple phone number. Before smart phones and when you were without a pen it was always: “Okay you memorize the first three digits, I’ll take the middle three, you take the last four.”

Try to remember these three words:

• Adam Sandler

• Billiard Ball

• Cat

Now try to remember these three numbers:

• 3

• 8

• 9

Words are much easier to remember, yea? You can picture them. You can come up with similarities or make up a story: “Adam Sandler playing pool with a cat.”

But what does the number 3 look like? What does it sound like? What does 3 make you think of? Well if you’re normal, probably nothing… it’s just a number. Unless it’s your favorite number or if you have it tattooed on your hand, it’s just not memorable. And what do 3, 8, and 9 have in common? I have no idea. Numbers are pretty arbitrary and it’s difficult to make connections amongst them.

But what if numbers… weren’t numbers?

If numbers are objectively hard to memorize, and the DSM-5 requires the memorization of a lot of numbers, I’m making the argument that you should… stop memorizing numbers.

Let me explain.

In one of my very first blogs I came across this post on a forum called “The Art of Memory” where a user said they had converted every number from 1-100 to an object or a person. I laughed a bit at that idea… until I tried it for the numbers 1-10. I stopped laughing. It works insanely well.

So here’s the trick: You should convert the numbers 1-10 (and beyond) to literally anything else: people, shapes, objects, foods, family members, celebrities, whatever. The more ridiculous, the better.

The number 1 for me is anything Pixar related (My #1 favorite movie studio): the Pixar Luxo Lamp, Woody, Steve Jobs (he was a founder), etc. Two is any set of twins: Olsen, Lindsay Lohan from The Parent Trap, real sets of twins that I’ve encountered in life, etc. Three at first for me was just Adam Sandler (I don’t have a clear reason for that one; it just stuck) but the number 3 comes up so often in the DSM, that I expanded to Drew Barrymore (his co-star in 50 First Dates), Happy Gilmore, etc. Eight is a billiard ball or a pool table. And 9 is a cat, Cat Woman, Anne Hathaway (played Cat Woman), just to name a few.

The absurd picture of a horse (my number 5 because 5 kind of looks like a seahorse) riding a cat (9) helped me remember that the age peak for Specific Phobia was 5-9.

The slight learning curve of remembering who or what signifies what numbers takes a fraction of time compared to how much time I’ve saved by using this strategy. The incidence of interference with the DSM is insane. Was it two criteria or three criteria? I would never confuse the Olsen Twins for Happy Gilmore. 

The other thing you can do is convert time periods. For me, 1 year is Santa or a Christmas Tree. So Happy Gilmore (3) attacking Santa (12 months) with a hockey stick (a physical act of explosive anger) is 3 criteria in 12 months, part of the criteria for Intermittent Explosive Disorder.

Six months is Fifty Cent (half of a year) or any rapper. So suddenly Snoop Dogg (6 months) underneath the Pixar Lamp (1), is 1 criteria in 6 months, for Specific Learning Disorder.

One week for me is a margarita (like at a happy hour at the end of a long week), so suddenly two twins (2) making a toast with margs (1 week) while a limo pulls up with a small rapper like Little Bow Wow (3 months) is: 2 events, weekly, in 3 months, the exact criteria for the other part of Intermittent Explosive Disorder.

Yes, I actually study like this. No, it did not take long to memorize who or what represents each number or time frame. If it took longer than 2 hours to memorize the entirety of 12 DSM-5 criteria, I’d be lying. I run through it once (combining this strategy with a memory palace), once again an hour later, and then once more the following morning, and I know I have it committed to memory. There’s little reason for me to have to review the information again before the quiz. It’s impossible to forget an image of Snoop Dogg under a Luxo Lamp, or Adam Sandler fighting Santa. Scenes like this that you can combine in any way you want are infinitely more memorable than just abstract numbers and has made tackling the DSM a breeze.

The magic of this is that you can scale this as high as you want. 18 for me is Ulysses S. Grant or the Civil War (he was the 18th president). So suddenly a Civil War battle with each side throwing eggs (my code for 6) at each other are the ages of 6-18 for Disruptive Mood Dysregulation Disorder.

As a side note, converting numbers to their respective presidents was extremely valuable for me for Women’s Health. I always have trouble remembering milestones for the weeks of pregnancy. Suddenly a cannon (15 for James Buchanan) being operated by Cleveland from Family Guy (in Grover Cleveland’s first presidency he was the 22nd) was the time-frame for a Quad Screen. A landslide (for Landslide Lyndon B. Johnson) for 36 helped me remember when to test for Group B Strep.

I know it sounds insane, but it’s been the most effective way for me to remember numbers, which have been the bane of my existence since the start of PA School. Blood pressure thresholds especially… for strokes, pre-eclampsia, grades of hypertension, etc. Those are tough to remember. But suddenly Abe Lincoln’s hat (16) with polka dots (James K. Polk = 11) gives me the severe threshold for preeclampsia of 160/110.

Obviously some knowledge of the presidents was necessary here (I only knew a handful), but I just looked up who went with which number and it stuck.

The biggest barrier to strategies like these that I’ve heard is “I don’t have time to come up with stories or convert numbers.” I’d argue this strategy affords you extra time. Ask yourself how many times you have to repeat a flashcard, or look over a DSM Criteria for it to stick and even with that, just to stick long enough to survive through the quiz until your forget it entirely. How much time are you actually spending when you really add it all up? And then how often do you have to revisit that same information again before the exam?

Behavioral Health in PA School deserves to be an event at the USA Memory Championship. And I treated it as such the entire summer and it’s been one of my strongest (and most enjoyable) classes all year.

And I believe this class has become this big reason the summer semester can appear so brutal because memorization takes time. But it doesn’t have to. If you spend your time hammering in nails with a rock, it’s always worth it to take a day to put down the rock and build a hammer out of steel. Do you lose an entire day’s worth of progress? Sure, but you’ll save weeks to months of time in the long run. It’s about memorizing information in a way that makes it stick so you don’t have to keep returning to it.

And maybe I was the only one who had issues memorizing numbers. But after 11 months, I’ve finally found my solution.

Three weeks and I’ll be a P2. I’ll see you then.

Summer Semester, The Problem With Memorization, and What PA Students Can Learn From Memory Athletes

17 PowerPoint decks, 942 slides, and 39,273 words. That was the amount of content I was responsible for yesterday morning for my second exam of my final semester of didactic year of physician assistant school. It was an absolute monster of an exam, on the entirety of orthopedics and dermatology, including pathophysiology and pharmacology.

It got me thinking… how many words exactly is 39,273? Considering the content I was faced with, I thought it had to be at least the entire length of a Harry Potter book. But when I did the math, it was only 51% of the entirety of the shortest book, The Sorcerer’s Stone, right about at the part where Harry learns how to fly a broomstick for the first time. Especially as an adult reader, half of that book—isn’t really that much information. You could read half of that book in a day and I could ask you questions and you’d probably get most of the questions right without having to study. So why is learning the same amount of words, provided on PowerPoint slides, so much more difficult? Well, because a story is memorable, right? A story has a setting, and a plot, and characters, and humor. It has themes that connect to your life and is relatable, even if it’s a fantasy. The study of medicine often doesn’t have any of those things.

But what if it did? What if Multiple Myeloma, a Lisfranc joint injury, Paget’s Disease, and Dyshidrotic Eczema were as memorable as a fantasy novel? And what if you could be the author?

The Problem With Memorization

We’ll talk about storytelling in a second, but first we have to talk about memorization.

The problem with memorization is that we don’t talk about it enough. We don’t acknowledge that a strong memory is one of the most powerful skills during didactic year of PA school.

There’s a science to medicine and we spend our time in PA school focused on understanding pathophysiology, medication indications and side effects, but we don’t spend any time on how to tackle or retain that information. There’s a science to learning and I think we really overlook it.

I think we have to be comfortable with the fact that memorization is a big requirement for PA school, as well as many other disciplines. But that’s okay—memorizing is still a form of learning. And there are simply better ways to remember things. We shouldn’t be annoyed when we’re met with a list to memorize; actually we should celebrate because it’s a lot easier to memorize a list than most people realize.

There are many things that memorization doesn’t work great for, like complex pathologies, how osmolality works, the Renin–angiotensin system, how to read an EKG, etc. But the problem we students face is we can’t give those processes the time they require because we’re inundated with material that needs to be memorized. The best strategy is to fast-track what needs to be memorized so you can spend your time truly understanding those other processes.

I think there’s a misunderstanding that to memorize something, you just have to repeat it over and over again until it sticks. That works well for shooting three-pointers and hitting a fast ball, but PA school is a different ballgame. You don’t need muscle memory, you need memory… with muscle.

You can brute force rote memorize anything—but that takes a lot of time, and you’ll likely forget it in 24 hours. So why do it? And the bigger issue with rote memory techniques like flashcards is that they don’t battle interference. Sure you can recite that triad, but do you remember what disease process it belongs to? You know what Auspitz’s Sign is—but do you remember what skin condition you see it in?

The Memory Experts

Listen, in any other part of your life, who do you look to for advice? The experts. You’d go to a personal trainer for fitness advice, or a pro athlete to learn how to throw a football. But who are the experts of succeeding in PA School? There is no olympics of learning—or is there? To me, it’s critical to break down what the actual constituent parts of academic success are.

What is succeeding? Passing, graduating. Okay, so interview the top students in the class and those that graduated before you and see how they studied. You could do that, but class intelligence and performance are spread across a bell curve. Some students are just more gifted than others; some can read through a slide deck right before a test and do just fine. I’m not one of those people so it doesn’t make sense to compare myself and you shouldn’t either. So now what? Well what do you have to do to pass? Score well on an exam. And how do you score well on an exam? You have to remember the content from the lectures. Well how do you do that? You have to study that material. Well how do you study? Maybe you look at a flashcard and try to remember what’s on the other side. Well, how do you know if you studied effectively? Well, if you remember what you studied when you’re taking the exam. If what you studied… stuck. If Topic A doesn’t interfere with Topic C. If you remembered what belonged where.

And there it is. The core skill to passing an exam isn’t how you studied, or how long you studied, it’s simply what you remember.

And who knows the most about remembering—who are the experts of memory? They’re not medical students or law students; they’re not students at all actually. They’re the folks who who practice memory on a professional level at the USA Memory Championship. And yes, that’s a real thing. Things that we devote hours of our time studying, like a list of 16 diseases that cause rashes on the palms and soles, memory athletes can memorize in seconds, and they do it for fun.

And what strategy does every single memory champion use? It’s called the Memory Palace / Method of Loci / Roman Room and it entails harnessing spatial memory of locations you’re familiar with and mentally placing pieces of information in those locations. It’s easy to learn and will change your academic life. It’s certainly changed mine.

And no, the memory athletes aren’t savants; they actually all have average memories (as do I). I just finished reading a book called Moonwalking With Einstein, where a journalist who was writing an article on the USA Memory Championship learns the techniques and then wins the competition the following year. And I want to give you an idea of what this competition is like. One of the events is called Speed Cards. You’re given a full deck of 52 randomly shuffled cards. You have as much time as you’d like to memorize it, in order. When you’re done, hit your buzzer and then you have 2 minutes to put another deck of cards in that same exact order without looking at the first one. How long would it take you to memorize the sequential order of 52 cards? An hour? A day? Do you want to know what the world record is?

Under 14 seconds.

Do I have your attention? The Method of Loci is that powerful. And I now almost exclusively study using this method, replacing rewatching lectures, taking extensive notes in class, and using flashcards.

And it’s been an absolute game changer for me. It’s allowed me to maintain a consistent sleep schedule now for 10 months and I’ve yet to miss a single hour of sleep. It’s been a breath of fresh air and I truly think it can change the way we think about PA and medical school and academics in general. It’s by far the most powerful, efficient, and longest-lasting study technique I’ve ever encountered, and it’s not even close. And I think more people should consider using it.

Storytelling: My Current Study Process

I’ll walk you through exactly how I study and use this technique and narrate how and why this works.

The first step is to look at each slide deck and figure out who the players are. How many distinct “characters” or disease processes are here, especially those with distinct treatments? And also, how much weight, or how many slides does that process have? And that looks like this:

I try to put everything into groups, or families. It’s a simple outline—nothing groundbreaking. Then I put each “family” into a matrix, or table, that looks like this:

Then I fill the table in with all of the details I think are important. I usually do this in class, in real time. Sometimes I fall behind, which is fine. But I’ll sort of passively listen to my instructor and pick up on hints; sometimes they allude to important topics, or even more valuable, tell us which slides are just “fun facts.” If they say “You definitely need to know this” it goes in my chart. I use a combination of what they’re saying, and my own judgment for what I think is important, unique, or testable. I ask myself, “If I was writing this exam, what would I ask?” I leave a lot behind; most topics require less than 5 things to memorize. Oh this condition warrants a CMP and this one needs a BMP? This one has fatigue and dizziness, and this one just has fatigue? Is that important in practice? Maybe. But I’m not there yet. I’m just trying to pass an exam. Even if it’s tested on, it’s one question, so it’s not worth my time to memorize the labs and generic symptoms for 150 diseases to score .8 points higher on an exam. PA School is about playing the numbers and you have to be comfortable leaving things behind. Shoot for 90s, not 100s.

Anyway, sorry for the rant. You’ll notice I use numbers instead of bullet points in the table. I try to make every thing very singular: Concept 1, Concept 2, etc. These are the 7 things I want to remember? Perfect.

Once I repeat the above process for the entire content for the exam, I build a dashboard that looks like this:

Then I write a story, preferably using a real location, as all of the Memory Champions do. For the above, I used my school library. Each row, each unique disease process, gets a scene and it looks like this:

It’s silly, entertaining, and a tad crude, and that’s precisely the point, because that all makes this information infinitely more memorable. Forever, dyshidrotic eczema will be synonymous with my school library elevator and I wrote the scene you see above sitting right in front of it. I wrote 60 scenes for Dermatology, and 55 for Orthopedics. Some of them just have a couple of points to remember, others have 10. I don’t always go to the location in which I’m referring to; I use a lot of locations from my past like hospitals I used to work at.

So I write the scene, encoding each bullet from my table into it, then immediately look away from my computer and recite the entire thing back. Then I set a timer for 1 hour, and repeat it the scene again from memory, and then once more the following morning, after a full night’s sleep. That’s an important part of this. The science says that memory is improved by quality sleep, so it’s critical that you stick to your sleep schedule above all else. You’ll see those 1 hour and 1 day milestones in the dashboard; I use that to battle the forgetting curve; it’s simple spaced repetition. I audit what I remember each time to make sure I didn’t forget anything. And every now and then, I do. But I’d say I remember 95%+ of what I encode in a scene as long as I stick to my schedule. And after that third repetition the following morning, not only do I remember nearly all of the information word for word, I remember it for weeks to months after. Just today I was asked what the treatment was for Tinea Versicolor. I wrote a scene for it for my Infectious Disease exam 81 days ago using a park behind my apartment building. So all I did was think of that location and I saw my old neighbor Celine standing there who I wrote into the scene to help me remember the treatment: Selenium.

And I know what you’re thinking, “Oh I don’t have time for all that.” I would argue that, per minute of time, this is the most efficient way to study. Does this process take time? Of course. But it’s extremely time efficient because it encodes new information into the already existing long-term memory of locations. With a dashboard, you can statistically give each concept equal time and repeat it at spaced intervals. Every minute of studying becomes incredibly purposeful and, more importantly, trackable.

Here’s why this works. Think about your childhood home. Will you ever forget the exact layout and every piece of furniture there? Never. Spatial memory and those neurons that hold that information are incredibly long-lasting. A Memory Palace works by taking new information and just placing it next to rock-solid long term neurons that already exist rather than painstakingly try and build new ones. Imagine a bunch of “full” storage boxes in a closet. And you have five new items you need to store. Sure, you could purchase or put together a new box, place those five items in and then put the entire box in the closet, taking up a box-worth’s amount of space even though that box isn’t completely full. Or you could sift through your already existing boxes and find little cracks and crevices to store your new five items, using the boxes that have been inside for months or years. That’s the idea here.

I encoded all of the different types of eczema in one section of the library near the elevator. Then I moved to the back and encoded all of psoriasis in an area around a giant statue that looked like a dragon scale. Distinguishing buzzwords between the two, like “Silver Scale” or “Tapioca” became effortless because I’d never confuse an elevator in the middle of a library for a sculpture in the back of the library. The plague of interference, which can mean disaster on an exam, is eradicated.

This also works because I’m not studying just words on a page anymore. I’m making Bullous Pemphigoid and Ewing Sarcoma come to life. And I use cartoon characters, family members, Pokemon, and everything in between to make things stick. I convert medications and numbers to objects and people and just place them along the path of these memory palaces. It’s engaging, allows me to be creative, and makes me laugh. I’m making studying as close as possible to a fantasy novel—and it’s pretty magical.

Onward

At the end of the day, PA School of course isn’t just about memory. Like I mentioned before, there are tons of things that require you to understand them from the inside out, and memorization can’t help you there. But when you’re tasked with memorizing a list of 50 pediatric milestones, or the side effects of countless medications, or the DSM-5-TR criteria, those are tall orders and can take up an inordinate amount of your time. And I’m here to tell you I think there’s a way to get some of that time back.

I don’t memory palace everything. It works best when you’re flooded with either long lists or a lot of “buckets” of things you need to distinguish amongst. I’ll still use Anki for one-off concepts, definitions, and things like that.

After being at this for 10 months now, I think the ultimate triad of learning is:

1. The Method of Loci / The Memory Palace

2. Free Recall

3. Spaced Repetition

The process I use hits all three and I would simply never study in any other way. So if you’re looking to raise your GPA, study less, get more sleep, or are just looking for a new way to study, reach out. I’d be happy to teach this process to anybody.

I’ll see you in the next one.

Mastering the Memory Palace: Using Toy Story, Finding Nemo, and Monsters, Inc. to Master Infectious Disease in PA School

What does throwing a rock and a shoe at Buzz Lightyear’s spaceship, Mike Wazowski chasing a sheep around his apartment while Sully inhales some toxic soup, and a nickel falling from the sky into the volcano of the fish tank from Finding Nemo have to do with infectious disease? Well, if you were me about seven hours ago, absolutely everything.

One of the big problems I encounter with the innumerable topics that we’re responsible for in PA school is that I can’t really speak to any of them in a comprehensive way. I can match the buzzwords like “Owl Eye Inclusions” and “Herald Patch” & “Hutchinson’s Sign” with the correct diseases, but I can’t really tell you about those diseases as a whole. I study for hours but then show up at exam review and completely freeze up at some questions. What I’m doing is working fine for exams, but I feel like I’m missing something.

As we we inch closer and closer to P2 year, the questions are becoming more vignette-focused and they’re giving us less buzzwords and hints. And that’s exactly what we need; clinical year is all about real-life practical scenarios. A parent isn’t going to say, “Hello, yes, I came to get my child’s strawberry tongue, sandpaper rash, and Pastia’s lines checked out.”

I think there’s a really fascinating question in PA school: “Okay, I have X amount of time left to study for this exam. Statistically, what’s the best use of my time?” And sometimes that amount of time is a few days, and other times it’s an hour at lunch. Per minute, what is the most effective, most comprehensive way to learn anything? I’m fairly sure I’ve found the answer.

I picked up a book called Moonwalking With Einstein by Joshua Foer over Spring Break. The book was mentioned in a video featuring USA Memory Champion Alex Mullen, who was a medical student when he learned how to memorize an entire deck of cards… in under 15 seconds. And Alex, along with every other USA Memory athlete all had pretty average memories before they started competing. They’re not savants; they’re just like you and I.

In the book, the author Joshua Foer talks about an experience he had with two other world memory athletes:

“Ed recounted how on a recent visit to Vienna, he and Lukas had partied until dawn the night before Lukas’s biggest exam of the year, and only stumbled home just before sunrise. “Lukas woke up at noon, learned everything for the exam in a memory blitz, and then passed it.”

If what the strategy Lukas used isn’t the most burning question you’ve ever had as a student, then I don’t know what is. Alex, Lukas, and pretty much every other memory champion uses the same strategy as their foundation for memorization. And the answer to “Per minute, what is the most effective, most comprehensive way to learn anything?” I think is unquestionably the memory palace.

An Uphill Battle

I want to say this morning’s exam, on 11 slide decks, split evenly between Infectious Disease (ID) and Neurology was brutal, overwhelming, stressful, and required an unreal amount of preparation, but I find myself saying those words for every subsequent exam so the words are losing meaning. How many antibiotics did we have to know? All of them. How many gram positive and gram negative bugs did we need to know? All of them. I counted 44 individual species of bacteria, all with overlapping symptoms, manifestations, some had single therapy, others had dual therapy, second line, allergies, inpatient, outpatient, prophylactic, supportive, antitoxins, empiric coverage, rashes on the hands, rashes on the feet, blanching, non-blanching, it was never ending. And to me, a task so seemingly insurmountable was extremely enticing.

So is it possible to borrow a trick from a medical student who can memorize a deck of cards in 15 seconds to remember almost every single detail about 44 different bacteria? It is possible, and that’s exactly what I did.

As much as I promote the use of flashcard app, Anki, and previously have had Anki decks with over 1000 cards for a single exam, I just took an exam where for half of all of the content, Infectious Disease, I made zero flashcards. My retention of the information of four entire PPTs relied on scenes from Pixar movies. Here’s an example:

For me, it was all about getting topics down to 7 bullet points. What is it called? How do I treat it? And then what are five facts about it. No disease process fits into a template, so not locking into: “Presentation, causes, diagnosis, labs, treatment” was useful; this process is very flexible. To me it’s “Hey, what are five interesting facts here that I can talk about, and that make this unique?” And sometimes, a disease has 6 or 7 interesting points, so I made some cuts. I can’t, and no one should, memorize every single detail. It’s simply not worth the time. Did I miss some points on the exam because I didn’t bother to memorize all of the diagnostic tests? Yes, but I picked up a bunch of other points elsewhere. Passing exams is a numbers game and you have to play to those. And sometimes that means being comfortable being uncomfortable missing some questions.

How a Memory Palace Works

Traditionally, for a memory palace, you choose a path in your house or any location you’re familiar with and place items mentally to help you remember. For example, if you were trying to remember the presidents of the United States, say when you walk into your house and turn to the right, there’s a table there. Imagine yourself Washing that table. Wash = Washington. Maybe next to that table is a bowl of fruit with an apple in it, Adam’s Apple for John Adams. And maybe next is just some empty counter space and you imagine knitting some Fur for your Son, Jeff, for Jefferson. I promise you, as ridiculous as it sounds, this strategy works insanely well for anything that you want to remember. Show me a list of 25 things you want to remember, and I can teach you how to recall it verbatim, in any order, in under an hour.

The first task I tackled was to cover 21 gram negative bacteria. First, I combed through the slides and picked out five facts from each. I’d remember 7 things in total for each (the name, the treatment, then the 5 facts), giving me 147 bullets of information. And that was just for one of eleven slide decks. Next, I “built” a 21 “room” house, very loosely based on a place I used to live. To be clear, this wasn’t a mansion: I put three bacteria in the garage, two in the basement, put some on staircases, created an imaginary backyard with a greenhouse, etc. What I discovered is that while helpful, memory palaces don’t need to be based on places that exist. It’s like reading Harry Potter for the first time; you had to imagine all of Hogwarts in your head before the movies were made.

Looking at it as a whole, it may look extremely overwhelming. But committing it to memory is actually very systematic, logical, and very fun. Here’s an example of how I remembered Yersinia Enterocolitica:

Once I would complete a “scene” I would look away from the computer and recite the entire thing, even the seemingly extraneous information, like the fact that I was calling an imaginary preceptor. 99% of the time, I could recite it all correctly. I’d move onto to the next scene, recite that one, but then recite the first one again.

After I completed the 21 gram negative bugs, I moved on to gram positives. I decided to place all of the gram positive information into scenes, or vignettes from Pixar movies:

• Strep would be Toy Story

• Staph was Finding Nemo

• Clostridium, Anthrax, Listeria, & Diphtheria was Monsters, Inc.

• Lyme Disease & Syphilis was A Bug’s Life

For one of the gram positive bugs, Strep Pneumo, I used Andy’s Room from Toy Story. I pulled images from Google to help orient myself, and just made a story. It’s wild how connections can be made, like using Wheezy for pneumonia, and pulling out his squeaker to do a lung biopsy. Mr. Potato Head was Otitis Media and Sinusitis because he was missing both his nose and his ears. Mrs. Potato head punched him with a boxing glove, reminding me the treatment was Amoxicillin.

The other thing I did, which worked incredibly well, was converting antibiotics to items and people. For example, Ceftriaxone (Rocephin) become Dwayne The Rock Johnson (ROCKephin) or just a rock, Penicillin G become Tigers Woods, or a golf club, or a golf ball, Vancomycin became Vans shoes, or any type of footwear, Flagyl was a flag, Clindamycin was Bill Clinton, or any president, or anything patriotic. Tetracycline was a four-wheeled vehicle, Doxy was a bicycle, and Azithromycin was zit cream, to name a few.

What was so cool about this was that I could combine them either together as one item, like a zit-cream covered rock for Azithromycin and Rocephin, a dual-treatment option for inpatient pneumonia, or as just multiple options, like an American Flag became Clindamycin and Flagyl, or a presidential motorcade became Clindamycin and Tetracycline. That picture above of of Leonardo DiCaprio toasting combines two medications: Cefotaxime is Leo’s character from Wolf of Wall Street who was charged with tax evasion, and anything alcohol related was Ciprofloxacin, like a sip of beer. Placing that image in that scene for Yersinia became an unforgettable way to remember the treatment.

You know what would take a long time to remember? That the treatment for erysipelas, one of the like 12 manifestations for Group A Strep: Strep Pyogenes is either PCN-VK, Clindamycin, or Erythromycin. How do you remember it? Do you make an acronym like VEC? How do you remember what the acronym belongs to? How long does that acronym take to learn? How many times do you have to brute force repeat that flashcard? How do you know the C in VEC doesn’t stand for Ciprofloxacin or any of the 27 Cephalosporins?

A few months ago, I would have chosen one medication to remember, likely the first one mentioned on the slide, but with the memory palace, it became almost effortless to remember multiple medications. For me, I was in Sid’s room from Toy Story, slipped (erySLIPelas) on a red-rug (that later raised like a plateau, the description for erysipelas), and a volley-ball net pulled us up like a trap (Volleyball = PCN-VK), Abraham Lincoln, who I had just freed from a Cell (Lincoln = Clindamycin because he’s a president, but also this is a Lincosamide, and this also treats Cellulitis), was trying to break us out of the net using his top-hat, but we were all jammed in this net because Clifford the Big Red Dog was also trapped in this net (Clifford = Erythromycin). That’s not something you forget easily.

What I loved about this strategy, besides it being a ton of fun, was that I could recall an entire disease process from front to back from memory after about 5 minutes of work. The key, however, was to repeat it again a few minutes later, about an hour later, and then the following morning, and then once three days later (this battles the forgetting curve). I’d miss details here and there, but I’d recall over 90% of the “stored” information each time and pretty much never had to look at it again after that third day. And even if I didn’t remember everything, I’d remember where I last left it.

Confidence

Another thing I liked about this strategy was the confidence it provided. Many times I’m asked something and I’m like “I think it’s this.” With a memory palace, there is no “think.” Which gram negative bug is more dangerous to patients with Sickle Cell? Well, there’s a giant Grim Reaper with a Sickle in the basement I used to live in, next to little Timmy who’s on the last legs of life, standing in front of a Salmon-filled fish tank. There’s no doubt in my mind that it’s Salmonella. How do you treat a kid with that? Fulfill his Make-A-Wish and have him meet The Rock (Rocephin). That one’s a little “grim,” but the more ridiculous you can make the story, the better. If a mnemonic can make you laugh, if you can work humor into your studying, you’ll start remembering more.

Before going all-in on the memory palace for this portion of ID, I tested it out for parasites and fungal infections for the last exam. A really fascinating occurrence happened just minutes before the exam started. I was talking with another student and a pretty interesting question came up that we thought might be asked. However, between the two of us we couldn’t remember which of two disease processes this question belonged to. The more I thought about it, however, I was 99% sure which disease it was. Why?

Because the last place I had left this piece of information was in a thrift store I used to work in, surrounded by Lenox porcelain figures and high-end hand me down clothing. The other disease in question was in an imaginary restaurant nearby with flat worms and trematodes.

A plague to the memory of a PA student is interference: getting two disease processes confused. I’ll hit an exam question and I’ll remember this buzzword was on the upper left of a chart I made… but both Measles and CMV were on an upper left corner of two different tables and I couldn’t remember which it belonged to. A memory palace is the greatest insurance to this because not only are these topics no longer in similar tables, they’re not even in the same movie or zip code.

Free Real Estate

So back to the original prompt: I talked about Buzz Lightyear and meningitis already.

What about Mike Wazowski chasing a sheep around his apartment while Sully inhaled some toxic soup? Well, that represents Bacillus Anthracis, or Anthrax. I didn’t need a mnemonic to remember their apartment was Anthrax; they just become one in the same. After Mike caught the sheep (a vector for Anthrax), he got a black eschar. Meanwhile Sully was cooking soup and inhaling it, but he was inhaling Anthrax, and he got mediastinitis.

And what about a nickel falling from the sky into the volcano of the fish tank from Finding Nemo? For this exam, the most overwhelming bug was Staph Aureus, but I worked every important detail into made-up scenes from Finding Nemo. So for Staphylococcus Scalded Skin Syndrome, I pictured swimming into the fish-tank volcano in the dentist’s office from Finding Nemo, where there were a bunch of babies with exfoliating skin, like a spa. And underwater, you look up and a nickel falls out of the sky: Nikolsky Sign.

This process is fun, but it’s not easy. It’s definitely time consuming but to me, it’s time well spent. It’s the only study strategy I’ve ever used that provides a comprehensive, logical, and incredibly organized way to recall information. You already have the layout of your room, your parent’s house, your gym, or your favorite movies permanently in your long-term memory. Those neurons are free-real estate. Use them!

You can’t use a memory palace for everything. It works best with long lists and topics with multiple “buckets” and ID was perfect for that. When you need to tackle multiple different topics in a pinch, it works wonders.

PA School isn’t all memorization, but it’s still a lot of memorization. And knocking out the laundry list of contraindications for TPA, triggers for a migraine, causes for elevated amylase, and every other list that exists so that you can focus more on the pathophysiology and the why is pure gold. When a large percentage of your time studying relies on memory, why not borrow techniques from people who practice it as a hobby?

P.S. I recorded myself making a portion of this memory palace which I’ve uploaded to my YouTube channel. You can view it here.

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:

View fullsize

View fullsize

View fullsize

View fullsize

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:

View fullsize

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.

View fullsize

View fullsize

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:

• https://pinfruit.com/

• https://major-system.info/en/

• https://mnemonic.ninja/convert/number

• https://forum.artofmemory.com/t/help-me-find-specific-major-system-word-generator/72871/2

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).

View fullsize

View fullsize

View fullsize

View fullsize

View fullsize

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.

Six Weeks In: Mnemonics, Medicine, & Mental Health

“I’m keeping a vision in my head of donning a short white coat and diving head first into PA school.” That’s a quote from a blog I wrote in June of 2020, two weeks into my pre-med post-bac at Jefferson. I described that process as “Furiously trying to outrun a hungry lion, or trying to out-swim a tidal wave, and I am just barely staying ahead.” Just three years ago I was wrestling with general chemistry. And now in October of 2023, I’m about to finish my sixth week of PA School.

I’ve had 8 exams, seen 2 standardized patients, rotated in 1 ER, presented 1 patient to an attending (and messed it up badly), learned how to scrub into surgery, and can draw the brachial plexus from memory. I can tell you that A Fib. is irregularly irregular, show you how to flex your digitorum profundus, and ask you 2 questions from 14 different body systems. I can probably palpate your brachial pulse and definitely not palpate your popliteal pulse. I can also, with zero hesitation, tell you if you have infective endocarditis.

PA School so far is… kinda fun? I wore pajamas to school yesterday and drank water out of a Prego jar today (it’s Spirit Week). I mean, it’s definitely a lot of work and I know it’s going to get worse, but I’m not miserable. It sort of feels like I’ve been dropped onto another planet. It’s really sort of hard to explain. School and my life have become a single entity, and I don’t mean that in an unhealthy way. I’m a student again… and you really have to lean into that lifestyle. I feel very fortunate and lucky not to have to wake up and go to a 9-5 job every day. I’m in a 2 year break from the real world.

I realize that every hour of my day is valuable and I need to be very purposeful with how I spend my time. If you’re curious as to what six weeks of PA school look like, I’ve been keeping track.

Here’s my current process (so I can look back a year from now and compare). I wake up every morning at 5AM, and try to do the same on weekends. To help wake up in the morning, I created seven 3-song playlists that go off every morning at 4:55. Waking up to pop-punk music beats the hell out of an iPhone alarm. I go to sleep by 10PM every night. I am absolutely committed to sticking to that sleep schedule as long as possible. They told us that on average, students spend 4-5 hours a night studying. I don’t think that’s sustainable at all. I’m done class by 5PM at the latest (earlier some days) and I schedule myself “flex time” from 5-7PM. I use this time to run errands, drive home, take my dog for a walk, check up on social media, cook, eat dinner, and watch an episode of Parks & Rec. If I feel like I’m behind on studying, I will cut into that time a bit. I try to get some very focused studying done between 7-9PM every night, and rarely do I make it past 8:30 PM. If I’m struggling at night, hopping on a call with another student or two does wonders for keeping me engaged and motivated. I then try to do another hour or so in the morning before class starts and usually study during lunch. I take every Friday night off. I couldn’t study if I wanted to because I have zero energy left by the end of the week.

So what is studying? Studying for me right now revolves almost entirely around Anki which I started using the first week of school. The rumors about Anki are true, it’s incredibly powerful and super fun. I have an addon that makes studying seem like I’m playing Halo 3, awarding me medals for strings of questions I get correct in a row. And now I’ve connected a Nintendo Switch controller to my Mac to control my flash cards; I can even AirPlay to my TV. I’ve turned studying into as close to a video game as possible… and I actually look forward to studying. Anki makes studying incredibly organized and time efficient. It’s not just flash cards, it’s an entire study management system. And anything that can do even a fraction of thinking for you is a godsend.

I generate my flashcards in class. I read that taking notes in class isn’t super effective. So I figure I have two options. I can either pre-study and outline the slides and make flash cards and then go to class and fully engage in the lecture, or I can use the time in lecture to make flashcards in real time. The former is probably better, but I just can’t seem to find the time to do it. Plus, I don’t know how far we are going to get in lecture, and I don’t have the personalized touch of a professor to clue me into important concepts.

I study mostly alone, but mix it up with other classmates and small groups very often. I think it’s absolutely necessary to study with other people; it’s like crowdsourcing and very synergistic. You bring what you studied solo to the table, and then you bring home what you grabbed from the group. Often, other students will bring up the most obscure detail from one bullet point at the bottom of a slide… and without fail that’s usually an exam question. You have to find those people that have a knack for sorting through the hundreds of slides for what’s likely to be on the test. Once you find those people, hold onto them for dear life. Now, don’t get me wrong, group studying has downsides. Sometimes, actually very often, I find myself in a group and it seems that everyone is way ahead of me. That’s not necessarily a bad thing; just ask them to teach you. It’s infinitely more valuable to know what you don’t know, as overwhelming as that might be. Take that knowledge with you and then keep working on the concepts.

Reviewing 400+ PowerPoint slides is like sifting through mud, rocks, and dirt looking for anything of value. Is this important? Is this something? Should I hold onto this? I definitely don’t need this; they’ll never ask about that (oops). You simply can’t memorize everything. It’s just not feasible. They also can’t ask questions on everything. So you have to flip some coins and hedge your bets. The benefit of group studying is that you grind away and sort through your pile and then you review that with everybody else. And sometimes you have nothing but a bucket of dirt and an old shoe, and they have a truck full of gold. The magic is that everybody filters information differently. But now instead of just using what you went through for 10 hours, you’re adding 40 hours of work from 4 other students who went through the same information and picked up insights you thought were unimportant. And if 3/4 of them all picked up on something that you missed, there’s a good chance it’s going to be tested. And for this reason, it’s important to crowdsource your studying; it’s free real estate.

For one of my exams, I did start StoryNoting which I’ve found helpful so far (this is a concept where you type out notes in a very matter of fact way, like a stream of consciousness, in a way that’s meant to be read by someone else). It makes the flashcards have some more life and context and I find my mind navigating to the tables and charts I’ve made when I’m recalling information.

I’ve discovered something else that works incredibly well for studying. I call it a Matrix. Okay, it’s really not that impressive because it’s just Insert > Table in Google Docs. It utilizes spatial memory to recall information. I was trying to remember a detail about Atrial Septal Defects and remembered it was the first / far left column on the table I had made which helped me remember. One I made was for nine different secondary causes of headaches. And I found that what was even more powerful was including images and memes along with words. Okay, Archer (tinnitus) was next to the meme about bright lights. And I knew the middle of the Matrix was Pseudotumor Cerebri. There’s a certain safety to think of a specific location where you left some information, and then visit it in your head to retrieve it. It’s much less chaotic than just searching your brain at random for what the heck Lidocaine does for dysrhythmias. A Matrix is somewhere between just jotting down notes and a Memory Palace. It works.

The Matrices I have been making have expanded and I’ve been sharing them with other students. I’ve had multiple mention to me that they’ve been useful. It’s unreal how much that inspires me to keep pushing. You mean I can study, make silly mnemonics and charts and help other people? Whoa.

I think when you make content meant for other students, you find yourself presenting the information in a simple way. That’s a big part of the Feynman Technique. And to present something simply, you have to have a more complex understanding of it.

Do you know the most successful therapy for chronic venous insufficiency? It’s laser therapy. An exam I took just hours ago asked me that exact question. Do you want to know how I remembered it? I included a meme of Dr. Evil from Austin Powers talking about lasers in the table I made. I had the dumbest smirk on my face when I saw that question. It’s so stupid but it works so well.

I have used a few Memory Palaces so far. I made one for the 14 systems for a Review of Systems (I used the layout of my Planet Fitness) and another for the 5 major / 5 minor Duke criteria for Infective Endocarditis (I used my Aunt and Uncle’s lawn and house). Putting a clock on a tree that rang every 12 hours to signify persistently positive blood cultures got me another exam question this morning.

I also have plenty of acronym and acrostic mnemonics. I think the biggest memorization struggle so far are lists. There are so many lists for causes of things and at this point they’re all sort of arbitrary because I don’t know enough to make the lists obvious. Causes of Hypopnea? MAGO. Heart murmurs? PASS. Restrictive Cardiomyopathy? SSS. Kussmaul Respirations? DUMP. Brachial Plexus? MARMU. In my Room I do ARMS on TueSday (Rheumatic Fever causes Aortic Regurgitation, and Mitral/Tricuspid Stenosis). Causes of Apneustic Respirations? Red (stroke), White (brain damage [like white matter]), and Blue (hypoxia). Causes of Barrel Chest? PESCA (like shooting fish in a barrel).

And do you know what I don’t remember? Most things that I don’t have some type of mnemonic for. Do you know what I do remember? That Claud and Ray Migrate to get Burgers (triad for Buerger’s Disease); Spilled Salt? Please Lick Floor (Class I Antiarrhythmics). Churg-Strauss Syndrome? Strauss AVEnue (Asthma, Vasculitis, Eosinophilia). Can I tell you what Churg-Strauss Syndrome is other than those three things and that it’s an arterial vascular disease? Not really. Does it matter? Probably not. PA School is like jumping out of an airplane with a needle, thread, and an iPad with a 2 hour lecture on how to sew a parachute that you can watch at 2X speed… and you have 5 minutes before you hit the ground. Just survive… somehow.

Just last night I was studying with a small group and we were scratching our heads at the PERC criteria for ruling in/out pulmonary emboli. I suggested a Memory Palace and we made one together to memorize all eight criteria; it took all of 3 minutes. The topic was on the exam, and we all got that question right! I don’t think anyone understands the joy it brings me to share memory techniques with other people and for them to actually work!

PA School feels much different than pre-med studies because I’m finally learning the culmination of what I’ve been studying over the past three years. And not just that, but I’m learning about what I’ve seen in the ER. I honestly can’t stress how impactful my experience in the ER has been, even just six weeks in. The content in class, even though it’s a lot, all makes sense when you figure it all out. And it’s… useful. You go home and you feel proud that you can talk about the muscles in the back and arm now, or that you can talk about medications for hypertension. Everything so far is really logical and just makes sense. And you can use our own body to kind of provide grounding for what’s happening. That’s so much different than anything in pre-med.

If I’m making PA school sound easy, that’s definitely not the case. There have been plenty of struggles. After an exam, discussing questions afterward is a double edged sword. You feel great when your answer matched up with everyone else’s. When your study group developed some harebrained way to remember something and it shows up, or the concept you talked about seconds before the test shows up, it feels great to high-five the crew and build that camaraderie. But when everyone else said A and you said B, you feel stupid and embarrassed. You feel like you’re missing something and you feel like you’re falling behind. It’s not a great feeling and you start comparing yourself to other people. You hear a student explain a concept in such a matter of fact tone and there are times when you don’t even know what they’re talking about. And of course you think, “Wow, is everyone on the same page like that?” “Did people really think that exam was easy?” You start to bend your own truth: “Yea it wasn’t too bad,” when in your head you’re quietly screaming. Or you feel completely spent at the end of the day and overhear some other students who are going to keep studying for a few hours and wonder how they have the energy. Or you go to bed early to keep up on your sleep schedule but you lie awake for a bit thinking that most of the other students are staying up late to study. You feel guilty for taking a night off or taking it easy for a day. It’s a lot to handle and navigate mentally and emotionally. You’re already battling that early imposter syndrome and trying your best to stay confident in your own personal identity.

I think the important thing is to internalize all of this, reflect upon it, and make sure your own actions aren’t making the problem worse for other people. Here’s what I’ve learned. Never say an exam question or concept is easy. Easy is subjective and different for everybody. I think self awareness and humility aren’t just the two most important attributes for a student to have, but the two most important attributes in all of healthcare and probably life in general. If someone said they had trouble with a test question or exam and you thought it was easy, then lie and say you thought it was tricky also. I’m serious; straight up lie to them.

Okay, let me explain. You saying it was easy does two things: it boosts your ego and makes the other person feel like crap. Both of those are bad. So don’t do it. Match their energy and show empathy. Also, objectively, it probably was a tricky question but you just happened to study that concept more. Or you have some prior experience. Or you just grasped that concept better. Be self aware as to why you thought something was easy and how you got there because it wasn’t always easy for you. I think wrapping your head around this phenomenon isn’t too far removed from empathizing with your patients. Are you going through what your patient is going through? No, but you need to pretend like you are and put yourself in their shoes. So at the end of the day, you aren’t lying at all. You’re checking your ego, stepping down from your pedestal, and making a human connection. If you can master that (and I certainly haven’t), I think that’s huge.

I’d say pretty much every day here is a lesson in humility. I’m surrounded by brilliant minds that have been weeded through a wildly competitive and rigorous application process. And there’s not a day that goes by where at some point I feel stupid and inadequate. I’m not trying to be too self-deprecating here, but I think it’s important to address the lows. There are definitely times that I feel smart because I can explain a concept, or I knew an answer in class, or I remembered some obscure detail. But at the end of the day, it’s all sort of arbitrary. So I knew something and got a little hit of dopamine. Who cares?

What I did start doing is elevating other people around me: “Oh, wow, how did he/she know that? That’s awesome. Nice job!” Rather than think: “Shit, why don’t I know this?” Again, this isn’t easy to do but when I can, I pull out the old Uno-Reverse Card and it’s been working wonders for my mental health so far.

So yea, that’s six weeks of PA School in a nutshell. I don’t know how I’ll feel in another six weeks. If I’m being honest, the forecast looks busy and I’m sort of freaked out about it. We’ll see. I’ll see you in the next one.

Oh and P.S. I have my own white coat now! And a track jacket with my name on it. I’m one gray Patagonia fleece away from really being in the thick of it. It’s funny because I’ve been surrounded by white coats for a third of my life and at a certain point they kind of lose their meaning. But being handed my own short white coat… that’s pretty special.

Can I Survive?

A few weeks ago I flew back with my older brother from a four-day trip into the Maine wilderness to play a live reality game based on the CBS TV show Survivor. It followed the structure of the show to a T: two tribes, tribal councils, making shelter, tending to a fire, cooking rice, a tribal swap, a merge, hidden idols and advantages, voting players out and back in, and immunity challenges copied right from the show. Also like the show we were also met with extreme weather conditions as we battled a daylong torrential downpour and flood warning. It was one of the most unique experiences of my entire life. My mind continues to race weeks later and this blog is my attempt to empty out my head.

There’s a community called “Live Reality Games” (LRG) and it’s very close-knit and widespread. It’s like an alumni network across the country of people who love starving themselves, sleeping outside, and blindsiding each other. You become someone’s friend and then they lie straight to your face and stab you in the back and then somehow you become even closer friends and fly across the country to be in their wedding. Some of the challenges are pure torture. “Go hike up and down this hill seven times and we’ll give you flint to start a fire to cook some rice. Oh, there’s a flood warning and all of the wood is wet? Deal with it.” And people go wild for the experience, leaving behind their jobs, friends, and families to compete. For God’s sake, we had a guy fresh out of surgery with a knee brace and crutches and he still made the merge!

The brand of game we were playing was called Can You Survive, or CYS, which started as an online reality game that morphed into one of the most respected games in the LRG network. Each member of the game raises money for a charity. My brother and I were playing for the American Red Cross to raise awareness for CPR and AED training. This was an important cause for us because our Dad sadly passed away due to a spontaneous cardiac arrest last year.

The amount of organization that leads up to the production of CYS is amazing; it actually felt like I was on a well-produced television show. The theme of this season was “Blood Vs. Water” which meant that 8 of us were playing against and then along with our loved ones. The social dynamics that unfolded were unlike anything I had ever experienced before. I was assigned to the light blue tribe, Medomak.

The Tribe

My tribe consisted of Joel, a fun-loving human being with an infectious spirit. We bonded over pharmacology and our lives as healthcare students. Joel was so humble that he still rooted for our tribe after we sadly voted him out. His best friend Jon was on the other tribe. Jon and I actually spoke and connected quite a bit and I was sad when he left. Then there was Emma, sweet, kind, and a wonderful challenge companion; her elimination stung, although her husband on the other tribe was a returning player and a fierce opponent. Melanie was an LRG veteran and a close ally member; almost like a caretaker of the tribe that pulled out our personal stories and bonded us together. She taught me a lot about the game of Survivor. Kc was my first ally; a mysterious outdoorsman with an undying passion for the game that eventually led to his victory. His sister Veronica was his greatest cheerleader. Connor was a clear athlete and challenge beast. He was friendly and kept up our morale and was one of my favorite tribal teammates. His charm took him all the way to the final two. Jeanna was new to the game like I was, and fought harder than anyone at challenges. Despite being new, she was playing with her daughter Frances who was secretly the most connected to the CYS game and surprised me by making it so far. I sat next to her on my flight in, unknowingly. I kept the window open for her so she should work on her crossword puzzles. She quickly tucked her puzzles away when she realized that Kc and Veronica were also on the flight as she did not want to come across as a puzzle-solving threat! Then there was Ethan, the youngest player in the game with a heart of gold. His laugh and smile were infectious and a stark contrast to the environment we were in. He faced and managed the elements better than anyone. His sister Caitlin was a wily game-changer and my jury companion. Finally, there was me, new to the game and eager to play alongside my brother who was on the other tribe.

I loved everything about my tribe and was heartbroken with every vote out. We had some wonderful victories and I embraced my teammates like they were lifelong friends despite just meeting them hours ago. The camaraderie, brotherhood, and sisterhood of this game was something truly special. I’ve never excelled at sports growing up, so being able to be a part of a team victory was a new and invigorating feeling for me. Once we had reached the merge, I felt a longing feeling for the team dynamic that had now turned into an individual game. Being alone is much less fun.

The Game

The first night I spent wide awake in a clearing, staring up at the overcast, starless, Maine sky. I had never slept outside without a tent before and I didn’t sleep a wink that first night. A cacophony of snores and coyotes, an inability to find a comfortable sleeping position, and anxiety about the next day’s tribal councils were not conducive to sleep.

My brother and I were fortunate enough to have immunity during our first two tribal councils since we had raised the most money for our charity. Thank you to everyone who donated! For me, having immunity was like playing the game with training wheels which I was fortunate for. Once my safety was lifted, the anxiety and paranoia crept in.

I learned that every action of the game has consequences. Where I slept, whether to actually force myself to stay awake or get some rest, who I took walks with, who was watching me as I took my 100th pee break to make sure I wasn’t looking for hidden advantages. One time, I was genuinely searching for raspberries to eat since I was starving and I was mistaken for searching for an idol. You learn to exaggerate certain aspects of your personal life and completely hide others. Am I talking too much? Not enough? Have I tried to make genuine personal connections with everyone?

My first mistake in the game was pushing to vote out Louie. A fellow Italian and family man, I was inspired, however intimidated by his presence. He was personable, making great connections, and strong at challenges, exactly the person you don’t want sitting next to you in a final tribal council. It was way too early to target him but as a new player I didn’t know that. It hurt when he left and I felt regretful; especially since it hurt his partner Connor who was an alliance member; Connor found a new alliance which took him to the final two! Louie’s elimination was actually an accident. Me and my brother’s powerplay to vote him out had fallen apart and I went from feeling in control to feeling helpless and vulnerable. A sort of “live” tribal council unfolded as my alliance members started whispering to seemingly everyone but me. I grew extremely paranoid and anxious and had to communicate a change of plan to my brother from across the entire tribal council, while he was eating a reward that he earned, while our host Kelsey was asking the tribe questions, while the smoke of the fire blew in our faces. It was wild. I had switched my vote to Caitlin, who was voting along with her brother Ethan; they were still voting for Louie. And then, just before the votes were read, Caitlin pulled out a cursed immunity idol which she had found seconds before at the voting booth, nullified eight votes for herself, and Louie went home. My jaw was on the floor. I didn’t vote for Louie, but the plan backfired and my brother and I became huge targets. Oops!

Surviving

As the game continued onto its third day, I was growing physically, emotionally, and mentally exhausted. My most glaring mistake was aligning myself with Andi, Melanie’s mother and the oldest and wisest player in the game. Andi had regaled us with the adventures of her lifetime of scuba diving, exploring caves, and climbing mountains. She was truly a wonderful human being to get to know and has inspired me to do more with my life. She had an unconventional playstyle that led to my demise. We were stuck in a 4-4 vote-lock between me and Connor. Had the second round of votes also been a tie, everyone but myself and Connor would be vulnerable, minus two players who had immunity. The game is a lot of quick math you need to calculate, which is tough to do on the fly when you’re exhausted. I remember sitting there and every biological process in my body was saying “Dude, you need to eat and sleep and rest your brain, get the heck out of here.” I think from an actual survival perspective, my body was persuading me to stop fighting. Connor made a plea to Andi to stay, but I was too exhausted to plead my case. Andi ended up switching her vote to me and I became the second member of the jury, taking 8th place. I was disappointed but pretty relieved at that moment. I knew my brother had a better chance to win and I felt like we both couldn’t continue through the game anyway.

When you’re out in the wilderness, disconnected from your phone and social media, your mind has nothing else to do but ponder the intricacies of the game and explore your innermost primal emotions. You lie awake at night, counting numbers for future votes on your fingers. You forget about all of the problems and worries of your normal life; it’s actually kind of nice. Besides, you have enough worries in the game to keep your brain buzzing. I don’t think I’ve ever exercised my mind to the mental capacity required for Survivor, and I took a semester of accelerated organic chemistry! Who am I voting for? Why am I voting this way? What do I say when my target asks me who is going home? How do I tell a lie by speaking the truth? How do I persuade a conversation toward a target by not saying their name? How do I manage my constant anxiety and paranoia? How do I think ten steps ahead and run multiple scenarios through my head at once in real time, all the while running on no sleep, little food, and pure exhaustion?

I learned about fear and my own insecurities. I compared my own abilities to my competitors and let my fear misguide my decision-making. I learned that keeping and surrounding myself with those that were seemingly better than me was not only a great Survivor strategy, but also a great strategy for life and the workplace. I learned that I should put my fear aside in the future; I don’t need to be a challenge beast to succeed at the game and I’m better at challenges than I thought! I learned that I underestimate people. Some tribemates that I thought were struggling were actually veteran masterminds of the game. The term “threat” can be applied using about 100 different criteria when you’re out there.

A secret gift of the game is you feel insulated from the chaos of the outside world. The sounds of the nearby roads are just a reminder that there’s life on the outside. I find myself in the days after longing to return to the wilderness because it was a pure escape from reality; it should be called an Alternate Reality Game.

The most difficult challenge of Survivor is separating human beings from their existence in the game to their existence in real life. You get to know people by their out of game existence; their hobbies, traumas, families, occupations, hopes, dreams, and their similarities and differences, but you are judging and evaluating them by their in-game actions. I myself am an introvert and found the constant conversation of the game tiring but I had to push myself to stay social so I wasn’t isolated as the quiet one. That was tough for me. I’ve struggled to make friends my entire life but I’ve now bonded and befriended a wonderful group of people and I’ll treasure those connections forever.

Socks and Memory

Let’s talk about socks. I’m not an outdoors guy. I enjoy camping but don’t do it often. I foresaw that my footwear choice would be important in this game. I conducted some research and found that a pair of waterproof trail running shoes and a pair of knee-length waterproof socks might keep my feet dry and warm. As the days continued, our shelter became decorated with hanging wet socks and most of my tribemates were now competing and walking in the mud barefoot. I had dry feet the entire time and multiple inquiries into my magic socks.

Let’s talk about memory. On the first night, right as we were all huddled around the fire, production came up and placed a small Bluetooth speaker on the ground. What played through it was a ghost story (the theme of this season was ghosts). A spooky voice began telling a story… filled with numbers. I was familiar with this type of challenge and was ready for it; we would be tested on our recall of the story at a later time, which ended up being 48 hours later, seconds after I was voted out (ugh!). Now, in this little blog of mine, I talk quite a bit about memory. I’ll be in physician assistant school tomorrow and I’ve spent the last year researching and practicing my memory. The technique I use is called a Memory Palace, also known as the Method of Loci, or the Roman Room. As the ghost story continued to mention numbers (July 15, 1867, 13, 17, 26 screams, 9 breaths, 130 paces, 48 whacks), I created mnemonics and stored these numbers in pieces of furniture in my living room. I know that sounds insane, but it works. Those are the actual numbers from a story I heard now over a month ago.

What I had neglected to remember was what the actual numbers coincided with; I had the numbers down, and the exact order in which they appeared but was missing pieces. Over the next day, I pretended that I had remembered nothing and asked around. Through other tribemates, I was able to pull out the remaining information. I repeated this information maybe fifty times over the next 48 hours. I was ready for this challenge which for me, never came. Unbeknownst to me, as I was doing my exit interview, my remaining tribemates competed in the memory challenge. When I found out, I was so disappointed. I still walked away proud of the fact that I was able to employ a memory technique that I had been practicing! I believe my studies of memory helped me with another challenge that required us to copy a series of tiles from one table to another. I completed it with just two glances, and on the live stream you can hear production say they made that round particularly difficult. Woo hoo!

The End

A brightside to me being voted out and a member of the jury was that I got to go behind the scenes of the show. I’m a photographer and hobbyist videographer and have helped produce many events in my career so I love that type of thing. I even got to go to “Ponderosa” where the production team was staying. That’s where I got just a glimpse into the immense amount of thought and work that went into this game.

The final two of the game was between Kc and Connor, two of my original tribemates and alliance members. It was an extremely tough choice for me to vote for one of them. During nearly my entire time on the jury, I was going to vote for Connor. I had actually felt betrayed by Kc because he had written my name down; this wasn’t exactly true because if the rocks plan had gone through, I would have been safe (he explained this during his answer to my jury question). I was still torn, up until Kc made his final speech. He mentioned that he was also an introvert, had some social struggles, and that his younger self would have been proud of him. That hit me right in the heart because it sounded just like me. I ended up voting for Kc and he won the game.

There’s this phenomenon I’ve heard about that is a type of post-Survivor-stress that carries into your normal life. You start being paranoid that people are lying to you. You kick yourself for making mistakes. For me, I have these pangs of regret. Why did I do what I did? Why didn’t I just think to do this? If I had made this decision, I could have won. It’s not a great feeling; it’s awful really. I can’t imagine what the contestants on the CBS show feel. They’re playing for a million dollars! I was photographing a wedding the following week and as the bride was coming down the aisle I had a random intrusive thought: “Damnit, why didn’t I just stick with my original final six!”

My brother loves this game and the LRG community and had many friends on the production team. I felt fortunate to be implanted into his world and discover why he was so obsessed with this community. I felt blessed to not only play the game with him, but to be playing memory of our Dad. Joe and I got to both compete against and alongside each other in the same game, which was a dream come true. I don’t think we’ll ever get the chance to do that again so I’ll treasure that experience forever!

I try to repeat a mantra: “Good thing? Bad thing? Who knows?” Maybe it would have felt worse to be eliminated at 4, or 3, or 2 than 8th. I have no idea. Maybe I would have passed out from exhaustion the following day and been medevaced had I not been eliminated. The question I ask myself is this: Would it have been better for me to not play at all, than to play and makes the successes and mistakes and have the regrets that I do? Heck no. No way. There is my clarity and peace that I have no regrets.

Would I do it again? In an absolute heartbeat. I would need to make sure that mentally and physically I’m in a great spot. You can’t just play an LRG and then return to normal life. You need at least three days to recover your sleep and eating schedule, and then at least a week after that for the mental stress to die down. I’m writing this as a reminder to myself in the future. Looking back, I wish I would have pushed myself into more challenging roles in the challenges. In the end I ended up placing 8th, reaching milestones of the merge and jury. I feel immensely proud of my performance. I’d love to try again and return to the most rewarding, punishing, unique experiences of my entire life. Thank you to everyone who was a part of that experience for me. I’ll never forget it.

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.

Diabetes Medications: Quick & Dirty

I recently came across an interesting mnemonic: Ben Stiller Took Meg Griffin’s Dog Across Some Bridge. This puts in order, diabetes medication classes, from most effective, to least effective at decreasing A1c levels. The classes are as follows:

1. Biguanides

2. Sulfonylureas

3. Thiazolidinediones (TZDs)

4. Meglitinides

5. Glucagon-like peptide-1 receptor agonists (GLP1s)

6. Dipeptidyl peptidase-4 inhibitors (DPP4s)

7. Alpha Glucosidase inhibitors (AGIs)

8. Sodium/glucose cotransporter 2 inhibitors (SGLT2s)

9. Bile Acid Sequesters

First, we should define what A1c is. There are different types of hemoglobin, the protein that transports oxygen throughout our blood. The main kind in humans is called Hemoglobin A, which slowly bonds with glucose, forming hemoglobin A1c. I can’t find where the term “1c” comes from exactly. This process of adding a sugar molecule to hemoglobin happens spontaneously and slowly and creates a glycated hemoglobin. As your blood sugar increases, so does your hemoglobin A1c. The key here is that this is a process so your A1c levels are showing a weighted average over 120 days of your blood glucose levels. Neat. So managing that by decreasing that weighted average in Type 2 Diabetics in the following medication is important. Double neat. Let’s dive into the nine classes.

Biguanides are aptly first, as Metformin/Glucophage is a biguanide and is the third most prescribed medication in the US. It is available in two combination forms, with Sitagliptin: Janumet and with Empagliflozin: Synjardy. There are many benefits of biguanides. Their main MOA is the decrease of gluconeogenesis (the creation of glucose from non-glucose precursors) and the increase of peripheral utilization of glucose. It also improves your lipid profile (cholesterol) and reduces macrovascular risk. Common side effects of Metformin are GI-related, namely diarrhea. There is actually an extended-release type for this but it’s expensive.

Sulfonylureas are next. An example here is Glyburide/Glynase also known as Glibenclamide. This is the 200th most prescribed medication. Another is Glipizide/Glucotrol which is more popular (49th). Lastly we have Glimepiride/Amaryl (87th) which actually dropped 25 spots from 2019 to 2020. Sulfonylureas can cause weight gain and are metabolized in the liver and kidney. They can increase macrovascular risk yet Glipizide/Glucotrol is better for the elderly. THey work by increasing the secretion of insulin.

Next, the mouthful that are Thiazolidinediones or TZDs for short. These work by increasing the storage of fatty acids, so cells become more dependent on their oxidation of carbohydrates, specifically glucose. Examples here are the -glitazones. We have Pioglitazone/Actos (168th) as an example here. Like sulfonylureas, they can cause weight gain.

In fourth place we have the Meglitinides. There are two notable examples, Repaglinide/Prandin which you can take with renal failure and Nateglinide/Starlix which you can take with hepatic failure. Neither are on the top 300 list. Meglitinides are insulin secretagogues which means they increase insulin secretion.

In fifth place, we have the first of four of the long-named classes. Enter the glucagon-like peptide-1 receptor agonists. Whoa. We can call them GLP-1 for short. Remember that glucagon is secreted by alpha cells in the pancreas to increase blood sugar. They have a benefit over sulfonylureas and meglitinides as they have a lower risk of causing hypoglycemia. The GLP-1s all end in “-tide.” Examples are Dulaglutide/Trulicity (96), Semaglutide/Ozempic/Wegovy at 129, which should skyrocket as it has recently been used widely as a weight loss drug, and lastly Liraglutide/Victoza (146). These can cause nausea, vomiting, and diarrhea as well as gastroparesis. Wegovy is the higher-dose version of Ozempic and is marketed as an anti-obesity medication; it’s been in short supply recently in the US.

In sixth place we have the dipeptidyl peptidase-4 inhibitors or DPP-4 for short; they all end in -gliptin. Our first example here is Sitagliptin/Januvia (74). It can be combined with Metformin to create Janumet (154). The other two in the top 300 are Linagliptin/Tradjenta (293) and Alogliptin/Nesina (295). Side effects include pancreatitis, URI symptoms, and joint pain. Linagliptin/Tradjenta can be used in renal failure.

In seventh we have the Alpha-glucosidase inhibitors or AGI for short. These work by decreasing carbohydrate absorption in the GI tract. You want to avoid alcohol with these. An example here is Acarbose/Precose which is not on the top 300 list.

The penultimate eighth spot are the sodium/glucose cotransporter 2 inhibitors or SGLT2 for short. These all end in -flozin. Examples here are Empagliflozin/Jardiance (102), Dapagliflozin/Farxiga (217), and Canagliflozin/Invokana (294). You can combine Empagliflozin & Metformin to create Synjardy (238). These can cause weight loss alongside biguanides and GLP-1s. You want to avoid low carb diets and excessive alcohol here because you can go into DKA. SGLT2s along with TZDs can increase the risk of fractures. You also want strong kidney function to take these.

Our ninth and final spot are the elusive Bile Acid Sequesters. These are adjunctive only, meaning they are added onto something else. An example here is Colesevelam/Welchol. Don’t take these with gastroparesis. These can cause constipation and decreased vitamin ADEK absorption.

So there we have it! The nine classes of diabetes medications.

The 5AM Club - 129 Days

I have 129 days until PA school; that 100 day milestone is coming a lot sooner than I thought. I decided to take 5 months off before school starts. It’s definitely been an exhausting past few years and I figured I could use the time. Many people have been asking me how I’m spending the time off. I just recently finished reading Robin Sharma’s The 5AM Club. It was one of the more bizarre books I’ve ever read, but I loved it. It’s purpose, like any other self-help book, was to get across several learning models, but it did so through a story. I purchased the book based on the title alone. I’ve read over the years that waking up early is a key success driver for many of the world’s greatest people. I was used to going to sleep around 5AM, because of my work schedule, but I’ve adjusted my sleep schedule by 24 hours, and now wake up at 5AM most days. At first, it was as brutal as it sounds. I had to be in bed by 9PM to fall asleep by 10PM, or at least that is the ultimate goal. It’s been getting easier and I’m finally adjusting. I enjoy the time in the morning. My meal schedule is finally back to normal which means I’m snacking and binge eating less, which is great. The 5AM Club goes into detail on what you should do during the 5-6AM block; I haven’t gone deep into that detail just yet. I just want to get my body adjusted first. Once August hits, class will start at 9AM so I want to be fully energized going to class, instead of rushing to get there. I’m trying to go to the gym more and have succeeded in going more regularly than ever before in my life. I want to erase bad habits and install new ones between now and August.

Waking up early is interesting. It feels in a way that I am losing hours in a day, even though I’m really not. With my old schedule, I found myself staying up late because I didn’t want the day to be over. I felt like I hadn’t accomplished anything. But now that’s erased. I want to get a good night’s sleep because I’ll feel bad not waking up at 5AM. Now, I have built in some flexibility. If I am out with friends (though I am getting sleepy around 10/11PM), I allow myself to sleep until 7AM or later, mostly on the weekends. The process in general has allowed me to spend my time awake more purposefully which is something I feel I’ve been missing.

By the way, I took a break from my Memory Palace venture, but just picked it up again. I didn’t hit 300 when I thought I would, but I took the break purposefully. I’ll report back when I complete that!

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.

Quiet - Susan Cain

For a book titled Quiet: The Power of Introverts in a World That Can't Stop Talking, to say I was interested in taking a read was an understatement. I have always been a self-professed introvert yet over the past ten years or so this notion has been challenged by others. People are shocked when I tell them this. I’ve learned that introversion and extroversion are a spectrum, and I think I am certainly somewhere in the middle. With the more modern definition that says that it all depends where your energy comes from, my energy does not come from social interactions. Susan Cain’s Quiet touches upon a lot of topics that expand on my introversion and I wanted to share some of those gems.

Many introverts are also highly sensitive, which sounds poetic, but is actually a technical term in psychology. If you are a sensitive sort, then you are more apt than the average person to feel pleasantly overwhelmed by Beethoven’s Moonlight Sonata or a well-turned phrase or an act of extraordinary kindness. You may be quicker than others to feel sickened by violence and ugliness, and you likely have a very strong conscience. When you were a child you were probably called shy and to this day feel nervous when you are being evaluated, for example when giving a speech or on a first date. 

So right out of the gate, this spoke to me. I think pleasant overwhelmedness is an understatement related to my experiences with music. There’s rarely a better feeling for me than discovering a new song and even better yet, sharing it with someone else.

Cain then talks about how studies have shown that introverts are more likely to well, be extroverted, online. They are more likely to express intimate facts about themselves, blog to millions, yet have trouble introducing themselves to strangers. This definitely tracks. Some of the strongest social networks I’ve formed were back in the Xbox 360 / Halo 3 days and those were completely online. Also, this blog and my YouTube channel certainly mask my introversion.

On page 81 she talks about the idea of Deliberate Practice, identifying a task or knowledge that is out of reach, and working on the task that is most challenging to you personally. The motivation has to come from within. This takes me back to the organic chemistry days with certain concepts that were getting the better of me. I’d lock myself in a room and just say, “I’m not leaving until I have understood, mastered, and can teach this concept.” That’s deliberate practice. And what Cain says in Quiet is that deliberate practice is best completed alone. And it makes sense when you think about it; you need intense concentration and others can be distracting. “If you want to improve what you’re doing, you have to be the one who generates the move.” She talks about Steve Wozniak as an example; he was deliberately practicing engineering alone since he was a kid. The book also mentions that a predictor for expert performers was “serious study alone” and found in chess grandmasters, athletes, and college students: “College students who tend to study alone learn more over time than those who work in groups.” How very depressing.

Later, Cain talks about open-plan offices… and rakes the concept over the coals. “Open-plan offices, at one point thought to be the next generation of the modern office space, have been shown to reduce productivity, impair memory, increase staff turnover, make people sick, hostile, unmotivated and insecure… increase blood pressure and stress, and it just goes on from there.” Yowza. “Top performers work for companies that give them privacy, personal space, control over their environments, and freedom from interruption.” And there’s more: “Open-plan workers… have fewer personal and confidential conversations with colleagues. They’re often subject to loud and uncontrollable noise, which raises heart rates; releases cortisol (hey, I just wrote a blog about cortisol), the body’s fight-or-flight “stress” hormone; and makes people socially distant, quick to anger, aggressive, and slow to help others.” I mean, if that doesn’t describe an emergency room’s nurse’s station, I don’t know what does.

Cain then talks about how population density is correlated with innovation. She talks about how she was much more productive in a crowded coffee shop vs. at home. She was still able to deliberately practice, just amidst a buzzing coffee shop. She could still control her environment by coming and going as she pleased. It was all about the mere presence of other people. I have personal experience with this. In one of my past jobs, I was so much more productive in the company of others. And just a single other person is all I needed nearby. But once I was working in a space by myself, my productivity plummeted. So I think studying and deliberate practice is different than the relatively low stakes operations of an office job; there’s almost a reverse effect there. So I think it’s about working around someone, not with them. I also worked twice in the lobby area of an office, and found that I was more productive there than in my own private office. A lot of nuance here! The conversation about the workplace continues:

Some companies are starting to understand the value of silence and solitude, and are creating "flexible" open plans that offer a mix of solo workspaces, quiet zones, casual meeting areas, cafés, reading room, computer hubs, and even "streets" where people can chat casually with each other without interrupting others' workflow. At Pixar Animation Studios, the sixteen-acre campus is built around a football-field-sized atrium housing mailboxes, a cafeteria, and even bathrooms. The idea is to encourage as many casual, chance encounters as possible. At the same time, employees are encouraged to make their individual offices, cubicles, desks, and work areas their own and to decorate them as they wish.

If you don’t know, I’m already obsessed with the Pixar workplace, so I loved everything about this. What’s more, when I first walked into the main building of the PA program I plan on attending next year, I was instantly reminded of the atrium on the Pixar campus; it had an open atrium in the center of the building, and even had a café, just like Café Luxo!

Cain then goes on to talk about finding your sweet spot, your place of optimal stimulation. Her example is is lying contently in a hammock reading a great novel; wow does that sound nice. Then she talks about, after a while, being underestimated so you seek out a friend for brunch. I think I’m in my sweet spot right now. I just had some family over so I feel overstimulated. I’m now in my quiet basement, with my smart lights on, in the absolute quiet and feel at peace enough to finish this book review. What’s interesting, though, is that I rarely find a time where I am seeking out additional stimulation; I’ve always been okay with the peace and quiet.

Popularized by psychologist Mihaly Csikszentmihalyi, the state of “flow” is the optimal state in which you feel totally engaged in an activity. Hours can pass without you noticing. “The key to flow is to pursue an activity for its own sake, not for the rewards it brings.” Probably the most resonant (no pun intended) of all periods of flow for me has to be in authoring a 400-page study guide for organic chemistry, just for the sake of doing it. I don’t think I’ve ever been more devoted to a project, just for the sake of the project, than that. I think that shows that I love both writing and teaching, but really just problem solving and understanding a complex topic to then put it into normal language, is the driving force there.

On page 200, Cain talks about restraint and quotes Gandhi:

I have naturally formed the habit of restraining my thoughts. A thoughtless word hardly ever escaped my tongue or pen. Experience has taught me that silence is part of the spiritual discipline of a votary of truth. We find so many people impatient to talk. All this talking can hardly be said to be of any benefit to the world. It is so much waste of time. My shyness has been in reality my shield and buckler. It has allowed me to grow. It has helped me in my discernment of truth.

There’s also a chapter here about comparing Easterners and Westerners (in the world) and the education gaps in science and math. They key, it appears, is what’s called “quiet persistence.” Westerners give up much more quickly than Easterners. We are less patient. It’s all about just throwing your whole self at a concept until you come out the other side with it fully mastered.

Later on page 209, Cain talks about Free Trait Theory, created by professor Brian Little. The idea here is that we do indeed have fixed traits that we are born with, like introversion, but we also have these other free traits. We can act out of character and act like extroverts for “the sake of work they consider important, people they love, or anything they value highly.” I think this explains how I was able to work as a student leader in college, or tutor a group of students in organic chemistry. I really care about that stuff. This is why I can lecture with such passion in the YouTube videos I create explaining organic chemistry topics; it’s Free Trait Theory!

On 233 Cain talks about the myth that venting sooths anger. It doesn’t; it fuels it. So what do you do when you want to vent? Take a breath. Take a break. Then ask yourself if it’s really worth getting so upset. If the answer is is, then tackle the problem as a conversation and not an attack.

The last section I quoted from my original notes is as follows:

Spend your free time the way you like, not the way you think you’re supposed to. Stay home on New Year’s Eve if that’s what makes you happy. Skip the committee meeting. Cross the street to avoid making aimless chit chat with random acquaintances. Read. Cook. Run. Write a story. Make a deal with yourself that you’ll attend a set number of social events in exchange for not feeling guilty when you beg off.

I LOVE this. Had it not been for the tradeoff at the end, it would be a perfect quote. But, I suppose, you can’t completely cut yourself off from the entire world. But normalizing everything else, like staying home on New Year’s Eve; I love that notion. Do what makes you happy, but be honest with yourself, you know? If you want to achieve specific social goals, then set out to do that.

Glycolysis and Friends: Pyruvate, Acetyl CoA, Ethanol, and Lactic Acid

So a couple of months ago I started experimenting with a new studying style; handwriting instead of typing. I actually wrote a blog a couple of years ago about which is better, and handwriting was the winner; it was actually one of the first blogs I ever wrote and I’m as obsessed with the topic then as I am now. Yet after over two years of pre-med studies, I’ve stuck with typing. But I realized not a lot of what I’m learning is sticking and I want to fix that. So I started reading the Pearson Biochemistry book because that’s apparently what I do in my spare time, and have been handwriting notes as I go through.

I actually started with this frustration about concepts such as glycolysis; it’s a topic I’ve studied for years yet I feel I can’t truly explain it in plain language; or any language for that matter. So I went back and spent some time with glycolysis, for no other reason but my own knowledge; I actually started all the way back in my biology textbook. And I handwrote what I learned. And over the next couple of days I practiced recalling the key ideas behind glycolysis. And… I think it worked. I mean, I had to review my notes just before writing this, but most of what I recalled was there. I wanted to, for the sake of finally committing this to memory, and creating a place that I can access in case that memory lapses, talk about glycolysis.

Glyco– comes from Greek glykýs, meaning “sweet” and “lysis” means… you know, to break apart. The idea here is to break a six-carboned sugar, glucose, into two, three-carboned sugars which are called glyceraldehyde 3-phosphate (G3P) and dihydroxyacetone phosphate (DHAP) but they aren’t really important here. There is, however, a 3-carbon compound that’s very important: pyruvate.

The main goal of glycolysis is to create two molecules of pyruvate. Pyruvate is a negatively charged, conjugate base of pyruvic acid. Pyruvic acid is a cool molecule, because it’s a combination of a carboxylic acid and ketone functional group. Before I talk about what happens next to pyruvate, I want to talk about oxidation. The age-old mnemonic for me is LEO / GER, where LEO stands for “lose electron oxidation.” And this is what we do to fuel, we harvest its electrons to give us energy. And a key fuel for us are carbohydrate polysaccharides like sucrose, lactose, and starch. First, however, our digestive system must hydrolyze these polysaccharides into the monosaccharide glucose before glycolysis can begin. The chemical formula for glycolysis is glucose + oxygen to create carbon dioxide, water, and “energy.” Oxygen is the oxidizer here; it plucks electrons from glucose. Unlike an acid/base reaction (glycolysis is technically a combustion reaction), however, it’s not just an electron that is being harvested, the proton goes with it or, in other words, an entire hydrogen atom; this is sort of where all of the carbon dioxide comes from. Oxygen is electronegative because it has a large number of protons in relation to its valence electrons, giving it a nice healthy positive charge that attracts electrons like crazy. Oxygen is not only the indirect oxidizer (electron harvester) of glycolysis (NAD+ is technically the oxidizing agent of glycolysis), it’s the ultimate electron receptor at the end of oxidative phosphorylation, where we get most of our ATP.

Okay, so glycolysis occurs in the cytosol. And now that we have pyruvate, which is a product of the oxidation of glycolysis (there are a bunch of steps to get there) it enters the mitochondrion (via active transport since it’s charged) and then it’s further oxidized into a high-energy compound called acetyl coenzyme-A or acetyl CoA. To become acetyl-CoA, Pyruvate is actually oxidized this time by something called NAD+, which becomes NADH because it is picking up a hydrogen. Acetyl CoA is… massive; it has 89 atoms in total! The only resemblance to pyruvate is that it’s just the lopped off ketone part, now called an acetyl group. Okay so I mean most of acetyl CoA is coenzyme A. Enzymes are proteins; they are long chains of amino acids. We’re getting serious now. It’s acetyl CoA that then enters into the citric acid cycle.

I want to talk about whether glycolysis is an aerobic or an anaerobic process. Here’s the deal. Glycolysis will oxidize pyruvate whether oxygen is present or not. If oxygen is available, then we can continue forward into the citric acid cycle; it’s about electronegative oxygen driving the cycle and the electron transport chain. If oxygen is not available then glycolysis can continue onto fermentation, an extension of glycolysis. And here’s the crazy thing, in alcohol fermentation, pyruvate is converted to ethanol.

Let’s take a step back for a second. Under aerobic conditions, NAD+ is recycled because NADH transfers its electrons into the electron transport chain. However, in the absence of oxygen, NADH can transfer its electrons directly to pyruvate. The purpose of this is to regenerate NAD+ as an oxidizer which can then further harvest electrons; that’s fermentation. There are two types: lactic acid fermentation, and alcohol fermentation.

In alcohol fermentation, pyruvate is converted to acetaldehyde which is then reduced by NADH, regenerating NAD+, the purpose of fermentation, to ethanol. Alcohol fermentation does not occur in humans, however we certainly use this process for baking and brewing.

Lactic acid fermentation, however, does occur in humans. We use this process when oxygen is scarce, like during strenuous exercise. It’s been mistakenly thought that lactic acid build up is what causes muscle soreness, but this isn’t the case (it’s likely just the stress and trauma from tearing muscle fibers). In lactic acid fermentation, pyruvate is reduced directly by NADH to form lactate, the conjugate base of lactic acid (remember the relationship between pyruvic acid and pyruvate). Lactic acid fermentation also has non-human uses and is utilized to create cheese and yogurt.

So there you have it! I found this all very interesting. Fermentation, specifically is a process I remember hearing about and “learning” about so often but I never grasped what its purpose was. Hopefully committing this all to a blog will help me remember this all!