Steroids: Quick and Dirty

Steroids. I’m taking one right now, prednisone (Deltasone / Rayos; thanks, memory palace!) because I’ve been sick for two weeks. So what are steroids, what do they do, and how does prednisone work? Let’s dive in.

What I do know is that steroids are lipid-based; they have that cyclic four-ringed structure and are related to cholesterol, which is a type of sterol, which are related to steroids. Steroids do two things: they are a part of cell membranes (I remember cholesterol also being a part of cell membranes) and act as signaling molecules, I believe as hormones. The adrenal cortex houses several lipid-based steroids, in a general class called corticosteroids: aldosterone, which is a mineralocorticoid (it increases blood pressure), and the three Cs, the glucocorticoids: cortisol (often known as the stress hormone), corticosterone, and cortisone. The glucocorticoids speed up gluconeogenesis, the creation of glucose from non-carbohydrate precursors, are anti-inflammatory in nature and suppress the immune response. So what about prednisone?

Prednisone, a glucocorticoid, was patented only in 1954 and is the 27th most commonly prescribed medication in the US. It’s mainly used to suppress the immune system and decrease inflammation. Okay, so that tracks with the three Cs. Prednisone is taken orally and is a prodrug that is converted to prednisolone by the liver before it becomes active. That’s interesting because I’ve been prescribed prednisolone (139th most prescribed) also. Prednisone is used to treat respiratory issues such as asthma and COPD. So, prednisone by itself does nothing; it’s a prodrug. It has to be converted/metabolized in the liver to prednisolone, so we need to look at the pharmacology there.

So prednisolone is lipophilic and can pass through cell membranes easily. Because steroids are lipids, they love fat, are uncharged and non-polar and mesh well with the C-H bonds of the cell membranes. They enter and bind to the glucocorticoid receptor (GCR) in the cytoplasm. I can’t find exactly where it’s located; I think it’s just sort of floating around. Once it binds, the end result is the synthesis of anti-inflammatory proteins and a block of transcription of inflammatory genes. Neat. So in terms of asthma, steroids reduce the inflammation of inflamed airways. My nose and throat are irritated and inflamed and the steroid is helping that. Double neat.

So what are other kinds of steroid medications? Well of the top 75 commonly prescribed, along with prednisone at #27, we have fluticasone (Flonase) at #18, which is a glucocorticoid and budesonide/formoterol (Symbicort) at #57, which is another glucocorticoid. And an honorable mention goes out to dexamethasone (Decadron) at #272, which is also a glucocorticoid that made me vomit when I had my wisdom teeth taken out. So there you have it. Steroids: quick and dirty.

Wait, but what about NSAIDs!? Non-steroidal anti-inflammatory drugs? That’s for another blog!

The Roman Room

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

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

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

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

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

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

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

Commit This To Memory

I wanted to talk a bit about memory & mnemonics. I’ve used mnemonics quite a bit in my studies, most notably to learn the hormones of the pituitary gland. I used them before that as well for the amino acids. I actually coupled the mnemonics with a number code system, and it worked great. The first thing I noticed is utilizing what I call “Smart Mnemonics” where the word you are memorizing is as similar to the real world as possible. For example, I used “professionally” for the hormone prolactin and “pros” for the amino acid proline. You might have to get a little creative with creating a string of words that make sense, but I’ve found that it helps a lot. The problem, however, is that I can remember the pituitary hormones, and in a specific order but I can’t remember their functions as easily. Does it make sense to create a second mnemonic that helps with the functions? Is rote memorization better? I’m also interested to see if there is a limit… how many mnemonics can you actually remember? And how long are they retained in your memory? The amino acid mnemonic I’ve since forgotten, but the hormone one I still remember, however I’ve used it a bit more recently, and over a longer period of time. Also, I’d like to find out if a photographic memory or the “I just need to read the chapter once” phenomena are true.

So the mnemonics I’ve used in the past are literally just acronyms, or name mnemonics, the 2nd of 10 types of mnemonics listed on Wikipedia. There is one that I’ve actually never heard of to memorize the diatomic elements, BrINClHOF or “Have No Fear Of Ice Cold Beer.” Other types include music mnemonics (the ABCs), model mnemonics (like diagrams or charts, which I’ve used in organic chemistry), and note organization mnemonics, which are flash cards and lists. Lastly, there lists the visualization mnemonics, an example being the infamous method of loci. Interesting. Okay, so there are plenty of types… but do they really work?

There’s actually a World Memory Championship and what goes on there is quite staggering. It does not appear, however, that the ability to memorize hundreds of words in minutes is due to some anatomical advantage, it’s simply via training and mnemonic strategies. Ah hah, and the most prominent technique? The ancient Roman/Greek method of loci, also known as the memory palace or roman room. So if the top memory athletes in the world are using that strategy, well I should look into it.

My initial exposure to this method was when I heard about the “memory palace.” Where you pick a room basically, your “palace” and you place things to be memorized in locations. Like glycine in a chair, and leucine on the stairs. But I guess I need to come up with some sort of connection there? Like maybe glycine is in the glyrage and leucine is loosely floating in the bathtub or something. Regarding the memory palace, there’s an interesting article over on Med Insiders:

This is what professionals use in memory competitions. Not being one myself, I would use the memory palace only for concepts that didn’t fit well into either regular flashcards or mnemonics. If a concept was particularly difficult for me the memorize, I would go with the memory palace. The reason for this was that the memory palace takes the greatest amount of time to create, but it is the most robust way to memorize information.

Yea, but that doesn’t make sense. The entire idea of these memory competitions is that they are timed. I would argue memorizing 100 flashcards is much more time intensive, because you can’t do it in a single run-through. I keep seeing that you walk through a location and place items. So perhaps I would walk around my entire house and place like 20 hormones.

I listened to a video today that outlined the strategy and I used my house as the “walk.” What I had to remember was a list of numbers, and I still remember almost all of it, 12 hours later. I walk into my front door and see 3 kids on the stairs (like at the bottom, middle, top of the stairs), then I walk into my living room and see 14 (I saw two weekly calendars, or visualized 2x7) then into my dining room where I saw 6 candles on my chandelier, walked into the kitchen and saw a 9 as a cat on the windowsill, then into the family room to see 2 people, then finally into the bathroom to see 5 candles. I’m a bit fuzzy on which was 5 and which was 6, but the fact that I remember this is pretty staggering.

The other thing I stumbled upon is a thread on a forum called Art of Memory where a medical student describes the memory techniques they used to memorize the characteristics of a certain disease. The whole post is worth sharing:

On a side note, an intermediate method that became one of my favorites was creating brief stories that either did or did not have a physical spatial setting involved. For example, to memorize the adverse effects of Tamoxifen, an antineoplastic drug, I imagined my friend’s sister Tammy. I thought up ridiculous things either about her or happening to her, each of which represented one of the adverse effects of the drug.

So I start with making an image of what the disease unit I am trying to study is (lets say Wilsons disease) something most med students have heard of but it has enough hard to remember information correlated with it that its a good example.

I have this disease placed in one of the nursing stations at a hospital I worked at prior to med school. My memory hook is Wilson the volleyball off of Castaway and also Tom Hanks. I picture them in the middle of my location just standing there to start. Everything that is going on in the image revolves around them and the end goal is when I hear Wilsons disease is to recreate Wilson and Tom Hanks in my head after which everything else should rematerialize when I need to recall it. I will break it down as follows: a black cat is my key code for the number 13 (I only have images for numbers up to 100 or so since that’s all I really need in regards to medicine)

Wilsons disease is on chromosome 13: black cat playing with the Wilson ball mutation in ATP B7 gene- ATP= batteries, B= a bee, 7= boomerang. a battery powered B toy throwing a boomerang next to Wilson. Copper builds up in liver, and basal ganglia (mostly putamen) So tom hanks has a copper liver and copper putters in his brain (a putter is my image for the putamen) copper build up causes cirrhosis = this goes without saying but lets make that copper liver nodular the copper build up in the putamen causes psychotic like symptoms (relatively to patient’s baseline), irritability, and Parkinson like issues. So essentially I picture Tom Hanks with swirly crazy eyes, while he’s looking all over the place all distracted and has cogwheels taped to all his joints while he walks around shuffling.

Labs- low cerumoplasmin- My picture for low is usually a red pet cage with a down arrow door. So I have flubber in this cage (flubber just sounds like cerumoplasmin doesn’t it)? High free copper (a ton of pennies floating around Wilson the ball, and high urinary copper. a bunch of pennies in a piss puddle by Tom Hanks. Most copper is excreted by bile (so I put a gallbladder in a garbage can that Wilson the ball is sitting on top of).

Tx- penicillamine- a bunch of pencils in a mine. Trientine- three ents (either from Lord of the Rings, or Warcraft 3).

Holy. Crap. Not only does the poster share my name, but they mention Lord of the Rings and Warcraft 3, two franchises I am fond of. So there’s a lot to unpack here, but what stood out to me most is that this person has image keys for the numbers 1-100. So if 15 was a cannon for example, (James Buchanan was the 15th president), and a certain medication’s dose was 15mg, then you would work a cannon into the image. That’s one of the craziest things I’ve ever heard. But you can already imagine the possibilities. You can put things in cannons, people can operate cannons, they can be certain colors, be in certain places, etc. So I can visualize how that would work with a string of numbers. I definitely want to try and apply the basic memory palace technique to the hormones and see how I do.

So one of the things I was really interested in was the idea of memorizing an entire deck of cards, and then picking up another deck and organizing it in the same exact way. The record for this by the way is under 13 seconds. Yes, 13 seconds. The whole idea here is yet another memory technique called person, action, object. What you do is assign every card a person, action, and a object. So the queen of hearts for example would be your mom, her action would be let’s say cooking, and the object would be with a spatula.

The method of loci is definitely something I want to look into. The Feynman Technique is also something I want to talk about eventually. Then there is the Major Mnemonic System where you assign letters to numbers; letters are easier to remember than numbers. This is how people memorize 100 digits of pi or a list of phone numbers. I also want to learn how to memorize an entire deck of cards. I’m becoming fascinated with memory.

Sources

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5439266/

Dresler M, Shirer WR, Konrad BN, Müller NCJ, Wagner IC, Fernández G, Czisch M, Greicius MD. Mnemonic Training Reshapes Brain Networks to Support Superior Memory. Neuron. 2017 Mar 8;93(5):1227-1235.e6. doi: 10.1016/j.neuron.2017.02.003. PMID: 28279356; PMCID: PMC5439266.

https://forum.artofmemory.com/t/memory-palaces-in-medical-school/34920/5

https://medschoolinsiders.com/pre-med/memorization-techniques-method-of-locimemory-palace-mnemonics-and-how-to-actually-use-them/

Big D-Dimer And The Kids Table

Another very common term I’ve heard in the ER is a “D-Dimer.” I mainly hear it with patients who are short of breath and are being evaluated for a pulmonary embolism. Let’s find out what exactly a D-Dimer is. 

First we need to talk about a very important duo in medicine: plasmin and fibrin and their precursor enzymes: plasminogen and fibrinogen. We’re first introduced to fibrinogen when we learn about the composition of blood. Blood contains two main components, plasma, and formed elements: 

  1. Plasma (55%)

    1. Water (92%)

    2. Plasma Proteins (7%)

      1. Fibrinogen

      2. Albumin

      3. Globulins

    3. Other Solutes (1%)

  2. Formed Elements (45%)

    1. Red Blood Cells (99.9%)

    2. White Blood Cells & Platelets (<.1%)

Formed elements are made up of red blood cells (99.9%) and white blood cells & platelets (<.1% each). So yes, nearly 45% of our blood is straight red blood cells. Well where does fibrinogen come in? Well the other 55% of blood composition is plasma. This is composed of 92% water, and 7% of what are called plasma proteins (the other 1% is “other solutes”). Within those plasma proteins we find fibrinogen (the others are albumin and globulins).

We can think of our bloodstream as a river, because well half of it is water. And swimming through it are a ton of salmon, like a ton of them (red blood cells). Plasma proteins are like the other animals just chilling in the river (otters, bears, beavers), far outnumbered by the salmon and let’s say one of them is a beaver. The beaver is fibrinogen and is a critical component of a blood clot (hey, let’s call that blood clot a dam in the river!). 

When our body needs to stop bleeding, it activates hemostasis (meaning a halt of blood), which includes the vascular, platelet, and coagulation phase. Fibrinogen is actually soluble so it would just wash away in the stream, but it’s activated by an enzyme called thrombin into its active, insoluble form, fibrin. 

Thrombin acts on Fibrinogen (found in blood plasma) to activate it to insoluble Fibrin

Insoluble fibrin produces blood clots, or thrombi; fibrin is like logs in a damn. So our fibrinogen beaver just needed some inspiration before doing what he does best which is why thrombin comes along and cheers him on. But here’s the thing right… blood clots can be dangerous. If this big fibrin damn were to break off and form an embolus (a traveling thrombi), it could block off a part of the river that we don’t want blocked and that could mean big trouble. 

Just for the sake of my dumb river creature metaphor, we aren’t blocking off the entire blood vessel when it’s bleeding. It’s like if the river spills over a bank into an area it’s not supposed to go, or breaks a levy, so we need to dam off that section to ensure all of the water is moving downstream where we want it.

So after the fibrin dam is built and bleeding stops, and our body recognizes that it’s all done with the fibrin dam / blood clot, it calls in the clean up crew to break it down. Enter fibrinolysis, which by its name we can see means the lysis (disintegration) of fibrin. Two enzymes come in to call the shots for the clean up crew, tissue plasminogen activator (tPA) and thrombin again (which is pretty interesting). 

Thrombin is like the superintendent of this whole project, noticed the dam is complete, and calls in the clean up crew. This clean up crew is composed of something called plasmin.

Thrombin and tPA  activate a proenzyme plasminogen to produce the enzyme plasmin, which can digest the clot and break it up. So it’s fibrin and plasmin, fibrin and plasmin. The clotter and the digester. 

And plasmin is going absolutely ham on this clot. So there’s pieces of wooden fibrin flying everywhere. A type of this shredded fibrin, or a fibrin degradation product (FDP), is called D-dimer. It’s like the splinters and parts of a shredded log. D-dimer isn’t normally present in our plasma unless some type of coagulation is happening, and thus the need for fibrinolysis has occurred. So if we notice D-dimer, a clot is being degraded, or attempting to be degraded somewhere in the body, which is an indication of a pulmonary embolism.

So here is sort of this whole process. We start with our soluble fibrinogen, which is then activated by thrombin. So then it forms this fibrin mesh, which I’m not sure is insoluble yet. It’s when Factor XIII (13) comes in (more on clotting factors later) that we form this crosslinked, insoluble fibrin mesh. Factor 13 is known as the fibrin stabilizing factor. And remember that plasmin is our clean-up crew that is deconstructing this crosslinked fibrin mesh, part of which is the D-Dimer. And we can see where the namesake comes from here. Fibrinogen has two “D” subunits, and the dimer (or two identical molecules) is two D subunits crosslinked together (both linked to an E subunit). But what does the “D” stand for!? I see there’s a D and an E domain of fibrinogen. I also see an alpha, beta, C, D, and E domain. So it’s just an alphabetical list and doesn’t stand for anything.

Pulmonary Embolisms

Okay so what exactly is a pulmonary embolism and why do we care about them? Well a thrombus is a blood clot and when it breaks off and starts to move, it’s called an embolus. See at first I thought a clot just sort of just appeared in the lungs. Or maybe it came from somewhere in the heart. So it turns out the most common source of these emboli are in the veins of our legs, known as deep vein thromboses. Blood in our legs already has a lot of work to do to fight the forces of gravity and come all the way up to reach the inferior vena cava and enter the right atrium. That’s why veins have valves in our veins to prevent backflow. Our muscles in our legs actually contract to help pump blood up through our veins. 

The vasculature of our lungs is very expansive. It’d be quite easy for an embolus to get trapped there, and cause ischemia to lung tissue and alveoli, prevent oxygen exchange, and cause us to breathe faster to compensate, and eventually be short of breath. So the embolus starts in the leg, goes into the right atrium via the inferior vena cava, and then the right ventricle, and then through the pulmonary trunk into the pulmonary arteries. So it’s deoxygenated blood that gets trapped, never getting the chance to get oxygenated. It can’t really go any further, right? It’s lodged there; the vasculature just keep getting smaller.

The interesting thing is that if you have a high risk patient, like a patient who just had surgery and is immobile for a while (there are other factors), you should just go straight to imaging (CT scan) and skip the D-Dimer as a screening test. A special type of a CT, called a CTA scan (CT angiography) with contrast to show the blood vessels in the lungs can be used.

So what’s the treatment for a PE? You can use a blood thinner to help prevent existing clots from getting bigger and from other clots forming. Some clots dissolve on their own.

Clotting Factors

In my research, I came across the mention of several clotting factors. There are 13 of them, named by roman numeral, in the order they were discovered. Our beaver fibrinogen is actually Factor I (fibrin I’ve seen is Ia) Factor II is prothrombin. Factor XIII (13) is involved in the creation of insoluble fibrin.

It’s also worth noting that there is a pretty extensive coagulation cascade with an intrinsic and extrinsic pathway featuring all of these clotting factors, but I think that’s outside the scope of this post.

Sources

Martini F, Nath J, Bartholomew E. Fundamentals of Anatomy & Physiology. 2018. Eleventh Edition. Pearson Education. 

Bounds EJ, Kok SJ. D Dimer. [Updated 2021 Jul 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK431064/

National Center for Biotechnology Information (2022). PubChem Compound Summary for CID 439199, Fibrin. Retrieved March 3, 2022 from https://pubchem.ncbi.nlm.nih.gov/compound/Fibrin.

Mpt-matthew, CC BY-SA 3.0 https://creativecommons.org/licenses/by-sa/3.0, via Wikimedia Commons. https://commons.wikimedia.org/wiki/File:D-dimer_production.pdf

https://www.mayoclinic.org/diseases-conditions/pulmonary-embolism/diagnosis-treatment/drc-20354653

Accepted

Over two years ago, my life was quite stable, but stability can be dangerous. I had a full-time, well-paying job. I was a homeowner. I was engaged, even. I eventually gave up all three of those things. I realized I wasn’t where I wanted to be, at all. I took a huge risk and decided to quit my job and move back in with my parents in order to pursue a career in medicine. I became a full-time post-bac student at Thomas Jefferson University and thus began the two most challenging years of my life.

Today, over two years later, I received a call from the Physician Assistant Program at DeSales University, where I interviewed just 8 days ago, informing me that I had been accepted to the program.

I’m in many ways speechless. I truly feel that I am a strong candidate, but I’ve spent the last 8 days overthinking every aspect of the interview day. Did I sit in the best seat during the group sessions? Did I participate enough during the class observation? Did I participate too much? Did I send enough thank you emails? Should I have written what I wrote during the ethical writing sample? Rest assured, whatever I did and said worked. I feel like my experience over the past 11 years speaks for itself. I am a non-traditional candidate in most definitions of the word and I sincerely think that worked to my benefit.

It’s such a strange feeling. First off, I plan to see if I receive any other interviews at other programs. However, what I’ve seen at DeSales has blown me away. Their pass rates, statistics, facilities, faculty, and everything in between are wonderful. I can truly see myself being a student there. I’m considering moving closer to campus, finally getting the other part of college experience I never got since I commuted for undergrad (with no regrets there, by the way). Returning to school, though, gives me a chance to get the best of both worlds. Just thinking about such a massive life change, going away to grad school, makes me so unbelievably excited about the future. I have 13 months until I would start the program and I know it’s going to absolutely fly by. Unfortunately, all of this joy is underscored by my father’s brain injury. Two months ago, he suffered a cardiac arrest and is currently recovering in rehab. His long-term prognosis is unknown at this time but I am remaining hopeful. I know he would be amazingly proud of me.

Here’s to the future. Here’s to never settling. Here’s to my Mom and Dad and my family for always supporting me (and for allowing me to move back in at the ripe age of 30). Here’s to the wonderful world of healthcare, namely Abington Hospital which has been my home away from home for the better part of 11 years. I’ve learned so much from those within those walls and hope to one day give that all back as a PA. Much more to come. I’ll see you on the other side.

The GRE

So I took the GRE last Friday and scored a 311, 158 in verbal, and a 153 in quant. And according to Google, between a 310-320 is competitive. Phew.

I didn’t study as long or as hard as I would have liked to, but I definitely put a lot of hours in. I started looking at example questions back in October, subscribing to the Kaplan Question of the Day, which I would highly recommend. I also started studying GRE vocabulary in October, building a deck of 177 words (maybe 1 of these was on the GRE!) over the subsequent months. So now I can drop words like auspicious, capricious, and kismet in conversations, ha. They also have short workouts you can do. I started studying more heavily probably 1 month before the exam, purchasing 4 practice tests and the QBank. I ended up only taking 2 practice tests and not using the QBank questions at all. It’s very important to take at least 1 practice exam so you can see how fast-paced the quantitative section is. I was shocked.

Through the questions of the day, I was able to take notes regarding my weak areas. I added to these notes after taking the 2 practice tests, unpacking every question I got wrong, and adding vocab words to my deck. I found Manhattan Prep on YouTube to be very valuable for my weak areas, especially exponents (there was 1 question about exponents on the GRE). The Tested Tutor was also very useful for combinations and probability.

The hardest part about the GRE, besides trying to block out the noise of the 6 students that were surrounding me, constantly fidgeting around for some reason, is your speed during the quantitative section. I probably guessed for 8-10 questions on the section, and it’s only 20 questions long. I simply did not have time to even begin those questions. You need to have an answer, even if it’s a guess, for every single question. Do not let the time clock expire without having an answer for everything. What I did was, the second I saw a question and was either like “Yea, I have zero idea how to even approach this” or “This is going to take more than 2 minutes to complete,” I would guess on it, flag it, and move to the next question. Most of the time, I never had time to even revisit that question. It’s that quick. There were entire quant concepts, like statistics (frequency distributions) that I never even studied. There were also quite a few questions about like, there are integers that start with 1, 3, 4, 7, etc. and increase by n + the preceding digit. What are the chances of getting an odd number if there are 100 integers. I tried to math it out, but just couldn’t get the answer.

The other strategy that was very key for me was outlining the verbal passages. They are exhausting to read. And jotting down an outline helped me out a ton. I also skipped some to knock out the vocab questions and then revisited the passages, finding I could focus better knowing I had completed the rest of the section. I had about 5-10 minutes remaining for each verbal section. For the quant section, I ran out of time on both sections (but was sure to guess on the ones I skipped).

But anyway, I did fine and I’m very happy with my score and incredibly relieved that I don’t have to retake it. I should have scheduled it for February so I had plenty of time to take it a second time, but I got lucky. I have exactly 1 month to CASPA!

How Big is Your Brain (Natriuretic Peptide)?

While shadowing some all-star PAs in the ER, I’ve heard the term/lab value BNP mentioned often in relation to heart failure patients. Let’s see what BNP is all about.

BNP stands for “Brain Natriuretic Peptide” or B-type natriuretic peptide and is also called ventricular natriuretic peptide. What a mouthful. It’s a biochemical marker that can help diagnose heart failure and is measured via the serum or plasma of our blood.

In terms of anatomy and physiology which I’m currently studying, BNP is first mentioned in the endocrine chapter as one of two hormones secreted by cardiac cells (the other is ANP, which stands for atrial natriuretic peptide). Now I know what you’re thinking, if these are both secreted by cardiac cells, why on earth is BNP called “brain natriuretic peptide.” Because… reasons: it was initially found in brain tissue of pigs and the name stuck. 

ANP is secreted by cells in the wall of the right atrium, and BNP the ventricles (mainly the left). ANP responds to blood volume and pressure and BNP responds to stretching/tension.

The word natrium (Latin) refers to sodium, -ouresis means urination, and peptide is a protein. This hints that BNP probably increases the expelling of salt in our urine, meaning a fluid loss, meaning an eventual blood volume loss and loss in blood pressure. Natriuresis literally means the excretion of salt in the urine. What triggers the release of BNP is the abnormal stretching of the heart walls. So if our heart is being stretched abnormally, something is wrong, right? Either there is too much pressure or blood, or the heart is weakened and not pumping blood effectively, which is where heart failure comes in. And if the heart is weakened, then pressure and volume will increase as it struggles to keep up. Makes sense.

Remember that heart failure can cause respiratory symptoms, distress even. If there is a problem with the heart, then either too much or not enough blood is going to enter the lungs. If there’s not enough, then proper gas exchange isn’t going to occur and our body will be starved of oxygen, causing us to breathe faster. Fluid build up can also enter the alveoli causing respiratory problems.

Effects

We learn more about ANP and BNP in the blood vessels and circulation chapter of A&P where we learn their effects:

  1. Increase sodium ion excretion by the kidneys. 

  2. Promote water loss by increasing urine volume.

  3. Reduce thirst.

  4. Block the release of ADH, aldosterone, epinephrine, and norepinephrine.

  5. Stimulate peripheral vasodilation.

Yea, so they don’t mess around. Once these five things reduce blood volume and pressure (therefore restoring homeostasis), the natriuretic peptides stop being excreted by our cardiac cells because they’ve done their job. That’s a negative feedback loop.

Let’s talk a little bit about #4 because we just mentioned four other hormones. 

  • ADH, the antidiuretic hormone, is secreted by the posterior pituitary (which also secretes oxytocin). Its function is in its name; it prevents uresis, or urination. In other words, it retains fluids. This is the hormone inhibited by alcohol, which is why we urinate when we imbibe. BNP does the same thing (except for making us drunk); it makes us urinate. BNP is blocking the release of ADH.

  • Aldosterone is secreted by the adrenal cortex of the adrenal gland. I like to think that it keeps “al dos” salts. And salt retention = fluid retention. Aldosterone is involved in the renin-angiotensin-aldosterone system (RAAS). BNP is blocking the release of aldosterone.

  • So what about epinephrine and norepinephrine? Well norepinephrine and epinephrine are vasopressors, which raise blood pressure. BNP is blocking those too.

Heart Failure & Shortness of Breath

When I was studying for the NREMT, I made the following note about heart failure:

LEFT-SIDED HEART FAILURE is associated with pulmonary edema and leads to shortness of breath because as blood is returning via the pulmonary veins to the left atrium and then left ventricle, the ventricle can’t pump out as much and there is fluid build-up in the lungs. Pink and frothy sputum found here. THINK L AND LEFT FOR LUNGS AND LYING DOWN! You will see respiratory issues like shortness of breath. The patient worsens when they lie down and worsens when they exert themselves because they can’t breathe adequately.

“An accurate and rapid diagnosis is crucial for the diagnosis of patients who present to the emergency room or outpatient examination room with acute respiratory distress.” (Yoo, 2014). So respiratory distress is a major symptom of heart failure. There we go.

Questions

  1. What about other sources of high blood pressure? Wouldn’t that trigger BNP? Can’t you have HBP but not heart failure?

  2. Aren’t BNPs block of epinephrine and norepinephrine counterproductive towards making the heart stronger? Don’t these make the heart, that is already struggling, weaker?

  3. If BNP is a protein and water-soluble, can it be detected in the urine?

    The data suggest that urine BNP is a new candidate marker for diagnosis and prognosis of HF mortality and cardiac events. This raises the possibility of using this relatively simple noninvasive test in primary care settings or in specific conditions where the collection of blood samples could be difficult. Source.

  4. Could high salt levels in the urine also point to heart failure?

Sources

Cortés R, Rivera M, Salvador A, García de Burgos F, Bertomeu V, Roselló-Lletí E, Martínez-Dolz L, Payá R, Almenar L, Portolés M. Urinary B-type natriuretic peptide levels in the diagnosis and prognosis of heart failure. J Card Fail. 2007 Sep;13(7):549-55. doi: 10.1016/j.cardfail.2007.04.007. PMID: 17826645. https://pubmed.ncbi.nlm.nih.gov/17826645/

Martini F, Nath J, Bartholomew E. Fundamentals of Anatomy & Physiology. 2018. Eleventh Edition. Pearson Education. 

Yoo BS. Clinical Significance of B-type Natriuretic Peptide in Heart Failure. J Lifestyle Med. 2014;4(1):34-38. doi:10.15280/jlm.2014.4.1.34 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4390764/

An Update: Six Months to CASPA

So it’s been a while since I’ve written a post, six months actually, so here goes. Since I finished up P4 and the JeffSTAT EMT program, I’ve since finished A&P I&II, psychology, statistics, and started a new job as a Patient Care Tech in the Abington - Jefferson Health emergency trauma center. I have 398 patient care hours and 120 volunteer hours. I’ve completed 11 EMT shifts and have seen 35 patients as a volunteer EMT. In the month of September, I picked up 168 patient care hours and I’m on target to hit 156 in October. With the remaining six months until the end of April when CASPA opens, I will pick up an additional 936 hours + a few here and there from EMT. I should have just south of 1500 which I’ll be very proud of. If I can pick up a few extra shifts and keep up with EMT I’m sure I can hit that 1500 mark.

An interesting thing that I’m doing is that I feel like I have a lot more learning to do from A&P than I got from the course. It’s a very dense subject. So what I’ve decided to do is keep working at the class even after it’s been finished. I’m StoryNoting (a term I coined myself where you slowly and exhaustively read, outline, and reference a textbook) the entire textbook. I have a 183 page Google doc of A&P and it’s probably one of my most treasured academic achievements. So every week I try and knock out another section or chapter. My goal is to truly have a strong and comprehensive A&P background before PA school. The other thing I’m doing is adding to a pharmacology Quizlet set with medications I hear about or see on EMT shifts or at the hospital. I want to have a basic pharmacology background as well.

I did decide that I want to take the GRE. After playing around with some practice questions, I found it to be challenging, yet familiar, easy, and sort of fun. A lot of the questions are like riddles which I love. Applying to Arcadia and Salus will be great additions to my applications. The other things on my list in the next six months are to pick up some more community service-focused volunteer hours, and shadow some PAs. I also want to make sure though that I take some personal time and relax over this winter break. Then come January I’ll take my last pre-req class for PA school, microbiology. I can’t believe I’ll have been taking pre-reqs for two entire years; the great thing is that they are all through Jefferson so I’ll have just a single transcript. Once my applications are in, I’ll be in a very interesting spot in life. The hustle stops. I won’t be taking any classes for the first time in two years. I’ll be able to truly breathe. I won’t need to volunteer anymore either. It’ll just be me and work, a few wedding shoots, and seeing where I get interviews. April 2022 - April 2023, when I’d be starting school at the earliest, will be the time in my life to live it up and hopefully do some traveling.

I also recently had to make a tremendously difficult personal decision in my life, the hardest decision I’ve ever had to make. I’ve been trying to do a lot of personal reflection and realized I have a lot of work I still need to do on myself, a lot of growing and maturing to do, even at the age of 32. I’ve also been thinking a lot about work-life balance and how much a toll my pre-PA journey has taken on my life and my relationships. It makes me worried about PA school, but I’m trying to go in with a level of self-awareness at what is and isn’t possible from a work-life balance perspective. You can’t do it all and this career path definitely requires sacrifices. I’m trying to stay optimistic and find new life after tragedy. I’m considering casting a wider net and applying to schools out of state, maybe even some across the country. Why not?

Well that’s about it for now. I have two concerts I’m going to solo in the next few weeks, Charmer, and Hot Mulligan, two of my favorite bands. This time two years ago I went on a solo concert spree, seeing The Starting Line / Oso Oso, The Menzingers, and Jimmy Eat World. It’s interesting how life repeats itself.

P4... It's Finished

If you’re a prospective or current P4 student, you can view my survival guide here.

So there it is. Just minutes ago I submitted my final assignment of Thomas Jefferson University’s Postbaccalaureate Pre-Professional Program. It’s over. It’s done. As has been my custom for three semesters now, I listen to Explosions In The Sky’s “With Tired Eyes, Tired Minds, Tired Souls, We Slept” the night of the end of the semester, which is what I’m listening to as I write this.

Where to even begin? What a strange feeling. And this all comes just one day after I passed the NREMT psychomotor exam, which is by far my greatest accomplishment this semester. But back to P4. Just looking around my desk a year later, I’m in a different house, I have a different computer, the remnants of my first semester still lie about my parent’s basement, which has been my “lab” for most of this year. The seven functional groups sit above me, from hydroxyl to carboxyl, to methyl, names that were foreign to me in Bio I and became like a primary language in Orgo. Large post-it notes are still on the walls, detailing cell communication, the citric acid cycle, and more. And my trusty iPad, my greatest technological tool this entire year is lying right in front of me, having been the canvas to everything I’ve written and drawn this year. Of course my iPad is also where I recorded countless videos that now populate my YouTube channel, which became a stream of consciousness of what I was learning. It’s incredible to look back at the first general chemistry videos that I made. P4 has been one of the wildest rides of my entire life. And I can’t believe it’s over. When it began, I wanted to quit so bad. It was one of the most difficult experiences of my life, getting over the learning curve and shaking off the dust that comes with being a career changer student. Change isn’t easy. But here I am, now with the ability to take on a chapter of entirely new information, make it my own, invent mnemonics, make connections… and learn.

I don’t honestly know what PA School is really going to be like. Learning is such a funny thing. What am I really going to remember about the last 12 months? What truly did enter into my long-term memory? I’m just so incredibly relieved for the bulk of my pre-reqs to be OVER. The grunt work, the grind, to even have half of a PA application is done. I’ve officially brushed up on my sciences.

So what’s next? Well, I’m one NREMT exam away from being a licensed EMT-B. That’s WILD. I didn’t anticipate picking that up this year. My plan is to volunteer as an EMT this summer to both sharpen my skills, but also pick up volunteer hours. Then my plan is to return to the birthplace of my healthcare career, Abington Memorial Hospital, now Abington-Jefferson Health, as a Clinical Associate in the Emergency Trauma Center. That’s where I plan to pick up 1500 patient contact hours. And then, just four weeks from now I start my next class, Anatomy & Physiology which I’ll complete over the summer. So yea, it’s going to be a busy summer. The fall will bring microbiology with the spring bringing statistics and psychology, my final two pre-reqs. That will complete two entire calendar years of nothing but preparation just to apply to school. And you know? That’s fine. My goal is to become a great Physician Assistant Student. That is the goal. I don’t want to get ahead of myself. I plan to apply to: Jefferson Center City, Jefferson East Falls, USciences, PCOM, Drexel, West Chester, and Rutgers. That’s 7 schools, all within driving distance, and all without requiring the GRE! If I somehow find the extra energy and take the GRE, I unlock Arcadia, Salus & Temple. And applications are going to open for my cycle in April of 2022. I have 365 days to prepare my application for Physician Assistant School. Whoa. Applications are open until like January of 2023 though, and then interviews. I wouldn’t start until either pre-fall or fall of 2023. So I am still 2 or more years away from even starting school. But that’s okay with me because I’m on a path and a journey and I am loving every second of it.

So thank you P4. Thank you Dr. Barrows, Dr. Belani, Dr. Jensen, and most importantly Drs. Heine and Byrne. You’ve all shaped me from a business student into a STEM student. And thank you to all of my P4 friends; we were able to make a connection online in the middle of a pandemic. That’s incredible. We’re all moving onto bigger and better things.

Roll the credits. I’ll see you in the next one.

On Organic Chemistry

So, days after my last blog post, something happened. Organic chemistry became organic chemistry. A workload unlike anything academically I’ve ever encountered unleashed itself on me like an unstoppable force. My life suddenly became organic chemistry; I spent 5 days straight, 8-12 hours a day doing nothing but organic chemistry, and still got 25% of the exam questions wrong. Thanks to the magic of curves, I ended up with a 90.

So what even is organic chemistry? If general chemistry is math (because it is), organic chemistry is art (because it is). There’s not one exam in orgo that you need a calculator for (except for maybe some basic division or something). There are no mathematical formulas to remember. It’s true that if you hated gen chem, you could love organic chemistry. If you’re into art, drawing, 3D modeling, legos, photography, anything like that really, there is a great chance that you will enjoy many aspects of organic chemistry.

Anyway, that’s really all I had to say. This semester is an absolute grind but I’m surviving, excelling even. I’m already starting to plan my next steps of the spring into the summer and fall with the end goal of being accepted to PA School.

Onward I go.

I'm Still Here... We're All Still Here (??? Weeks In)

I’m still here! Surviving (thriving?) It’s been a heck of a semester so far. I can’t believe I’m learning organic chemistry and just days away form sinking into the Krebs Cycle in biochemistry. I never thought I’d be here but here I am.

I had a lot of big breakthroughs in terms of studying this semester. Last semester I discovered that recording myself learning / teaching topics increased not only by comprehension but my retention. I adopted a modified version of this and started creating videos with my iPad, drawing out and commentating on concepts. Here is one about memorizing all 20 amino acids. The greatest thing about these videos is that they’re not just for me. I shared some of my videos from last semester with the new students and I am sharing my current videos with my fellow students. A couple of them even told me they memorized the amino acids using my video. So cool!

I also stopped taking handwritten (well with Apple Pencil) notes from lectures. I now take notes on Google Docs. The first benefit I saw here was collaboration (the theme of this semester). The value of sharing information with other students is incredibly useful and rewarding. Also, it’s just easier to input screenshots, pictures, etc. And accessing the files from any device is a bit easier. Also, my handwriting isn’t always the best. I can also revisit notes and build an entire journal from a chapter; I keep adding all the way to the exam.

The other new thing this semester is that I’ve been studying on campus. A lot. And it’s like a 50 minute drive but it is absolutely worth it. Doing a problem on a white board just hits different. And collaborating on a white board in person with other students is simply incredible. The simplicity of returning to something like this after quarantine has made collaboration such a powerful moment.

I’m really starting to start to see the light at the end of the tunnel (though still very far away) of going to physician assistant school and becoming a physician assistant.

This semester has been more difficult when compared to the summer in many ways. But with that difficulty has come a lot more fun. Meeting students for the first time after being online for months is an incredibly unique and rewarding experience.

Five Weeks In

Tomorrow is five weeks in to the P4 program at TJU. And to put it simply, I’m surviving. I did really well on my first Biology exam and I feel incredibly proud of that. Each day I learn more and more about how to study, how to manage my time, and how to make sure I save time for what is most important, my loved ones, my family, and myself. There was a point in this last week where I finally felt ahead. It was amazing. Then I quickly feel behind again. That’s how quickly this program moves. I’m starting to plan two weeks ahead of time so that I can keep rolling with the punches. Chemistry I is over next week. An entire undergraduate semester of Chemistry nearly finished. That’s mind blowing.

I can’t end this post without a shout out to the following people:

These wonderful group of people have been my most valuable teachers over the past five weeks. I wouldn’t be surviving if it weren’t for them.

P.S. My laptop died this week which is pretty bad timing. I’m very happy I invested in an iPad Pro which has been an incredible tool this semester.

Two Weeks In

So I’m two weeks in to the post-bac pre-med program at Thomas Jefferson University. I have to be honest; this is unlike anything I’ve ever gone through in my life. This program has so far been the most overwhelming, stressful, frustrating experience of my life. Yet, each day it gets ever so slightly easier.

There is a taste here of the overwhelmed and “on” feeling I had managing the Jefferson Health Hack. That was non stop for weeks. But the stakes here are so. much. higher. I feel like I am furiously trying to outrun a hungry Lion, or trying to out swim a tidal wave, and I am just barely staying ahead. It’s my hope that I can keep increasing that gap.

It’s tough that we are starting this thing as “distanced learning” via online means and Zoom. There’s just so much to do. Homework assignments take 8 hours. I am supposed to remember algebra that I haven’t used since college, even high-school, nearly 15 years ago. Chemistry so far isn’t science; it’s math. So much math. I’m proud of myself though because I’ve all but mastered dimensional analysis (except for some of those density problems) when two weeks ago I had never even heard of dimensional analysis.

During orientation, P4 alumni said this program was hell. They were not joking. Every aspect of my life has now become this program. It’s all I think about. And honestly I think that’s a good thing. Stress can be good; it shows that you care. And I do care. But I have so much riding on this. I am in the process of moving out my own house into my parents basement.

I am trying so hard to rewire my brain and stay positive and realize that spending 2 hours on a single problem is absolutely fine. I am just quickly learning about time management like I have before. I’ve already forged some strong connections with some fellow students which has been so helpful. It’s very easy to feel lonely in this program.

I’m keeping my eye on the prize. I keep thinking about the hundreds of medical and PA students I’ve met and worked with over the years. Even the pre-med students. They all did this. This is so incredibly possible. I know it. I’m keeping a vision in my head of donning a short white coat and diving head first into PA school. And I’m also keeping a vision in my head of one day returning to Abington Hospital, the place I’ve spent so much of my life already, but not as a payroll intern like I was when I first started. I’m envisioning myself returning as a physician assistant, finally able to combine everything I’ve ever learned in my whole life. everything I’ve learned as a patient advocate, as an Innovation communications coordinator, as a UGME manager, and everything in between.

Let’s go.

Flashcards

Flashcards seem to be a popular way to study, but do they really work? Why are they so popular? Let’s take a look.

During my initial research I came across the Leitner system, developed by German science journalist Sebastian Leitner in the 1970s. Basically, it utilizes three boxes and a promotion / demotion system:

The advantage of this method is that the learner can focus on the most difficult flashcards, which remain in the first few groups. The result is, ideally, a reduction in the amount of study time needed.

The Leitner system uses the principle of spaced repetition, which is also used in popular flashcard app Anki. Spaced repetition exploits the psychological spacing effect:

The spacing effect demonstrates that learning is more effective when study sessions are spaced out. This effect shows that more information is encoded into long-term memory by spaced study sessions, also known as spaced presentation, than by "cramming", or massed presentation.

Yet another proponent for the Pomodoro Technique.

I came across a 2017 research article titled Reinventing Flashcards to Increase Student Learning. It cites a bunch of different studies:

In reviewing the efficacy of 10 commonly used studying techniques, Dunlosky and colleagues (2013) identified practice testing (or practice retrieval) and distributed practicing (or spaced practice) as the two most effective techniques. Students can engage in both of these high utility techniques through the use of flashcards (Wissman, Rawson, & Pyc, 2012).

…

Although flashcards are relatively easy to create and commonly used by college students (Wissman et al., 2012), the effectiveness of student-created flashcards in a classroom is unclear. In an introductory psychology class, Golding et al. (2012) found that students who used flashcards for the first exam scored higher than students who did not. However, the use of flashcards was not beneficial on the second exam, and the effect was only marginal on the third exam. Furthermore, Hartwig and Dunlosky (2012) demonstrated that student-created flashcards use was unrelated to students’ grade point average (GPA). These results suggest that retrieval practice and distribution of practice increases retention of information, but the way in which flashcards are typically used may not be sufficient to be successful in college courses.

…

Flashcards can facilitate repetitive learning, but repetition is only a superficial level of processing (Brown, Roediger, & McDaniel, 2014). While 82.9% of students in a study indicated they used flashcards to remember vocabulary, no students reported using flashcards to develop deeper understanding of or the application of concepts (Wissman et al., 2012).

…

The FP strategy begins in the same way as traditional flashcards. Students identify bold-faced terms from the textbook and write them on one side of a notecard. Students write the textbook definition on the other side. Students memorize the definition from the textbook (or the instructor) to increase retention. While most students stop here with traditional flashcards, FP creates deeper levels of learning by having the student perform two more actions. In the next step, students write a definition for the same key term in their own words. Rephrasing the term helps students understand the material that will increase comprehension. Finally, students generate a realistic example of the key term from their own lives that will increase application.

…

The FP strategy involves one of the most well-known memory-facilitating processes. Remembering is enhanced when the meaning of material is fully processed at the time of encoding (e.g., Craik, 1979, 2002; Craik & Lockhart, 1972; Paller, Kutas, & Mayes, 1987). For example, students who are asked to create their own explanations of a concept recalled that information better than those who were given explanations passively (Pressley, McDaniel, Turner, Wood, & Ahmad, 1987). Furthermore, information processed in relation to one’s self results in particularly strong recall (Klein & Loftus, 1988; Rogers, Kuiper, & Kirker, 1977).

I really like the sound of this method. Fashion your usual flashcard, but create your own explanation, and then relate it to something in your life. It’s expanding using flashcards to “learn” on a surface level and drives a deeper understanding. I imagine this method coupled with Pomodoro might pack quite a one-two-punch.

Note Taking: To Write or Type?

I remember the days in grade school science class. We’d have “notes” days. An entire hour or so of just copying down information from transparencies. I remember the pain in my right hand as I struggled to keep up with the faster writers. Pages and pages and pages of notes; it was just arbitrary labor. Looking back, I can’t believe our teachers got away with this lackadaisical method of “teaching.” What a vapid and boring way to present information. This makes me thing of modern day note taking: typing into a laptop or tablet. I’m sure students still hand write notes. So I’m interested: what’s the best way to write notes? Are notes even a valuable way to collect and retain information? Let’s take a look.

Here’s Jennifer Gonzales, writing for Cult of Pedagogy (2018):

Whether it’s taking notes from lectures (Kiewra, 2002) or from reading (Rahmani & Sadeghi, 2011; Chang & Ku, 2014), note-taking has been shown to improve student learning. In other words, if we want our students to remember more of what they learn in our classes, it’s better to have them take notes than it is to not have them take notes.

The thinking behind this is that note-taking requires effort. Rather than passively taking information in, the act of encoding the information into words or pictures forms new pathways in the brain, which stores it more firmly in long-term memory. On top of that, having the information stored in a new place gives students the opportunity to revisit it later and reinforce the learning that happened the first time around.

…

Compared with writing alone, adding drawings to notes to represent concepts, terms, and relationships has a significant effect on memory and learning (Wammes, Meade, & Fernandes, 2016).

The growing popularity of sketchnoting in recent years suggests that teachers are well on their way to taking advantage of this research.

I’ve been using an iPad Pro and Apple Pencil to take notes in an emergency room for the past year. Although not an academic setting, it’s made capturing information so much more fun, engaging, and streamlined. Jennifer’s thoughts feed my interest of picking one up to aid in my studies.

Finally, if students collaborate on this revision with partners, they record even more complete notes and score higher on post-tests (Luo, Kiewra, & Samuelson, 2016).

With this in mind, it would be a good idea to plan breaks in lectures, videos, or independent reading periods to allow students to look over, add to, and revise their notes, ideally with a partner or small group. This partner work could happen after students have had time to revise their notes alone, or students might be given access to classmates for the duration of the pause.

This fits in with the Pomodoro Technique that I wrote about last week. It’s good to see some proof that collaboration with peers leads to higher scores.

This research confirms what a number of educators suspect about the negative effects of digital devices in the classroom, and some have taken it to mean they should definitely ban laptops from their lectures (Dynarski, 2017). Others argue that prohibiting laptop use robs students of the opportunity to develop metacognitive awareness of their own levels of distraction and make the appropriate adjustments (Holland, 2017).

Because technology is always changing, and because as a species, we are still adjusting to these new formats, I would hesitate to ban laptops from the classroom. Here’s why:

  • Research on this topic is still pretty young: Some researchers have found no significant difference in performance between paper-based and digital note-takers (Artz, Johnson, Robson, & Taengnoi, 2017). My guess is that more research will pile up and get more refined, so we should take a measured approach for the time being.

Metacognitive awareness. I’m going to use that one. Handwriting and sketching notes, even annotating onto already prepared slides on an iPad could be a great hybrid approach to note taking.

I found a summary via Clearvue Health on a 2014 Princeton Study, The Pen Is Mightier Than the Keyboard: Advantages of Longhand Over Laptop Note Taking. I found four years later that an addendum was published with some corrections. Here’s what they initially found:

  • Efficiency (word count): typing (310 ) wins over writing (173 words). No surprises there.

  • Quality (percentage of words copied): typing (12.1%) vs. writing (6.9%). “Notably, researchers did find that word overlap was negatively correlated with performance, meaning that the less overlap a student had, the better they remembered the material.

  • Learning (conceptual recall): typing loses to writing. “When the students were tested to see whether they remembered what they wrote down, students who wrote their notes remembered more than typing.”

  • Exam Performance: writing wins over typing. “When they scored the exams, they found that the students who wrote their notes tended to score better on the exam on both conceptual and factual recall.” *See first bullet below.

After the addendum, here are the corrections:

  • On factual-recall questions, participants performed equally well across conditions. However, on conceptual-application questions, laptop participants performed significantly worse than longhand participants.

  • Participants who took longhand notes and were able to study them performed significantly better than participants in any of the other conditions.

It still remains pretty clear that longhand notes are worthwhile.

“If you’re on the fence, consider writing. It’s low tech, it can be ugly for those with terrible handwriting, and it’s pretty slow. But, in the end, you may just end up learning more.”

The Ride of a Lifetime - Bob Iger

Recently I finished reading The Ride of a Lifetime, in Disney World, in fact. I was there just days before it shut down due to the coronavirus. The book was incredible. I’ve read just about every book there is that talks about the founding of Pixar, so I was delighted that there was a whole chapter devoted to Pixar. The details surrounding the Lucasfilm and Marvel acquisitions were equally fascinating. Here are some of my favorite passages from the book.

To this day, I wake nearly every morning at four-fifteen, though now I do it for selfish reasons: to have time to think and read and exercise before the demands of the day take over. Those hours aren’t for everyone, but however you find the time, it’s vital to create space in each day to let your thoughts wander beyond your immediate job responsibilities, to turn things over in your kind in a less pressured, more creative way than is possible once the daily triage kicks in. I’ve come to cherish that time alone each morning, and am certain I’d be less productive and less creative in my work if I didn’t also spend those first hours away from the emails and text messages and phone calls that require so much attention as the day goes on. 

Luckily, I’m a morning person. I can appreciate that quiet time each morning that he mentions here. I just wish I could pull it off on a consistent basis.

It was a big job, and a big title, but it wasn’t my life. My life was with Willow and my boys, with my girls back in New York, with my parents and my sister and my friends. All of this strain was ultimately still about a job, and I vowed to myself to try to keep that in perspective. 

This is a huge philosophy of mine and it’s inspiring to see Bob share the same one. I wrote earlier how this philosophy steered me toward PA over physician.

“A few solid pros are more powerful than dozens of cons,” Steve said. “So what should we do next?” Another lesson: Steve was great at weighing all sides of an issue and not allowing negatives to drown out positives, particularly for things he wanted to accomplish. It was a powerful quality of his.

Bob is quoting Steve Jobs here. They are talking about the Disney / Pixar merger. Throughout the book, Bob talks about some pretty intimate details about what it was like working with Steve throughout his career.

There’s a passage from Ed Catmull’s Creativity Inc. that I think pairs nicely:

When I advocate for protecting the new, then, I am using the word somewhat differently. I am saying that when someone hatches an original idea, it may be ungainly and poorly defined, but it is also the opposite of established and entrenched—and that is precisely what is most exciting about it. If, while in this vulnerable state, it is exposed to naysayers who fail to see its potential or lack the patience to let it evolve, it could be destroyed. Part of our job is to protect the new from people who don't understand that in order for greatness to emerge, there must be phases of not-so-greatness.

Here’s more from Iger:

...there’s not much to be gained from putting additional pressure on the people working on it. Projecting your anxiety into your team is counterproductive. It’s subtle but there’s a difference between communications that you share their stress—that you're in it with them—and communicating that you need them to deliver in order to alleviate your stress.

I’ve seen this countless times in my lifetime. Self-awareness is too important to have a manager without any.

All in all, The Ride of a Lifetime is an enlightening read outlining one of the most interesting careers of our lifetime. As far as leader and CEO, and overall human being, Bob Iger gets it right.

Should You Become a Physician Assistant or Doctor?

Delece Smith-Barrow and Ilana Kowarski, reporting for US News:

Jonathan E. Sobel, the current president of the AAPA and the chair of its board of directors, adds that PAs have the option of not only serving as health care providers but also as health care administrators. "In addition to practicing clinically, PAs are increasingly in leadership roles within hospitals and health systems, helping them meet quality metrics and improve care," he wrote in an email.

Something about this resonates with me. As ironic as it would be for me to go the great lengths to becoming a PA, just to end up in the long term back on the business side as an administrator, something about that seems to fit. I think a hybrid approach would suit me well. I don’t just want to practice medicine. I’d like to be a part of some decision making council that affects the work that I do. I enjoy innovation and process improvement.

Dr. Will Kirby – a dermatologist and the chief medical officer for the LaserAway aesthetic dermatology group, which employs many physician assistants – says one advantage of being a PA as opposed to a physician is the freedom to shift between medical specialties as your work-life balance needs change.

"Physician assistants however have much more flexibility when it comes to areas of specialization and a PA who starts out in a kinetic field in his or her early 20s, like emergency medicine for example, may decide that they want to start a family and that a slower-paced, more predictable field suits them better in their early 30s and can transition over to dermatology with very little effort."

Definitely some encouraging words and from a Big Brother alum!

Have You Missed Your Chance to Go to PA School?

Ryanne Coulson, PA-C, writing for Be a Physician Assistant (October, 2018):

Regardless of your age, you're better starting-PA material than you were five years ago. You've gotten better at relating to and interacting with others and have navigated more tricky situations than the younger version of you did.

PA schools care about this. A hot topic in PA education at the moment is how to assess the maturity level of PA school candidates as part of the application process.

The curriculum of PA programs is packed; there's no time to try to teach students how to behave in social situations or how to approach patients on a basic human level.

That last bit might point to the shortcomings of many health profession academic programs. As a patient advocate, I’m often shocked at the way some people talk to patients. I think 75% of empathy and humanity comes from within. You can only teach and refine that other 25%. If you don’t have an innate ability to connect with people, it’s impossible to make that fundamental change. We are who we are.

Some of the best PA students I've ever worked had a winding path to a PA career, and their training experience was heightened because of everything that came before it.

There's unlikely to be 80 students interviewing for your program who are just like you, so being a bit different is an advantage.

…

But this doesn't happen to new-grad PAs who are a bit older. Patients will automatically assume you've been practicing for a while and know what you are doing.

While that may be a bit scary for the first 6-12 months, it will give you confidence and the freedom to practice without worrying that patients are second-guessing you because you seem "too young" to be doing what you're doing.

If all goes according to plan, I’ll be 34-35 when I’m all finished school. There seems to be many benefits to entering the PA profession in your mid-30s. Patients will assume I know what I’m doing? Hey, I’ll take it.