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:

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🧮  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!

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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:

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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:

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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.

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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).

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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.