The preclinical years of medical school reminded me of high school. A class of ~180 students forming cliques and competing to distinguish themselves. There’s class government, social politics, and a range of type A personalities striving for excellence. While I will always cherish my experience in medical school, the preclinical years leave much to be desired. In this short post, I want to highlight my experience during this time and how I adapted to be successful in this novel, yet familiar environment.
The novelty was that for the first time in my academic career, I was average. Everyone was smart and motivated to do the most. I went from setting the curve in college to dangling at the median. I studied hard and put in the time to become proficient with each topic, but excelling at the multiple choice exams of medical school required more. Could I have reached the > 90th percentile on these exams? Yeah, probably. But at what cost? Was memorizing ever more keyword associations and minute subtext around an already rare topic worth my time? It seemed more valuable to re-define how I evaluated my self-worth in this new academic context and strive for success on my own terms.
What defines the preclinical years?
There are 2 major curricula for the preclinical years of medical school: traditional and modern. The traditional curriculum is 2 years focused on the basic science of medicine in a modular format. You take courses on genetics, biochemistry, molecular biology, etc., before you learn the clinically relevant integrations. In the modern curriculum, which is the one I completed, you start integrating the basic science into physiology, pathophysiology, and pharmacology from day 1, which condenses the duration to 1.5 years. The modern curriculum is in my view far superior in its preparation of medical students for clinical medicine and should be adopted as the standard of medical education.
“Drinking water from a fire hose”
One of the greatest problems with medical education is the massive amount of detailed information students are expected to learn. It’d be one thing if it were all useful information, but a lot is not clinically relevant. Regardless of the curriculum, preclinical training is a deluge of information from the molecular to macro scale. From understanding the function of neuronal synapses in one lecture to learning the clinical presentation and treatment of type 1 vs type 2 Bipolar disorders in the next, you are presented with wide-ranging information. Context switching is a skill you should develop because the fluidity with which you can zoom in and out allows you to better connect the dots.
For example, synapses function through activation of signaling cascades mediated by proteins and ions. Genetic mutations and environmental contributions over one’s life might cause proteins to dysfunction, resulting in changes to ion flux and synaptic function. Synaptic dysfunction in particular brain regions drive behavioral instability that underlie psychiatric disorders such as Bipolar. The pharmacology of treating bipolar is indicated by specific clinical manifestations, and various drugs target different proteins that might be malfunctioning. Valproic acid is one such drug that has a mechanism of action of increasing GABA levels in the CNS (inhibitory neurotransmitter) and blocking voltage-gated sodium channels (proteins necessary for neurotransmission). In an overly simplistic sense, the mania and hypomania evident in bipolar disorders is characterized by neural hyperexcitability; therefore, valproic acid can increase inhibitory neurotransmission and reduce excessive neurotransmission to calm the central nervous system, in theory. This is one of many drugs that can be used, which must be carefully selected based on certain indications and contraindications for the individual and situation. Sheesh. That’s a snapshot into two lecture slides of material, and psychiatrists and neuroscientists alike would surely have a fit with how I simplified this paradigm.
How does one study to succeed in medical school?
For me, sitting in the lecture hall was a crap shoot. Depending on my mood and the lecturer, there was great potential for me to get little from the lecture experience. There’s nothing worse than wasting time at a boring lecture from a professor reading from powerpoint slides. Lectures go for 4 hours a day, 3 days a week with other forms of group learning in between. At my medical school, lectures were recorded and attendance was only encouraged. I stayed home, went to coffee shops and libraries, opting to study at my own pace, in my own space, and on my own terms. So much of medical school is following the schedule and directions prescribed by your professors; I often felt that I had little control of my time, and thus the opportunity to take more control by studying from recorded lectures was important. It was the same content as viewed from the lecture hall, but I could speed it up, slow it down, pause and rewind as my understanding required. I could watch the lecture for a second time while walking on the stairmaster, and make time for myself throughout the day as my energy ebbed and flowed.
While this study approach covers your base for the medical school quizzes and exams, it is likely insufficient. To even score average, I required different perspectives on the subject matter that emphasized the most “high-yield” topics. High-yield might be the most common word in medical school education. I used select resources, including: Pathoma, Boards and Beyond, Netter Anatomy, Sketchy Micro, and the USMLE STEP 1 book. These resources allowed me to hone in on what was most important from the national curriculum’s perspective, which is tested on the STEP 1 board examination. With these resources, I gained more insight into the relative importance of the broad information being taught in my medical school’s curriculum. However, to score above average, still more was required.
An exam in medical school typically covers 4–6 weeks of material. Once you’ve developed a foundation for each topic and understand the principles and connections between them, you have to organize your mind for how these topics will be asked in the exam. Almost every question I’ve been asked on medical school exams is in the form of a “clinical vignette”; a clinical scenario that gives you essential and distracting information regarding a hypothetical patient. Exams are timed and these vignettes can be 6 sentences long. You have to be fast and precise in reading the vignettes and identifying the important pieces of information. There are only so many ways a particular topic can be tested, and once you have seen several clinical vignettes for a topic, you will recognize the underlying patterns and keyword associations. Therefore, the most high-yield form of preparation in medical school is answering question banks. Especially in the 2 weeks leading to the exam, double down on the time spent answering questions to solidify the foundation and understand how the principals are being tested. The more you answer questions on a range of topics, the better you will perform. At least, this is my experience.
A few question banks that were useful for me: Osmosis, MedBullets, Boards and Beyond, and UWORLD. While I reserved UWORLD for STEP1 and STEP2 studying, the recent change that made STEP1 pass or fail means that I would recommend using UWORLD STEP 1 as an essential prep resource throughout preclinical training. It’s that good of a resource and if you study with it from the start, I imagine you will be able to receive a passing score on STEP 1 with little additional preparation aside from the NBME practice exams.
Clinical Skills and Preceptorship
In addition to multiple-choice exam preparation, you will be expected to learn the fundamentals of patient care throughout the preclinical training. From learning how to interview patients, to completing a cardiac physical exam, to managing difficult patients, you must learn the checklist of actions required to receive good grades. The grading on these interactions is highly subjective yet there are certain steps that must be followed to display understanding of physical exam best practices. For example, if you auscultate (listen with the stethoscope) each of the heart valves to assess for murmurs, but forget to measure jugular vein distention (JVD) in the neck, you lose points. If you conduct a thorough patient interview, but forget to ask about sexual partners, practices, and drug use, you lose points. To prepare for these scenarios, bring a checklist and a friend to a clinical-like room and go through it step by step. Once you establish a workflow and are thinking critically about each of the possible problems you need to assess for in a given situation, it becomes much easier. Nonetheless, the subjective nature of these assessments means two people can receive different scores for doing the same things. While unfair, this is how most of your grading will be done in the hospital. You must play the game by their rules. When you arrive in the hospital for clinical rotations, the subjective grading will continue and these marks will play an important role in your competitiveness for residency programs. My experience learning how to be helpful and productive as a medical student in clinical rotations will be coming soon in a separate post.
Whether you are MD/PhD or MD-only, the summer after the first year of medical school is typically when students begin research. MD/PhD students use this time to rotate through different labs and determine where they might pursue their PhD research. MD-only students seek opportunities to explore fields of interest, generate publications, and form relationships with faculty for future letters of recommendation. The first summer is also the most free time you will have during medical school, so I encourage you to enjoy this time.
Prioritize your mental health
To excel in the preclinical years of medical school, you should prioritize mental health. For students who pride themselves on being high achievers and excellent at school, the transition into medical school can be challenging. For most people, the study hygiene from college won’t cut it anymore. You will routinely be getting more questions incorrect than you have throughout your academic journey. If you attribute self-worth to your academic performance, you might find yourself feeling at a loss, especially if your identity is tied up in your past academic success. Each person has to come to terms with this transition in their own way, yet realizing that this is the norm and that many students are also struggling with it is key for not feeling so alone. If you let things like class rank and percentile scores rule your mind and dictate your mood, your self-confidence will suffer. I’m not encouraging mediocrity; on the contrary, I’m encouraging that you derive self-worth from a more intrinsic source.
Extrinsic validation is toxic when it’s your only means of valuing self-worth. For students who come from underrepresented backgrounds and struggle with imposter syndrome, relatively poor performance causes students to feel like they are letting down their families and communities. The feeling that you don’t belong and should just go back home is suffocating. You get caught into a perpetual cycle and the mind aches. It’s not surprising that mental health problems are rampant in medical school education, but there are strategies and resources to manage these problems.
While boredom was one reason I didn’t attend medical school lectures in person, mental health was a more important reason. By protecting my time and taking more control of how I spent it, I gained a sense of autonomy that was valuable for my education and performance. Exercise was a crucial means for me to dissipate the frustrations and break-up the long hours of studying to reconnect with my body. We owe it to our melon heads to make sure our mind-body axis is in check. Make exercise a source of pleasure and not another box to check off, and your mindset will benefit greatly.
Like in high school, you spend countless hours with peers. Find your people early. In medical school, study groups are a key support system. I preferred to study alone for the majority of time, but in the week leading to an exam, I found comfort with my people. By seeing the way my friends understood the principles allowed me to increase my own retention. My friend and I would grab a whiteboard and a screen to go through the topics of the exam and teach each other. Just conversing and storytelling about the topics improved our understanding, and we came up with the most ridiculous and sticky mnemonics to remember the minutiae. We bonded through these experiences and our friendship fortified through the shared struggle and mutual support. Finding the personality types and group sizes you vibe with when studying is important.
In addition, therapy is a major key and underutilized resource. I avoided therapy because I didn’t think I needed it. After finding myself in a depressed state that was affecting my performance, I made the leap to set an appointment. Having confidential conversations with a trusted person outside of medical school helped me to reevaluate my circumstances and find tools to manage the anxieties driving my depressive episodes. Most medical schools have resources for therapy available to students. I encourage you to take advantage of these resources before you hit an emotional bottom.
The preclinical years is an optimal time to prioritize mental health because the coping skills you develop will be valuable for the rest of your medical training. Build your foundation early and let your skills compound over the duration of your training. You owe it to yourself and your future patients to be on point. When a patient in need presents to you asking for help and you need to solve a challenging problem with no straightforward solution, your mind must be prepared to empathize and problem solve. Being an excellent physician is often more about EQ than IQ. If you don’t bolster your own emotional stability, you will struggle to support your patients adequately, which is the last thing you want. After all, the patients are why you signed up to do this gauntlet of training in the first place, right?