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In Pursuit of Excellence (Knowing Things)

July 16, 2023

Hi everyone,

When I was a resident, we joked that we carried external brains in our white coat pockets, which bulged with laminated ACLS cards, to do lists, and weathered Washington Manuals. Hard questions sent us to textbooks like Harrison’s and Cecil’s, and harder questions sent us to the library, where old issues of JAMA and the NEJM lined the stacks. We were years away from PDFs, UpToDate, #MedTwitter, and handheld computers, which we now take for granted. Someday soon, we’ll probably have robots presenting on rounds, ordering tests, choosing antibiotics, and writing our notes.

With all these resources, you might ask why we don’t just leave the thinking to computers and release our brains for other uses. With so many on-line calculators, AI tools, and Care Signature Pathways to guide us, why bother knowing things ourselves?

These resources are amazing but none replace the value of knowing things. Pathways, algorithms, and online calculators are valuable partners, but only when applied by knowledgeable physicians.

Of course, I could be wrong. Most of you will be practicing medicine for 40 or 50 years, so maybe in 2063, when I’m 100, you’ll have residents relaxing in the workrooms while robots do the actual work. But I wouldn’t count on learning going away, so I’d get ready for a lifetime of study. Here are some suggestions:

  1. Learn from your patients: Every patient can teach you, even those with seemingly straightforward problems. Why do we treat COPD flares with 5 days of prednisone? Why do we treat septic shock with Lactated Ringers and not normal saline? If you don’t know, check UpToDate or search PubMed. Share your new knowledge with your team.
  2. Study every day: Endless resources are just clicks away. Sign up for email alerts from the NEJM, JAMA, JAMA-IM, and the Annals of Internal Medicine. Read editorials, perspectives, and reviews. Study MKSAP synopses and listen to podcasts like The Curbsiders. We’re all busy, but even 15 minutes a day adds up.
  3. Attend conferences: You can learn so much from Firm Rounds, Teaching Rounds, 8:30A conferences, M&Ms, the Emergency Lecture Series, Grand Rounds, and Report. This year we’re going to minimize remote learning, because there’s no substitute for learning in person (and it’s much more fun).*
  4. Do practice exams: MKSAP provides hundreds of high quality, succinct, realistic case-based practice questions, covering all of Internal Medicine. I aim for at least 5 questions per day. Doing practice exams is the best way to prepare for the In-Training Exam (ITE) and Boards. And it’s a great way to discover what you don’t know, which brings me to my last point…
  5. Embrace your deficits: Smart doctors are intellectually humble. They’re glad to be corrected and have no trouble asking for help. Smart doctors love being surrounding by smart colleagues who know things they don’t (which is how I usually feel at Resident Report). Capitalize on your mistakes. That’s how we learn.

Later this summer, all PGY1s and PGY2s and several PGY3s will take the ITE, which is a low stakes test that has no bearing on promotion or graduation. Average scores in our residency are high, but no matter how you do, you should use the ITE as a tool to gauge your learning and focus your studies.

Excellent internists know things. Knowledge breeds efficiency. It helps us ask the right questions, harness medical evidence, and identify errors. Knowledge builds our confidence, bringing joy to our work. Most importantly, knowledge helps us become excellent physicians and healers, which is the ultimate goal. So let’s open our books, computers, iPhones, and iPads. We have a lifetime of learning before us.

Enjoy your Sunday, everyone. Heide and I are headed to New York for brunch at Harvest on Hudson.


*Learning together is fun!

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Submitted by Mark David Siegel on July 16, 2023