ASMPH MD/MBA: What I’ve been up to

My first week of online internship began last August. Since then, I’ve been going through the stress of basically having two to four video meetings every weekday, plus one or two during the weekends. Nothing else to it but to adapt.

Normally, I’d write my ASMPH MD/MBA blog posts for the benefit of any wandering pre-med or younger med student who are worried about the specifics of a particular rotation. In this case, I don’t think that what we’ve gone through the last few months would be repeated for the next batch (at least I hope).

But I will still share my thoughts for those who want to know what I think is inherent to the school: how the administration reacts, how the students cope, and how the whole community rallies through this pandemic.

Also this is for me.

The PlanTM

August, September, October and now November. I’ve already gone through three major rotations (one month each of online surgery, obstetrics, and pediatrics, with anesthesiology) and three minor rotations (ENT, ophthalmology, and radiology).

Earlier this year, during our very first townhall meeting with the dean and other members of the faculty, a general plan of the year was outlined. For each major rotation, one month will be spent online during the first semester, from August to December. The second half of that rotation will be spent onsite in hospitals during the second semester, from January to July.

At that time way back in August, there were no hints as to where the pandemic response was going. Apparently the answer was nowhere, but the bare bones of the plan still remains. (The simulations labs seem to have been dropped). During our latest townhall meeting early this month, the tentative schedule is still to have interns back in the hospitals by mid-January.

There are a lot of uncertainties around this plan. I am actually quite frustrated by that. Given a very democratic and slow process where our opinions as students are solicited (and where our batch’s Executive Board is driven to stress by the effort to coordinate), everything’s still up in the air. What can we expect as preparations to go back? Can I get my vaccines done first? What’s our insurance coverage? Can I at least practice some skills somewhere? How many PPEs will we be provided? Can the CEIP students still rotate in Barangay Toro Hills?

But I am at least in agreement with the big picture goal. The competencies of an intern cannot be developed with just online learning. The effort to consult and coordinate, while not perfect, is still a lot better than the blunders of the PRC, APMC, and other schools which I won’t name here.

Also, the PLE (Physician Licensure Exam) for 2021 is set for September. Only 10 months to go!

P. S. Send hearts to batch 2020, who are taking the PLE this season, scheduled November 10, 11, 15 and 16.

Drinking at SGDs, zoom exams and virtual suturing?

There are many styles of blended learning. Here in our medical school we depend entirely on online synchronous and asynchronous sessions. We don’t have any print modules. It’s not practical, especially for our year level. We also already have a ridiculous amount of online and downloadable sources to draw from.

Most student have print or PDF copies of the main textbooks. Telegram is a surprising treasure trove of textbooks and USMLE prep materials. There are public access online lectures. Some have subscriptions to Lecturio. I still go back to YouTube’s Armando Hasudungan, Osmosis and OB-Gyne lectures by Dr. Ina Irabon for a quick fix. For pathophysiology and clinical correlates, nothing beats the Calgary Guide to Understanding Disease.

(I have more notes on how I’ve been studying down below. Like a thousand words more.)

And honestly one of the true MVPs would be the ASMPH Library. I’m really getting my tuition’s worth. I’ve never had such easy legitimate access to journals and anatomical models or whatever from my own desktop before.

A variety of discussion styles

For the most part, our cluster of 30 or so interns go through several group discussions per week. Depending on the rotation, the discussions can be as a big group (TMC surgery) or as small subgroups (TMC and OsMak surgery, obstetrics, pediatrics). I honestly prefer smaller groups, at most 15 students, because that allows enough space for everyone to participate. But I do understand that teaching consultants don’t grow on trees.

So this is an example of a GIANT group discussion. Find me??? Some days I feel very participative and even extrovert. I can recite a lot, especially when there are too many awkward silences (better to try and fail than never try at all?). For this OB session, I had a lot to say. But other days I can get away with just reciting once or presenting several slides before turning my brain off. I guess this discussion style is heavily dependent on the individual learner’s disposition for the day.
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Some rotations were a bit more loose than others. Whether we’d be allowed to turn our video off as an audience to a report or whether we’d be allowed to enjoy a snack or two as long as we turn our mics off depends on the consultant and the rotation.

We either participate in free-flowing discussions (TMC surgery, TMC pediatrics) or we prepare presentations for a textbook-based report (anesthesiology, half of my CEIP sessions) or for a given clinical case (almost every rotation). Sometimes, things get exciting and we watch videos of surgical procedures or discuss the admission census.

Some small group discussions do stand out though, like this evening pediatrics session where we were asked to bring drinks. As a non-alcohol beverage drinker, I enjoyed some late-night soda. :)
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TMC ophthalmology was extra neat because we finally tried out Canvas by Instructure, which younger year levels have been using for some time already. It’s an online learning platform where students and faculty interact through asynchronous discussion boards, and where we can read up on linked resources, watch embedded videos, and answer quizzes.

New ways of assessing knowlege and skills

Before we had the privilege of trying out Canvas, quizzes and exams were a bit more complicated. It required a two-device setup, with the laptop for answering the Google form questions linked through Google Classroom, and another device mounted to check our activity for any signs of cheating. Honestly, just trust us. We’re all adults here.

So this was my tripod setup. Clearly this wasn’t while I was answering an exam. It was while I was studying something else, probably. Peep my Php300 (??) desk mirror with lights.
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Speaking of innovation and change, I did appreciate the attempt of the TMC obstetrics faculty to give us some skills training. They asked us to procure sets for suturing (expensive, but there are workarounds like borrowing or using meat). I’m still not going into a surgical field, but as a primary care physician I should at least know how to suture lacerations and to do episiorrhaphy.

If you’re looking for affordable and high quality suturing sets –whether for first aid, medical or dental practice– check out A x L Silicone Suture Pads. I bought a Suturing Starter Kit from them, inclusive of a standard suture pad, needle holder, toothed and regular tissue forceps, iris scissors and two catgut sutures. This shop is also run by ASMPH students, so I’m even more confident about the quality and value for price.

For the life of me, I still can’t do a two-handed surgical knot. Why is a one-handed knot so much easier?

Back to basics, desirable difficulties, and Anki

I remember clerkship being a whirlwind of always having to be somewhere and having to do something. Basically there was always a long list of things to do in my tickler notebook.

(I wrote about the things I learned in clerkship here).

There was never any time to really read full chapters of Harrison’s or William’s or Nelson’s or Schwartz‘. Sometimes you can only read as far as you need for a case report and nothing further. In some ways, the nature of online internship gave me time to go back to the basics. Many of the chapters I’ve read the last few months were chapters I’ve never even touched before, not even during my classroom years. (I mainly survived YL5 to YL8 using transes).

It’s been pretty exciting. This is the kind of understanding that I think is essential for actually being a physician. And it’s great to come back to these textbooks after seeing patients during clerkship. This time, I can appreciate the sections on pathogenesis and clinical features and management a little bit better. There’s just more color to it.

Surprisingly, despite not reading the bibles that much or even actively trying to exceI, I still made it into the the top 5 of my batch for YL8. I just wanted to survive clerkship? But I am grateful. I got a cake out of it. And an excuse to wear eyeshadow during the (virtual) award ceremony.

Like what? Hahahahaha.

My main friend when it comes to studying the basics has always been Adobe Acrobat Reader. I don’t even know if anyone uses a different app. And for topics that I feel are essential and that I will repeatedly go back to for boards review, I create really comprehensive and stylized notes on GoodNotes. I think it’s a great note-taking app. I unfortunately can’t maximize it because I don’t have an iPad. (Baka naman). I’ve also transferred some of my YL6 and YL7 notes from OneNote and Google Docs.

There’s something really satisfying about seeing all your notes in one place.

But note-taking isn’t actually a good way to review. It’s a good way to understand, I think, in terms of reorganizing information into pathways that your own brain is comfortable with. But long-term learning and effective studying is something that comes with what I now know to be desirable difficulties.

What are desirable difficulties?

I’ve slowly been going through this well-researched book entitled “Range: Why generalists triumph in a specialized world” written by David Epstein. There are a lot of things going on in this book, but it introduced to me the term desirable difficulties.

A desirable difficulty is a learning task that requires a considerable but desirable amount of effort, thereby improving long-term performance… Research suggests that while difficult tasks might slow down learning initially, the long term benefits are greater than with easy tasks.

Wikipedia, lol.

Right now, everything I’m doing to study is geared towards the long-term outcome of me practicing as a primary care physician (plus me succeeding in the 2021 boards). It’s okay for me to give the wrong answers in small group discussions. It’s okay for me to stutter and take some time to answer a consultant’s followup question. It’s okay for me to keep repeating the same flashcards because I can’t remember the connections well.

Sometimes, the best trade-off is to sacrifice short-term performance for long-term gains. The point of is to force the brain to use multiple retrieval paths for different problems. This skill makes knowledge more accessible in the long-term.

There are many types of desirable difficulties. You can obviously google them. But I’m happy to share some that I’ve been actively applying to my own studies.

First is interleaving and spacing.

The modular curriculum of ASMPH means there can be very little interleaving of subjects. For a week, everything about the thyroid is studied. This includes pathophysiology, pharmacology and public health. For the next week, it’s everything about diabetes. This is called blocked learning. And it’s easy, because the exam at the end of thyroid week is entirely about the thyroid.

But in truth, we will be tested about different topics at different times of our lives. Exams won’t be so considerate of our study syllabus. Interleaving is the practice of switching between topics, instead of studying one set of information at a time. This means that while I’m in radiology rotation, I don’t just study radiology. I spend some time studying biochemistry or pathology. I go through a variety of clinical and basic subjects everyday on Anki (more on that later).

CEIP is a big part of interleaving. I go to at least one non-regular rotation session each day. It’s usually a review on medicine, surgery, obstetrics-gynecology, pediatrics, ENT or ophthalmology.

Another big asset are the efforts from our academics committee. My honorable batchmates have been asking daily questions on Telegram and hosting monthly Kahoot quizzes on rotation-agnostic topics. I don’t always attend or participate, but every other week or so I remember to check these resources out.

The second is generation effect. I’m taking the definition from this article. Generation effect is the result of formulating your own answers rather than studying the answers of others or getting the answers from google.

Imagine being asked something you don’t know yet, such as “why is there palpable purpura in HSP?” or “what is the pathophysiology behind Horner Syndrome?” or “why is IVIG the treatment for Kawasaki?”, and forcing yourself to answer by making connections and deriving conclusions from what you already know.

In medicine, I think this drives you to come up with very useful patterns of problem solving that are applicable to more than just one organ system or disease entity.

I’m also trying to put in some variability in studying. This is a bit harder because there are only so many hours in one day. In an ideal scenario (aka my peak productivity days), I answer flashcards in the morning, watch related YouTube videos right before my synchronous sessions, take down notes and come up with self-constructed Q&As as I participate in lectures or discussions, then end the night with note-taking on GoodNotes and adding to my Anki database.

And if there’s an extra extra hour, I work hard to add more content to my passion project –trying to simplify medicine into lay terms. I think the benefit isn’t just to the public (rather obviously), but also to the way I personally comprehend a subject.

This is from my page, Salinsina PH. The inspiration for this project comes from the words salin, to translate, and medisina, which means medicine. I translate what I read from my medical textbooks, from the latest journals, from the WHO or CDC, into infographics that are hopefully helpful to more Filipinos. I also have an Instagram and a Twitter account. Feel free to share and support!

The last thing I want to write about is Anki. This has been cropping up everywhere. In terms of desirable difficulties, flashcards trigger encoding and retrieval processes that support learning. It has the benefit of the testing effect.

Anki is a program which makes remembering things easy. Because it’s a lot more efficient than traditional study methods, you can either greatly decrease your time spent studying, or greatly increase the amount you learn.

About Anki on their website

I think I’ve talked about Anki to so many different people ever since I discovered it. But let me do this here as well.

Using Anki in internship

As far as I know, there are Anki packs for medical students and for people studying for the USMLE; many of my batchmates use these pre-made packs. Maybe someday soon I’ll get to that too.

I personally use Anki as a way to integrate the pearls I’ve learned during synchronous sessions and independent study. I make at least 15-20 flashcards per session, then I spend up to an hour at the end of each day to read more about these ideas and to add them to different desks.

Every morning, I study some cards following Anki’s algorithm. Cards I mark as “hard” crop up more often until I’m confident enough to mark them as “good” or even “easy“. When it’s exam season, I go through a specific tag or deck all at once (though that’s usually overstudying hahaha).

Here are examples of my cards on desktop (apparently I’ve made 1906 cards since August, who would have thunk!). I prefer to answer them on my phone.

I have a big deck for clinical rotations and subjects, and another deck for basic medical sciences. Specific subjects are nested under the decks.

Using Anki has also improved my question-making skills; sometimes the official exam questions I encounter are worded almost exactly the same as the flashcards I made. Easy!

Old friends, new people, great teammates

What else have I been up to? To the surprise of myself, I’ve been making (and maintaining) friendships.

Cluster 3 (++ some preceptors). I can confidently say I haven’t carried an actual conversation with at least 1/5 of this group before August. So it’s been nice to be forced into the same virtual space as these new and old friends day in and day out. Nothing strengthens bonds like the trauma of trauma room. And the truth that all people are interesting still holds. Ish.
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We don’t have a photo (I think), but I really enjoyed my subgroup for our anesthesiology rotation as well. Because it was set up in alphabetical order, the subgroup was a big throwback to our anatomy dissection days and other classroom groupings.

Pedia subgroup something. I’ve been shuffled through MANY subgroups through the past few months. But I like this group for the associated memories; a lot of the SGDs were just mentoring and/or chika discussions in disguise. Also because of Jana and Raph, if I may be so bold as to namedrop in a blog. I didn’t know they were so precious. Hello. :)
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Even though CEIP sessions can be tiring (we literally have double the work), I almost always go in with a light heart. I like this mix of people, and I like that there are people who understand exactly the amount of stress I’m going through as an online intern. It’s a safe space (extra exams and presentations and all). Also, despite having only 1 extrovert among us, we still make do.
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Another obvious confession: I’ve never properly talked to a quarter of the other CEIP interns before this academic year. I’ve talked to them casually, probably, but I can’t remember any outstanding conversation. So it’s a bit exciting. There’s something fascinating about each person in this group. We also have stellar and passionate teaching consultants; I wish I had the time or the right to wax on and on.

And nearing the end, I am here now with a new-ish bunch of people to share my single brain cell with.

Somehow this mix of people (my minors subgroup for the last three weeks) has been alternately triggering my fight, flight or fond reflex. I love them. I can probably write an essay on my new friends. It’s fine. I’m fine. Also, they got me playing Among Us late at night, which is a great stretch for an introvert. The quality time is excellent. I think. If I squint.
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Finally, I’ve had the pleasure of maintaining the friends I’ve made in the past. Here’s to you. :)

Mostly a shoutout to Maryan, Faye, the UPM A Alums, Chika Minute, my fellow simps on twitter, my fellow non-simps on twitter, the Permanent People In My Mailing List. Thank you for existing.

Keep hustling. But always take care of yourself. I’m in a current slump (physical and mental health-wise), so writing this post (and my recent birthday post!) has been an exercise in mindfulness.

Until next time! 💖

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