Book Review: So You Got Into Medical School….Now What?

Newly minted orthopod Daniel Paull MD’s So You Got Into Medical School….Now What? came out last year. The book attempts to be a one-stop shop of medical school advice with a big focus on how to study. I bet the idea of a detailed how-to guide for medical school seems compelling to a lot of people (particularly the anxious type A variety), but I find it odd how specific authors and various internet people attempt to be for study advice given how variable the coursework and grading are for the basic sciences nationwide.

Chapter 1 (“Conceptual Learning and Detail Worrying”) is 7% of the book, extremely dry, and could be summarized by saying medical school is hard, there is a lot of information to learn, and given that, you should try to really understand material and not cram. I’d argue that the argument that studying over time leads to better long-term retention over cramming requires no argument at all. It’s self-evident. Even people who cram (and I’m one of them) know that it is a test taking strategy of procrastination/weakness and not a good method for truly learning the material or preventing self-hatred and sabotage.

Paull also advocates strongly for reviewing the material before lecture. Conversely, many students would argue that avoiding lectures altogether when possible is a more time-efficient solution. His discussion of anatomy is pretty old school without any discussion of how anatomy instruction has changed at many institutions around the country (with many schools placing a greater emphasis on prosections, virtual dissections, etc instead of lots and lots of hours in the lab).

I did really like one bit of counterintuitive advice: keeping a study schedule can help you prevent the feeling that you should always be studying more. The schedule as a means to say “you’ve done enough” sounds like a great idea! Everyone needs balance.1

When it comes to specific test advice like Step 1, he again focuses on the idea of the magical schedule (without supplying an example himself). He doesn’t mention anything specific about book recommendations, question banks, or any recommendations on how to structure your review. I wonder if he avoids mentioning any books by name so that his book doesn’t become outdated? Either way, all the conceptual writing about studying then falls short without any specific advice when it might count. Paull falls prey to thinking his own specific experiences and school set-up are totally generalizable (because they’re not). His take:

Review books and question banks are equally important in preparing for the Step 1, and just about every study schedule will dictate the use of both.

Again, the best approach is to ask upperclass students which materials they found most helpful. Usually you’ll get a consensus on this.

Which is a huge cop-out! You’re the upper classman in this context! People are reading the book because they want your thoughts! If there is really a “consensus,” then give it. You ask enough people, especially completionists, and you won’t get a consensus. In reality, ask enough people and you’ll eventually get a list of more good/reasonable resources than you can handle. (I’d also personally argue that the question banks are generally more important than books in preparing for Step 1, but that’s just my take.)

Regarding shelf exams:

Another mistake students make is not reading the books they select in their entirety; too often students rely entirely on practice questions. Despite their usefulness, practice questions often do not cover all the necessary details of a topic and are designed simply to test the base of knowledge you will gain from books.

Agree that you need to read the entire book, but I’ve never met anyone who really relied too much on practice questions; I have however met a lot of people who haven’t done enough.

Regarding clerkship evaluations:

The subjective component can comprise up to 50 percent of your clerkship grade.

Up to but not more than? Really? 50% of your grade from evaluations is the maximum cut off nationwide?

Regarding Step 2 CK:

In fact, most medical schools simply require students to take this test before graduation.
On average, students study for two to three weeks for the Step 2 CK
Second, find someone who did well on the Step 2 CK and ask how that person studied.

The appeal to authority fallacy is really a terrible way to live your life. Many (most? who knows?) schools require Step 2 CK long before graduation, and more importantly, a growing number of programs require passage before ranking.

Regarding Step 2 CS:

Most nonnative English speakers will have a more-than-sufficient clinical skill set to pass those aspects of the test, but the spoken English proficiency section can be a challenge.

The data don’t necessarily demonstrate that. Spoken English Proficiency (SEP) is the least likely cause of failure in all groups (US and IMG). International students (which doesn’t distinguish between native and non-native English speakers) fail ICE > CIS > SEP, the same order as US students. I wrote about this here (with actual data).

Regarding The Match:

A personal statement won’t make or break your application.

A great personal statement can only “make” an application in extreme circumstances, but truly terrible personal statements absolutely can and do break applications.

Either way, if an institution doesn’t have a majority of residency positions filled by people who rotated there (this includes students from the program’s home institution), consider that a bad sign.

This is highly field-dependent. Small surgical subspecialities like Ortho and Urology differ greatly from typically larger residencies like Medicine or even Radiology.

Anyway, you get the idea.

Ultimately, the book falls prey to the obvious limitation: Paull is a single author who hasn’t made a huge effort to see how his medical school experience might differ from other students across the country.2 The general advice is reasonable but not mandatable. Study hard but not too hard, over time instead of overtime. The specific advice is occasionally way too narrow,. and of course, the whole thing is mostly common sense. That’s the nature of these things.

Overall: If it would make you feel better to have a solid road-map of medical school to keep you grounded, give it a spin (especially if you have a free trial or subscription to Kindle Unlimited, making it free to read). I know that during med school I was always wanting to know more about what happened next and felt that the class meeting that discussed it was inevitably further away than I wanted. If you want specific advice though, you’ll still have to (and should) look elsewhere.

Book Review: Core Radiology

Jacob Mandell’s Core Radiology is the book that first year residents should be reading to get a foothold in radiology. The classic Brant & Helms is too unwieldy, too long for a first shot, and a mishmash of styles with lots of words, comparatively few pictures, and a relative dearth of diagrams and other helpful practical knowledge. I wouldn’t characterize Core Radiology as a true Core exam review book; I think he’s using that title as a hook, but it does have the “core” of practical radiology with an obligatory sampling of useless/”classic” board/pimping tidbits.

When I was an R1, I don’t think reading B&H really helped me get a strong foundation in radiology, and I don’t think the ratio of words and concepts to pictures and actionable material helped me with my practical knowledge or approach to daily reading. Core Radiology isn’t as detailed as B&H–which is I think the point: no multicolumned walls of text. It’s a single author viewpoint written over time by a resident (with faculty consultation) and represents a “for us by us”-type First Aid approach to learning radiology. You can read the big textbooks later, but sometimes the big guys just aren’t manageable. Reading them too early can be a lost opportunity, as the extra nuance has no foundation to grow from. It’s a lot of extra work for little payoff.

So I like the book (kinda wish I had written it), but it’s definitely not perfect. A book by a single non-expert author training at one institution is going to have some flaws merely by its narrow world-view. Room for improvement:

  • Needs more images. Call me old-fashioned, but I don’t think a book should describe the “head cheese sign” and not include a picture of it (especially if it gets several paragraphs of text). It always breaks my heart a little that radiology books love to describe ten diagnoses with three pictures. B&H may be a bigger offender in this regard, but both suffer from a relative dearth.
  • Incomplete/misleading descriptions. True mistakes are very rare, but there some specifics that are occasionally off the mark. Sometimes an approach, rule of thumb, or a controversial/debated subjected is characterized as a widely accepted fact. Random examples include leaving breast cancer off the hypervascular metastasis list or that Kasabach-Merritt syndrome is for “splenic” hemangiomas (other locations count too). The OB sono section definitely contains some numbers and statements my attendings would have balked at (e.g. any embryo visible at ultrasound should have a heartbeat in order to be viable).
  • Oddly missing facts. Random examples include discussing polysplenia heterotaxy syndrome without even mentioning asplenia and not discussing testable facts like the association of antimitochondrial antibody (AMA) with primary biliary cirrhosis.
  • Physics section is basically a joke. This section is almost an afterthought. It reads like some physics notes coupled with a few decent diagrams. Much of it is too terse and unsubstantiated to be helpful for anyone without a solid background, though a few factoids might stick. Super weak. You’ll just need to look elsewhere.

As I mentioned already, this isn’t exactly a Core review book in that it’s not really written toward the test, but it definitely contains enough classic findings, useful differentials, and Aunt Minnies to help for taking cases during lectures and enough of everything else to provide a strong foundation for rotations and the rest of residency. It’s probably the best book available for R1 longitudinal non-case-based reading, and it’s solid for the Core Exam as well.

For those wanting to start some “light” board review in the fall (especially those who haven’t been prodigious readers), Core Radiology makes an excellent springboard for Core Exam prep. I myself read it during the beginning of my dedicated board review and was glad I did, but I wished I had started it earlier. The print is big, the style of concise, and the bullet points keep things moving…but it’s still not exactly short. It’s (a relatively brisk) 895 pages.

Overall: Highly Recommended.

 

Book Review: Physician Finance

Next up through the Kindle Unlimited tour of “free” books written for physicians is Physician Finance: A Personal Finance Guide for Doctors by KM Awad.

This book’s style is very casual. Normally that’s fine, but I wonder if perhaps among the jokes and looseness if the message is maybe diluted (some may appreciate it more than me; I found it tiresome but it certainly keeps things light). This book covers the basics. In fact, every book covers the basics. And in practice, the basics can always be summarized in a few bullet points.

  • Spend less than you earn. If you can, spend a lot less.
  • Housing and transportation are people’s two biggest expenses. If you can, definitely spend less on these.
  • Pay off your debts as fast as you can: the higher the interest rate, the faster you need to pay it off.
  • Invest for retirement (in tax-advantaged accounts like 401(k)s, 403(b)s, 457(b)s, and Roth IRAs). The earlier you start and the more you save, the better.
  • Seriously, stop spending so much money.

But here, some of the “details” are wrong. And if not wrong, some are definitely fringe viewpoints expressed like facts.

Incorrect view of credit cards and credit card perks

Credit cards aren’t the work of the devil; they’re a (potentially dangerous) tool of convenience. No one likes the idea of being in debt (or actually being in debt), but Awad writes with an almost irrational fear of it (to the point that otherwise reasonable arguments begin to lose steam). There’s been a recent push among some authors to encourage people to use cash over plastic, as it’s been shown in some studies that people spend more per purchase with credit cards than cash. This may be true, but using cash is super inconvenient (and try booking a hotel without a credit card). Credit card perks are in fact real (and there are whole sites dedicated to this), and while it’d be silly to think that the card companies are doing this for charity, if you pay on time, it’s the merchants you buy from who are paying the fees, not you. The only people who should really be staying away from cards are the ones carrying around high-interest credit card debt month to month.

Poor understanding of car leases

Don’t get me wrong, no one is being “frugal” when they they get a car lease (or buy a new car at all), but Awad is wrong on some basic lease facts. Anyone who simply writes that leases are always worse than buying is equally wrong as someone who says renting is always worse than owning. A simple common misconception. Don’t get me wrong, ideally everyone should buy a three year old Honda in cash. But given that not every reader is going to do that, this treatment comes across as ridiculous. If you are going to go get a brand new vehicle, then you should know that whether you lease or buy, the vast majority of all that money goes to depreciation. Even if you buy, there’s minimal equity after a typical three year lease term. So whether leasing is worse than buying depends entirely on the terms of your lease versus the terms of your purchase as well as how long you plan on holding on to the car. It’s not that leasing is always worse than buying, it’s that getting a new car every few years is a costly luxury.

Poor understanding of mortgages

Treatment of mortgages is also overly simplistic and somewhat misleading. Awad is particularity wrong regarding adjustable rate mortgages, particularly with regards to loans like 5-year ARMs, where the rate is fixed for a set amount of time and then adjustable afterwards. Again, you can get in a lot of trouble if you use a nice low rate on an ARM to buy a house you can’t afford, but depending on your plans, an ARM may make perfect sense.3

He also argues for a 15 year over a 30 year mortgage without any consideration of their tax consequences, for example. No one would argue that a 15 year costs less (it does) or will have a better interest rate (it will), but that doesn’t mean that depending on the interest rate difference that a 30 year isn’t a better choice, say for someone getting a super low fixed rate and who has plenty of tax-deferred retirement space left to invest the excess.

Useless discussion of student loans

The biggest, most complicated, most-“physiciany” issue facing young docs is their large student loan burden.This book does a terrible job discussing student loan debt, being both too succinct and simplistic, out of date, and also inaccurate. Awad spends time discussing subsidized loans, which you can’t get anymore for medical school. He recommends deferment, which you also can’t get anymore (forbearance is different and with worse terms). No meaningful discussion on any of the actual payment options, IBR, PAYE, REPAYE, consolidation, or private refinancing. Nothing about PSLF. This topic is one of the things that actually deserves some detail in a finance book from docs and is conspicuously absent.

Overall

One downside to Awad’s viewpoint of extreme debt fear is the potential quality of life hit. The purpose of money is to make you happy (i.e. many of us “work to live”). Sometimes trying to save a buck here and there results in a big happiness hit, especially during the medical school time period. It’s not always worth it, and it’s silly to pretend it is. It’s at least as alienating as it is inspiring.2

The core message of the book is fine. The core message of the book is also the core message of every personal finance book, which could also be a blog post (which is true of every self-help book). The details though, from credit cards to loans to retirement, are just too patchy to recommend.3

Verdict: While this book is free for KU subscribers, anyone paying should just read The White Coat Investor, which while definitely not perfect (and particularly lacking for student loans), is a substantially better book overall.

Book Review: Pay Yourself First & Changing Outcomes

I recently started a 30-day Kindle Unlimited free trial, which gave me a chance to pick up a bunch of Kindle titles (to read on my phone).4 I used the opportunity to take a look at a large fraction of the (mostly self-published) books on medical school advice and physician finance.

My first review is a combo of two sibling books written by financial planners of “TGS Financial Advisors.” These folks specialize in “servicing” physicians; they’re CFPs and not MDs.

The first, Pay Yourself First, is geared toward doctors just out residency/fellowship (potential clients for their $5000/year fee-based advisor service). The second, Changing Outcomes, is directed toward mid-career physicians (who presumably could fork over even more money). This is amusingly reflected in the price, as Changing Outcomes costs a bit more.

Both books are short and share large portions verbatim. Pay Yourself First focuses on convincing you to save more and not spend too much of your new-found income. Changing Outcomes begs you to save more and stop spending so much. The actual financial advice is physician-directed though almost entirely not physician-specific.

The covers are nice, and they paid Kirkus a few hundred bucks for a blurb, so they’re taking the “book as native advertising” concept seriously. There are a few typos and whatnot, perhaps less than average for self-published. I think most recent medical school grads with their massive student loan burdens are more in tune/fearful of their financial future than older docs of the more lucrative medical past, but the discussion of why a high savings rate is the foundation of building wealth and retirement security is nicely written.

A few of my favorite passages.

Here at the beginning of your career your assets are probably smaller than those owned by the average public school teacher. Asset poor and cash flow rich; in your first years of practice, everyone will want a piece of that cash flow.

This is a hidden cost of medical training that most non-physicians simply cannot understand. Not only have you studied longer than any other professional, incurred hundreds of thousands of dollars in education loans, and deferred a serious payday until your mid-30s, you have also lost precious years of potential compounding on your savings.

When you finally start making money, you’re already way behind. You have tons of debt and haven’t saved nearly enough, and those valuable years of compounding interest are gone forever.

Unfortunately, the relationship of wealth to happiness is asymmetric. Moving up is often only temporarily rewarding. But losing ground—suffering even a limited reduction in socio-economic status—is durably painful.

Lifestyle inflation is much easier to avoid than reverse.

Spending on possessions has the most transient effect on happiness, while spending on relationships and experiences has more durable emotional benefits. Unlike status based on earning or spending, research suggests that attaining $1 million of net worth is associated with a permanent increase in confidence and self-esteem.

Having enough money to tell the hospital admin to do something profane to themselves: Priceless.

Outside of these general themes, there is almost zero detail. This is not a DIY book, so other than the inspiration, the books are pretty much useless. Hint: They think you should get a financial advisor.

Overall, the you-need-an-advisor sell isn’t particularly egregious, but it is a bit amusing as it comes after discussion of how low-cost low-fee index fund investing is the right choice (something you definitely don’t need an advisor to set up). Fee-based financial advisors are essentially life coaches who focus on your money. You really only need one if you can’t be trusted to not sabotage yourself.

Verdict: If you need convincing to save more and spend less, either one is a pretty well-written plea and is a fine free read if you have KU. Otherwise, save your money and look elsewhere, like WCI or Bogleheads’.

 

Review: ExamGuru Shelf Exam Question Bank

Updated 5/16/2015 to reflect new prices, new discount code, and some additional changes.

ExamGuru is the brand new and currently only question bank geared specifically for the third year NBME shelf exams. While the product itself is new, the company is not: it’s a new brand of the COMQUEST family, one of the two big players in the osteopathic question bank market (for the COMLEX exams, which are analogous to the USMLEs). It was released to the general public this week, but I had early access in order to write this review. I was also able to secure a discount for readers, so if you sign up using the code BW15 , you’ll get 15% off whatever package you get, and I’ll get a few bucks.

Before we get started with the actual review, full disclosure: I wrote a small number of questions for this question bank as a freelancer several years ago. These were sold on a per-question basis; they are no longer my intellectual property, and I have no financial stake in the company or its success outside of the time-limited coupon above.

Size and Cost

The ExamGuru question bank is divided into separate shelf exam products, each with a goodly number of questions (as of the time of this post): family medicine (375), internal medicine (412), ob/gyn (369), pediatrics (406), psychiatry (395), and surgery (399). Each question comes with the detailed explanations we’ve come to expect from medical school question banks: 1) Concept/question explanation 2) Detailed answer choice explanations, including explanations of the incorrect options, and 3) Take home point.

You can buy a subscription for a single shelf product at a time: 1 month for $49 $37 and 3 months for $99 $79. Alternatively, you can buy all six products for a length of time ($129 for 1 month up to $379 for the year). Given that buying a month of each product would add up to almost $300, it would seem that the product is priced to encourage you to either buy a few products for a month each or just shell out for the whole year, which would allow you to the use the bank both as a shelf study resource and as an alternative/secondary Step 2 CK qbank.

Software

The website imitates the FRED software you’re intimately familiar with (and also has an option to change the layout to the one used on Osteopathic examinations for DO students). Everything is accessed via the website itself (no downloads or creepy UW spying/tracking), and the site is responsive: it works appropriately on your computer or your smartphone.

Peer percentage correct for each question is provided a la other competitors. Questions are also rated by difficulty, though I’m not sure how this was calculated; oddly, it seemed like most of questions I did were graded as “hard” in their software. I wasn’t sure if this was simply chance or reflects how they’ve self-graded the difficulty and the relative proportions of each within the qbank. Additionally, EG does provide good actionable data about your performance, including a breakdown by question task (establishing a diagnosis, management, etc), which may be a nice way to pick apart areas of weakness you didn’t know you had. If you’re getting the diagnosis questions but missing the management ones, then presumably it’s time to focus on the “next best step” and drugs of choice.

Question Quality

The question quality is good for its first iteration, but it’s not yet at the UW level of polish. This isn’t surprising: I remember using USMLERx back when it was a newer product, and it was awful and a total waste of time and money. The EG house style in particular a bit spotty and could use more homogenization: Multiple question writers and their particular quirks remain surfaced, and occasional aspects, particularly when it comes to the final stem and answer choices, sometimes stray a bit from what you’d actually see on game day. Buzzwords are overemployed and are even sometimes “in quotation marks” whereas nowadays these terms are more likely to described rather than simply called out. Explanations range from relatively short to long & fluffy, sometimes casual “Don’t forget XYZ on test day” and sometimes stiff.

Topics and narratives are fine overall, but some of the questions slipped through without matching the official question writing guide (which I’ve discussed before). A random example: a question about cirrhosis with blatant over the top SBP contained unbalanced answer choices (1 antibiotic choice versus multiple diuretics). That’s probably too easy and not reflective of the standards. I’d argue the question should have been a bunch of antibiotics asking you to know which type is used to treat SBP, or an even combination of both. One answer choice that stands out from the list is to be avoided. On the flip side, the family medicine section has some really great rash/skin questions, which are high yield and not well represented elsewhere.

EG also still needs a copy editor. Shelf questions are often long but almost never because of fluffy prose (only extraneous details!), and comma errors remain (inappropriate comma use before a coordinating conjunction used in a phrase will always be my pet peeve). Again, not necessarily substantive criticism but certainly one that signifies a lack of polish in its first iteration. The material is there, but these little differences do detract a little from question experience, which otherwise is well designed to approximate the real deal. As above, the software is solid.

Update: The EG CEO informs me that they brought on a copy-editor to deal the issues I raised in this review. He also tells me they’ve updated a lot of questions from user feedback. I haven’t personally taken a look again, but if nothing else, most question-banks generally get better over time, not worse.

On the whole, these are mostly nitpicks. But to me, the level of polish of a product is really important if you’re going to spend a lot of time with it. Errors and inconsistently can detract from the experience and distract from your education. 2 That said, ExamGuru is probably one of the best things to come around for the Shelf exams for a while and breathes some new life into the static review lineup. The mistakes I found during my review were nearly all ones of style, consistency, and grammar. These are the things that are easiest to fix gradually. The core content I saw was just fine.

So my overall impression is that this a supplemental product, not a UWorld replacement. While the important topics are covered and the explanations are generally thorough (sometimes a bit lengthy, I’d argue), the overall quality is not yet up to the consistent quality of UW. The main benefit of EG is that it adds some meat to the UW bones, which are nearly ideal for Step 2 CK but a bit thin for several of shelf exams. UW is still I think a critical component of shelf review, but there’s definitely space for another question source. And on the whole, I think ExamGuru is a better question source than the usual alternatives (e.g. PreTest) in terms of depth, ease of use, powers of software, etc. I’d much rather do dedicated shelf questions in a simulated USMLE environment on my computer or phone (yes, EG is mobile enabled) than thumbing through a book or shelling out for another Step 2 qbank.

Conclusion

So should someone use or buy this product? Depends. If I were a third year again, I would for family (maybe peds and ob/gyn as well). Certainly not internal medicine, UW had plenty of that for me to chug through. Ultimately, as readers of this site are well aware, I believe strongly in doing questions, even as a core study method. UW just doesn’t have a very satisfying number of questions for several of the shelf exams (it’s well-pruned for Step 2 CK). Financially, it either makes sense to buy 1-3 of the shelves for the one-month period to use during a dedicated review push or, if you want more, just get the whole set for the year (ouch). I don’t think the quality or consistency is at the UW level but it’s a tailored source of questions in a friendly NBME style package that you can use on your computer or on your phone. And that’s a great start.

If you do end up using the EG product, shoot me an email or comment and let me know how it holds up to thorough use.