Psychiatry & Psychotherapy Podcast - The USMLE: How To Rock It

Episode Date: September 1, 2020

If you are a medical student or someone studying for a big exam, this episode is for you. We will first discuss the mental roadblocks that prevent students from performing at their top potential for exams. We also break down and outline some effective study strategies, and provide a sample day-by-day study plan for any 2nd year medical student preparing for the USMLE Step 1 exam. Finally, we have also created a 3-step challenge all students can follow. By listening to this episode, you can earn 1.75 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com. Sign up, sign in, take the test, and the certification is email to you in seconds.

All right, welcome back to the podcast. I am joined today with Trace Huang. He is a fourth-year medical student who is doing a project with me. Today we will be talking about a medical student's roadmap to success on the USMLE, mindset, planning, executing. We're going to be talking about common issues that medical students have, fear of failure, self-fulfilling prophecy, viewing mistakes as failures, not being motivated enough, test-taking anxiety.

going to talk a lot about test-taking anxiety, studying with a poor method, thinking thoughts like I'm a horrible student, not giving yourself enough credit, perfectionism, everyone seems fine, why am I struggling so much? This is really for two audiences. Number one, it's for the medical student in the trenches, about to take or prepare for a big test. It would also apply if you're taking like the MCAT or another big test. But specifically our handout that we're going to give is a ton of info for step one. We're kind of like gearing it towards the big test, right?

Step one. Because that's the one that usually medical students have the most anxiety about. And Trace is actually a step one coach. And he has about 30 clients right now that he has been coaching on how to prepare, mindset. that it's kind of a passion project. So we found something in between our two worlds, psychiatry.

He's going to go into psychiatry and step one. And I thought, wow, let's really go into this. So to prepare for this, we wrote down all the things that we thought are some of the things that get in the way of people succeeding that we've seen. Then we interviewed Darcy Temple, Darcy Trinkle. she is a psychiatrist who worked at Loma Linda before saw medical students for a bunch of years and she had a lot of really good stuff to put in and we'll if we don't cover everything that she talked about we'll put that in the handout as well in the resource library and we also

interviewed a psychologist who was the name of psychologist dr. Jerry Hoyle dr. Jerry Hoyle who has been working with medical students for like 40 years so he's seen it all and So we kind of wanted to get, you know, different people's perspectives that we could bring in. And so we'll have some quotes from them. So where do you want to start? All right. We can start with all the mindset issues that a lot of medical students tend to run into. Wait, before we do that, how did you get excited about this?

Because this is kind of like a unique kind of journey, right, to get into both your own journey of going through it, right? Having gone through the steps recently, more recently, and myself and then now coaching people. Like, what gets you excited about that? Let's just hear a little bit about that. Right. So I've always been very passionate about teaching in general. Ever since I was a violin major in undergrad,

I always enjoyed teaching music the most. And then I transferred that passion to medical school. And, you know, this coaching business actually started with family. I have a sister and a brother-in-law who are, positions in Hong Kong, and they are trying to take the USMLE so they can move to the states. So they reached out to me, and they asked me for help, and of course, I agreed. So I helped them gather their resources based on my best knowledge. I help them develop a study plan.

I help them develop effective study methods. And sure enough, I think they're doing very well right now, and they're on the right track. So my sister is pretty, pretty big on Instagram, and she started a study gram to document her USMLA journey. And then sure enough, people started asking her, hey, who's your coach? I want coaching too. And, you know, I thought to myself, why not? I love doing this kind of stuff. So then people started asking me to coach them. And here we are. Here we are. Yeah. And so we also had you read a an ACT book, acceptance commitment therapy to kind of prepare for this to sort of think about how that might apply to some of these things we're going to be talking about. I asked you to read

a book on cognitive behavioral therapy. See how that applies. So yeah, let's get into it. Okay, we're looking at fear of failure. Yeah. So what are the common sort of thoughts that students will have fear of failure? Yeah, this is very common. A lot of us will think, or a lot of us will be even afraid to do practice questions because we are afraid the score might not reflect our efforts. You know, that's a very common problem that we run into. And something interesting that Dr. Hoyle actually mentioned is that most medical students who have not experienced some sort of failure previous to medical school or have never really had their limits truly tested are usually the ones who struggle with failure during medical school because it's kind of

of a new concept. So something interesting to try is to actually practice failure on a daily basis to kind of desensitize ourselves, therefore changing our definition of failure. And something we can try to do is to find a safe space, to practice the act of failing over and over again. And this can look like something like learning an instrument, like the guitar or the violin, learning a new hobby, doing a new exercise challenge. These are new, new activities that can really, really desensitize ourselves to failing over and over again. So in doing so, the feeling of failure normalizes and eventually might increase our failure threshold in other areas of our lives. And this is something that I found to be pretty useful. Yeah. Yeah. And I think that there's a

really good point there of there's a lot of people who get to medical school and they've had straight days all the way through or you know almost straight days they've done really well they have because that's what's you know required to sort of get in right and then all of a sudden you're in a class of people who also aren't you know at the same sort of intellectual level as you you know and it's like oh my gosh i got you know an average score on that test and that that can itself be like really sobering or below average right and so yeah i like how i like how you mentioned that you can actually practice doing something that it's okay to fail at sometimes in the men program that everyone will have people do finger painting specifically because

it's going to be messy oh wow and you know to not have to do everything perfect right that sometimes I think it's good to, you know, be okay with not being the best at something. So maybe doing something new like swimming. Like I was in medical school, I started swimming. I would watch YouTube videos and try to swim, but I wasn't very good at it. So yeah, I think there's something really good about that the behavioral approach of just knowing that it's okay to not get the, you know, maybe the test questions that you're doing that you're supposed to be doing every day. not doing them all the correctly right but you can look at the answers when you get it wrong and sometimes that's what really sticks is when you get a question wrong and then you get look at the

answer and see why you got it wrong so that's one thing I always recommend is always look at why you got the question wrong and learn from it so it's like fail forward right yeah yeah and actually yeah something that in in terms of test taking um spending more time with the activity in which you fear, such as taking practice tests or doing question blocks, if you spend more time with this activity, this can decrease your fear of failure over time if you remain consistent. So even if your confidence level in the beginning is pretty low, this does not mean that your fear of failure won't decrease as long as you keep practicing it. So that's something really useful to incorporate into your studies as well, just being consistent

and about doing the thing that you fear every day. Yeah. Okay. The next one, self-fulfilling prophecies. So like some of those thoughts are, I'm a slow learner, I'm not cut out for this, school is not my thing. So self-fulfilling prophecies are when you then jump to conclusions

about what will happen in the future. So it's kind of, it's cognitive distortion because you're jumping to conclusions, you're predicting the future. which we can't do. Yeah, so interesting story related to this self-fulfilling prophecy is actually a person who broke the record of a four-minute mile. So he believed in himself.

He imagined himself crossing the finish line under four minutes every day. And sure enough, he did it. And it was only after that he, after he did it, that everybody started to try. And sure enough, other people were able to break the four-minute mile as well. So that really kind of shines some light into the concept of you are what you believe and the self-fulfilling prophecy. It's a very powerful thing.

And cognitive behavioral therapy is very highly effective. And it's an evidence-based practice that is driven by the, concept of belief drives behavior or belief can influence behavior. Right. So we want to put those thoughts on trial that are not serving us that are not true, right, and move towards more of true thoughts. Yeah, I've experienced this as well with like lifting. So, you know, you kind of have this thought in your mind that once I get to this certain weight, it's going to get really heavy. And so you, you march up to that weight and then you put that weight on and because you psychologically think that that is really, really heavy, right?

All of a sudden, when there's four plates on the deadlift bar 405, that is really, really heavy. And so that kind of becomes that place that it's like psychologically really hard to push past because you think it's really heavy or you think it's going to hurt you. So, yeah. What study did you find here that sort of looked at self-fulfilling prophecies? This one was pretty interesting. This study examines the evidence for the self-fulfilling prophecy effect on parents' beliefs and their child's marijuana use. Okay.

This study took about 3,000 adolescents and gave them two surveys at two different times. So in the beginning, they assessed if they've ever used marijuana before. And then one year later, they assessed how much marijuana. did they actually use. The parents of these children were also surveyed independently about their beliefs about their child's marijuana use. So the result showed that children of parents who expressed the belief that their children had used marijuana initially reported more frequent use of marijuana one year later. And this was graded based on a five-point scale. And the result was a two-point difference in the children who reported marijuana use one year later.

So the conclusion actually is that the adolescents of parents who believe that they were drug-free in the beginning, those adolescents actually used less marijuana than those who had parents who believed that they were users from the beginning. And this result held true whether or not the adolescent admitted to using. marijuana in the past. Yeah, this is kind of like if you believe in a student, like hardcore, you actually may get the best out of that student. You know, there's been studies where they have teachers that are told like these are gifted children and that the teachers will pay more attention and give them the better education, better teachings, and then the students do better. And so there's something about belief that is very powerful.

And so maybe as a parent, it's better to believe that your kids aren't using drugs, even when they are. You know, it's better to just keep believing. Yeah. Yeah. And if you're a medical student, you know, it's actually more helpful to believe that, you know, you are the best student out there. You are, you're going to ace the USMLE. It's those types of beliefs can drive behavior to actually line up with what you desire and your end goals. Yeah.

Yeah, it's like, gosh, so many stories. My growing coach back in college used to say, you know, every stroke, every stroke we're preparing for the national championship to win. We don't come here to not prepare to win. We come here to prepare to win. Every stroke with intention, you know. Yeah. And I didn't really understand how learning theory works back then

or how, you know, practice and focused discipline and practice, you know, focus, when you focus on what you're doing and you're able to critique it with like an open mind, it actually will allow you to be better at that thing. That's exactly what he would talk about. So what do you learn about CBT and the sort of effectiveness? Yeah. So a lot of the self-fulfilling prophecy comes from our core beliefs about ourselves to begin with. And CBT is actually a very effective strategy and it's an effective therapy to help identify and help us manage our core beliefs. There is actually an online CBT program called Good Days Ahead. We'll include the link. But this program will provide an interesting and effective way to help people manage stress,

anxiety, and depression, and to achieve optimal wellness and productivity, to be honest. this, a medical student might benefit from this not only for their studies, but in other parts of life as well. Yeah. Yeah, online CBT has been shown to reduce suicidality in first-year residence. The problem that I have with online CBT is actually getting someone to do it and not despise it and not hate it. Like you have to choose that you want to do it to better yourself because it takes work, right? CBT, the problem with CBT, from my perspective, is that it's really hard to get people to actually do the homework. But you get the right motivated person who sees the value of investing in yourself and your thoughts and how that can determine things. Then it can be very powerful.

So hopefully we can convince some people to do that. Yeah. And one other important thing for a medical student is it's important to surround ourselves with people who believe in our abilities and our success is this will maximize our chances of achieving our goals, whether that means doing well in the USMLE, becoming a great doctor, if we surround ourselves with people who believe in us, it's a lot more productive at the end of the day. Yeah. Yeah. I have some patients who surround themselves with people that don't believe in them and almost like gaslight them to the point that they don't even see the greatness or the giftedness.

of this person, you know? And so sometimes, well, a good therapist can be that person, right, to support as well. Or coach. Okay. So viewing mistakes as a failure. Yes. This is sort of the next thing. So this is a little bit different than fear of failures.

Like my mistakes are failures. Perfectionism. Yes, exactly. This is very, very common. I believe probably all medical students deal with this at some point. Yeah. But, you know, the interesting thing is perfectionism is actually perceived failure. It's a subjective standard that we set for ourselves based on our past life experiences and exposures.

But something to keep in mind is making mistakes right now in your preparation for the big exam is actually a good thing. So you don't make these mistakes later when it actually matters on exam day. So seeing mistakes as flat-out failures, this may be related to maladaptive perfectionism. Because mistakes are not failures. They are learning opportunities, especially for medical students. Yeah. Yeah. It's getting into a mindset of more of a growth mindset, which we'll talk about more.

But having the ability to see that it's part of the process, making mistakes. and then being able to learn and move forward. You know, if you make a mistake on a test and then you learn something that gives you some information about where you didn't understand some piece of medical knowledge, really that's going to help you be a better doctor someday. It's going to help you better treat patients someday. So having the mindset that really we're here to help that person in the future and all of this testing and all of this training is really to do that.

And it's a practice of medicine, by the way, too. It's like, I'm still met with questions that I don't completely know how to answer. So learning how to learn, learning how to be humble and to not always know the answer, but to know how to look things up. Yeah. Okay. Yeah, anything, any studies you wanted to mention about this? Yeah.

I found one study that explored the outcomes of two different randomized control trials. There was a Swedish trial and a UK trial. And this study explored the outcomes of an internet-based CBT program in terms of perfectionism. And they also assessed depression and anxiety as well. But we'll talk about perfectionism here. So in these two trials combined, there are 120 subjects. and they were split into two groups. One group received either 8 to 12 weeks of CBT, the online CBT,

and the other group was the control group, so they did not receive any CBT. And the follow-up questionnaires were given at either 12 months later or 6 months later. So the results showed that the CBT group, the effect sizes were 1.21 in the Swedish trial and 1.24 in the UK trial. This was based on the Frost multidimensional perfectionism scale. So the conclusion is that the use of a web-based CBT program may be a promising intervention to help target perfectionism. Yeah, I think that's good.

And I think what that shows is that part of what's going on here is that there are those cognitive distortions, there are those thoughts that we have that we need to put on trial that can get in the way of us really thriving and enjoying life as much because, you know, depression, anxiety decreases well in the study. The effect size is significant. A 1.2 effect size is really good. So this could be part of someone's journey out of sort of a more perfectionistic mindset.

Yeah. Yeah. How does one develop a perfectionistic mindset? I think it's a combination of that people are wired towards more conscientiousness. I'll do a deep dive in that in a future episode. It's one of the big five personality types.

So some people are wired towards more of, you know, future goal-oriented behavior and how they value success, value those kind of things intrinsically. And then on top of that, some of the messages we get from our parents early on, right? Maybe we're only given attention when we are succeeding and doing awesome.

And otherwise, we're given negative attention or no attention, nothing. And so I've had several colleagues where it's like, that's what happened. They would only get good things from their dad when they were succeeding and doing really, really well. And when they weren't doing well, they got just a blank, blank face, no connection. So it's kind of like, I need... to really, really succeed in order to be someone that this person is going to care about. Okay.

So big takeaway for that one? So big takeaway. CBT, in the context of correcting perfectionism, can be very effective in identifying and reducing these negative automatic thoughts that we were born with and reinforced since early childhood, like you said. So it might be helpful to consider starting a CBT journal or even seeing a therapist to help rewire our perfectionistic mindset to optimize our performance in medical school. Yeah. Okay.

The next big thing is I am not motivated. Some people think I'm not motivated. Introduce that. Yeah, this is probably the most interesting one. There's a lot we can talk about here. But motivation is very personalized. and it looks different for each person. If your reasons for pursuing medicine can line up nicely

with your deeply rooted values, things that are important to you, then it's generally easier to stay motivated throughout the process. And this is based on ACT, which is acceptance commitment therapy. So for example, for me personally, something really important to me is connecting with people in my life on a deeper level. That's something that's extremely important to me. since a young age. So I've identified that as one of my core values.

So naturally, medicine, especially psychiatry, lines up very nicely with this value of mine. Therefore, when I'm feeling less motivated while I'm studying for the USMLA exam, I can really hold on to this value and it can provide me with direction. Yeah. Yeah, that's good. So it's like your value is aligning with what you're aspiring towards. Mm-hmm. Yeah, and a quote that I really liked from one of the books that I read about ACT is values-oriented behavior is constructive. It's about moving in a particular direction or fostering a particular quality in life. Values tend not to change frequently. Once you clarify, state, and commit to your values, those values become a lighthouse that can keep you steer clear of the rocks,

during psychological storms. Choosing life directions based on the intrinsic properties of actions tends to work better. Yeah. I think one thing that jumps out for me is I have a similar value of the connection of like connecting with clients. And part of that is like my value, like I really value like psychotherapy.

And so when I took my first job out of residency, I had one job offer that was doing ECHA which was three times higher pay. And then I had another job offer, which was two times higher pay, which was basically doing just pure med management. And instead I took this like really low paying, you know, job. It's not bad anymore, but it was initially very low pain at Loma Linda. And part of that was to be mentored by Dr. Tar to be able to co-teach with him for years.

And they were going to pay for me to go out. and get further training in psychotherapy and supervision and stuff like that. So it was it was kind of like, okay, what are my values? What is my long-term goal? What do I really aspire to be doing long-term? And sometimes then you come up against that with other things that are important to you, like making money or, you know, but those, I think understanding your values are so important. So what we're going to talk about a little bit is how do we find those?

right right so so we we came up with this exercise that we can take you through yeah let's mention it and then you know if later you want to get get this and go through it yourself i think it would be really good okay yeah so the first thing that we recommend you can try to do is to make a list of reasons you want to do medicine and then rank them and examine them then on on another sheet of paper, list the important values in your life. And then try to see if your reasons for pursuing medicine can line up nicely with your life values. But in case you have a hard time coming up with some of your values, here are some, we also

made a list of some common values that a lot of medical students tend to have. And you can read those in the text below. Here are some of them are serving others. compassion, empathy, communication, honesty, competence, commitment, humanity, respect, integrity, responsibility, lifelong learning, connecting with people, humility of working with vulnerable population. So which of these jumped out to you is like, yes, that's what I really value. One of the problems I see in students is when they felt very forced to go into medicine based on family structure or family values that weren't their own values. And then they get into medicine and they're

like, wait a minute, this is really, really hard. So what if you can't at this point connect what you are doing with your values? Right. And that is a very high possibility, to be honest. Well, so that goes to exercise two. Yeah, exercise two. We recommend you can look at your list of values and consider how they might apply to medicine. If you can't figure it out, then it's probably a good idea to ask your seniors or other doctors how they might apply. So the idea there is to sometimes you don't know how you can live out of value in medicine, right? So for example, if you value providing for your family, so, you know, making a good

income is one of the values that you have because maybe finances were really tight growing up. Okay. How do you know how you might be able to do that in medicine? And so asking people, right, hey, what are the options? Like, how does the, how does this work, you know, doing some research there? Maybe another value is like connecting with people. And you're like, what does this actually look like as a psychiatrist, connecting with people? Well, unfortunately, as a medical student, a lot of your experiences are inpatient,

where you're seeing people for maybe a couple days, and then they're gone. And so it's really hard to picture what that's going to look like when you haven't had that sort of outpatient experience. So talking to someone who's an outpatient psychiatrist and asking them what that's like. Yeah, exactly. And it's very possible that because you have not connected your values to why medicine is valuable to you, this makes motivation even harder, right? And in turn, this will make exams like the USMLE even harder to tough through and study for. But the nice thing is even if you cannot connect your values to medicine right now,

it does not mean that they're not there. Yeah. So for example, let's say you're like, man, but I really wanted to do business. Like you can get through medicine and then you can work on the business side of some large practice, right? I had another person who really decided they wanted to do more computer programming, like work with artificial intelligence. And I encouraged him, hey, get through medical school. You're almost done, right?

Because we're going to need artificial intelligence stuff for medicine. And so learning medicine and how doctor thinks is so important if you want to potentially combine passions later in life, right? or maybe you have the desire to teach, you know, so it's like, okay, can you combine medicine with teaching? Or maybe you have the desire to be an actor. It's like, well, maybe seeing real life for a number of years is going to make you a better actor. It's going to give you some real life experience, you know? Maybe it's going to help you be that director or that writer that you want to be because you have seen real life, you've seen people suffer, you've seen people in the

trenches, and you get to kind of witness life in a way that most people don't get to witness. Okay. So, yeah, I can think of a number. I have a lot of different, like, how they connect when they don't. I see people who can't connect them, you know? So there's a lot of options. Oh, here's another one. Maybe you're more attracted to, like, the legal aspects of things.

and you're like, you know, but I really wanted to be a lawyer, but my parents forced me to go into medicine. I know a lot of people who go into law after medical school, and then they do like malpractice cases, or they do, you know, different things where they're defending doctors or helping patients get justice. Or they go a more forensic route, like forensic psychiatry, where they look at like where psychiatry and the law kind of intermingle. And they know how to do psychological assessments. and psychiatric assessments. So even if it's hard to kind of picture how that goes, that's where I think talking to people

who are maybe further along can help you connect those dots. Yeah, I think clarifying our deeply rooted values is a very true and deep way to extract motivation from this. And another exercise that we came up with is imagine a physician who's treating you or your family in an amazing way and really helping. What are aspects of this person that you appreciate the most?

What aspects of their interaction do you value the most? Yeah. So it's like picturing that perfect mentor, which by the way, most of us won't probably have. but that's okay right but we can picture what this perfect mentor would look like and we can write down all the attributes of this person while they're on time they care about me they respect me regardless of my mistakes they listen they explain their thought process to me they you know when they talk to me they give me specific things i can improve not generalizations you know all these things that we know well, you know, it varies person to person, right?

And you could even do the opposite. Imagine a horrible physician treating a family member. What are they doing? What do you despise the most, right? And then so you can take the most positive, the most negative, and you can start to create what your values are based off of that, right? So now reverse those negative things and make a list of positive things. And look at those positive things that you really valued in that physician.

and see and see if you can pull out like, oh yeah, I do value these things. So sometimes I use the mentor idea with people like the ideal mentor, the ideal physician, to sort of pull out what their values are. You know, it's sometimes harder to do it for yourself. Like, I don't know what I value. But if you think about what you idealize, what that mentor is, it can really help. Yeah. something interesting.

We talked a lot about values and how this relates to motivation and how it can really help a student feel more motivated during, you know, when we're feeling very lost in this test preparation. Something interesting that Dr. Hoyle talked about is that motivation comes after the act. A lot of us believe that we have to have motivation before we sit down and study, right but he was saying that sometimes we first have to commit so let's say the act of studying today i want to study for five hours for the us m le exam sometimes that commitment comes first you sit down

you complete your five hours and then the motivation comes because you feel achieved you feel rewarded i thought that was very interesting and the example that he he used was like an investment you first have to invest before you can get your rewards. And I think a lot of us have this backwards, and we rely on motivation to be one of our driving forces to make us study. But motivation at the end of the day can be a fluctuating emotion, and it may not be completely reliable to depend on it every day. And it's important to recognize that sometimes motivation comes after the fact. Yeah. So it's, you know, I think it's important to have a specific time of your day, which is like your study time. And no matter what, it's like you're just studying. Like your phone is far away. You've disconnected, you know, other things that would distract you. And this is your study block. This is your time to really focus in. And sometimes you're not going to feel like it. But you just. show up anyways, you know, and you just are putting in the time, but you're also disciplined time,

like time where you're actively, active learning. We'll talk about that more. Okay. Good. So that's, that's an important topic, how to stay motivated, how to find your values. And hopefully that was helpful to you guys. Let's talk about test technique and anxiety. Yeah. So what this looks like for a lot of students is I start to panic. I can't think straight when I'm actually taking the test, but I've been so prepared. I've been studying. But on test day, I'm shaking. I'm sweaty. My mouth is dry. You know, this is kind of what it looks like. Which, by the way, that's a perfect response if you're running away from a bear. Yeah. Right? If you're running away from a bear, you don't need your frontal lobe very much. You just need your muscles to be well oxygenated.

You need the blood to flow from your brain to your muscles, and it's go time. You know, so we have this equipment in our body that's like hundreds of thousands of years old. You know, and you think about mammals basically, right? So millions of years old. And now we're doing something, which only has happened for a couple hundred years, okay, taking tests. and so it's kind of this really unique experience where all of a sudden now we can we have to calm ourselves out of that fight and flight

out of that dorsal vagal, you know, which is kind of more of a dissociative space. The dissociative space, by the way, is that high, high stress, high anxiety. That's the place where students really get themselves in trouble is when they start like getting light, they feel disconnected, numb, maybe even nauseous while they're taking the test. It's so, the anxiety is so high that they can't even think.

And then they look at the test later, they look at their results, and they did not score well. Yeah. So, or they miss questions that they knew. Yeah, exactly. So the question here is, everybody gets anxious when they have to perform. That's a fact. And sometimes this anxiety can actually give you the edge that you need to perform. Even better, but...

Oh, yeah. I mean, you can actually stay awake. Yeah. Like, if the anxiety is at a place that's like a good amount of anxiety or excitement, it's like you can actually focus and take an eight-hour test, which is pretty phenomenal. Like, I can't do that anymore. Like, if there was no anxiety, I couldn't do it. Yeah.

For myself, I feel like my anxiety helped carry me through a nine-hour step two, C-K. exam, you know, that definitely helped. But the question is, how much is this anxiety affecting our level of function? Is it affecting it in a negative way or a positive way? So it's always safe to first get evaluated by a doctor for test-taking anxiety because they are an objective, trained professional outside of our own head. And this is something Dr. Trankle really emphasized. She talked about how we live inside of our heads every day. So we really have no. objective way to measure our anxiety, our test-taking anxiety. So that's why it's important to be assessed by somebody outside of your head, such as a doctor, a trained professional.

I remember having a lot of test anxiety during the MCAT. And I think I didn't do as well as I would have done if I would have been a little bit more clear-headed or like in a better space. and I remember talking to my mentor who was a researcher at that time, like how I did and comparing it to my grades, which were a lot higher. And he said, you should go get evaluated. And it was like a death sentence when he said that. It was like there's something, he thinks something's really wrong with me.

Nothing's wrong with me. And I never got evaluated. Nowadays, I see it totally different. It is not, it actually is really helpful. right like go go get evaluated get some psychological test done you know get tested for ADHD you get tested for IQ what's the discrepancy between those things and you know do you have test anxiety is is is the anxiety the physiological arousal level so high during the test that you can't think straight yeah um so as a psychiatrist i think about propanol as one of my early go-to medications for this

what study did you find on propanol? So there was a study that assessed the efficacy of propranol in improving test anxiety in high school students who need to retake the SAT. The SAT is a standardized test that high schoolers take. It's a big test, probably the biggest test that any high schooler has to take. So this study took 32 students, all of them had to retake the SAT,

and all of them had a history of test-taking anxiety based on their previous test, whether it was the PSAT or their previous SAT attempt. All of them took 40 milligrams of propranol, one hour before retaking the SAT. And the results showed that their mean improvement in the verbal section of the test was 50 points. And that is half a standard deviation.

And even more impressive, their math improved by almost one standard deviation. And that is 80 points. Wow. So this is a pretty, powerful. It's a small study, but it sheds some light because these students, they did not receive any additional, they didn't participate in additional prep courses between this time, between their first and their second attempt. All they took was propranol, one hour before.

Yeah. Yeah. And it's interesting math more than verbal, which makes sense to me because that math, you really need that frontal lobe for that math part. Okay. Yeah. And something important to also know, Propanol, we're not saying that this is like a magic fix to test anxiety, you know, but something Dr. Trinkle mentioned that was really important is to actually try it in a safe way, because not everybody responds to propranol the same way.

So what she recommends for medical students is to try taking X dose the week before exams when you're prepping. The problem with just taking it on exam day is you don't know how your body is going to react. Yep. I usually like to get people to take it like on a Saturday. Hey, take 10 milligrams. See, if they don't feel much of a difference, take 20.

And then, you know, they'll come back to me and we'll talk about it. And if that wasn't much, then we might go up to 40. with some students with test anxiety, propanol is not enough. So they're in therapy. They may take the propanol, but they're also going to be maybe on an SSRI or something for anxiety.

And it takes a little while to plan that out because you have to be on the SSRI for like six weeks for it to reduce the anxiety. But for some students who fail step one, one time or two times, that's when we start looking at, at, okay, what are all the things that we can do to reduce this person's anxiety? Had one person fail a big test twice, had them on an antidepressant.

Anxiety was low. And then I got them evaluated for ADHD. And lo and behold, they have ADHD as well. And so it's like put them on some, you know, methamphetidate, get the dose to a good dose. And all of a sudden, now it's like they're rock and the test because they have lower anxiety and their focus is there. So sometimes it takes a little bit of time to get that right sort of combination of treatments that allows for someone to optimize their test anxiety. That being said, you know, psychotherapy, the CBT, all of that 100% as well.

Yeah. Unfortunately, as medical students, it's really hard to get a medical student to do weekly anything because they're so busy. So as a medical student, if you're listening to this, or if you're a professional talking to medical students, try to convince them that actually doing the weekly therapy is going to make a huge impact, because we'll do it if it makes a big enough impact. If we feel like it's going to help us enough, we'll do it. The other thing is, like, if your student consider looking at cognitive behavioral therapy as an adjunct, you can do some of those things on yourself, on your own, in your own time. But the in-person therapy, I think, as well is really, really important. Because, you know, imagine talking with someone who literally

has worked with hundreds of anxious people and taught them how to calm themselves. Yeah, exactly. I think it's very important to be evaluated by a professional in regards to our test-taking anxiety. And something Dr. Trankel mentioned that was very valuable is any student that gets referred to her, she does a broad objective screening for a bunch of different things. So it's not just testing anxiety, but she's also doing the PHQ9, GAT 7, yes, ADHD, yeah, all of those. And we'll put those in the handout here as well so that you guys can, you guys can test yourself and look at the scores and contemplate what the scores might mean to maybe get your courage up to go get to go get some help. Yeah, it's a whole field where there's a lot, a lot more than we can't probably add in.

There's also meds that can worsen cognitive function. So, you know, benzodiazepines, about 0.7 standard deviation change, decrease in working memory. if you're on benzodiazepines. Anticholinergic medications. So like Benadryl, you know, stuff like that. Topiramate. I once had a student who was put on topurimate by some primary care dog or some neurologist. And it started affecting her ability to focus concentrate.

So sometimes it's very subtle, but you have to look for those subtle things. And sometimes if you're in your own brain, you may not notice the difference. but if you're talking to a professional and they get a timeline and they're like, oh, you started this medication six months ago and then you increased it two months ago. And when you increased it, that's when it, that's when the focus really went. So you get passionate. I did a four-part series on Sensorium if you're listening to this. And we have in my resource library an Excel sheet with every medication and the cognitive dysfunction. It's an Excel sheet. We'll put it on this one as well so that you can take a look at it to check all the meds that you're on. Some meds will surprise you. Some meds you

probably haven't heard cause cognitive function. Yeah. And the most important thing, we're talking about medications. Sometimes it's beneficial to take medications like propranol. But the goal is to return your level of function to your fullest potential because when test anxiety hits, the first parts of the brain that get shut off, like you mentioned before, are your frontal lobe, which is important for problem solving in memory, and then also your hippocampus, which is responsible for recording recent memories. So both the frontal lobe and hippocampus, you would imagine this is very important for test taking, especially on a huge exam like the USMLE, where you have to remember and analyze every single word that's on the page for eight hours

straight, nine hours if it's step two. Yeah. I highly recommend it as well to many students. exercise. I think specifically cardio, like the long, low, like cardio, do it every morning. That specifically helps with anxiety. And so getting that physiologic level lower. Strength training as well, but strength training is more of a long-term investment. The cardio before the test, I think, is helpful as well. I actually did a lot of cardio during my exams. During your exams. Yeah.

Yeah, I would, I took every break possible. So it's 40 question blocks, right? Okay. Step one and step two, 40 question blocks. And then I would just take about five minutes after every section. I would go to the bathroom, go outside, and do a couple squats. I was really big into high intensity cardio, especially during my second year. And that helped me immensely to reduce anxiety, release the stress. Yeah. Because there's a lot of that fight. that gets in you, right, when you want to win.

And that fight response is not something that you really want while you're trying to do complex cognitive puzzles. Right, right. And some other practices that might help is also to practice the same anxiety-provoking scenario at home frequently. So this goes back to what we were talking about earlier, practicing the act of failure. But in this case, not necessarily failure, but the act of something that makes you anxious. And slowly, you know, if you're consistent with this, you can start to ground yourself.

And also, it's important to practice the same method each time. Well, first of all, make sure it's a good method. And then once it's a good method, practice it the same way every time you perform to establish normalcy and, quote unquote, muscle memory in your brain. So this is touching on the concept that practice makes permanent, not perfect, right? But practice does make permanent at the end of the day. So whenever, whatever you practice at home will likely be

how you perform on the test. And this ties into neuroplasticity. But basically any practice-based profession heavily relies on this principle. Yeah. I remember for the MCAT, this was so crucial, like with those verbal prompts,

doing one after another, like on a Saturday morning and then actually timing yourself. it creates a stress, right? And also there's a value of kind of creating the environment that's going to be the most similar to the test-taking environment. So if you know what room you're going to be tested in, going to that room and studying in that room.

Or like, you know, doing a behavioral approach is what it's considered, right, of reducing fear. So we want to repeat the fear, inducing event over and over again, and that decreases fear. Same thing for dating. You know, if you're, if you're highly anxious when you go dating, you know, going on more dates, coffee dates, doing things that are low-threatening dates, right? Not like maybe we're going to, we're going to sit across from each other for five hours, right? That's a high-intensity date. Maybe it's like a half an hour, like, hey, I only have half an hour, but we can meet up.

and kind of like a low intensity date at a coffee shop, right? Maybe that's too fear-inducing, right? So it's like finding what is a little bit less fear-inducing and then repeating that and then building up to that thing. Yeah, so the stepwise fashion is really important. So for a medical student, what that might look like is, okay, I'm trying to work my way up to doing 40 questions in one sitting. But right now, I can probably do five.

and feel okay. Otherwise, I'm not okay. So start with five. And that's okay. Do five, do it timed, do it with the same method that you would on your test. And then maybe a couple days later, try to bump it up to 10. And then slowly work your way up to 40. Yeah. Yeah, because you do five. And somewhere in those five questions, you start to fear that you don't know what the hell's going on. And then that creates the stress response. So maybe you can't get past the five. Maybe you do the five. maybe you go do some vigorous squatting, get that stress out, right? And then go back and do another five. Or wait till tomorrow and do another five.

Or go back to the five and look over the questions and learn from them. I like that idea. Okay. Let's talk about studying with a poor method. This is a huge topic. Study methods, it's extensively studied. It's not easy to quickly figure out a study method that works for you, but a good place to start would be with research-proven effective study strategies.

And these include things like doing practice questions using active recall activities rather than studying passively and using space repetition. Those are the main principles that I've extracted from my research. And those are also the study techniques that Lomelinda taught us. What do you mean by spaced repetition? What do you mean by that? So space repetition means use use. let's say today I learned about propranol.

Okay. It's important for me to repeat or revisit what I learned about propranol in a couple days. Yeah. For me, everybody's intervals are a little bit different. There are some studies that say it's important to review the material that you learned within 48 hours. I think there's still more evidence to be looked at for that.

But me personally, my interval is if I study about propanol today, As long as I review it by the weekend, one more time, get my second pass in, that really helps to consolidate a lot of memories. And then maybe three or four weeks later, if I revisit it again, then my memory consolidation is even better. So that's space repetition. Yeah. Okay.

Active recall, kind of just recalling it. Yeah. And then practice questions. The only way that I studied for step two is practice questions. and that's the one I did the best on. All I did was practice questions because I wanted to purely test my knowledge,

push myself with what I didn't know. So I wanted to find out what I didn't know and then learn it. Then I would make some like notes and stuff based on what I didn't know. Yeah. Look at that later. Exactly. Practice questions are crucial

for step one, but especially step two. And my coaching program actually relies on all these principles because I know that these tend to work and these are proven strategies. So active recall activities include things like using your own words, interacting with the material, basically recreating the information in your own words or in your own way or answering questions actively from flashcards or practice questions. I don't know how effective this is for everyone, but my personal way of getting through

the first two years of med school was to make a one sheet piece of paper for every lecture, pretty much, except for anatomy. Maybe I would just write in my netter. So my netter is like well documented, well detailed. But for most things, I would just, I would, and I wouldn't try to use the words of what I was reading. I would try to put it in my own words or sort of like catabolize it, make it more clear. And so I still have this binder in my office of like, you know, all the different acid base issues. You know, like, it's all, like, detailed.

Each one has a one page piece of paper for each lecture. Yeah. And then when I went through preparing for step one, I would do questions. And then I would look at these pieces of paper that I had well organized. And I would input the new data into those sheets of things that I didn't have on there. So that's the way I did it. I think everyone finds their own little, like, way of doing it. actually yeah that is something i recommend for a lot of my students as well that's another form of

active recall basically you you make a resource that is your own and the act of making it you're you're forced to actually interact with the material analyze it and then output it into a piece of paper yep and it's funny how like when you make it your own then it's like okay i know the answer to that it's on this page and you can quickly get there yeah And even if, so with that, I sometimes would split the page into four parts because I knew that there were four different diseases. And I could remember which, if it was on the top right, the bottom right, bottom left or top left. I couldn't remember a lot of things, but I could remember pieces were on one of those four. And so it was something about the paper having a spatial orientation, you know?

Yeah, that's really helpful for a lot of visual learners. I actually have a whole page of study methods for each high-yield resource that medical students tend to use. Feel free to look at that and read through it. So these resources include U-World, obviously, the question bank, pathoma for pathology. Are we going to put that in the resource library here? Yeah, we can. We can. I have it ready to go.

We'll put that as an appendix. We'll put that as an appendix. literally you have people on your wait list. So like I think there's value of just giving people the information and then people can learn a lot themselves if they have more questions they can reach out. Yeah, absolutely. You're going to be busy in residency. So although this is a passion of yours, that's yeah, that's why I have it all written down and ready to go. Yeah. For those who really are looking for better ways of studying from those resources. And you know, something, an interesting cross-sectional survey that I ran into, the subject size was 679 students. It showed that 82% of these

medical students are still using ineffective learning strategies. Because it's passive, because it's easy. Yeah. You know, it is much harder to do 10 questions and then look why you got them wrong, than it is to just kind of read a book passively. Yeah. Right? Yeah. And this also ties into the personality type as well. I forget which one exactly, but there are certain personality types that will feel like they're learning a lot in the moment, but they're actually not. And that's something to pay attention to when you're reading something, when you're highlighting something, it all makes sense to you because you're passively absorbing it, but are you able to recreate it later on a test? Or are you able to recall it on a test? That's another question. Yeah. Okay. So,

Any big takeaways for this portion? Well, obviously it's important to know what the effective study strategies are. It's important to know how to take notes efficiently. So like we said, using your own words, interacting with the material. And there's actually evidence that handwriting is superior to typing whenever possible. But the problem that I run into with this is there's such a high, volume of information that we have to learn every day, that sometimes handwriting is a little bit too slow. Or it's too hard to edit your handwriting when you catch your mistakes later,

when you do the space repetition. But if it works for your handwriting is a really good way to go. And then obviously, space repetition, reviewing your notes, and then having a hierarchy of information is actually very important. Dr. Hoyle talked about this. He said, said it's important to first learn the skeleton of any concept and then later you layer on each layer of detail 100%. Yeah, creating that framework to lay on future information is a lot of what we're doing the first two years. We are creating that framework. That's why it's like a lot. It's very painful. You know, you need to understand some of the frameworks that you can then lay on what is clinically relevant, right? So we learn a lot of stuff that's maybe not clinically relevant,

but then that gives us a foundation. Yeah, and something interesting as well is knowing your learning style. There is a Honey and Mumford classification. And then basically this classification has four different learning styles. We'll include the table in the text so you can see. But there is one study done in Pakistan that analyzes learning style. of pre-clinical medical students. So for us here, that would be students in your first and second years versus clinical students

who are in their clinical rotations. So for us, that would be third and fourth years. And it was interesting because based on the questionnaire, it showed that students in their pre-clinical years were mostly activists. This is one of the learning styles. And activists learn best

by doing problems, problem-based learning, case-based learning, doing group assignments, hands-on learning, doing interactive learning. And it showed that students in their clinical years learn better in the reflector or the theorist style. And you can read the description on those two learning styles as well. So the main takeaway that I got from this study was that all four learning styles are prevalent among medical students. it's important to have so that's why it's important to have a variety of teaching strategies available and it seems that most medical students in their pre-clinical years from this study have a strong preference for the activist learning style i mean this could be due to the demands of school so

lectures exams studying sitting at home and interestingly enough the most desirable learning style for medical professionals are actually pragmatists and reflectors this was just very interesting to me, but my main takeaway is that, you know, it might be beneficial to take this questionnaire and see what your current learning style is. It may not be the same once you graduate, but it's important to kind of know when you learn best and when you learn least. Then based on this, you can determine your strengths and weaknesses and take control of how you are learning your information rather than blindly following somebody else's learning style. And something Dr. Hoyle also mentioned is that so many medical students are so brilliant and we get by prior to medical school

with poor study techniques and no discipline. However, this pattern gets broken once we get into medical school and then we have to really learn about our learning style. Yeah. So this is kind of a good place to start. The Honey and Mumford classification. That's good. Yeah, I think a lot of, I'm looking at like the learns best when for a lot of these and it's very active. It's, it's, um, real life experience is active problem solving. I'm thinking about how I often will ask the resident to tell me what they want to do, commit to a plan, even if I think it's a bad plan. I'll tell them if I think it's a bad plan.

Usually it's pretty good. But it's just committing to it, it actually causes them to think through and problem solve and use those parts of their brain. And then, you know, if you do run into a patient that you don't understand, reading up on it. So then using real-life examples, real-life things that are going on to learn, right? So your learning is very congruent with what you need to know. And I think those are great ways to learn as a third year, especially. Okay. So let's go on to the next one. Yeah. So I'm a horrible student. What if people believe that?

Yeah, and, you know, this is, this is very common. It's surprising to me how often students, by the time they get to third year, they don't think that they're very smart. It's like that has been beaten out of them. They measure their self-worth based off of a three-digit score. And they walk around not thinking that they're very smart. They're very smart. By the way, 30 years very hard.

It's hard to jump into a new specialty and have to basically know what you need to know to be on that specialty and help patients. Like, you're thrown in to the scenario expecting to know enough to be able to help people. Which is like, what? You know, and then by the time you get a little bit more comfortable, like one month in, you're on to the next one where you're like in a completely different world. like OB and pediatrics, very different worlds. Pediatrics and surgery, very different world, you know.

Psychiatry and everything else, very different worlds. Okay. Yeah, I'm glad you mentioned that. That is definitely, that was probably my biggest struggle during third year too, just bouncing around all the time, being on my toes all the time. And like, always feeling like I'm never enough, you know, because there's so much to learn. and then we switch services once we start getting the hang of things.

Yep. So this idea of feeling like a horrible student, I talk to Dr. Trankel about this a lot. And something that she mentioned is that identity formation begins from a young age. And when this is threatened, it causes massive dissonance, massive psychological dissonance. And for medical students, a lot of us form our identity of being a good student from a very young age.

18 or even younger for a lot of people. Oh, much younger usually. Yeah, much younger. Much younger, yeah. And usually this doesn't really get tested until we get to medical school when things become much more difficult. So something that we talked about is the importance of recognizing and fulfilling our other roles in life, having a more balanced identity.

Because our existence as a human being is not only as a medical student. You know, like for me, I'm also a friend. I'm a son, I'm a brother, I'm a boyfriend. We have other identities in our lives. So sometimes if we take focus away from our medical student identity, we might actually find ourselves performing better because of a healthier and more balanced mindset. And from Dr. Trinco's experience,

she has seen many students improve simply by having a more balanced identity. They start doing better on tests. They start feeling better every day. Yeah. So there's this aspect there of as a medical student, you can start to only talk about medical student stuff. Like I've run some groups after, you know, I graduated. And it's like after a couple years, it's like,

oh, medical students only really talk about medical school. Because that is so stressful. They become monolithically focused on it. There's a lot going on outside of medical school. that like you might not, you forget that's part of your identity. You know, you are a violinist, right? Very nice violinist. So kind of balancing that identity, right?

Yeah. Yeah. And then realizing that the nature of medicine is that, like, there's just so much to learn and you may not know a lot of it until you get into that sort of place where you've practiced this for a number of years, you know? And so it's kind of like gaining the tolerance that, gaining the tolerance of just not knowing a lot of things, but that you can still be competent.

Yeah, absolutely. I agree. Okay. The next one is guilt, not giving yourself enough credit, which is kind of, it's kind of similar. It's kind of the other side of I'm a horrible student. So another thing with the horrible student, by the way, is the cognitive distortion that's very common in that. It's a negative mental filter where you only look at the negative and not the positive, which is very common with medical students.

So common, it's so common to just focus on that one thing that you don't know or the one bad interaction with that attending rather than all the good interactions that you've had. And you forget about the good interaction to focus on that. the bad ones. So not giving yourself enough credit for all of those good ones, right? Yeah. So, you know, feeling guilt and not giving ourselves enough credit, it's important to first to find to ourselves what is enough for us. This can be difficult because what's enough tends to be subjective. But one helpful strategy to use is to actually do practice questions to assess our level of understanding.

So for example, today, if I finish this lecture, it's important that I can find some practice questions to do right after this lecture. And then if I do okay on them, that's a very objective and safe way to tell myself, hey, I've done enough. This is good. and this also helps me decide what is enough. You know, am I aiming for 90%? Am I aiming for 75%?

And, you know, with this, basically doing a few practice questions after each lecture can be a cap to kind of seal the deal in a way. And this builds confidence, the more that you do it. And then seeing that your studies are paying off is all. also a very motivating thing. So that's one technique that Dr. Hoyle actually recommended. Okay. So it's kind of like when I was a student,

I had a lot of guilt if I wasn't studying. Like it was really hard for me to like put the books down. One way that I found of kind of overcoming this was to have periods of time where I called it like guilt-free. guilt-free, like, just I'm not going to study. So after, for me, after 9.30 at night, no way I'm going to study. On the weekends, I wouldn't usually study Friday night, Saturday night. You know, so at like 6 p.m., I was done. Yeah, me too. And that's something that helped me remain sustainable for two whole years of book studying. And this is also a commitment in

itself. You commit to stopping your studies, the same way that you commit to starting your studies. And something that a lot of us don't recognize is that we don't really have to earn rest. It's an essential part of life. But unfortunately, this is something that some of us learn from a young age. We do something right. Then we get to enjoy something nice. And this pattern is called operand conditioning. But sometimes too much of this prevents us from simply relaxing. having fun, taking a breather, which is actually an essential part of human existence. Yeah.

You know, the low millennia community here is like an Adventist community. So this is something that I kind of came into as a medical student, you know, interacting with a lot of people who are Adventists. And they take something called the Sabbath. So it's like the Jews do, the more Orthodox Jews. They have like a very sort of, you know, at sundown on Friday night, we're not going to do anything work related until,

Saturday night, so from Friday night to Saturday night. And I didn't grow up with this practice. And so I started to try to take a Sabbath and I would end up doing cleaning, my laundry, you know, all of the work that is not schoolwork, right? And it wasn't until I think my senior year, I started hanging out with some people and they would go on like these long hikes on Saturday and play music and just friendship stuff. And I like loved that. That was. so restful. And so I think it's so important as a medical student if you're hearing this to find those times during the week of guilt-free spending times with friends. And when you're preparing for a big test, what I recommend is start early in the morning and finish some time

in the day where then you have a little bit of time every day for that sort of those pleasurable activities. So get the hard work done and then have some of that guilt-free, you know, connection with other human beings. Yeah. Okay. Everyone seems fine. Why am I struggling so much? That's another comment.

Yeah, this is super, super common. Well, first of all, this is not true, as hard as it is to believe. But the important thing to ask yourself... I thought this was true. Yeah, me too. I thought it was true until I became a psychiatrist and then I knew how many people were struggling.

Yeah, everybody has their own set of problems. But it's really hard to believe this. So the question that we ask ourselves is, which cognitive distortion does this statement have? You know, we all see the world with cognitive distortions, but sometimes it hinders us from being at our fullest potential. So it's good to put these thoughts on trial. Something also important is to refine or expand our community

until we feel less alone. So again, this is about the people that you surround yourself with. It might be healthier to spend more time with people that you can actually relate to and maybe even cut down on social media because on social media, you only see the good side for most people, right? Social media, like, if you haven't listened to our social media episode, it might be good to go back to that one. But, you know, only 5% of time on social media is actually communicating with another human

being, like sending direct messages or whatnot. So most of the time is spent scrolling. It's like entertainment. It's really unsocial. And yeah, so then you see the positive aspects of other people's lives. And then there's this cognitive distortion field of like everyone's life is awesome. Because if you post something that's not awesome, it usually doesn't get shared. Or, you know, you're posting it because you want to post something that's not awesome to get attention or something like that.

I don't know. There's all these, you know. Anyways, my point is that. everyone is probably struggling, but they're not talking about it. Exactly. And I used Instagram as my platform for my business, and I'd really make it a point to also post my bad scores. You know, like during my preparation for step two, I was doing practice blocks every day. If I got, sometimes I would get like a 40%. I would post that and make sure that my followers know that this is part of the process and it's it's normal to be

struggling you know it's normal to to score low and then work your way up so that's something i really i really value as well when people are able to post their journey in a very transparent way not only posting the good not only posting the bad but posting both yep yep so important cognitive distortions here, you know, there's the all or nothing thinking, overgeneralization, black and white thinking, negative mental filter, so focusing on negative things that you're doing rather than the whole picture. So there's a lot of different cognitive distortions that can apply to this, right? So, you know, in cognitive behavioral therapy, what you do then is you look at the cognitive distortions, you look at the evidence for and against it, and then you make the most accurate statement.

and it could be I'm struggling and so are a lot of other people and we're going to get through this together some of your best friends will come from medical school because you suffered together in a way suffering kind of brings people together it's the same for rowing you know you suffer with a group of people for four years it kind of bonds you together whereas like if they need something later in life it's like hey I'm there for you yeah I think some of my my strongest bonds are from my rotations where we had like a really tough team or a really tough attending. And we just bond. And it's just this unspoken bond that can't be broken.

Yep. And then you have doctor privilege later on in life. Like I have like different specialists pretty much in every domain that I could call up for little issues my family has. You know? And it's like, yeah, I get better. I get better health care than most people. That's doctor privilege. Okay.

So we're getting close to the end here. We have a couple more to go through. Falling into the trap of the negative feedback loop. This is so common. What it looks like is this. I did badly on my practice question block. Now I must study more. Or I did so badly on this question block,

I've made no progress. Now, remember? how Pavlov discovered classical conditioning with his dogs. I know this sounds a little bit silly, but we can do this to ourselves too. Try to prevent pairing our studies with a bad experience like fear or punishment. You know, if you don't do well on a question block, try to pair it with something nicer so you're more likely to forgive yourself and come back to studying the next day. Also, it's important to recognize that a 40 question block is not enough to measure your entire medical knowledge. Yeah, I didn't, I didn't pay attention to the scores that I would do on these

40 question blocks or 20 question, you know, like I would just do them. And then I would just look at the answers and work on like learning what I didn't know. And I would look at questions I got right and look at like, did I really know it? Did I really know all the parts about it? Or was there something I was missing? So I don't know. I just didn't like pay as much attention. I didn't think it was worthy or like helpful you know yeah so i don't know i think i take a little bit of a different approach what did dr trankle say about this so i asked her about this this whole concept of classical conditioning okay you know pairing studying with something nice and she agreed with everything but with one caveat she said that it takes a healthy brain to be able to actually experience the reward so if a student is

depressed they won't be able to properly experience the reward therefore the conditioning might not work. So for example, if I failed a question block today and then I treat myself to ice cream, somebody with a healthy brain might feel the reward and say, okay, yeah, this is nice. You know, I did something, I completed the question block, I'm having some ice cream now, I feel rested. But somebody who might be suffering from depression might only see the bad side of things. They might think, I don't deserve this ice cream. I'm just going to get fat. I'm going to gain weight. So that brings up another really important topic that I'll just insert here.

It's like if someone has depression, you know, treating the actual depression will help them considerably do better on testing. So if you have depression, you know, decrease interest, high guilt in all things, low energy, poor concentration, poor sleep, change in sleep, maybe passive thoughts. I wish I was dead. I wish it wasn't alive. You know, sickie caps, right? if you have those symptoms. If you score high on something like a PHQ9, getting help can be really, really important.

It's hard to study for a big test when you're depressed. I've seen people do it. I've seen people succeed in these tests despite being very depressed. But if you can get treatment. Okay, let's keep going. I'm wasting my time. Yeah, so this one is, it's definitely a mindset thing. but it's important to recognize that every step brings us closer to our goal, even if we can't detect it today.

But what if I feel like I'm not really doing anything that's going to help me? You know? Like I'm just doing these questions, but I'm not seeing any progress, right? Yeah. It's, well, I mean, this is the same thing as, you know, any weight loss program, any bodybuilding program. Progress usually can't be seen day to day, but that's why it's important to have, get help. Sometimes that help means getting an advisor to take a look, assess your study methods. Sometimes that means getting a coach.

Sometimes that means doing practice questions to really assess your level of understanding. Give yourself objective data to really tell yourself, hey, am I truly wasting my time or not? And even so, sometimes I personally call it a sticky phase where sometimes you do. don't see your progress, but you have to keep going and then you'll break through. That's a very common thing for practice questions that I've seen from my experience with my students and myself. Yep. And also, it's important to redefine our goal beyond our USMLE score. This can bring some clarity and even some motivation.

Yep. So, yeah, you are more than a number. You are not a number. You are more than a number. it's it's funny how the further you get away from medical school the less those mean to you like I was looking up on my score it's like oh I didn't I don't remember scoring that wow and uh in my mind I'd even decrease the score in my head it's kind of funny true story I was going through my I was looking through my paperwork because I was looking for something and I was like oh did I score that high So it's kind of like you get away. When you're in medical school, you're so close to it.

You think it's so important. Or for psychiatry residency. I can point out some psychiatry residence in our department. I wouldn't that have very low step one scores, lower than the average. But they're awesome. They're awesome. Interpersonally, they're awesome. They make good clinical decisions. Some people are just not very good at testing.

And we try to look at the whole person. So I think, especially in our field, we look at the whole person. And we take into account, like, all the aspects and the gut feeling. And we get from people when we interview them. So, so, yeah, you are more than your score. And there's some programs that may really look at scores heavily, but not all of them do. There's a lot that look beyond that quite a bit. Okay.

So, but I'm wasting my time. I think it's so true with a good coach, you kind of can hopefully feel some confidence that your plan is a good plan. For me, my plan was very simple. Like I said, for step one, get through all the questions for the US Emily world and go through my binder. Like, that's it. At that point, that's what I was doing. For step two, it was just doing questions. So it was very simple, like objective. and I think whatever it is for you, kind of like saying like, okay, it changes, right? So I took it years ago.

So I think you're a little bit closer to what to study. You study a little bit differently than I did, which is probably why you did so well. Okay, I can't focus. Yes. A belief that I can't focus. Yes, very common. I talked to Dr. Hoyle about this a lot.

I could only study for eight hours a day. I can't focus. Yeah. what a problem. It's like now it's like 10 minutes is like really hard, you know? Yeah. As like post-attending life. Yeah.

And now, but back then it was like all day long. Yeah, right. Eight hours is a normal thing. Eight hours of the light day almost. Yeah. It's expected. Right. You know.

Yeah. But, you know, something Dr. Hoyle mentioned is that most students, most of us, believe that our attention span is much longer than what it actually is. So, first of all, it's important to recognize our own signs of loss of focus. And common signs are, you know, if you're rereading a sentence over and over again, getting distracted by the most, the smallest thing, slowing down. Everyone has a different threshold for focus. And then studying past this threshold means that our focus decreases and so does our productivity.

Mm-hmm. And one common method that helps a lot of people is the Pomodora method, where you take scheduled breaks at regular intervals. So the one that Dr. Hoyle tends to start his students on is do 50 minutes, 40 minutes of concentration. Okay. And then take five to ten minutes of a break. And then after three or four hours, you take a longer break. And then, yeah, something that can also help with staying engaged and feeling focused. and feeling focused while you're studying

is to interact with the material. Again, this is the learning strategies that we talked about earlier. You can interact with your material that'll help you focus. So you can draw, make summary statements, make your own quiz questions, answer flashcards, teach a friend.

I taught a lot of my classmates. We would teach each other during second year when we were tired. At the end of the day, we were like, oh, we've done, we've only done eight hours. Come on, guys, let's go. Let's push for one more hour. and then during that hour, instead of trying to read from a textbook,

we would teach each other what we learned that day. And that's a very, very useful thing to not only expand your focus, but consolidate what you learned. That's good. Yeah, I think that we need little micro breaks, you know, to kind of get our, to kind of get, you know, whether you're doing your squats in between your test questions, right? We need those little micro breaks.

Sometimes I'm at at my desk when I'm working during the day and the light goes off, which tells me I've been completely still at my desk for like an hour or something. And I'm like, okay, I'm going to get up, get some water, right? Do some pushups, you know, take a little break. And so important. So, you know, a couple other things that I think are really, really important for preparing for a test like this. is creating good practices of sleep. So like I said, like after 930, I was done, done.

And part of that was that so I could prepare for sleep and I would want to be in bed at 10, lights out, phone. You know, I did not have a smartphone back then. It's a lot more tempting now with a smartphone to like scroll aimlessly, right, for an hour or so. So, but considering that your sleep is part of your program. Yeah. getting that sleep, consistency.

For sleep, also, first thing, exercise, right? If you exercise during the day, you're going to sleep better. I'm glad you mentioned sleep because this is something Dr. Jankal and I talked about as well. She said, most medical students know that sleep is essential. We know that sleep consolidates our memories. It helps us focus. Yep. But nobody uses sleep as a tool.

Yeah, it's, I've known a bunch of type A people. And the only way to convince them to sleep is to prove to them that they'll be more productive. Yeah. So there's all these studies that show if you're slept well, then you can drive your car more accurately. You know, if you're sleep deprived, it's like you're intoxicated on alcohol almost. Yeah. You know? And so, you know, if you can't sleep, there's cognitive behavioral therapy for sleep.

That's like a first thing you can do. sleep hygiene, right? There are medications that you could take if you really needed to, but I think, you know, exercise, sleep hygiene, going to bed at the same time, waking up at the same time, not having your phone on for an hour before you go to bed, you know, not having screens in front of your eyes, not binging on Netflix, right, before you try to go to bed

on some like, you know, thriller. That's what gets me. Yeah. Okay, so sleep is important. diet i think as well like i was eating slow burning fuels oatmeal beans you know so slow burning carbs lentils quinoa these are slow burning slow burning carbs you want to get some good fats avocado olive oil you know these types of things and then some good proteins as well right especially if you're doing your exercise so you want to get good good good amounts of protein

eating healthy is really, really important for just the long marathon of studying. We talked a little bit about dopamine overload. There's kind of a fad of completely disconnecting from anything pleasurable. That's not what we're talking about. But thinking about getting off of the things that are highly dopamine stimulating, which are not studying. So when I went through my step one, step two, completely no video games. No video games, no video games, no Netflix, right? So I wanted to completely eliminate those highly stimulating activities

that then kind of like would then reboot my brain to be able to just focus. Yeah, and there are activities that you can do during your rest time that are actually rejuvenating and activities that are maybe not so rejuvenating. So, yeah, like you said, for me, during my first two years and my third year as well, yeah no Netflix I tried to stay away from games but what I would do instead I was cook I would cook good food I would connect with people I would exercise a lot and those were the tasks that really helps me feel better and made my rest actually restful yeah for me in medical school my exercise was very simple wake up at 630 I was out the goal was to get out the door in five minutes completely still asleep right brain still slow, run 15 minutes, run 15 minutes back, done. When I would go lift weights like two times a week, you know, I would just do one exercise and then another exercise and then another exercise like back to back.

So I was literally in the gym for like 15 minutes. Nowadays I do like two minutes or two hours, three times a week of like power lifting. I take long breaks. I wouldn't take breaks, right? Because I wanted to get quick exercise in, didn't want to spend. two hours at the gym, you know, in and out, go swimming for half an hour, maybe twice a week, done. Maybe on the weekends, on the days I would take off, longer bike rides, like two, three hour bike rides,

but with friends where we'd be having a conversation, talking or long hikes, talking, enjoying community, right? Yeah. So, okay, let's talk about what we're going to give resource wise here for people. Right. Because we're coming to an end of our long block of talking about this. So in the resource library, in this PDF, you'll see a lot, all this information we talked about. So you can, what is that time delay thing called?

Space repetition. Yeah, you can do a little space repetition with this stuff. Hopefully it's been helpful for you. Hopefully it's kind of challenged some of your negative beliefs that you might have around test taking. And if you're a psychiatrist or therapist, hopefully it's given you some more ideas for what medical students go through or any student who's at a high caliber, right? We're applying it to what we've done, but this could apply to nursing or to any other field where there's big tests and it's a long journey. And we'll also give a little bit about what you tell people to study.

Yeah, so I created a three-step challenge. This is basically a whole-person approach to studying, not just what you study. and how you study, but also other things. So the first step, I created a dopamine detox journal. You can download the PDF and then see if that works for you. And then the second step is to actually develop a study plan. This is what I provided. I basically took all of the most helpful resources for step one, USMLE,

and then wrote out how exactly to study to be, very efficient. And I actually created a six-month plan for any second-year medical students who are starting to prepare for step one. And this plan is five months of slower studying because you're still in school at this time. You still have to study for your classes. So I made the plan so that you can maybe just do one to two hours on top of your school work. Right. And this is good. So you put down specifically, you know, how much pathoma they're studying, how much BNB, Bords and Beyond, U-World, Skechy Farm, Sketchy Micro, First Aid. So I think that's really helpful. And so we're going to give this to you guys for free. We don't want anything from you.

We just want to help you. If this is helpful, you know, and you're on this journey, let us know. You know, I'm sure Trace would love a DM. on Instagram saying, hey, I've read your thing. It's really helped me. Like that makes our day, believe it or not. When I get a message like that, it's really, really cool. So I hope this has been helpful for you. We're going to put all this in my resource library,

psychiatrypodcast.com. Pretty easy to remember. It's a nice URL. And if this was helpful, let us know. Any final closing statements? No, I'm just, really thankful to have been able to do this project because this is what I'm passionate about. And yeah, it's just, you know, don't be afraid if you're a medical student out there and you're

struggling or even if you're not struggling, you just want some more guidance. That's okay too. Don't be afraid to reach out. There's, there's, you know, you can reach out to me on Instagram and I'm sure you have a lot of classmates that you can reach out to as well. Right. So hopefully if this helped a couple of students do better and feel more confident and it helps you in your journey become a doctor and then you see 10,000 patients and those patients are helped a little bit more, that's a multiplier effect. That's what I'm doing it for. So if we helped a couple hundred thousand patients from helping 10 students, you know, through this, I think it's worth it. And hopefully we'll will make that impact.

So yeah, let us know what you think. Send us some DMs on Instagram. We'll put that on this handout as well that we're given out. And we'll go from there.