Recipe: How to Become an Effective Learner in Residency

Find a textbook that suits you. I have used Tintinalli as this is the textbook that my residency has chosen. Others prefer Rosen’s. I’m sure there are others out there. (feel free to comment on your textbook of choice and why).

Personally, I don’t believe the exact textbook matters, but more so that you are reading one. Make a schedule and stick to it. Again, my residency made this easy for me and has assigned reading which is covered once monthly (topic review). Make sure the assigned reading is feasible. You will not be able to read 200 pages while on your ICU rotation with 24 hours shifts every three days (and be able to sleep, eat). A manageable schedule may include roughly five chapters a month. This equates to roughly one chapter a week. With the flexibility of emergency medicine, I think that this is easily achievable.

Pro-tip #1: Avoid being the intern who says something in conference or rounds like “I read in [textbook of your choice] that…” I’ve made the mistake. For one, you’ll come off as “that guy [or woman]” in your residency class, and it’ll be hard to shake. More importantly, the attendings in the room and the senior residents will quickly correct you with more evidence-based and practice-relevant knowledge that has come out since the publication of the textbook edition you are reading. (Example: I have yet to order a Water’s view or Panorex X-ray for facial trauma in the era of “CT it if it hurts”.)

So why is this important? Regardless of what pizza you like (deep dish, thin crust, burnt, $1 slice, $20 slice, vegan, meat), all require dough. It’s the foundation of the pizza. Without a good crust, the pizza will fall apart (hence, chicago deep dish is not good pizza because it requires a fork and knife.) Back to medicine briefly. Your textbook knowledge will give you the foundations to build upon. You can’t simply read the ESETT study without some basis of what status epilepticus is. So put in the time and build your foundation.

Dough is good, but at the end of the day it’s just bread. If you’re Oprah, you may love bread. What separates focaccia from a true pizza dough is the sauce. You may be a white pizza person (technically not a sauce, but go with it), a California pesto snob, or a firm marinara traditionalist.

The question bank is that sauce. The sauce is the key underrated element to a pizza that ties together the dough with the toppings and cheese. Likewise, those 1500 questions designed to help you pass the boards, is the bridge from the knowledge you received in the textbook (dough) and applying it clinically (cheese and toppings: more to come).

The issue with sauce is that it is underappreciated. Except for the true pizza snobs, most people don’t write yelp reviews based on the sauce, unless it stinks.

So question banks are the underrated sauce. It takes a long time to perfect (as my imaginary Nonna said to me, “dont rush the sauce, make it slooowly”). Likewise, it takes a long time to get through the question bank. But you have to do it. It will reinforce what you’ve learned from textbooks (the dough) and it will give you a chance to make a truly great physician (or pizza.) Without it, you won’t pass the boards, and you’ll never get a chance to make it to step 3 of the post (the good stuff.)

How do you get through it? I haven’t found a short-cut other than time. Do it on your commute to work (if your commute is a subway, don’t do questions while driving). Do it at 3am when you’re waiting for a new drunk patient to ask for a sandwich. It doesn’t matter how you do it, as long as you get through it.

Again, just like a sauce, you won’t be able to make it in a half-hour and likewise, you won’t be able to cram 1500 questions in the month before in-service or boards. So spread it out. Realistically, you’ll likely do more questions closer to the test, but you’ll thank yourself (and your Nonna) if you do 40 questions a week.

Pro-tip #2: While it may be tempting to do questions while watching your favorite show [select trashy reality TV show of your choice], this probably isn’t a wise choice as you’ll do 5 questions an hour, not remember any of it, and you’ll burn your sauce.

Don’t forget to taste your sauce along the way: If you want to go to the next level, doing the questions is great, but remembering what you learned is better. I make a study guide (ask me for it if you like) of the questions I get wrong or something I want to remember. Closer to the test, I’ll review this study guide.

Podcasts. Now that you have your base, it’s time to make something really memorable to get that great review.

I’m a big FOAMed guy. Without any bias or financial disclosures, here’s a list to the Podcasts I listen to:

EMRAP: 3 to 4-hour episodes released monthly broken down into 10-20 minute segments. Given by FOAMed leaders in the field (including Clinical Monster alumni Guy Carmelli), subjects will often go beyond textbook level knowledge, discussing controversial topics as well as clinical pearls on all things EM. 

EM Abstracts: also produced by EM:RAP, 20-30 segments summarizing some of the newest, hottest articles on EM and related subjects. While you likely won’t be able to read 30 full-length articles each month while in residency, I’ll try to pick out one or two that interest me and will read the full article. 

Skeptics Guide to Emergency Medicine (SGEM): producer Ken Milne will take you on a deep dive into the latest emergency medicine research. Covering a single paper each episode, the SGEM is a good introduction for those who want to learn how to critically appraise articles. Their signature “quality checklist” provides a good framework for analyzing the quality of research.

EMCRIT: produced by the infamous Scott Weingart. A good listen if you’re interested in critical care. While he will quote studies, Weingart himself will admit that much of what he preaches is “expert opinion” (often his own) aka not evidenced-based. So take with a grain of salt.

Ultrasound GEL, 5 Minute Sono: two of my go-to ultrasound podcasts to empower me with the tools to anger the anti-sono attendings out there (we love you Silverberg). Produced by ultrasound gurus including the Jacob Avila, 5 Minute Sono provides short (5 minutes…) segments teaching you how to perform various bedside scans. Ultrasound Gel takes a deeper dive reviewing relevant ultrasound research.

Obviously, there are a TON of great podcasts out there (and as our faculty editor notes, of varying quality), and this is by no means an exhaustive list or even the correct list. More importantly, I believe you’ll become a better resident by listening to people who are experts in the field (or at least in the FOAMed world). The key to successful podcasts is that they are short segments, entertaining, and pertinent. Typically, they’ll include more cutting-edge research (however, be skeptical about what you’re told – read the papers yourself.)

Pro-tip #3: Don’t quote a podcast in rounds or conferences. Podcasts are opinions that may or may not be adequately evidence-based and not formally peer-reviewed. You will rightfully be embarrassed by someone who has read and appraised the original study. However, while I again encourage you to not be that “guy” like I have, that shouldn’t stop you from listening to podcasts.

While you should take what you hear with a grain of salt (don’t forget to season your pizza), perhaps you’ll hear something new that will encourage you to read up on a topic. Or maybe, you’ll learn a quick tip that you can use on your next shift.

Like a good topping, it’s simple and pure. Unlike cheese, it can’t be ultra-processed, but has to be the real deal. And that’s the original research papers.

No, not the 30-second summary you listened to at 5x speed while ordering your coffee and remembering all the tasks you have to do in your final hour to avoid signouts. You have to take the time and read the original thing.

Why? The more you read, you’ll realize that it’s actually enjoyable. You’ll pick up minutiae that won’t be covered in podcasts and have clinical implications (did you know that hydroxychloroquine may not be a Panacea: yes you did because you read about it here). This is where you’ll graduate from the intern talking about unstable angina from Tintinalli’s, to discussing the utility of invasive therapy for stable angina (warning, this will not help your cause to lose your title of “that” obnoxious resident).

Most importantly, here’s where you’ll help your patients. You’ll know the evidence behind what works or what doesn’t. It’ll allow you to empower your patients with available evidence to use in shared decision-making. 

Pro-tip #4: If you want to sound smart and don’t have the time to read the primary literature, peruse the NNT.

However, maybe you’ll find like I have that there is value in reading the original studies. Maybe it will help you to remember the key findings. Or better yet, you’ll discover a source of bias that wasn’t covered in the media headline. Or it can save your patients from a potentially non-evidenced based intervention recommended by a consultant. Or if you’re really lucky (or unfortunate), maybe it will encourage you to pursue a career in academics. Worst case scenario: you’ll make a really good pizza.

Don’t do it alone:

Finding an article that interests you can be hard and daunting. So, attend your residency’s journal club or interest group. For fear of being called on, it may pressure you to not skip the methods section. Better yet, you’ll learn something from your peers that you may not have otherwise. Plus, what’s better than having a beer while discussing ultra-high-sensitivity troponins with your friends. And beer goes well with pizza.

Pro-tip #5: Eating an entire pizza by yourself is not healthy. Share with a friend.