Medical School Pre-Clinical Years: Twenty Questions (Part 1)

(With a hat-tip to EMphysician for the idea. -PB)

What’s the Secret to Medical School?

There is really no secret except the obvious. First, you have to be intelligent. Not necessarily Mensa material but smart enough to assimilate the material. Next you have to study…a lot although the actual amount and method will vary. Finally, you have to have the desire. The application process does a good job of selecting for people who fit the profile because not too many people fail out. It’s not that medical school is easy. It’s not. I have a fairly rigorous undergraduate degree but medical school was an order of magnitude more difficult. Rather, medical schools weed out the non-hackers at the front end instead of wasting time and money later on. In the old days, admission was easier but the attrition was much higher and it was very possible that the “person sitting next to you” might not make it past first year. My class started with 102 students and graduated with 98 of the original bunch plus a couple of students who had been held back a year and fell into our class. We had two people (to my knowledge) flunk out and two quit because they couldn’t handle the pressure. One who quit managed to come back the next year.

Is the Material Difficult?

Some of it is. Renal physiology, for example, gave me the heebie-jeebies and I didn’t really get a handle on it until I did a nephrology rotation. For the most part, however, it’s not the difficulty but the tremendous volume of material. When I was in college, I now know that we moved through the material at a leisurely pace. Most classes met three times a week and, in my major anyway, an entire class period might be devoted to solving a couple of the assigned problems. I recall the great pains the professors took to explain concepts and we might dwell on one topic, say lateral torsional buckling of a steel beam, for a week. This is because in undergraduate education, understanding the concept is stressed over memorizing facts. In medicine, while understanding the concepts is important, there are also a lot of straight-up facts that you need to memorize. A whole lot.

Which is sort of the difference between, for example, an undergraduate physiology course and the equivalent material in medical school. In college, you sort of lollygag along learning the big picture with your progress punctuated by the occasional reassurance from the professor that you don’t really have to know this or that. Serious pre-med students (I mean the ones who eventually matriculate and not the ones who decide that a psychology degree is less scary and allows more party time) sleepwalk through this kind of course.

In medical school on the other hand, although the occasional moron asks, “Will this be on the test?” they may as well save their breath because the answer is always, “Of course it will be. We’re not training half-assed doctors here.” Hence, the material comes at you as if from a fire hose (to use the popular analogy) and you do not have the leisure time as you did in college to sort it out before even more is sprayed at you. The syllabus for one course in medical school, I mean if you printed it out (which I never did, preferring to study directly from my laptop), would be a stack of paper the size of a medium-sized city’s phone book. Multiply that by six because several courses run concurrently at most medical schools and you have an idea of the volume of material that you are expected to review and regurgitate on your exams, not to mention retain for the USMLE Step I and eventual clinical practice.

The only class in college I took that even compared to the feel and pace of medical school was a basic circuit analysis course taught by a senile professor who spent the first two weeks teaching an advanced signals processing course instead. It was a week before we decided that something was wrong. The professor would call us to the blackboard to solve incredibly complicated operational amplifier problems and then berate us for not knowing a thing about them. It was two weeks before our complaints were believed and three weeks before the professor grudgingly started teaching the right class. (I failed the class but after making a huge stink got my grade raised to an “B.”) The first couple of months of medical school felt something like that. You look around and wonder if you are really as smart as everybody has been telling you because nothing is clicking and for the first time in your life you are struggling for just a passing score, drowning in the huge volume of unfamiliar and highly intricate information. What you learned in undergrad? Please. As EMphysician points out, they cover that in the first couple of days and then you move on.

On the first day of medical school I was prepared to take notes as I did in college but after ten minutes threw away my pen and never took another note in class again. It’s almost impossible to keep up with the speed of the lectures and take notes at the same time. I don’t have that kind of hand-eye coordination and if I looked down to write, I would have missed something.

How Did You Study

My medical school had most of the course material posted online by the professors. The occasional old-school lecturer still brought his early Bronze Age slide projector and the tired old slides he had been using to teach anatomy since the Kennedy assassination but almost every lectures was on Powerpoint and could be downloaded. Consequently, my preferred study method was to review the lectures on my laptop ten to twenty times in the interval between when they were given and the exam. We had a note-taking service but I never used it because the notes usually just recapitulated the Powerpoint lecture. I had a few of the major textbooks and used these to fill in gaps or when I didn’t understand something and needed a little more depth. For variety, I had the Board Review Series “Gridbooks” for every course and when I got tired of looking at my computer read the relevant sections in those.

Reading textbooks, by the way, was fairly low-yield. Test questions usually came from the lectures and while there is nothing fundamentally wrong with reading a textbook, you can get bogged down in the minutia of the minutia. You just don’t have the time, trust me, to read all 1200 pages of the “required” physiology textbook. What most students do is eschew the voluminous tomes and acquire a set of smaller, cheaper, and more focused review books (like the aforementioned BRS series) and if they must use textbooks, use them for reference. (Hint: Do not rush out and buy all of the textbooks on the “required” list. You can easily drop a thousand or two on books that you will rarely use and can be found in the library when you do need them. Big biochemistry book? $150. Review book? $20.)

I attended almost every lecture because, well, I like lectures and found that reviewing the material later made more sense if I had heard it straight from the horse’s mouth. Some people skipped almost every lecture and studied on their own. You can certainly do this with no penalty. Even at the few schools with mandatory attendance, as long as you are doing well on all the tests the administration will have a hard time making an issue out of you missing lectures. My own routine was to go straight from lecture to a library, any library, in town and study until it was time to go home. At my medical school, the lectures were generally over by two or three PM and I usually studied until five or six. I also studied on the weekends, the hours depending on the proximity of the upcoming exams.

Wait a Minute, You Only Studied Three Hours Per Day?

Yes and no. Remember, I went to every lecture, sat in front, and paid attention. You know, the funny thing is that most of the material is fairly interesting. The professors tend to get carried away in their own area of research but as I wasn’t coming from a background in the biological sciences it was all new and wonderful, even if I knew I’d eventually forget most of the details. So I’m going to count that as study time. Naturally I studied a lot more in the first few months of medical school before I learned what it took to pass the tests. On average, however, I generally couldn’t take more than three hours a day and that was that. Towards the end of second year I studied even less but that’s normal because by that time, you know how to study, what to study, and are generally conditioned to effortlessly assimilate the same large amounts of information that caused you to panic in the first confused days of first year (plus second year course work is more clinically oriented and a lot more interesting anyway).

Did people study more? Of course they did. Some of my classmates lived at the library. Keep a few things in mind, however. First, there is studying and there is studying. If you look, you will see that a lot of “study groups” full of nervous medical students burning the midnight oil as they frantically cram for tests are actually highly inefficient circle jerks. There is studying going on but there is also a lot of socializing, bitching, complaining, and general “grab ass.” You would also notice that some people study inconsistently and may not crack their notes for weeks after an exam. As the next exam approaches, they are thus forced into manic overdrive trying to catch up with all the material. These are the people smuggling their coffee pots into the library and bringing a change of clothes.

Too much for me. Many years ago in my first attempt at college before many of you were born, I used to regularly fall behind with my college classwork and frantically try to cram it all in as the tests approached, often pulling bleary-eyed, extremely non-productive all-nighters in what became an unsuccessful attempt to pass enough classes to not get kicked out of for bad grades. It is far, far better to have the self-discipline to study every day for a set amount of time than to periodically study in a crisis mode which does happen with medical students. Did I cover myself in academic glory as a medical student? No. And as long-time readers of my blog know I probably could have studied a little harder. But after the initial shock of first year, I settled into a very comfortable, low-stress routine and comfortably passed every test I ever took.

I even grew to enjoy the first two years of medical school because sitting in lectures was pleasant, my study method was not difficult or complicated, and as I looked at medical school as nine-to-five job no different than what I had been doing for the previous eight years or so had plenty of free time and was very rarely stressed out.

Things I Did Not Do Even Though at Orientation They Warned Us We Would Need To Do to Pass:

1. Highlight. Not in one color or many. The BRS books and Powerpoint lectures are outlines anyway so it is pointless to highlight.

2. Take notes on notes and then produce written summaries of the notes from my notes, color-coding where appropriate. Vishnu P. Shiva. Who has that kind of time? I did not make flash cards either.

3. Study in a group. Not once. I am not convinced at the utility of group studying. There is the potential for a lot of wasted time not to mention that dealing with other people’s learning styles can be distracting. I did not want to quiz and be quizzed by other people on material that I could learn on my own in a much shorter time seeing as I can read about ten times faster than I can talk.

4. Cram before a test. Look, at my school the tests covered about a month of material. If you haven’t got it on the day before the test, staying up late trying to fit it into short-term memory is only marginally effective. Suppose your cramming nets you a couple of correct answers that you would have otherwise missed. As our tests usually ran to about 200 questions, the real effect on your grade is almost undetectable and you’d probably do better if you came to the testing center fresh and alert after a good night’s sleep. Although it has been close to 25 years, the memories of those sleep deprived nights of futile cramming, nights which soon deteriorated into watching crappy television infomercials or the Reverend Jimmy Swaggart, are still vivid and I abhor losing sleep for any reason.

Did You Do Any Research or Anything Else to Make Yourself Stand Out?

No. Most medical students don’t. If you want to match into something extremely competitive research is a de facto requirement but otherwise you are probably safe to do some bullshit public service activity if you want to buff our resume. Have I ever mentioned that I am extremely jealous of my free time? After a long day of lecture and studying the last thing I wanted to do was to be some professor’s research scut biach. But if you want to match into something like Radiology, Urology, Dermatology, or Opthalmology you need to consider doing some research. Likewise if you have your eye on a particular prestigious program in an otherwise generally non-competitive specialty.

What Was Your Curriculum Like?

Our curriculum was organ-system based. The first six months of first year were devoted to the basic sciences as well as an introduction to gross anatomy. In the second semester of first year we started a Grand Tour of the human body organized by major system with lectures in each block for the physiology, pathology, and pharmacology of each system. In other words, we didn’t have one physiology course for six months that covered everything but instead had these lectures spread out over first and second year. We did the same for gross anatomy with an eight week introductory course in first semester and then a few days in the lab during first and second year for each system. On the cardiovascular block, for example, we dissected the heart in detail.

Some courses were taught en bloc such as Biochemistry, Embryology, and Microbiology but most of the other lectures were organized by organ system.

We had a smattering of Problem Based Learning but only enough for most of us to learn to despise it. We also had a smattering of the usual hand-holding, kumbayah type classes instructing us to celebrate diversity and the other touchy-feely stuff. We had a lot of that kind of thing during orientation but after the real curriculum started these lectures were viewed more as a pleasant break, a diversion if you will, from real lectures that required us to actually learn something other than “You have to respect primitive cultures and their backwards-ass beliefs about medicine.”

Next: Gross Anatomy, USMLE, Early Patient Contact is a Waste of Time

26 thoughts on “Medical School Pre-Clinical Years: Twenty Questions (Part 1)

  1. As a young (compared to you) high school student just considering the possibility of medical school (except that I’m not taking too much science right now), this article gives me hope! Thanks!

  2. Excellent! Sounds almost exactly like our curriculum (I’m a second year med student at a state university). I too am a non-traditional student and have a mechanical engineering undergrad degree. We have the same type of curriculum with the occasional horseshit PBR (problem based learning) sessions and touchy-feely social medicine discussions.

    I still haven’t learned from my undergrad days, so I still cram, cry and pop propranolol and adderal as test day approaches. But I barely pass most exams….although haven’t flunked a class yet (that might change since I have an upcoming organ system test that I find the subject matter really hard).

    However, I found some of my engineering courses much more difficult (fluids, thermodynamics), but from a different aspect. Engineering courses didn’t require as much raw knowledge assimilation, but problem solving and trouble shooting on exams was much more difficult. Especially if you blow at math like I did. Overall though, I have to study a lot more in med school than I did for undergrad.

  3. “Take notes on notes and then produce written summaries of the notes from my notes, color-coding where appropriate. Vishnu P. Shiva. Who has that kind of time? I did not make flash cards either.”

    Haha, too true. I would go crazy spending that much time making my study aids as opposed to just studying. If I have flash cards, it’s because I bought them (anatomy and pharmacology were all I got).

  4. Three hours of studying each day sounds like quite a lot to me. I don’t think many people have the tolerance to study more than that every day for two years. Granted, there were times such as the week before a test that I “crammed” for 5 days straight, but putting that much energy into one task can quickly lead to burn out. I know of only a few people who can pull the six-hours of studying routine. One did burn out and had to take a leave of absence during third year.

  5. Some more questions to consider touching on- Overall, how would you rate the “quality” of your life during med school? Did you still have ample time for your hobbies, TV/movies, cooking, cleaning, etc.? Given that most schools’ lectures these days are duplicated in audio/video available on the internet in addition to the student note-taking service and provided Powerpoints, do you think you would still go to class? Do you think the ability to go through the lecture and material at your own place would be better, or do you think getting the material 2 different times/ways is more important? Here’s a big one for me- why library over going home to study? I’ve never done the library thing, but this seems to be very popular among medical students.

    For part 2 on gross anatomy- how did your lifestyle change with the added lecture+lab hours?

    I think this series is great timing- all of us accepted pre-meds have little to do over the next 4 months but start thinking about how life is going to get a lot worse…

  6. Excellent advice.

    One other thing not to do — the biggest waste of time in the history of students until YouTube came along — recording lectures.

    Most classes have a couple of students who seem to enjoy making a big production of setting up their tape or digital voice recorder at the start of each lecture. I think they dream of listening to lectures during spin class but the reality is it’s usually hard enough sitting through the lecture the first time, much less hearing it again in real time.

  7. Kypdurron5-

    I agree with dear Uncle Panda. These next two years are going to be way easier than what some of us have gone through. Right now I work full-time, school in the evening, family, and routine volunteering. Two years of just studying sounds like a breeze. Going from 4-5 hours of sleep a night to 8 sounds like a dream.

    Thanks Uncle Panda…you’re always a pragmatist.

  8. Great post as always. I have similar study habits as you and hope that I will be able to absorb enough info from lecture to only have to study a couple hours after lecture. Wish me luck.

  9. “all of us accepted pre-meds have little to do over the next 4 months”

    This accepted pre-med has a lot of brain cells to kill in the next 4 months.

  10. Can’t believe you got it all on a post — great list for people starting out. Of all of them I always thought consistent studying was the hardest but most productive. I found there was a direct relationship between the person that studied 1/2 hour per day (got a 70) and the person that studied 5 hours per day (got a 90). Above and below that i always thought it was raw talent.

  11. I can’t wait for “early clinical experience is a waste of time”! One of my biggest pet-peeves regarding pre-meds. Like that DRE in first year will make your med school experience better or different by the time graduation comes around. Please.

  12. Half MD, please tell me you’re kidding?! If you’re serious, then WTF medical school do you go to? Sign me up! Where I go to school I know of nobody who (generally) puts less than six hours a day into studying, and we’re talking several weeks out from a test. Now, everybody has their own methods, and perhaps you don’t spend much time studying, but really, don’t give the pre-meds the wrong idea here…

    (But look, do you really study six hours per day?  I occasionally pulled long study sessions but the only regular all-day studying I did was for Step One and since we are on a break, studying was my “nine-to-five” job.  I also think it’s a question of efficient studying.  Making outlines, flash cards, and color-coded notes takes time, not all of it productive.  I just read and believe me, you can do a lot of reading in three hours, especially if we’re talking about BRS books and online lecture. -PB) 

  13. Again, we all have different approaches. I don’t go to lectures, ever. I sleep later, and study leisurely until lunch, go for a run, come home and study until I go to bed. Yes, I most definitely study 6 hours a day regularly (no flashcards for me), as do most of my classmates (and I DO consider going to class studying, just not my kind of studying)…But to say that 3 hours a day of studying in med school is a lot, that to me comes across as disingenuous, anecdotal, and just plain false.
    Truthfully, at this point in my med school career (2nd year), 6 hours is a walk in the park and a fairly easy day. And things definitely get ramped up for about 2 weeks before tests, depending on the amount of material I daily put in 8+ hours (in some instances during path and MIP up to 15). I’m not claiming my schedule to be the norm, just saying that 3 hours seems pretty light, and that goes for everyone I know.
    I would also like to espouse the delightful advantages of not going to lecture for those that can break free from the bondage of many years of formal education that says otherwise. It’s not for everyone, but it allows me to get more sleep, study more, remain physically active (very important to body and mind in med school), and also go out and have something resembling a social life.


    (Fair enough.  But as you point out, since you don’t go to lectures you actually do enjoy a leisurely pre-clinical lifestyle.  I went to almost every lecture, I think I missed about ten in two years, so if you count six hours of lecture a day, I actually had a nine-hour “study day.” The other difference between undergraduate education and the first two years of a lecture-based medical school is that while you may only have a few classes a day in the former, you have wall-to-wall lectures five days a week in the latter. -PB)

  14. love your blog. i’m a ms2, former ChemE and do the total opposite style that you did in your day. i don’t go to class, i write flashcards like they are going out of style and cram like crazy with a group the day before a test. it works for me, so to each their own.
    ps nice to see some no bs opinions on CAM.

  15. From my med school days I remember for the most part that the guys who did well (AOA)went to class, then went to the gym, then went home for a couple hours of INTENSE studying without distractions.

    Those that struggled were the ones in the midnight study group circle jerks with colored markers and flashcards eating crappy junk food and pots of coffee.

  16. A point of curiosity: It is my understanding that one dissects cadavers during medical school. How do you find it? It must be a very strange experience the first time.

  17. Dissection isn’t really as big a deal as you’d think. It’s pretty much just a slab of meat in fairly short order, and nobody really got the heebie jeebies for long. Sawing the skull and the pelvis in half were a bit disturbing and stuck with me, though. The guy in my group who did the eye said it freaked him out a little bit, too.

  18. Dear Dr. Panda,

    I am an internist with a medical news website, Hot Medical News which your readers may be interested in.
    If you agree, perhaps you could link to my site.

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    Brian Carty, MD, MSPH

  19. Thanks for the great post.

    I am entering medical school this September and ur post is very timely.

    I am looking forward to the rest of the series especially the USMLE write up.

  20. Lordy but things have moved along. I sat in front of a guy using chalk on a blackboard. What probably hasn’t changed in 30 years is that the main thing is just showing up every day.

  21. Hi i’m high school senior and science fascinates me, special if i, myself can apply it. i got thank you you have given me a real sense of what medical school is. i’m a person with many ambitions and you see i was thinking of pursing graduate while being in medical school. from this blog and other research i h have done i realized that won’t be possible. Thank you for setting me straight and second thank you for making medical school a real school that has negatives and positives, most opinions i have seen fantasizes being doctor.

  22. I’m in undergrad finishing a B.S. in psychology and want to do some post grad study and research in neuroscience to see if I would like the field of neurology. Its a big financial commitment and time commitment that may be too much considering the residency, despite being paid, it is not much money so I would still have to pinch pennies like a student even if I completed the M.D. Well, medicine is interesting but to me you have to start early and not skip a beat because I worked before going to school and I feel I’m too old now, maybe even lack the energy. Hey, if you are still in highschool, make sure you get comfortable with math and chemistry. Plan early, don’t get distracted.

  23. Thank you so much.
    I failed my 1st year medical school.
    So I have to do it again.
    And from now on,, I’ll follow your advice and try my best to get better grades.

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