Aug 252016

overnight intensivists icu 24-7Jon-Emile S. Kenny [@heart_lung]

"Let the wild rumpus start!"

-Maurice Sendak

Many of you are preparing for the Critical Care Medicine Board Examination; thank you to those who have downloaded my free review notes.  I often receive a question or two about the exam and how germane my notes were, in retrospect.  This is a difficult question to answer because preparing for an examination is so intensely personal.  Reading through my own review notes was entirely different for me because I had created them while wading through various study resources; the notes were a rapid and poignant reminder of material that I had already digested – a bit like acid reflux.  I do not recommend, therefore, using my notes as a primary resource.  I do humbly suggest the following:

Firstly, like anything in life, you have to practice what you are expected to perform.  As flawed as using multiple choice questions are to assay one’s ability to work in an ICU, multiple choice questions are what you need to practice.  Do as many SEEK questions as possible; go back many years.  I think I did the last 4 sets.  One way to motivate your self is to pair up with one of your co-fellows.  Set a deadline for completing a number of questions, then meet for a few hours to discuss those questions that didn’t make sense.  Reflect on the questions and answers and relate them to actual patients you have encountered in the ICU.  These conversations will cement this data in your memory; make the information personal!  The self-reference effect and story-telling are very powerful forces for laying down memory.

Secondly, do more questions.  As you are answering questions, jot down a few notes – a sentence or two – for each question and answer.  You will find yourself puzzled with future questions and answers and want to return to previous, related questions that you had been perplexed by weeks prior.  It is helpful to have a guide or system to track down old quandaries so you can relate the two.  After reflecting on personal experience, reflecting on previously-answered questions is another good way of deepening cognitive bonds.

Thirdly, after finishing as many questions as humanly possible, turn to a narrative, high-yield summary of critical care medicine.  There are many excellent resources here; I used my notes as this summary and you can too.  Nevertheless, as we are all keenly aware, passively reading material can be incredibly inefficient.  One must continuously interact with the information in a deep way in order to hold it down.  One prescription for how one should engage material is the classic “Bloom Taxonomy” for which an hierarchy of cognitive activity is postulated.  Like Maslow’s Hierarchy of Needs, Bloom’s Taxonomy provides descriptors of depth by which one interacts with information and this ranges from the base “remember” [e.g. rote memorization] and ascends in the following order: “understand, apply, analyze, evaluate and create.”  So as you read reviews notes, evaluate them for yourself and try to create your own order out of the material.

Lastly, I suggest taking a break.  I know this is impossible for many, but it was invaluable for me.  Nearing the end of my fellowship I returned to a great source of wisdom throughout my life – Ferris Bueller’s Day Off – and especially the final scene when Ferris puts his hands behind is head and notes:

Life moves pretty fast.  If you don’t stop and look around once and a while, you could miss it.

Having seemingly burned through undergraduate studies, medical school, residency and fellowship without pause, I took a step back; it helped me tremendously.  So while I studied, I had my proverbial Day Off.  I sought out and visited my very old friends; I made new friends.  I spent some time living alone in a cabin in northern California.  I grew a big beard and took precious moments to be – even fleetingly – The King of All The Wild Things on sun-soaked beaches of the Pacific Northwest.


Figure 1: Jon-Emile's Day Off.

The pace at which we move through our lives as physicians can be relentless; reflection in study can be a fertile time to stop and look around at what one has accomplished, what one considers important and what life may hold following the next exam.

Happy Studies,


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