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Perspective, Targets and Limits: Medicine from 50,000 Feet


Learning Medicine

Medicine is a fascinating field with endless amounts of knowledge that can be obtained. Someone could, and many do, spend an entire life striving to learn as much medical knowledge as possible yet, like someone travelling the world, so much will always remain unexplored.

It can be a satisfying feeling to go from ignorance to relative expertise in certain topics. There are other incentives to work hard to obtain this knowledge too, such as admiration from your peers, praise from your parents and points for your CV.


A common pitfall

However, this leads to a common pitfall: working too hard. You may have heard this before a million times, but let me use a personal example to demonstrate a point.

In my first year of medical school I was aiming high. At the end of the year, I was disappointed with my result so I resolved to do better the following year. I made a lot of sacrifices; I skipped social events, spent less time with my friends and spent many late nights in the library. Half-way through the year, we had a full ‘mock’ exam and the hard work paid off; I achieved a mark that, based on projections from previous mock and actual marks, predicted I’d finish in the top 10 of our 400-person cohort. However, my approach wasn’t sustainable; before the end of the year I became apathetic, burnt out and achieved a good but, compared to my personal target, disappointing result once again.


Learning from failure

The following summer I spend a lot of time reflecting. My approach that year contributed to me breaking up with my girlfriend, feeling more distant from my friends and family and ultimately feeling less happy. I had sacrificed so much — what had it all been for?

I began to assess my motives. For a long time, I had been telling myself “I need to study hard so that I can be the best doctor I can be” but I realised this didn’t hold up to scrutiny: the difference between a good and a great result wouldn’t make me a much better doctor, yet the reduced life experiences from living in the library may well make me a worse one.

I realised that being the best had become part of my identity during school, causing me to lose perspective on how important it really is relative to other areas of life. I also realised that I cared too much about what other people thought of me and part of my motivation was to prove myself to others and show everyone how smart I was.

I want to stress that I don’t think that working extremely hard is a bad thing. On the contrary, I think it is important and admirable to work hard towards a worthy goal. Most people don’t work hard enough. However, we must be clear about our priorities, honest about our motives and strive to maintain perspective at all times.

I appreciate it is not that simple. If I had told my second-year self that exams aren’t the be-all and end-all, I doubt he would have listened. I needed that tough summer of soul-searching to figure things out. Sometimes you just have to make your own mistakes and learn from your own experiences.

Different people will come to appreciate their priorities and motives in different ways. Two techniques which, if undertaken with an open mind and honest approach, can help provide this clarity are ‘Following the Trail of Whys’ and ‘Attending Your Own Funeral’.

Follow the Trail of Whys

It is easy to ask ‘why’ and accept the response, even when it doesn’t really answer the question. For example:

Q: Why was the patient’s intravenous fluid run at the wrong rate?

A: Because the previous nurse didn’t change the run rate.


If we accept this answer without probing further, we will assume that this was the nurse’s fault and that she should be blamed or held accountable in some way. However, this doesn’t get to the bottom of the problem and is not a solution.

The founder of Toyota, Sakichi Toyoda, is credited with advising people to “Ask why five times.” The exact number is not important, but continually asking why can be effective at finding new answers and uncovering flaws in previous assumptions.


Let me demonstrate with the above example:

  1. Why was the patient’s intravenous fluid run at the wrong rate?

The previous nurse didn’t change the run rate.

  1. Why didn’t the previous nurse change the rate?

The doctor’s order had gone to the pharmacy and the medication administration record (MAR) was not updated.

  1. Why wasn’t the MAR updated?

The MAR is updated only once per day.

  1. Why is the MAR updated only once per day?

The hospital has chosen to use oral instructions for updates that happen more frequently.

  1. Why are oral instructions used?

The process was constructed a decade ago, when medication orders changed less frequently due to longer lengths of stay. Upon further study, the hospital determines that 40 to 50 percent of its medications change every day.


It isn’t until the fifth why that the actual answer to the question is found.

This technique can be applied to any situation, including understanding why you think or act in a certain way.

If I had been honest and objective with myself during my first two years of university, the Trail of Whys may have produced something like this:


  1. Why do you study so hard?

Because I want to get one of the highest marks.

  1. Why do you want to get one of the highest marks?

Because I want to show everyone that I’m the best.

  1. Why do you want to show everyone that you’re the best?

Because I derive some of my sense of self-worth from what others think of me.

  1. Why do you derive your sense of self-worth from what others think of you?

Because my upbringing taught me to seek the approval of others. This was an adaptive response to my environment but is not serving me well while studying a competitive course at a competitive university.

Therefore, the solution is to deliberately re-appraise how I evaluate myself, rather than to focus on how hard I am studying or working.


As you can see, this technique can get deep and personal pretty quickly. This is why absolute self-honesty is so important.

This technique can also be useful in academic learning. I shall discuss explore how in a future post.

Attend your own funeral

This technique involves visualising your own funeral, imagining how it could go and how you want it to go. The aim is that, by doing so, you will appreciate what really matters and is most important to you. There is a wider philosophy termed ‘memento mori’, meaning ‘remember that you have to die’, which believes meditating on our death can bring profound insights about ourselves.


Insights from a palliative care nurse

A palliative care nurse called Bronnie Ware revealed the five most common regrets that people have at the end of their lives:

  1. I wish I’d had the courage to live a life true to myself, not the life others expected of me.
  2. I wish I hadn’t worked so hard.
  3. I wish I’d had the courage to express my feelings.
  4. I wish I had stayed in touch with my friends.
  5. I wish that I had let myself be happier.


The technique

Below is a description of the technique, from the book ‘The Charisma Myth’ by Olivia Fox Cabane. It can stir up emotions, so you are encouraged to do it in an environment where you feel comfortable being emotional and with time to process things after the exercise.


Set the scene and involve your senses:

  • Sit or lie down, close your eyes, and set the scene.
  • Where is your funeral being held? What day of the week? What time of day? What is the weather like?
  • See the building where the ceremony is being held. See people arriving. Who’s coming? What are they wearing?
  • Now move into the building and look around inside. Do you see flowers? If so, smell the flowers’ scent heavy on the air.
  • See people coming through the door. What are they thinking?
  • What kind of chairs are they sitting in? What do these chairs feel like?


Watch your funeral:

  • Think of the people you care most about or whose opinions matter most to you. What are they thinking?
  • See them stepping up one after another and delivering their eulogy. What are they saying? What regrets do they have for you?
  • Now think: What would you like them to have said? What regrets do you have for yourself?
  • See people following your coffin to the cemetery and gathering around your grave. What would you like to see written on your tombstone?


For a recording of the above guided exercise, visit


View exams as a game

A medical student colleague of mine wrote a great article about how he approaches exams by viewing them as a game.


Set limits, not just targets

Medicine can consume your life. With clearer understanding of your priorities, you can set not only more appropriate targets but you can also set limits.

It may be that you still want to aim to finish top in your medical school, and that’s fine. However, you may be content with a more modest target. For example, after my summer of reflection I set my target as finishing in the top 25% of all exams alongside enjoying life, spending time with friends and family and investing time and energy into other pursuits.

This limited the amount of time I spent studying and gave me more stress- and guilt-free time to enjoy. It also helped guide my studying. Whenever I came across new content, I would ask myself “would someone in the top 25% know this?” In some cases, the answer was “definitely yes”, in which case I would work hard to learn it as efficiently as possible, using techniques I shall outline in future posts. In other cases, the answer was “probably not”, in which case I decidedly did not learn it. As well as saving time, I found my studying was more consistent, as were my results.

Don’t get me wrong, I still work hard. But now I vent that same energy and determination into goals that I consider more worthwhile and more in-line with my deeper intrinsic values. I will elaborate more on this in a future post.

One fear that some medical students have is that if they don’t study as much as they can, they won’t pass their exams. However, if you are intelligent enough to get into medical school then you are definitely smart enough to pass exams with the right approach. There are approaches that you can take, such as spaced repetition, which can enable you to do better while studying less.



  • Studying medicine is competitive, there is an endless amount to learn and there are continuous exams. This means that many people sacrifice too much for work.
  • Perspective and clarity can be increased by following the ‘Trail of Whys’ and ‘attending your own funeral’, as well as by other techniques.
  • This enables us to set targets and limits. Limits can increase studying efficiency and help us find a good work-life balance.


If you enjoyed this article, please share!

This article is an excerpt from my latest book, The Modern Medical Student Manual, which offers guidance for succeeding at medical school, while finding deeper fulfillment in work and setting yourself up for an impactful medical career. For more information, click here. It is available now on Amazon.


Also published on Medium.

By | 2018-01-10T18:10:30+00:00 December 20th, 2017|

Spaced Repetition: How to Learn Medicine Faster

We all know the feeling. We spend long hours studying, desperately trying cover everything ahead of exams, only to feel that we’re not making any progress.

Yet there is a better way, which is grounded in neuroscience and psychology research. It’s called Spaced Repetition.


What is spaced repetition?

Spaced repetition involves reviewing content at gradually increasing intervals. Research has shown that it dramatically increases the memory retention and thus efficiency of learning[1]. The first scientist to demonstrate this phenomenon was Ebbinghaus[2].

Fig 1. Ebbinghaus forgetting curve


A system for incorporating spaced repetition into daily medical life

A practical way to use this in medicine is as follows: when you learn some new information, recall it from memory and review your notes after about one hour, then one day, then one week, then one month, then six months and then one year.

The principle is more important than the exact time spacing and can be adjusted around your life and schedule as required. You can organise this in a number of ways, on the micro (facts and concepts) and macro (topics) levels.


Micro (facts) level

One option for the micro level is to use electronic aids, such as Anki (where you can make your own flashcards) and Memrise (where you can use those created by others). These present you with flashcards and will re-present them at increasing intervals, based on your ease of recollection.

I found Anki most useful for fuelling active recall by having a condition name or an important concept on one ‘side’ of the card and lots of reference information copied from my notes on the back.

For example, Anki presents the card like this:


I would then spend about thirty seconds writing out as much as I can about Mallory-Weiss Syndrome (often using the rough format; aetiology, signs and symptoms, pathophysiology, complications, investigations, treatment).

I would then click ‘show answer’ at which point it would show the reference information, as below, for me to see how much I got and what I missed out.


Based on how easy I found it and how much I was able to recall, I would select the appropriate option at the bottom and would then be re-presented with this card after the relevant period of time.


Macro (topics) level

I created a Review System which is easily organised through a central document as shown below. This is only one way to incorporate Spaced Repetition, but I will explain it to demonstrate the principle.



The system works as follows:

At the end of each day, I spend about an hour recapping things that I have seen, learnt and been taught that day. Anything worth reviewing the next day is added to the ‘Daily Reviews’ column.

At some point during the following day, I will review topics in the ‘Daily Reviews’ column (by recalling content from memory and often doing some further study to clarify important concepts). If I feel the topic is worth reviewing again, I will move the topic into the ‘Weekly Reviews’ column. This means that I will review it again in approximately one week’s time and perform the same process (putting some into the ‘Monthly Reviews’ column and so on). Some smaller topics will be grouped into larger topics as they progress right-wards.


Here’s how this works on a daily basis:

Whenever I have a free moment during the day (such as between teaching sessions, before a clinic, between theatre operations or any other time when no learning opportunities are present), I open up the central document and work through the topics for review in the priority order shown above, from left to right. This usually involves grabbing a piece of paper and recalling as much as I can on the topic before later referring to my notes (which I sync to my phone). If necessary, the recall can be purely mental, such as if bored during a long operation.

I have found using this system a very effective way to make the most of gaps during the day. I can recount numerous occasions where I had a gap of 10-30 minutes, during which previously I would have killed time checking my phone or emails, but instead reviewed some content. I would often get home in the evening having covered the majority of my reviews during the day so I had the option of taking the evening off knowing I’d made good progress.


I would estimate that this system alone enabled me to spend 30-40% less time studying with a noticeable improvement in long-term retention. It also meant I was far less stressed during exam period, particularly finals, as the majority of the content was in my long-term memory thus reducing the need to ‘cram’.


[1] Melton, “The Situation with Respect to the Spacing of Repetitions and Memory.”

[2] “Classics in the History of Psychology — Ebbinghaus (1885/1913) Chapter 1.”



If you enjoyed this article, please share!

This article is an excerpt from my latest book, The Modern Medical Student Manual, which offers guidance for succeeding at medical school, while finding deeper fulfillment in work and setting yourself up for an impactful medical career. For more information, click here. It is available now on Amazon.

By | 2018-01-10T18:10:36+00:00 December 6th, 2017|

Why you shouldn’t tell people your exam results

Stop Trying To Define Yourself

The world we live in is pretty damn complicated, beyond levels our brains are able to comprehend. To cope with this, we instinctively look for ways to simplify things in order to understand them. This has served us well throughout history and continues to do so but it comes at a price.

The complexity of all things means they are not easily defined. Everything falls on a spectrum. For example, size can range from a quark to a Universe and any point in between. Human beings exist at any point on an infinite number of spectra, which can be challenging to comprehend.

So we often define ourselves in ways that can be measured far more easily; exam results, achievements, jobs, our social circle, Instagram followers, Facebook likes, etc.

We do this because it’s easier. It doesn’t hurt our brains as much. But it is damaging. Why? Two main reasons:

  1. If you only pursue things that can be defined, you will not invest time in things that can’t be. And it may just be that activity without a defined outcome which makes you the happiest.
  2. It inevitably leads to comparison. We all know that comparing ourselves to others unhealthy, but at times it can be difficult not to. Learning not to define ourselves and others can help.

So how can I stop defining myself and others in this way?

A useful approach is to cultivate what the notable 19th-century poet John Keats termed ‘negative capability’ — “the willingness to embrace uncertainty, live with mystery, and make peace with ambiguity”. In other words, being able to live without the need to define everything and categorise people into one box or another. We should also appreciate that this need can stem from our own insecurities.

Why I don’t tell anyone my exam results.

For the reasons described above I don’t tell anyone my exam results. When I start my revision I make this promise to myself, even if I were to come first in the year. I want my motivation to come from a place of healthy self-competition, not from a desire to prove myself to others. When my motivation is derived internally in this way it is more stable and less influenced by the words and actions of others.

In the words of another notable poet, this one from the 21st-Century:

“Accept yourself.
You don’t have to prove shit to no-one except yourself.”
– Drake, Tuscan Leather (2013)

By | 2018-01-10T18:10:40+00:00 November 30th, 2017|

What will British healthcare look like in 20 years’ time?

What will British healthcare look like in 20 years’ time?

At 8:40am, a medical student named Derek entered the doctor’s office on the Enhanced Recovery post-op ward and sat down by a computer. Two of the foundation doctors, Amir and Sarah, looked up to acknowledge his presence before continuing their preparation for the imminent ward-round. Derek was feeling pro-active so he grabbed the office’s VR headset and looked up which operations were currently being streamed. To his delight, a patient undergoing a spinal reconnection had consented for educational streaming and the operation had started 40 minutes ago. Derek promptly re-winded to the start of the operation then skimmed through, stopping briefly to watch the sural nerve harvest, until he was watching in real-time. He had read about this operation recently; he knew that the surgeon would now inject cultured olfactory bulb cells into the spinal cord above and below the lesion that had just been bridged by the sural nerve. As the surgeon prepared to do so, Derek submitted a question about the depth and angle of injection. He was pleased to see it received a few early upvotes from fellow viewers. It consequently appeared on the surgeon’s headset, who promptly answered it out-loud as he prepared the injection.

As he was watching the injections, he felt a tap on the shoulder and removed the headset to find the room was now full of doctors and handover was about to begin. He listened attentively as the new admissions were recounted by the on-call doctor and then the ward-round got under way.

The first patient, Mr Powell, was a 78-year-old gentlemen who had undergone a valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) the previous day. His original TAVI from 14 years prior had begun to leak, warranting the insertion of a second, slightly smaller aortic valve within the first. The consultant placed his electronic stethoscope head on the aortic region of the patient’s chest and stepped back to analyse the reading on the computer. It displayed the S1 and S2 heart sound waveforms, as well as a faint diastolic murmur, and computed the estimated functional improvement.

Figure 1. Electronic stethoscope head and waveform


As Mr Powell was medically fit for discharge, they just needed to ensure that his Shared Care Plan had been approved by all parties. They checked on the computer – the GP had seen and approved it that morning but they were just waiting on the allocated district nurse, who was scheduled to review it later that morning.

“If all goes according to plan, Mr Powell, you’ll be home by lunchtime” the consultant commented, cheerily, and the team left the bay.

“The next patient has dementia”, the consultant commented, turning to Derek, “what strategies do you know about in the community to help him?”

“As a recently-certified ‘Dementia-Friendly Community’, the Cambridge area has successfully implemented a number of schemes, from public transport services that help people get on and off at the right stops to dementia-friendly supermarkets with regular maps and sign-posting as well as trained staff,” Derek replied.

Amir’s bleep went off. It was an automated message from EPIC, so he pressed a button on his earpiece: “This is the EPIC Early-Warning System. Based on the latest pattern of blood results for Mrs Esquire on Dover Ward, there is a 56% probability of her developing sepsis within the next 24 hours. Please attend to her as soon as possible.”

Derek shadowed Amir for the rest of the morning.

At lunch, Derek planned his afternoon. He checked the ‘Patients for Students’ list on his phone and saw that a lady was coming in for removal of a malignant melanoma. He’d read about these in textbooks but since the Early Detection Program was implemented in supermarkets it was rare to see them beyond an early stage. Many supermarkets were now offering bonus club card points for people who regularly got themselves checked out by stepping into one of the booths by the check-out machines.

He had a gap between the operation and a history-taking chat bot session, so opened another app to arrange a teaching session. He saw that an F1 on HPB was expecting a quiet afternoon, so requested a teaching session on liver function tests – his request was later accepted and two other medical students signed up to also join.

After the operation and teaching, Derek spent an hour in a booth in the library taking histories from different chat bot personalities with various complaints and receiving tailored feedback. He then headed home, opened up ‘Dr’s Assistant’ on his computer and recounted what he had seen that day. The software used this recollection, plus data from his past records of study, projections for future assessments and a spaced repetition-based algorithm to present him with relevant learning material and questions to conclude his day.


This was originally written for an essay competition. It came runner-up and was published in the Cambridge Medical Journal  here.

By | 2018-01-10T18:10:45+00:00 July 31st, 2017|