Strategic Plan for Medical Education: A New Constructivist Model of Cognition

A New Model of Cognition

My main driver for getting a Masters degree in Medical Education was to have the opportunity to do high-level research in the field of clinical reasoning and medical decision-making.  Even as a fourth-year medical student tutoring first-year students through their Problem-Based Learning seminars, I was very keen on the process of developing a differential diagnosis and becoming an expert diagnostician.  I recently discovered an old email showing that I looked through the literature with a librarian for this exact question:

Hello, I am a fourth year medical student interested in conducting a research project on the cognitive process of generating a differential diagnosis (ddx) geared to second year medical students…  the project I want to do involves teaching second year med students how to be systematic in making a ddx and avoid the pitfalls, with a pre-unit and post-unit survey to measure their progress and confidence in differentials.  Some of the questions I might ask are:·         How many ddxs do you routinely make in PBL sessions on the first page of your [case]?
·         How often do you feel that you have the right, specific diagnosis in your HCPs before the conclusion of the case?
·         How confident are you that you have a broad number of ddxs in your [case]?
·         How would you rank your ability to generate a ddx compared to your peers?
·         Pick the best definition for the following terms: heuristic, bayesian analysis, attribution error, pre-test and post-test probability
I have done some general searches on Pubmed looking for articles on medical education and differential diagnosis, but I have not found any literature that has done any similar projects in the past.  It would be helpful to know if there are any surveys that have similar assessment measures.

I recently discovered a new constructivist theory that explains the cognitive process of clinical reasoning that I am calling “[redacted, pending publication]”.  In a nutshell, the current dominant dual-process model involves weighing judgments as Type I automatic thinking vs Type II deliberate thinking, in which we toggle between the unconscious heuristics/biases brain and our rational, conscious brain.  I think this is incorrect.  I feel that we form ALL ideas as spontaneous, self-assembling “crystals.”  The formation of diagnostic crystals is catalyzed during the brewing process by nucleation on heuristics/rules/prior experience under the right cognitive conditions.   (see Appendix 1 for details)

My vision is that in the next 10 years, I will change the way doctors think about clinical reasoning.  I plan to accomplish this in the next 6 months by doing research to justify my “[thesis]” theory through a demonstrative literature review for my Dundee thesis project.  I plan on showing how my new theory meets the criteria of quality (trustworthiness, transferability, dependability and conformability) as well as authentic criteria of fairness (ontological, educative, catalytic and tactical) as outlined by Guba and Lincoln (1989).  Then, I plan on working as a clinician/researcher and in the next 5 years, I will publish articles on this subject in several major journals (aiming for Academic Medicine, Medical Education and Psychological Review where most of my literature review has derived).   In the next 10 years, I write a book on “[redacted]” as a new theory on the psychology of judgment.

These are “big, hairy audacious goals (BHAGs).”  I will share my vision by telling stakeholders that "We will change the way doctors think about clinical reasoning, using procedural methods to ---[to be revealed]."  According to Collins and Porras,

“A true BHAG is clear and compelling, serves as a unifying focal point of effort, and acts as a catalyst for team spirit... A BHAG engages people—it reaches out and grabs them. It is tangible, energizing, highly focused. People get it right away; it takes little or no explanation.”  (Collins and Porras 1996)

The idea of changing the way all doctors think is compelling.  Even though the theoretical concept will need to be explained, I feel that everyone intuitively“gets” the concept that our brains bubble and brew and sometimes, while we are in the shower or out on a walk – BAM!  An idea comes up seemingly from nowhere.  "[The thesis]" model elucidates this process and invites people to maximize their chances of creating “Eureka!” moments.

My institution has a Department for Clinical Decision-Making (CDM) that is well-known for its leaders in the field of CDM.  (Tufts, n.d.)  We have a course for first-year medical students called “Introduction to Clinical Reasoning” that I will be building on by preparing fourth-year medical students for residency in an elective called “Family Medicine Exploration Elective” in which I plan on exploring the concepts of flow and intuition for expertise development.  In order to gain alignment with the CDM department, I plan on utilizing Kotter’s model (1996) for Change Management, to determine how to best accomplish our shared goals.  I will share a hybrid model that adds in Heath and Heath’s “Switch” concepts (2010) that use a visual analogy that making change is hard, like a human rider trying to force an elephant to walk down a path.  (Appendix 3.)

The first step in the hybrid Kotter-Heath-Heath model is to Motivate the Elephant.  This means that I need to “Find the Feeling and Create a Sense of Urgency.”  I plan on instigating a change with a shift from the analytical Bayesian approach that the Department for CDM is used to and publishing my radical new theory which is an intuitive “adaptive toolbox” approach that Gigerenzer (2002) utilizes.  (Appendix 2.)  Convincing the majority of people that change is needed (Kotter recommends convincing at least 75% of managers that the status quo is more dangerous than the unknown) will hopefully prompt a forthright discussion, leading to the next step.

Next, I will Shape the Path.  This means that I need to “Rally the Herd and Form a Powerful Guiding Coalition.”  My fellowship advisor can facilitate a meeting with various members of the CDM department to discuss the implications of my research.  I need members with enough power to lead a change effort.  Kotter specifically encourages the team to work outside the normal hierarchy:

“This can be awkward, but it is clearly necessary. If the existing hierarchy were working well, there would be no need for a major transformation. But since the current system is not working, reform generally demands activity outside of formal boundaries, expectations, and protocol.” (Kotter 2007)

Together with a group of change agents, we will Direct the Rider.  In other words, “Find a Destination and Create a Vision.”  My preliminary vision statement to share with stakeholders is: "We will change the way doctors think about clinical reasoning and help them [in ways outlined in future works]."  I would like to focus on medical education by changing our curriculum for PBL and clerkships to include these scaffolding concepts.  I already have a hand in creating a new fourth-year FM elective that will integrate these principles for outpatient primary care.

Providing rational explanations is not enough to push the broader community to change.  Next, we will Motivate the Elephant by “Pointing to the Destination and Communicating the Vision.”  If we are going to push all physicians to change how they think about generating a differential, we have to tap into their feelings.  All physicians strive to become expert diagnosticians and are afraid of missing the diagnosis.  Achieving “expertise” is nebulous, but Ericsson (2004) provides us with a clear goal.  Deliberate practice and the acquisition and maintenance of expert performance require 10,000 hours over 10 years of practice.  It is my belief that we can get the attention of various parties within the institution with the following message:

•  Medical students: “You CAN dedicate 160 hours of 10,000 hours towards becoming an expert in Primary Care reasoning in a month-long elective.”
• Family Medicine Residents:  “You CAN accumulate around 2,000-3,000 of the 10,000 requisite hours towards becoming an expert in clinical reasoning”
• Family Medicine Faculty: “You will only be supervising residents for ~300 hours of primary care clinical reasoning in a year.”  How do you plan on making the best use of this time?

With enough medical students, residents and faculty sufficiently motivated, we need to Shape the Path and “Tweak the Environment and Remove Obstacles.”  This involves revamping the first-year medical student “Introduction to Clinical Reasoning” curriculum so it is developmentally appropriate.  I would propose moving material like illness scripts, better suited for the onset of clinical exposure in the third-year.  Additionally, memorizing numerical likelihood ratios for determining post-test probabilities is not practical for real clinical practice.  Research by Czerlinksi, Gigerenzer and Goldstein (1999) has shown that utilizing the Tallying heuristic (Appendix 2) can achieve a higher predictive accuracy than multiple linear regression analyses when applied intelligently.  After the concepts of numeracy are established, we can change these burdensome LR to more teachable concepts like the Tallying method.  A smartphone “app” can be created to make the cognitive checklists we will design freely available for everyone to use (and hopefully if someone else does this grunt work for me... they will also make it free to the public!).  Many of these ideas are nontraditional and risky, which is encouraged (Kotter 2007.)

Finally, we will establish a set of Milestones for the Rider and the Elephant to achieve.  Typically, this is done by “Following the Bright Spots and Scripting Critical Moves” for the Rider to perform, as well as “Shrinking the Change and Recognizing/Rewarding Contributors” so the Elephant isn’t frightened and feels motivated to contribute.  However, my ideas are completely novel (my initial literature search in 2009 and updated search in 2014 provided no leads), so I will have to forge a path ahead.  I hope we will be able to set up curriculum for all years of medical school and my family medicine residency to include relevant clinical reasoning topics.  Personally, I have already achieved some milestones for myself in terms of spreading this information: designing medical student elective curriculum, presenting a Grand rounds on this subject in 2012, and give a regional conference on this topic in 2014.  My future milestones will include presenting a national conference on my thesis material in the next 3-5 years as well as publishing in major journals in medical education and psychology.    I hope to give a TED Talk on the subject of [redacted] as an analogy for judgment in general and spice it up with some memorable clinical examples.  Eventually, I will strive to write a book.

Kotter has a few more steps on “Systematizing Wins” and “Institutionalizing New Approaches” that will not matter to me specifically, unless I become a department chair or some other leader in medical education.  The vision statement and milestones I’ve set up for myself are ambitious and I would be happy even if I can make a local change within my residency.

In summary, one of my goals in life is to become a master clinician and systematize an approach for clinical expertise.  I feel that my theory on [redacted] is novel and opens up a lot of avenues for future research, medical education and continuing professional development.  The hybrid Kotter-Heath-Heath model I outlined above will help me align my personal goals with my institution.  It also helped me develop a key strategic plan that I can enact to become a leader in the field of Clinical Decision-Making and change the way doctors think.

Appendix 1.  [redacted theory.]

Appendix 2: Gigerenzer’s Adaptive Toolbox.

Combined Model for Change Management  (Heath 2010 and Kotter 2007)

	1.       Motivate the Elephant: Find the Feeling and Establish a Sense of Urgency a.       Knowing something isn’t enough to cause change. b.      Make people feel something.
	2.       Shape the Path: Rally the Herd and Form a Powerful Guiding Coalition a.       Behavior is contagious.  Help it spread. b.      Assemble a group with shared commitment and enough power to lead the change effort c.       Encourage them to work as a team outside the normal hierarchy
	3.       Direct the Rider: Find a Destination and Create a Vision a.       Change is easier when you know why its’ worth it. b.      Create a vision to direct the change effort c.       Develop strategies for realizing that vision
	4.       Direct the Rider: Point to the Destination and Communicate the Vision a.       Change is easier when you know where you’re going. b.      Use every vehicle possible to communicate the new vision and strategies for achieving it c.       Teach new behaviors by the example of the guiding coalition.
	5.       Shape the Path: Tweak the Environment and Remove Obstacles a.       Remove or alter systems or structures undermining the vision b.      Encourage risk taking and nontraditional ideas, activities, and actions
	6.       Milestones: a)      Direct the Rider: Follow the Bright Spots & Identify Potential Wins b)      Direct the Rider: Script the Critical Moves & Engineer Wins c)       Motivate the Elephant: Shrink the Change & Recognize/Reward Contributors
	7.       Systemize the Wins a)      Motivate the Elephant: Develop/promote/hire visionary employees b)      Motivate the Elephant: Tweak the Changes a.       Reinvigorate the change process with new projects & change agents c)       Shape the Path: Tweak the Environment and Build Habits a.       Use increased credibility from early wins to change systems, structures, and policies undermining the vision
	8.       Institutionalize new approaches a)      Direct the Rider: a.       Articulate connections between new behaviors & corporate success b)      Shape the Path: a.       Create leadership development & succession plans consistent with the new approach

Heath, C. and Heath, D. (2010) Switch: How to Change Things When Change is Hard.  Broadway Books: New York.

Kotter, J. (2007) Leading Change: Why Transformation Efforts Fail. Harvard Business Review. Jan 2007.  Reprint R0701J.

References

Croskerry, P. (2003)  The Importance of Cognitive Errors in Diagnosis and Strategies to Minimize Them.  Academic Medicine. 78(80) pp775-780.

Collins and Porras (1996) Building Your Company’s Vision. Harvard Business Review. Sept 1996. Available from: https://hbr.org/1996/09/building-your-companys-vision

Czerlinksi, Gigerenzer and Goldstein (1999)  How Good are Simple Heuristics?  In G. Gigerenzer, P.M. Todd, & the ABC Reseach Group, Simple heuristics that make us smart (pp. 97-118). New York, NY: Oxford University Press.

Kruglanski and Gigerenzer. (2011) Intuitive and Deliberate Judgments are Based on Common Principles.  Psychol Rev. 118(1) pp97-109.

Gigerenzer, G. and Selten, R. (2002) Bounded Rationality: The Adaptive Toolbox. Cambridge, MA: MIT Press.

Heath, C. and Heath, D. (2010) Switch: How to Change Things When Change is Hard.  New York, NY: Broadway Books.

Kotter, J.  (1996) Leading Change.  Cambridge, MA: Harvard Business School Press.

Kotter, J. (2007) Leading Change - Why Transformation Efforts Fail. Harvard Business Review. Jan 2007. Reprint R0701J. Available from: https://hbr.org/2007/01/leading-change-why-transformation-efforts-fail/ar/1

Tufts Medical Center: Department of Clinical Decision Making.  Available from: https://www.tuftsmedicalcenter.org/patient-care-services/Departments-and-Services/Clinical-Decision-Making/Overview.aspx

We Do what is Needed.

New York Times: Where Life's Start is a Deadly Risk

BEREGA, Tanzania — The young woman had already been in labor for two days by the time she reached the hospital here. Now two lives were at risk, and there was no choice but to operate and take the baby right away.

It was just before dawn, and the operating room, powered by a rumbling generator, was the only spot of light in this village of mud huts and maize fields. A mask with a frayed cord was fastened over the woman’s face. Moments later the cloying smell of ether filled the room, and then Emmanuel Makanza picked up his instruments and made the first cut for a Caesarean section.

Mr. Makanza is not a doctor, a fact that illustrates both the desperation and the creativity of Tanzanians fighting to reduce the number of deaths and injuries among pregnant women and infants.

Pregnancy and childbirth kill more than 536,000 women a year, more than half of them in Africa, according to the World Health Organization.

One of my early dreams in medicine was to volunteer for Doctors Without Borders (aka Medicins san Frontieres) after the completion of medical school and residency. I was a pre-med at the time and a part of the Medical Student Mentorship Program at UH. I told my mentor what I wanted to do and he said "That's charity work. Your debts will accrue and you'll fall behind." He went on for a few more minutes and I got the distinct impression that A) it would not advance my career if I wanted to pursue a fellowship and B) it would bring about financial devastation.

If I cared about those things, I would have taken his words to heart. Part of the reason why I did some research (a sideline to medical school) on Malaria was to get in contact with some of people with similar interests. I worked with a lab that has extensive connections in Cameroon and participated in research with involving the risks of malaria infection in pregnant women. (more on that to come.)

"Am I ready for something as big as this? Can I handle it? This would be a huge change in lifestyle." These sorts of anxious questions give me pause in pursuing such ambitious dreams wholeheartedly. The NY Times article has a real sense of urgency and fatigue to it. These undertrained, underappreciated doctors and nurses are working so hard and with such little help. What could I do? I would be but a drop in a bucket.

I found the words of Paul Farmer to be very inspirational.

For me, an area of moral clarity is: you're in front of someone who's suffering and you have the tools at your disposal to alleviate that suffering or even eradicate it, and you act.

My future plans to have a private practice with greatly motivated patients is tempered by my equal desires to become a teaching faculty member for a medical school and train young physicians, as well as travel to rural areas. Why do I want to do all of these things? I am reminded of something I said at a homeless clinic to my preceptor -- "We Do what is Needed." As a physician, I feel a sense of strong duty to the world to ensure that I make the biggest difference possible... and that means tackling the problem from as many angles as possible. That's my dream at least. We'll see how it all plays out.

Top Ten: Study Methods and Habits

Medical school is one of those interesting fields where obsessive-compulsive behavior is reinforced and rewarded to no end. While I am not an inherently organized and disciplined person, I decided that I needed to change for the better upon entering med school. Here are some of the strategies that I employ:

1. Buy a lot of different colored highlighters
   I use each color for a specific purpose when I read.  Colors are a fast way of categorizing items. It helps keep me awake if nothing else.  The bonus: having nice colorful notes that are easy to review.
   

Yellow = important facts

Green = examples, lists, subheadings, lab values/Diagnosis, (+)/increasing

Orange = Key Topics/Vitally Important facts

Pink = In contrast to, (-)/decreasing

Blue = Treatment/medications

Purple = difficult to remember names/eponyms



2. Tag chapters in textbooks
   Dog ear or put in little tags for chapters.  When I tag more than the chapters, there's too many slips of paper and it takes a while to find what I want.  I also try to use different colored tabs to represent different things: Red = CV, Pink = OB, Blue = Pulm, Purple = ID, Yellow = Renal
3. Develop concept-maps/case-maps for basic physiology/pathophysiology concepts with integrated management.
   Algorithms are boring and thus, terrible ways to learn.  A concept map that systematically thinks through a problem is much more engaging.  I use C-maps for this purpose.
4. Use mnemonics.  Use them often!
   Mnemonics are highly individual and some do not work at all for anyone else but yourself.  I've done my best to try and share ones that I thought others might appreciate or those that I've heard but were not readily available online.  I made a bank of mnemonics in an excel spreadsheet with the comments as the expanded version -- when I float my cursor over the mnemonic it pops up with the reminder of what it means.
5. Learn how to think.
   Problem-Based Learning helped me develop on the spot differential diagnosis development and consequential workup, diagnosis and management.  I like it when experts tell me how they think through a problem... that's why one of the books I'm reading right now is Learning Clinical Reasoning (Excellent resource; unfortunately, it seems like its no longer in print.)
6. Stay up to date.
   Read medical journals, news and blogs.  Clinical Cases and Images answers the question: "How do you Eat an Elephant?" by setting up Google Reader. I read feeds on the latest articles in NEJM, JAMA, Annals of Internal Medicine, AFP and The Lancet.  Also, I follow some great blogs -- I share the entries that I find of special importance (seen in the sidebar.)
7. Use a multi-monitor setup.
   Buy an extra monitor!  The more desktop real-estate you utilize, the more you can read and learn.  Typically, I use one monitor for reading something and the other monitor for taking notes on the subject.
8. Centralize ALL of your notes.  When I was studying for Step 1, all of my notes went into First Aid.  Now that I'm studying for Step 2 and all of my different shelves, it'll take more than a book to hold my notes.  Which takes me to my next point...
9. Use an online notetaking service.
   Evernote is my all-time favorite application now.  I can put text notes into it as well as pdf files... perfect for clipping key parts all of those articles I'm reading!  It has the benefit of being available on any computer (so I can find my notes on diabetes anywhere I go.)
10. Use a question-bank to keep things in perspective.
    I use USMLE World.
    It is easy to lose track of what might be considered "important/high yield" for exams if you don't use a Q-bank on a regular basis.  Mark all of the questions you get wrong (be honest!) and review those specific topics and questions again.  Repetition is the key to rote memorization... and sometimes that's whats necessary to remember things like drug names.  Ugh!
11. Above all else... Have fun!
    Otherwise you'll just end up wasting time .  :)

Cheers,

Finding Common Ground

When you run up against a patient who is difficult to talk to, how can you come to a meaningful compromise?

Interest-Based Negotiation and Conflict Resolution:
by Roger Fisher and William Ury’s Getting to Yes

1) Separate the people from the problem.
2) Focus on interests, not positions.
3) Generate a variety of possibilities before deciding what to do
4) Use objective criteria to judge the solution, rather than pit one personal opinion against another.

These tips make a lot of sense and I'm thrilled that my Family Medicine rotation had us read an article on this all-too-important subject. It is difficult to learn these sorts of things... a lot of it is intuitive and to be quite frank, I've had to work very hard because it does not come naturally to me.

As a medical student, I lack a lot of the clinical judgment that my preceptors and residents have. About the only good tool I have on hand comes from being systematic, being thorough and hoping that nothing slips through the cracks. I've found this strategy to be especially effective in dealing with long-winded, opinionated patients. Only students have the luxury of time to outlast patients by performing an exhaustive interview. I plan to use this tool for as long as possible, because in the end, my patients walk away happy knowing that someone listened to them -- even though I might not have offered them everything they wanted.

"Evidence-Based" Pre-Meds!

Premed survival: understanding the culling process in premedical undergraduate education. Lovecchio K, Dundes L. Acad Med. 2002 Jul;77(7):719-24.

n=97, 100% response rate
44 decided to pursue another career

Premed students were attracted to the field by the intellectual stimulation and the power to help others, yet most were also very concerned about being in debt, dealing with patients who might die, and the compatibility of medicine with having a family.

Women students were more concerned than the men about having only limited time to become acquainted with patients on a social level.

The decision of students to forgo a career as a physician was shaped by apprehensions regarding the years of work required in residency, the need to be on call, unacceptably low grades, and the realization that other attractive career options are available. Of those who said low grades were a deciding factor, most (78%) named organic chemistry as the single course that had affected their plans.

When I was in undergrad, it was almost a "bragging" right to say that you finished o-chem. Of course, for the chemistry majors I bet it was met with silent indulgence as they moved on to physical-chemistry, meta-physical chemistry, spiritual chemistry (or whatever the progression is.)

It's interesting how o-chem IS the filter for all pre-meds. The phenomena can be observed within the class itself -- starting the year with a room full of students and in the course of a week, a month and after the first quiz -- seeing the class cut down by a third, a half, and then 2/3s of its original size.

The irony is that once you get to med school... you don't need to know any o-chem at all. Sure, it's nice to know what NMR is for certain tests in neurosurgery to detect brain tumors (Hunter's angle and such.) It might come in handy when trying to recall the name of some obscure biological molecule based on what it looks like (like p-aminobenzoic acid) . The reality is that MANY of the facts of life in undergrad do not apply in med school. Perhaps that's not such a bad thing after all.

Pre-Med content featured in this month's NEJM

Relevance and Rigor in Premedical Education
Jules L. Dienstag, M.D.

In recent decades, scientific knowledge has changed dramatically, once-settled scientific principles have been replaced by more sophisticated concepts and entirely new disciplines, and parallel changes have occurred in medical practice and health care delivery. In the face of these new realities, medical school curricula have had to adapt. Yet despite these sweeping changes, including the permeation of most areas of medicine by molecular and cellular biology and genetics, requirements for admission to medical school have remained virtually unchanged for many decades.
...

This article talks about the ever-expanding knowledge base required to become a physician... and Dienstag questions whether or not the old admission criteria for medical school are appropriate for the always-lifting expectations of our future doctors.
1 year of biology + 2 years of chemistry (1 yr gen chem, 1 yr o-chem) + 1 yr physics isn't enough. I agree.

However, I don't think that raising the bar on the admission criteria will somehow magically improve the crop of incoming medical students. Some of my best friends in medical school are History, English, even Real Estate majors and they are excelling. They have admitted to me from time to time that they struggle with some of the basic science subjects we are forced to learn rapidly on our own (i.e. microbiology, embryology) but really... would requiring people to take these courses as an undergrad really be beneficial? A lot of what I learned as a biology major WASN'T applicable to the study of Human Medicine.

Regardless, Dienstag makes a good point that the best pre-med courses would be INTEGRATIVE... encouraging students to make connections across basic science subject lines. I wonder if medical schools could ever require this, since it would be a pre-med subject that would vary greatly based on the lecturer (as no textbooks exist for such a course.)

From All Walks of Life — Nontraditional Medical Students and the Future of Medicine
Sandeep Jauhar, M.D., Ph.D.

When I was growing up, my parents wanted me to become a doctor, but I had other ideas. I wanted to be a television journalist, or perhaps a trial lawyer or private investigator — something with panache. In college, intoxicated by the mysteries of the universe, I ended up studying condensed-matter physics, in which I eventually earned a Ph.D. But after a close friend contracted an incurable illness, I began to have doubts about my career path. Seeking a profession of tangible purpose — like many older students — I was drawn to medicine.
...

Jauhar talks about the benefit of having "non-traditional" students in a class of students straight from college. While they possess different qualities of maturity and dedication, knowing full well the luxury of a student's lifestyle (as opposed to working paycheck to paycheck with little other reward)... they also have fewer years of output towards society before they end up retiring. They also have more outside life to attend to, with husbands/wives and kids. Can the U.S. medical system afford this in the long run?

I think this is the major sacrifice we have to make to have more well-rounded physicians. More female doctors, more older students, more foreign graduates will help to break down the stereotypes of the medical profession. In the ideal world, I think everyone would be a physician -- basically, the knower of their own body -- in the philosopher-king, artist-scientist Renaissance sort of way where we can all be equally enlightened in our equal access to the information we need (Yay, internet!)

Is there a best pre-med school?

HalfMD responds to a reader's question:
Is there a best pre-med school?

Abstract: No! Your academic dedication (GPA, Letters of Rec), your ability to perform (MCAT), your compassion (volunteering), and your familiarity with the health field (shadowing, personal statement) strengthen your application.

However, you might want to consider one of the "Big Five" if you need someone to hold your hand for the application process (the reader's parent submitted the question....)

1. University of California at Los Angeles
2. University of California at Berkeley
3. University of Texas at Austin
4. University of Michigan at Ann Arbor
5. University of Florida

I mean no offense by that, by the way. I was completely clueless about what it took to apply for medical school and quite honestly, my first application was a complete BOMB even though I had enough of the right stuff. It would have been really nice to have a pre-med advisor. The closest thing we had was the Pre-Med Association... but really... would you expect your fellow classmates (i.e. your "competitors") to give you the best advice and review your application? That's why I'm really thankful that I had the support of a more objective and reliable group: the Medical Student Mentorship Program.

Test taking strategies

There's a few basic strategies when approaching questions. This works for any sort of multiple choice examination, but your results will vary. I suggest swiftly adopting one that works for you. If you run into a question where it doesn't work (and you will!) then slow down, reread the question and use a different strategy.

I've become fond of a few methods as I studied for the USMLE Step 1. I'd recommend using them in the following order:

1. Stop. Think. Predict.
2. Question-directed searching.
3. Answer-directed searching.

Stop. Think. Predict. Start at the beginning and highlight the important clues/buzzwords. Blot out the negatives. Think about the diagnosis (and some of the evident treatments.) Predict what the question will be and what the answer is. If you anticipate the right answer and it's there, BOOM! You're done. You should still review the other answers just to make sure that there isn't anything better. I love this strategy because it MAKES YOU THINK. It's exactly what you'll be doing for the rest of your life as a doctor... might as well get used to it!

Question-directed searching. This strategy is the preferred method by Drs. Walker (Tips for Taking the USMLE) and Dimov (How to Do Well on Boards). Basically, read the question first and look for clues to help guide you. This spares you the frustration of a "bait and switch" question where you read a long stem only to discover that the question is asking you about a basic science topic that's minimally relevant to the stem. I've never ran into this particular scenario myself, so I prefer to read something the way I read a novel -- skipping to the end cheats you out of the pleasure of figuring things out.

Answer-directed searching. Sometimes, you have no idea what the question is asking. Sometimes you have no idea how to guess what the answer is. I've learned a little lesson from Sesame Street. It's called "One of these things is not like the others." :) This proves that ignorance is bliss. Sometimes you can get the right answer even if you totally ignore the question and just look at the answers, isolating the one answer that's different from the others! It might be a drug from a different class than the others or a diagnosis that accounts for that one weird physical finding noted in the stem.

If you've got any other ideas, let me know. I can't think of any other ways to read a question and answers other than top-> bottom, bottom->top->bottom or just bottom...

Discover's "Vital Signs" Podcast

One of my favorite sections of the Discover Magazine has always been "Vital Signs," in which a medical mystery was presented and solved in an articulate article. It's House, MD without the attitude.

I recently found the podcast version of these articles!

Medicine is a man-whore

For you aspiring pre-meds out there, heed this advice:

-get the training over with while you're young; don't take breaks (or alternatively, wait until you're a bit older)

-keep it in perspective. You are not a saint because you are a doctor (don't be arrogant and think more highly of yourself than you should). It is not a calling. See it as a stable, respectable, secure, job. Your work is valuable, but not more valuable than yourself, or your family.

-know the drawbacks, and balance those with the benefits of becoming a doctor today.

-the money *does* matter (both the student loans, and the eventual salary).

-don't sacrifice having children, visiting aging parents, or other significant life events in lieu of becoming a doctor. It will not be worth that sacrifice.

-Choose your specialty with care. Chose based on your personality...not based on what is most prestigious, what other people want you to do. Your specialty will determine your potential work environments, your pay, your lifestyle, and the number of years you spend 'training.'

-Finally, don't work too many hours. If you do, you'll be more tired, less healthy, and more likely to experience dissatisfaction and fatigue.

EM Physician makes some really good points with a healthy dose of good humor. I'm worried about a few of these things myself... I've been more aware of maintaining balance recently and I am so much happier for it. However, I have been rather dependent on my student loans for sustenance and I'm sure that this will come back to bite me. :-\

It's an interesting point to say that you should treat medicine as a man-whore. A seductive, back-stabbing, all-consuming vacuum. Don't fall in love with it or it will hurt you.

I'll do my best to keep that in mind.

Reflection on a reflection

I wrote an email out to the med school classes to recruit for a mentorship program. It was interesting, because I wrote as if you, my blog readers, were my main audience and apparently it was well-received. When I came to school today, two of my classmates came up to me and said "I read your email last night!"

They seemed excited about that for some reason. "Yeah, it was like a bedtime story for me..." one woman said. Whoa! Bedside tales by Yours Truly. "It was inspirational," said another. I was flattered. I didn't really expect that it would recruit more people to join the club; I just wanted to share my reasons for why I joined. I think that is my approach to a lot of things in life.

I thought I'd share it with you as well.

I had my first musculoskeletal CSP (clinical skills preceptorship) today and I was just thinking about what it means to be a preceptor. These doctors take time out of their busy schedules to help train us to become great doctors! They probably remember bumbling through the questions in the history and getting confused during the physical exam. All in all, having access to helpful preceptors so early in
our careers helps to ease us into our roles as confident providers.

Teaching is a great skill to have! You don't have to wait until you get your M.D. degree to make a difference in the training of future doctors. Mentoring is a skill that the Medical Student Mentorship Program fosters. With that in mind, I just wanted to remind you about MSMP's upcoming Mingler! This event will be taking place this Friday 9/7/07 at My University's Center 5:30-8pm. If you are curious, please come on down.

Your parking passes are valid on campus after 4pm!
If you need a ride, I'd be more than happy to take you there. Check out our website for contact info.

Mingler details: First we will meet in the meeting rooms on the third floor for some icebreakers to introduce the mentors to the potential mentees. Then we will adjourn to the Gameroom on the lowest floor for some pizza, salad and billiards/games.
Please RSVP if you are interested in attending. Also, we would like you to submit an
online MENTOR application by Saturday, 9/8/07 so we can have the mentor/mentee
matchups finished by Sunday.

Cheers,
Not My Second Opinion, MS-II, MSMP board



P.S. I know that this has been "club week" at school and there has been a lot of activity. You might be wondering why you should join yet another club. MSMP is unique among the interest groups because it extends beyond the medical school community and it is worthwhile! After all, it made a difference for me, since I'm a med student today. :-)

Writing a Personal Statement

This is the most difficult part of any application -- the free and creative portion in which you distill your essence into something that falls within the 5300 character limit.

How do you do this? I've talked about my own personal statement in the past.

TheReporter has some other tips and thoughts on writing a personal statement:

Humility and honesty that must come out in your essay.
A successful personal statement FOR MEDICAL SCHOOL is about the patients, and their perceptions/feeling, more than anything else. Try this before you do your next draft: describe a patient's experience/thoughts, from the first person viewpoint, from the time they first suspect they are ill to the time they see a doctor.

This goes beyond a mere essay to get into medical school. We're talking about a philosophy on how to approach patients. How a doctor ought to use the Golden Rule. This is a life-long concept... and what TheReporter is really doing is asking -- are you the type of person who has enough social intelligence that you can put yourself in someone else's shoes? How did that make you feel?

Writing a personal statement is not about echoing the tired cliche of "I want to help people" or "I want to be like Dr. X and Y because they changed my life." A personal statement should be a personal revelation with emotional content that makes people tilt their heads and go "hm..." Find your personal character flashback moment.

Strive for insight, but don't push the boundaries and make bolder claims than you can support. Practice expressing yourself. Take chances and open up with a patient when you reach a point of awkward silence when they wonder why you're in the exam room. Smile. Laugh. Ask questions. Creating experiences will inevitably lead you down a road that you can look back on and say "wow, I've got a lot of material I can draw on for a personal statement."

I heart House

There's only two TV shows that I'll drop all of my studying to sit back and enjoy. The first one is Lost on Wednesday nights. The second one is House on Tuesday nights. I've missed a lot of House, but I always keep myself up to speed on the best website ever!!!

Scott is a family doctor that runs Polite Dissent, home to House MD reviews. He posts a summary of the case with links to all the diseases mentioned and then he provides his own analysis of the results. "House" is rarely up to par with real medicine.

When I was watching tonight's episode, I was all happy because I thought I cracked the case halfway through. I commented on his blog. Here's a longer version of my analysis:

Hey, a first-year med student here. I thought I'd try my hand at a diagnosis tonight. When they mentioned strep infections, I thought about post-strep glomerulonephritis as the cause of the bleeding. It bothered me that it wasn't even mentioned. Do the writers even bother looking up the common differential diagnoses anymore? Rheumatic heart disease-induced clots come from atrial fibrillation (which would be easily seen on an EKG,) but I guess an RF vegetation could have embolized. :-\ The balloon catheterization struck me as bad medicine.

Before they came up with Mirror syndrome, I was rooting for Budd-Chiari syndrome.

My differential diagnosis went something like this:
Since this is a TV show, they'll pick something totally random and rare. It needs to have a cool name and involve as many different organs as possible. Hyperestrogenism is a hypercoagulable state. This could cause clots to form and cause strokes and a blockage of the hepatic vein. The hepatic vein blockage could be asymptomatic at first. Blood would back up in the portal venous system and jaundice would result. Weird splanchnic vasoconstriction would have fetal abnormalities and possible kidney involvement with the hepatorenal syndrome. Acute tubular necrosis could cause protein and blood to show up in the urine. It's all a stretch, but "House" always is.

My fun diagnosis was shattered when the transjugular procedure was clean. Drat! Besides, my diagnosis neglected to consider the ethical and curable issues... a "House" diagnosis needs to be controversial and it needs to have a miraculous recovery at the very last second.

I don't know how corticosteroids leads to pulmonary edema. I don't know how it speeds up the development of the fetal lungs also. If the fetus had a lower urinary tract blockage that restricted the development of the lungs, wouldn't there be oligohydramnios? Wouldn't that lead to POTTER sequence? Less amniotic fluid (which is just baby pee) would mean less room for the baby to grow, which could cause problems with limb development.

I didn't know enough about fetal development, so I just went along for the ride after that.

I liked all the drama in this episode. I thought that there were a bunch of very interesting role reversals... House/Cutty, Chase/Cameron, Cutty/Wilson. The way House stared at his hand at the end of the episode makes me think that there's potential for him to want a baby with Cutty! Haha! That would eat away at Cameron and in turn, break poor Chase's heart.

How To: Request Letters of Recommendation

I checked my email today and I was happy to see an email from an aspiring pre-med in My Medical School's mentorship program. He asked me the following questions about Letters of Recommendation (LORs):

1. How "early" is early enough to get LOR's? I'm planning to embark on a study abroad scholarship opportunity. [...]


2. So, I don't know if I should ask a LOR right now, or wait until January, or wait until I get back?? [...]


3. Maybe you could tell me any tips or advices on a good way to ask them for a LOR, & what they expect from you in order for them to write a good one for me.

I thought that these were excellent questions, certainly ones I wished I knew the answers to when I first started applying for medical school. I mentally wince when I review all the things that I could've done much better in "round 1" that still could have used a little polish in "round 2." I'm happy to share my wisdom to spare others the same agony, not because I'm a know-it-all (though I am a wanna-know-a-lot!)

Here's what I said in response: (scroll to the bottom for key points.)

• I think that it would be a great time to ask your professors for a LOR. It gives them some time to think about it and compose it while your experiences with them are still fresh in your mind.
  (Look into whether or not your institution has a Credential filing service that can take care of your LORs for you. Your LOR writers can submit their LORs to the service and they will send the letters for you, to the organizations you request in a confidential manner. It will save on all the envelopes you have to give to your professors, not to mention the worry that comes with your insecurities about the different stages of transit.)


• When approaching someone with an LOR request, schedule an appointment with them ahead of time and take some time to sit down and talk with them. Tell them what your intentions are and what they will be writing for, especially for your liberal arts/humanities professors. Come prepared with your curriculum vitae (CV) that they can hold onto and reference as they wish in the construction of the LOR. A lot of good things come out of this visit and I learned the hard way that it is not a good idea to ask someone via email -- it's a lot more difficult to follow up with them if you haven't established that bond before you bug them about things like that. :)


• If you're wondering how many to get and who to ask, look at the reqs for the schools you're interested in. I made an excel sheet to keep track of what I needed to do for which schools by what deadlines, because it can sneak up on you all too quickly if you're not organized. I'm not sure if this formatting will work, but here's the sample categories from mine:
  
  Medical Schools//Status//Website//LORs//2ndary due//progress//fee//interview


• It sounds like you still have a lot of time, so it's great that you're being proactive and you're thinking about these things! Scout out on the internet for a sample questionnaire. Some medical schools have a questionnaire that the recommenders fill out to address various areas. "Does this student apply critical thinking to your subject? Strongly agree<-->disagree." Then it all boils down to whether or not they would score you as a "Highly recommend," "Recommend," "recommend with reservations" and "do not recommend."
  
  The strongest LOR you can get is one that says "I would go to this person if I were sick and send my friends and family to see them too, without a doubt." I've heard of cases where faculty have actually gone out of their way to call the medical school to talk about the student, but of course, you can't ask your LOR writers to do any of these things for you. :)
  

Key Points on LOR requests:
It's always better to ask early than late.
Approach them face-to-face and chat with them about your interests.
Come organized with a CV and topics they should address in the LOR.
Use a Credentialing Service if it is offered by your institution.
Follow up with your LOR writers as the deadline approaches.

Other resources to check out:
http://www.psichi.org/pubs/articles/article_75.asp
http://www.studentdoctor.net/downloads/index.asp
http://notmysecondopinion.blogspot.com/2006/06/helpful-pre-med-links.html

My scars make me unique.

Perhaps when I smile, your eyes are not drawn to my dazzling pearly whites. You might notice the half-moon shaped scar that crinkles like a dimple when I smirk. Or maybe the scar slashing across my upper lip. I might be tilting my head just so and you'd also see the scars underneath my chin and the flattened red keloid on my cheek.

Such scars seem like the beginning of some great story and many people might be hesitant to ask me about it. Was I attacked by rabid dogs at a young age? Did I get into a knife fight trying to save an old lady from a group of gangbangers? Was I the sole survivor of an Unforgivable Curse (tm) like Mr. Harry Potter?

No, my dear friends, it was a mere speed bump at the bottom of a great hill that did this hero in. I was always a clumsy kid. I have scars on my forehead from a thump on the corner of my uncle's bed during my third Thanksgiving dinner. I seem to have a thing for holiday accidents.

It was a chill and eerie Halloween morning that I went bike riding with my dad. I was groggy and I was riding on a new bike I'd never rode on before with very sensitive front brakes. I closed my eyes as I raced down a hill in the quiet botanical garden a few blocks away from my house... and at some point I lost consciousness for about 10 seconds because I found myself on the ground with about 10' of street gravel rubbed into my face. (It's rather strange how my story seems so silly and similar to Dr. Charles.)

My parents took me to the ER and I had a few rocks the size of quarters taken out of my cheek.


A few weeks later when the itching was subsiding and the keloid was injected with steroids to make it sink down, I was asked if I wanted cosmetic surgery.

"Nope!" I'm proud of my scars. While they might be reminders of my idiocy, they give my face character. They make me a unique person. If I were ever cloned in a laboratory and someone tried to replace me with my identical double, people who know my face would know which one is me.

And that makes me smile even more.

Medical Student Mentoring

Four years ago, I was a pre-med student. I joined a new group just starting up, filled with medical students eager to mentor young fledglings like myself. It was a bit rocky in the beginning and I was paired up with a mentor in his 3rd year. He was so busy in his clerkships that I only got to see him once -- he didn't make it to any of the planned activities through the year. I ate lunch with him once and he intimidated me. I expressed an interest in Doctors without Borders and I got a lecture about how it would be all work and no fun and basically, a waste of time unless I liked to volunteer and acquire larger debts from idle school loans that would be harder to pay off.

It was after that encounter that I made a resolution. If... no... When I became a medical student, I would strive to be an encouraging mentor. An "inspiring, down-to-earth and good storytelling" mentor, as I wrote in my Personal Statement earlier this year.

This past Friday we had our mixer for the mentors and mentees. I gave a little speech in which I talked about the transition from being a pre-med to being a med student. I talked about being challenged enough to be "whelmed" as opposed to overwhelmed. I also quoted Stephen Colbert, a witty fake-news commentator on Comedy Central. He gave a commencement speech that I found online and I really enjoyed it. I've spliced it up so hopefully it'll be enjoyable for you too.

Say “yes” as often as you can. When I was starting out in Chicago, doing improvisational theatre with Second City and other places, there was really only one rule I was taught about improv. That was, “yes-and.” ... To build a scene, you have to accept. They say you’re doctors—you’re doctors. And then, you add to that: We’re doctors and we’re trapped in an ice cave. That’s the “-and.” And then hopefully they “yes-and” you back... It’s more of a mutual discovery than a solo adventure...

Now will saying “yes” get you in trouble at times? Will saying “yes” lead you to doing some foolish things? Yes it will. But don’t be afraid to be a fool. Remember, you cannot be both young and wise... Cynicism masquerades as wisdom, but it is the farthest thing from it. Because cynics don’t learn anything. Because cynicism is a self-imposed blindness, a rejection of the world because we are afraid it will hurt us or disappoint us. Cynics always say no. But saying “yes” begins things. Saying “yes” is how things grow. Saying “yes” leads to knowledge. “Yes” is for young people. So for as long as you have the strength to, say “yes.”

And that’s The Word.

I enjoy "yes-and." Some might say that it is sucking up... just like some people call BS on corny or cliche things. Funny how cynical that sounds. :) "Yes-and" is about enthusiasm and participation. That's the side that I want to focus on.

I also organized some mixer games for the group. My favorite one was a "Coat of Arms" with a blank shield emblem split up into four parts. Everyone was directed to draw something about themselves in each of the quadrants:

1. My "Great Doctor" Quality
2. My Medical Quirk (something weird about themselves that they were willing to share)
3. Favorite Pastime
4. Favorite Food

My personal experience with "thinking" icebreakers is that people don't really want to work too hard at them... so I tossed in the last two categories as an easy gimme. The mentors all stood in a circle facing outwards and mentees stood around them and they got to talk for about 2 minutes or so to get to know each other. It was successful... perhaps too much so, because people ended up just chit-chatting towards the end.

Here's the file if you ever want to try a similar activity!

And in case you were curious...

1. I drew a picture of an open book. Partly because I'm so open, but more so because I love stories. Doctors get to hear the most interesting and intimate stories people can tell... and they have to turn them into something relevant in their 15 minute visits! Wow.
2. Hyperhidrosis. I've mentioned it before. I drew a stick figure with a blue marker, dripping from the hands and an arrow pointing to a guy with cartoony sweat flying out of his head.
3. I drew a wizard with a green robe and a magic wand. I love to play role-playing games. It feeds my addiction to stories. In particular, I love to play Dungeons and Dragons.
4. I drew some shrimp diving eagerly into a cup of cocktail sauce. Mmm... shrimp. The tasty "cockroaches of the sea," as one of my seafood-ophobe friendswould so delicately put it.
   

My Personal Statement

Dr. L entered the room as my heart anxiously pounded. I hesitated before shaking hands with him, not because I was entrusting my life in his but because I knew my hands were cold and clammy. "This will be the last time I'll have to shake someone's hands like this," I said with a grin. He had told me how the procedure would work: the sympathetic nerves of Kuntz would be severed to alleviate my hyperhidrosis. Although the surgery itself was quick, it changed my life drastically. I knew then that I wanted to be a doctor. Even though I now had the confident hands of a doctor, I needed more to actually be one. With my new hands, I started working on gaining the head and the heart of a doctor as well.

My critique: I'm sure many applicants have struggled as I did, trying to tighten prose without losing the context. Just to clarify, I had a bithoracic sympathectomy (video link), a surgery to cure palmar hyperhidrosis. I was disappointed that I couldn't adequately explain "hyperhidrosis"... it would have taken too much room to explain it. The people who read it caught on well enough, so that was good to hear. I could only hint at the details I really wanted to cover. Now that I know a little bit more, I'm embarassed to say that the facts are minorly incorrect too. The entire sympathetic chain was severed, not just the weird excess Nerves of Kuntz... but I tossed that in because it sounded cool.

Looking back at this PS makes me wince. This is what got me into medical school? Granted, it was a significant improvement over my opening statement from the prior year (which had the same gist, except I didn't make the hands/head/heart connection until the end of my PS.)

The poetry of gaining the hands of a doctor from a thoracic surgeon was something that I would have liked to elaborate on. I didn't see the doctor very often as a child, but palmar hyperhidrosis was something that I had been dealing with since 2nd grade.

You might be asking yourself: What's the big deal about sweaty palms?

Well, we're not talking about damp hands like someone who is just nervous. Yes, my sweaty palms were triggered by nervousness too, but we're talking about minor anxiety triggers. And it wouldn't go away... I would have to deal with sweat dripping off of my palms for the rest of the day. Imagine washing your hands and not drying them off afterwards. That's how my hands would be at their worst, mere seconds after I would wipe them on my jeans.

I would have to wear jeans everyday and a light colored shirt otherwise sweat stains would show on my thighs and armpits. My hands would freeze in cold weather, because the sweating just... kept on going.

Paper was my adversary. I would ruin books just by holding them and flipping the pages. I needed a folded up pad of paper to soak up the sweat when I took notes in class. My computer keyboard and mouse were all gummed up. I was afraid to touch anyone, especially girls, afraid of their barely concealed looks of disgust; I was afraid of intimacy.

I knew it would be a hindrance in pretty much any profession that did something hands-on, from social handshakes to labor-intensive crafts. I was concerned about shop, art and especially science LABS. Putting on gloves is a nightmare with damp hands. Wiping off equipment after touching it is annoying and disgusting.

I'm sure you get the point by now, after my woe-is-me story.

It was amazing to me that a decade of grief was wiped away after a same-day surgical procedure! I had tried so many other things, like topical antiperspirants (Drysol) and even palmar electric shock (Ionophoresis).

In typical understated doctor-speak, this surgery "improved the quality of my life."

I was inspired by the changes I saw in myself... something so minor that had such a large effect on the rest of my life and what I could do with it. I felt a newfound confidence from it, free from social anxiety and frustrating note-taking.

I was ready to make the same changes with other people. I wanted to become a doctor.

Despite the rough and clumsy nature of my opening paragraph, perhaps the admissions committee saw my PASSION and my . To you aspiring applicants, that's what you should put in your words. Share yourself and share your passions.

So you're starting med school...

And you're wondering what sort of things you need for this venture. It can be overwhelming and there are a TON of resources that you'll be utilizing. You're strapped for cash and this whole school thing is already cutting into your future pay. So what do you do?

Some professors will have a recommended reading list -- they might even require some texts. There's only a few that I've been told are really required and those are the only ones you should really buy in your first year.

You might also be hearing about PDA software. You don't need to fork over a lot of money to get the portable info you need. There's a few programs that everyone I've talked to uses and I'll share them with you.

First, some reading lists:
So you'd like to... know what books I bought for medical school Amazon.com
So you'd like to... succeed in medical school Amazon.com
Notice the overlap in books.
A medical dictionary like Taber's or Stedman's comes with software. I bought the Stedman's with PDA software and I really like it. Since I'm pretty clueless at this stage in the game, it has been very helpful.
Robbin's Pathologic Basis of Disease is a must buy. Some people recommended that I read through the 1st ten chapters of this big book by the end of the semester. Sure. That doesn't sound so bad, but it is dense reading. Perhaps "baby" Robbins (Basic Review of Pathology) would be better suited for this purpose.
Lippincott's has a review of Biochemistry, Pharmacology and Microbiology. Biochem is the favored Lippincott's text; the other subjects have different books that suit different people.
Clinical Microbio made ridiculously simple looks ridiculous alright. At first, I didn't really like the pictures, but they are starting to grow on me now. I already took microbio in college, so most of the concepts are not very helpful. There are a lot of fun mnemonics though!

Each school has their own curriculum. My Med School is geared by case-based studies of organ-systems, so the books that I have are mainly looking at differential diagnoses, rather than "basic" science subjects covered in the USMLE Step 1.


PDA software sites
Ectopic Brain is a blog with a lot of up-to-date resources.
Doctor's Gadgets
CollectiveMed.com
Yee's Medical Palm Info is little outdated, but he still has some good info.

Epocrates Rx free is a drug reference program that also has a formulary based on local insurance policies so you can write the right prescriptions.
Medical Mnemonics.com - Use this! It is a lot of fun... and I've already been posting up a few mnemonics from this program that I've found useful.
Johns Hopkins Antibiotics Guide is an "Epocrates Rx" for Abx.
MedCalc - I'm hoping I won't get in trouble by relying on this one too much in the future.

On a different note, I really like using McPhiling to switch quickly between my programs without going to Home first. It also has a cool pseudo "Alt-Tab" feature to flip back and forth between your current and previous program.

Well, I hope that has been helpful!
If you have any other links or books to recommend, please feel free to comment.