Jason Ryan
@jason_ryanmd
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Creator of Boards and Beyond. Fiction writer: Author of The Gunner. Physician. Cardiologist. Teacher. New England Patriots. Boston Celtics.
West Hartford, CT
Joined April 2024
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My Twitter account was hacked and support told me I have to start a new account. So here I am. It's me. If you were one of my previous 35k followers, hope you'll follow me again here.
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@urcervix_
When you're a specialist, it's easy to criticize those outside your field for not knowing things that are obvious to you. Remember they don't do this everyday like you do. For students, I only care if they don't know something the SECOND time I ask.
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Medicine is about repetition. You see disease patterns over and over and learn to recognize them and react. This comes from experience not classes or board exams. So if you struggle with Step 1 don’t worry. The real learning comes later. Excel there and you’ll become a great
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Ten years ago this month I launched Boards and Beyond with just 44 videos in cardiology. Never knew it would grow to a site with hundreds of videos used around the globe. Thank you to all the students who have subscribed over the years. Your support means everything to me. Hope
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Research = good
Research just to match = bad
Need PDs to stop rewarding the second one. Lots of students without research become great physicians.
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Took my daughter to a dermatologist today who used a scribe. Man, this scribe got orders barked at her left and right. Doc didn’t even use her name. “My scribe will schedule your follow up after I leave the room.” Seems like a rough job, especially if the doc treats you like a
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A student showed me a UWorld question asking for the anatomic location of an atrial fibrillation ablation procedure (answer: pulmonary veins). I didn’t know this until I was a fellow. Most M2 students haven’t seen a single patient with Afib. Are we really asking them to
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When you're in med school, do all you can to ignore competition with your classmates. Don’t worry about what others are studying, their grades, etc. You’ve entered an amazing profession. Soak up all the knowledge you can. Enjoy the journey.
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We’re so hyper-specialized in medicine with tons of narrowly-focused fellowships. I swear one day we’ll have cardiologists who only treat the left atrium. “I’m sorry, sir, your issue is in the right atrium which is outside my expertise - you’ll have to see my colleague Bob for
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Avoid competing with others in medical school. Focus solely on your own learning, and becoming the best physician possible. You'll be happier if you do this. You'll also be more successful.
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At US MD medical schools, a large percentage of students (25- 50%) are deferring Step 1 because they are unable to pass practice exams, and fear failure on the actual test. This can completely disrupt their training. Underreported story that deserves more attention.
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As an attending, you see the same things over and over. After a while, it feels like these things are obvious, basic facts. So, when some med student or resident lacks knowledge, it’s easy to think they’re stupid. “How could they NOT know that!” is something I hear a lot from
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If you want to shine as a medical student in front of a nephrologist, mention Addison's disease in the differential for hyponatremia.
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Here’s something I’ve learned from talking to Gen Z medical students: textbooks are dead. Once the younger generation runs academia, textbooks will hardly ever be used by students. Video learning is how young people acquire knowledge.
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Medical school can feel overwhelming sometimes but the first patient that says “thank you” will make it all worthwhile.
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Heard from a former student today who struggled severely with Step 1. Barely passed, disappointing score (before P/F). Now a chief resident with bright prospects for fellowship. Remember: this test does NOT determine your future. Plenty of great doctors struggle. Hang in there.
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One reason for burnout in medicine is the current state of medical knowledge. We know so much more than we did decades ago, which is great. But this means more drugs, tests, procedures, specialists. A thread ...
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There's a ton of drugs that prolong the Qt interval and may cause Torsades de Pointes (TdP). But are you really going to memorize every one? Follow my suggestion and just remember the drugs that MOST COMMONLY lead to TdP. Here's that short list as a 🧵...
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To perform well on clinical rotations, med students should “know their patients.” But what
exactly does this mean? A 🧵
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Years ago, when Boards and Beyond was still new/growing, someone made the LightYear Anki deck which EXPLODED interest in the website. To this day, I don't know who this mysterious Anki deck creator is. But I will always be grateful to him/her. I hope they're out there in the
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So many students/residents with research publications actually hate research. They’ve done research because it’s obligatory for matching into competitive training programs. We are turning off a generation of trainees to scientific inquiry. Time to stop the insanity.
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I was bad at anatomy. Also bad with microbes and neuroscience. I was often outperformed by my peers. Still made it through medical training. So can you.
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I met a student today who scored a 310 on USMLE Step 2! I have never seen a score that high. His only prep material was a 1957 copy of NEJM.
Also, don't believe things you read on social medial about USMLE scores. A lot of people make stuff up.
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In training, try to find mentors who really know the data behind what we do. Just because "everyone does" something doesn't mean it's always right. The best doctors I know spend time to understand the data behind medical care on a deep level. A thread ...
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If Trump were a trainee on rounds …
Attending: “What antibiotic would you give this patient?”
Trump: “I am the best at giving antibiotics. I give the best antibiotics. Everyone knows it. Lots if people are saying it. If anyone says I don’t give the best antibiotics, its fake
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Just saw two cardiologists I know at Jake's Wayback burger eating chili fries and shakes. I joined them and ate a bacon cheeseburger. Please don't ever ask doctors for dietary advice.
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Regular reminder that the foundation of medicine is not board scores, honors or the match, it's patients. Medicine is a service profession. The more you focus on service to others, the happier you will be.
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USMLE Review: Polyarteritis Nodosa. SOOO hard to remember this rare condition. Here are some things to focus on. Look for a middle-age patient in 50s or 60s (highest incidence in 60s). There will be nonspecific systemic symptoms like fever, fatigue, and achy joints/muscles. None
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The concept of a board exam on basic medical science like Step 1 is certainly reasonable. But this test has some major downsides that should be addressed. A thread ... 🧵
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If you want to stay happy in medicine and avoid burnout, it's very helpful to have some activity you do outside of clinical medicine. This could be teaching, research, administration, legal consulting, writing, or many other things. Some people call this the "diastole" of your
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Maybe one day the scribes will rise up in revolution and overthrow their overlords.
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If your attendings were forced to take a UWorld block or NBME they would all bomb. No one practicing medicine knows the full breadth of material on Step exams. Remember that next time you struggle.
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You need to pass a lot of exams to get through medical training. Lots of us struggle to do this and that's okay. I know tons of amazing doctors who were not great test takers. Some of us only thrive with actual patients.
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Many of your attendings in medical school and residency did NOT get honors in the speciality they now practice. Keep this in mind if YOU don’t get honors. It’s okay. Happens a lot. Just believe in youself, keep going and you’ll be fine.
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Seems to me that if you pass your med school in-house requirements, then study for 4 weeks for Step 1, you should pass the test. If this is not what's happening, then there is a problem with either (1) the exam or (2) school curricula.
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USMLE Step 1 review: Be prepared for up-down-no-change questions. Know the disease states where the renin-angiotensin-aldosterone system (RAAS) is chronically active: heart failure, cirrhosis, nephrotic syndrome.
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We go to a lot of effort in medical schools to modify bad behavior: peer feedback, professionalism training, clerkship evals. But sometimes I wonder: if you’re an adult in your twenties who is rude/obnoxious/inconsiderate, can anything really change that?
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Medicine is changing from where the doctor knows everything (true decades ago) to where the doctor can’t possibly know everything. But we still teach that failure to know things is bad. And we don't teach when/how to look things up effectively.
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USMLE scores have very little to do with being a good doctor. Get the exams behind you then focus on taking great care of your patients. Outstanding patient care defines a great doctor, not board scores.
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If you think med school is hard, and you're not sure you can do it, you are normal. I thought this too. Everyone does at some point. Just keep grinding and you'll make it.
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Regular reminder that your performance on UWorld or NBME questions does NOT determine whether you will be a good doctor or not. Plenty of those who struggle with board-type questions go on to become outstanding physicians loved by their patients. Hang in there.
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I keep hearing stories of med students delaying Step 1 because their practice test scores are low and they fear failing the exam. This is a national problem. We are not doing enough to prepare students for this test.
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I get asked all the time by students, residents and even attendings for a video series that teaches high level EKG interpretation. As far as I know, there is no definitive resource like this. Seems to me like a huge opening for a talented educator.
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For applicants with research publications, at interviews, I always ask them to describe the study they authored. A fair number over the years have been unable to do this well and its clear they participated just for credit. Don't let this happen. Know your pubs inside and out.
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The online digital version of First Aid for the Boards (First Aid Forward) is now linked to Boards and Beyond. Next to each video on the BnB site, you can click a link and see related pages in First Aid on your screen. You can also scroll through digital First Aid content and
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I don’t know who gives medical advice to TV shows, but if you shout “I need an Xray STAT!!” in the middle of an ER nothing will happen. Same thing if you shout, “Get me a Chem 7 and cardiac enzymes now!”
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Just had a terrific Zoom chat with medical students from Jinnah Sindh Medical University in Pakistan. We talked about Boards and Beyond, cardiology, Step 1 and my new novel, the Gunner. Amazing age we live in where students and teachers connect across the globe.
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Professionalism is very important to the practice of medicine, but the way we promote this in medical students is flawed. A thread ...
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Anyone smart enough to get into medical school is smart enough for any specialty. If you can’t match in derm and instead go into something else, you’re not dumb. And if you do match in derm (or rads or ophtho or whatever elite program) you’re not smarter than everyone else.
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One of my goals is to get through life without ever having my troponin level measured.
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When is someone going to invent an app that lets you take a picture of a skin rash then tells you the diagnosis? I feel like this is an obvious million dollar idea waiting for a person with the know-how to build it.
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USMLE review: Mechanisms of hypoxemia. Famously dreaded topic for students. Patient has low O2 saturation. What is the cause? Three fundamental mechanism: shunt, VQ mismatch and diffusion limitation.
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Regular reminder that the Step 1 exam does not determine your capacity as a doctor. Many who struggle and barely pass will become outstanding physicians. The test is simply a right of passage. Get it behind you so you can move on to the true focus of medicine: service to
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I have big time respect for IMGs who work so hard to become doctors in the US. It's a very long road, but some of my best colleagues over my career have been IMGs. If you are an international applicant, there is a bright future for you as a doctor in the US. Keep grinding.
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If you are a DO student, Boards and Beyond now offers an Osteopathic Manipulative Medicine (OMM) video series with 22 videos and associated practice questions. Videos were made by Dr. Lauren Davis, DO and they are outstanding.
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At an interview, don’t say you want a career in research unless you REALLY want a career in research. It’s okay to say: “I don’t want a career in research but I want a program that will give me strong training in research methods so I can use the literature to help my patients.”
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I see so many students worn out by the competition in medical school. Seems so much worse than when I was in school. I wish it could be different. Wish students could learn to look after their patients and not worry about honors, evaluations, class rank.
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Must know images for USMLE: Hexagonal cystine stones in the urine. Seen in cystinuria, hereditary defect of PCT with impaired reabsorption of amino acids cystine, ornithine, lysine, and arginine.
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I don't like to say that I "save lives" as a doctor, although that sometimes happens. First of all, it's a team effort, never just me. Second, we often can't save someone's life, but if the public thinks that's what we do everyday, they have unrealistic expectations. I like to
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Who's idea was it to change the name from carcinoid tumor to "neuroendocrine neoplasm?" I bet these people name their kids "humanlike cell collection (HCC)."
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How long until all the Qbanks that med students use are replaced by AI? "Hey, ChatGPT, please give me a 40-question block of Step 1 questions in tutor mode." Feels like this is coming.
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If you’re ever in group meetings pay attention to who talks the most. It’s usually the men. I’ve always noticed this because my mom complained about it to me as a kid. So, gents, do the world a favor and try to choose your words carefully. No need to weigh in on everything. Let
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USMLE review: Do you know the difference between LVEDP and LVESP? Just like we use two numbers to describe arterial blood pressure (systolic/diastolic), we use two numbers for pressure in the left ventricle: LV end-diastolic pressure (LVEDP) and LV end systolic pressure (LVESP).
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Just to be clear: I’m not opposed to teaching this. Afib ablations are a common procedure worth learning about. But testing memorization of where the catheter goes in an ablation procedure seems like something that can be assesed later in training. We don’t need to add this to
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Lots of med students suffer from anxiety, depression, burnout. So do lots of attendings. If you're in training, and you're struggling, talk to someone. You'd be surprised how understanding people can be.
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I know that I am heavily biased so take what I say with a grain of salt, but I think the online integration of First Aid for the Boards with Boards and Beyond is amazing. You can watch the video, then click a link and see the exact page(s) in First Aid corresponding to the video.
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I once worked with an advanced EP fellow when I was a first year fellow. She would refer to me as the “diagnostic fellow” as in “The diagnostic fellow said the patient has a murmur but I have not verified this.”
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Joe Biden is a great man. I have so much respect for him. This is the right decision.
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Had a high school student ask me what they should do if their long term goal is medical school. My answer: read. A lot. You can learn orgo or anatomy with hard work in a class. But reading comprehension and vocabulary are built by years of reading books. These skills are
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Ran into a med school friend who I remember barely passed step 1 and almost didn’t match. This person is now a partner in private practice and has a great reputation among colleagues. Also married, two kids, a house, even a dog. Medicine can be a great career no matter ur scores.
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At the graduate education level (med school, other grad school), I don't think lectures/conferences should be mandatory. The students are adults. Tell them what they must learn and later assess their knowledge. Offer them ways to learn, but let them choose their own path.
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There is no such thing as a “must use” resource for medical school. I’ve seen people skip UWorld, BnB, First Aid and all the others but still crush exams. Have also seen people succeed with these resources. Don’t get FOMO if you don’t like a resource. Use what works for you.
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Ever wonder how USMLE questions are written? The more you understand the writing process, the easier the questions will be to answer. Read my essay about this topic here:
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@urcervix_
I think maybe your original tweet wasn’t clear about lack of interest. If you told the student to know this, and the student had experience in the OR to know what things look like during surgery, then that’s a lack of interest. But if it was day one in the OR, then gotta give em
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USMLE Review: The Glomerulus. Remember it is a CAPILLARY system that filters blood into the nephron. Like all capillaries, it allow fluid and electrolytes to leave the vessel and enter surrounding tissue beds which, in this case, means the nephron.
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Remember it’s REALLY hard to get into medical school. Everyone who gets in is smart. Whether you got your first choice or didn’t match,you’re an exceptional person with a bright future.
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In the name of professionalism, we hold students accountable for tardiness, absenteeism, rude behavior, etc. But we don’t hold attendings to the same standards. Med students routinely see attendings do the things they are punished for. They notice this difference.
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What is the hardest subject to UNDERSTAND for the Step 1 exam? Not the hardest to remember/memorize, but a subject where the concepts themselves are difficult to master.
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I passed the adult cardiology boards but somehow assembling this bed frame from Amazon is too difficult for me.
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Meanwhile, the place where I went to med school has microphones that don’t work and most of the clocks are one hour behind.
Beginning in the fall of 2024, Johns Hopkins University will provide tuition-free Medical School for most medical students and expand aid for future nurses and public health pioneers. Learn more:
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Be wary of advice on how to study for Step 1/2/3 that you read online. Lots of biased folks like me who want to push their products on you. Best way to get advice about resources is talk to real, live people at your school who have taken the exam before you.
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It’s tempting to call a lot of foundational medicine topics useless, but I think that’s the wrong argument. Someone in medicine probably needs to know how aspergillus branches (researchers? pathologists?). The question is: why does every med student need to learn this year one or
I was watching med school vids from another uni, & the "teaching" point for 1st year students was 🔽🔽
Students finish med school unable to read a journal article well, but we test on absolute useless BS
Med ed is a failure
Read more here
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Serious question: What is the benefit of testing for COVID if you have mild symptoms? Is there anything to do differently than if you had any other common respiratory virus?
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If you are an educator, I highly recommend making videos of your teaching and putting them online. This will dramatically improve the quality of your teaching. A thread 🧵...
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Wow! This tweet upset a lot of people which was not my intention. I have heard from many credible students and faculty that this is happening. I thought it was widely known. There's obviously no data because what school wants this known about their students. Don't take my word
At US MD medical schools, a large percentage of students (25- 50%) are deferring Step 1 because they are unable to pass practice exams, and fear failure on the actual test. This can completely disrupt their training. Underreported story that deserves more attention.
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Here’s what I’ve learned about electronic communication (email, texts, even social media posts): words often come off meaner than you intend. Write something nice, it comes off even-toned. Write something even-toned, it comes off rude. Write something rude, it comes off as a
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“The ears bleed more than any other part of the body.” - Donald Trump dishing out Step exam tips in his acceptance speech tonight.
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Central thyroid disorders are very rare, but often come up on Step exams (and IM boards, too) to see if students can interpret labs correctly. Here's a quick thread so you never get these questions wrong ...🧵
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Almost every day in medicine I’m faced with something I don’t know. This happens even in my area of expertise: EKGs, echos, cardiac disease. I often have to ask for help, look stuff up. Not knowing in medicine isn’t a weakness, it’s normal.
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Questions you must be able to answer for interviews:
1. Why did you choose this speciality?
2. Tell me about an interesting case you saw.
3. Where do you see yourself in 5/10 years?
4. Tell me about this study listed on your CV.
5. What do you like to do for fun?
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I get a lot of messages from IMGs looking for observerships, but my hospital does not offer these, and I don't know any that do. Is there somewhere I can refer people to find hospitals that do offer observerships? In other words, has anyone setup a website that helps IMGs find
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USMLE Review: Mobitz I 2nd degree heart block. Most people know there is progressive PR prolongation followed by a dropped beat (i.e., a p wave not followed by a QRS complex) as shown below:
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The real learning in medicine occurs in the first five years as an attending. Training gives you a foundation to get started, but there is so much you won’t really know until you’re on your own. I learned so much as a new attending - constantly seeing new situations, looking
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A great way to shine on clinical rotations is to care for your patients deeply. Attend to their needs, learn all about them, and look for ways to help them. This will stand out to most attendings. Also, it's just generally a good thing to do.
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Coagulopathy or coagulopathic is the OPPOSITE of hypercoagulable. It means increased risk of bleeding not clots. This vocabulary issue leads to a lot of incorrect answers for students. So much of medicine is simply knowing what words mean.
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It’s not fair but many medical students get bad evaluations for behaving like the interns/residents. Don’t join in the bitch sessions, cut out early, eat during rounds, put your feet up on the desk, whatever. Play it by the book even if others on your team do not.
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At the end of an interview, you will often be asked if you have any questions. Make sure you have at least one! A great question is to ask the interviewer about themselves. Why did you come to work here? What’s the best part of your job? People love to talk about themselves.
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Taking Step 1 in the next 6-12 months? Read my tips for how to prepare here:
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When I was a student, I thought the attendings knew everything. When I was an attending, I thought I was the only one who didn't know everything. Then I realized no one knows everything. Wish I had discovered this much, much earlier.
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And because the scope is so broad and detailed, students lack time to explore medical concepts. Better to memorize the correct answer and move on then spend time understanding WHY the correct answer is correct. The student who dives deeply into the science quickly falls behind.
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