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Readying for the Long Run


The New Physician November 2001
Medical training isn’t a sprint; it’s a marathon. More specifically, it’s like preparing for an Olympic marathon. In order to improve your performance as a physician, approach your medical training as if you were an athlete headed to the world-renowned games. You’ll achieve the greatest chance of success if you combine talent with hard work, superior training methods and exceptional coaching. It’s not enough to simply work hard at the day’s tasks or to focus only on what seems most urgent. And because most students selected for medical school are talented and hard-working, superior training methods and coaching are the chief variables in your journey to success. So, how do you optimize training? Let’s continue with the athletic analogy. The following training principles, which I have adapted to medicine, are largely what the great running coach Jack Daniels encourages:

Principle 1. Organisms Adapt to Stress – Whether learning to run, play an arpeggio or care for patients, organisms exposed to stress adapt by being able to tolerate further exposure to the same stress. Optimal training means exposing yourself to the right types, intensities, quantities and frequencies of stress. Simply put, training is purposeful stress.

Principle 2. Specificity of Training – You adapt specifically to the stress to which you’re exposed. Your “student behaviors,” while helpful in getting you into medical school, should not continue to be the focus of your training. Concentrate instead on being a successful physician. Your training to become a better student isn’t the same as becoming a better physician. For those of you entering medicine from the work force, you may also find your previous activity hasn’t helped you become a physician. Taking on the duties and responsibilities of a physician, uncomfortable and unfamiliar at first, will eventually become more comfortable.

Principle 3. Specific Stress Produces a Specific Result – This is a refinement of the second principle. The right stresses need to come in the right amount and at the right time. One doesn’t simply jump to being a good physician in one step. Becoming successful requires mastery of a number of behaviors, skills and knowledge sets. Medical training lies in adapting to each of the competencies outlined by the Accreditation Council for Graduate Medical Education (see “Competencies,” p. 30).

While it’s important to be always mindful of the competencies from day one, the emphasis during medical school should be on competencies A and B. Some of you may be more interested in medicine’s larger context (competency F); however, emphasizing this area is for naught if you don’t have patient skills and medical knowledge mastered. Don’t kid yourself and train hard in the wrong things; one doesn’t prepare for the decathlon by throwing the javelin 10 hours a day. Even though that sort of stunt would demonstrate your ability for hard work and discipline, the effort is misplaced.

As for tests and evaluations, think of them as intermediate competitions leading up to a major championship; they are not the main objective, which is to improve your ability as a physician. However, tests give you an idea of how your training is progressing, and good grades can help you qualify for a better quality of training (such as a desired residency) or coaching (the training program or rotation of your choice).

Principle 4. Specificity of Overtraining – This is also known as the “Principle of Under-resting.” Rest is an essential part of training. Indeed, some coaches refer to it as the most important part, because useful responses such as muscle growth and enzyme pathway adaptations can only occur during rest.

Stress without rest leads to stagnation and then injury. Top athletes save their mojo for competition and don’t squander all of it in training; likewise, you should save your best energies for patient care and further learning. You will need to learn to read your body, psyche and soul for signs of stagnation before injury occurs. Symptoms of too little rest and recreation include apathy, insomnia, reduced appetite, weight loss, irritability and increase in resting pulse rate. There are many guides to medical student wellness, so check them out. Investigate the American Medical Student Association’s information online at

Principle 5. Rate of Achievement – It takes a certain amount of time devoted to a specific training task to maximize the return on performance enhancement (see principle 7 for the flip side of this). You shouldn’t move on from or increase the intensity of training until you have wrung out as much adaptation as possible from that level of effort. In addition, you shouldn’t make a mishmash of training types. In running, you get faster by running fast, but short, and you improve endurance by running slow, but long. The truth is that most recreational runners run somewhere in between, thereby neither improving their speed nor their endurance. In medicine, don’t be a jack-of-all-trades and master of none; your patients are counting on you for competency and not on being a well-intentioned amateur. No matter what you’re studying, devote enough time and effort to learning that subject or skill so that it sticks with you.

Principle 6. Personal Limits – We all have individual desires and talents. In training, what works for one person may not work for another. As early as possible in your career, establish sound training based on your limits. Don’t tinker with your system without testing causes and effects, and until you know for sure that you will clearly get better results with an alternative method. Observe other physicians or trainees both in and beyond your year of training to gain ideas on better practices, but always adapt to your core methods; don’t copy blindly. For those whose competence you trust (including patients, fellow students and residents), ask for specific feedback regarding your performance. Best of all, try to find a mentor who has insight into your talents, desires and personal limits; it’s difficult to be your own coach.

Also remember that you will have good and bad days. Never confuse your training or the result of your training with your worth as a person. You will have bad results and you won’t help yourself or others by thinking that a bad result makes you a failure as a person. People who confuse the results of their work with their worth won’t be in a position to improve their work. Concentrate on performing your training and tasks as a physician with excellence, and devote yourself to improvement.

Principle 7. Diminishing Return – The amount of time you can devote to training is limited. This is why being clearsighted about the overall training program is so important. It may be better to get 80 percent of the result in four hours and move on to another area needing work than to struggle to get 90 percent of the result in eight hours. Be disciplined about the amount of time you devote to a particular competency.

Principle 8. Accelerating Setbacks – The more intensely you train, the greater the risk of burnout (see principles 4 and 6). Don’t run such a tight schedule in that you’re counting on everything going correctly. Don’t let lack of sleep cause errors in patient care or less optimal learning.

Principle 9. Ease of Maintenance – This training principle is good news: Once you’ve learned something, it comes easier to you when you review it. This allows you to shift to a different training emphasis and still maintain the benefits of previous training.

Principle 10. Time Erodes Memory – Once you’ve achieved competency in an area, you forget how hard it was to achieve in the first place. This is why you should focus on those skills and habits allowing you to be a good physician from day one. It’s too difficult to pick up those habits once you’re out in practice! Likewise, choose your field of specialty carefully. It’s tricky to switch fields and restart training from block one; this would be like switching from ice dancing to marathon running. In fact, those who switch from one residency to another often have to unlearn those habits that were so helpful for the first residency (see principle 3).

By using these principles, I predict your training will become easier because you’ll drop things that aren’t helping you.
Daniel W. Collison is chief of dermatology at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire.