High-yield and protected time: A medical student’s take

Learning in medical school often feels like learning a completely new language. There are numerous acronyms (OPQRST, CAGE) and molecules (IL-1, TGF-beta) and more. But most striking to me are two particularly ubiquitous buzzwords: “high-yield” and “protected time.”

I feel like I heard both these terms — and particularly the former — thrown around every single week of this past school year. High-yield has been used to refer to, as you might guess, the material that yields the highest amount of gain – for us students, it’s the material that’s going to show up on our tests. This term pervades not only conversations among classmates but also study materials. First Aid – one of the main step 1 book resources — takes pains to highlight “high-yield” concepts, and Pathoma — another Step 1 resource — goes even further, identifying ideas that are not just high-yield but also “highest-yield.”

This idea of focusing on high-yield concepts bothered me at first and continues to bother me a little bit today, largely because my classmates and I often determine for ourselves what is high-yield and what is low-yield, dedicating our study time to the former and ignoring the latter. The worst part is that we may be ignoring information that may be low-yield in the context of exams but actually high-yield in the context of patient care. The flip side of this is that we only have a certain number of hours in the day; perhaps it makes sense for us to be judicious about what we focus our attention on?

Another phrase that has been widespread in medical school is the term, “protected time.” I started hearing this during the very first week of medical school, when we had part of our afternoon off for protected study time. Later in the year, I attended a panel featuring five pediatricians. The question of work-life balance came up, and one of the doctors mentioned that she carved out protected time to be with her 2-year-old daughter every evening between 5 and 7 p.m. This statement was met with general appreciation but also minor panic. There are so many aspects of our life that deserve protected time: family, friends, time for creativity, and more — and yet, again, there are only 24 hours in a day. Where does protected time start and end? And what does it include? And is it really reasonable to expect protected time when there are so many patient care demands for physicians to navigate?

As I’m about to enter my second year of medical school, some of my questions remain unanswered. How can my classmates and I make sure to learn medicine well enough and thoroughly enough that we can both meet and exceed expectations in patient care? Is identifying high-yield material an ineffective, shortsighted approach? And how do we identify what falls under protected time? Here’s hoping I figure out this tentative balance during this upcoming year,

Hamsika Chandrasekar is a medical student who blogs at Scope, where this article originally appeared.

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  • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

    As you note, “high yield” may differ when you are in school vs in practice, and also depending on your specialty, practice setting, etc. It’s a helpful way to highlight certain teaching points, if taken with a grain of salt.

    “Protected time,” at least in the program where I teach psychiatry residents, means time shielded from clinical duties, so that seminars, meetings with supervisors, and similar teaching isn’t interrupted. I believe such apportioning of time is essential in a training program; others may disagree.

    Using the term “in real life,” as in protected time with one’s child, is a relatively recent concept in medicine. Traditionally, the trick was to live your life while always being available to your patients too. Only a few specialties like emergency medicine had work shifts where one is truly “off duty” when not working. Increasingly, this concept of being “off duty,” i.e., having “protected time” away from the obligations of patient care, is becoming more popular and is expanding into medical practice generally. It’s controversial, as many feel this sacrifices “continuity of care” and professional standards of practice. The good news is, it’s not the only way to avoid burnout. The landscape of medicine is changing, and many forces are conspiring to make medicine a more difficult and thankless field. Yet with conscious forethought It remains possible even today to have excellent work-life balance, while still being available 24/7 for the infrequent patient in crisis. It isn’t necessary to “protect” yourself from patients.

    • guest

      The residency program where I teach also has protected time for residents. Although I agree with the concept that there must be designated time for learning, other attendings and I have to laugh a little about how often our teaching is interrupted by emergency pages, court testimony, affidavits needing to be signed and various other clinical matters, forcing us to scamper around taking care of business in the middle of lectures while the residents sit and gossip and wait for us to be able to resume teaching.

      We do wonder how well it prepares residents for life as an attending to have four years of regular “protected time,” following which one must plunge into a work life in which there’s no such thing…

  • Dave

    I would caution that high yield is a term that gets misused and is relative to your own personal goals. If your goal is simply to pass, then focusing only on high yield material is probably the best strategy. If it requires every ounce of your intellectual ability just to pass, then by all means don’t waste your time on lower yield material. However, if your goal is to be one of the top students in your class and in the country, then everything is high yield. If your goal is to develop a lasting knowledge base so you don’t have to constantly relearn things you’ve already studied, you’ll need to learn all of it and incorporate it in such a way that it becomes second nature to you. You’ll meet clinicians like this in your third year and they will likely be some of the most brilliant and impressive people you work with. There are no shortcuts to becoming that sort of doctor.

  • SteveCaley

    “Yield” is a tricky concept – yield, according to whom?
    Medical education is not unlike the vaccines given by rote on induction to the military. The list says ‘yellow fever,’ so yellow fever vaccine you shall have, because the protocol says so – and once you’ve had it, you never have to have it again (the vaccine). But if you haven’t had it, you have to have it. See?
    Material in the first two years of medical school is that for which the USMLE 1 tests; and the USMLE tests for questions constructed by USMLE panels of medical school faculty. In this scenario, “high-yield” means only those questions most likely to be on the test. Over time, simple evolutionary forces combine for a rigid consensus of “necessary facts,” that of course, will be drilled into students – not for their intrinsic value, but rather for their ‘necessity.’
    I wish that medical schools would bring in every-day Joe Physicians to talk about the “high-yield” stuff you see in practice – the “Hundred Most Common” things. As we all know, pityriasis rubra palmaris manifests itself with a carnuba-wax like texture to the palms. Have you…umm…ever seen carnuba wax? If not, that memorized factlet is amusing and useless. Contact allergies, on the other hand, are everywhere, all the time, and the puzzle should be reviewed and solved in a case presentation at least a half-dozen times during one’s training, no matter if one is going to be a pediatric neurosurgeon or a geriatric rheumatology. It is a landmark, a familiar observation against which one should be able to orient one’s self, like geo-tracking.
    Measles used to be that way, and the phrase “morbiliform rash” is tossed off wantonly – but few people have seen it in a real patient since the fifties. (I have seen it once.) How do you teach what you haven’t seen? It went from a benchmark to a wuzzit – and wuzzits are what are high-yield on the test, but useless in practice.
    So, a long question over the question – high-yield according to WHOM?

  • guest

    I would offer a comment about “high yield” material but I am too busy reeling from the implication (by a pediatrician no less) that ten hours of “protected time” per week is enough to provide good parenting…

    • SteveCaley

      I’m sure there’s a website on how to do Rapid Injection Parenting or some such thing, for physicians. Probably has CME’s.

  • guest

    You will forget about 90 percent of what you memorize in 1st two years of med school. In residency and fellowship you will have little time to read. Learning will be patchy and incomplete and you will feel incompetent most of the time. Real learning will start happening in the first five years of practice. That will be truly high yield and you will learn from your colleagues and senior mentor like figures if you are lucky to find them. They will be much more invested in your learning than residency mentors who are just seeing you as a helper to write notes for them so they go home at some reasonable time, like 7 or 9 pm, which is becoming the norm in medicine.

    • Eric Strong

      Guest, I’m sorry that you apparently had a non-supportive environment during your medical training. However, Hamsika, I happen to know a bit upon your current institution, and there are truly wonderful mentors available during both med school and in all of the residency programs.

      While it’s true that much of what is learned during the first two years may be forgotten after Step 1, to help prevent this I would advise attempting to integrate the knowledge you are learning now from all different domains of the curriculum. Part of this integration is very informal, and almost subconscious (e.g. thinking about possible pathologic diagnoses when learning to feel thyroid nodules). And part of it can be very intentional (e.g. starting to use practice questions for Step 1 now, which are generally more integrative than the typical subject-specific exams seen in the first two years). This is much better than focusing only on the memorization of random facts from individual courses. While pure memorization will help score high points on short-term exams, it is a poor strategy for long-term retention, and an even worse strategy for actually understanding how the body works.

      I do agree with “guest” that an increase in “real learning” happens in the first couple of years after residency. However, the physicians who find success during this period are typically the ones who worked hard and developed strong and individualized learning strategies during training (starting now).

  • guest

    Protected time is very important if you are in a stressfull career like medicine. Stress comes from inability to control your schedule, lack of autonomy, and high risk, such as possibility of harming someone or being involved in a lawsuit. I recommend mindfulness and meditation. Yoga and exercise. It will pay off in the long run. Anyone can memorize a bunch of text and pass the boards but not everyone can stay cool under pressures medicine puts you under or find meaning in a sea of negativity which medicine has become for most of my colleagues. Even better advice would be to quit now as your student loans are not so high and enter PT program or something that is far less demanding so you would not have to waste a decade of your life on nonsense and realize it was just not worth it.

  • guest

    The really sad thing is that much of what we do these days has zero to do with things that our patients truly need, and everything to do with tasks that regulatory and corporate bodies set for us.

    For example, today I spent about 15 minutes trying to decipher a tortuously worded email from our group’s “Chief Compliance Officer” about the appropriate use of company email accounts.

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