Mikael Häggström [note 1]
This section consists relatively more of opinions based on experiences by the author rather than hard science, but is nevertheless aimed at maximizing the potential of any reader to do the greatest amount of net benefit to patients in a cost-effective way.
Downloading pay-walled articles and books for free
Sci-Hub gives you access to vast numbers of otherwise closed-access articles that you would otherwise have to pay to view. Similarly, Libgen and Z-Library offer you to download copyrighted textbooks for free, such as for the WHO Classification of Tumours, and the AJCC Cancer Staging Manual. If your hospital or other location blocks access to such pages, or if you are worried about cyber-police, it is possible to use your own smartphone to access such articles, potentially using VPN to browse anonymously (although the cyber-police have better things to do than to hunt individuals who download educational material for personal use). You are more likely to access such a site by adding "mirror" to the Google search, such as sci-hub mirror, as mirror pages generally work even if the main site is blocked.
Using such sites can not be recommended, as the provide their content illegally. It can be argued, however, that circumventing pay-walls is ethically right if you use the knowledge therein to help others and thereby cause an overall good effect in the world.
How to deal with Internet denialists and their exams
An Internet denialist is basically a person who probably knows about the existence of the Internet, but keeps teaching as if it didn't exist. The main problem is that when Internet denialist has memorized something, he or she often assumes that pathology trainees should memorize it as well, and will waste time and effort from the pathology trainee to memorize facts that can presumably always be looked up in time of need, and sometimes even practically useless information (see Learning pathology for memorization-worthy information). In reality, when something is encountered and looked up enough times, it will generally get memorized, and apart from the necessary items listed in the Learning pathology section, it is generally more efficient to let time tell which situations will be common versus uncommon, rather than trying to memorize knowledge that will likely never be needed.
Some recommendations for dealing with Internet denialists are:
- Don't be ashamed to say that you don't know the answer when an Internet denialist puts you on the spot about a piece of look-up information, and don't be ashamed to say that you usually look it up when a clinician asks about look-up information (but you may act ashamed to please them).
- Strive to spend the minimal time and effort tasks given by Internet denialists for memorizing look-up information, just enough to please them, in order to spend more time with your patients at hand, or learn things that are necessary to memorize. For example, when conveniently possible, be out of reach from Internet denialists that frequently put you on the spot with questions regarding look-up information, as long as it does not affect patient management. Also, while you should initially focus on learning the most common conditions, seniors may already have learned the common conditions, at least in their field of interest, and they will often distract you from your pursuit by presenting rare conditions to you, because that is now interesting to them, but do not spend more than minimal time or mental effort on such rare conditions during at least your first years. Yet, you may still encourage their enthusiasm by pretending to be interested in their rare cases.
- Generally do not directly reproach Internet denialist when they put you on the spot about look-up information. Generally do not defy Internet denialist study instructions from seniors, even if they seem like a relative waste of time, but possibly politely question if it is necessary. Many Internet denialists take great pride in their memorizations, and may identify with their memories to the point that they may take such criticism personally. Rather, if you want to make a change in the teaching of pathology trainees, try to do it in a more broad and system-based manner rather than directed at individual people. Similarly, never call a senior an Internet denialist, even in gossip, out of respect and professionalism.
- Be more doubtful about the need to memorize things that a subspecialist teaches about that subspecialty (unless you intend to pursue that subspecialty yourself), because they have themselves memorized much more about that subspecialty than what is needed by most pathologists. The other way around, pay more attention to whatever any pathologists has memorized beyond their own subspecialty.
An Internet denialist exam is basically any exam wherein the examiner does not have access to the Internet, and typically is not allowed to ask colleagues either, and does not get such pertinent information presented, even for non-emergent topics that can conveniently and timely be handled by such resources. Since the Internet and teamwork are fundamental parts of everyday practice, such exams are thereby of a different dimension compared to reality, and their score do not correspond to actual pathology proficiency.
How to study for Internet denialist exams
Efficient studying for Internet denialist exams will allow you more time, effort and brain space to memorize what you actually need, as well as to perform for example studying for solving your actual everyday pathology cases (as per the Learning pathology section). The best approach is arguably to spend enough time and effort on memorizing what is memorization-worthy, to the point where you will pass an Internet denialist exam even if you will fail multiple questions that ask you about look-up information or practically useless information.
For an Internet denialist exam that still asks enough questions that require direct memorization of look-up or practically useless information to pose a threat of exam failure, accept that potential outcome for non-mandatory exams. For such exams that are mandatory for your path to helping people, it is arguably ethically right to spend time on exam studying. Since Internet denialist exams and everyday practice are generally very different, it is more efficient to study either specifically for such an exam, or to study specifically for solving each case you encounter in everyday practice, rather than trying to study any material with the intention of covering both purposes. After all, you will become proficient at what you do: If you read textbooks from front to back then you will be more proficient at reading textbooks from front to back, and if you study to solve everyday cases on your table then you will become good at that, whereas the best way of becoming more proficient at Internet denialist exams with multiple choice questions is to practice question banks with a similar multiple choice format. There are multiple ones for that purpose (PathPrimer, PathDojo, BoardVitals and ASCP RQB), and you should preferably go through all of them and then repeat at least the questions you failed the first time, before continuing with any other types of study materials. People differ in their opinions of what are the best question banks, so form your own opinion which you think works best for you during the first round, and preferentially repeat those. By practice, your mind will in time be primed to select the most likely answer according to the epidemiology in the population you practice on, and when comparing to the real life population, the typical imaginary population in exams has for example a much higher rate of serious disease (particularly cancer) rather than benign, unspecific or artefactual findings. The exam population also has a vast overrepresentation of very rare diseases that happen to be related to certain (but still not directly clinically useful) molecular processes. For example, an exam patient with bleeding diathesis has a relatively high probability of having for example Bernard–Soulier syndrome because it is related to a receptor of the clotting cascade. After you are done with the exam, you need to more or less re-prime yourself back to the real population where for example idiopathic thrombocytopenia is far more common. For highest yield, study as follows:
- Get a habit of reading the question first (usually the last sentence), and then read the rest of the presentation, so that you can focus on the parts that helps you answer it.
- When reviewing questions, don't read every explanation for every answer, but just the answers that contradicted your belief, just enough to learn why it wasn't what you initially thought.
- Spend just enough time on answer explanations to get a hunch of what makes the right choice most likely, because that's basically all you need to choose that right answer if it would appear in the actual exam. Don't memorize every clue and every detail in answer explanations. For example, for a picture of a hairy cell and a question about mutations, your brain probably just needs to associate it with for example "barf 600 something", rather than knowing that suspected hairy cell leukemia is confirmed by genetic testing for the BRAF V600E mutation (and in everyday practice this can timely and conveniently be looked up when you need it). Likewise, in presentations that include a myriad of test results, the brain usually only needs to recognize a few of them to indicate the most likely disease. To check if you have remembered a question sufficiently, you may for example review the correct answers for a test until you almost immediately find them to be reasonable rather than unfamiliar, and repeat the question later if you have the time, since repetition generally is more efficient than lingering on the answer explanation.
- If the Qbank shows the average percentage of test takers who got a question right, put somewhat more effort on learning and repeating questions that you got wrong but has a high percentage, since you generally have more of an expectation of knowing those.
- Any statement that a disease would never have a certain feature can generally be regarded as false, since even exam makers cannot exclude that such a feature may at some point occur somewhere in the world.
- If you don't know the answer directly, try to put yourself in the mind of the creator of the question, who often wants to prove a certain point, often something unexpected, and favor answers that conform to such an intention.
- Focus on what is easy to learn and memorize, and skip whatever that takes long time to learn and has a relatively high risk of being forgotten before the exam (and it is not memorization-worthy besides for exams). Examples of look-up information topics that are generally hard to remember and quickly forgotten include chromosome numbers for various mutations, lists of immunohistochemistry and genetic results for diseases, and most large tables. Focus on memorizing such information only after you feel you've already memorized everything that is easy to learn and remember.
An example of where reasoning can be used to memorize several pieces of look-up information is that hereditary defects in enzymes are generally inherited in an autosomal fashion because there are more non-X chromosomes than X-chromosomes, and a recessive fashion because the enzymes from the unaffected genes are generally sufficient to prevent symptoms in carriers.
On the other hand, hereditary defects in structural proteins (such as osteogenesis imperfecta, Marfan's syndrome and Ehlers–Danlos syndromes) are generally autosomal dominant, because such structural proteins functionally work as beams and chains, so it is enough that some components are defective to make the whole structure dysfunctional. You can pass your exam without further memorizing what diseases are autosomal recessive versus dominant, by focusing on reasonable knowledge like this.
Although this resource outlines what you should focus on learning for everyday pathology practice, also keep in mind that nothing forbids you from learning less useful knowledge, such as reading pathology-related trivia for fun in your leisure time. Also, keep in mind:
- For real patients: cheat! In reality, do what it takes to result in the best outcomes for patients, including what is considered cheating in Internet-denialist exams, including looking things up on the Internet and/or asking colleagues.
- The man in the historical picture is Louis Pasteur.