Achieving Happiness While Studying for the Boards

By Mark Ard

“Don’t aim at success—the more you aim at it and make it a target, the more you are going to miss it. For success, like happiness, cannot be pursued; it must ensue…as the unintended side-effect of one’s personal dedication to a course greater than oneself.”
– Vicktor Frankl, Man’s Search for Meaning

In the bestselling book “Flow: The Psychology of Optimal Experience,” author Mihaly Csikszentmihalyi’s takes on the very difficult topic of happiness and what conditions put people into the state of “flow” that only seems achievable to world-class extreme athletes (think about the Red Bull Wingsuit). Below are six conditions to achieving this state of eudaemonia and how you can get there yourself while studying for boards. I also highly recommend the book for people who need an answer to “what books have you read recently?”

  1. Intense and focused concentration on the present moment. One of the most difficult aspects of medical school is getting into “study mood” for a sustained period of time. You need to be ruthless in your demand for presence. The easiest way is to have a dedicated study location. You can even have a few, one for solo-studying and one for group-studying. When you feel yourself fading, get out of that place, physically. Your study place is no place for day-dreaming. You will tell your patients the same thing for insomnia as “in-study-a.” Think about it. You tell patients to try to sleep, but if they can’t, get out of bed and go do something else. Bed is only for sleep…and sex.
  2. Merging of action and awareness. Presence and awareness are similar, but in the context of learning and test-taking, I like to think of awareness as the ability to paint the mental picture as you read. Read the vignette at the end of this post. First, can you see her? She is miserable and her family is concerned. Can you see her eyes? Her skin? The empty toilet? (Ok, too far). Now can you see your illness script? Can you see that your differential diagnosis list for each finding is long, but the venn-diagram of symptoms really overlap on one disease? What if I simplify. Neurologic findings, Renal failure, Fever, Thrombocytopenia, Anemia. (Mnemonic: Never Run From The Anemia). The action, you reading the question and painting the picture of the sick patient, needs to merge with the awareness of the actual picture you are painting. You need to both qualify the findings (Temp of 102 = fever, purpura = thrombocytopenia, etc) and expand their meaning and significance (exposure to Shiga-toxin producing bacteria)
  3. A loss of reflective self-consciousness. This one is a bit more straightforward. While you must be present and aware, flow means being in this state without reflection on the “self”. I had back surgery a few months before Step 1. When I was studying, I always knew when my mind was wandering because my back hurt. It always hurts, but when I get into that flow state, I do not register discomfort. If you start to notice yourself or get distracted, try this: Acknowledge you are falling out of flow, close your eyes, gather yourself, and try again. If you’re just studying and you can’t seem to get back into it, set a timer and go do something else. Come back, remind yourself what you’re doing and why, and try again. A 1 min time out on Step 1 is also a good idea. I’d rather rush the last 2 questions but be in flow for 44 than bungle through them all.
  4. A sense of personal control or agency over the situation or activity. Confidence in your ability. There was a point near the end of 2nd year where I could see light at the end of the tunnel. I had covered almost all of the big topics in the preclinical years. Nothing in First Aid was foreign. I was still learning a ton while reviewing MCQs, but it all started to feel familiar. I was still getting a lot wrong, but I could at least narrow things down to 2-3 choices. I could get blocks done in time. I was also in charge of my schedule. Lectures were thinning out, and I could map out my ambitious plan. Step 1 is called the beast, but two years of work had trained and prepared me to slay the beast. If you’re not confident in your control yet, take heart that with a sustained effort, over a reasonable and manageable time period, you too can join the ranks of successful Step 1 conquerers. (Now the clerkships are a different story…I’m looking at you surgery).
  5. A distortion of temporal experience, one’s subjective experience of time is altered. This was probably the most profound change during my study time. I slowly grew into the student who could sit for an hour and focus on questions. I never really mastered the ability to do an entire question block on tutor mode and review in one sitting, but what once seemed like an insurmountable obstacle, an 8+ hour test, became doable. At least twice, make sure to do seven blocks in a row. If your Qbank doesn’t offer full length exams, do whatever they offer, and add some NBME or regular blocks. Get used to the time commitment and it will start to seem manageable. (Again, clerkships are a different story…I’m still looking at you surgery)
  6. Experience of the activity as intrinsically rewarding, also referred to as autotelic experience. I hope that this one doesn’t need explaining. Perhaps we will just call it a form of Stockholm syndrome.

Here’s the vignette I refer to in number 2:

A 34 year old woman is brought in by her family because of an illness that has begun to manifest with visions of people who are not present. Her mental status is waxing, and she cannot recall the year or month. She also complains of a band-like headache. Her temperature is 102.4. She has not urinated in 24 hrs. On physical exam, she has scattered purpura and scleral icterus. Key lab findings are elevated billirubin with decreased direct fraction, increased lactate dehydrogenase, decreased haptoglobin, and an Hgb of 7.4. Which of the following findings in her history would be most consistent with her condition?

A) Exposure to a bacteria that lacks a cell wall while visiting her cousin in her college dormitory.
B) Early onset of a disease which leads to destruction of the substantia nigra.
C) Eating a hamburger at a restaurant which was recently shut down for health code violations.
D) Infection with a virus which has a readily available vaccine.
E) A long history of migraine headaches with aura necessitating multiple visits to the ED.


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