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How Issues with Executive Function Are Impacted by ADHD in Med School

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On the STATMed Podcast: Conversations About ADHD in Med School: Part 3

In episode three of our podcast miniseries, Conversations About ADHD in Med School, host Ryan Orwig returns with Mike, a former STATMed class participant. They dig into how issues with executive function can negatively affect students with ADHD. During this conversation, they discuss what they term “executive dysfunction.” Ryan and Mike also share strategies med students can use to mitigate these issues.

“I think executive function issues are probably the widest and biggest of all the ADHD issues. With being a first-year student, even getting tasks completed, getting papers done, getting notes mapped out, and getting the lectures done [is extremely difficult]. Because your brain is always running and you always want to be focused on something else when you really have to stop and focus on one thing for an extended amount of time is probably the most difficult time. Trying to finish up whatever thing you’re working on at that time because your brain always wants to skip to the next thing.” Dr. Mike

We’ll dig even deeper into various ways learning in med school is complicated by ADHD in future episodes. Be sure to stay up to date on our latest podcast episodes, videos, and posts by joining our mailing list!

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 – Announcer- Welcome to the STATmed podcast, where we teach you how to study in med school and how to pass board-style exams. Your host is Ryan Orwig, a learning specialist who has over a decade of experience working with med students and physicians. In this third episode of our “Conversations About ADHD in Med School” miniseries, Ryan and Mike, a former STATmed class participant, discuss issues with executive function. They explore what it is and strategies to mitigate these issues. [Ryan] It falls on the learner to learn methods to hack into this. But, regardless if it’s PowerPoint, if it’s a Word-based document, I think that for the ADHD brain under this umbrella of executive functioning, what’s happening first and foremost is a lack of an ability to find that hidden structure. [Ryan] Hey, Ryan and Dr. Mike are back again, talking more about issues med students with ADHD might experience in the first early years of med school when we’re doing classroom learning. Executive functioning is another big area where we see issues for the ADHD brain. This is the control center for emotions, for cast generation and completion, for the building of workflows, among other things. So Mike, what’s one area where executive dysfunction can negatively impact, say, a first year med student?

– [Mike] I think the executive function issues are probably the widest and biggest of all the ADHD issues. Even with being a first-year student, even getting tasks completed, getting papers done, getting notes mapped out, getting the lectures done because your brain’s always running and you’re always wanting to be focused on something else when you really have to stop and focus on one thing for an extended amount of time is probably the most difficult time. And trying to finish up whatever thing you’re working on at that time because your brain always wants to skip to the next thing.

– [Ryan] So this idea of task generation, and task completion? So we could be talking about lecture A, versus lecture B, versus lecture C, right? So maybe you start watching lecture, you start reading, start trying to encode those details from lecture A, but then are you saying then that just the management of that, like, When do I get that done? How do I get it done? Versus moving on to lecture B? Is that part of that toggle, part of that challenge?

– [Mike] Yeah, because at some point, either it gets boring or it gets more difficult. And it makes you think about it a little harder. And so at that point, your brain wants to move on to the next thing, the next lecture, the next project, whatever it is your brain wants to move on and do something different.

– [Ryan] Yeah, no, that’s fascinating if you think about it. So like, and you and I talked about this before, it’s, like, you know you are working so hard to get through lecture, working so hard to then read the material the first time after lecture, right? But really, we don’t expect the true mastery of the encoding happening until deep into the reading. Or after the reading when you’re sort of doing any kind of retrieval practice. That’s the hardest work that’s going to give us the most yield. But what you’re saying is since just the executive functioning, the organization, the task completion, this is where things fall apart. It’s like you’re quitting when you’re getting to the part where you seal the deal and you’re moving onto the next thing. Is that a fair way for me to interpret what you’re saying?

– [Mike] Right. It’s just the hardest part to get to because it exponentially gets harder as you go through whatever task it is. And so, the final details of a lecture are the hardest to get to and they take the most mental effort. But if you’re already tired and you can’t get there and you move on to the next thing, then you never get to the point where you’re getting what you need out of whatever lecture it is.

– [Ryan] You’re not getting into that level of deep encoding and mastery because of all the uphill sledding you’ve already done. One of the things we know about learning is effort is a key piece of learning, right? And our ADHD med students are probably putting- we were talking about this. They always say like, “I work harder than everybody”. “I put in more time than everybody.” Now, that might not be universally true, but I know that when I hear this from people, and if you really track what they’re doing it’s often true. They are working so hard putting in so much time and effort, so much blood, sweat, tears, but they’re not getting the payoff. And maybe a piece of this puzzle. I think part of it is methodology. I think part of it is that by the time they get to putting in the right kind of effort, because effort by itself doesn’t translate results. It’s the right kind of effort. You’ve got to put in the right kind of effort to get the yield for the encoding and the retrieval. And it’s got to start with the organization, Organization, we’ve already talked about, is probably falling apart. And so then, they’re letting off at the end. So I don’t know, let’s say I’m doing like a pushup routine. And I do like 15 reps of push-ups and I start to feel it in my chest. And I’m like, “Ooh, I’m starting to feel it a little bit. I’m going to quit.” Like that’s actually like, I did the effort to sit down and do the 15 push-ups. I’m not an exercise physiologist. I’m not someone who knows a lot about the best way to exercise. So just take all this with a grain of salt, right? But I feel like what I really need to do is to work those muscles to exhaustion. So if I were to- it’s like I did the work to get to the 15 push-ups, but I would really see the growth as if I really pushed myself for seven to 10 more reps. And I’m really struggling at the end. My arms are shaking and can’t even finish those last two reps fully. Isn’t that where the most gain in the muscle is going to happen, Mike? Like in that final piece of effort and exertion, right?

– [Mike] Right. And in this example, your mind wants to go do sit-ups. And so you’re still working, you’re still doing something, but the ton of efficiency isn’t there because you’ve switched before you get all the reward out of the effort. And so you’re onto the next thing. And you’re, so you’re still working. You’re still putting in time, but you’re not getting the maximal return off of what you’re doing.

– [Ryan] Yeah. I’m not paying off for like the 15 reps already did just suffer through five more, seven more. If I do that, every time I work out, I’m going to get more gains a month down the line. But instead if I’m always cutting it short right when the, I need to switch my focus to this other kind of effort, I’m not going to have those, those optimal results. And you know what, like for my push-up routine doesn’t really matter, right? But when the stakes matter, like in med school, where time is the greatest resource, and you, you’ve got to learn to get the most bang for our buck, being able to complete those tasks is, I mean, is the key. So one thing we see, we can expect what the ADHD learner is, perhaps not taking tasks all the way to completion. Whatever that might mean. And then toggling between other activities, getting things started, not taking them all the way through. I mean, I think there’s all kinds of challenges, but what we’re talking about here with the ADHD med student in the classroom years. I think not having discrete steps in the study sequence, not having discrete tools to deploy along a continuum of studying is part of the problem here. I think it’s harder to fix. I think that that needs to be addressed. I think we don’t teach smart, motivated adult learners, the best steps in the learning circuit. I think that after you read something, once you’ve got to get into retrieval practice, and I don’t think that’s always something that people know how to do. We, we certainly teach that in our stat med class, and we have different aspects of that scattered throughout our, our, you know, our podcast channels and our YouTube channels. But I think if we just zoom back out, Mike, what we’re saying is being aware as the med student, that I’m not finishing this lecture, I’m not finishing my work with this lecture and I go onto lecture B could be problematic. Is that a fair way to really zoom out and look at this problem?

– [Mike] Absolutely. And so it, and it affects everything downstream. So you don’t get the, you don’t get the effectiveness out of the first lecture. You’re moving on to the next one. You’re already a little more tired so your initial studying isn’t as effective because you’ve already put a lot of effort into the first one. And so then, you know, as you go downstream, you’re dropping off and you’re losing efficacy just based on time and not focusing on the right things at the right time.

– [Ryan] Yeah, no, absolutely. So, so this idea of like tast completion is, is definitely something that we see. It just, it just creates loss all along the continuum of learning. I think another aspect that falls under executive functioning with the ADHD med student, with the ADHD learner, is where that student’s brain does not find the framework. The organizational hierarchy of a given learning concept. I mean, this applies to reading from a dense textbook. This applies to reading from a given set of PowerPoint notes. I think they’re worse, honestly, in PowerPoints. PowerPoints obliterate the road signs and markers that tell us about the implicit hierarchy. I’ve had students come to me with, from their lecture notes the professors have given them in PowerPoints and they’ll swear there’s no rhyme or reason to the structure, but we can often find it. Not all, not every time. I mean, I think that teachers are teaching with PowerPoints and that you should have to have a license to teach with PowerPoint. That’s never going to happen. Nobody is taught how to use PowerPoint in instructive way. Blah, blah, blah. It doesn’t matter. It’s never gonna happen. Med schools from across the country are gonna be given death by PowerPoint. It falls on the learner to learn methods to hack into this. But regardless if it’s PowerPoint, if it’s, if it’s a word based document, I think that for the ADHD brain under this umbrella of executive functioning, what’s happening first, first and foremost is a lack of an ability to find that hidden structure. And Mike for you, your first year of med student, med school, when it didn’t work out for you, that was one of the key problems, right? You just could not make heads or tails of where, how the details connected and related framework wise. Is that, is that a fair, I mean, this has been 15 years now. Is it? Am I right on this?

– [Mike] Yeah. And the problem with PowerPoint is it breaks up the structure. So you’re basically chopping up a pathway. They’re just putting so much information on each slide and they move on to the next, whether it’s a good break point, whether it’s not, and whether you’re just chopping up the structure in a way that sometimes makes sense and sometimes doesn’t. The structure is always underlying.

– [Ryan] It’s arbitrary and you lose the sense of hierarchy. Right? I mean, it could be like a, it could be literally an outline, but they’re taking out all the Roman numerals. The A, the B, the C. The one, two, three. And it’s all just being broken up and you can’t tell what’s a Roman numeral one versus a Roman numeral two. What’s a capital A versus capital B. I mean, that’s that’s what’s happening for a lot of these. And the structures’ there, we just have to learn how to find it. So I think that this is where things break down. And again, I’m sorry, like for you, that was definitely a part of the problem was like, you, you, we had to teach you a way how to find that, correct?

– [Mike] Yeah. You had to completely break- you had to take their information and then put it in your own structure. And that was one of the most helpful things for me, was making the entire structure for myself so that I could see it the way it could, you know, the way I could see it and break it down. And then that way, when you needed to go and retrieve the information, you could go to your structure and you could go through it. People in my class would make outlines and send them out thinking that they were helpful, but really their help was they were making the structure for themselves and the work was already done. So I couldn’t use someone else’s outline or a structure, even though all the work was done, it didn’t, it wouldn’t help you study at all. And I think, you know, that’s probably still happening. Just like some of the textbooks are outlined based.

– [Ryan] Yeah. Yeah, I think that for some learners, the making of is obviously valuable. For most learners it’s going to be valuable. There probably are people who benefit from receiving created outlines, It’s just not, it’s just, that’s just not your brain. I think that our, our students need to be able to seek, find, extract, make decisions, to find those frameworks. That that is going to activate this entire inductive learning experience. That is going to then fix this executive functioning breakdown is the act of finding, and seeking, and building through some trial and error. Some problem solving. That does sort of help bridge this gap with executive dysfunction. And again, this is one of those things we think we see. I mean, there’s so many ways that executive functioning can negatively impact a med student. I mean, another one could be just, I don’t know, keeping all your ducks in a row, like all with all the classes you’re responsible for, the content for each class broadly, each lecture for each class. Like how, how are you? Like, where are these documents going? If they’re all digital files, if they’re coming to you hard copy, how are you keeping stuff physically organized? How are you keeping things digitally organized? How are you keeping track of which lectures you’ve watched versus which ones you’ve halfway watched? Getting back to that task completion. It’s, it’s, it’s so much. You really need to almost adopt an entrepreneurial mindset with managing all this. You, if you try to run your life as a med student, like an office drone, like punching a time clock. And I think there are probably are high functioning med students that do this. It’s probably not going to work for our, those with executive dysfunction. You need to run this thing like you’re running the business. You are both the owner and all the office drones. And to, to really strategize, and plan, and map out, and track. Now, obviously you can go too far with this and it becomes just a bunch of apparatus, but you do need to sort of run this, your life as a first year med student, as a third year med student, as somebody prepping for boards, like you’re, you’re the boss. You’re in charge of mapping out your plan. Does that speak to you in any way, Mike? I mean, I’m sure at some point you, you had to adopt that mentality.

– [Mike] Yeah. I mean, that was one of my ideas was that make it like a full-time job. This is a full-time job. You work eight to five, eight to six every day. This is your spending the time. And it doesn’t work. It doesn’t work that way. And with all the different things you’ve got to do, and-

– [Ryan] You were wanting to punch the time clock basically. And that did not work?

– [Mike] Right. It doesn’t work. It’s not even close. I mean, you’re, you’re in lecture most of the day, you know? You, you’re spending this time and it should be efficient and it should be getting something out of it, but it doesn’t happen. So then you’re, you know, finishing the day at four o’clock or like, okay, I have two hours to study, but you just sat in lecture for eight hours. And so, you know, it just doesn’t work that way.

– [Ryan] No, no, I, and like I said, so if you read books or listening to podcasts about business, about the entrepreneur’s mindset, that, that translates much more to how I think we need to start thinking about this. You have to be sitting in the seat of the business owner. Like I’m a business owner. I own STATmed. Like that’s different, I mean, when I was teaching at a university, when I taught at the university, I can leave at 4:30 and I was done. Like, you know, when you own the business, you’re never done. And just because you want to take 40 hours a week, maybe you have friends that it does take 40 hours a week for them to study and be committed. That might not be what you need. You might need 60 hours. You might need 70 hours. And then you get into efficiency and planning and tracking and all that stuff. But you gotta sort of reframe how this looks and how it works for you individually. And again, I think adopting these kinds of mindsets can help. And I think getting better tools and better skills can help. Just depends on what the individual needs.

– [Mike] The other issue is you, you know, our, our school was on two or three weeks cycles. You’d have a test, you’d have information for two weeks and then you have another test. And so, you know, if your framework and your time management and your way of about going through the lectures, wasn’t very good. You know, you take a test, you’d have a week where you’re getting all just new information, but you’re so tired from the week before, because you spent 90 hours a week before. So then you couldn’t put in the amount of time that you wanted then that week. And so then you’re at the second week, a week until you have the test. And so then you’re trying to, you know, double up and catch up because you got a test in a week and then that cycle just continues. You, you know, you have, you know, you’re so tired from the week before that you take some time off and you’re not studying effectively. And so it just cycles through, and this just doesn’t work.

– [Ryan] This is where you got to have those, we call weekly business meetings with yourself. You sit down before the week starts on, say, Sunday. Could be Saturday. And you map out your week, whatever that looks like. And this is the best chance you have of not spiking and crashing, Which is what Mike’s describing, the spike and crash cycle. So that you can at least have a plan to stay on top of that. And then what about, I mean, just balancing, like never before, like now these first and second years are inundated with resource option. It’s an overabundance of resource. This is different than when you were in med school, Mike. It’s changed so much. Now, it’s like, okay, how much do I focus on the lectures that are being given to me? But how much do I also spend on like first aid or step one level one prep? First years, certainly second years. How much do I spend on practice questions? They’re using practice questions as like a formative learning experience, Not like test prep, test training. What about like things like external resources, like sketchy, or a board review program, or Picmonic? Or how am I, you know, creating Anki decks? Or that I’m making? Or that are coming from somebody else? There’s so much. And then you’re doing, you’re spending all this time, it’s this it’s clerical work. You know, let me look for these resources and weigh these resources and decide from this resource. It’s a possibility of becoming familiar with several resources, but mastering none. It’s an illusion of productivity because you’re, you’re looking at sketchy. You’re looking at this Anki theory, downloading stuff and putting it on your computer, but not using it. It falls under this illusion of mastery, like, “Oh, I spent three hours studying,” but what were you actually? Where was the effort being deployed? Was it the right kind of effort? Really getting into the meat of the material.

– [Mike] Well, and that’s assuming that you’re even getting to the, to whatever you need to whatever resource. A lot of times you’ll get distracted before you even get there. And you’ll go off on a completely different tangent and you never get to the resource that could have been good, but you’re, you know, you’re going off on a completely different deal. And, you know, you’re searching something on Google or you’re watching some video on YouTube. And so you’re not even getting close to the resource that, you know, if you would have used the one or two resources that you could have gotten the information out of, because you’re getting distracted and getting lost trying to even get to it.

– [Ryan] Which for our ADHD brain is more likely to happen even than the average person. And it’s bad enough for the average person, but for that ADHD, sparkly, click link, dopamine rush, all that stuff, it’s, it’s very insidious and something that can, that can fall, you know, get sort of sucked into, right? And managing that again, falls under this, everything falls under executive function here. What about work-life balance? How can that be a problem? Especially in this first few years of med school, when we have some executive functioning challenges with that ADHD brain.

– [Mike] You’re just trying to function as a med student first, and then everything else gets pushed to the side. Whether it’s going grocery shopping or going to get your license renewed. Or whatever, whatever mundane thing it is, it gets pushed off because you don’t have time because you’ve wasted time while you’re quote unquote studying, or you’re looking for some resource. Any time you have to take that time to do something in actual life, paying bills, or paying rent or whatever, then you’re getting completely off the rails. And then you feel guilty because you’re not studying. And even if you took a break, you can’t even enjoy it because you feel guilty because you’re not studying. And so there’s really no balance at that point because you think you always have to be studying and you have to be spending time, even though when you’re studying you’re not being effective. And so it just spirals out of control, again.

– [Ryan] And your little power bar, right? The power bar is at zero. And you’re out of your out of fuel, but the guilt pushes you to just keep grinding, keep pushing, keep going through material, which again probably gets more superficial. Trends toward more familiarity instead of actual encoding and retrieval. And then, you know, you get to the test and you recognize stuff. And this is where you narrow down to two. And you’re like, “I know it’s one of these two, but I don’t know which one.” That’s different than some of the test taking issues where you narrow it down to two. You like A, you don’t know everything about A, you pick B. The former is more of a knowledge based, encoding based, study based issue. The second is more of a test taking strategy issue. And they can look the same, but be very different because this is where that work-life balance sort of work. The study side sort of overwhelms the ability to find life balance. And I’m not saying life balance has to be perfect, or idyllic, or life of the party as a med student. Some people are going to need more time, but I think with better approach, better strategy, better ways to offset this executive function overload. You can do better. So solution-wise here, again, I think it’s more about understanding where the breakdowns are. I think it’s about offloading tasks, making things more external and explicit, but I think with this stuff, it just has to start with an awareness of where your weaknesses are. Where you can anticipate trouble to come from. And then what you can do to offset it. So, Mike, for you, just to wrap this up, where do you think the key intervention or interventions were for you? When we talked about these type of executive functioning struggles in this first, in the first, first, first year, second year in med school. In those classroom learning years.

– [Mike] I mean, just starting with a basic studying skills that I learned in the class that makes your, your time that you’re spending studying much more efficient. And so then you’re not trying to catch up and you’re not trying to feel guilty about the hour you take to go to the gym because you’ve actually spent a good six or eight hours studying those six or eight hours are much more efficient and effective. And once you start seeing the results in the tests, you start feeling more confident. And so once you start getting that confidence back, then you can not worry about I’m going to take an hour and go to dinner tonight. And so that break actually helps. Those things actually help the mental and the physical problems that come about with the anxiety from not studying, and the guilt from not studying, and the guilt of not doing well on a test, or not having time for your family or, or anybody else. So the framework and the, the skills open up a lot of things that help, overall.

– [Ryan] Yeah. I hate, I hate like when I’m like, “Hey, all you have to do is do our class and that’s the solution.” But I mean, this is a big umbrella we’re talking about right here. And I do like, I, I’m long-winded on things like, I know these skills take time to teach, and learn, and implement. And sometimes that is the best thing to do, you know? And then, then to take it and make it as simple as possible. It is hard because I think that these are hard problems. And I don’t, I’m not a big tips guy because I think tips are just enough to frustrate. But I think at least whenever you get overloaded, if you can make a plan on Sunday, understanding that that plan’s not going to come to fruition, but it’s like a hypothesis. Okay, this is my sketch for how my week’s going to go. These are the things I have to do to. Make lists. Have a list of non study things on one side and a list of study based things on the other. Understand you’re not always going to get to them. Keep it external and explicit. Check it off, cross it off. Understand that you got to prioritize, things aren’t always going to get done. And then if you do that every week, multiple times a week, multiple times a day, that will help manage. I guess if I’m boiling it all the way down, which I hate to do ’cause I think it’s hard, make things external and explicit. Is that a fair thing to say to somebody, Mike? And you’re like, if you can put yourself in those shoes, I mean, I could also see everything or every tip I say, I could see it being equally frustrating because I mean, these things require complex answers. I don’t know. I don’t know. I mean, I know what the answers are. They just, they take, they take a class. Anyway, what are your thoughts on that, Mike?

– [Mike] Yeah. And there’s so much information coming at you from school and lectures that anything you can do to decrease the mental burden, the mental stress of things outside of school, will only help. Even just going for a walk and being able to eat a little healthier and being able to do those things. Those are the first things to get cut out. But realistically, those are the most important things to be able to help focus your work later.

– [Ryan] Short-term versus long-term stuff, right? Like in the immediacy, it’s like, I don’t have time to take that 10-minute break or that 30-minute walk. And it’s funny because we talk about the complications of it. Like I still, like, any kind of interval studying 50-10 model, 45-15 model. I don’t care, but I like it because of the compartmentalization, like I’m now done. I’m going to go do something. And I do like the idea of moving around on the break. Just anything that can increase the highly oxygenated blood flow to the brain. Anything you can do to, to bring some movement back. And we don’t, we do know that movement is a big factor for improving cognitive function, especially over the long-term. But I, you know, I also hate like, just go to the gym, but it doesn’t have to be the gym. Just any kind of movement is good, but I think it has to start with bigger picture structural plans. For this, especially for our med students with ADHD that are just trying to run autonomously in the background because, “Hey, I was successful in undergrad. Hey, I was successful in my master’s program.” Not doing that. The arena is different. The challenges are different. You have to realize you’re in a different arena in med school and make some structural changes that are going to actually put you in control. And as Mike said, offload some of that cognitive burden. I think that’s a good distillation point. Your processor is going to be heavily burdened and overburdened. So anything you can do to unburden it, and if that’s like life tasks stuff, all the better. Definitely a major factor. Executive functioning is a big one, guys. It’s a big umbrella term, so many different aspects to it. So we’ll come back and talk about a few more things that we might see with ADHD in those early classroom years. Be sure to look for that. Thanks for listening.

– Thanks for tuning into this episode of the STATmed podcast. In future episodes, Ryan and Mike will continue their conversations about ADHD and med school. If you like the show, be sure to rate it on iTunes, Stitcher, Spotify, or wherever you listen to your podcasts. And be sure to subscribe so you don’t miss future episodes. You can find more test-taking and study strategies, specifically designed for med students and physicians, over at our blog, Thanks for listening.

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