I write to you now, briefly, as someone who has dis- and then re- appeared.

I have successfully completed the final two years of medical school.  Most people view the two clinical years as the most interesting years of medical school.  I think I agree with that.

I have gone through the process of applying for a competitive specialty.  I have gone through the match.  I have landed a job.  And I have thinkings about all of it which I’d love to share.

I probably will.

For those of you that still check back to this space, that still wonder “what the hell happened?!”, this is for you.  What do you want to know?

Whatever you suggest, I will address.  Be my impetus.

I can’t wait to start – topher.

Why do you write?

***

I don’t have a handle on what’s happened here, though it’s completely under my control. The Rumors Were True began as a manifestation of envy. I’ve told this story before, but I used to write just to make my friends and family laugh. With some practice, I got to the point where I had a reputation for pulling it off. And as it has happened so many times when I find myself becoming successful with something originally challenging, I bore of it and stop. So it was with writing for a laugh.

I needed a new challenge.

Two years ago, I found PURRTY GUD and I was blown away by his writing. I thought, “here’s a guy that is just better than me. Usually with some work, I can match people at things like this but not him and not now. He’s just better.” I knew I was forever less, so it was a perfect place to begin. And fueled by my feeling that I would never measure up and my jealousy for this talent, I began RWT.

In the beginning, it was very stupid. It was very distant. I’m not sure that someone who started reading at that point would have ever gotten a picture of who I was, other than somewhat snarky and in love with my own diction (you can laugh at that). But slowly I started to write things that were a little more naked and personal, and it was from these things that I received the strongest responses. Soon, the goal of every week was to write something good enough to be included in Grand Rounds and I chased that for months.

At this point, I wanted to be famous. I fell into the trap of obsessing over my statistics. How many people read my last story? Where were they from? How long did they stay? Who thinks my story is good enough that they’re telling people to read it? And so on. Finally, I reached a point where 100 people were coming to read every day and I was very proud. I wrote to a friend of mine, “In one year, 1000 people will come to read me every day.” This is what passed for my goals.

Beginning in August of 2006, I was intoxicated with medical school and the Welcome to Grenada project. I was writing about my love of Anatomy, my research, my introduction to clinical medicine on the islands, and about the islands themselves. Writing the WTG guide began to take over the RWT, and I split it into its own blog with its own management, but already the character of my writing was changing again.

I began writing about what I was thinking. I began reacting to things instead of planning every word. I started writing about Flash Raves, MicroCredit, and I struck a chord with my reaction, “A Lazy Attack on Atheism.” What I wrote was becoming less and less about medicine and more and more about me. It was because I was becoming more comfortable with the thought that strangers could know my secrets and that would be “okay”. It was also because I was running out of ideas, grasping at straws. I thought often about ending RWT.

I tried to suck some water from the well by writing Pancakes Every Morning. I hosted Grand Rounds because I was hungry for some new kind of challenge. Immediately after, I gave everything I had left to The Old Man, which I consider to be the best thing that I have ever written and the only thing I ever did outside of my comfort zone. And after that, I felt done.

I twitted away the next month writing pieces I didn’t care about. I started researching the business and law behind the practice of medicine because it was interesting and I was ignorant. But I was empty. I had nothing left worth writing and I had stopped finding joy in it.

RWT should have died long ago save for the USMLE. I found in writing about that experience a steady supply of “new” and a comfort zone of writing guides for others. Telling someone what to do is an easier thing than writing to evoke a feeling. I was jumping over the lower bar.

And then I found a reason to write again.

I became so engulfed in the material while preparing that I began to see deeper into it than I had before, and I was able to spot conflicts and connections as easily as you would spot marinara on a pressed white shirt. It became clear to me. I discovered this while using the First Aid for the USMLE book, and when I went to find a website that listed its errors, I found not a single one.

And I complained about there not being a source. I have written before about my own guiding principle: The Categorical Imperative. In this case (as in all cases), complaining required action: since I wished someone had already made a list of errors, I could not complain about it unless I was willing to make the thing that I felt was missing. This became my reason for writing: to compile a perfect and complete list of errors. To scour the book as few others had ever done and, in doing so, to know more about everything.

Before I knew it, RWT was no longer a place for my writing: it was a one-stop-shop for USMLE adivce, textbook corrections, and so on. This was more interesting to more people than my stories ever were and I quickly reached an average of 1000 visitors a day. The success was discouraging, and insomuch as my statistics were a progress report, I felt that connection had been completely lost.

And as it has happened so many times when I find myself becoming successful with something originally challenging, I bore of it and stop. So it was with writing about medicine.

Perhaps I set the bar too low or that I chose the wrong metric for success. Whatever the case, it couldn’t have happened at a worse time as I left for Asia and from writing for the next six weeks. Long distance for any weak relationship delivers the final blow. I felt done with writing. In the weeks after returning, my only reason for coming back here was to update and maintain the USMLE portion of this site. Whatever drove me before was gone.

And now as I begin the second half of my medical school career, I find I need something from this space, from whomever has stuck around this long to see if I have anything left to say, that I cannot get. RWT feels ruined by its success. From the First Aid Errors project, I earned the attention and interest of the First Aid Team. Shortly, I will begin working for them. This is fantastic news that I have not been able to share with you until now.

At the same time, I am applying for transfer to US medical schools, and the successes of the Welcome to Grenada Guide and the FA Errors have become selling points on my application. This has made RWT public (as it always was) and has stripped me of any illusions of anonymity. I have never been as diligent about keeping myself anonymous as I could or should have been, but its loss has never been so obvious to me as it is now. At a time where I need this space to be a place for me to be my most honest, where I need the catharisis of venting and a chance to share my frustrations with feeling uncertain about my future and my fears that medicine has facets of it that I feel strongly against, RWT has begun to feel as much a liability as an asset.

I feel watched. I feel known in an uncomfortable way. I feel twisted into self-censure.

I cannot write the way that I need to on RWT anymore. It no longer feels like my journal and a safe for my memories. Now, it feels like a bulletin board of updates and other stale things. I could continue to write here about happy things, about funny things, about critiquing things but I cannot write about sad things, frustrating things, about hating things. I am not Ying or Yang, but the pair, and I worry that this simple thing that is true about all of us could hurt me to show it. I worry about a dishonest portrayal of what life is like.

And now I think it is time for RWT to end. Not deleted (because people still find use in it), or forgotten (it remains the safe for everything that happened to me early on in this new life) or regretted (I learned so much about myself while writing it).

It will end because I was sloppy and couldn’t keep it from mixing with the reasons not to write.

***

Why do you write?

I write to think.
I write to remember.
I write to help others.
I write to stretch and twist and understand new ways of seeing the world.
I write to help people understand me, if for no other reason than to feel understood. To connect.
I write to make you a part of my life so that mine feels larger.
I write for vanity.
I write for the freedom of anonymity.
I write because I need to feel whole and this gets me there.

***

I look back to PURRTY GUD now and I better understand him. He was anonymous to the world as he wrote but his family and friends were all reading. He wrote about it ruining things, about feeling like it was bringing more harm to him than good. When he graduated, he decided to end the blog and start a new one for his residency. It was then that he revealed his name. It wasn’t a few weeks before it completely disappeared. He gave out his email address for those that wanted to know if he was ever writing again and if they could follow him to this new anonymous place.

He hasn’t. I think I get it now.

I am still writing.  I have a bank of stories that I’m going to release after the Match about everything that has happened over the last two years.  With all my free time since ignoring the internets, I’ve been able to do other fun things.  This is one of them.  Also, this is my face and my voice.

As far as the cube goes, I bought one in November of 2007 and went to Lars Petraus’ website. 

1. Step 1 – Build a 2×2x2 corner
2. Step 2 – Expand to 2×2x3
3. Step 3 – Twist the edges (I use one algorithm from this)
4. Step 4 – Finish 2 layers (I use one algorithm from this)
5. Step 5 – Position the corners (I use one algorithm from this)
6. Step 6 – Twist the corners (I use three algorithms from this)
7. Step 7 – Position the edges (I use one algorithm from this)

It took my about two days to figure out my first solve (basically following the website move for move).  It was another week before I could solve it without looking at my cheat sheet of written algorithms.  Another week before I was sub-5 minutes.  A week later it was 3 minutes.  I spent about a month hovering around 90 seconds and have been stuck at 45-60 seconds for the past three months without any real improvement.

I have no plans to solve it blindfolded, but appreciate all the people that tell me they won’t be impressed until that happens.  You people suck.

Don’t let the books swallow you, topher.

You start with seeds and their finite potential. You are going to make something great with this field and these seeds. You plant them, water them, love and dote on them. They are nurtured and they sweeten in the sun. And then, when they cannot grow this way any more, you pluck the best.

You take these grapes, throw them into a barrel, and ignore them. You don’t give them sun, activity, or anything familiar. It’s quite a shock to the grapes. You do this for years. And years.

Out pops wine.

Pretty inefficient, but I don’t know how I would fix it. I don’t know that trying to speed it up won’t make for something unpalatable. I guess I just have to deal with the ignoring and waiting until those grapes magically turn themselves into something more.

Pretty much what the third year of medical school has felt like. I haven’t written about it.

Before, my shtick was looking around and sort of cataloging all the interesting things that were happening around me. Not a lot of introspection going on. Nothing to write about inside the barrel that is my hospital. Or there is, but that’s not the story.

The story is the fermenting. My classmates and I are taking on new flavors and textures. A few might be prematurely alcoholic. Others have lost their sweetness. Most rougher for the wear and rarely anyone smoother.

And it is incredible.

I put up a hell of a fight. A nine month spectacle of twisting, thrashing and spitting. On March 5th, 2008, I broke. Emotionally. Mentally. Broke. It was awful. I haven’t written about it because I’m unsure on these new, wobbly legs.

But for the first time I know what language is supposed to do. I know how people reward their physicians. I understand patience. I have experienced the risks and rewards of vulnerability. What is and is not important has been impossibly rearranged in my head. When I look at the decisions I am making now, I don’t recognize them as coming from my past. All of it seems to come from very different stuff.

But then you never could have told me, after I rolled one around in my mouth, that grapes could give way to wine.

A little over a year ago, I was behind in my work and trying to catch up. Procrastinating, I wrote a short blurb about how going to medical school is like having to eat a stack of pancakes every morning. Some people thought it was funny. About 10 months later, a good friend of mine at Saint Louis University Medical School called me up to ask if he could use the concept for a 72-hour film competition. Of course, I said yes.

So he and his friends expanded it, added new portions, and really transformed it into something better than it was before. They pulled off the 7-minute feat in 72 hours, submitted it, and then on the night of the festival came home with FIRST PLACE!

Finally, it’s up on YouTube.   Merry Christmas, everyone!

Med School Metaphor: Pancakes Every Morning (orginal story)

Pancakes Every Day (prize-winning short film)

There are a lot of things you should do for your interview, and Iserson’s Getting into a Residency covers all of them. I bought this book a month before I anticipated any interviews and read it cover to cover in the first two days. I was left dumbstruck by this book. When speaking about special situations like being an FMG, his advice is that the most important thing you can do is transfer to a US medical school. That knocked me in the head. There is a chapter called “The Questions – The Answers” that lists over 300 questions that people have been asked in residency interviews, what these questions are trying to discover about the interviewee, and strategies for handling them. I sat down and typed out every single question, printed them out, and then spent the next week forming my best answers. He will teach you how to stand, how to sit, and how to pack your suitcase so that things do not wrinkle. What to wear, what never to say, and what to do before during and after the interview are all topics that are covered very well in this book. If you walk into this interview without a resource like this, you are making a mistake.Why am I recommending a book about getting into a Residency? As a transfer student, you are already in medical school and are expected to know a little more about the field, its problems, and your place in it. There is an assumption made that if you have the grades and the recommendations to transfer, then you must be a very serious and driven medical student. Serious, driven medical students know what they want and have researched how to get it. In this way, you are much like a residency applicant who knows what type of physician he wants to be, where he wants to live, and which program will help you achieve this.

After reading this book, doing the research that it outlines for each institution to which I was applying, and answering all of the questions, I was in a place where I could enter the interview confident that I had not forgotten anything and that I had prepared as well as I Possibly could have. The confidence that comes when you can stop worrying about these things is invaluable, and I highly recommend the book for this purpose.

The second book I recommend it Dale Carnegie’s How to Win Friends and Influence People. This book changed my life. The way I read people’s response to what I say, the way I understand what they are saying, and how I handle every situation has been informed and altered by this book. I can say with confidence that a great deal of the good that has happened to me in the last year has happened because of the way I handled situations after reading this book. During my interview day, I saw so many of the other students making mistakes (some of them crippling) that are outlined by Carnegie. There was also one applicant that I noticed because she was so expertly handling the same questions and situations that were killing the other applicants. After the day was over, I told her that out of the entire field, she had her best foot forward the entire time and that if anyone was going to get in based on their interview today, it would be her. She emailed me a week later with the good news that she had been offered a spot. Do yourself the favor of reading this book. There are almost 500 reviews at Amazon.com (avg 5 stars). Here is a review of the book and how it changed someone else’s life.

Depending on your academic calendar, the timing of your application and your options may change. As an SGU student, I will speak about our problems specifically.

Students that begin in August have a good chance to apply for a second year spot at the end of their first year. Most schools begin accepting applications in February march, interview in June, and accept at the end of June/July for an August start date. Having completed only a year of medical school, you likely have had little time to explore research and develop strong relationships with the faculty that may write your recommendations. The school does not have much to use when considering you. They have your first year grades (mostly useful in comparing you to your classmates) and your MCAT scores. Know that you will be competing against people with a 4.0 and a 30+ MCAT. If you can get a hold of someone that has successfully transferred into the second year, ask them who wrote their recommendations. There is a good chance that this person has a reputation for endorsing strong students.

If you are planning on applying for a third year spot at the end of your second year, you will find this to be much harder. Most schools will want to see your USMLE Step 1 score when considering your application. Any January students from the term ahead of you will have already taken their Step 1 and have scores in hand. It will be very hard to compete against someone that already has a 99 even if you end up with a similar score. You can still apply for a third year spot at the end of your third year (which means repeating a year of clinical work). If you decide to do this, know that it will not be enough that you are “so far ahead” of the other applicants in terms of experience, the school will want to see that you have Honors in your clerkships.

Students that begin in January have more options. As a January student, I had the option of applying for a second year spot halfway through my second year. In this way, you have the opportunity to demonstrate A-level work on the second year material that you would have to repeat, you have a little more time to develop relationships with the faculty in hopes of having a strong letter of recommendation written, and you have enough time to become involved in research or other projects that might set your application apart.

You are also well positioned to apply for a third year spot at the end of your second year. Finishing in December, you will have five months off until you begin your clinical rotations. You can use this time to prepare as much as you need to for the USMLE Step 1, you have time to receive your scores and submit them by April (two months before the application deadlines), and you have plenty of time to make sure that your essays, recommendations, and transcripts are heading in the right directions. You also have an opportunity to pursue research or some other project to strengthen your application. The drawback is that you will have to begin your clinical rotations before the interviews begin. This means moving to a new area, finding a place to live, and taking time off to interview. I went through this and recommend starting your rotations instead of deferring them (if you defer, you may have some difficult questions to answer in the interview), subletting an apartment for two months instead of committing to a lease that you may have to break (and leaving any roommates in a difficult situation), and giving ample notice to your site director that you may need to take some time off for interviewing.

It changes. Coming from the Caribbean, you are part of an institution that is outside of the Liaison Committee on Medical Education (LCME). Almost all the medical schools in the US and Canada are LCME-accredited and this is the requirement to move between them as a transfer. Few schools elect to consider non-LCME students. To find out which schools accept non-LCME students, I went to the AAMC’s website for transfer policies by school. I asked to search by policy then narrowed my search by selecting ALL schools in ALL regions and selecting all the boxes accept for the first four (LCME-accredited applicant, Osteopathic applicant, Dental applicant, Oral and Facial surgeon applicant). This generated a list of 54 institutions accepting transfers into the second year and 73 accepting applicants into the third year. There is some overlap.

I then sat down and called every single institution to ask about their transfer policy for non-LCME students. This is important to do if you are serious about transferring and this level of effort will separate you from your peers. You will find out before applying if a school that has always accepted transfers has recently changed its policy, has no availability this year due to an oversubscribed first year class, or has recently begun to accept transfers. There have been cases where the school said “no” over the phone, the student applied anyway and was then offered an interview. The determined student will always have an advantage over the complacent student. Decide which one you are going to be and then plan accordingly. The programs that I contacted told me that the information on this site concerning number of available spots is inaccurate, so do not let a “0 spaces available” stop you from inquiring. Plus, it builds character.

There are several schools that often have spaces available nd are well known to those that frequent the discussion boards. These school are:

1. Drexel University

2. George Washington

3. New York Medical College

4. Northeastern Ohio University College of Medicine (NEOUCOM)

5. SUNY Upstate

6. Tulane University

7. University of Medicine and Dentistry, New Jersey (UMDNJ)

In addition to this list, I was able to confirm that eight other schools would accept non-LCME applicants. I do not feel like I have given too much away with this list as it is available everywhere, but if you are willing to search for the remaining schools than you deserve to be separated from others for your effort. Do not forget to call the medical schools in the state where you have residence. Several state schools do not accept non-LCME applicants but do accept applicants that are residents of the state regardless of school affiliation.

As the information begins to pile, it is a good idea to remain organized. Open a spreadsheet with a space for the school, its application deadline, fee, email contact, phone number, application cost, number of required recommendations from undergraduate and medical faculty, required transcripts, etc. Happy hunting.

I wrote a guide about attending a Caribbean medical school, singing the praises of St. George University. I kept a blog for two years at the Rumors Were True shedding light on some of the uniqueness of the island experience. SGU was a place that invited me to test my mettle and gave me the space to realize my potential in medicine. I love the school, the Caribbean, and still count it as the first great decision that I made in a new life of great decisions.

Then I transferred to Drexel University College of Medicine. Why?

When I applied to SGU, I knew that I wanted to be a physician in the United States, that medicine was the only thing that I felt could fulfill me as a profession, and that no matter what obstacles I faced I was going to make this happen. I was not sure what I wanted to do in medicine and it was important to me that as many doors remain open as possible. Going to the Caribbean (you will be told) can close many doors, and you will hear people tell you that you cannot do such-and-such if you come from the Caribbean.

SGU has an earned reputation for producing strong students and their residency placement list each year boasts this, showing students in fields such as Anesthesiology, Diagnostic Rad, ER, Ophthalmology, Orthopaedics, and Urology. The list of residency placements between 1997 and 2002 impressed me particularly when I decided on SGU. That said, my understanding of the residency application process has matured to reveal things previously missed.

The first is that Foreign Medical Graduates (FMGs) are able to accept residency placements outside of the match. This can be to the advantage of FMG applicants that might be able to secure a spot now that they would not get if they waited for the match (plenty of stories of this happening). The list available through SGU does not draw a distinction between how their students’ placements were secured, so looking at the list alone does not tell you how you can expect to fare when it is your turn to open the letter on Match Day. The second thing I have come to appreciate is that while there is a bell curve for desirable fields, there are bell curves within those fields for desirable residency programs. For example, while Orthopaedic surgery is a desirable field and incredibly competitive on the whole, there are Orthopaedic residency programs that are incredibly desirable and those that are less so. If your goal is to become an Orthopaedic surgeon coming from the Caribbean, this is certainly possible. If you want to do Orthopaedics at the Mayo Clinic, this truly approaches the impossible. It is also important to keep perspective on how many students are able to place into these fields. If only three students from your school made it into the specialty that you want and your class size is somewhere near 600, you need to honestly asses where you stand in your class and if it is likely that you will be one of the three in the coming years.

The process of “auditioning” for certain programs is also at issue. SGU has many hospitals for its students in the New York and New Jersey area and you are more or less free to complete your rotations and electives at any of them. When it comes time to apply for residencies, it is sometimes a good idea to complete an “away” elective at the desired hospital. In this way, the program gets to see your stuff and give you a much better look when it comes time to invite people into their program. This process of completing “away” rotations is open for US medical students but is much more difficult for FMGs, and this is because of reciprocity. Reciprocity is the agreement that schools like Mayo will accept and train a Harvard student during an elective “away” rotation with the understanding that Mayo students can be accepted and trained at Harvard should they so choose (an example from NYMC). These agreements are often non-existent between Caribbean schools and their US counterparts. If you plan on staying in the New York/New Jersey area and completing your residency training at one of the hospitals already associated with SGU, then this is not an issue. For those looking to enter competitive programs spread across the US, this is an issue that puts you at a disadvantage.

Finally, insomuch as residency program directors and medical school administrators represent an Old Boy’s Club (I have no idea if this is true or its possible extent) where a well-placed phone call can mean your application at the top or bottom of the stack, I wanted that resource available to me. I wanted to make sure that the clinicians that were teaching me were also faculty with my university and that their professional connections could be opened up to me should I impress them. Moving from the islands to the US left me with the feeling that my mentor, advisers and teachers were largely unavailable to me and that any influence they could have offered stopped in the tropics.

It is good to be aware of these concerns, but they are not unique to anyone. As an FMG, when it comes time for you to answer the “why transfer?” question at your interview, you are not setting yourself apart by regurgitating this. This may be fine since the interviewer is looking for someone that knows why he is doing something as opposed to being just another guy that heard he should apply for transfer since he has good grades, but it does not help the interviewer remember your answer.

Anymore, it’s hard to write.

It’s been hard to write for months. A lot of that was masked by my time in Asia, but really I didn’t want to write while I was there either. It’s strange to be surprised by yourself over something like this. I have always felt that writing was something that I had to do, but this isn’t the case.

I don’t have to write.

I’ve been thinking about everything that changed. So much of my writing before was driven. No one to have met me these last two years could help but concede that I was driven. Driven by fear of failure, by a desire to prove all the invisible people that thought I was less for being from the Caribbean that they were wrong, driven by competition with my classmates, driven to surprise everyone.

I’ve always taken a great deal of pleasure and satisfaction from RWT. The success of this space (as such a thing can be measured by the hit counter or your thoughtful comments) was always a source of pride. It’s nice to have an audience, especially when you’re convinced that you’re being ignored or dismissed. I’m not claiming that any of this was reasonable, but it was all felt just the same. But this space took a sharp turn in my mind in June and that change was really alarming. It’s part of why I’m stopping, but not the whole of it.

I saw RWT as a liability. I had never been as careful as I should have been with my anonymity, and several people have figured me out (especially those from my new Drexel class). I made it pretty easy, and this was foolish. RWT used to be a place where I pretended to be a writer. I tried to be funny, or shallow, or helpful, but recently I’ve needed this to be a space to vent and be laid bare. As I met with the hospitals in New York, I became incredibly disoriented and upset and I needed a place to scream at the top of my keys.

And then I thought of the people reading this. I thought about the admissions committees of different schools coming to this place and finding a student with light and dark sides, and I imagined them seeing this and rushing to judgment. We all, I think, would prefer to imagine each other as shiny happy shells and to show the rest is to risk the rest. As the days fell from the calendar without word from any of the schools to which I applied, I become more and more convinced that this was happening. True or imagined, the risk was real and I had previously ignored it.

I was stupid to do this.

And yes, I had the stupid argument with myself about “censorship” vs “honesty.” As regulars know, I deleted everything on this blog that was negative. Old posts, new posts, anything that could be seen as criticizing the medical establishment. I decided that transferring was more important to me than all the rest. After all of it, I was still being driven.

So my goal of transferring and keeping best faces forward (I’m a Janus, after all) meant that RWT was becoming less a journal and more a resume. Keeping something that sterile (at least for me) means writing very little worth reading. All of this worry was immediately followed with fantastic news. My worst fears were not realized; I was accepted into Drexel.

What happens to someone that gets what they want? For me, things fall apart. I don’t feel like celebrating (and didn’t when I was accepted). I was happy for the news and shared it with everyone that had been working on an ulcer with me (parents, mostly) but these things are never the way they play on television. The celebration is in the act, not the aftermath. Executing the interview successfully was a celebration. Submitting my application materials and coordinating my recommendations was a celebration. Studying for the USMLE and sitting for the exam was the celebration; the score was just the memento.

RWT has been my celebration of these last two years in the Caribbean and what I went through to get into a US medical school. I’ve gotten my wish and as a result I’m being redefined. My previous hurdles were my previous identity, and anymore I don’t feel like myself. Now I’m just a US medical student about to enter third year and there’s this huge part of me that wants to quit everything and just focus on being a great student. No more research, no more writing, no more side projects and whatnot. I want to lose myself and have a simpler life.

It won’t hold. I’ll find new challenges, find new roles and projects. Soon enough, I’ll have this new identity driven by new hurdles and I’ll want to write again. But if I start again, there’s no sense in repeating old mistakes. Choosing to continue RWT would be the first such mistake. The stakes are only going to get bigger and they drag the risk along with them.

I’ve also become complacent. Originally, I wanted to write and I’ve fallen incredibly short of this. I’ve done a good job of setting the levels academically and straining to clear them, and in this way I’ve accomplished more than I really thought I could have. But in writing, I’m so often running on autopilot. I can think of only one time where I ever challenged myself, and that was with The Old Man. I still think it’s the best thing I’ve ever written, and it kills me that it sits alone in my “creative writing” file. If I plan on chasing the dream of writing something worth reading some day, I’ve got to become unstuck from easy ruts.

Loss of anonymity, loss of drive, a sense that it’s time to start over and to break some bad habits. These are my reasons for ending this chapter in my life.

Finishing the Guide to Transferring and telling you a little bit about Asia are going to be my encores.  It should be good, so stick around.

Thanks for celebrating this with me, topher.

Things to do this week.

1. Write about the transfer process
2. Write four stories from my trip to Asia (with pictures)
3. Attend orientation at Drexel University and meet my new classmates
4. Explain to everyone why I am going to stop writing here at the Rumors Were True
5. Pack my bags, move to Pittsburgh, and start a new life.

It’s going to be a busy week.

Short version: many good things have happened.

Long version:

I took two months to study for the USMLE Step 1, a test that covers the first two years of medical school, and while in Cambodia on my 6 week tour of Southeast Asia, I found out that I scored a 240/99 (the goal I set for myself). While studying for this test, I began editing a review book (First Aid for the USMLE) just for fun and submitting my corrections and suggestions to the authors. They contacted me and asked for my CV, and now I am working for them and credited as an author on the 2008 Edition of the book. During this time, I applied for transfer to several medical schools in the US. Drexel University in Philadelphia invited me for an interview. What follows is the story of that interview and the outcome.

***

Forgive the writing style. For the last week, I’ve been reading The Remains of the Day which is narrated by a proper English butler.

Last Wednesday, Friday, this past Monday and this Wednesday, Drexel invited people to interview for positions in the 2nd and 3rd year. There are 5 spots available for 3rd year and 16 interviewees. There are 4 spots available for 2nd year and 21 interviewees. Of those interviewing for 3rd year, I know six very well. I chose to interview on the last possible day so that 1) I would be remembered best, 2) I would be compared to no one else on my interview day, and 3) to learn as much as I could from people that had gone earlier in the week. This worked out well.

With my little attache case filled with my updated resume, research papers, Welcome to Grenada guide, and a few other things I took the train from NY to Philly, slept the night at a Bed and Breakfast, and headed to the interview. There were eight other students interviewing this day (all for second year). I was the last to arrive before 9am and took the head of the table. I introduced myself to the room, memorized everyone’s name and school, and started the room talking (they were staring at each other when I showed up). I am now always aware that I am being evaluated from the moment I walk in the door and that certain things (like command of a room, ease with strangers) are things that are always on display. Having done this so many times in Asia, I was very comfortable.

My interview went well. I was interviewed by a woman with whom I had spoken once previously on the phone. I had heard from other students that they only had 30 minutes to interview and that it was hard to get their message across in that time. I was aware of this as I shook her hand and sat down.

She then stared at me for four seconds.

“I have some presents for you,” I offered, at which point I opened up my little case and pulled out my updated documents. “This is my updated CV, and I’m very excited about the newest edition. I can’t wait to tell you about it.”

“Ok, then tell me.” I then told her the story of the First Aid Errors, how the job was offered to me, and that I was now a Contractor for Dr. Tao Le to manage the online site for the books. I was glad to have this out in the open early. She then began to ask me pointed questions and the tone of the interview was serious. I got the strong impression that she wanted to flush out people that didn’t know what they were doing with their life as she asked, “Why Drexel? Why Medicine? When did you decide Medicine? What will you be doing in five years? What sort of projects will you do if you come here? Explain to me exactly how your research was conducted.” And so on.

Oh, and my favorite: Why not become a writer?

I did my best to maintain eye contact, avoid looking away, and to sit with back straight and forward from the chair towards her. I have read that this makes you appear more interested and interesting. At every opportunity, I would answer in such a way as to lead the next question and in this way I was able to talk enthusiastically about things for which I had real enthusiasm. This made it easy to smile and hold her attention in a way that drew a smile from her.

And with that, she asked if I had any questions. The night before, I had prepared six questions that sounded specific but were in fact broad and I figured this would cover me, but I ended up not using them. Instead, I asked about very practical things like, “Do Drexel students take advantage of international rotations?” I knew the answer to this, but asked anyway to bring up the fact that I understand the importance of being bilingual and have plans to do a rotation in Ecuador (with Aunt Lucy and Uncle Fred) and that I have already traveled and have stories to tell you that will kill some time and make you think that I am well-rounded and interesting.

I told her about Laos and how much I loved the people. I told her about filthy, filthy Cambodia and the Killing Fields. I told her about the motorcycle trip in Vietnam with Kelly’s heroics, our first stitches, and the pictures that I’d show her if only she’d accept me. The interview ended with her telling me that they would decide later that day (or possibly on Thursday) who would be accepted and that I would know either Thursday or Friday.

So the interview was split very much in two and while I handled myself as well as I could have in the first half, I think we both enjoyed the second half much more. After this, my day was over. I then went down to the bookstore, bought Drexel stationary, and wrote her the following letter.

Dear Mrs. XXX,

As a writer, I depend on stories. There is something extra and hidden between the lines of a good story that would be harder to see if stated simply. You can imagine a much more interesting version of “he went to medical school,” for example. As an applicant, I notice when others have higher scores and I worry that someone might not see my stories tucked between my A’s and B’s. I wanted to thank you for inviting me to interview; it was my chance to show you some of the extra and hidden parts of my life that otherwise might have been missed on paper.

For Drexel, I hope to become a great story.

Sincerely, Me.

I would have mailed it, but as I said, the decision was being made later that day. I left the envelope with her secretary and caught the train back.

***

After working on an ulcer all day Thursday, I was called at 6:00pm. Drexel offered me a spot in their 2009 class and I took it immediately. This weekend, I fly to Las Vegas to give a speech at an Anatomy Research Congress and to share the good news with my mentors there. I’ll be giving the speech, then flying back to New York to pack up my life in Brooklyn and move to Philly.

What a ride.

Thank you, everyone, for taking an interest in my stories over the past two years. The encouragement to continue writing is what opened up so many of the doors that I ended up walking through in medical school. I never could have guessed that they would have taken me here, and I wanted to celebrate this awesome thing with all of you.

Thank you so much,

Topher.
Drexel University Class of 2009.

The following is a list of corrections/suggestions that the readers of this site have submitted.  Thanks for contributing.

Miscellaneous

1. P.92, Collagen synthesis and structure
   1. In both Lipp Biochem (p47) and High Yield Histo (ch 5- p 45)say that both hydroxylation and glycosylation occur in the RER as does formation of the of procollagen (triple helix) from pro-alpha-collagen. In First Aid it says Glycosylation and procollagen formation occurs in the Golgi.
2. P. 109, Lipoproteins
   1. diagram of chylomicrons. Shouldn’t have Apoprotein A–A is found only on HDL particles.
   2. On second reading, perhaps CM do contain Apo A, but HDL seems to be the main location of Apo A.
3. P.139, Stains
   1. PCP appears also on page 139, and should be changed to P. jiroveci
4. P.155, Microbiology – Virology
   1. +ss RNA virus mnemonic

                                                              i.      Flava-flav is having a Retro Toga-Corona party in Pico Cali

1.       Flavivirus

2.       Retrovirus

3.       Togavirus

4.       Coronavirus

5.       Picarnovirus (no envelope)

6.       Calcivirus (no envelope)

1. P.158, Viral Vaccines
   1. MMR, with the R [Rubella] being in bold type, is indicated as being an egg based vaccine.  However, measles and mumps are the egg based vaccines, while Rubella is from lung fibroblasts
2. P.171, Protein synthesis inhibitors
   1. I changed the 50S mnemonic to: chloramphenicol, erythromycin, lincomycin/clindamycin, Linezolid. I did this because as you noted, lincomycin/clindamycin are in the same class, and they don’t mention linezolid, which is important as a 50S inhibitor used to treat MRSA.
3. P.201, Tumor nomenclature
   1. Benign: mature teratoma (women)
   2. Malignant: immature teratoma (women), mature teratoma (men)
4. P.250, Cardiovascular therapy
   1. positive inotropes raise cardiac ouput (the + sign and the down arrow are confusing)
5. P.303, Basophil
   1. in TAIL the I is not “Iron deficiency” but is “Iron Overload”
6. P.333
   1. It should mention that PAN is NOT associated with granulomas like Wegeners; also that PAN lesions favor branching points of arteries; Lastly, the last line under Churg-Strauss syndrome stating “often seen in atopic patients” should be followed by commonly has new onset or worsening of asthma preceding symptoms of vasculitis.
7. P.372, Neuromuscular blocking drugs
   1. Everything I have read says there is no pharmalogical antidote to succinylcholine (especially not an acetylcholinase inhibitor like neostigmine, which is what is written under phase II of the depolarizing NMJ blocker succinylcholine).
8. P.426, Lung relations
   1. The figure of the trachea and bronchi is confusing.  The right lung bronchus is shorter, wider and more upright when compared to the left main bronchus.  The figure has this relationship reversed.  See Gray’s Anatomy.

A friend asked in a letter,

Still thinking of being a people doctor? have you switched at all more toward research?

The question has been on my mind a lot, and I guess it had built up enough pressure. My response was disproportionate.

As it stands, I’m still curious about damn near everything. I have a folder called “million dollar ideas,” one called “essays” and one called “research.” I see problems everywhere and I love obsessing over solutions, and all of these interests pull me deeper into medicine. It’s just so deep and so wide, there’s enough room for anyone to lose themselves or find themselves. That’s why I’m here, I guess.

I’ve always joked with people when they ask me, “So why do you want to be a doctor?” My typical answer is that I’d be too bored with anything else, and that’s a half truth. I only see the rest when I work backwards:

I’d love to be a surgeon, but the malpractice risk and insurance along with dropping pay are off-putting, so I guess I want to be paid well according to my skill and don’t want to enter a field where that may not happen. I’d love to be a pathologist with all the time to write, do research, dissect. But I’d miss the patients. I’m reluctant to admit it, but I would miss the satisfaction that comes from someone you’ve treated thanking you with their eyes. Internal medicine is appealing for the challenge of trying to know everything about everything, but the patient exposure is above what I’d like and the pay seems off the worth. I guess I want to see people, but not all the time. I want to write, I want to teach, I want to cut, I want to cure, I want to be paid what I’m worth and I want time to enjoy the fruits and to share it with a family. I have two years left to figure out if anything fits those criteria, but from here things still look pretty messy.

I still don’t know what I’ll end up doing, but I hold fast to the belief that something fits. I want to transfer because I feel like I’m running out of time to make that decision cleanly. More exposure, more people, more resources and all of it right now would go a long ways to convincing me that I’d seen the field, taken stock, and decided on my future. If it turns out that there’s some unanswered question that I think I can tackle and is worth my life’s efforts, then I want to be exposed to it. I worry, a lot, that I’ll miss that opportunity if I stay with my current school.

The facilities, the people, and the open doors of a US medical school would be an embarrassment of riches for me at this point. In the time that I’ve studied with less, I feel like I’ve used everything available so that now, finally, I know how valuable those opportunities are and I’m ready to make the most of them. I’m praying for the chance.

Until that happens, I won’t know if it’s people or research.

Seen on the R subway line between Atlantic-Pacific and 7th street.

When it comes, will it come without warning?

Just as I’m picking my nose?

Will it knock on my door in the morning?

Or step in the bus on my toes?

Will it comes like a change in the weather?

Will its greeting be courteous or rough?

Will it alter my life altogether?

Or tell me the truth about love?

I still don’t know what “it” is. Any thoughts?

I have received a version of the following email half a dozen times in the last few weeks concerning when in the first two years of medical school it is best to begin preparing for the USMLE. Here is one response.

Knight

The extra mile here is tutoring. I tutored Anatomy, Biochemistry, Neuro and Physio. In this way, I had a full year’s exposure to each topic instead of the four month term. This was invaluable. What many people found while studying for the USMLE, I discovered in tutoring: it’s only the second time around that all the connections fall into place and the interrelationships become intuitive. I was a much stronger student for it.

In a nutshell: don’t buy a First Aid until it’s time (around 5th term, I’d say), do your absolute best in every class, regardless of how innane the material, and tutor with a friend for every class that you can. That, if done, should fetch you a fantastic score.

All the best, topher.

This comes from an email from two students in my year but a term behind at SGU.

You’ll do fine, just stay on schedule. Never break schedule. Worship the schedule. Hope it helps, toph.

P.S. Kelly never broke the schedule while I broke it all the time. I once spent an entire day on antiarrhythmial drugs, which you just shouldn’t do. I put off viruses, protazoa and fungi, cranial neoplasms, and a host of other topics due to time. Looking at my USMLE summary, these were where I lost all my points.

Finally, I am back in the States. I brought back with me custom-tailored shirts, shoes, and suits, a tan (no tattoos) and a few stories. It’s going to take me a while to get back in the swing of things, what with the big move to New York just around the corner.

One great thing that happened while I was gone was the posting of a preliminary errata list by the First Aid folks. After looking through the pdf, I’m thrilled to say that we have been thorough: fourty-three of the the fifty official errors were already listed here. Whether or not we were responsible for submitting them first is unclear, but at least we’re catching them. Five of the errors were added from readers of this site (thanks guys).

I’m going to spend the next few days going through what everyone has submitted and then updating each section, as well as the word documents. I don’t anticipate there being another major update before the July 15th deadline.

For those students asking about my transfer status, the schools to which I applied, etc.. I do not plan on addressing those topics until mid-June. Sorry to put it off.  The remainder of this week will include a few stories from Asia and a few miscellaneous thoughts about the USMLE before I put it behind me.

It’s good to be back.

I have many stories from the trip that I cannot wait to write but that will have to wait since they charge me by the minute to use the Vietnamese computers.  Greetings from Vietnam, by the way.

Dr. Le of the First Aid team just sent me an email, and the team now has their own blog for updates.  Still no forum for responding, but I’m sure that will come soon enough.  Thanks everyone for the suggestions and please keep them coming.  I have read them all, but (as described above) I cannot respond to them now.  Look for more come mid-May.

WOO HOO!

I’m in Cambodia right now and I just received my USMLE score after 3 weeks.

240/99

WOO HOO!

Decisions can be the once only, nip-it-in-the-bud kind of easy when you already know the why. And I’ve known the why about medicine even before the thought crossed my mind to become a physician.

What I do has gotta be consequential.

It’s gotta matter, writ large, even when it doesn’t feel like it does.

I’ve found the “so what” factor to be so pronounced, so severely a part of business that I can’t go on with that life, no matter the money.

Let’s think for a second about the majority of the new “rights” that the United Nations and many individual countries have attempted to confer upon all of humanity. These include things like healthcare and a “living wage.” These things violate the negative rights of others. Because healthcare doesn’t exist naturally, it must be created. To confer healthcare as a positive right, it must be confiscated.

1. What Exactly is Wrong With “Patient Care?” You use the phrase like it were some kind of swear word but isn’t this our purpose as residents?
2. What, exactly, is wrong with the current system of residency training and how would things work in the Pandaverse?
3. B-b-but Panda, you can’t possibly train a doctor without working him 80 or more hours a week as a resident. Are you saying that we need to extend residency training?

It took me only a few minutes to realize that answering May’s question was the least of my concerns: although Rosie had significant delays with stereotypic movements, her mother had deep cognitive deficits of her own that prevented her from understanding the depths of her daughter’s limitations. Although she had only slightly more comprehension than Rosie, it was enough to allow her to express one of her major concerns: “I don’t want her to grow up to be like me.”

Gibraltar is absolutely the most beautiful place I have ever been to. I am going to live there one day. Or at least own a home there. Or at least visit again. Or think about visiting. One of those.

The complete list of all the corrections/suggestions for the First Aid is now available for download as two Word documents in the First Aid section. All of the individual sections are updated as well.

I have cobbled together the best of my advice into a 6-week guide for the Boards. Expand or contract according to your whim.

I’m off to Asia, so I will be slow to respond to comments, suggestions and the like. I will read them all eventually, so please keep them coming. Thank you, everyone, for contributing. Everything here is better for it.

And with that, I am off!

All of this information is contained in the USMLE GUIDE.doc so that you can take it with you and not worry about your internet connection. I post all of it here for those that do not have Microsoft Word and so that people can find it through search engines. Hope it helps.

A word on this guide:

I just finished my second year at St. George’s University School of Medicine. Figuring out what you are going to do for the Boards is a pain in the ass and gets people nervous that they do not have a plan. Many of them sign on to Kaplan or Falcon for this reason. I would like to prevent as many people as possible from signing up for those courses for those reasons, as they are expensive and you are poor. I want you to have a plan, an idea of what to expect, and all of that free. I hope this helps.

A word on advice:

I am wary of most advice. It is often unqualified, and by this I mean that I do not know why I should believe in your expertise. Did you score well and are you willing to tell me the score behind this advice? Are you like me in that we learn, memorize, and study alike? What works for Peter may fail for Paul and it is good to keep this in the back of your mind as everyone begins to tell you what you should and should not do. The other problem that I have with a lot of advice is that I am not told the reason behind the conclusion. It is easy to say, “Just do questions”, but it is much harder to give a well thought out argument to support your advice. There may be an excellent reason, but many people do not think to ask for it or to give it. Also, it takes a fair bit of time.

If someone says that there is a lot of Embryo on the test, please kick him in the face. That sort of advice (even if it ends up being true) is worthless for planning. The most frustrating part of this whole experience is that n=1 and it is hard to draw conclusions from a sample size that small. You will wonder if you did it correctly, how you would have scored if you changed blah blah, and so on. That leads us to why I am writing this:

Medical school is great because it is the end of decisions. Decide to go to medical school. Three and a half years later: decide what kind of doctor to be. Three to five years later: decide which job to take. That is three decisions over ten years and medicine is great that way. I was so tired of making decision about how to study that I wished someone had done it all for me. This guide is meant to be a turn-off-your-brain and do-as-I-say outline so that you can save yourself from all of that. It is the guide that I wish someone had made for me.

A word on irony:

I am aware of the irony that I am writing a little guide filled with advice while not offering my score, telling you about myself, etc. What I can give is my reasons for each decision so that even if you do not end up following it, you at least see the problem of planning and studying as manageable. If you are interested, when I get my score I will post it and at that point, you can decide to continue using this guide or decide to forget everything written here. Deal? Now on with the show…

THE SCHEDULE

I am assuming that you are taking six weeks to study for this test. If it is shorter or longer, I have structured this so that it is easy to change according to your unique schedule. This schedule is built using the newest edition of the First Aid for the USMLE Step 1 (Systems based) as I think it is the best game in town and damn near everyone seems to own it. We need a calendar, and we need to divide it into two main sections: cramming and pre-cramming.

CRAMMING

Cramming is undervalued. I took an incredibly long time to prepare (9 weeks) so that I would not have to cram because (cue lame music) I wanted to really understand the material. Fair enough, but the last two weeks are for cramming. You can realistically cover two topics each day. Anything more and you are skimming. I have good reasons for each of these choices, but first you should just take a look at what we will call “the cramming”.

The day before the test, you will be tired of studying (more so). This is when you are most vulnerable to total mental collapse. A friend described it to me: “I opened up Micro to look over viruses once more before the test and I realized that I had forgotten how to read. It was as if my head had exploded onto the table and I could not pick it back up again. I postponed the test a week after that.” To avoid this, I advocate taking a half-day and seeing a movie. It was one of the few things that I did that worked.

Before you start this final sprint, take a day off. You have earned it. I think you should begin with Biochemistry because the meat of this subject is in the underpinnings of other diseases. A good look in the beginning will help you interpret things later on and will reinforce the pathways that actually matter. By putting this first, you effectively study it all week. It is a big topic, so it gets two days. Molecular genetics and Immuno cover some similar ground (signaling) and this is a nice lead in to Micro. I will make the same argument about Micro, that putting it this early means that you study it with every system to come, reinforcing the pathogens. It is big, so also earns two days.

Cardio and Heme/Onc are thrown together because of the pathology. For similar reasons, I have placed them next to Musculoskeletal. As you will find, the vasculitides are covered in Musculo, not in Cardio or Heme/Onc, so these three topics are overlapping in the First Aid which is why I have grouped them. Cardio, Heme/Onc, Gastro, and Musculo are also grouped because chances are that one of these topics is a strength for you, so going through that subject quickly allows a weakness in the others to expand into that day.

Neurology and Psychiatry are next to each other for the association. Neuro, unfortunately, is just too big to group with a second large topic, so this is as good a place as any to split up Behavioral with Psych (they pair naturally) and Biostats with Neuro. Renal and Respiratory are not as big as the other sections and this should make for a somewhat easier day. These are grouped together in hopes that you finally sit down and learn Acid/Base compensation. After two years, it is time.

Embryology is tricky. Most of it belongs with Reproduction and Endocrine while the rest is spread out among all the systems. The best advice I have is that you study the Embryology for each system in the morning before getting into the thick of each subject and save the Repro/Endocrine stuff for the end. That it is a hodgepodge also makes it a natural move to group it with Basic Pharmacology and Basic Pathology. These sections are short and represent a little bit of everything. If you give it a good read, it can pull topics from earlier in the week together and is not too stressful to be studying up to test day.

And with that, use the last day before the test to print out your permit, print out the directions to your testing center, and look over some topics that you had to skip. Try to force yourself to stop studying by midday and do something non-medical that night like watching a new movie with a friend. The night before my test I caught 300, and it was great to think about something other than pathways for at least those two hours.

PRE-CRAMMING

That was cramming. Now, onto pre-cramming. Since we have six weeks and I just stole the last two weeks for cramming, that gives us exactly 30 days to prepare. Remember that you are not preparing for the test during this period; you are preparing for “the cramming”. If you do not cover everything in a section in the time allotted, it will not be the end of the world. You will get another crack at it, at which point not getting to it will be the end of the world. Ready for the suck? Seriously, stay optimistic.

If you are a numbers person, we have 30 days to cover 329 pages of the First Aid, which works out nicely to 11 pages a day. This is a lazy way to weight things, but who cares? I have gone to the trouble of counting each page per section for you, and arranged the following. Here is the first two weeks.

We start out with something general and familiar: the basics. Most of the connections in this section went over my head and I did not pull them together until the end, but it is nice to have the early exposure and to ease into this whole thing before the real subjects start. This brings us to Biochemistry. It is big and intimidating for a lot of students and three days does not seem like enough, but it has to be just three days. First, we give it two full days in the last two weeks of cramming. Second, the other subjects need to be given time and are likely higher-yield.

It does not let up as Biochemistry feeds into Immunology and Microbiology. Again, three days is not enough to cover Microbiology, but the other subjects need to be covered and we give Micro two full days during cram week. Behavioral science and Biostatistics are meant to be your first break. The ground of Behavioral science will be touched again during Psych, and Biostatistics is not that big. You can either take half the day off or use the extra time on Micro. As always, make sure you are not seeing anything for the first time during “the cramming”.

Embryology is just not big enough to get its own day and should be learned in pieces with each system that follows. What is important for now is the developmental aspect. You can combine it with the first day of Endocrine (as I have done) or group it with Reproduction, does not really matter so long as you get to it. I think these three topics together makes each of them stronger, and this might be the first time you really understand the menstrual cycle.

The second two weeks begin the systems. I was taught subject-based, but for the type of thinking that makes for good test scores, the integration that comes with doing Anatomy, Physiology, Pathology, and Pharmacology together just cannot be beat. If your school taught this way then this is old hat for you, but for me it was a shock to see all the new connections.

We begin with the Cardio/Heme/Onc/Musculoskeletal combination for the reason I described earlier. Cardio looks big in the First Aid and the pharmacology of Heme/Onc can be intimidating. Just remember that “screw it, I’m just not going to know that” is a perfectly good assessment for some of the material and if you can make peace with that, you will be less stressed. It probably will not be on your test anyway. Or you fly through these sections and earn a day off.

Gastrointestinal is there because where else would you put it? Renal and Respiratory go together with their acids and bases, and this brings us to the skull. Psychiatry is a new section with the First Aid and I think they have done a good job. It may bleed over into Neuro (as far as BRS and other review books go) but the two of them together get four days now and two more days during “the cramming”.

All together now:

If you are taking less time or more time, you simply shave or add a day here and there from one of the blocks in the first four weeks. I do not think it is a good idea to steal or add days from “the cramming” as this is a period favored by the gods. Why not add? “The cramming” is the period where you realize that everything you are reading is the last time you will get to see it before the test, and this is a shocker if you have not prepared for it. Cramming is also useful in the short term, and once you extend that period past two weeks, I think it is a hard argument that your short-term memory is still holding onto the lessons in the first days. Just my advice, but then again I could have done poorly and you should ignore all of this. You can access this calendar online. The dates used are from May 20^th, 2007 – June 30^th.

QUESTIONS

Which QBank is the best? USMLE WORLD. But that would be shitty advice, right? I could just cut and past the whole thing here, but I would like to keep this file manageable. Please read my evaluation of free questions and Qbanks available online.

BOOKS

Everyone is chasing after that magic bullet: the high-yield book. My experience was that few books can pull this off well and that most try to be miniature textbooks and are unmanageable in the time you have (HY Cell and Molecular by Dudek, HY Neuroanatomy by Fix) or are bare bones and do not help you make many connections (BRS Path). After spending a good chunk of change on these review books, I should have just covered the material in the First Aid using my own textbooks. Most of what you read you will not have to look up (because you learned it) and the things you do look up will be surrounded with full explanations. Anything less than a full answer is annoying and wastes time (if, like me, you tend to dwell). If you have played it correctly, you should also have old review notes from your courses and it is always easier to remember what you used to know instead of starting from scratch with everything. By the end, I was using Golan’s Principles of Pharmacology, Robbins’ Basic Pathology, and the Merck Manual. The Pathology BRS by Schneider and Szanto was useful as an outline (which I used to focus on Robbins) but the questions for each chapter are absolute crap. Costanza’s Physiology BRS was good in parts and her questions were reasonable, but there are a few uncovered topics.

FIRST AID

I tip my hat to Graham Azon of Over!My!Med!Body! for this piece of advice: put the First Aid in a binder. I took my copy to an Office Max, had the spine cut off and the book three-hole-punched, and put it into a 1.5” binder. Best move I ever made. I was able to take separate notes and include them exactly where I needed them and I was able to take my notes from previous courses and include them (my roommate expanded the book to fill two 1.5” binders). It is hard to overstate the advantage of having everything you need in one place.

THE EXAM ITSELF

It is hard to anticipate the pace of this test. When doing timed questions in preparation, there were instances where I would finish with 10 or 20 minutes left. I thought to myself, “Self, you’re going to have plenty of time to look over questions in each block”. I was wrong. On test day, I had around 10 questions marked per block that I wanted to give a second look and two minutes to do it. It was unexpected and unsettling, and for this reason I wished that I had taken the NBME practice test at the center. It is worth it just to remove the final few unknowns for test day.

The clock counts down for each block while you move up the list of questions. Unless you are willing to do the calculation (even subtraction can be stressful), it is hard to know how fast you need to move to finish. For pacing purposes, I ended up starting each block with question #50 and ending with #1. This way I knew exactly how many extra minutes I had to devote to problems as I went along and it helped me gauge whether I had to come up with an answer now (because I was falling behind) or could mark it for later (since I had a seven minute cushion). I would do this again.

I am thankful for the advice I received from a stranger: “You are going to walk out of the test with incredible relief that it is over. This will be mixed with some despair since you will think that you failed. It is over. You did not fail. Everyone feels that way.” He was right, and every one of my friends has echoed it. I went from relief, to defeat, to anger that I had not done better. A week later, I feel “okay”. When you go through it, remember that you are not the first, not the last, and it is normal.

Hope it helps, topher.

I am interested in a lot of things and I have many hobbies.  It’s an adverse effect of loving learning for its own sake and it leads to the familiar label: jack of all trades, master of none.  And so it is with medicine.  I do not know where I belong, and I feel torn between the worlds of medicine, law, and business.  That they often overlap should come as some conciliation, but it just muddies the issue for me.

So what is one to do?  I try to seek the advice of people I think are learned.   I am trying to decide whether or not to become an MD, MD/JD, or an MD/MBA.  I have a relative who works in the State department.  He’s as sharp as they come, and has the enviable life of traveling to a new country every three years to learn their language, represent the US, and manage the affairs of foreign relations and immigration (as I understand it).  He comes from physician stock so he is no stranger to the world I am entering.  He has an MBA and he has many smart friends with JDs.  He seemed like a logical person to ask.

But within the first few moments of speaking with him, I heard so much that betrayed that impression.  Why do people think that it is “okay” for physicians to work for less and less pay because medicine is so expensive?  How can they keep a straight face when saying, “Well it’s one of the qualities of a physician that no matter what the conditions, no matter the pay, that they are healers and will help people”?  Why do people think that because my future livelihood is invaluable means that they can strip away its monetary value?  Shouldn’t it be the opposite?

To all of those that say, “Even if you are payed less in salary, there are other benefits such as the gratitude of your patients and that is a sort of payment”, I ask you: why should they be separate?  When I pay someone to fix my car and they do a fantastic job, I am grateful AND I pay them what they are worth.  Why, in medicine, do you think it’s okay that they are separate?

Why?

As always, comments are welcome. I’m sorry to say that I did not do a good job reviewing the section on viruses as this is my weakest subject.

Microbiology

1. P.137, Bugs with exotoxins
   1. Bordetella pertussis does not stimulate adenylate cyclase, it instead inhibits GTPase. This differentiates its action from that of cholera toxin and the LT toxin of E.coli, whose actions stimulate adenylate cyclase.
2. P.140, Intracellular bugs
   1. For facultative intracellular, I offer the following:

i. My Liege, Your Niece Lists Frank, Bruce and Sam.

ii. Mycobacterium, Leigonella, Yersinia, Neisseria, Listeria, Francisella, Brucella, Salmonella.

1. P.144, Lactose-fermenting enteric bacteria
   1. After including Serratia, change the mnemonic from “lactose is KEE” to:

i. “Test lactose with MacConKEE’S”.

ii. Citrobacter, Klebsiella, E.coli, Enterobacter, Serratia.

1. P.145, Bugs causing diarrhea
   1. O157:H7 should refer to Enterohemorrhagic E.coli (EHEC), not Enteroinvasive E.coli.
2. P.150
   1. The heading “Microbiology-Mycology” is on the wrong page, and should be on P.151.
3. P.152, Pneumocystis carinii
   1. This microbe is now referred to as Pneumocystis jeroveci.
4. P.154, Medically important helminths
   1. There should be some mention that Schistosomiasis can cause granulomas in the bladder and has a role in Squamous cell carcinoma of the bladder.
5. P.163, HIV diagnosis
   1. A test with high sensitivity has low false-positives, not high. A sensitive test with high false-positives indicates that there is low prevalence of the tested disease in the population. It is more appropriate to use NPV for this type of statement.
   2. A test with high specificity has low false-negatives, not high. A specific test with high false-negatives indicates that there is a low prevalence of the tested disease in the population. It is more appropriate to use PPV for this type of statement.

i. You may not think that these distinctions are important, but they are. Sensitivity and specificity are qualities of a test and do not change depending on the population tested, but a test conducted in Africa (where prevalence of HIV is high) versus the same test conducted in the US (where the prevalence is low) will have different PPVs and NPVs, i.e., different numbers of false-positive and false-negative results.

1. P.164, Prions
   1. Fatal Familial Insomnia should be included in this list of Prion diseases.
2. P.169, Bactericidal antibiotics
   1. I think that Rifampin, daptomycin, the combination treatment SMX/TMP and the polymyxins should be included in the list of cidal drugs
3. P.169, Methicillin….
   1. “Don’t need MeNDing: Methicillin, Nafcillin, Dicloxacillin”
4. P.170, Cephalosporins
   1. The MTT group responsible for the disulfiram-like reaction is only found in 2^nd generation cephalosporins cefotetan and cefamandole. I think it’s worth changing to “(in 2^nd generation cephalosporins with a methylthiotetrazole group, e.g. cefamandole and cefotetan)”.
5. P.172, Macrolides
   1. I think it’s worth mentioning that Erythromycin is a potent inhibitor of P450, that Azithromycin is used in prophylaxis of MAC, and that their clinical use is for atypical pneumonias.
6. P.172, Clindamycin
   1. Lincomycin is listed on P.171 as one of the 50S inhibitors, but it is not mentioned that this drug belongs to the same family as Clindamycin. I think this should be changed to “Clindamycin, Lincomycin”
7. P.173, Trimethoprim
   1. I think that the following grouping is interesting:

i. Methotrexate – inhibits human Dihydrofolate reductase

ii. Trimethoprim – inhibits microbial Dihydrofolate reductase

iii. Pyrimethamine – inhibits parasitic Dihydrofolate reductase

1. P.176, Antifungal therapy
   1. The antimicrobials were listed as being either cidal or static, but this is not done for the antifungal drugs. I think this should be included with each description.

i. Polyenes (Amp B and Nystatin) – cidal

ii. Azoles – static

iii. Flucytosine – cidal

iv. Caspofungin – cidal

v. Terbinafine – static

vi. Griseofulvin – static

I’m working on the Microbiology section now and it will be up shortly. In the meantime, I’m compiling all of the errors/suggestions/figures into Word documents so that you don’t have to keep clicking around here (you can all thank Jarrad for this).

Each section will be updated seperately, but for those following along, it’s a pain in the ass to recheck. Here are the most recent additions:

Miscellaneous

1. P.204, Paraneoplastic effects of tumors:
   1. Hepatocellular CA is also capable of expressing erythropoietin as a PNP syndrome.
2. P.218, Sympathomimetics
   1. Clonidine and a-methyldopa are centrally acting alpha-2 agonists. They are listed here as simply “alpha”.
3. P.230, High-Yield Clinical Vignettes
   1. The sixth vignette concerning Temporal Arteritis belongs in the Musculoskeletal section as this topic is not covered in Cardiovascular.
4. P.231, Auscultation of the heart
   1. Pulmonic Area: Pulmonic stenosis is a systolic murmur, not diastolic as listed
   2. Tricuspid Area: ASD is a soft midsystolic murmur on the upper left sternal border, not a diastolic murmur as listed (Merck, 18^th, p.2407)
   3. You might as well label the Left sternal border as Erb’s Point.
5. P.242, Eisenmenger’s syndrome
   1. “As pulmonary resistance [up arrow], RV hypertrophies, the shunt reverses…”
6. P.243, Coarctation of the Aorta
   1. “Infantile type: …of ductus arteriosus (preductal). Rapidly fatal.”
7. P.249, Bacterial endocarditis
   1. “(round white spots on retina surrounded by hemorrhage)” should be placed after “Roth’s spots” and not after “Osler’s nodes”.
8. P.263, Adrenal Steroids
   1. 3B-hydroxysteroid dehydrogenase is listed as 33-hydroxysteroid dehydrogenase.
9. P.284, Salivary secretion
   1. Serous on the Sides (Parotids)
   2. Mucous in the Middle (sublingual)
10. P.290, Stomach cancer
    1. Virchow’s node – involvement of left supraclavicular node by mets from stomach.
11. P.293, Colorectal cancer
    1. “’Apple core’ lesion seen on barium enema x-ray.”
    2. I think it’s worth mentioning that colonic adenocarcinoma is most commonly found in the Ascending colon.
12. P.293, Cirrhosis and portal hypertension
    1. Because of the role that cirrhosis plays in increased levels of estrogen and the effects that these estrogen levels have, I think the following symptoms should be grouped:
       1. Hyperestrinism
          1. Spider nevi
          2. Gynecomastia
          3. Loss of Sexual hair
          4. Testicular atrophy
          5. “liver palms”
13. P.297, Carcinoid
    1. There should be some mention that the “Classic symptoms” refer to carcinoid syndrome, and that this occurs only after metastasis of the carcinoid tumor to the liver.
14. P.298, H2 blockers
    1. Cimetidine and Ranitidine [down arrow] CR clearance.
15. P.298, Bismuth, sucralfate
    1. I think it’s worth mentioning that bismuth is directly toxic to H.pylori.
16. P.300, Pro-kinetic agents
    1. Metoclopramide’s anti-emetic effects are due to central D2-antagonism while it’s peripheral pro-kinetic effects are due to its M1 agonism. I think this should be mentioned.
17. P.315, Histocytosis X
    1. There is no mention of Birbeck granules on EM in this section, despite the fat that on P. 439, this is the classical finding for Histocytosis X.
18. P.327, Osteopetrosis
    1. “chalk stick” fractures are characteristic of Osteopetrosis but are not mentioned here. They are instead mentioned on P.328 under Paget’s disease.
19. P.328, Polymyositis/dermatomyositis
    1. Under dermatomyositis, I think it’s worth mentioning the Gottron papules over the knuckles and the heliotrope rash.
20. P.332, Primary bone disorders
    1. Osteosarcoma is listed as the “Most common [primary] malignant tumor of bone.” As stated on P.312, multiple myeloma is the most common primary malignant tumor of bone. I think that “(excluding multiple myeloma)” should be added.
21. P.335, Arachidonic acid products
    1. “Neutrophils arrive B4 others” to help remember that LTB4 is neutrophil chemoattractant.
    2. “LTC4 Contracts”
22. P.367, Herniation Syndromes and Uncal Herniation
    1. By far, the best figures to illustrate each of these sections can be found in Fix’s High-Yield Neuroanatomy. His descriptions are confusing and would have to be changed, but please consider Fig. 2-2 and Fig. 2-3 for the next edition.
23. P.401, Wilm’s Tumor
    1. Hemihypertrophy is seen in Beckwith-Weidman syndrome with deletion of the WT2 gene, not in Wilm’s tumor with WT1 deletion.
24. P.401, Transitional cell carcinoma
    1. Schistosomiasis is responsible for bladder wall irritation, leading to squamous metaplasia and then squamous cell carcinoma. It is less often responsible for Transitional cell carcinoma.
25. P.433, Pancoast tumor
    1. There is no mention that Pancoast tumors can invade the lower portion of the brachial plexus (nerves T1 and T2). I think this should be mentioned as vignettes commonly have paresthesias in these dermatomes.
26. P.439, Classic Findings
    1. C-ANCA, P-ANCA – polyarteritis nodosa is listed. This contradicts P.333. This should be changed to “microscopic polyangiitis”.
27. P.450, Most Common Associations
    1. H. Influenzae type B is no longer the primary cause of bacterial meningitis in kids and E.coli is not the primary cause of bacterial meningitis in newborns. The causes are in the correct order on P.165. Group B strep in newborns, S. Pneumoniae in children.
28. High-Yield Images, Image 12
    1. Left ventricular hypertrophy typically involves an expansion of the cardiac outline on both the right and left of the mediastinum. Right ventricular hypertrophy typically expands the cardiac outline left of the mediastinum alone. This picture looks like the “boot shape” of RVH.

As always, comments are welcome

Reproductive

1. P. 414, Reproductive Pathology
   1. There is no section for vaginal pathology. I think the following should be added:
      1. Vaginal Carcinomas
         1. Squamous Cell CA – typically an extension from the cervix
         2. Clear Cell CA – seen in women exposed to DES
         3. Sarcoma Botryoides – rhabdomyosarcoma variant. “bunch of grapes”
2. P.417, Polycystic ovarian syndrome
   1. One of the ways to treat PCOD is with clomiphene, which is neither an OCP or a gonadotropin analog. In women with PCOD that want to conceive, clomiphene is used. In women that do not want to conceive, oral contraceptive pills are used. I think that clomiphene should be included in the treatments.
3. P.417, Ovarian non-germ cell tumors
   1. Serous cystadenocarcinoma is responsible for 50% of ovarian carcinomas, not 50% of ovarian tumors.
4. P.418, Breast tumors
   1. I think “commonly found in the upper outer quadrant” should be included in the general description of malignant tumors.
   2. Invasive lobular – often multiple, bilateral. Cells in Indian file.
   3. Paget’s disease of the breast – ….suggest underlying ductal carcinoma.
5. P.418, Common breast conditions
   1. Cystic – fluid filled. “Blue dome“
   2. Fat Necrosis, …..Pendulous breasts
6. P.419, Cryptorchidism
   1. I think the following should be included:
      1. Leydig cells spared – [up arrow] FSH, [up arrow] LH
      2. Increased risk for seminoma, embryonal germ cell tumors.
7. P.419, Testicular germ cell tumors
   1. Seminoma – radiosensitive
   2. Yolk sac (endodermal sinus) tumor - infancy and early childhood
8. P.420, Clomiphene
   1. Under clinical use, I think it should include “induce ovulation in PCOD”

Return to First Aid Errors page.

As always, comments are welcome

Psychiatry

1. P.379, Other anxiety disorders
   1. “Anxiety disorder – emotional symptoms (anxious, depressed mood) causing impairment following an identifiable psychosocial stressor within the last three months (e.g. divorce, moving….”
2. P.379, Malingering
   1. I think it’s worth adding: “Patient avoids treatment and complaints cease after gain.” This is in contrast to factitious disorder where the patient undergoes treatment ( e.g. surgery) and the complaints recur (grid abdomen).
3. P.381, Eating disorders
   1. A useful distinction between anorexics and bulimics is that anorexics have incredible control over their eating, while bulimics have no control over their eating. Anorexics are often perfectionists while bulimics are often shoplifters.
4. P.381, Substance Abuse
   1. Substance abuse does not require dependence as stated.
5. P.387, Monoamine oxidase (MAO) inhibitors
   1. Atypical depression is characterized by mood reactivity (the ability to feel good when something positive happens) and reversed vegetative symptoms (such as overeating and oversleeping). It is not characterized as accompanying “psychotic of phobic features” as described.

Return to First Aid Errors page.

As always, comments are welcome.
Heme/Onc

1. P.302, High-Yield Clinical Vignettes
   1. The patient presenting with macrocytic megaloblastic anemia that receives folate (when a B12 deficiency is to blame) is not at risk of masking signs of neural damage. The neural damage is either present or not. This should be changed to:
      1. “Masks signs of anemia while allowing neural damage to progress with vitamin B12 deficiency.”
2. P.303, Basophil
   1. Bosiphilic stippling is scene in RBCs, not Basophils. “Basophilic stippling is seen in TAIL” should be moved to p.307 with the other “RBC forms.”
3. P.307, Blood groups
   1. I think it’s worth mentioning that the Rh+ and Rh- is referring to the D-antigen.
4. P.308, Anemia
   1. “Macrocytic” should include “hypochromic”.
   2. The category for “Microcytic hyperchromic” is missing and should list Hereditary Spherocytosis and Hemolytic Anemia.
5. P.311, Lymphomas, Hodgkin’s
   1. I do not understand why this is listed as “more common in men except for nodular sclerosing type” since nodular sclerosing type is the most common form of Hodgkin’s lymphoma.
6. P.313, Leukemias
   1. I think it is worth mentioning here that ALL is the most common childhood malignancy and pointing out the association between basophilia and CML.
7. P.320, Etoposide
   1. This is listed here as G2-phase specific. It’s activity is both in S and G2-phase and this is correctly illustrated in the figure “Cancer drugs – cell cycle” on page 318.
8. P.320, Tamoxifen, Raloxifene
   1. These drugs have different activities but are described together, and this leads to confusion. Tamoxifen is a receptor antagonist in breast and a partial agonist in the endometrium, but it is not an agonist in bone nor is it clinically useful in preventing osteoporosis. Raloxifene is an agonist in bone and an antagonist in breast and endometrial tissue and is useful in preventing osteoporosis. To recap:
      1. tamoxifene has no activity in bone and is not used for osteoporosis.
   2. I think this section should be rewritten to:
      1. Tamoxifene: receptor antagonist in breast, partial agonist in bone, no bone activity. Useful in treating breast cancer. Increased risk of endometrial CA.
      2. Raloxifene: receptor antagonist in breast and endometrium, receptor agonist in bone. Useful in treating breast cancer and preventing osteoporosis. No increased risk of endometrial CA.

Return to First Aid Errors page.

It’s done. At eight o’clock tonight, I sent out the last FedEx package and now my home is empty of all things “transfer”. A few schools wanted to know what high school I attended. Even after two years of medical school and having taken the boards, they still wanted to know what my undergraduate science GPA was. Will you ever stop haunting me, 3.145 Science GPA?

I’m past the point of handling AIDS kittens for the homeless Inuit clans of Alaska, so I had to scratch real hard for an essay topic.

Would it surprise you that for all the writing that I do, I can’t write a personal statement to save my life? That’s not true. I can’t write a good personal statement to save my life. I’d love to post all of them here so that we could all share a hearty laugh, but I’ve decided that I’m competing with other students and the advice here is too easy to find. I’ll post them all after the last deadline of June 1st. We’ll laugh then.

I was sort of shocked at how much of a pain in the ass it all was. It took three solid days of inefficient work to get every application, every transcript and test score, every recommendation and every check heading in the right directions. One school wanted my reasons for transfer. Another wanted my compassionate and compelling reason for transfer. Another wanted the name of the family member dying of a flesh-eating bacteria that was already attending their medical school whose care would require my transfer so that I could be by her side as we both wrote SOAP notes. But only if I was a resident of the state.

It stretches my imagination none to think of students looking at some of the applications that I just waded through and deciding, “Screw it. Not worth it. I’ll apply somewhere else.” I hope they all do.

Imagine my surprise when the brand new Thieme Atlas of Head and Neuroanatomy arrived in the mail today. I don’t remember ordering this, though the invoice clearly shows that I paid for it online the night that I took the USMLE. This means that I must have been drunk with a credit card, and I decided to order an Anatomy Atlas. Does anyone else do these types of things? Am I the only one? Do I keep it?

Of course I keep it; it’s beautiful. Onto the links.

But in those dark hours between signing the consent forms and prepping The Missus for surgery, I slipped down to the hospital chapel, locked the door and laid myself bare.

I’ve been shot at and narrowly missed. I’ve been in more than a few situations when the feces have struck the thermal agitator and everyone else was lost in the fog of panic, and I like to think that I rarely lose my cool. I’ve always thought of it as my gift.

But I found out I can be paralyzed by fear. And so on that night, I laid my head on that communion rail and I wept and I made bargains with God and I promised that if He would let my kid live, I’d do anything that He asked.

Him: “What are you staring at?”
Me: “I’m just waiting. If I’m right, you’re gonna puke any second now.”

George Orwell in his classic dystopian novel 1984 invents a nightmarish world where, in the time of Big Brother, the very language was being modified to prevent both the expression of dissent and its conception. In the novel, the Party sought not only to eradicate words that could lead to the discussion of thoughtcrime but to prevent even the possibility of it.

In a similar manner, residents lack the conceptual vocabulary to protest their obvious mistreatment and, because they are unable to frame the debate in any other terms but that of the establishment’s brand of Newspeak, they are reduced to sheepishly shuffling their feet and muttering vague self-centered sounding complaints.

Kelly and I are sitting next to each other, each in our own cubicle. Our tests are different, our questions are different. After 9 weeks of 12-hour-a-day studying, we’re ready for everything and anything.

Kelly starts his block and sees an easy one:

Q: Which of the following amino acids is involved in the synthesis of Dopamine?

That’s easy. Phenylalanine to Tyrosine to L-Dopa to Dopamine to Norepinephrine to Epinephrine. He knows the name of each enzyme, the cofactors necessary, what symptoms you would see with a block at every step, and where the Cu2+ comes in to play. He prepared for questions this stupid. This is a joke. He looks down at his options:

A through J.

Chemical structures!

***

“Topher, I came so close to just tapping you on the shoulder and making you look at that question. I didn’t really care if they kicked me out and I forfeited my test, it was just that ridiculous. What do they want from me? Answer me that. What do they want from me?”

“I think they want you to fail, Kelly.”

“It’s not even clinically relevant. That’s what kills me. Even if I knew that, it doesn’t make me a better doctor.”

“You’re wrong, man. You just killed a patient.”

If someone receives multiple blood transfusions and becomes hypocalcemic, it’s because there are chelating agents in stored blood products. If an astronaut is in space for 30 days, his muscle and bone mass will start to decrease and he’ll lose calcium to his urine. If a woman comes in with uncontrolled diabetes and hypertension, eats red meat three times a day and is an alcoholic, the best thing you can do is form a “therapeutic alliance.”

If a grandmother insists that you treat her grandson with chamomile tea, do not sit her down and show her your diploma to remind her that “you are a doctor, and she is just a grandmother.” Also, don’t tell a patient with poor lung function that continuing to smoke is “a complicated and roundabout form of suicide.”

These are the lessons that I learned yesterday while taking the USMLE. It was long, the breaks were short, and I felt rushed with every question. It was challenging and fun.

I really don’t like not knowing my score.

The best thing about the whole thing is it being over.

I don’t ever want to take a test like that again.

Thank you, everyone, for the well-wishes.

So I felt pretty good about my preparation. I had kept to my schedule, more or less. I had kept current with questions, spent as much time as I needed to on special topics like acid/base, PV Loop, etc. And through all of this, I never felt too upset if I had to leave a page or two from each section for later, so that I could “come back to it when I had the time.”

And that’s exactly as it’s gone. There’s just one problem with this system: it fails in the last week. I never anticipated the change, but there came a point about a week before this coming test when I realized that every time I was reviewing something, it was the last time I was going to see it before the test. After spending two months looking over everything with a sort of focused laziness, I had set up a pretty stressful situation.

The reason I wanted to take so much time to prepare was to completely avoid this stress. Sigh.

So now, reviewing is an exercise in abuse. Oh yeah, I remember not remembering that fact that I’m not going to remember in a second or two. Hope to God that isn’t on the test. Repeat. Repeat. Repeat.

It’s the feeling of losing. I set out to hold everything in my head, and reviewing is just hammering home that no matter how much I prepared, it was just going to keep falling out, falling out. Every reread line re-remembered is testament.

I feel like I’ve stepped into the ring, seen my opponent, and gone four out of the five rounds. He’s stronger, faster, bigger. Through the blood, I can barely make out that he’s joking with his coach; that he’s not tired. The judges are looking at the girls with the placards, sharing cigars, not worrying about the last round since no effort on my part could change the ruling that is so cemented. I look at my coach.

“Coach, this fight is over. I can’t beat this guy. I’ve already lost.”

“I know, kid. But that doesn’t matter. Rules is rules. You have to fight the last round even if that means he kills you.”

With three days left, I stagger up. I slap my gloves together hoping the thud stirs some lost adrenaline. My legs change places not from heart, but from habit. I meet him in the middle and tense for the blow. The futility.

Meh. I have this imagined responsibility that I should point people towards things I read in the week that are worth sharing. If you don’t read at least a few of these, then we have to work through some trust issues.

By the way: males starting about age 14 are asked, “Do you use condoms when you have sex?” thus forcing the explicit answer, “I don’t have sex.” I call it the “Have you stopped beating your wife yet?” approach.

Problem is, these are subjective criteria. What typically happens in the MSM is that, by some quite mysterious process, an editor or publisher decides that some particular person with opinions would make a good pundit, whether its because of the sparkle of their prose or the cut of their jib. A column or regular TV appearances are granted. And then, amazingly, they’re in forever. Rarely are columnists fired for not making sense; once they claim that status, they tend to keep it, no matter how pointless or uninformed their work turns out to be. It’s as if the NBA drafted players straight out of high school, but then they never had to play a game; they all just received long-term contracts, with salaries based on how good they look during lay-up drills and dunk contests. Maureen Dowd will be taking up space on the New York Times Op-Ed pages for decades to come.

The medical director of my clinic once gave me a book on burnout. I never read it. Didn’t have the time or energy.

Because a young reader considering a career in surgery referred to stories he’s heard of depressed and disappointed surgeons and asked for my thoughts, I’ll try to address it. Parenthetically, I’ve heard from more than a few readers that my blog and/or book has inspired them to consider surgery as a career. Don’t know whether to smile proudly, or shoot myself.

His rant continues beautifully in the second post, Burnout: Fanning the Flames.

A wise man would concoct a lie. A creative fellow would contrive a plausible story. A careful man would consider his words before delivering an answer.

I blurted out the truth.

“So, Mr. Kelso, what brings you to see us today?”

From top to bottom Mr. Kelso is a walking pathology textbook. An impossible combination of signs, symptoms, and disease who is probably only alive because his many comorbidities haven’t decided which will have the honor of finally dispatching him.

I want to trust people and I don’t want to be scared or suspicious. Being low level scared would be a constant drain. It would cost me some slight mental processing to be assessing risk. It would take energy to feed the nervousness. It would be weigh slightly on the don’t-do-things side of the scale, where sloth and inertia are already plenty heavy. Years ago I decided that I am not scared. I believe in probabilities, I decided, and scary people are rare.

Looking at his blood test results during a quiet moment in the hospital tonight, I can see that he is dying.

Through the computer screen, he is as far away from me as I was from him on that day, when he opened the conversation that I quickly closed. If I had listened to the meaning of his words and his unmuffled voice, maybe I would have heard what he was asking me–if it was OK for him to let himself go.

I should have taken off the stethoscope.

The test is a week away. I expect the next few days to be a blur, filled with stomach pits, flipping pages, nervous questions and highlighters. But we’re professionals, and we’re comfortable with the worry.

We started on January 4th. That was two months and a handful of days ago. We’ve put in (conservatively) 600 hours for this one test. This one test with its terrifying 350 random questions. This test with the two-year scope.

I have developed personal relationships with the authors. I think Glasner is a genius, that Dudek mailed it in, that Sczanto and Schneider have the worst questions imaginable, and that Costanzo has more than a few blindspots. Fadem needs to get an MD. The Merck is my bedrock; the Robbins is my quick consult; the First Aid is my rough guide.

The boys at WebPath, Tulane’s Pharm, and UW keep me honest. I can pretend to know so much more than I do, and it’s these guys that call me on the bullshit. That, and all the people reading the First Aid Errors that point out mistakes I’ve made. Thanks, to everyone.

And thanks to everyone that had something encouraging to say when I felt that thing were going to shit, that I was fucking it all up, and I just wanted it to be over. Shortly after I changed scenery, changed my routine, and found my stride.

I’m writing this down so I don’t forget that no matter how rough it feels in this next week, I was in the right place when it started. Over all the tests, Kelly and I have developed a program. When Grenada was invaded by American forces after the communist coup, the operation was named “Urgent Fury”. Dorks, we know, but we’ve always tried to bring that silly intensity to the last week of studying before any test. And so we’ve named it “Operation: Urgent Knowledge”. During this period, all knowledge is urgent and will be memorized urgently. Tomorrow, it begins and I’m giving myself a moment to reflect on it all.

I have a line of sight to the finish, and goddamn it feels better than I thought it would.

It’s the morning, and I’m pissed off. I hate the mornings, and for a good two hours after I wake up I will respond to everything with grunts and fuck-offs. This morning, the window is extended because we’re covering Psychology. I’ve written before here and here about my love-hate relationship with this field. I’m fascinated by the science and the ability to so expertly manipulate someone towards their own health. And I hate the greyness of it. The discipline seems too much organized by symptoms and not enough by mechanism.

So despite my attraction, I can never love Psych and like so much unrequited love, we have agreed to hate each other.

I am not alone, as Kelly hates Psych too. Dyslexic as hell, Kelly fights tooth and nail to remember all these facts without rhyme or reason. Pharm is especially difficult for him while Physiology and Pathology come more easily because they “aren’t retarded and make sense like they’re supposed to.”

***I asked him once to describe how he remembers some of the drugs.

It’s not that bad. Chlorpromazine is Chlorxxxxxxxx. Carbamazepine is Carbxxxxxxxxxx. Carmustine is Carmxxxxxx. I get by.

For all the precocious dyslexic children out there: Yes, you can become a physician.***

Kelly and I are sitting in the Commons at Xavier University, hating life and Psychology with it’s lack of any framework when Kelly let’s out a victory cry. By this, I mean he cried out, “VICTORY FOR KELLY!” to the entire Commons (empty with everyone off to Spring Break).

Kelly’s a humble guy and not the type to dabble in the third person, so I’m curious. “What’s your problem?”

“Dude, remember those asshole clinical tutors in Grenada?”

“Of course.”

“Okay, just play along. ‘What brings you here today?’”

“That’s easy: an ambulance.” Here, I think I’m being clever. I wrote about it here, but the “What brings you here today?” question is famous in Grenada for quickly unmasking the good clinical tutors from the dicks who jump down your throught.

You cannot ask that question! The patient could say ‘car’ or ‘taxi’ or ‘ambulance’. You have to ask a question that can only be answered with the information you want.

Wow, you’re so right. I can’t believe I made such a mistake. I should always assume that the patient coming to me with a problem won’t be able to fight the urge to be a smartass as you’ve so expertly demonstrated. I’ve made a note to myself. Moving on…

And this is why Kelly had declared victory. “You’re Schizophrenic!”

“What?”

“Yeah! Schizophrenics have difficulty with abstract thought, cannot understand irony, and use language literally. The only person that would ever answer “ambulance” is probably schizophrenic! Do you have any idea how many people presenting to the ER have a psych problem? I think it’s all of them! If you can separate the schizos from everyone else with your first question, then that makes this the BEST question you could probably ask! They should be teaching this to everyone! Oh GOD how I wish I could travel back in time and make those tutors feel like morons over this. Toph, you have to promise me that you’ll write about this on your blog. You have to make sure that every student at SGU knows about this so they can rub it in those tutors’ faces.”

Well, I promised.

Today, we played tic-tac-toe on a whole new level. Moves are numbered in red.

At this point we decided to call it a Cat’s game. Debate ensued as to whether that should be called “Turner’s game” (XO) or “Androgynous” (with no clear winner).

Legend for the non-medical:

1. Gower’s maneuver is seen in Duchenne Muscular Dystrophy, which is X-linked.
2. That is supposed to be a Basophil.
3. Lesch-Nyhan is also X-linked. I was biting my lip at this point.
4. Krukenberg tumor has signet ring cells, which look like perfect circles.
5. Hemophilia is also X-linked.
6. Tinea corporis is otherwise known as ringworm.

If anyone has there own Med-Tac-Toe board, feel free to send it to rumorsweretrue at gmail.com and I’ll be happy to post it.

Dear Internets,

I think you know that I love you. That, I think, goes without typing. I remember when I received my first computer so that I could visit you. It was seventh grade and I was fascinated with your bounty of porn. I learned HTML and Javascript and began making webpages to impress you. We shared some great times that summer, away from the sun and all the people that didn’t understand our love.

I was certain we would be together forever. I was going to go to college to get a Masters in computers, you were going to keep searching for new things to share with me. We would strike out west to California and start a life together. It was all going to be so perfect, but you just couldn’t wait.

“Things weren’t moving fast enough,” you said. You were leaving me to see the coast on your own. Yes, you were outgrowing me and yes, I wanted you all to myself. Looking back, I know that you were too beautiful to keep all bottled up, but you never had to be so harsh about it, leaving without saying goodbye and taking the mouse (even though we bought him together).

I remember growing jealous as older men (with their fancy Computer Science degrees) ran off to the Silicon Valley with their signing bonuses and their shiny cars, whispering “dot com” and you ate it all up. I had to sit on the sidelines and watch. Year after year, I sat in the classroom still convinced that I wasn’t going to be too late, that I’d get my degree in time before you promised yourself to someone else. I mashed my teeth and watched as the money grew and you changed.

Every quarter, things just getting better and better for you and all the new people in your life. Oh, it was so fabulous what with all the free giveaways and the new software and the fancy CSS. It made me so mad inside to see you so happy without me, I wished for all sorts of horrible things to happen.

I know it was a rough time in your life, but I smiled from ear to ear for weeks when the Bubble burst and you came crashing down to earth with the rest of us.

I know now that my response was out of jealousy. You see, I called Al Gore and got some help. He knew your type and helped me see that if we were meant to be, then we would be. So I took some time to work on some “me” issues, you know, really explore some deep places and try to understand my feelings. That was several years ago.

Well I’m older now, in the 18th grade, and you’ve settled down quite a bit. I was only half surprised to run into you at the WiFi Starbucks; I felt like fate was waiting for the right time. I feel like we’re finally starting to connect in all the ways we couldn’t before. We were both young and immature and that you grew up so much faster was sure to create problems but I’m glad that’s all behind us and that you’ve come around. It’s been a long wait.

These last few years have been great. You have more facets than I could ever explore, your mystery is boundless and that is part of why I love you so much. But lately, I’m feeling a little tired. I want to keep up with you, but it’s almost too much. I come home after a long day of work and I know that you’ve been waiting for me so that you can tell me about Britney Spears’ day or that funny thing that Bush said but didn’t mean, he thinks. I know that nothing would make you happier than if we both sat down in front of the Tube to watch every show you taped for me, but I just can’t.

No no, baby. I’m not saying that I don’t love you anymore. Yes, I’m still in love with you, but you have too much energy for me and if we continue like this, I think it might turn into resentment on both our parts. We’ve come so far and I’d hate to see it all get mixed up again. I’m not saying we should break up. That is not what I am saying. What I think would be best, for both of us, would be if we took just a tiny break. You know, recharge our batteries and rediscover all the reasons we came together in the first place.

Anyway, that’s my idea. That’s how I feel. I still love you, Internets, it’s just that I can’t spend every moment with you anymore.

I think we need some space.

Poking around the Student Doctor Network, I saw a neat question and just decided to have fun with it.  I’m playing with the idea of tackling a few topics in this manner, complete with Podcasts so that you can listen along (and I don’t have to type so much).  If this sound like something you’d use, let me know; Ill let the interest drive it.

To everyone else, sorry to bore you to death.

Quote:

Originally Posted by guitarguy09 I noticed FA 2007 p.255-256 lists “amiodarone” as being both a Class Ia and Class III antiarrhythmic, while Lippinocott’s and Wikipedia list is being solely Class III. Does it act in some other way aside from blocking K+ channel outflow during phase 3 (prolonging the AP and effective refractory period)? Lippincott’s says that it has Class I, II, III, and IV actions, but that it is unlike Class I because it does not prolong the QT interval (although it’s listed with the other Class III antiarrhythmics as increasing QT in FA). What’s up with this??

Awesome question with a cool answer. Unfortunately, it requires some detail to explain. Here’s a table I made when I was sorting it out for myself.

The Na+ channels of the SA and AV nodes are always firing (more or less) and are termed “active”. This is in contrast to the Na+ channels of the ventricles that are usually off or “inactive”. This all makes sense when you remember that the slow depolarization of the SA/AV is via Na+ channel, whereas the Na+ channels of the ventricles are off except for a very brief phase 0 upstroke (not a lot of time for a drug to take effect).

So, what makes a Class I a Class I is its action on these active Na+ channels. From this, you expect their action to be in the nodes and not in the ventricles. What makes Quinidine a Ia is its additional K+ action. In the SA/AV, this would prolong repolarization. In the ventricles, this would also prolong repolarization. Now, the prolonged QT, the slowing HR, etc begin to make sense.

If you can keep the differences between the SA/AV and the Ventricles straight AND commit the table I included to memory, then the effects of these drugs start to come together. Shockingly, more detail up front requires less memorization later on and leads to a real understanding of antiarrhythmials.

So when people say that Amiodarone is also a Class I, they’re missing it! Amiodarone doesn’t have the basic action that makes a Class I a Class I, and instead includes the actions that make a Ia and a Ib different from a standard Class I.

Lot of details, but interesting nonetheless. The only thing I’ll add is that the Na+ channel in the SA/AV is a “funny” channel and that the Ca2+ channel in the SA/AV is an L-type channel. Why do you care? Well, the actions of Beta-Blockers don’t make sense otherwise. Beta-blockers like Propranolol can act at the Funny channel and the L-type channels in the SA/AV, and can also act at the Ca2+ in the ventricle, but you don’t see them affect the Na+ channel in the ventricles.

You should be able to piece together the rest. In the meantime, here are the bullet points.

Block: Effect

K+: Delays repolarization ↑AP duration, ↑ ERP, ↑ QT interval (risk for Torsade de pointes)
Na+ (SA/AV): ↓ automaticity, ↓ slope of phase 4, ↓ cell excitability
Na+ (Vent) : ↓ conduction, ↓ slope of phase 0 depolarization
Ca2+: ↓ conduction (SA/AV), ↓ slope of phase 4, ↓ phase 2 plateau (Vent), ↓ contractility, ↓ QT interval
Beta-receptor: Na+ (SA/AV)-block and Ca2+-block; negative chronotropic, dromotropic, and inotropic

Mg2+: Functional Ca2+ blocker; first line in Torsades de Pointes, Digitoxin toxicity
Adenosine: Receptors on SA and AV node; ↑ K+ and ↓ Ca2+ conductance, hyperpolarizes; may cause AV block; DOC in diagnosing/abolishing AV nodal arrhythmias. Toxicity: flushing, chest burning. t1/2 = 10s.

Hope it helps, topher.

As always … corrections, suggestions and additions are welcome in the comments.

Gastrointestinal

1. P.280, Abdominal layers
   1. Not necessary, but I’m just begging you to change this image. In contrast to a typical cross-section on CT, this image is flipped over its axis. This means that with left body on right page, we are looking from head-to-toe and not toe-to-head (as in a CT) and the anterior abdominal wall is placed below the spine on the page instead of above (as in a CT). The simplest solution is to remove all the labels, flip the image across its horizontal axis (as opposed to rotation which would place the IVC and Aorta incorrectly), and then reapply the labels.
2. P.281, Femoral triangle
   1. The Femoral nerve is not labeled correctly as a nerve. Instead, the “Femoral a.” and “Femoral v.” labels are both pointing to the Femoral nerve. The Femoral artery and Femoral vein are not labeled. This image is also missing the “Empty space and lymphatics” of the femoral triangle.
3. P.282, Inguinal canal
   1. The “Deep inguinal ring” label is not labeling anything. I think a bar pointing to the ring should be added.
   2. The label “Medial umbilical ligaments” is pointing to one (of two) of the medial umbilical ligaments and (incorrectly) to the median umbilical ligament. The labeling should change appropriately.
   3. The labels “Deep inguinal ring” and “External inguinal ring” are not consistent with the next page, and I think the small changes to “Internal (deep) inguinal ring” and External (superficial) Inguinal ring” would clear up any confusion and bring it in line with the descriptions on the following page.
4. P.284, Salivary secretion
   1. I think a fourth bullet point with “Lingual lipase begins TAG digestion; activated at low pH on reaching stomach” should be added. This offers a contrast to the activation and action of alpha-amylase.
5. P.285, GI hormones
   1. I think it’s worth mentioning that Gastrin’s effects are inhibited by Somatostatin. According to Costanzo (BRS Phys), it is a pH of 3 (not 1.5 ) which is the checkpoint for the gastrin/acid-secretion feedback loop between the antrum and the body of the stomach.
      1. Vagal stimulation of gastric acid secretion is due to ACh (as listed on P.284), but no mention is made that vagal stimulation of gastrin secretion from G cells is due to Gastrin Releasing Peptide (GRP). Because this explains why anti-muscarinics do not prevent the secretion of gastrin, I think it should be mentioned.
   2. Cholecystokinin should include “(CCK)” since this abbreviation is not stated elsewhere and is used within the same row of the table. It is also worth mentioning that CCK potentiates Secretin’s effect on pancreatic HCO3- secretion.
   3. Secretin’s effect on increased bile production is not mentioned.
   4. I think it’s worth adding the second-messenger systems used by each hormone. Since Gs, Gi and Gq were previously covered (P.214) I think it’s helpful enough to list the following next to each hormone:
      1. Gastrin (Gq)
      2. CCK (Gq)
      3. Secretin (Gs)
      4. Somatostatin (Gi)
      5. GIP (Gs)
      6. VIP (Gs)
      7. NO (cGMP)
6. P.286, Regulation of gastric acid secretion
   1. The pattern established by this figure is that each drug with a line towards a receptor is inhibitory for that receptor. This is not the case for Misoprostol, which is a PG analog and stimulatory at the receptor. To avoid any confusion, I think that + and – signs are more appropriate here.
7. P.294, Alcoholic hepatitis
   1. Changing the mnemonic from “You’re toASTed with alcoholic hepatitis” to “ToASTed, Sam GOT alcoholic hepatitis” helps you remember that SGOT is also known as AST (which is easy to forget).
8. P.296, Primary sclerosing cholangitis
   1. I had no idea what an ERCP was, nor would I expect most other second-years to know it. If it’s going to be mentioned, I think it should be spelled out to “endoscopic retrograde cholangiopancreatogram (ERCP)”
9. P.296, Reye’s syndrome
   1. In the way that acute pancreatitis is associated with gallstones and ethanol (for example), Reye’s is not associated “with viral infection … and salicyclates;” it is associated with the combination. It’s subtle but important. I think “and” should be changed to “treated with“.

Return to First Aid Errors page.

As always… all suggestions, additions, corrections are welcome.

Neurology

1. P.345, Basal ganglia
   1. I think this image is confusing and could benefit from a few additions. Specifically, I think it should be made clear that neurons from the SNc are synapsing on neurons in the Striatum. The Striatal neurons are currently labeled as “Putamen” which would lead to confusion if a test stem referenced the “striatal neurons” that are the sites of Huntington’s lesions.
   2. I think it is appropriate in this section to repeat that Dopamine is inhibitory through its D2 receptor (currently unmentioned) and stimulatory through its D1 receptor.
   3. The light and dark shading of the pathways is not very intuitive, and I think a return to + and – signs might be worthwhile.
2. P.349, Spinal tract anatomy and functions
   1. Under 3rd-order neuron, “sensory cortex” is listed for the Dorsal column-medial lemniscus tract. The third order neuron is actually that neuron originating in the thalamus (receiving the 2nd-order neuron as described) and then projecting to the sensory cortex. It is the 4th order neuron (within the sensory cortex) that is the end-point of this tract and responsible for any conscious experience. “sensory cortex” should be changed to “ascends from VPL of thalamus to sensory cortex.”
   2. This same criticism applies to “sensory cortex” listed for Spinothalamic tract.
3. P.357, Visual field defects
   1. The 6th bullet for “Left hemianopia with macular sparing” should include the “(PCA)” since this is the most commonly cited cause. The image should also include a bar across the fibers in the posterior part of the optic radiation. As it stands, “6″ is the only number in the figure without a bar marking the site of the disruption.
4. P.359, Aphasia
   1. Just for the repetition, I think the following should be added here:
      1. Broca’s (44,45)
      2. Wernicke’s (22)
5. P.363, Primary brain tumors
   1. Childhood peak incidence
      1. F. Pilocytic (low grade): this tumor is correctly described as being found most often in the posterior fossa, however, it is drawn in the anterior fossa and supratentorial. Further, the image of the brain is backwards from what is traditionally shown, which may have led to some confusion during the illustration.
6. P.364, Tabes dorsalis
   1. Because space is not an issue here and the term has not been used recently, I think it might be worth extending “DTRs” to “deep tendon reflexes”.
7. P.365, Brown-Sequard syndrome
   1. First bullet point is followed by “not shown”. Similarly, the fifth bullet point is also not shown on the diagram. I do not understand this, since the territory of “Ipsilateral UMN signs” is identical to the territory of “Ipsilateral loss of tactile, vibration, proprioception sense”. It seems the labeling could read “1,2″ instead of just “2″. My point is similar for bullet points “4,5″ instead of “4″ when describing the territories of “Ipsilateral loss of all sensation at level of lesion” and “LMN signs at level of lesion”.
8. P.366, Facial lesions
   1. Instead of the current mnemonic “ALexander Bell with STD: AIDS, Lyme, Sarcoid, Tumors, Diabetes” I suggest the shorter “BLASTeD: Bell’s palsy from Lyme, AIDS, Sarcoid, Tumors, Diabetes”. A small change, but somewhat easier to remember. Or, if you like, “Bell-LASTeD“.
9. P.367, Parkinson’s disease drugs
   1. When describing bromocriptine, I think it’s important to say that it is not simply a “partial dopamine agonist”. It is instead a selective dopamine agonist at the D2 receptor, and has its action not in stimulating the direct pathway of the basal ganglia, but instead suppresses the indirect pathway.
10. P.370, Anesthetics – general principles
    1. The line beginning “Drugs with [up arrow] solubility…” could use a little changing. I suggest beginning with the reciprocal relationship between MAC and potency, followed by the conclusion. I also believe that MAC is not Minimal Anesthetic Concentration but Minimal Alveolar Concentration. The distinction is important as the two are not the same.
       1. MAC = Minimal Alveolar Concentration. Potency = 1/MAC. [up arrow] solubility = [up arrow] potency = [down arrow] MAC.
11. P.371, Intravenous anesthetics
    1. I propose an alternative for the mnemonic “B.B. King on OPIATES PROPOses FOOLishly” for memorizing Barbiturates, Benzodiazepines, Ketamine, Opiates and Propofol.
       1. KOPs keep them BEhind BARs: Ketamine, Opiates, Propofol, BEnzodiazepines, BARbiturates.
          1. Bonus: …where they are put to sleep by IV anesthetics.
12. P.371, Local anesthetics
    1. In the second bullet point, when dealing with the order of nerve blockade, the small myelinated/unmyelinated fibers of the ANS could be included “temperature > ANS > touch”

Return to First Aid Errors page.

More funny lines from Veritography (in the middle of a month of tests):

Last night, I was trying to memorize my dreams. I’ve never been able to remember my dreams. But right now my brain is so wired for intake of data that any experience I have is something I assume I’m going to be tested on later.

Cat said it right: Studying in medical school is like having sex while you are drunk. You never actually finish, you just keep going until it’s not worth it anymore.

God I love medical school.

This sent me into a giggle-fit.  Horribly off-key spoof of the Bud Light “Real Men of Genius” campaign.  Courtesy of The Ramble Strip.

1. Mr. Always Late to Small Groups Guy (guilty)
2. Mr. Will This be on the Exam Asker
3. Mr. Always Prepared For Everything Guy
4. Mr. Awesome Floor Team Avoider
5. Mr. Really Bad With Children Guy
6. Mr. Walk Behind the Lecturer Guy
7. Mr. Falls Asleep During Everything Guy (guilty)
8. Mr. Accidental Scrub Out Guy

“Should I take a prep course?”

Shrug. I don’t know if you should or shouldn’t. The best I can do is tell you why I didn’t. Comprehensive review courses make a few implicit promises that include:

1. Structured lecture, pacing of material, routine
2. A community of other serious students
3. A one-stop-shop for your review materials
4. Some diagnostic component
5. Confidence that you’re studying the right way

If you’re thinking about taking the Kaplan course, this is more or less what you’ll get. A great many of my classmates went this route and chose the Step 1 Prep Retreat which includes a full-service hotel setting and costs $5,599. That’s a lot of money. I could have chosen to take out a “bridge” loan for $6000 to cover it, but I decided to make damn sure that it was worth it before I added to my debt.

Could I accomplish everything the review course was offering on my own? The structured lecturing was out of the question. I didn’t go to class for the first two years, so taking a live lecture course made little sense for me. I’ve written about it before, but believe me when I tell you that my ears are stupid. I’ve never been the type to sit passively and absorb information; I instead need to be actively involved by rewriting the material (time-consuming) or teaching it.

As far as the pacing goes, I got a hold of the Kaplan lecture schedule just to see how much weight they gave to each section. Then, I just picked something upon which to base a schedule (First Aid), looked at how many days I had to study, and made one for myself. It wasn’t that hard to do. Sticking to it is often a pain, but chances are that every time I want to fall behind my study partner is keeping pace. At this point, my competitive nature takes over and I buckle down.

Daily routine has been incredibly important and we screwed it up. Trying to find a good place to study is hard in the winter when all the public libraries keep banker’s hours and all the academic ones are for students only. Having to sneak in, find parking a mile away, and worry about freezing to death all got in the way for us. Eventually, we found a great library and have been going there every day from 8am-6pm, but we wasted about four weeks trying to find it. So far, wasting that time has been one of my biggest mistakes. Things would have been so much easier if I was the type that could get work done at home.

I couldn’t exactly get a community of students around me, but I thought that might be a good thing. As it stands, I struck a deal with my roommate: I’ll make you study if you make me study. We shook on it and things have been going well for six weeks now. I recently spoke with a classmate of mine at the Kaplan Retreat in Alabama and found out how different it is.

“Kaplan Spring Break 2007! WOO!” I was afraid of that, to be honest. So many medical students reliving their dorm days sounds like a recipe for distraction. “We all wake up for eight hours of lecture with an hour break for lunch and by the end of it, we’re too tired to do anything else. We either spend the rest of the day watching a movie, going to the hotel bar, or lifting weights and relaxing in the indoor pool. It’s pretty great.” All that’s missing is a few testimonials about all the hot singles waiting for your call and a 900 number. I’m glad I passed.

As my roommate Kelly put it, “This is two months of your life where you make yourself a deal: life is going to suck, you’re going to work, you will have no fun so that after it’s over you don’t have to regret any of it.” Sounded good to me.

Being on your own outside of a class also means having to figure which books to get. There’s a great book called The Paradox of Choice that I recommend, but the nuts and bolts of it is that by having so many options and having the time to compare them against each other, we end up paralyzing ourselves and no matter what we choose (even if it’s better than what we would have chosen without all the options) we’re more unhappy with it. Such is life when buying review books. I thought I had a handle on it but have since learned that the books everyone else thinks are great I think are shit, and that no matter what happened I wouldn’t have had the time to find the “right” ones anyway.

So if you get the Kaplan books when you take the Kaplan class, you’ll probably be really happy with them. I have been unhappy with mine because I can compare them against other books to see their strengths and weaknesses. Ignorance is bliss. If I had to do it all over again, I might have just gone to Amazon.com, looked at a list of books I should buy, and then done so without questioning.

As far as the diagnostic component goes, I started studying for the USMLE thinking that the Kaplan QBank was the only game in town. I’ve since discovered quite the opposite and ended up going with USMLE WORLD. You have to wonder how many people never investigate and end up going with Kaplan classes because of how famous the Kaplan QBank is.

The last one is a doozy: confidence that you’re studying the right way. I struggled with this one before beginning. Ultimately, I looked at my last two years in school and decided that I had done enough things correctly that I could fake my way through preparing for the Boards. It also helped that I found the Step1Blog and talked to a few successful people a year ahead of me that also studied on their own. I’ve tried to figure out the best way to cover the material and I’ve failed at it more than a few times but I’ve also had some success and now I’m in my stride. Good thing since the test is now three weeks away.

In all, I’ve lived at my roommates house rent free, paid for gas, spent $500 on books ($200 of which I wasted on the Kaplan Lecture Notes), $200 on warm clothes because Cincinnati is freezing, and spent $700 to register for the actual exam. That comes to the grand total of $1500. What am I doing with the extra $4000 that I didn’t spend on a course?

My own Kaplan Spring Break 2007!

• Flight from Midwest, USA to Bangkok, Thailand on March 27th.
• Canon D60 digital camera with two Sigma lenses
• Northface backpack (I will be living from this)
• Flight home, May 8th

WOO!

Return to USMLE Step 1 page.

On this post, I wrote about being frustrated with the amount of material I have to cover. An indivdual from SGU (my school) left a comment on it that encapsulates my biggest frustrations with the way this school is packaged and sold to prospective students. It essentially said (as I read it) that I should paint a rosier picture of what studying is like so that people don’t get scared of hard work, become discouraged, and fail at life. My response, while possibly out of proportion, reflected my anger at such dreck.

SGU is not a lemon. It’s a damn good school, one that I loved attending, and one I would recommend and defend. The school should be proud of this, the school should be honest about what it is, and it should be honest with its students (both present and future). My father has been selling cars he fixes for years, and he is always up front about what the car is and isn’t. I’ve learned from watching people respond to him that an honest scratch is worth a hundred dollars of bullshit shine. I believe in this, I try to live by this, and when I wrote the guide to the school I held myself to that standard.

And now I’m selling myself off piece by piece with compromises. I know, I know, this isn’t a principled world and so much can be accomplished in the grey that can’t be done in the black or white, but it still doesn’t sit well with me. The Administration’s approval (so that the guide can be distributed to all incoming students) is coming at the cost of some honesty.

Specifically, the culture of the island. Grenada’s culture was different from my own, the average work ethic is below the manic American standard, and island living means sometimes living without certain amenities. I’ve learned from all of these differences, but when I came to the island I had little warning and I managed to offend my bus driver and a hostess because of it. I wanted to save other people that experience, and so I wrote the School Culture section. When this was veted by people at SGU, it was judged “offensive” and I was told that it had to be removed. I’m not holding a lot of cards here (as the school has no problem not providing this information) and I have more to gain by it being shared with the change than I have to keep it as is.

So that’s where I am, pissed and moaning and giving in. You can see the original here and compare with what’s below. Please, tell me that the differences aren’t important so I can feel better about it.

“The people of Grenada are wonderful. You will make many friends on the island, not only with your peers, but also with the Grenadians that are kind enough to share their island with us. Greeting people is considered basic courtesy and should occur before any business transaction. Not greeting people is a sign of disrespect. Just remember to always smile and wave. Being polite goes a long way.

Med students are a stressed out bunch in general. Med students living in Grenada, without the comforts and conveniences of home can be even more on edge. The school does a pretty good job of trying to eliminate the unnecessary stresses. The administration and Facilities Manager are very receptive to student suggestions. Keep in mind that the internet is not always going to work. Sometimes the washing machines will break. If you have a healthy sense of humor, the stressful things about Grenada can be hilarious

Try to remember that there is no hurry and life will be a lot easier on you.”

I have taken today off from preparing for the USMLE to call 80+ US medical schools. This is in the hopes that they are accepting applications for transfer into their 2nd or 3rd years. It’s not fun and I am assured by students that have done it themselves that it is good to do because it “builds character.”

“Do you accept applications from foreign medical students?”

“No. Wait, are you a resident of this state?”

“No, I’m not.”

“Then hell no.”

Repeat 80 times. So much character I need a drink. It’s a shame that life is filled with stories of people being told “no” a hundred times before hearing a single, life-changing “yes” because it’s that possibility that keeps me trudging along when I’d rather not. I already have a list of 15 schools that I know will take my application; the rest of this is just masochism.

Of course, it’s just a bunch of secretaries on a phone somewhere. I’ll get over it.

*Addendum*

These folks saved themselves the trouble of my phone call:

Q: Are students from “off-shore” medical schools eligible?

A: No.

 

Q: Are students who are U.S. citizens enrolled in a foreign medical school recognized by the World Health Organization (WHO) eligible?

A: No.

As always, this comes from an email sent to the First Aid team. If you find any errors, please include them in the comments.

Renal (all references from Merck Manual and Robbins Basic Pathology)

1. P.396, Hormones acting on kidney
   1. Atrial Natriuretic Factor (ANF) is listed as Atrial Natriuretic Peptide (ANP) on the preceding page. I think one term should be used consistently.
2. P.401, Kidney stones
   1. To help remember which stones are largely radiolucent:
      1. “I can’t C U on XRay.” for Cystine and Uric acid stones.
3. P.405, Mannitol
   1. Mannitol can be used clinically to decrease intracranial pressure (as listed). If given too rapidly, it can also cause an increase in intracranial pressure. I think this should be listed as well under the toxicities.
4. P.405, Ethacrynic acid
   1. “Similar to furosemide; can be used in hyperuricemia, acute gout (never use to treat gout)” is not correct. This should instead say, “can cause hyperuricemia, acute gout (never use to treat gout).”
5. P.406, ACE inhibitors
   1. One of the clinical uses for these drugs is to decrease proteinuria. In toxic doses, it can also cause proteinuria. I think this should be mentioned under clinical uses.

Return to First Aid Errors page.

As always, this comes from an email sent to the First Aid team. Please add any errors or suggestions in the comments section.

Musculoskeletal (all references from Merck Manual and Robbins Basic Pathology)

1. P.326, Smooth muscle contraction
   1. This diagram shows Myosin light-chain phosphatase (MLCP) acting before contraction. Every other reference I have found details SMC contraction in the following steps
      1. Calcium binds calmodulin
      2. Calcium-calmodulin activates Myosin light chain kinase (MLCK)
      3. MLCK phosphorylates myosin, allowing a crossbridge to form
      4. Contraction follows
      5. MLCP dephosphorylates myosin, allowing for relaxation.
   2. I think this diagram should be changed in the following way:
      1. “Cross-bridge formation with contraction“
      2. After the action of MLCP, “contraction” should be changed to ” relaxation.”
2. P.327, Rheumatoid arthritis
   1. In RA, the DIP is completely spared. A small point, but the image of the Swan-neck deformity should be pointing to the involved joint (hyper-extended PIP) and not the DIP (normal).
3. P.327, Osteopetrosis
   1. In addition to be called “marble bone disease,” this condition is frequently referred to as “Albers-Schonberg” disease. I think this should be mentioned.
   2. Osteopetrosis also presents with hepatosplenomegaly (secondary hematopoiesis due to loss of bone marrow) and cranial nerve palsies. I think both of these should be mentioned.
4. P.327, Osteitis fibrosa cystica
   1. This disease is also often referred to as “von Recklinghausen’s disease of bone.”
   2. In the same way that alkaline phosphatase is raised in states of high osteoblastic activity, Tartrate-Resistant Acid Phosphatase (TRAP) levels are raised in states of high osteoclastic activity. I think it is worth mentioning both of these correlates in this section.
5. P.328, Polyostotic fibrous dysplasia
   1. This disease is often referred to as McCune-Albright. I think the text should be changed to “(McCune-) Albright Syndrome”
6. P.329, Gout
   1. I think it would be helpful to include “glucose-6-phosphatase deficiency (von Gierke’s)“.
7. P.330, Scleroderma
   1. After the first bullet point, I think it should say, “Associated with anti-Scl-70 antibody against topoisomerase“.
8. P.331, Skin disorders
   1. Atopic dermatitis has pruritic eruptions within skin flexures, not on flexor surfaces i.e. you would expect to see them within the elbow crease and around the neck instead of on the surface of the bicep and forearm.
   2. Seborrheic keratosis should include the common vignette descriptions of “ stuck-on appearance” and “greasy.”
9. P.332, Primary bone disorders
   1. A constant feature of osteoid osteoma (in contrast to osteoblastoma and osteoma) is complaint of pain at the site of the lesion. I think that this should be briefly mentioned: “pt. complains of pain”
   2. A feature of Giant Cell tumor of bone is the complaint of arthritis in a young person (20-40 yoa). I think this should be briefly mentioned: “young pt. complains of ‘arthritis’”.
   3. Osteosarcoma has a bimodal peak in incidence, once in 10-20 year olds associated with Retinoblastoma, and once in the elderly following Paget’s disease of bone. Without this distinction, it makes no sense so list Paget’s disease here because this rarely (if ever) occurs in patients younger than 40. I think this should be changed to:
      1. “Most common primary malignant tumor of bone. Peak incidence in men 10-20 years old (associated with familial retinoblastoma). Smaller second peak in elderly (associated with Paget’s disease of bone, bone infarcts, radiation). Commonly found….”
   4. A feature of Ewing Sarcoma is the complaint of pain and warmth over the site of the lesion. I think this should be briefly mentioned.
10. P.333, Other ANCA-associated vasculitides
    1. In the same way that the “Lesions are of different ages” in PAN, I think it is worth mentioning that the lesions are all of the same age in microscopic polyangiitis.
11. P.335, NSAIDS
    1. I do not understand why there is no mention of Aspirin in this section.
12. P.337, Immunosuppresive agents: sites of action
    1. I do not understand why Tacrolimus (FK506) and Cyclosporine (CSA) are shown as having completely non-overlapping sites of action since they inhibit the exact same pathway at the exact same step (one by binding cyclophilin, the other by binding FKBP).
       

Return to First Aid Errors page.

As always, this comes from an email sent to the First Aid team. If you find any problems here or things that I’ve missed, please note them in the comments.

Endocrine (all references from Merck Manual, Robbins Basic Pathology)

1. P.267, Cushing’s Syndrome
   1. The left sidebar states that ACTH-producing tumors can be identified after a high dose of dexamethasone as having “[down arrow] cortisol.” This is not the case for ACTH-producing Small Cell Lung Cancers which do not respond to feedback inhibition of cortisol or its analogues. Instead, these tumors have the same profile in the Dex test as Cortisone-producing tumors described in the sidebar. The sidebar should be changed:
      1. Healthy — [down arrow] cortisol after low dose
      2. ACTH-producing Pituitary tumor — [up arrow] after low dose; [down arrow] after high dose
      3. Cortisone-producing tumor — [up arrow] after low and high doses, unilateral adrenal atrophy (or hyperplasia)
      4. Ectopic ACTH-producing tumor — [up arrow] after low and high doses, bilateral adrenal hyperplasia
      5. Iatrogenic Cortisol administration — [up arrow] after low and high doses, bilateral adrenal atrophy
2. P.269, Subacute thryoiditis (de Quervian’s)
   1. No mention made that this condition involves granulomatous inflammation of the thyroid, a major characteristic.
3. P.269, Thyroid Cancer
   1. I think this section should be retitled “Thyroid Tumor” and the following bullet point added first to highlight that the majority of nodes are not malignant:
      1. 90% Benign, adenoma – “hot” on scintigram, Hurthle cells

Return to First Aid Errors page.

First Laugh of the Day goes to Ambulance Driver:

I’m going to start my own worker exchange program. I’ve got six malingering, whining, healthcare system abusing, hypochondriac, chemically dependent, Professional Victims of Life that I’ll willingly trade for three hardworking illegal Mexicans who want a shot at the American dream. They can have the jobs that these hunnert percent, by-God Murkins can’t seem to find or hold.

Second Laugh of the Day goes to Indexed:

Renal, Endocrine and Musculoskeletal First Aid sections go up Sunday night.

Every morning I work through a crossword puzzle. Typically, it will reference a few things I know and the rest I ask Google. I bookmark these things and (at night, as a reward) read through them. I hope this becomes a life-long habit. Without further ado…

The Awful German Language, by Mark Twain

This explains why, whenever a person says sie to me, I generally try to kill him, if a stranger.

I heard a Californian student in Heidelberg say, in one of his calmest moods, that he would rather decline two drinks than one German adjective.

O, horror, the Lightning has struck the Fish-basket; he sets him on Fire; see the Flame, how she licks the doomed Utensil with her red and angry Tongue.

You can begin with Schlag-ader, which means artery, and you can hang on the whole dictionary, word by word, clear through the alphabet to Schlag-wasser, which means bilge-water — and including Schlag-mutter, which means mother-in-law.

“In the daybeforeyesterdayshortlyaftereleveno’clock Night, the inthistownstandingtavern called `The Wagoner’ was downburnt.

There were so many other great lines that I had to leave for you. I couldn’t bring myself to rob you of the context.

P.S.

ich habe gehabt haben worden gewesen sein, as Goethe says in his Paradise Lost — ich — ich — that is to say — ich — but let us change cars.

Dear Past Self,

I’ve traveled back in time to give you some advice because right now, I’m a little pissed off. You probably don’t care (which is why you’re indulging in this “rut,” you pussy) but because you’re not going to be around to deal with the consequences, I felt the need to bring them into sharper relief:

You’re fucking up. You’re fucking it all up.

Every day you waste feeling sorry for yourself because you don’t feel “excited” or “energized by the material” is another step you’re falling behind the goals that way-past self set. Now, I think those were good goals and, frankly, I like way-past self way more than you, past self.

If you don’t stop, I’m going to kick us in the balls.

Way-way-past self spent so much time working so that we could even have this opportunity. Way-past-self understood and respected that sacrifice and carried on the tradition and I’m just waiting for you to pass me the torch so I can take us even further. So pass me the torch.

Or just sit there collecting ash on your lap, you lazy shit.

I don’t want to do anything drastic. The last time a future-self had to take the place of a past-self prematurely was in college to end the great marijuana period and to get us in shape. Not only do we not remember anything that happened while pot-self was around but that move (while necessary) came too late to get us into medical school in the US. Do you think I’m going to wait around much longer for you to get your act together before I erase you from our consciousness?

If you hadn’t read Enoch Arden yesterday, I would have already done it.

I’m in a rut. For the past five days, I’ve just been going through the motions, not really getting excited by the material or finding any joy in it. Pulmonary was boring, Renal is annoying with all of its ridiculous buzzwords and “subepithelial humps of bullshit” on electron microscopy that I can’t imagine I will ever see in my life, and this has lead me into the slow agonizing march that is endocrinology and reproduction.

I haven’t finished any of the sections. I spend a day on the embryo/anatomy/physiology, a day on the path, and a day on the pharm (if it needs it). Where cardio had me excited, doing questions in WebPath, Robbins Review of Pathology, and in the Usmle World Qbank, I’ve just limped through each day for the better part of this week.

And this is just feeding on itself. Doing well makes you want to continue doing well, and the converse is true. As it stands I look back on all the subjects that I’ve read but haven’t really “finished” and I’m thinking too much about being behind to concentrate on not falling further behind. At this point, I think the only way out is to completely skip the current section and use these days to tie up the loose ends in other subjects.

Maybe I’d rather be completely behind in one subject than a quarter behind in four subjects. Who knows. I’m just writing this here out of desperation. I need this rut to be over before it swallows more than it already has, and I thought writing it down would get it off of me.

Hope it works.

Return to USMLE Step 1 page.

As always, this comes from an email sent to the First Aid Team.

Pulmonary

1. P.428, Oxygen-hemoglobin dissociation curve
   1. High altitude decreases P02 and decreases Hb saturation. This results in a decrease (or down-shift) in the dissociation curve, not a right shift as described.
2. P.428, Pulmonary circulation
   1. While exercise does decrease the perfusion limitation, it never reaches the point of diffusion limitation i.e., the SaO2 on an athlete will almost never be lower than it is at rest.
3. P.431, Obstructive lung disease (COPD)
   1. “[up arrow] FVC” is incorrect. RV increases, FVC is decreased or normal, FEV is decreased, TLC is increased.
   2. Emphysema and Asthma are both listed as having decreased I/E ratios. I assume this means Inspiration/Expiration ratio. This seems impossible as a ratio other than 1 would lead to progressive deflation and collapse of the lungs or the opposite expansion. What this should instead indicate is that in both cases, the breathing is shallow. In any steady state of respiration (including shallow breathing), I/E = 1 and the tidal volume (Vt) is lowered.
4. P.431, Restrictive lung disease
   1. “([down arrow] VC and TLC)” should say “([down arrow] FVC and TLC)”
5. P.431, Neonatal respiratory distress syndrome
   1. The opening description describes “lecithin” as the important surfactant. The surfactant is then described as “dipalmitoyl phosphatidylcholine .” I think everyone might benefit if this was changed to:
      1. Surfactant–dipalmitoyl phosphatidylcholine (DPPC, lecithin)
6. P.432, Obstructive vs restrictive lung disease
   1. The FEV1/FVC ratios are listed for Normal and Obstructive, but not Restrictive even though “>80%” was listed on the previous page. For consistency, I think it should be included here.
   2. The curve for “Normal” is not drawn correctly, listing a ratio of 80% but showing a ratio of 60%.

Return to First Aid Errors page.

“Offensive” is a word abused by morons. The latest example is the brouhaha over the Snickers advertisement in the Super Bowl. A synopsis from the Americablog.

A bit of background. The ad in question showed a mechanic eating a Snickers bar. Hi co-mechanic is so desirous of the Snickers that he starts eating it from the other end of the same bar that’s already in the other guy’s mouth. The two butch guys eat their way down the bar, like the dogs eating the same string of pasta in the Disney movie – until they’re accidentally kissing. The guys, naturally, recoil in disgust – then, oddly, start ripping out their chest hair with their hands.

The conclusion that Americablog reaches (as do too many others to list) is that the add is anti-gay, hateful, and supports homophobia.  This is of course followed with protests, angry letters, and blog posts calling for the withdrawal of this clearly offensive add.   Here’s my interpretation:

Two mechanics accidently touch lips because Snickers is so delicious. Each, being a homophobic idiot (HI), worries that the other HI thinks that he is a homosexual. So terrified with this thought (being a HI), they each decide to prove how not gay they are by either:

1. Hitting each other with wrenches
2. Drinking motor oil and antifreeze
3. Ripping out clumps of their chest hair while screaming

Commercial ends and we all laugh at the HIs.

Unless you are a homophobic idiot or a Moron Not Otherwise Specified, I don’t see how you were offended. Unfotunately, it’s easier to placate morons than educate them and Snickers pulled the advertisement.

MNOS or HI? You Decide.

From Worth Repeating

Messages:
1) It’s OK to beat the crap out of gay guys;
2) If you do something gay-ish, consider countering said act with self-mutilation or a hate crime;
3) Using gays as the butt of jokes is funny — and profitable!

From the Lost Remote:

The backlash was entirely predictable, and Snickers and its ad agency deserves it for being so detached from today’s reality.

He’s right, but it’s by accident. Had they test-marketed it with “real” people I’m sure they would have known this real stupid response was coming.

I hope this writer over at “The Gentleman’s C” knows what he has here.  A book of these would sell like so many hot cross buns.

The Angry Kid went to a “Princess Party” this past weekend. I overdosed on cheap tulle and the color pink and, to my horror, she now speaks of nothing but her own “Princess Party,” which she believes I am required to provide. Saturday night, at bedtime, the Angry Kid asked for a story. This is what she got.

A  little later in the greatest fairy tale ever…

Snow White sighed. “You idiot,” she declared. “There’s no such thing as magic, and wishing for things won’t make them come true. Evil, stupid Queen, get away from here and don’t come back!” With these words, Snow White raised the hammer up high, and the Queen thought Snow White was going to hit her with it. She dropped her basket of nasty apples and ran into the woods, afraid for her life. Unfortunately, she didn’t watch where she was going, and she ran right off a cliff and died.

This is a good post.

I think the clinician’s assessment of the patient’s pain is more useful than the patient’s assessment of their own pain, as far as triage is concerned. The currently used pain scale is only helpful in assessing response to treatment (the trend). Mine is more realistic:

Scalpel’s Pain Assessment Scale

From my small experience in a hospital, I left with the strong impression that personal pain ratings are more often about what the patient wants than the level of pain the patient is experiencing.  Everyone on my floor new the magic number: 7.  If you’re a 7/10, you get morphine.

Tales from the Emergency Room and Beyond… hosts this week. Come get the weekly best of the medical blogosphere.

As always, this is from an email sent to the First Aid team.

Cardiovascular (BRS Physiology, Merck Manual and Robbins Basic Pathology)

1. P.235, Myocardial action potential
   1. The line indicating the flow of currents omits the K+ current responsible for Phase 1, and instead shows the K+ current active midway through Phase 2. This missing current is voltage-gated, above and beyond the “leak” current shown.
2. P.241, Normal Pressure
   1. Normal pressures for the Aorta are listed as “<130/90.” Other texts put this diastolic value at 70mmHg (leading to an aortic MAP of 90).
3. P.241, Congenital Heart Disease
   1. “Children may squat to increase venous return” is not correct. Squatting posture is used to increase systemic vascular resistance and thereby reduce the R-L shunting seen in the Tetralogy of Fallot. Increasing venous return would increase Preload, SV, and CO from the R ventricle, exacerbating the R-L shunt that is causing the cyanosis. This should be changed to “Children may squat to increase Systemic Vascular Resistance and thereby decrease R-L shunting.”
4. P.241, Congenital Heart Disease
   1. When discussing the L-R shunts, a brief explanation for Eisenmenger’s syndrome is given. On the very next page, this is explained much better. I think this could be shortened to “Uncorrected L-R shunts may lead to Eisenmenger’s Syndrome.”
5. P.242, Tetralogy of Fallot
   1. The physiological explanation given should have the bold words added: “Patient leans to squat to improve symptoms: compression of femoral arteries increases Systemic Vascular Resistance, thereby decreasing the R-L shunt.”
6. P.242, Transposition of great vessels
   1. “Not compatible with life unless a shunt is present to allow adequate mixing of blood ( e.g. VSD, PDA, or patent foramen ovale [?]” I do not understand why “patent foramen ovale” is used here since any ASD would do (e.g. foramen primum, sinus venosum). I think this should be changed to “( e.g. VSD, ASD, PDA)”
7. P.243, Congenital cardiac defect associations
   1. After listing “22q11,” I think including “(DiGeorge)” might save people some time looking it up.
   2. “Aortic insufficiency” is not a congenital defect in Marfan’s. Ruptured Aortic Aneurysm is a late complication of Marfan’s, as is Mitral Insufficiency, but not one of these is present at birth and so cannot be considered “congenital.” I think this should be removed.
8. P.244, Atherosclerosis
   1. I have attached a picture below to help people remember the incidence for plaques at each location.
9. P.244, Infarcts: red vs. pale
   1. The liver is not listed under red infarcts but is included in the illustration. I think this should be included in the write up as well.
   2. The brain is listed under pale infarcts. The brain is subject to both red and pale infarcts, depending on location. Red infarcts occur in “watershed areas” where cerebral arteries overlap their supply and white infarcts where there is a single arterial supply ( e.g. the thalamus).
10. P.245, Evolution of MI
    1. “Risk for arrhythmia” is listed under “2-4 days.” While true that most arrhythmias occur within the first 4 days, the striking example of this in sudden cardiac death is within the first few hours. This is mentioned on P.246, under “MI Complications,” but needs to be listed consistently between the two pages. I suggest adding “Sudden cardiac death from arrhythmia” after “No visible change by light microscopy in first 2-4 hours.”
11. P.246, MI complications
    1. Bullet 4: “can lead to cardiac tamponade” is listed as an outcome of the preceding three complications of ventricular free wall rupture, iv septum rupture, and rupture of the papillary muscles. This is confusing and omits the specific outcomes associated with each. I think this should be rewritten:
    2. Rupture (in order of incidence):
       1. IV septum – L-R shunt
       2. Papillary muscle – severe mitral regurgitation
       3. Ventricular free wall – cardiac tamponade, almost always fatal.
12. P.247, Heart Murmurs
    1. I would change both the picture and description of Mitral prolapse. The description should follow the order of events, so I feel that “ Midsystolic click followed by late systolic murmur” is less confusing than “Late systolic murmur with midsystolic click”. The picture does not show the midsystolic click . The picture shows the late systolic murmur as a mid-to-late crescendo rumbling. The murmur is more commonly listed as being “barely audible to holosystolic (after the click)”. I have attached a drawing based on the mitral valve prolapse phonocardiography available at the American Family Physician website.
    2. I would change both the picture and description of Aortic regurgitation. The picture shows the diastolic murmur as being a crescendo-decrescendo murmur. As the pressure in the aorta is falling down a gradient, this does not make sense. The murmur of aortic regurgitation is regularly described as an early diastolic decrescendo rumbling.
       1. I think this is also the appropriate time to mention the Austin Flint murmur with the following description: Pure aortic regurgitation without interference from aortic valves. Returning blood pushes against mitral valves, causing diastolic vibration mimicking Mitral stenosis. Unlike Mitral stenosis, no opening snap is present.
       2. I have attached pictures for both Austin Flint and Aortic Regurgitation
13. P.248, Cardiac tamponade
    1. “Compression of heart by fluid (i.e. blood)” is incorrect as a definition. Cardiac tamponade often results from pericarditis with serous, serosanguinous, hemorrhagic, chylos, or suppurative pericardial effusions. I think it should be changed:
       1. “Compression of heart by fluid (e.g. blood, pericardial effusions)”
    2. “Equilibration of pressures in all 4 chambers” is not complete. This should say “Equilibration of diastolic pressures in all 4 chambers of the heart with intrapericardial pressure.”
14. P.249, Pericarditis
    1. Findings of pericarditis do not include “diffuse ST elevations in all leads.” One of the EKG hallmarks of pericarditis is “diffuse ST elevations in all leads except aVR and V1.” There is also an absence of pathologic Q waves, further helping one distinguish it from a transmural MI.
15. P.250, Cardiac tumors
    1. Kussmaul’s sign is mentioned here but there is no mention that this occurs in any cardiac restriction ( e.g. cardiac tamponade, pericarditis). I think it is worth mentioning this with each of the previous entries, or giving it its own section:
       1. Kussmaul’s sign: paradoxical [up arrow] in systemic venous pressure on inspiration. Caused by pathologic [down arrow] in RV filling ( e.g. restrictive cardiomyopathy, constrictive pericarditis, right heart failure, cardiac tamponade).
16. P.251, Antihypertensive drugs
    1. Captopril is listed as having “Proteinuria” as an adverse side effect. This is incorrect. By decreasing levels of angiotensin II, the efferent arteriole dilates, thereby decreasing GFR. This leads to a decrease in proteinuria. “Proteinuria” should either be omitted from the mnemonic or changed to “ Prevents proteinuria “
       1. The plot thickens and I eat crow. Captopril is used to treat (and even delay the onset of) proteinuria. It does this by the mechanism I have described. Its toxicity, however, can also cause proteinuria. So the First Aid is incomplete but not incorrect. The mnemonic is fine.
17. P.252, Antianginal therapy
    1. The table says that Beta Blockers “affect afterload.” This is not true. They affect contractility . This is specifically true for the cardioselective beta blockers that would be used in cases of angina. B1 = contractility.
    2. Nitrates + Beta-blockers is listed as having “Little/no effect” on contractility. As B-blockers have their principle effect on contractility, I do not see how this is possible. In combination, the reflex increase in contractility seen in nitrate use would be blunted by the B-blocker and any basal sympathetic activity would also be blunted, leading to a decrease in contractility.
18. P.254, Cardiac Glycosides
    1. To help make the hypokalemia/hyperkalemia relationship with digoxin more obvious and intuitive, I think that “Direct inhibition of Na/K ATPase” should be changed to ” Competitively inhibits Na/K ATPase at K-binding site.”
    2. “+ IONOtropy” should be “+ INOtropy”
    3. “Hypokalemia (potentiates drug’s effects),” while true, is not at play clinically. In acute digoxin toxicity, hyperkalemia results. In chronic digoxin use (or when combined with a K-wasting diuretic), hypokalemia can result and this then leads to digoxin toxicity. I think this should be rewritten:
       1. “hypokalemia (when combined with a diuretic), hyperkalemia (in digoxin overdose);”
       2. I’ve omitted the “potentiates drug’s effects” part because this is covered when we state that digoxin “competitively inhibits Na/K ATPase at K-binding site.”
    4. “anti-dig Fab fragments (Digibind).”
19. P.257, Antiarrhythmials – Ca2+ channel blockers
    1. “Phase 2 (Ica and Ik)” should be “Phase 2 (Ica) and Phase 3 (Ik)”.
20. P.257, Other antiarrhythmials
    1. “K+ — depresses ectopic pacemakers, especially in digoxin toxicity.” should be changed to “K+ — depresses ectopic pacemakers in hypokalemic digoxin toxicity.”

Return to First Aid Errors page.

I have a list of things to write about transferring from the Caribbean. It swells and shrinks with my ideas, but it stands now at the following:

1. Make Peace With Your Decision
2. Why Transfer?
3. Writing the Essay
4. Which Schools Accept FMGs?
5. Getting a Good Recommendation.

Mind you, the thought of publicly failing (in the pseudo-anonymous sense) does weigh on me, but I’ve made peace with it. What stops me now from continuing is the amount of interest in the topic. I don’t normally get more than 100-200 visitors a day at this tiny blog, but since I wrote the first few posts about this process, that has increased considerably.

There are many students that would like to transfer. Whether they began happily in the Caribbean and have since made the decision to transfer (as I have) or began abroad only to buff their application for this purpose, I cannot know. What I do now is that there are a lot of them and that they are looking for information.

I began writing this series because of my frustrations. While I am going through this process, I have not found the information that I want organized and readable in one place. As you may know, I am a Kantian living accordingly to the Categorical Imperative, and this dictates that I must create the things I wish I had if they have not existed for me. It sucks at times, but those are the sacrifices I have come to accept for living the life that I do.

This means that if what I write is worth a damn, it will help prepare those people with whom I am competing. I’ve long thought that if I met a few of my friends at an interview that we would exchange awkard glances before realizing that, “Hey, we both want the same thing. No use hiding it.” And for the most part, I’ve been somewhat comfortable with this. My thought has been that I am a very strong candidate and that if I am not accepted, it’s because I am really not the guy that they want and not because I’m weak on paper. If I fail, I want it to be in the interview. I want it to be me they are rejecting, and not a recorded version of my accomplishments.

I don’t know if anyone reading it realizes what an enourmous move forward that thought is for me.

So now I’m stuck. This is still anonymous, but it is not unseen. I can be found on google. These are no longer my trade secrets, and everything I share has the potential to help others and harm me (as so much as it is useful). It would be different if I was writing this retrospectively from a safer perch, but it is not and I am not. So now I must choose whether to suspend it until I have gone through it, or to continue as I progress with secrets laid bare.

Am I actually comfortable with my chances against the masses, or was I just comfortable with my chances against the masses that I knew? Will I decide to keep my advantage of information against my competition? Should they benefit from the time I spend on the phones, doing the legwork, figuring the deadlines, and creating a schedule? Am I slowly becoming part of the problem that spurred me to start a solution?

I’m still not sure.

My ass has been handed to me and these are not happy days.

I went through the Anatomy in Rapid Review: Gross and Developmental Anatomy. This book is so much fun that my roommate (after hearing a few examples of the clinical correlations therein) left to buy his own copy from the bookstore. I recommend this book twice on Sundays.

Later that day I went through Costanzo’s Physiology BRS. It’s fine, but it’s really lacking in detail. It’s a review book (I get it) but it’s a review book for the Boards. It could have brought a little more to the table (at least in Cardio). Other than claiming that baseline MAP should be 100 mmHg (instad of 93), showing ventricular volume changes on a graph during isovolumetric relaxation (wrong by definition), and showing no ventricular volume change with atrial systole (accounts for last 10% of EDV), there were no major errors. The questions are cookie-cutter and do not ask you to think a single order above the basest level of detail. I judge this section as “adequate.”

Day two was Schneider and Szanto’s Pathology BRS. I wrote about this book before and think that the chapters on basic pathology are good, and the sections on Heart and Vascular System are “okay.” Again, review book, I get it. But come on. The coverage of topics is pretty superficial and for the time I spent trying to find reasonable detail in Pocket Robbins and Merck, I could have just as easily skipped this book. While so far some sections have been better than others, the questions in the Path BRS are universally weak.

I was pretty excited to finish Anatomy, Physio and Path in two days and was scheduled to begin Pharm, but I stopped. Instead, I opened up Merck and started reading. I skipped over epidemiology and treatment regimens, but I lingered over clinical symptoms and pathology for each entry just to have a fighting chance of redoing the Cardio Pathophys in a day. I didn’t make it. It took two solid days but I don’t regret it.

The next day was for questions. First, I went to WebPath and worked through their tests. I did very well. Next I opened up Robbins Review of Pathology for their questions and, too my surprise, did well again. Feeling pretty cocky, I walked up to the 116 Phys, Path, and Pathophys questions in the USMLE WORLD qbank.

If you’ve seen Fight Club, then you’ll understand the following scene:

***

In the basement of a dank bar, the men are circled around each other and in the center, two are fighting. USMLE WORLD grabs Medstudent by the collar bone and drives his head into the student’s nose. He falls. Standing back up, he is able to land a few blows against USMLE WORLD’s jaw. He should be down, but he’s not. He’s smiling. USMLE WORLD proceedes to knock Medstudent to the ground, letting his fists drop into student’s face with a sick, wet, smacking that hides the student in his own blood. The faces of the other men hang slack, each of them uncomfortable with this particular show of brutality. The fight should have been over seven blows ago. USMLE WORLD stands up, shrugs his shoulders, and walks away. Medstudent coughs up a tooth through his nose.

“What got into you, Psycho-boy?”

“I felt like destroying something beautiful.”

***

It was the Pathophys questions that did it. I’ve learned all about Pressure-Volume loops. I thought I understood the pathogenesis and sounds of every valvular disease. And I was completely wrong. Throughout the entire, horrible experience of getting question after question incorrect, I began to realize that there was a level of detail simply lacking from what I understood that was essential to tackling these problems.

I’m reminded of what Bobby Jones said about the young Jack Nicklaus. “He plays a game with which I am unfamiliar.”

Thanks to google, I finally found the rules to the game. I could kiss Richard E. Klabunde on the mouth for creating his Cardiovascular Physiology website. It is through him that I discovered that there were not just direct effects on the PV loop due to Preload, Afterload and Contractility, but there were INTERDEPENDANT EFFECTS as well! It’s the missing move in the Rubicks Cube!

He has a book! He has another site for Cardiovascular Pharmacology!

Excuse my enthusiasm, but you have to understand: this was like Ignorance prison and I’ve just let the Physiology Jesus into my life. I’m parolled!

So not such a bad day after all. After spending two hours internalizing the PJ’s message, I took the remaining questions and fared much better. Tomorrow is Pharm, and I will let the PJ’s site be my guide (PBUHHN).

Return to USMLE Step 1 page.

What you want to do with this test, with this opportunity, is up to you. However, if you’ve googled the topic and are reading things like this, chances are you’re not looking to coast with a modest passing score. I, sure as shit, am not. I want to keep as many doors open as I can for my residency interviews and I know that coming from the Caribbean puts me at a disadvantage.

People come down to the school to tell us things like, “The passing score is now 185. If you want a residency program that has empty slots each year like Internal Med or Family Practice, that score is fine. But if you want anything even mildly competitive, don’t show up with anything below 215. Don’t even bother applying. At that point, your best bet will be to sign outside of the match. Remember that there is a difference between having a score good enough for a residency and having a score good enough for a competitive program in that residency. It is always better to have a better score, regardless of your goals.”

In light of all of this, I’m going to state my goals and try to put everything that I’ve written about my preparation into context. When I say that the BRS questions are weak or that for a certain book the topic was covered superficially, I mean that it was weak and superficial for what I want to do. I do not want to just pass the Boards. I don’t even want a high pass. I am locking myself in a library every day to score above the 95th percentile. If you glazed over a subject, feel weak in it, and could use a stepping stool to competency, then the BRS Path (for example) is fine. But if you’re reaching for the brass ring, you should just sit down with Pocket Robbins or the Merck Manual and take the time to really get into it.

Yes. I know that you know a guy that barely studied and got a 99. Yes. There was a guy that did nothing but review the First Aid and he also got a 99. If you’re going to be the kind of doctor whose decisions are swayed by anecdotes like this, then you probably need to review Epidemiology and Study design. As far as I go, I’m not willing to follow their examples because, regardless of what they accomplished, I’m not that guy and you probably aren’t either. So let’s just dispense with the bare bones approach.

Reviewing this stuff (cramming) without achieving deep understanding at each level (internalizing) is like renting an apartment for a month at a time when you know you’re living in the neighborhood for the next ten years. Why waste your money? Instead of paying just enough each month, it’s worth it to go into debt (time-wise) to own it. Every day after that, the investment pays for itself, but you have to make it that first time. I’m not here to rent the knowledge; I’m here to own it, and every criticism I ever make of review materials is in that light.

There are books that I’m going to really like because of their incredible (but necessary) detail or because they are exceptionally well-written. There will be books that I trash for being riddled with errors and grammar mistakes or for being superficial to the point of uselessness. But whatever conclusions I reach, yours may be different because of time constraints (I have the luxury of two months) or learning style (in the eyes and it stays, in the ears and its out the other).

State your goals. Have a plan. Set a Schedule. Buy your books. Pick a QBank. Don’t crack. Have fun.

***

I think it’s now worth saying that of all the things I’ve done so far, bringing the Merck Manual to the library every day has been the best decision. I left it at home one day because it was taking up too much space. I am never doing that again. Pound for pound, I don’t own anything more useful. In fact, I’ve decided that from now on I will rate everything in units of Merck. Let’s establish a scale:

18th Ed. Merck Manual = 100 Mercks = highest rating.

Dudeck’s HY Cell and Molecular Biology = 1 Merck

“Dudeck” might be its own scale, sort of an inverse to utility… like a feacalith.

Return to USMLE Step 1 page.

“Happy Birthday, Topher!” I’m half asleep at 7am as Mrs. Thatcher gives me a hug. I sit down to poke at my porridge (had to look up the spelling) and drink my orange juice. I turn to Kelly, “We’re working too much. If your mom hadn’t told me, I would have completely forgotten that today was my birthday.”"You’ve turned into that guy.” I know it. Our plan was to return from the first two years in the islands and hole up in a library for two and a half months, studying furiously for the Boards. Coming from the Caribbean with the deck stacked against you, it’s not enough to pass this test; you have to destroy it. Regurgitating everything we’ve learned during two years (in an 8 hour test) sounds like fun.

We are studying at the University of Cinicinnati medical school library. It’s six stories tall with walls of glass, no furniture, and doors at both ends to let the heat out with everyone’s smoke break. We shiver underneath our long underwear, hats, fleeces, coats, scarfs and mittens. Since coming, I have spent $200 on layers. Not clothes; layers. If it weren’t for the desks, I’d study in the Thatcher’s front lawn and save the drive. We put in ten hours at the library, come home for dinner, and put in another three hours before bed. Saturday is not different from Wednesday. My week is seven Studydays in a row and I guess I wasn’t that surprised that I forgot about my own birth. C’est la vie.

We’re here more than any of the medical students, and people are getting curious. We’re learning names as they stop by to size us. Tim is my favorite. Tim’s skin is taught across his face, revealing the bug-eyed intensity that drives him to walk fitfully, arrange everything on his desk perpendicularly with one inch margins between objects, and has him sniffing around wondering why we’re sitting in the spot that he has clearly sprayed with his urine. Tim’s obituary will include the fragments “26,” “dedicated to helping people,” and “massive heart attack.” We really like Tim.

Then there’s Puss n Boots. If you’re reading this PnB, I love you.

The rumors have circled and everyone knows we’re from SGU. A few students stopped by for help with Pathology and Physiology, and we took some pride in being “the guys from Grenada who probably know the answer.” We’re wearing it on our sleeves. Our SGU sweatshirt sleeves. I guess I owe you that story too.

Kelly and I loved SGU and our time in Grenada. For my money, I’ve never lived so well and my life was never so rewarding and simple: wake up, learn things, sleep. Also tan. Like anyone proud of his school, we both wanted SGU tshirts and sweatshirts to wear back home and around campus. Problem was that the SGU bookstore didn’t carry things you’d want to wear and their prices made sure of it. Trying to change the world, Kelly and I contacted the main offices with ideas for shirts. Six months later, nothing had happened.

So we were in St. Vincent at this point with no bookstore and no chance to buy these shirts. “You know, we could just make them ourselves and sell them to people.” I looked at Kelly like he had two heads. “My brothers and I did it all the time. It’ll work.” So with that, Kelly and I searched the island for a tshirt printer, made a few designs on our computer, and did some market testing. Once we settled on a design and colors, we started paying people that were traveling to the US to fill oversized suitcases with cheap clothing. After a few rounds of this, we had the merchandise, the design, and the means. We invested $1000 of our loan money into the project and began selling them in class to students, faculty, staff, anyone.

We ran deals on buying three shirts at a time. We took custom orders for new shipments. We had all sizes, all colors, a cash drawer and a functioning inventory. We cleared an obscene amount of money and still managed to sell them for less than the bookstore in Grenada was charging. Illegal? Not in the Caribbean, mon. The profits paid for our rent and utilities for almost three months. Good times all around.

Back in the library, in what was turning into a pretty decent birthday, Deathmetal came by. Deathmetal is the skinny kid that plopped down for an early dinner in the library, put in his headphones, and proceeded to blast Metallica so loud that I could hear every lyric and sweet guitar lick from thirty feet away. Everyone stopped what they were doing to stare at him, waiting for him to figure it out. Each of them, so miserable being so polite. The pageantry was killing me. It was like a priest farted in church, was how hard it was to suppress my laughter right then. My schoolgirl giggling got Deathmetal’s attention and he looked at me with a question mark on his forehead. How he heard me, I don’t know. Guy’s got to be deaf from the volume.

I had his attention; what could I do?

I COULD ROCK. Slow at first, I began to lip sync every lyric as I heard it and began pantomiming Lars Ulrich’s thundering drum set. I didn’t half-ass this either; I could have been at a bachelor’s party three beers away from a canceled wedding for how committed I was to this performance. It was glorious. It took a few beats for him to realize that (a) I could hear his music and (b) this was inconsistent with the intention of earphones. He stopped the song, looked around, and sorry’d us. We laughed so hard after that, I thought I’d get sore.

I went to bed that night surprised to be 25 and totally oblivious to the fact that I had no missed calls on my phone as I set its alarm.

The next morning was the same as all the others. The day in the library the same as all the others. It was Studyday, just like last Studyday. It was not untill I came home and checked my email that I saw a few well wishes, and none of them belated. I went downstairs to see if the envelope from my parents had arrived a day late as my dad had promised (no luck). I then headed upstairs to see eight missed phone calls. I checked the date on my computer: Jan 30th, 2007. 8:40 pm.

Mrs. Thatcher had gotten the date wrong and I hadn’t realized it. This meant that twice in two days (in the same year) I had forgotten my birthday. I never thought I would be THAT guy. I told her and Kelly and we all had a nice laugh, but really I was feeling pretty disoriented. I guess I had it coming the next morning.

Half-asleep at 7am, I walk downstairs to eat my porridge. Mrs. Thatcher walks up to me, gives me a big hug and says, “Merry Christmas, Topher.”

har.

noun: Who was that? Don’t worry about him. He’s some worthless foad.

verb: Oh yeah?! Well FOAD!

adjective: Well that was a foad way to say it.

present participle: By the grace of God, he’s foading.

The Fuck Off And Die competition starts today! Conceived by the Dinosaur, it’s a competition between writers to write the best FOAD letter without letting the receiver know it. Tact misapplied, if you will.

From the Dinosaur:

Alternative post titles were:

• Lessons from my Father
• How to Say “Fuck You” So Elegantly They Don’t Even Know You’ve Said It

Inspired by Medblog Addict, #1 Dinosaur would like to announce a contest to see who can write the classiest “Screw You” letter. First prize is a copy of my book (which includes disclosure of my true identity.)

I am participating in the contest and, while I won’t tell you which is mine, I encourage you to vote for it. There will be five new FOADs each day for a week. For my money, this is the best one ever written:

“I am sitting in the smallest room of my house with your letter before me. Soon it will be behind me.” — Voltaire to Morat

Laugh today, topher.

I’m not going to question my attitude about the whole thing. I still think the way to prepare for the USMLE is to be enthusiastic for the chance to show the world what you’ve learned and to be excited for the opportunity to give two months to simply “reviewing.” Despite the hard work involved and my inability to articulate it in the form of an application essay, I love science. And despite the transient wish for a cat’s simple life of breathing, complaining, and rubbing against things, I know that none of that is what I really want. This, trully, is the greatest thing I could be doing right now.

“This” is 8-5 studying every day at the University of Cincinnati medical school atrium with all of the other medstudents, each of us shivering underneath our long underwear, hats, fleeces, coats, scarfs and mittens; each of us cursing the smokers for opening the door to the outside world every few minutes to the point were we’re thinking, “Fuck it, I might as well have a smoke;” each of us staring at the page with all the fun facts that make all of this worth the shaking.

I take breaks every half hour to run my hands in the warm, warm bathroom faucet just so I can take more notes. Yesterday, I bought two cups of coffee at the same time: one to drink and the other to hold. I say again:

This, truly, is the greatest thing I could be doing right now.

Everything is so interesting, that I’m slowing waaaay down in sections where time will not permit. Microbiology, for instance. I was so caught up in seeing patterns between the bugs and the drugs that I let it eat into virus-time. So now, I have to create two free days that don’t exist and I’m re-living an old problem born of my unchecked enthusiasm.

Falling behind means knowing less.

Excuse my hubris, but I was trying to be the first to avoid this. I am taking 9 weeks were others take 7. I could have sworn it’d be enough. Parkinson, however, couldn’t care less. I give you his Law: “work expands so as to fill the time available for its completion.” Truer words, truer words. But that’s not an option. I’m not postponing my test to allow time to catch-up. I’m not going to drop other interests like writing about this experience. I’m not going to learn less. Something’s got to give.

It’s probably appropriate, then, to introduce a new law.

Medical Student’s Law: “Sleep contracts as work expands.”

High Yield: S = (1/W)

Return to USMLE Step 1 page.

Today I turn 25, so to celebrate I took the morning off to solve Einstein’s riddle. It was a good day.

This has been an interesting week in the blogosphere. The debate over Health Care, whether it should be universal, whether it is a right, and how or why we would strive to enact it has been healthy. I’m incredibly interested in this and have been reading as much as I can. What follows is a synopsis of the debate as I have seen it. Throughout, something has not been sitting well with me, and that I finally figured it out is why I’ve brought these excerpts together. My conclusion is at the end.

Kevin M.D. posted this under the heading “Health Care is Absolutely Not a Right.” The comments that follow are fascinating, and I would encourage everyone to read through them.

This is the fundamental philosophical difference between what I (and others) believe and the stance of the single-payer supporters. Thanks GruntDoc for linking to the money quote:

As with any good or service that is provided by some specific group of men, if you try to make its possession by all a right, you thereby enslave the providers of the service, wreck the service, and end up depriving the very consumers you are supposed to be helping. To call “medical care” a right will merely enslave the doctors and thus destroy the quality of medical care in this country, as socialized medicine has done around the world . . .

The debate that followed in the comments circled around the EMTALA law, which mandates that any hospital must accept emergency medical cases, regardless of ability to pay. Hospitals abide by this law at considerable loss because the governement has threatened to remove funding for any hospital that does not. This would mean loss of Medicare, Medicaid, etc. One poster, Okulus, had the best comment:

In my view EMTALA is bad law. It mandates services under the threat of withdrawal of funding for unrelated services, which is extortion, particularly given that the taxpayers are providing that funding. (No different than threatening to take away a state’s allocation for highway subsidies if that state fails to comply with an unfunded mandate regarding education). Certainly I have a right to vote for candidates who want to repeal EMTALA. But even if I didn’t, that does not make EMTALA any more a good law. And it doesn’t make expropriation of services a right.

So is health insurance a right? Of course not. It is neither a de facto nor de jure right. And neither is postal service or 911 ambulance service or sewage disposal. They are services, available to the public when the public chooses to pay for them, and the converse when not. Any one of them could be here today and gone tomorrow, unlike real rights, which are far more durable.

So with the link to Graham Azon’s blog as the “single-payer supporter,” he responded with a two-parter (1)(2). These excerpts are truncated, so for his full argument you should visit his site:

Honestly, I think many people in the media use “socialized medicine” as a scare term, a blanket term for any sort of “government” health care. If that’s how you’re using it, fine, but if you’re presenting information as policy arguments, you sound a little sophomoric if you use it incorrectly. (This is like referring to the rectum as “the poop chute.”)

Socialized medicine is what the UK has.

Socialized insurance is what Canada has.

“Pay or play” is an employer-based system, where employers either have to offer coverage, or contribute to a fund to provide coverage to the uninsured.

***

From where I’m standing, then, if we’re going to take care of the acutely ill, we might as well keep societal costs lower by preventing people from becoming acutely ill (or from developing the consequences of chronic illness). Am I crazy? Am I missing something here? You can’t tell me that our system makes sense in this way. We will allow an uninsured diabetic to go years without any preventive care, because lack of ability to pay, but once his foot becomes necrotic and he needs an amputation, and gets an ICU stay for becoming septic–oh well, let’s definitely pay for that!?

Look, if you have a problem with the “political feasibility” of single-payer, that’s fine, we can debate that. If you’re weary of allowing a government entity to set all health care reimbursement, that’s fine, we can debate that. But to stick your thumbs in your ears and ignore that we’re already ready to pay for emergency care, because of the consequences of the alternative is just stupid, plain and simple.

So, what’s your better solution?

So from all of this, it strikes me that people are either holding steadfast to their philosophy that no resource can be mandated as a right (as that necessarily limits the rights of those providing the service), or they are holding steadfast to their pragmatism (that leaving people with their injuries because they cannot pay is not something that we are comfortable with as a society, so let’s fix that). I like Graham’s challenge though: what is the better solution?

So here’s mine.

FUND EMTALA. The Emergency Treatment and Labor Law was enacted in 1986 as a response to the act of “patient-dumping” by hospitals. In essence, the statute:

• imposes an affirmative obligation on the part of the hospital to provide a medical screening examination to determine whether an “emergency medical condition” exists;
• imposes restrictions on transfers of persons who exhibit an “emergency medical condition” or are in active labor, which restrictions may or may not be limited to transfers made for economic reasons;
• imposes an affirmative duty to institute treatment if an “emergency medical condition” does exist.

That last bullet point costs money. Lots of money. Where does it come from? EMTALA is an unfunded mandate, meaning that it was decided that providing medical care was so important that it required a law to be passed to ensure it, but not important enough to be supported financially. The weight of this law rests inapprpriately on the hospital, not where it belongs on the taxpayers whose interests are represented in Congress. Why would any hospital agree to this? The guillitoine of severed Medicare payments should they not comply.

Unless you run a hospital, why should you care? Imagine a hospital that is running without making a profit. They make enough money to cover all of their expenses and meet all of their salaries. Everything is only as expensive as it needs to be and all the prices charged are fair. If this hospital had to abide by EMTALA, it will begin to lose money. It’s options at this point are to ignore EMTALA (in which case it loses money anyway as the governemnt withdraws payments for patients on Medicare), go bankrupt and close (happens way more often than you think), or make up the loss by charging paying customers more.

I give you the $10 tylenol. Now we can debate the many factors for the rising costs of health care until we’re too dead for it to matter, but the fact that a hospital that abides by EMTALA must then overcharge paying customers is inescapable. It is also unfair. If you cannot pay for your own healthcare (and receive it anyway because of this law), then you are making healthcare more expensive for those that can pay. If this doesn’t happen, then the hospital closes and you’ve not only lost that resource, but you’ve stressed the remainging hospitals that now experience increased patient loads.

I give you a downward spiral. So for anyone that will ever need hospital care, this does matter. The solution seems pretty straightforward to me, and that is to reimburse the hospitals for their costs. It makes no sense to demand that hospitals pay for your service so that it is free to you. If we are as serious about giving everyone care in an emergency regardless of insurance as we claim to be, then that requires a serious sacrifice on our parts. Our taxes are going to increase. You will have, in effect, given universal accident insurance to the nation.

The details of payment can be left to the hospitals and lawyers to discuss, but the hospital should be able to demonstrate its expenses and the US government should send a check in the mail. So that’s my first solution: fund EMTALA.

Of course, what happens next would be interesting. If hospitals were able to do this and still saw all of the current cases in the ER, they would likely welcome the non-emergency cases that they currently detest. If the governement (and by that I mean all 300 million of us) were to see the bill, there would likely be some sticker shock. “We can’t afford to fund EMTALA,” we’d realize. “We’ve got to figure out a way to keep these non-emergency cases out of the ERs,” we’d decide. And it’s because we would likely be pushed into this future that I like Graham’s second point.

To paraphrase, emergency cases cost a lot of money, and these emergencies are sometimes the result of an uncontrolled chronic condition (amputation of a diabetic’s foot) that could have been prevented at a much lower cost. So if we’re going to have a funded EMTALA with effective universal accident insurance, wouldn’t the taxpayers save even more money with universal and comprehensive medical insurance?

I stumble with his conclusion. Not every American presents to the ER, and while providing preventative care for the person that does would save tax dollars, I can’t know which person’s preventative treatment to target. In other words, universal medical insurance has perfect sensitivity but poor specificity. It seems to me that any preventative measures should be specifically targeted and if that was truly cheaper the investment would be worthwhile.

Joe Paduda at Managed Care matters has a good point and I’ll let him have the last word. He’s absolutely right that we have to define our goals and these have to be in line with our principles. So in the interest of openness, I’ll be very specific about mine:

No one can claim a right to anyone’s service. It follows, then, that health care is not a right, but a want. It also follows that the weight of any proposed solution should fall on the backs of those who benefit (the tax payers) and not on the backs of those that provide it (hospitals, physicians).

No one can arbitrarily decide the worth of a service. By capping what a physician (lawyer, artist, whomever) can charge for his service, you are robbing him of his value and destroying the distinction between good and bad service by removing its incentive. It is for markets to decide what a service is worth, not governments.

I am open to (and would support) any program that successfully makes health care more accessible while not conflicting with these first principles. It remains to be seen if Single Payer is the solution to this, and I think everyone is going to be very interested with the results from the single-payer experiments in Main, Mass, Maryland, etc.

Joe Paduda’s last word at Managed Care Matters

What are we trying to accomplish with health care reform?

Lower costs today? A sustainable trend rate so care is affordable for the foreseeable future? Better outcomes, defined as healthier people and/or fewer avoidable deaths and/or higher levels of functionality? Coverage for all so no one goes without? Equitable reimbursement? Less interference in the doctor-patient relationship? Greater self-responsibility on the part of consumers? A reduced financial burden on employers, especially small ones and really big ones with lots of retirees? Ever healthier, longer-lived citizens?

All of the above?

A Day in the Life of an Ambulance Driver.  Started writing recently, all of it good.

I gotta confess…I love it all. Aside from my professed world-weariness and cynicism, this is what I was born to do. So if you want a real Day In The Life of An Ambulance Driver, here is what we REALLY do…

We make far less money than our health care brethren with similar education. And the sad fact is, a whole lot of us do not even deserve the pittance we’re making.

We bitch and moan about low pay, yet we steadfastly oppose any attempt to advance our profession through higher educational standards.

We make a Big Deal of the whole lifesaving myth, smugly convinced of our own inflated sense of worth, yet we ignore the actions of the untrained bystander who probably made the greater difference.

We eat our own young.

When choosing a QBank, I went with USMLE WORLD (UW). It is much cheaper than the competitors Kaplan and USMLE Rx, it gets higher reviews from students that have used more than one QBank, and everything else (interface, online stats) was equal. Something of a no-brainer.

After using it for almost a month, I can say a few non-comparative things.

It’s fair. I haven’t had a question yet where I felt the wording was ambiguous or the answer was a stretch. Every time that I have looked at the options and thought to myself, “I have no idea,” it was because I really didn’t know (instead of knowing the answer and not knowing how to apply it).

It’s interesting. Each question has a full explanation (usually with an illustration or table) for right and wrong choices with a summary “Learning Objective” at the bottom. This is just a smart thing for the company to do, as every wrong answer leads to a new concept learned. I regularly go through my incorrect responses and copy down the new objective into my notes.

It’s hard. While at SGU, my favorite tests were in Pathology. Whoever wrote those tests was a sadist of the fourth order. For example:

1. The test stem would have symptoms. [appendicitis with Hx of appendectomy]
2. You’d have to figure out the disease. [Crohn's]
3. You’d then have to realize what the appropriate treatment was. [Cortisol]
4. You’d have to know the side effects of that treatment. [abd striae, bull neck]
5. Finally, you can answer the question: Given this patient’s symptoms, what is the most likely side effect of his treatment? [weight gain]

Everyone complained about how hard those tests were, but I had been waiting for that type of challenge in a course my whole life. I loved those tests, and for similar reasons, I love the questions in the UW Qbank. There have been a few times where, after reading a question and figuring out the answer have thought, “That was the coolest way I have ever seen that asked.” I couldn’t give it higher praise.

If you’ve decided to use UW and are working through the questions, it might help to know how you’re doing. With each question, it will tell you the percentage of people that answer it correctly. With each subject, it will tell you your percentile against other test takers. Useful, right? I’m having a few problems with this.

The stat for “percentage that answer correctly” doesn’t say if that is on the first try or includes all attempts, including repeats. I wish there was a separate statistic for this. Your overall percentile is based on your test average against the mob, but again this can be manipulated by taking the same questions over and over (I’ve tested this myself). For the person going through the questions once without repeating, you may feel that your percentile is a little low (or just hope that it is).

Here are my percentiles on first past through all the available questions in a section. I will expand this list as I continue to cover material. You’ll notice that the scores are very low. As I mentioned before, these aren’t true percentiles as they are not compared against the mob’s first attempt and I list them here just so that people don’t feel so defeated when they take the questions themselves.

• Biostatistics (74th) – I felt very well prepared
• Behavioral Science (waiting to do Psych until later)
• Embryology (71st) – I felt well prepared
• Genetics (48th) – Curse you, Dudek and your horrible book.
• Biochemistry (79th) – I felt very well prepared
• Immunology (70th) – I felt well prepared
• Histology (32nd) – I wrote this off. Maybe I should look at it.
• Anatomy (74th) – Just for fun. I’m an Anatomy geek.

ADDENDUM: I sent an email to the USMLE WORLD team about these questions and I was pleasently surprised to see them respond the next day.

The “percentage that answer correctly” only records the first attempt of the user if the question in taken in the unused mode.

The cumulative performance is based on the entire test percentage and you are correct in assuming that the percentile might be manipulated if a person repeatedly takes the test and answers all the questions correctly. However for the percentile to skew greatly, a large number of users will have to “cheat” the system this way by repeatedly taking the same questions.

However, most of our users take the test first in unused mode and then they use other modes like incorrect or marked questions if they have sufficient time left. This might skew their overall percent by 2-3 % but over a significantly large data set this offset becomes negligible.

Hence, the presented percentile should only be used as a rough indication of where the user stands and preferably should be ignored during the initial tests.

Return to USMLE Step 1 page.

I have always insisted on making my own mistakes. I often have to repeat my mistakes. This eats up a lot of my time.

I’ve griped before about not knowing how to handle this period of studying for the USMLE. What I have really meant is that I don’t trust anyone else’s advice and insist on screwing up a little before getting it right.

“You’ve bought too many books, you’ll never read all of those.”
“I never did a single question and got a 99.”
“Just stick with First Aid. It’s all you need.”
“You don’t have to study Emrbyo. There were hardly any Embryo questions on the test.”
“Do nothing but questions. Questions, questions, questions.”
“Man! There were a lot of Emrbyo questions! It’s definitely high yield.”

I still believe now what I believed before: that I have one shot at this test (I have no intention of failing it). In statistical parlance, this means that n=1 and df=0. You cannot draw conclusions from that study. People peddling specific advice to you forget this. Both people that stopped me in the library with their two cents about Emrbyo forgot this. And I will slowly forget this.

Since I broke up the subjects into General and Systems (the organization of the 2007 First Aid), I’ve tried to work on each section a little differently to see what is working. So after Biostats, Behavioral, Embryo, Biochem, Immuno, Autonomic Pharm, Basic Path and Micro, n=8. What follows is a breif chronical of my personal mistakes.

Biostatistics – 1 day

I read through the First Aid section briefly before slowly going through my old notes. I then opened up the Kaplan Lecture notes and read their Biostats section. For the first time, I started to notice that there were disagreements between sources. This sort of thing drives me mad, so I would often waste ten minutes on a piece of minutia to protect the house of cards. I then read the HY Biostatistics by Glaser. It was, by far, the best thing out there. I can’t say enough nice things about this excellent book. Finally, I took out a few pieces of paper and wrote a few pages of notes that I will later use to refresh the week before the test. I spent too much time on this section. I should have just used HY Biostats and taken my notes straight from it. Could have saved half a day.

Behavioral Science – 2 days

Going in, I am less than enthusiastic. Behavioral Science has always felt a little soft and doesn’t lend itself to learning a few core principles and then extrapolating the rest. It’s low yield. I start with Kaplan. It’s overkill. All of the epidemiology is over the top and I am falling asleep. Many of the tables and charts start to conflict with each other (two sentences each claiming different #1 killers for this or that) and I pitch it. After taking a look at the First Aid, I’m desperate to believe that there isn’t much I need to know as I finally turn to the HY Behavioral by Fadem. Everything is compact, well explained, and of a manageable size. This is what I wanted from the beginning. I take all of my notes for later review from this book and move on.

Embryology - 2 days

I wanted to work on Embryo as its own topic, and in the Kaplan notes it is intertwined with each system under Anatomy. Trying to learn from the previous three days, I head straight for the HY Embryo by Dudek (the BRS is also written by Dudek). This book is long, filled with pictures, and weighs in at 177 pages. I really liked this book for its clear explanations. There were several shaky concepts that were finally made clear (meiosis v mitosis, I’m embarassed to say) and it was worth the investment. It was detail heavy, but not to the point of being irrelevant and included plenty of pages devoted to genetic disease. All of this ended up tying in neatly with Biochem, so I consider it time well spent. Two days is a lot to devote to this, but I figured it was worth it on the assumption that it would help me make more connections down the road. I took all my notes onto Post-Its and put them in the First Aid section. I would do this the same way again.

Cell and Molecular Bio – 2 days

At SGU, genetics was a sort of half-assed course. Unfortunate, because I love this stuff and was completely put off at the time. I tried to repeat the success of Embryo with the HY Cell and Molecular Biology book by Dudek.

What trash.

This book has a bizarre number of typographical, illustrative, and conceptual errors. To be sure, there were some bright spots. The first chapter on cell signaling is fantastic and chapter 10: The Human Nuclear Genome was just fascinating, but I spent so much time trying to fact-check this book (after you find one error, you find another, and another) that I reached the point where I just couldn’t trust it any more. It’s largely cobbled together from his other books (almost twenty pages are straight from his HY Embryo) and the patchwork shows. This book was far from high yield and cost me two days before I gave up. I would never recommend it. I decide to cut my losses (Chapter 17 of 27) and go to the next topic.

Biochemistry – 5 days

I spent the first two days doing nothing but looking at the First Aid and reading through the corresponding notes from my first year. At the time, we were using Lipincott’s Illustrated Biochemistry, so having the book next to me made it easy to make sense of my chicken-scratch. I was cruising through the topic, confident, and then an amazing thing happened: I realized how much I didn’t know. You forget about it at the time, but going through Lipincott in first year, every term is alien, every disease and drug tie-in is ignored, and you’re happy to just get a “feel” for what’s going on. The second time around, it’s like seeing the world with new eyes. You understand every reference and all the things that haven’t made sense in other courses are finally connected. It was relevatory. I had originally planned to skim this book but finally decided to reread the whole thing. I didn’t have time to take any formal notes for later review (the Fed-Fast chapters were too engrossing), so I’ll have to carve this out later. This was also the weakest section in the First Aid, and I found myself wasting valuable time fact-checking Lipincott against First Aid against other texts to keep my head on straight.

If I had it to do again, I would have read through my old notes once, and then started on the book. I would have then used the two days that I wasted on Dudek’s HY Cell and Micro to write some review sheets. Oh well. My roommate spent the entire period going through Kaplan’s notes and had positive things to say. I wish I could confirm, but I ran out of time.

Immunology - 2 days

This was another SGU course that fell short for me. Fortunately, you can’t escape it, so that I didn’t learn it formally didn’t stop me from picking it up in Micro, Path, Pathophys, and Pharmacology of Immunosuppression. To get a feel for the scope, I cruised through First Aid and found that I had already covered a great deal of the material in Dudek’s HY Embryo. At this point, I’ve stopped looking at Kaplan all together. I went through the first four chapters of Rapid Review: Immunology and Microbiology. It is bare bones. They make it very obvious what they think is important and I did manage to make some new connections in these chapters, but it was not good enough to be a stand alone. There were several things (like lymph tissue anatomy) that were covered more in depth in the First Aid. I didn’t think that was possible, but there you have it. Between the two of them, I was reintroduced to everything that I saw in Path and my bases are covered. I even had time to take some good review notes for later. For the material I covered, I spent too much time in this book. That said, I didn’t have the time to read a proper text, so, c’est la vie.

Pathology of Neoplasia and Inflammation – 1 day

Path, how I’ve missed you. I’ve been looking forward to cracking open my brand new beautiful Path BRS since the day I bought it, and it was hard to limit myself to these two sections. I like the layout of the book, that the pages are thick enough that highlighter doesn’t bleed through (a previous problem), and the pace. The questions at the end of each chapter are inappropriately easy, which disappoints me. The subject came as a welcome break and I took one page of notes from the BRS and the First Aid.

Pharmacodynamics, kinetics, and ANS – 3 days

I started by reading the sparse entry in the First Aid on dynamics and kinetics before opening my Pharmacology for the Boards and Wards book. It covers these topics in the first 12 pages. It took my three hours. I’m probably just dense, but I didn’t feel this was well presented in either place, so if you already understand the topic, then FA might be enough. I floundered in this, but by the end was happy with my understanding. That left two days to cover autonomic pharmacology. That might have been enough, but the pace to date was too exhausting, and my roommate and I decided to quit for a day and recharge. It was necessary and we felt like a million bucks, but this means that I haven’t covered adrenergic drugs yet and will have to make it up later. If I had this to do over again, I would have traveled back in time and learned it correctly the first time. I also wouldn’t have tried to plow through three weeks of work without a single day off. Live and Learn.

I took a look at the Kaplan pharm section, and they have some very interesting pictures and graphs for conveying difficult topics. There pictures on the effects of cholinergics and adrenergics on the heart rate and BP are amazing, and the picture showing the ionization of drugs in the urine at varying pHs and resulting excretion is one of the most amazing pictures I have ever seen. As Pharm for the Boards and Wards is frustratingly filled with errors, I think I’ll switch over to Kaplan’s pharm when it comes to the systems.

Microbiology - 8 days

This is our first big topic, one of our weakest topics (competing with Pharm), and something I was afraid to begin. I decided to take a completely different approach and this has been the most successful to date.

I read the basic information in my main text, the RR: Immuno and Micro. Although it was painful to admit, I had to relearn about gram negative, positive, and the differences therein. After making some very basic notes, I used the FA bacteria-trees for gram positive and gram negative bacteria. I then wrote out all of the toxins for each bug and came up with some mnemonics for them. This would be my base. I spent the rest of the day writing the best notes that I could, trying to combine all the relevant information from the FA and the RR so that I would never have to look at either again. This took all day.

The next day I spent the first two hours trying to recreate the list of toxins from memory and draw the bacteria trees from memory. I accomplished this by noon. For the next two days, I did nothing but read about antibacterial drugs, their mechanisms, targets, and side effects. Every morning I would reread the notes I had made from the previous day until they were almost second nature. I tweaked my mnemonics.

By the time I had to sit down and learn about each bacteria, I found I knew almost everything I needed to simply from the drugs, the bacteria tree, and their toxins. Everything new that I was reading fell neatly into my pre-existing framework and this made everything before and after more solid for me. All in all, I spent four days on the bacteria alone, two days on viruses, and two days covering the remainder (protozoa, helminths, fungi). Nothing I have done has worked out so well.

Because the pharm section in the RR is small, I had to supplement it with the FA (suprisingly complete) and the Boards and Wards book (this section wasn’t too bad).

General Reference Book

Of all my decisions so far, the best one has been to have the Merck Manual with me at all times. It covers Micro, Pharm dynamics and kinetics, Path, Phys, EVERYTHING. It has been the great oracle whenever my review books conflicted and I would be lost without it. Of course, you could always study with your computer on and the internet running, but that would be a disaster for me. Instead, I keep my focus and have this book in front of me at all times

So what have I learned?

Less is more. Some books should generate automatic refunds for all the mistakes in them, and I would have done much more research on reviews before buying many of them (as it was, I went by First Aid’s recommendations alone). Instead of finding one incredibly solid book for each section, I have at least two books for every section (considering Kaplan) and sometimes three (Pharm, Path). This has been a mistake so far and one I’ll try to avoid as we enter systems.

First Aid is not enough. It has errors and will not give you an understanding of the topics. The First Aid is for someone that already knows everything and is looking for reinforcement and an idea of concepts previously tested. While it may be true that most questions you’ll see have their answers in the FA, that’s a far cry from being able to say that the FA helped me answer all the questions. After you read it, you’ll understand what I mean.

Repetition goes a long way. I find that writing out the information and making my own set of notes has worked for every class I have taken in medical school and this is no different. To paraphrase the late Frank Netter, “you can’t lie in a painting.” I feel the same way about writing: the things that are unclear to you become obvious when you try to take notes. It is, however, incredibly time consuming and I’m 3/4 towards my very own carpel tunnel syndrome. I’ve also found that taking notes on a piece of paper folded down the center is helpful, with prompts on the left and the information hidden on the right. It’s an idea stolen from teh Cornell method of note-taking, and it makes it very hard to lie to yourself as you read something that, “yeah, I remember that.”

When the answer is hidden, there’s no way to fake it.

So if you believe my experience, here’s what you keep and what you throw away from my original list:

• HY Biostatistics (great)
• HY Behavioral (great)
• HY Embryo (for the motivated student)
• HY Cell and Molecular (trash, don’t buy)
• Lipincott’s Biochem (long, great if it was your text book. Might want to consider Mark’s BRS)
• Pathology BRS (great)
• Pharmacology for the Boards and Wards (look for something better)
• RR: Immunology and Microbiology (Straight to the point, no frills)
• Kaplan lecture notes (Biochem and Pharm are strong sections. Biostats and Behavioral are weak. A wash).
• Merck Manual (my rock)

Hope it helps, topher.

Return to USMLE Step 1 page.

These are blogs I feel lucky to have found and, after the first post, compelled me to begin from the beginning and devour the archives. Each contains a link to one of their earliest posts and I’ve included the first thing that I read from each of them that made me want to read them all.

PURRTY GUD

Battling a sinus infection. The notes were few from my standardized pelvic exam. The major good one was “Good pressure!” The bad one was “Must learn to avoid clitoris.”

If only they knew how many years of conditioning I’m working against.

PANDA BEAR MD

Empathy training is the latest fad to hit medical school. Large quantities of your time will be wasted on this sort of thing. I didn’t dislike empathy training. In fact, because it is so non-rigorous and intellectually vaccuous it provided a pleasant distraction from the usual boring lectures. What’s not to like about sitting in a circle listening to some idiot drone on about the wonderful things you are going to do for your patients once you learn to relate to them? It was even more entertaining to listen to the small minority of students who take this kind of thing seriously and wax orgasmic about making a difference and touching the lives of patients.

MED SCHOOL HELL

Welcome to med school hell. This is a blog about my life as a medical student and the “truth” about medical training. I thought I’d get started with a little introduction.

I’m a senior medical student training in the US. I hate medical school with a burning passion like I have never before felt. In future posts, you’ll get to share what it’s like to be in my shoes on the wards. You’ll get to really experience what it’s like to be a medical student or a physician in training. You won’t hear any pansy-ass crap, basically because I don’t give a fuck. You’ll hear it like it is, and I promise I won’t hold anything back.

The administration hates me about as much as I hate the school that pays their salary. I tell it like it is, and they don’t like that. They really don’t know how to take it. I’m more C=MD and FYIGML than they have ever seen. I walk by the Dean and he thinks “that’s the guy who doesn’t give a fuck.” Yep, that’s me.

VERITOGRAPHY

I can feel his blue eyes locking onto my own with a grip I’ve not experienced outside a battlefield. They are not the eyes of the desperate dying, they are the eyes of someone who knows exactly what he is doing and exactly what he is saying. I’ve seen that look in someone’s eyes before. Mr. Smith isn’t giving me advice, he’s giving me an order.

I’m just going to assume that I feel the way most people do about the unknown: I don’t like it. Even though I’ve known about this test for two years, it still feels like it’s springing up on me and I’m frantically trying to prepare.

What’s on it? Where there a lot of Biochem questions or was Neuro more stressed? Were the Path questions hard? And on, and on.

For most of us, it’s also the first time we’ve ever taken a test like this on a computer. Like most, I have my habits of underlining key words in a question stem, putting *’s by things that I have to skip now but may get later, putting an “X” next to a question that I could never answer correctly, etc. That I’ll be staring at a mouse, keyboard and glowing screen on test day is an unnerving thought.

To get over all of this, we look for practice questions. The good news is that there are thousands of practice questions on Al Gore’s internet and the companies worth their salt have some great supporting software. There are free questions and expensive questions and you get what you pay for. Let’s look at some free/semi-free sources first.

Free/Semi-free sites

• Official USMLE tutorial and practice questions (2007)
  • Gives you four blocks of 50 questions for practice with the testing interface FRED. No explanations for answers and reviewing your questions is awkward.
• Tulane’s Medical Pharmacology Exams
  • I wish I had known about this site when I took Pharmacology. The questions are broken down by subject with explanations of all answer choices. Straightforward multiple choice and great for review.
• Web Path
  • I used this site religiously when I took Path and it was an enourmous help. I recommend it to anyone and everyone. Great questions, great pictures, great format.
• Anatomy at University of Michigan
  • I used this site throughout anatomy and I still give thanks to this site.  Surface anatomy, gross anatomy, radiology, and Anatomy Jeopardy. After the Boards, I owe these guys a bottle of wine and a nice card.
• Lipincott Williams and Wilkins
  • 350-question comprehensive USMLE test, available to anyone that has registered with the site. If you have bought one of their books (Physio BRS), there is an access code in the jacket.
• Student Consult
  • I have access to this because of the two Rapid Review books that I bought (Gross and Developmental Anatomy, Microbiology and Immunology). This site also has 350-question tests for you to use (with the scratch-off code, of course).
• Facts in a Flash
  • Not USMLE format, but if you like working on flashcard questions without the rubberbands and mess, this might be for you.

So after looking at those sites you decide that, while very good for your normal review, you need some professional help for the Boards. You need this enough that you’ll part with some loan money. Whichever company you choose, you should look for the following:

1. Their question bank (QBank) should have enough questions for you to give yourself a fair evaluation, there should not be so many questions that you could not comfortably do them all, and the quality of the questions should be more important than the quantity.
2. The questions are given in the FRED computer format that you are going to see on the USMLE, complete with question marking, annotation, highlighting and strikethrough.
3. Detailed explanations for right and wrong responses.
4. Questions broken down by both subject and system, i.e. Cardiovascular Pharmacology.
5. The software shows your strengths, weaknesses, progress, and performance against all other students using the same questions.
6. THE HOLY GRAIL: The questions are of equal or greater difficulty compared to those on the USMLE.

Question Bank Subscriptions

• KAPLAN ($279, 3 months, 2100 Qs, FRED)
  • This was likely the first company that sprang to mind. Kaplan runs review courses where you live in a hotel for 6 weeks cramming, they have online course content, video lectures, on and on. This company has worked the USMLE inside and out, and it seems a right of passage that students slog through the 2100+ questions before sitting for the exam. I was a little wary of this company, though, as people told me that by the end of the course, they were scoring in the 90s on each block and that the actual USMLE was much harder.
• USMLE WORLD ($110, 3 months, 1730 Qs, FRED)
  • I had never heard of this program, but three people that I consider intelligent (each scored 95+) told me that UW’s questions were more difficult than the actual USMLE. Each of them also subscribed to Kaplan, used its program, and found the programs to offer the same features. After hearing this, visiting their site, and considering the prices, I had to take them seriously. It seemed like a great deal (less than half of Kaplan with a higher rating). The reviews at Prep4Usmle were positive as well. I also like that UW let’s you try their product for a month and if you like it, you can buy more months at a discount. My review of UW Qbank.
• USMLE Rx ($199, 3 months, 2000 Qs, FRED)
  • Written by the same authors of the First Aid for the USMLE. On glance, they seem to be doing everything correctly. They let you test their product and they offer integration between their online product and the First Aid book. The reviews that I have found put it on par with Kaplan. I’m intrigued.
• SCORE 95 ($99, 3 months, 4300 Qs, FRED?)
  • That this site is slick and has a string of testimonials (which read like a third grader’s homework assignment) is not impressing me. I am also having a lot of trouble actually learning about their program (does it run off your computer, what features does it have, etc.). What I am impressed with is their accompanying note set, that they show you the breakdown of their questions, and that they offer a daily podcast to anyone that wants to listen to a new subject each day. The reviews I was able to find online say that the program is poor and the questions are disappointing. Quantity > Quality. In fact, the number of questions scared me off well before my research. 4,300 questions comes to 360 questions a week for 12 weeks. I currently average 150, and that pace is keeping me busy. I cannot fathom the amount of work it would take to complete these questions, so why have them?
• EXAM MASTER ($179, CD, 8,700 Qs)
  • Absolutely not. On first glance: no. After reading reviews: no. If this program helps your score, it’s probably a placebo effect.

So where does that leave us? If you’re going to start doing questions 3 months before the exam, anything more than 2500 questions isn’t practical. You have to realize that you’ll be spending all day learning the material, and that it might take 3 days to cover a topic. At a reasonable pace, you can expect to do 150-200 a week (which will take you 3 hours and 15 minutes, remember). Anything more than this might burn you. So let’s just throw Exam Master and Score95 right out.

If you believe the worst reviews of the anonymous, Kaplan, UW and Usmle Rx are the same difficulty. If that’s true, then you should go with the cheapest program: UW. If you believe the best of the reviews, UW is harder than Kaplan and Rx, and you should go with UW. Though it has fewer questions, I got the strong feeling that the Quality >>> Quantity, and since I only have so much time to devote to questions, I want them to challenege me and teach me something new. I dropped the $110 and am incredibly happy with it. The questions are stout, and with all my over-preparing for each section, I have yet to crack an 85% in any discipline. This was a good choice for me.

However, if you don’t have much time, are planning on putting all your eggs in the First Aid basket, and would benefit more from reasonably challenging questions (whereas harder Qs might hurt your confidence more than help your score), then I can see a strong case for buying the Rx. It’s twice as expensive as UW, but the formats are indistinguishable and the integration with the First Aid book is appealing. If this wasn’t priced at $199, I might have bought this after finishing UW.

I’m sorry to beat up on Kaplan here, but after going through their QBook and the questions in their Lecture Notes, I’m just not impressed. I have consistently felt that the questions were either written to make me feel good about owning the notes, or that the notes were written to prepare me for those exact questions. Either way, I never had the feeling that Kaplan’s questions were independently difficult (if that makes sense) and from what I’ve read and heard from others, my concerns have merit. And for $279! Get over yourself, Kaplan.

So those are my thoughts on picking a QBank. I assure you that all the research was anecdotal and supplemented with gossip. I suggest heading over to the forums at prep4usmle to read for yourself, and if you have any comments on these products, I’d love to hear them.

Hope it helps, topher.

Return to USMLE Step 1 page.

My world has been flipped. I had to take some time away from the books to absorb this article from the New York Times (1996). Brilliantly written, it took me on a journey of discovery that recycling is garbage, we’re not going to suffer a “garbage landfill crisis,” and that the solution to excess waste is beautifully simple and already practiced by places like Minneapolis, San Francisco, and Seattle.

Recylcing is Garbage, by John Tierney.

“We’re not running out of wood, so why do we worry so much about recycling paper?” asks Jerry Taylor, the director of natural resource studies at the Cato Institute. “Paper is an agricultural product, made from trees grown specifically for paper production. Acting to conserve trees by recycling paper is like acting to conserve cornstalks by cutting back on corn consumption.”

Fifty years ago, for instance, tin and copper were said to be in danger of depletion, and conservationists urged mandatory recycling and rationing of these vital metals so that future generations wouldn’t be deprived of food containers and telephone wires. But today tin and copper are cheaper than ever. Most food containers don’t use any tin. Phone calls travel through fiber-optic cables of glass, which is made from sand-and should the world ever run out of sand, we could dispense with wires together by using cellular phones.

By now, many experts and public officials acknowledge that America could simply bury its garbage, but they object to this option because it diverts trash from recycling programs. Recycling, which was originally justified as the only solution to a desperate national problem, has become a goal in itself–a goal so important that we must preserve the original problem. It’s as if the protagonist of “Pilgrim’s Progress,” upon being informed that he could drop his sinful burden right there on the road, insisted on clinging to it just so he could continue the pilgrimage to get rid of it.

Why is it better to recycle?

I also learned where the term “muckracker” came from. Good day, all around.

The following is from an email sent to the First Aid Team concerning errors/corrections/suggestions to their 2007 edition.

Biochemistry (reference: Lipincott’s Illustrated Biochemistry)

1. P.79, Vitamins
   1. Fat soluble: in any deficiency of these vitamins, liver and egg yolk are a source in the diet.
   2. Tox: D>A>K>E, Vit D is Deadly (toxic), Vit A is Also bad.
   3. Synthesis by microbes: K and B12
   4. Antioxidant: C, E, and beta-carotene
   5. Liver storage: DAKE + B12
2. P.79, Vitamin A (retinol)
   1. Excess – Arthralgias, fatigue, headaches (cerebral edema), skin changes…
3. P.79, Vitamin B1 (thiamine)
   1. Diagnose: [up arrow] RBC transketolase activity after thiamine treatment.
4. P.80, Vitamin B12 (cobalamin)
   1. In the right column under causes for B12 deficiency: “lack of intrinsic factor (pernicious anemia, total gastrectomy)”
5. P.83, Chromatin structure:
   1. Heterochromatin – Condensed, transcriptionally inactive – methylated histones
   2. Euchromatin – Less condensed, transcriptionally active – acetylated histones
6. P.84, Genetic Code features
   1. “Methionine encoded by only one codon (AUG).”
7. P.85, DNA replication and DNA polymerase
   1. Within the replication bubble, only the lagging strand creates fragments. The description of DNA poly III elongating “until it reaches primer of preceding fragment,” while true for one leading strand meeting another replication bubble, confuses the issue here. I think it could read:
      1. “On the leading strand, elongates the chain by adding deoxynucleotides to the 3′ end until it reaches another replication bubble. When on the lagging strand, it performs the same action repeatedly as the replication bubble grows, creating Okazaki fragments.”
      1. This would of course have to be preceded by an explanation of the replication bubble that might also incorporate a definition and illustration of a helicase.
      1. 1. Helicase – an enzyme that separates the two strands of DNA into single strands allowing for replication to occur. The position of these separated strands is called the replication fork.
         2. Replication bubble – area of DNA between two replication forks that marks the site of replication in each direction along a chromosome. There are several replication bubbles along the chromosome during DNA replication.
      1. To avoid confusion, state upfront that
         1. DNA poly III reads 3′-5′, makes 5′-3′ and proofreads 3′-5′ “Poly III proofs 3′ first.”
         2. DNA poly I reads 3′-5′, makes 5′-3′ and proofreads 5′-3′
8. P.88, tRNA
   1. The figure is very confusing. The accompanying paragraph makes reference to syntheTase scrutinizing the amino acid before and after, but the figure shows only one syntheTase and one synthAse. Further, the image flips over its vertical axis for some reason, and the “AA” attached to the middle tRNA’a 3′ end is changed to a “Methionine-ACC” without explanation. The figure should be changed to clearly show:
      1. The first step is the attachment of a methionine to AMP (leaving PPi), creating an aminoacyl-AMP (not attached to tRNA).
      2. The second step is the attachment of the Met-AMP to the tRNA’s ACC site, creating an aminoacyl-tRNA (attached to tRNA).
      3. tRNA syntheTase and tRNA synthAse are two different proteins or two regions of the same protein.
9. P.88, Protein synthesis
   1. Figure shows a eukaryotic ribosome while the description is of a ” 30S ribosomal subunit.”
10. P.89, Cell cycle phases
    1. The description of Permanent cells suggests that “neurons, skeletal and cardiac muscle, RBCs” all “remain in Go, regenerate from stem cells.”
11. P.91, Cilia structure
    1. Iinclude the following:
       1. Dynein = retrograde (towards nucleus)
       2. Kinesin = anterograde (from nucleus )
12. P.91, Kartagener’s syndrome
    1. Include the following: “…male and female infertility (sperm immotile, immotile fallopian cilia)…”
13. P.95, Hexokinase vs. glucokinase
    1. Glucokinase is found in the liver and the Beta cells of the pancreas.
14. P.96 , Regulation by F2,6BP
    1. This is a difficult concept. In the figure, the arrows are pointing in the wrong directions, i.e. PFK-2 is shown dephosphorylating F(1,6)BPate into fructose-6-P. The problem with most diagrams is that it is difficult to take into account the following in a single picture:
       1. Fed and Fasting states
       2. PFK-2 and F2,6BPase (the bifunctional protein’s two states of activity)
       3. Stimulation of glycolysis and inhibition of gluconeogenesis.
    2. To capture these three variables, you effectively need three circles in your diagram. This is my best effort at such a diagram. See below.
15. P.96, Glycolytic enzyme deficiency
    1. “glucose phosphate isomerase (4%)” ??
16. P.98, Electron Transport chain and oxidative phosphorylation
    1. The outcomes of the oxidative phosphorylation proteins are not correct.
       1. Electron transport inhibitors will cause a decrease in O2 consumption; this is not mentioned.
       2. ATPase inhibitors will cause an increase in O2 consumption; this is not mentioned.
       3. Uncoupling agents increase the permeability of the membrane to H+ ions; it is listed as decreasing permeability.
       4. Uncoupling agents will cause an increase in O2 consumption; it is listed as causing a decrease.
17. P.99, Pentose phosphate pathway (HMP shunt)
    1. The two sentences beginning, “All reactions…” and “Sites: lactating…” are immediately repeated within the section. One should be deleted.
    2. The HMP shunt is locating in RBCs, allowing them to handle oxidative damage by replenishing glutathione. RBCs are excluded in the following sentence : “Sites: lactating mammary glands, liver, adrenal cortex – all sites of fatty acid or steroid synthesis.”
18. P.100, Disorders of galactose metabolism
    1. “Galactosemia ” is a symptom. Classic Galactosemia is the name of the disease described. In addition to the later symptoms of “cataracts, hepatosplenomegaly, mental retardation” the more immediate symptoms (not included) are galactosemia, galactosuria, vomiting, diarrhea, jaundice.
19. P.101, Amino acids
    1. Everyone has there own take on which are and are not essential, but I’ve found the following to be useful:
       1. Conditionally Essential (3) “Babies CRY,” important early in life and during periods of growth.
          1. Cysteine (Cys), glucogenic
          2. aRginine (Arg), glucogenic
          3. t Yrosine (Tyr), gluco/ketogenic
20. P.101, Transport of ammonium by alanine and glutamine
    1. I found the layout of these diagrams to be confusing. The first diagram does not indicate that B6-dependent AminoTransferases are involved with each exchange of the NH3, and the last step showing Glutamate going straight to Urea is incomplete. The interesting point about alanine transport versus glutamine transport is the different enzymes used and the different tissues involved, and the diagrams do not make this clear. Further, the second diagram shows glutamine transport of ammonium as ending with Aspartate and NH4. While these are the substrates for the Urea Cycle, Glutamine is the amino acid donating the NH4 in Glutamine Transport. Lipincott’s Illustrated Biochemistry has a great diagram on P.251 (3rd Ed).
21. P.101, Transport of ammonium by alanine and glutamine:
    1. Treatment: Arginine should include (see Urea Cycle).
22. P.102, Phenylketonuria
    1. The diagram shows a double arrow, implying that THB to DHB is a reversible reaction through Phenylalanine Hydroxylase (PAH). This is not the case. I also feel that this section should address that elevated levels of Phe are what cause the side effects, and that this can come from a deficiency of maternal or fetal PAH. I think the following table should be included (see below).
23. P.102, Alkaptonuria
    1. This section does not make mention of the striking symptom of black/blue cartilage of the nose, cheek, ear, and splotches in the sclera. I think it should be changed to:
       1. Congenital deficiency of homogentisate acid oxidase in the degradative pathway of tyrosine; often benign. Resulting alkapton bodies deposited in various connective tissues may result in
          1. Erosion of large joint cartilage, causing debilitating arthralgias
          2. Blue/black discoloration of cartilage in the nose, cheek, eyes and black splotches of the sclera
          3. Urine that turns black on standing.
24. P.103, Homocystinuria
    1. The neat thing about this pathway is that a block at cystathionine synthase can be treated with vitamins to reverse or continue the pathway and that a build up of homocysteine is associated with the side effects. I think this section should be changed to reflect this:
       1. 3 forms (all autosomal recessive):
       1. 1. Cystathionine synthase deficiency (treatment: [down arrow] Met, [up arrow] Cys, [up up arrow] B12 and [up up arrow] folate in diet)
          2. [down arrow] affinity of cystathionine synthase for pyridoxal phosphate (treatment: [up up arrow] B6 in diet)
          3. Homocysteine methyl transferase deficiency
       1. Results in [up arrow] HomoCys, [up arrow] Met and [down arrow] Cys in blood and urine. Cys becomes essential.
       2. Side Effects: mental retardation, osteoporosis, tall stature, kyphosis, lens subluxation (downward and inward), and atherosclerosis (stroke and MI; associated with [up arrow] HomoCys)
25. P.103, Maple syrup urine disease
    1. The severe side effects of this disease only occur if left untreated. Patients with this disease typically present early in infancy. I think the following should be added:
       1. Classic type presents in infancy with difficulty feeding, vomiting, dehydration and severe metabolic acidosis. Diaper smells of “burnt sugar.”
26. P.104, Purine Salvage Pathway:
    1. Arrows show AMP going to IMP in two steps; IMP going to AMP in one step. This is backwards.
    2. Could mention that Allopurinol inhibits Xanthine Oxidase here.
27. P.105, Insulin
    1. The diagram with all of its +’s and -’s is confusing and requires time to “translate” what it means for the phosphorylation/dephosphorylation of the enzymes shown. I’ve attached a diagram that shows the controls and also makes the regulators unique to the liver and muscle more obvious. See below.
28. P.105, Glycogen
    1. Enzyme converting Glucose-1-phosphate to UDP-glucose is incorrectly labeled as Glycogen Synthase (should be UDP-glucose phosphorylase). Glycogen synthase is involved in the next step for extending the chain of glycogen.
29. P.106, Glycogen storage diseases
    1. Deficient enzyme in Von Gierke’s is listed as “Glucose-6-phosphate.” Should be “Glucose-6-phosphatase“
30. P.111, Heme Synthesis
    1. This drawing shows Lead inhibiting ALA synthetase.
    2. Lead inhibits ALA hedehydratase and ferrochelatase, not ALA synthetase (correctly noted in following section, Porphyrias).
    3. Heme -> Hemin -> inhibits ALA synthetase. This is a great feedback inhibition and represent the emergency treatment of porphyrias, i.e., the administration of IV Hemin.
    4. In the right margin, it should mention that this pathway is in the liver (P450) and Bone Marrow (hemoglobin synthesis). This is why phenobarbital, griseosulvin, etc can cause attacks of porphyria, by inducing the increased expression of P450, increased need for Heme, and exacerbation of deficiency.
31. P.111, Porphyrias
    1. In addition to the “5 P’s” of Porphyria, I suggest making an addition
       1. Painful Abdomen
       2. Pink Urine
       3. Polyneuropathy
       4. Psychological disturbances
       5. Precipitated by drugs
       6. Pruritis
       7. Photosensitivity

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More interesting reading today. This came to me from Medscape and I thought I’d share it. As an aside, I would have no problem reciting the Weill Cornell Medical College’s Hippocratic Oath. Some excerpts:

Oaths for Physicians — Necessary Protection or Elaborate Hoax?
Erich H Loewy, MD

The ritual of taking an oath upon graduating from medical school is, with a few exceptions, a routine requirement for graduation. Albeit that many students believe that they have taken the Hippocratic Oath, this is virtually never the case.

According to the oath, physicians (in virtually all formulations) swear that social standing (and by implication economic factors) will not change the way in which patients are treated. This becomes impossible.”

I think that the prospective physician having to take an oath that promises to place the biopsychosocial interests of the individual patient first while at the bedside and to work for a healthcare system that is accessible to all is not coercive to students as long as students are aware before they enter medical school that taking such an oath will be one of the requirements for graduation — no more and no less than anatomy or a clerkship in medicine

[I]t is a problem that we must at least start to recognize as an imperative and consequently to work on setting up fair but strict criteria, which are known to the student. For example, it seems obvious that convicted felons should — even after they are released from prison — not be allowed to enroll in medical schools or practice. This sounds harsh: After all, the felon “has paid his price to society” (whatever that means) and should now be able to engage honorably in an honorable profession.

In my experience — and that of many of my colleagues — we have graduated the undoubted sociopath or psychopath, and have graduated students who falsified records, stolen books, and repeatedly made obviously demeaning remarks about patients or colleagues.

It is surprising — and disheartening — that medical boards are quite ready to either reeducate or otherwise sanction physicians who have a record of consistent malpractice or to give help to those who are substance abusers, but that medical societies are hesitant to deal with ethical violations.

I think this author has the current attitude among medical students dead to rights; I spend no time thinking about this oath and I don’t think others do. He’s also right about the ethical “slips” in medical school. I wrote previously about a student in my class that tried to cheat on a test (feigning sick, then asking about the test before his makeup) and I know plenty of students that take advantage of the “I’m sick” route test after test after test. And while it’s easy for me to agree with him that, if we take these promises seriously, then we should punish those that break them seriously, I stop short of his conclusions.

I think throwing all types of felons together is lazy and ignores the difference between a murderer and a drug offender (and he addresses this, indirectly, by the support that medical boards give to MD’s abusing drugs). I think sanctioning physicians with a history of malpractice fails to draw the distinction between suits that represent Deriliction of Duty resulting in Direct Damage (you need all four D’s for it to be malpractice) d those aimed at gold (the courts can’t even draw this distinction).

I DO AGREE that any of these precursor infractions in medical school should be grounds for immediate dismissal, if for no other reason than it’s easiest to monitor. Like him, I already know two sociopaths that (God help us all) will earn an MD and practice.

So, no, the oath doesn’t seem to be taken seriously in house, but it will probably make everyones’ chests swell with pride against the buttons of their white coats just the same.

As for me? I believe in all the parts that don’t conflict with my right to earn a living that correlates with my skill in whichever discipline I choose. If I end up being a shitty doctor, I shouldn’t get to charge as much as a great one. As I said before, the Weill Cornell Medical College’s Hippocratic Oath looks solid.

But while we’re talking about professional duties and the good of patients, the honor of the guild and role in society, how about we introduce one more oath? With all that is demanded and expected of physicians, shouldn’t the State remove some of its barriers to make it easier for us to fulfill these expectations?

The State’s Oath to the People’s Health:

The State does vow, to that which society holds most dear:

That the State will honor the Profession of medicine, be just and generous to its members, and help sustain them in their service to humanity; The State and its legislature will recognize the limits of its knowledge and allow physicians to pursue their lifelong learning to better care for the sick and will support physician-recommended programs to prevent illness; That no legislation will be passed that affects the practice of medicine without the expressed support of the physicians of the State as the State recognizes that physicians are more expert in medical matters; That the State will not withdraw from patients in their time of need; That the State will govern with integrity and honor, using its power wisely; That whatsoever the State shall learn of the lives of patients shall not be spoken, but kept in confidence; That the State will maintain this trust, holding itself to the highest standards, from corruption, from the temptations of industry, from any disruption to the practice of medicine and its physicians; That above all else, the State will serve the highest interests of the patients through the support of those providing their care, and the institutions that seek to suport it. The State enters this promise with its physicians to preserve the finest medical traditions, with the reward of long service and a well-served populace. The State makes this promise upon its honor.

I was really happy with this section. Under the new divisions, Basic Pathology gets a few pages early to cover neoplasia and inflammation. The majority of Pathology is spread out in the Systems from the second half of the book (which is why so little is covered here).

As always, this is from an email sent to the First Aid team.

Pathology

1. P.204, Paraneoplastic effects of tumors:
   1. From Robbins Pathology: “Definition: Symptoms not directly related to the spread of the tumor or elaboration of hormones indigenous to the tissue from which the tumor arose.” “Cancer-associated hypercalcemia also results from osteolysis induced by bony metastases; this, however, is not to be considered a paraneoplastic syndrome.” This section in the First Aid lists “bone metastasis (lysed bone)” as a paraneoplastic syndrome causing hypercalcemia. This is not “para” neoplastic or an endocrinopathy like the elaboration of PTH-like peptides from Squamous Cell Lung Cancer.
   2. Hepatocellular CA is also capable of expressing erythropoietin as a PNP syndrome.
2. P.205, Cancer epidemiology
   1. The way that these percentages are listed makes the pattern non-obvious. I suggest simply rearranging the data.

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I like it when people surprise me, and sometimes bloggers do that by going off their normal topic to show, other than being intelligent in their own niche, they think intelligently elsewhere. Admit it: it’s encouraging. This from A Farrago Of Gallimaufries (no idea what it means).

While driving home the other day, I saw a giant sign on the side of a building that read, “AMERICA WILL NOT FORGET – Dec. 7, 1941 – Sept. 11, 2001.” Okay, I thought, that’s acceptable, especially since those events were pretty atrocious moments in US history. Let’s review.

• Dec. 7, 1941
• Sept. 11, 2001
• Aug. 6, 1945
• Aug. 9, 1945
• Mar. 20, 2003–current

Click here to see how it ends.

Best sentence of the day.  Really, I’m tickled.

‘Judge Tries to Unring Bell Hanging Around Neck of Horse Already Out of Barn Being Carried on Ship That Has Sailed.’

Click here to laugh along.

Second best sentence of the day:

It takes a special person to want to do family medicine as you must not only run between the Scylla and Charybdis of your peer’s ridicule but you must also lash yourself to the mast of primary care against the siren call of more lucrative specialties.

Via Panda Bear MD, my new favorite blog.

As always, comments are welcome.

Pharmacology

1. P.218, Sympathomimetics
   1. Clonidine and a-methyldopa are centrally acting alpha-2 agonists.  They are listed here as simply “alpha”.
2. P.223, P-450 interactions
   1. Quinidine is listed as an inducer of P450.  Quinidine is an inhibitor of P450 (BRS 4th ed, P.13)

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Until I write this section, please feel free to add any errors that you’ve found in the comments section.

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As always, this comes from an email sent to the First Aid team.

Immunology

1. P.191, Complement
   1. “Membrane attache complex” should be “Membrane attack complex.”
2. P.191, Complement
   1. “Deficiency of C1 esterase inhibitor leads to angioedema (overactive complement).” The angioedema is due to overactive bradykinin as C1 Inh is responsible for inhibiting this pathway. The parenthetical remark should instead be ” (overactive bradykinin pathway).”
3. P.194, Diseases caused by hypersensitivity
   1. Several texts list auto antibodies as a finding and alternative cause to IDDM (against islet cells) and Hashimoto’s Thyroiditis (against thyroglobulin, thyroid peroxidase), but these are both classified as strictly Type IV hypersensitivity reactions. This is inconsistent with P.196, where auto antibodies to “antimicrosomal elements” are mentioned.
   2. Rheumatoid arthritis is listed as a Type III hypersensitivity disorder. Most medical texts agree that the likely pathogenesis of RA involves CD4+ cells sensitive against the synovium that begin releasing cytokines. The Rheumatoid factor (anti-IgG IgM) is absent in 20% of patients and is a byproduct of the type IV hypersensitivity, not the cause itself. Because Rf does contribute to the vasculitis and subcutaneous nodules characteristic of the disease, RA should be listed as a Type IV with Type III characteristics. SLE represents another mixed hypersensitivity reaction with characteristics of Type II and Type III. I suggest a separate section for mixed hypersensitivity reactions to avoid confusing this issue.

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Apologies to anyone that has been reading this post and wondering why I haven’t done any new work on the First Aid.  This section moved here.  Please change any links that lead you to this page so that you can find the updated version of the errors.

Sorry for any confusion, topher.

The following is from an email sent to the First Aid Team concerning errors/corrections/suggestions to their 2007 edition.

Embryology (reference: HY Embryo by Dudek)

1. P.122, Embryological derivatives: Under neural crest cells, it lists “cranial nerves.” This is not true. Neural crest cells are responsible for the sensory ganglia of V, VII, IX and X and the parasympathetic ganglia of III, VII (ptery), VII (submand), IX and X. Motor ganglia of all cranial nerves come from the neuroectoderm of the neural tube. The remaining cranial nerve precursors: sensory ganglia of I (surface ectoderm), II (neuroectoderm), VIII (surface ectoderm for both vestibular and cochlear ganglia). Another way to display the CN origins:
   1. Surface ectoderm gives sensory for CN I and CN VIII (both cochlear and vestibular ganglia)
   2. Neuroectoderm gives sensory for CN II.
   3. Neuroectoderm gives motor ganglia for all cranial nerves (III, IV, V, VI, VII, IX, X)

                                                              i.            Sensory for CN II

1. 1. Neural Crest cells give parasympathetic ganglia for all cranial nerves (III, VII [pterygopalantine and submandibular], IX, X)
2. P.122, Embryological derivatives
   1. It is mentioned that neural crest cells give rise to odontoblasts but not that they produce dentin . It should also be mentioned under ectoderm that ameloblasts produce the enamel.
3. P.123, Twinning
   1. Monozygotic ( 65%), Dizygotic (fraternal) or monozygotic (35%).
4. P.125, Fetal Circulation
   1. I’m sure someone has probably brought this up, but the shading for this diagram is inaccurate. It shows the umbilical vein as carrying less oxygenated blood from the mother to the fetus and more oxygenated blood carried in the umbilical arteries from the fetus to the mother. The fetal circulation cannot be divided into left and right as it can be in the adult (and is in this diagram). The order of oxygenation should be as follows (and represented graphically with gradient shading instead of gray v. white: from most to least

                                                              i.            Most oxygenated blood from L. umbilical vein to end of Ductus venosum

                                                            ii.            Mixing of blood with return from IVC (where it meets ductus venosum) to R. atrium

                                                          iii.            More oxygenated blood following along strong arrow, entering the L. ventricle without much mixing in the R. atrium and R. ventricle with less oxygenated blood from the SVC.

                                                          iv.            Medium oxygenated blood delivered straight to arch of aorta, leaving through R. and L. subclavian aa, L. coronary.

                                                            v.            Less oxygenated blood returning from head into SVC, entering R. ventricle without much mixing with more oxygenated blood from the IVC followed by ejection into Pulmonary trunk through Ductus Arteriosis and into thoracic aorta.

                                                          vi.            Least oxygenated blood leaving via R. and L. umbilical aa.

1. P.127, Ear development
   1. “Eardrum” should be replaced with “tympanic membrane.”
2. P.128, Cleft lip and cleft palate
   1. In describing the cleft palate, “failure of fusion of the lateral palatine processes, the nasal septum, and/or the median palatine process (formation of [secondary] palate).” I found the bold part very confusing. After describing the primary palate with relation to a cleft lip, why is the term ” median palatine process” used instead of the already introduced “primary palate?” I think that this should be changed, with “primary palate” used instead.
3. P.128, Diaphragm embryology
   1. I think that the adult derivatives of each part of the diaphragm could be mentioned along with special mention that congenital hiatal hernias are more often through the L. pleuroperitoneal membrane.

                                                              i.            Septum transversum (central tendon)

                                                            ii.            Pleuroperitoneal folds (muscle)

                                                          iii.            Body wall ( muscle)

                                                          iv.            Dorsal mesentery of the esophagus (crura)

1. P.129, Genital ducts
   1. I suggest adding the following:

                                                              i.            “Mullerian inhibiting hormone (MIH) secreted by the Sertoli cells of the testes suppresses development of the paramesonephric ducts in males. [Up arrow] androgens secreted by the Leydig cells cause development of the mesonephric ducts.”

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The following is from an email sent to the First Aid Team concerning errors/corrections/suggestions to their 2007 edition.

1. Behavioral Science (references: HY Biostatistics and HY Behavioral Science)
   

   1. P.66, Statistical Distribution: I found the (mean>median>mode) v (mean<median<mode) labeling to be unintuitive for right and left skew. To emphasize the idea that the mean is sensitive to skew, the median is insensitive to skew, and the mode is totally uninfluenced by skew, the order should have instead been: (mode< median<mean) and (mean>median>mode). But even this falls somewhat short. The best diagram I have seen is on P.11 of Glasner’s HY Biostatistics. I have attached a quick drawing of it (bottom of page). It is intuitive and requires little (if any) explanation.

   2. P.68, Reportable Diseases: Of the 50+ reportable diseases nationwide (CDC website), I thought the absences of Chlamydia, Hep C, and Lyme disease from this list were significant. Should these be included, the mnemonic would have to change from “Be a smart chicken or you’re gone” to something more straightforward, like the following triplets:
      1. (Hep) ABC, MMR, SSS, TLC, SEX (AIDS, Gonorrhea, Chlamydia)
   3. P.70, Written Advanced Directive: This definition implies that a Living Will can only contain wishes to “withhold or withdrawal life-sustaining treatment.” This is not the case.
      1. Living Will: A document which specifies the life-prolonging measures an individual wants and does not want taken on his/her behalf in the event of a terminal illness or incapacitation.
      2. A Living Will, unlike a DNR/DNI order, can have instructions for both positive and negative measures.
   4. P.74, Sleep stages: Stage 3-4 is described as containing “bed-wetting” while in #6 it says, “Imipramine is used to treat enuresis…” Just to be consistent, I think it should say, “…to treat enuresis ( bed-wetting)…”
   5. P.75, Operant Conditioning: The following three lines are not consistent in their terms/descriptions and I found them to confuse the issue for me. My suggestions follow.
      1. Learning in which a particular action is elicited because it produces a reward.
      2. Positive Reinforcement – desired reward produces action (mouse presses button to get food).
      3. Negative Reinforcement – removal of aversive stimulus [up arrow] behavior (mouse presses button to avoid shock). Do not confuse with punishment. (a definition or example of punishment was never given)
         1. Operant Conditioning – learning in which a consequence produces a behavior.
         2. Positive Reinforcement – introduction of a positive stimulus [up arrow] the behavior (Child cleans room to earn money).
         3. Negative Reinforcement – removal of an aversive stimulus [up arrow] the behavior (Child cleans room to end mother’s complaining). Do not confuse with Punishment.
         4. Punishment – Learning in which a consequence (following the behavior) [down arrow] the behavior (Child is denied dessert for frequently interrupting others. Child now allows others to speak ).
   6. P.76, Immature Ego Defenses: This list is good but is missing a few terms. My suggestions for inclusion and a change to the definition of Isolation:
      1. Somatization - Psychic conflict manifested as physically real bodily symptoms – After hearing bad news, wanting to vomit.
      2. Intellectualism - avoiding/replacing emotion with intellectual detail – cancer patient obsesses over the workings of a CT machine instead of facing poor prognosis.
      3. Isolation (change) – separation of emotion from idea – a child describes his birthday party in a monotone.
      4. Undoing -carrying out symbolic behavior to atone for unacceptable action – A nun making the sign of the cross after cursing.
      5. Passive-Aggression – unconsciously falling short of expectation after creating the expectation – Friend leaves you at campus after promising to give you a ride home.

Right Skew – Left Skew

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These last two days have been exhilirating and frustrating. Exhilirating because I’m exposing myself to incredible concepts in Cell Biology that make me want to live in a lab for the rest of my life to discover more; frustrating because of the vessel. Dr. Dudek’s High Yield Cell and Molecular Biology (2nd Ed. 2007) is riddled with errors in grammar, spelling, punctuation, etc. As an English marm, I find this incredibly distracting. Further, there are a number of times where the book is not internally consitent (i.e. page 10 contradicts page 20), presents concepts in obfuscating ways (this may just be me being dense), or makes factual errors.

I didn’t schedule the time to spend a few hours each day trying to decipher conflicting statements. Though I found sections of this book amazing, the confusing tradeoffs weren’t worth it. If I were to do it all over again, I would not buy this book.

But if you did buy this book and just searched for “errors in High Yield….” then what follows is what I’ve found. This comes from an email I composed to Dr. Dudek, notifying him of the problems. You have to appreciate an author that gives out their email address like that.

Comments are arranged by Chapter-Page-Section. Important errors are underlined and emboldened. Please escuse my hubris:

Chapters 1-13 (out of 26)

1. The Cell Membrane
   1. P.6, A.13.17: Abbreviation “DST of the loop of Henle” not explained. I knew this term as Thick Assending Limb and not Distal Straight Tubule.
   2. P.7, B: “across the membrane and [verb?] generally called ion channels.”
   3. P.10, B.2: Title: “Transmitted-gated ion channels” should be “TransmitteR-gated…”
   4. P.11, B.2.c: “..the gate is opened and the influx and Na+ and efflux..” “And” should be replaced with “of”.
   5. P.11, B.2.d: “Purinergic 2x” conflicts with P.16, E: “Purinergic 1,2y” These may be different; I raise it only because both are found on “peripheral terminals of nociceptive neurons.”
   6. P.13 is amazing, by the way.
   7. P.14, C: “..trimer with GDP bound to the [alpha] chain..” The [alpha] should have a “q” after it.
   8. P.15, B: You refer to the actions of both Beta-agonists and Beta-antagonists as having “(positive chronotropism; B1 effect).” This is confusing. As I’ve seen it, these drugs are typically described as being “negatively or positively chronotropic” for antagonists and agonists, respectively.
   9. P.16, C: You have the PLc pathway as producing a “[down arrow/decrease in] IP3 + DAG” when it actually produces an increase in IP3 and DAG.
   10. P.18, P.4: last sentence: “…receptor antagonists and are used to [verb?] opioid toxicity…”
   11. P.21, VII: last sentence: “When LDL … binds to the LDL receptor, receptor-mediated endocytosis [verb?] in the following steps:”
   12. P.21, VII.C: You abbreviation “HNG-CoA reductase” should be “HMG-CoA reductase.”
2. Cytoplasm and Organelles
   1. P.23, I.E: “…and a DNA-binding region that activate gene…” It should be “activates.”
   2. P.30, C.2: last sentence: “The absence of glucose-6-phosphatase enzyme in skeletal muscle prevents the degradation of glycogen to free glucose,” while certainly correct, is confusing if you don’t already know that this absence is normal, and that no skeletal muscle has this enzyme. Without this context, I would have read this as being a disease state. I think it could be reworded:
      1. “Skeletal muscle lacks glucose-6-phosphatase, thereby committing the stored glycogen to be used by the muscle in glycolysis.”
   3. P.32, Figure 2-2, O: “High magnification of a mitochondria with tubular cristae.” The significance of mitochondrial tubular cristae in steroid-secreting cells was not addressed in this chapter.
3. Nucleus
   1. Figure 3-2 was really helpful
4. Protein Synthesis
   1. P.38, II.A: “DNA sequences that flank the gene sequence at the 5′ end of the template strand are called upstream sequences. DNA sequences that flank the gene sequence at the 3′ end of the template strand are called downstream sequences.” This is not correct and conflicts with every mention to follow of upstream/downstream sequences, i.e. P. 95-97.
      1. Template strand: upstream: 3′ of gene
      2. Template strand: downstream: 5′ of gene
      3. Non-template strand: upstream: 5′ of gene
      4. Non-template strand: downstream: 3′ of gene
   2. P.43, Figure 4-3: For some reason the last drawn ribosome has the two subunits separated.
   3. P.44, Figure 4-4, A(3): After giving the translation of each codon-to-amino acid sequence, you omit that UAA codes for STOP. I think that this should be included for completeness.
5. Chromosomal DNA
   1. P.45, II.B: “…impart a positive charge to the proteins that enhances it binding to…” It should be “..enhances its binding to…”
   2. P.46, II.C: “(an enzyme can pass on DNA double..” This should be “can pass one DNA double”
   3. P.46, II.D: “During metaphase of mitosis, [subject?] can become…”
   4. P.46, III: last sentence: “Microtubules produced the by centrosome…” should be “by the centrosome“.
6. Numerical Chromosomal Abnormalities
   1. P.54, II.B: You state that chimerism is the “reverse of twinning.” While I understand what you are going for by way of analogy, genetically-speaking, chimerism is not the reverse of twinning and this analogy is potentially confusing.
   2. P. 57, Figure 6-3, (A,B): When describing Patau syndrome, you list “fingers flexed and overlapping” as a key feature. This is a key feature of Edwards syndrome.
   3. P.61, III.I. The notation for each of the multiple myeloma translocations is out of order, i.e. t(14;4), t(14;6), t(14;11) should instead be t(4;14), t(6;14), t(11;14).
   4. P.66, VII.A: last sentence: “…encodes for DNA polymerase eta[?] that is involved…”
   5. P.66, VII.C: missing comma between “hypogonadism” and “microcephaly”
7. Structural Chromosomal Abnormalities
8. Chromosome Replications and DNA Synthesis
9. Meiosis and Genetic Recombination
   1. P.82, Figure 9-2, A: This figure is confusing because the end product shows only a swapped intermediate sequence and does not show how the remainder of the chromosome arms can be switched between the two chromosomes using a Holliday junction. This site has a very good demonstration that might be adapted to fit the space of this page.
10. The Human Nuclear Genome
    1. P.87, III.F-H: These descriptions are great, but why is there no reference to Figure 12-3 (P.104) which shows how each of these works? Most of the information here is also repeated word-for-word in chapter 12. I think moving Figure 12-3 into this chapter and then (instead of repeating the information) simply referencing III.F-H when the time comes in chapter 12 would help.
    2. P.89, V.C: “Simple variable number tandem repeats (VNTR) polymorphisms called microsatellite DNA or SSR polymorphisms … are typically found in microsatellite DNA.” This is self-referencing and confusing. I don’t know what you mean when you say that microsatellite DNA is typically found in microsatellite DNA.
    3. P.91, Figure 10-2 (F): It was my understanding that two transposons, flanking a gene, carrying out gene transfer required the “cuts” to be on the outermost edges of the transposons, thereby incorporating both transposons with the gene into the new location. This figure shows the gene being transferred without accompanying transposons.
11. The Human Mitochondrial Genome
12. Control of Gene Expression
    1. P.07, II.B.3: “CREB (cAMP response element binding protein) binds to the CRE in response to elevated cAMP levels in the cell caused by a protein hormone binding to a G protein-linked receptor and thereby induces gene expression.” I found this sentence very confusing. Because the sequence of events is very linear, I think a more linear sentence is appropriate:
       1. “A cell signal produced by a G protein-linked receptor (resulting in an increase in cAMP) triggers CREB (cAMP response element binding protein) to bind to CRE.
    2. P.100, Figure 12-2 (A): The drawing of the folded Homeodomain protein has the COOH terminus and NH2 terminus switched.
    3. P.101, V.D: “There a[are?] several human genes that [verb?] two or more alternative promoters which…”
    4. P.101, V.D: “Alternative promoters start transcription from different versions; the first exon, which is then spliced into a common set of downstream exons, which produce an isoform of the same molecular weight.” This should say:
       1. “Alternative promoters start transcription from different versions of the first exon, which is then spliced into a common set of downstream exons, and produce isoforms of the same molecular weight.”
    5. P.101,V.D: “…but different amino acid sequences in the NH2-terminal end.” This should say “…but different amino acid sequences in the COOH-terminus.”
    6. P.102, V.G: “…~20% of the total genes on the X chromosome escape inactivation. These ~20% inactivated genes include…” This is contradictory. This should say “These remaining active genes include…”
    7. P.103, VI.D.4: “Glucose and lactose(+)” should be “Glucose(-) and lactose(+).”
    8. P.104, Figure 12-3 (D): “Note that each alternative promoter uses in own first exon” should be “promoter uses its own.” “The size of the dystrophin isoforms are show” should be “shown.”
13. Mutations of the DNA Sequence
    1. P.107 III: You describe nonsense mutations as producing “non-functional (truncated) proteins” and frameshift (or DNA splicing) mutations as producing “non-functional (“garbled”) proteins.” According to the mechanisms described, both frameshift and DNA splicing mutations can produce “garbled” and truncated proteins.
    2. P.107-108, III.F-G: After stating that Translocational and Unstable Expanding Repeat Mutations have been previously covered (and you reference them), you reprint the text. I think you could save this space.
    3. P.109, IV.A: No examples given of haploinsufficiency but several examples given for gain of function mutations. I would have liked to read about a few of them.
    4. P.110, IV.B: “In order for gain of function mutations to become clinically relevant, the individual needs to be heterozygous (i.e. Rr).” Because homozygotes are not excluded (through inheriting these traits), I think it is more correct to say that:
       1. In order for gain of function mutations to become clinically relevant, the individual needs to have at least one copy of the gene (i.e. Rr or rr).
    5. P.110, IV.B.1: “Pittsburgh variant is a missense mutation in the [alpha]1-antitrypsin protein that produces a gain of function mutation known as the Pittsburgh variant.” This is confusing. I do not know what you mean to say that Pittsburgh variant produces Pittsburgh variant. “…methionine358 in the reactive center acts a bait for…” should be “…acts as bait…”
    6. P.110, V: “Fourth, a polymorphism is the occurrence of two or more alleles at a specific locus in a frequencies greater than can be explained by mutations alone (a polymorphism does not cause a genetic disease).” I found this explanation confusing and it does not mention that it is judged on the characteristics of the population that carries it. I think that the Oxford definition is less confusing:
       1. The occurrence of two or more alleles for a given locus in a population where at least two alleles appear with frequencies of more than 1%.“
    7. P.110, V.A.2: When writing about Unequal Sister Chromatid Exchange, you write that: “…cleavage and rejoining of sister chromatids occurs at different positions on the maternal chromosome usually within a region of tandem repeats.” followed by the exact same sentence, changing only “maternal” to “paternal.” I think you should change this into one sentence, reading:
       1. …cleavage and rejoining of sister chromatids occurs at different positions on the (maternal/fraternal) chromosome usually within a region of tandem repeats.”
    8. P.111, V.A.3: When describing replication slippage, you don’t mention that the strand that is slipping either “forward” or “backwards” refers to the parent or daughter strand (respectively). You also don’t mention that the insertions and deletions only affect one arm of the sister chromatid. I think you should expand the description of replication slippage and include something similar to this figure (click to enlarge) that illustrates that the templates are unchanged, therefore there is a 50/50 chance that no insertion or deletion will be passed on.
    9. P.114, Figure 13-1 (G): “PNA splicing” should be “RNA splicing”

Return to USMLE Step 1 page.

Over this winter break, I went to my Uncle Neurphysiologist for some advice. As you may have gleaned from this story, I’m about ready to give up on the idea of practicing medicine and to start devoting my life to changing the laws under which physicians are forced to operate. So over dinner I tell him about everything I’ve been reading about malpractice courts, medicare reimbursement, HMOs, and so on. Then he tells me something that I could hardly believe:

“You know last week a group of physicians were in an online discussion forum that was meant for something or other, and the conversation inevitably went to those issues you’ve just described. A colleague of mine said that, ‘it was ridiculous that I am paid $$ for a procedure by XX company and $ for the same procedure by company X.” We all voiced similar complaints until a lawyer that was present in the forum and representing the hospital told us that we couldn’t talk about the prices of our services.”

“Why not?”

“He said it was against the FTC’s Antitrust laws.”

“How the hell is a room full of physicians knowing what each other makes violating antitrust?”

“You’d have to ask him.”

I couldn’t really believe it, but I had to know for sure. Since then I’ve been trying to find more and today I have. Here are some excerpts:

“In the late 1970s, the Supreme Court decided the antitrust laws should apply to “professionals” such as lawyers and physicians. In 1993, lawyers at the FTC and the DOJ’s Antitrust Division made up a set of rules governing how physicians and other health care providers should run their businesses. To avoid antitrust charges, independent physicians had to organize their practices according to a government-approved economic model. Experimentation or deviation from this model would subject doctors to criminal price-fixing charges on top of potential treble-damage civil lawsuits.”

“The FTC and DOJ said strict rules were necessary to “protect competition” among physicians.”

“Each of these cases presents a similar scenario: A group of independent physicians band together to deal with the administrative and regulatory burdens imposed by managed care. The group negotiates contracts with various HMOs, PPOs, and employer-based plans. The payers soon become unhappy with their contracts—they think the doctors should have agreed to lower prices—and they petition the DOJ or FTC (but mostly the latter) to intervene. The FTC opens an investigation and demands the physician group turn over thousands of pages of documents at the group’s expense. Then without further investigation, the FTC tells the group to sign a “consent order” invalidating its existing contracts and restricting the group’s future ability to represent its members (in some cases, the group is disbanded altogether.) As a matter of FTC policy, the physicians are not afforded an opportunity to tell their side of the story.”

“In the health care market envisioned by antitrust regulators, physicians should “negotiate” contracts as individuals, never in a “coercive” group. Of course, no individual physician possesses any meaningful bargaining power when dealing with an HMO that represents thousands of buyers. That’s precisely the point, however: Competition, in the government’s view, means sellers accept whatever price the buyer offers, irrespective of the sellers’ costs or economic self-interest. In antitrust parlance, the buyers have an inalienable right to the “benefits of competition”, while the sellers are presumptive price-fixers eager to subvert the government’s carefully designed market scheme.”

“Both of these models shift risk from the insurer to the physician while simultaneously distorting the price paid by the ultimate consumer. It is illegal for consumers to know the true cost of health care and for the physicians to take any action that might enable services to be produced more efficiently. “

Read the full article by SM Oliva, President of Citizens for Voluntary Trade.

The poor little medical student is tired after nine straight days of 8:30am – 5:30pm studying.

You never really forget that you love science and that you find molecular biology and biochemistry to be interesting, but it’s only when you set out to review the whole subject in one week that you are reminded that it is breathtaking. I’ve been giddy over the material these last few days and despite being a little tired and sensing that I need some time to let my mind stray, I am loving this.

Studying for the Boards is so much more fun when you’re looking forward to the test.

But it’s still two months away and I need to pace myself. Tomorrow will be a half-day. I’ll have from 2:30pm till midnight to run errands (buy longjohns because the library is freezing and I’m in Cincinnati), do something physically active, and read a few chapters in a non-medical book for pleasure.

For those keeping score: 5 subjects, 618 pages, 9 days.

• HY Embryology (177)
• HY Biostatistics (115)
• HY Behavioral Science (87)
• HY Molecular and Cell Biology (189 of 227)
• Lipincott’s Biochemistry (50 selected pages)

Return to USMLE Step 1 page.

This new contest over at Musings of a Dinosaur.

 Alternative post titles were:

• Lessons from my Father
• How to Say “Fuck You” So Elegantly They Don’t Even Know You’ve Said It

Inspired by Medblog Addict, #1 Dinosaur would like to announce a contest to see who can write the classiest “Screw You” letter. First prize is a copy of my book (which includes disclosure of my true identity.) (Second prize is two copies of my book, but with my name redacted.)

I’ve already sent in my entry.  It was deliciously fun to write.

How do you set a schedule? Well, how much time do you have?

For the US medical student, I think 5-7 weeks is the standard break from last class to next, and it’s in this time that they have to prepare. Of course, knowing this heading in means you can start reviewing material during your regular classes, but I think most just put it off. In the Caribbean (with SGU at least) it’s a little different.

As a January student, I’m off from Dec 17th (end of 6th term) till the beginning of my clinical rotations (end of May). For those counting at home, that’s 5 months. This should sound like 3 months too long for even the most dedicated, and it is. If you’re in the position where you need to cram information for the Boards (which describes most of us) then whatever you crammed weeks ago has fallen out well before that week when you need it.

The courses that are set up to prepare you seem to know this already. Kaplan’s program takes place over 6 weeks and they recommend taking one week off between the end of the course and the USMLE to conduct a “rapid review” of the most high-yield material (whatever that is at the end of two years). Talk to the people that have gotten antsy and delayed the test for an extra two weeks after the course and most of them will tell you that it was a mistake. So let’s believe them and not repeat it.

My plan was to relocate to Cincinnati where I knew no one, stay with my medical school roommate, and live in a library from Jan 4th until test day, March 14th. That comes to one day shy of 10 weeks, or 70 days (compare against 48 days for the average US student). To keep our sanity, we’re taking one full day off each week, bringing us down to 60 days. To build confidence, we’re finishing all material one week before the test to leave one week of “rapid review.” So with roughly 54 actual days of covering material, we had to figure how to divide it.

As always, I decided to fall on the First Aid for the USMLE. In the 2007 edition, everything has been rearranged. The second half of the book takes a systems-based approach, incorporating anatomy, physiology, pathology and relevant pharmacology into each. This is a completely alien way of learning for me as SGU is subject-based, and I decided to try something knew if only to make old information new again. The first half of the book contains the fundamental concepts like biochemistry, biostatistics, pharmacokinetics, and other things that didn’t fit neatly into a system. After some back and forth, we decided to weight each subject according to the First Aid, down to the last page.

I counted every page in each section (omitting title pages, vignettes, etc) to get to the meat. I took the total number of pages (329) and divided them by my total number of days (54) to find that 6 pages each day was a good pace. In certain places I added or subtracted a day to reflect how weak/strong I felt in a subject, but for the most part I stuck to it. You can do the same calculation with however many days you have. These were my page counts per section with days allotted in parentheses:

First Half – 146 pages (26days)

• Behavioral/Biostatistics – 13 (2/1)
• Biochemistry/Molecular – 41 (5/2)
• Embryology – 8 (2)
• Microbiology – 47 (8)
• Immunology – 14 (2)
• Pathology (neoplasia and inflammation) – 7 (1)
• Pharm (kinetics and dynamics) – 16 (3)

Second Half – 183 pages (33 days)

• Cardiovascular – 27 (5)
• Endocrine – 14 (2)
• Gastrointestinal – 24 (4)
• HemeOnc – 18 (3)
• Musculoskeletal – 16 (3)
• Neurology – 31 (6)
• Psychiatry – 13 (3)
• Renal – 16 (3)
• Reproduction – 13 (2)
• Respiratory – 11 (2)

We ended up going over our allowance and eating into some of our days off. If we stay on our original pace, we will earn those days back as reward, and I would rather earn a day off then lose a day to falling behind (perspective is so important). My schedule is available on Google Calendars (for those that are curious) as “USMLE Step 1 (topher).”

For those still couting at home, that leaves 9 weeks off between the Boards and clinicals in New York. What should you do with this time? You could always piss it away, or you could take the money you saved by not taking a Kaplan course and travel Asia/Africa/Europe/S.America for 6 weeks. Your choice.

Return to USMLE Step 1 page.

I am so completely impressed with this Stanford medical student.  Please take a look at what he has made (video):

Doctors, nurses, med students, patients, we should be embarrassed.

Welcome 2007. You can email, send instant messages, order airline tickets in seconds, track that airplane as it flies across the globe, manage your calendar, work on documents and spreadsheets in real time with your friends and colleagues, even read newspapers from around the freaking globe. But our computerized medical records (or whatever you want to call them) can’t even print out labs in the right order. This is, in a word, ridonkulous. Hospitals and clinics should demand more. The big medical record makers should provide more. Their interfaces, truly, look like they’re from 1990.

I have spent a little over a year in hospitals, working as an upcoming doctor, and I’ve seen 8 completely different electronic medical records.

Over the year I’ve tried to collect ideas about the best features (and worst) of these different systems, and I’ve put them all together in something I call (for lack of better): the GMR (Grahamazon Medical Record).

I’m not feeling great today. Day Four is almost over, and I’m overwhelmed. In the back of the HY Biostatistics, Dr. Glasner says that most students give Biostatistics 4-5 hours review for the USMLE. I gave it a solid 12 hours. It’s a weak subject for me and since I’m solid in others (like Physio) I figured I could indulge myself a little.

I barely finished the material with any confidence. I logged on to the USMLE World Q Bank and tested myself against their 60 Biostats questions, expecting a score for the effort: 71% and a kick in the teeth. After 100+ pages of Biostats no less.

That was Day One. Day Two and Three were spent with Behavioral Science. After 200+ pages of it (between the High Yield and the Kaplan Lecture Notes) I am nowhere near where I want to be. Most of the Epidimeology goes in one eye and out the other and I disagree with most of the Legal/Ethical issues for which I have to provide “correct” answers. It’s a frustrating subject for me anyway, and now I have to move past it without any confidence in what I’ve learned.

Today is the first of two days devoted to Embryology. The High Yield Embryo is 177 pages long, and I’m on 93 after 10 hours. I like to go slowly, making sure I completely understand a thing before I leave it, but this is killing me. It’s all interesting and I’m making new connections between different disciplines and, dammit, I’m feeling that rush of being constantly challenged… …but I’ll have to give it up.

I can’t maintain this, or at least I don’t feel like I can, and I don’t want to admit that I’m not going to know everything for this test. I want to believe that I have enough time and that I’ve done enough work in the last two years that this is attainable.

But the volume. The VOLUME.

My ass is sore, my back hurts, my eyes are straining, and I feel like taking the test tomorrow just so it’s over with. But that’s March 14th, 65 days away.

Return to USMLE Step 1 page.

Generally speaking, US medical schools begin accepting applications from Feb/March until mid-May or April and do not interview transfer applicants until mid-June to mid-July when they know who has failed or withdrawn from their own ranks. Whether schools offer spots in both or either year varies, so there is homework to be done. I began laying the foundation for my application one year before I hoped to be accepted and 9 months before I was applying. As a January student from St. George’s University, I had some flexibility with my schedule. Here is what I did in preparation for applying.

• June: Visit with professors in Grenada to discuss your intention to transfer and ask if they would write you a letter of recommendation.
  • Schools vary on their requirements. A Dean’s Letter of good standing is mandatory in addition to 2-3 letters of recommendation from previous teachers.
  • Some schools also require the recommendation from your Undergraduate PreMed advisory comittee. I think that is a little silly.
• September: Fly from St. Vincent to Grenada to speak again with professors, tell them what you’ve been up to, ask for advice on strengthening your application and help in contacting any students that have successfully transferred for more guidance. Visit the Dean of Student’s Office to inquire about transferring procedure and acquiring a Dean’s Letter.
  • Previously successful students can not only give you advice on mistakes they made, but can also give you advice on which professors’ recommendations were helpful in their own admission. The school may already trust the recommendation of Professor X, so if you are also able to get a recommendation from X, it may help your case.
• December: After finishing exams and flying home, contact previously successful transfer students for advice and create list of schools that have accepted transfers from SGU.
• February: Begin comprehensive search of all US medical schools to determine where you can/will apply. Download as many application forms as possible. Contact both Undergraduate and Medical Professors that have agreed to write recommendations with the tentative date of submission.
  • As I said before, every school is different. They vary in their essay questions, recommendation requirements, schedules, fees, etc. I suggest opening up an Excel file and creating a master table to give you a better idea of your deadlines.
• March: Have final list of schools that will definitely or possibly entertain your application and make sure that your USMLE score is released to them. Mail pre-addressed and pre-stamped envelopes to each professor for submitting recommendations. Have all available applications filled out and proofed by two other people with your photographs attached (regardless of whether or not it is required). Confirm with each Undergraduate/Graduate/Medical school that transcripts have been paid for and sent. Mail each application.
• April: While backpacking through Southeast Asia, enjoying your time off from school, call each medical school to confirm receipt of application and all materials. Continue calling each school every two weeks until this is confirmed. If not confirmed by end of April, contact appropriate schools and have things resubmitted. Receive USMLE Step 1 score via email from back home (your parents are nosy). Celebrate.
• May: Arrive in US. Pack up life, drive to New York. While spending a few nights on a host’s couch, look for apartment. Whenever approaching a landlord, make it clear to them that while you will sign the 1-2 year lease, you may have to break the lease in three months. You will probably still have to pay the fine for breaking the contract, but it’s better to have an amicable landlord than a blind-sided one. Should it come to this, expect to lose a few thousand dollars (depending on rent). Alternatively, you can find several sublets for your area on Craigslist. Begin rotations.
• June/July: Wait for a phone call or email. If you’re lucky, you’ll be invited to interview. On days where you have scheduled an interview, you will have to be excused from your rotation. You may have to schedule these interviews on Fridays and fly out on a Thursday night. This will cost money, so have some saved.
• July/August: Life-altering phone call? Your acceptance (lucky bastard) may come less than two weeks before you are scheduled to begin. You will have little time to rearrange your finances, withdraw from SGU (they typically pro-rate your tuition), break your lease, say your goodbye’s, and move your things. I imagine this period in your life will be incredibly stressful but worth it in the long run if you’re going for a more competitive residency or have interests in academic medicine.
• September: After giving yourself a few weeks to adjust, send thank-you notes to every single person that was involved in your application process. Let every professor know that you will make yourself available to help future students with their questions.

So this USMLE test is supposed to cover everything vital that I should have learned in the first two years of medical school, and aren’t you curious what the hell that is? Some of the facts are suprising, and you just have to wonder why I’m learning this. E.g….

Ethical situation: A terminally ill patient requests physican assistance in ending his life.
Appropriate response: Refuse involvement in any form of euthenasia (physician-assisted suicide). Physician may, however, prescribe medically appropriate analgesics that coincidentally shorten the patient’s life.

REM sleep is like sex: rise in pulse, penile/clitoral swelling, takes longer to complete each time throughout the night, decreases with age.

• I am easily bored.
• I am easily frustrated by imperfect things.

The way I used to deal with this frustration was destruction. With a college education, working as a tech in a hospital, I was so bored and frustrated towards the end with having superiors that I did not consider intelligent that I coped by doing the least amount of work possible. Today, I learned that this is an immature ego defense mechanism called Passive-Aggression.

By the time I was in Grenada, frustrated with the lack of information provided to me before arriving on the island, I engaged in a constructive behavior: I wrote the Welcome to Grenada guide and website for future students. Today, I learned that this is a mature ego defense mechanism called sublimation.

It’s nice to put a name to a thing.

Three great ER links came across my browser today:

The perfect day at the ER. Stories like this make me consider the specialty more and more.

The mental gymnastics in figuring out the diagnosis on 90% of the patients becomes reflex. But the real challenge — to be efficient, to Move the Meat, to manage the limited resources in your department in the most effective manner — that is always different and never gets old and, strangely, sometimes offers more satisfaction than does the actual patient care.

Don’t play with Fireworks. One day you’re having fun tying your shoes, the next day you have a flesh mitten.

An Eye for an Eye. I hope this happens more often, but Charity Doc had a lawyer that filed a frivilous malpractice lawsuit against him present in his ER.

“Yeah, I’m a personal injury lawyer. I have no problems telling doctors that. I get better care that way, actually. Makes you guys more careful around me.”

“Yes, I know you very well, Mr. Cochran. You were the plaintiff attorney accusing me of being a baby killer, remember?!”

Via Kevin MD, I find this article by the folks over at Health Care Matters.  The post is about a job description that is filled with opportunities to shape the way that technology is used and made to be of the most use to those in health care, and being qualified for it (appearently) disqualifies you.  Read on:

When I inquired about this role with the large national firm’s recruiter retained by the healthcare system to conduct the search, I received an initial positive response on my voice mail the very next morning. Then, I found I could not contact the recruiter for several days, only getting voicemail, and the recruiter was not returning my calls.

I finally reached the recruiter yesterday, and the the response I received was unexpected and disappointing: “the organization was looking for a nurse and they would not even talk to a physician.”

Frustrating…

January 4th, the first day of studying and it’s headlong into Biostatistics. Armed with my hand-written notes from 3rd Term, First Aid for the USMLE, Kaplan Lecture Notes: Biostatistics (bought the whole set off of someone for $200, completely unmarked), and the High Yield Biostatistics book I begin Operation Overkill.

I begin by settling into the local medical school library and then lazily looking through my own notes to regain some familiarity, which takes about an hour. I open up the First Aid and carefully read over every concept that they stress, adding Generic Post It Notes to each page to hold extra mnemonics or figures that help me remember what is important. After this, it’s on to the Kaplan Lecture Notes (each source is slowly increasing the level of detail). This takes much longer, maybe three hours to absorb everything with some understanding (finding mistakes along the way, see below). Having started at 9am, I’m now finishing up around 3 o’clock. I don’t feel solid, but I feel competent.

I begin the High Yield Biostatistics. This is the highest level of detail I’ve seen and also the easiest read. I’m thrilled to find diagrams and tables that are much better than the ones I found in the First Aid or Kaplan Notes and they feel like tiny treasures. I love that this author not only offers clear explanations of similar but different terms and concepts, but he then spends some time highlighting why their differences are important. His analogies are amazing the way magic is amazing, and I’m thinking about writing Dr. Glaser an email to thank him (he supplies his email address). The questions at the end of each section are appropriately difficult and after reading the material several times over earlier in the day, this is sort of pleasurable. Biostatistics, pleasurable? Well, yes.

After an hour spent eating dinner (sack lunch swallowed over notes in a hurry), I finished the book around 9pm with all of the questions in each section. And now, after playing on the computer and writing this, I’m going to go through the things I may forget from each source and combine them into one or two pages of notes that I will review in a week’s time and again in the week before the actual test.

**Warning: not high yield to continue reading**

So what errors did I find in these books?

First Aid for the USMLE

Though techinically tomorrow’s material, I found a description of an Advanced Directive on page 70 (2007 Ed.) that I believe is flawed. I think they’re describing a Do Not Resucisitate Order or DNR. Changing “withhold or withdraw” to “withhold or provide” would probably solve this.

Living Will — patient directs physician to withhold or withdraw life-sustaining treatment if the patient develops a terminal disease or enters a persistent vegetative state

I prefer this definition from Prudential:

Living Will: A document which specifies the life-prolonging measures an individual wants and does not want taken on his/her behalf in the event of a terminal illness. Living wills are often used in conjunction with a healthcare power of attorney, which appoints someone to make healthcare decisions on your behalf.

Kaplan Lecture Notes: Behavioral Science

On Page 7, there is a statement that I do not agree with. It states that:

point of optimum sensitivity = point of optimum negative predictive value; point of optimum specificity = point of optimum positive predictive value

This is incomplete, and I need an example to demonstrate it. In the usual square (Fig 1) you have true and false positive results (TP and FP) and true and false negative results (TN and FN). Our shorthand for this is A,B,C, and D. Without going into further detail, Specificity is calculated as D/(B+D) while positive predictive value (PPV) is calculated as A/(A+B). Sensitivity is calculated as A/(A+C) and negative predictive value (NPV) is calculated as D/(C+D). So if Kaplan is incorrect, let’s see if we can demonstrate it.

Assume a population of 100 people, split perfectly down the middle. 50 have the disease, 50 are disease free. We would like to see if a company’s new test can help diagnose this disease. The new device doesn’t work and the results are poor:

• Specificity = 1/50 = 2%
• Sensitivity = 25/50 = 50%
• PPV = 49/98 = 34%
• NPV = 1/2 = 4%

Specificity is low, Sensitivity is low, and the PPV and NPV are at also low. Well, it turns out we weren’t using the device correctly, and we run the experiment again.

• Specificity = 1/50 = 2%
• Sensitivity = 49/50 = 98%
• PPV = 49/98 = 50%
• NPV = 1/2 = 50%

According to Kaplan, the rise that we see in Sensitivity should be accompanied by a rise in NPV, and we see this. But without any change in Specificity, we see a rise in PPV. My point, after all of that, is that Kaplan’s statement is incomplete becuase it doesn’t take into account the effect that Specificity has on NPV and the effect that Sensitivity has on PPV, and instead paints an incomplete picture.

Dr. Glasner in HY Biostatistics takes it further:

Whereas the sensitivity and specificity of a test depend only on the characteristics of the test itself, predictive values vary according to the prevalence (or underlying probability) of the disease. Thus, predictive values cannot be determined without prior knowledge of the prevalence of the tests’s charateristics and of the setting in which it is being used.

Long story short: increasing the prevalence of a disease increases the PPV of a test and decreases the NPV of that test, without changing the Sensitivity or Specificity at all. So as I hope you can see, the sentence from Kaplan falls quite short of the truth and would be harmful to just memorize and use come test day.

Return to USMLE Step 1 page.

Thank you, Google Reader, for all of these presents.

To begin my education in the Health Care of these United States, I’ve traveled around trying to find the blogs that are already writing about these topics.  Here are a few:

Kevin MD covers the daily news of malpractice, health care reform, etc.  He doesn’t offer much commentary, but he makes up for it with access (there is little that he misses).  He’s like medicine’s Matt Drudge.

Joe Paduda over at Managed Care Matters is a regular read these days.  His writing is great.  This article about Senator Wyden’s proposal to fix health care caught my attention.  I’m also paying close attention to his “Essential Blog Reads” in the right-hand column.

The Health Care Blog: Everything You Wanted to Know About Health Care but Were Afraid to Ask.  I liked this recent synopsis on how to fix the problem of the uninsured.

Consumerism Commentary just started a series of posts about getting his MBA online with the University of Pheonix.  While I’m thinking about an MBA, I have to wonder whether I’ll go brick and mortar or straight to the series of tubes.

A Stitch in Haste has this whirlwind post covering many of the topics that concern opponents of Universal Health Care (and should concern the supporters).  Not a lot of pro/con balanced argument, but a quick survey of the topics nonetheless.

“I need crutches, stat!”

That’s how I feel right now, getting ready for this test. I want someone to have done all of the work, laid out a plan of attack, shown me exactly what I need to know, and have it be easy. All of this exists, of course. I could have signed up for a Kaplan or Falcon course. I would have lived in a hotel for 6 weeks, listened to great lecturers, been fed information in outline format, and taken 2,000+ preperatory questions. It was all laid out.

But it costs several thousand dollars. You may be the type to write that expense off as an investment in your future, but I’m not. I see $6000 as a monument to my laziness because I know I can probably put together a program of my own, it’s just going to be work. I see $6000 as a trip around the world in celebration of doing things the hard way and still coming out on top.

The first piece of real work is picking the best crutch, and for this I turn to what will be my staple: First Aid for the USMLE ($45). Why? Well, the most frustrating thing about this entire process is that I get one crack at it. This is n=1 with zero degrees of freedom and I can draw no real conclusions. I’m left to scrounge for anecdotes, and the reverberating truth about the USMLE Step 1 is that the First Aid book seems to earn a few thousand thumbs-up each year. So we begin there.

In the back of this book is a list of several review books that have been described, reviewed and graded by previous test takers on an A/B/C level. So for two days of my winter break, I drove to the local medical school bookstore and pull every single top-rated book from the shelves. I pulled four books for Physology, Pharm , Path, Micro and so on. I take one subject and read the chapter devoted to it in each book to compare styles of writing. I consider length (shorter is better), number of review questions available in the book and online, and my personal impression. It takes six hours over two days. I’m tired, but I’m happy with the results.

Anatomy/Embryo/Neuro

Anatomy is a strong subject for me and one of my favorites. I have always written off Embryo, but I figure I’ll give it a fair shake if I can find the time. I have the Anatomy BRS by Chung from first year, but this book gets poor reviews because of its length, so I shop around. I’m able to narrow it down between Rapid Review: Gross and Developmental Anatomy ($35) and USMLE Road Map: Gross Anatomy ($25). Road Map is shorter, and the illustrations are so interesting and unique that I’m thinking about the anatomy in new ways, but I can’t ignore the abundance of clinical correlates in the Rapid Review and how much fun it is to read, so I buy it.

As for Embryo, I don’t have the strongest feelings. I pick up all of the books and read through them. I ultimately choose the High Yield Embryology ($25) because it has the highest rating in the First Aid and it has lots and lots of pictures. I’ll probably give myself onefull day to review Embryo, and if I’m going to have to do it, I’d like to be entertained. Neurology is sort of a thorn in my side. I understand the tracts and the geography, but I’m never quit sure where Neuroanatomy ends and Neurphysiology begins. Should I be covering this in Physio, Path, Histo? I throw up my arms and buy the highest-rated book: High Yield Neuroanatomy ($25).

Biochem/Molecular Biology

Biochem is another subject where I feel strong, but I’m told that everyone gets kicked in the head on this section. I’m going to be careful. I have the Lipincott’s Illustrated Review of Biochemistry ($45) from first year and it has a high rating, so I’m sticking with it. SGU (when I took the class) did a poor job of preparing my for the molecular genetics, so I’ve decided to pick up a second book for this alone: High Yield Cell and Molecular Biology ($27). After reading a chapter, I think this book will cover my needs. The High Yield series is growing on me.

Histology

Screw Histology. Anything I know about this subject, I’m going to pick up from Physiology or Pathology. I refuse to give this topic its own review book. Immediately after this, I begin spitting on the ground whenever anyone metions Histo.

Physiology

Physiology is one of my favorite subjects. I didn’t use a textbook when I took this course and instead used the amazing handouts that were prepared by our teachers. For a good review of things though, my notes won’t do, and since there seems to be an absolute consensus that Costanza’s Pathology BRS ($37) is the best book on the market. I buy it without batting an eye.

Microbiology/Immunology

These two courses are weak spots for me. When I should have been learning them, I was instead learning Pathology so I have a lot of catching up to do. I hadn’t realized this yet, but not feeling confident in a subject makes buying a review book harder since you don’t recognize which books are hitting all of the important topics. I hem and haw between Clinical Microbiology Made Ridiculously Simple ($24) and the Rapid Review: Microbioogy and Immunology ($35). Both books get high marks on reviews, but I end up going with Rapid Review because it has an Immuno section, online access to Student Consult, and some of the silliness of Ridiculously Simple annoys me

Pathology/Pathophysiology

SGU did a fantastic job of making these courses life or death for me. I’ve spent a lot of time with them and don’t feel so intimidated that I can’t enjoy myself. In the course, we used Robbins Basic Pathology (amazing), Robbins and Coltran Review of Pathology ($42), WebPath (free online site), and the Merck Manual. I have more than enough information from these courses and that’s a problem. I need to keep things simple, so while I plan on doing all of the questions from the Review of Pathology and from WebPath, I also decide to buy the Pathology BRS by Schneider ($35). It gets glowing review from everyone that uses it, and that’s good enough for me.

Pharmacology

Again, one of my weaker subjects and I’m a little bit nervous about it. I’m comfortable with the concepts, but memorizing name after name with it’s idiosnycratic side effects and routes of administration has me sweating. I need some support here, but I also need to keep it simple. I own Lipincott’s Illustrated Pharmacology ($45) from when I took the course and while I didn’t like it as a stand-alone text, it should do fine for review. I also like the layout and portability of Pharmacology for the Boards and Wards ($35) and decide to pick that up as well. Both books have very high ratings and useful tables.

Biostatistics/Behavioral Science

Not my strongest subjects or my weakest, word on the street is that people blow these sections off and it burns them on the test. I have some notes from when I took this class, but it was 3rd term, the same term where I blew off school to work on research and dissections, so I need some help. After looking through both the High Yield Biostatistics ($25) and Behavioral Science ($25), I’m thrilled with how short they are, their ratings, and their readability (one chapter each, in the store). I’m sure that these will do.

So those are the review books that I bought for the USMLE Step 1. The tab, after tax, came to $380. Normally, I’d wince. But for this test, I’m not cutting corners or using old editions. Maybe it’s a dumb move, but it makes me feel better.

Return to USMLE Step 1 page.

Happy New Year everyone. 

Grand Rounds is up at Musings of a Distractible Mind.  The theme is things that explode.

After two years of work, I am now semi-qualified to square off against a cumulative hell-test known as the “Boards.” I have to figure out what I’m fighting and how I’m going to fight it, so first things first.

http://www.prep4usmle.com/

Besides being a one-stop-shop for all things USMLE, the greatest strength of this site is their forums. You can talk with thousands of other students about their strategies, their book choices, enourmous pools ranking review books in every category, etc.

http://www.testprepreview.com/

Several online quizzes in each subcategory that you will see on the Boards, complete with a description of the question breakdown by percentages that you will see on test day (rough estimate).

http://www.usmle.org (Orientation Materials)

Information from the horse’s mouth. Information on recent changes to the test, preview of the materials provided on the test day, sample test questions, instructions on taking diagnostic tests and a very helpful FAQ. A necessary bookmark.

There are also helpul descriptions of the test and how to mentally steel yourself in the First Aid for the USMLE review book and Kaplan’s QBook. So now that you I know a little more about my test, how should I prepare for it? Medstudents (like me) love to think that their advice is important and they like to write about it. So where is all of this great advice?

The Step 1 Blog

This blog was set up and maintained for the express purpose of cataloging one student’s adventure with the USMLE. The author is an FMG (like me) and the observations he makes on the process are great, making for an easy read. His story has a happy ending; he finishes with a 248/99. You can read the entire blog in under twenty minutes.

Alpha Omega Alpha

This is the nationwide medical honors society and University of Illinois chapter has some dedicated members. USMLE Study Tips is a feature that is updated often with several members’ impressions and advice about what it took for them to prepare. Many of these entries are very useful.

Over My Med Body!

Graham Azon, medical student extrodinaire, wrote a short post about the very basics that he used in prep for the Boards. I agree with most of his suggestions.

Return to USMLE Step 1 page.

A few things are going to start popping up here. First, I’m going to begin studying for the USMLE come Jan 4th and I plan on keeping everyone who cares up to date on how I select review books, choose a plan of attack, and generally fare over the next two months with a “How to I Prepared for the USMLE” series.

Second, the medico-economics of health care continues to fascinate/infuriate me. I’m a Pessimistic Kantian, so if I’m going to walk around wishing that someone had already written a personal guide to explain this to me then my ethic dictates that I have to make one myself (since I wish some future-self had saved me the trouble). I’ll be gathering what I can online and bringing it here for your easy consumption as “My Health Care Education.”

Third (and a sensitive topic for those in the Caribbean), I am applying for transfer to a US medical school in March with the possibility of interviewing in June/July of 2007. This will be interesting for me because 1) I have no idea how to go about it as information for prospective transfers isn’t exactly advertised or accessible at SGU, 2) I may end up producing a helpful guide while publicly failing myself, and 3) I’ll get to address some of the reasons why I think transferring is an important step for me and whether that contradicts what I’ve written (a guide about how great SGU is) and said (with MedScape) previously. “Transferring from a Caribbean Medical School” should be interesting.

But that all starts in a week. In the meantime, I’d like to draw your attention to the updated “SGU Guides.” Whereas before it was simply a link to the Welcome to Grenada site, it now has a menu of things I’ve written that don’t fit easily into the longer version but still deserve a home. I hope it helps.

Cheers for now, topher.

My family reads what I write here and I struggle sometimes with that knowledge. Exactly how free am I to write stupid things and reveal embarrassing secrets? I handle this in the style of our times: denial. Sometimes, though, I am reminded that they are out there in Al Gore’s internet when they send me their opinions about my writing. After receiving the following email, I realized that instead of writing about a small thought that belongs in a larger argument, I should have just written the whole thing.

Where did you get the idea that Universal Health Care meant that the Doctor was not compensated for his services? My understanding is that you (the Doctor) would be compensated for your services, at a possibly reduced rate the same as Medicare and Medicaid compensate the Doctors. While I know this is not the full amount, you are under no obligation to accept the patient in the first place. There are Doctors all over this country that do not accept Medicare patients for this exact reason. However, if you hope to have Hospital privileges, the Hospital’s policy will trump yours.

Just curious. Mom.
For some background, she is responding to my post No Right to Health Care. I wrote it because the more I read about Medicare, Medicaid, and the “funding” of physician services (hat tips to KevinMD) the more frustrated I get. It’s been happening a lot lately. It’s the frustration of having to enter a system that (in my mind) shouldn’t be allowed to function the way that it does. I’m a strong believer in markets. I believe in the meeting of supply, demand, and value complete with a fulminate crush on Dagny Taggart. These days, I’m frustrated over that fact that the value of the service that a physician provides is not strongly coupled to what he can charge, and instead his recourse is to make his salary through volume. I started writing this during exams, so in that spirit I offer you a medico-economic vignette.

***************

The value of having access to a physician (let’s say you have diabetes) that can take an active role in your care, help you correct some mistakes that are leading to uncontrolled glucose levels, and not only extend your life but help you extend it without the complications of the disease is incredible! But as only one man, the number of people for whom he can do this is limited. His service is not scalable.

Even if this person has their own insurance to pay for this care, that payment is likely standardized (we pay $25 per check-up, $40 for new patient consult) and based off of the standardized prices from Medicare/Medicaid. Even if the patient isn’t on these government programs, he is still affected by their prices. So our doctor has little control over the price he can charge.

For a patient with options (amazing Dr. A or mediocre Dr. B), her power in the market is to choose which physician gets her business. Dr. A’s power in the market is to provide a better service so that patients will choose him over Dr. B. But this is only an advantage so long as 1) Dr. A has the space in his practice to accept this patient and 2) there aren’t enough patients for Dr. A and Dr. B to both have full practices. If there were too many patients for Dr. A and Dr. B to handle, then it wouldn’t matter which was better since everyone needs to see a doctor (in our two doctor microcosm) and both practices are full.

Now Dr. A is working full time, handling as many patients as he can in a manner that is still excellent, and he is not making enough money (under the fixed pricing) to pay the bills for his practice, malpractice insurance, employee wages, and to then pay himself a wage befitting someone excellent. Because he cannot change what he charges, he must make it up in volume. The only way for him to increase his volume is to drop the quality of his service and speed up his appointments. He does this.

His patients are less satisfied on average and he is less satisfied on average. But he has to pay the bills and he has to pay himself a salary that makes running his own practice more attractive than quitting for hospital work, so he continues with the higher volume. The prices do not change with inflation and the vise tightens. He is forced to do cosmetic procedures on the side like Botox injections and instead of popping a cyst on a teenager’s face, he lances it so it will qualify as a “procedure” (which pays better). He makes Friday “Stress Test Day” and has every one of his Congestive Heart Failure patients come in for a complete workup because insurance pays well for this. He didn’t get into medicine to be fixing wrinkles or to spend his time figuring out ways to game the system of physician reimbursement. He just wants to do his job, at his price, and help people in the way that he finds rewarding.

Now his insurance premiums have gone up. Unlike his pay, the increase in insurance premiums has kept a healthy lead on inflation. If he continues running his practice this way, he’ll go bankrupt and lose it. He doesn’t want to even think about what would happen should one of his patients sue right now. It would ruin him. So he decides to opt-out.

He’s heard (everyone has) about concierge medicine and “cash only” clinics. Opting Out means no more worrying about Medicare codes and billing procedures. No more being second-guessed by insurance companies saying that they will not reimburse for a CT because they don’t feel it was indicated (no, they didn’t go to medical school and no, they have never seen a patient). No more having to worry about a piece of legislation that would cut Medicare reimbursement by 5%.

Only he’s trapped. In the interim of dropping his Medicare patients, seeing to it that his billing is changed and that no new claims are filled in the next two years, and educating his patients about the changes, his malpractice insurance premiums continue to consume what’s left and he has no chance for air. Gulliver himself couldn’t escape the net of obligations that are binding him to this system and taking away his freedom. In the time it takes to change, he’ll be bankrupt anyway. He closes the money-sink that was once his shining creation. He locks the door on his practice.

***************

Right now, this is what medicine looks like to me. Terrifying, right? I have hopes on hopes that I am wrong and that there is a way to avoid Dr. A’s fate (maybe I’m awfulizing). And I know that there are plenty of doctors running practices, making money, and living comfortably but unless they are completely free of the forces that took down Dr. A in my example, they’re just the last line before the firing squad. Even if I manage to escape it (as physicians do by having concierge or cash-only practices from the start), I don’t want any other physicians to have to deal with it. It’s unjust.

I know that I don’t have the whole story and that a few times in my example it might seem like I’m getting ready to fight a windmill, but I do want the whole story and am desperate for it. This winter break I’ll be reading books on the Health Care system for leisure! I want this information before I’m going to need it. I don’t know about others, but my medical school doesn’t have any sort of class or series of lectures to prepare us for the business of medicine and from what I’ve heard, you’re supposed to just sort of “pick it up.” No thanks.

All of this has me seriously considering (I’ve all but paid the registration fees) to take time off from medical school (or between graduation and residency) to get an MBA. These fears have also made me want to have an active role and voice in stopping the machine that’s eating away at the livelihood of physicians (the potential of a well-read blog). There are many heads to the Hydra, and if that means changing Medicare/Medicaid/Insurance to instead be a promise from the government or insurance company to fully reimburse a physician (based on his established prices) or taking the verdicts of malpractice cases away from citizens and putting them in the hands of medically-trained judges in some sort of specialized Health Court, so be it.

You need look no further than the field of cosmetic surgery to see how this should all be working in the first place. If he had been a surgeon, Surgeon A would have the freedom to change his patient volume and price in response to increased demand for his excellent services. Mediocre Surgeon B would have less demand at the same price, but could increase that demand by lowering his price and then still make a good wage through an increase in volume. While Surgeon A will always have the ability to make more than Surgeon B, they both have the freedom to make what they’re worth in the market of cosmetic procedures. Patients win under this system as well. They have the power to trade the outcome/risk of the procedure (as it differs between surgeons A and B) against the price, and may choose the increased risk of having an unfavorable Rhinoplasty under Surgeon B (the risk is acceptably small to them) for a savings of $5,000 on the procedure. And by participating in this market, the patient’s demand ensures that there will always be a supply of surgeons vying for their business.

Cosmetic surgery is this wonderful exception because the majority of it is not governed by the pricing of any organization other than the market for the service.

I wish all of medicine was operating in this way and am not excited that it isn’t. I do not want to enter a system where my hands are tied (price control outside of market forces), I’m blindfolded (no business education), and I have no power to change it. It removes incentives for physicians to do better (as does any ceiling) and I think everyone is worse off (except the insurance company).

Therefore, since brevity is the soul of wit, and tediousness the limbs and outward flourishes, I will be brief: that’s why I was upset about the idea of a right to Health Care the other day. I believe that if legislation was ever passed to make this happen, it would be underfunded and the taxpayers wouldn’t pick up the tab (as paying for things is politically unpopular). The coins would instead come out of the physicians’ pockets, squeezed with a few more turns of the screw. And who are physicians to complain? We’re in it to help people so why would we care about the money? Isn’t it our duty and moral obligation to provide care to the sick and injured, regardless of ability to pay?

And my answer today, as it was yesterday, is no. It is shortsighted to think that ignoring the value of a service results in the best for anyone or that physicians feel obligated to provide something that is valued (in theory) but not rewarded (in practice). I believe in the opposite approach. Paying attention to the value of a service and rewarding the difference gives everyone the incentive and ability to do better and gives the consumer better options for obtaining it. If you still don’t believe me that this matters and that physicians do care about the rewards of their service, then go to any medical school on Graduation day. Look to your left, look to your right. Neither of them will be going into Family Practice.

P.S. For any physician that reads this, shakes his or her head and then mumbles, “You. Idiot.” please take the time to tell me what I’m missing. I cared enough and it bothered me enough to write this long thing, so it goes without saying that I would want to know what’s right more than I care to avoid the embarrassment of being publicly wrong. I know I’m over my head here, so please use the comments section to give me the education that I so sorely need.

Cheers, and thanks for sticking around till the end. topher.

Can you imagine being tapped for this procedure? (Courtesy of the NYT)

The Man on the Table Was 97, but He Devised the Surgery

As he sat alone, [Dr. Debakey] decided that a ballooning had probably weakened the aorta, the main artery leading from the heart, and that the inner lining of the artery had torn, known as a dissecting aortic aneurysm.

No one in the world was more qualified to make that diagnosis than Dr. DeBakey because, as a younger man, he devised the operation to repair such torn aortas, a condition virtually always fatal. The operation has been performed at least 10,000 times around the world and is among the most demanding for surgeons and patients.

Over the past 60 years, Dr. DeBakey has changed the way heart surgery is performed. He was one of the first to perform coronary bypass operations. He trained generations of surgeons at the Baylor College of Medicine; operated on more than 60,000 patients; and in 1996 was summoned to Moscow by Boris Yeltsin, then the president of Russia, to aid in his quintuple heart bypass operation.

Now Dr. DeBakey is making history in a different way — as a patient. He was released from Methodist Hospital in Houston in September and is back at work. At 98, he is the oldest survivor of his own operation, proving that a healthy man of his age could endure it.

Today was spent writing a research paper and tomorrow will be spent travelling.  No matter how many times I’ve packed up everything to move, it’s always stressful.  While I’m in transit from 9:45am till 11:45pm, trying to sleep through crying babies and fighting for the armrest, I’d like to announce a “Best of Rumors” section.  For those of you that haven’t been with me for the past two years, it’s a chance to get better acquainted.

Now if you’ll excuse me, I have to figure out the Cp of my wireless router.

Cheers, topher.

**This post’s content and format was inspired by The Simple Dollar.**

You can bring 100lbs+ to school but can only return home with 50lb and now you have to decide what stays and what goes. Ready to pull out your hair?

When coming to the islands (either Grenada or St. Vincent), a typical flight takes you to San Juan on American Airlines followed by a prop plane taking you the rest of the way (American Eagle, Caribbean Star/Sun, Liat, etc.). To benefit from the business of the larger companies, these smaller island carriers agree to handle the promised luggage allowance. So coming to the islands, I was allowed 2 x 50lb checked luggage, 1 x 40lb carry on and a 1 x personal bag not to exceed 15lb. For those keeping track at home, that’s 155lbs.

These smaller airlines have smaller airplanes and so cannot possibly take all of this promised luggage, so instead they take what they can with each flight and come back for the rest later. This means that most students coming to the islands wait a few days to receive everything.

Going back is a different story. The larger airline may have changed its guidlines and will now allow two checked bags not to exceed 70lbs in total (that’s a loss of 30lbs) or the smaller airline may decide (at their discretion) not to honor your previous luggage allowance when leaving the islands and restrict you to a single 50lb bag.

So what are you to do? Many students donate piles on piles of clothes to charity, others pay FedEx or Amerijet to ship their items home, but very rarely is this cost effective. Why pay $200 to ship 40lbs of used books? So nerd that I am, I suggest the following:

Let’s say you have the worst case scenario of one 50lb bag and one carry on. First, weigh the bag and subtract that from the total. If you have a soft bag with rollers and a metal back brace housing a retractable handle, this weighs around 7lbs.

Now that we’re only working with 43lbs, it’s time to separate the wheat from the chaff.

1. Identify items that are truly invaluable i.e. they cannot be replaced and under any circumstances (non-digital photos, hand-written lecture notes, annoying yearbook you made everyone sign). Weigh these and place them in your bag. Subtract from total.
   1. This category does not include your computer, digital camera, text books, etc. as these can be replaced.
2. Assign each item a packing coefficient (Cp). To do this, decide the monetary value of an item and divide that by its weight. Your coefficient for each item will be in units of $/lb. Here are a few examples:
   1. Braun Activator Shaver, used one year. Originally $150 now $80. Weight 6 ounces (half a pound).
      1. Cp = $80/0.5lb = $160/lb. A high coefficient!
   2. Motioncomputing Tablet Computer, used two years. Originally $3,000 now $1800. Weight 3lb.
      1. Cp = $1,800/3lb = $600/lb. Extremely high coefficient.
   3. Hanes white t-shirt, used one year. Originally $1.5 now $0.1. Weight 2 ounces.
      1. Cp = $0.1/0.125lb = $0.8/lb. Should probably just throw away.
3. Rank your items in a descending fashion.
   1. Invaluables Cp =
   2. Motion Computer Cp = 600
   3. Braun Shaver Cp = 160
   4. Little black dress Cp = 30
   5. Blue Jeans Cp = 15
   6. Beloved Merck Manual Cp = 13!
   7. Beloved Golian Principles of Pharmacology textbook Cp = 10!
   8. Cargo shorts = 3
   9. T-shirt Cp = 0.8
4. Increase the worth of your suitcase by filling it, starting with the highest Cp items and working your way down until you have reached your weight limit.
5. Armed with the knowledge that it costs you money to bring anything else, donate the rest to charity!

While I expected most of my shirts to be worthless, I was shocked to find that my beloved textbooks were worth less for their weight than my denim jeans (the little black dress is for illustration, I do not wear dresses in my spare time). Had I not gone through this exercise (originally for fun, I’ll admit), I certainly would have tried to save the books and then lost money back home buying a new pair of pants.

Ahh, the fruits of nerd labor.

DISCLAIMER: Stictly using Cp is effective if we assume that the space that each item occupies is negligable, i.e. to be truly complete we would have to factor in the volume that each item occupied and for that calculation, price/density (price/mass/volume) would have been more appropriate.

For example, nice bedding with a Cp of 40 might end up taking half the space in your luggage, thereby preventing you from using that same space to add more items at lower Cp, the sum of which would exceed the bedding’s worth. Fortunately, this is rarely an issue and we can concern ourselves with price and pounds alone.

I’ve got two days left to finish writing a research paper concerning the coronary arteries. Unless you’re in it, I don’t know if many aspiring students know what research is really like. When you’re not collecting data or bent over a dissection for hours on end, you spend the rest of the time reading the literature and trying to find the connections between different ideas about how something works (vague, right?).

And unless you’re the type to find the fun in anything, it can be a real pain in the ass. Publications have their own stale version of english where nothing can be said that someone hasn’t already said (citations) and when two papers offer conflicting results the most that one can say about the other is something like, “we attribute the difference in findings with X to be due to criteria for inclusion and dissecting technique.” Translated: “The other guys can’t dissect for shit so missed this important finding.” It’s all very WASP-y.

But sometimes you find authors that are not afraid to drop the pretence or (and more rewarding) use the sweet tact to deliver posion. Of course, these authors are British.

• The Elusive Coypu: the importance of collateral flow and the search for an alternative to the dog.
  • “There are several ‘villains’ in this story: (i) researchers who convinced themselves that myocytes could stay alive without blood; (ii) authors who discarded (or journal editors who refused to publish) negative studies; (iii) dogs that had too much and too variable collateral flow; (iv) legislation and animal suppluers that made the use of canine preparations) and an intriguing alternative [the coypu] impossible or prohibitively expensive; and (v) a UK government plot to exterminate the coypu (nutria).”
  • “Interstingly, the guinea pig heart was found to be totally collateralized making it impossible to induce infarction in this species — how great it would be if the human had the coronary artery anatomy genes of the guinea pig!”
• Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials
  • Conclusions As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials. Advocates of evidence based medicine have criticised the adoption of interventions evaluated by using only observational data. We think that everyone might benefit if the most radical protagonists of evidence based medicine organised and participated in a double blind, randomised, placebo controlled, crossover trial of the parachute.

Do you have to feel sad to feel nostalgic? Do you have to miss something?  Two days after taking my last exam in the Caribbean and sewing up the first two years of medical school, this is what I’m wondering.  In the last two years I have made writing a big part of my life and so there’s an expectation that I have that the end of this period would move me to write something inspiring.  But it’s not there; I’m not sad enough to be nostalgic.

Instead, I am simply ready for it to be over.  After two years of staring at books, notes and PowerPoints I feel like the velcro has worn through and things are sticking less.  I need a change of scenery and a change of context.  Studying for the Boards followed by a 6 week vacation in Southeast Asia will go a long way to resetting things, but moving to New York and working in a hospital every day with patients as test material will be the thing that keeps me going.  That this is ending now is just great timing.

Goodbye, St. Vincent.

I’m in medical school (partly) because I can’t shut my brain off and need to constantly be assuming information.  Boredom is a fate worse than death and this field is the balm.  So aside from reading about Infectious Diseases for my Pathophysiology exam this Thursday, I’m also reading the blogs of Cosmologists, Financial Advisors, Politics, and Economists.  Today, we have synergy.

In Infectious Diseases, I’ve just learned about the rates for sexual exposure to HIV among different groups.

• Male exposes Female (1/200 – 1/2000)
• Female exposes Male (1/700 – 1/3000)
• Male exposes Male (1/10 – 1/1,600)

Do those look low to you?  These rates are not sufficiently high to either cause or sustain an epidemic!  So how the hell are these epidemics sustained in Africa?  The hypothesis provided in my notes:

• HIV transmission rates are too low to explaoin the epidemic
• HIV transmission is intermittently amplified by increasing genital tract shedding
• Amplified transmission is critical to the spread of HIV

So imagine my absolute excitement to find this article by the famous economist, Emily Osler!  Three Things You Don’t Know About AIDS in Africa.

1. It’s the wrong disease to attack
2. It won’t disappear until poverty does
3. There is less of it than we thought, but it’s spreading as fast as ever

I encourage you to read it for yourself.  But we’re not done yet.  If you really want to stretch your mind, you have to surround yourself with mind-stretching ideas.  That’s where TED comes in.  Technology Education Design is an annual conference that brings together remarkable people from around the world into one space to share something valuable: their ideas.  I subscribe to the TEDTalks Podcast and often listen to these 20 minute videos again and again (if you don’t use iTunes, you can listen to them on the web here).  And thanks to this wonderful resource, I’ve learned about Larry Brilliant.  He is a physician and his life story is remarkable including living in India for 10 years studying under a Hindu sage, becoming a diplomat for the United Nations, and in his capacity as an epidemiologist he presiding over the last case of smallpox on the planet.  In his talk (you can listen to it here) he describes the effort it took to hunt down the disease, door to door, over and over, for years.  He’s amazing, and it will take people like him to actually take what we are learning about the spread of AIDS in Africa and actually turn that information into eradication.

And I wouldn’t have put any of this together if I had decided to study something else.

Thanks to the brilliant folks that invented aggregators, I have the ability to subscripe to over 60 blogs and have their new posts sent straight to me without having to check their site each day. If you haven’t picked one up yourself, I highly recommend them. They are so choice. My favorite is Google Reader though I hear that RSSOwl is also good and would suffice.

So I read a lot and a good portion of it is worth sharing. If you’d like to see everything that I think is worth sharing, click here. While I can’t contribute just now (test tomorrow morning and on Thursday, followed by celebration for finishing up the first two years of medical school) I thought I’d offer a few links to keep you busy.

Aggravated DocSurg writes,

“I belong to this quirky group of docs that gets together once a month — we have a few adult beverages and a nice dinner, and then each evening two of us give a talk.”

He then gives us his story about Rudolf Erich Raspe. I have read this article three times over and still want to read it again. I can’t imagine the thunderous applause that greeted him when he finished. If you’re like me and want to know more after reading it for the fourth time, bone up on “The Surprising Adventures of Baron Munchausen.”

Steve Mirsky writes Antigravity for Scientific American and he always gets a laugh out of me. This article was one of his best.

It came as quite a shock recently when the stupidest thing I’ve ever heard turned out to come from England. I had assumed it would be from the U.S., but no. Anyway, here it is. A government minister said that some pregnant British teenagers were purposely smoking during their entire pregnancies to try to have low-birth-weight babies, which would make for easier deliveries. Even more breathtaking than smoking itself, isn’t it? Take a moment to get a bandage for where you hit your head when you passed out just now.

Surprisingly, the post I wrote about a Lazy Attack on Atheism sparked some interest. I made the claim that monkeys have morals and that moral systems arise in nature without the need for dogma. This article explores some experiments that ask the same question:

He describes one of his best-known demonstrations that animals care about fairness. In the experiment, he had pairs of capuchin monkeys perform simple tasks in their cages. For successfully completing each task they would get a reward, sometimes a slice of cucumber, sometimes a grape. All the monkeys would work for and eat the cucumber slices, but they preferred grapes. If one monkey kept getting paid in cucumber and it could see that its partner in the next cage was getting grapes, it would get mad, like Darwin’s Jenny. After a while the monkey would refuse to eat or throw the cucumber right out of the cage.

Is religion good for society? Science’s definitive answer: it depends.

“In general, higher rates of belief in and worship of a creator correlate with higher rates of homicide, juvenile and early adult mortality, STD [sexually transmitted disease] infection rates, teen pregnancy, and abortion in the prosperous democracies,”

“[W]hen it comes to charitable giving and volunteering, numerous quantitative measures debunk the myth of “bleeding heart liberals” and “heartless conservatives.” Conservatives donate 30 percent more money than liberals (even when controlled for income), give more blood and log more volunteer hours. “

My God Problem by Natalie Angier is incredibly well-written (she won the Pulitzer Prize as a science journalist for The New York Times). In this article, she takes scientists to task for bemoaning the general public’s belief that evolution is something less than a fact while remaining mum over the “77 percent of Americans who insist that Jesus was born to a virgin, an act of parthenogenesis that defies everything we know about mammalian genetics and reproduction.” I wish I wrote as well.

I’ve been thinking a lot about health care and the mess I’m about to inherit in the next couple of years as I earn my MD and enter Residency training.  As a student of medical blogs, it’s hard to be keep my head in the sand about such things as they clearly occupy a good deal of the discussions.  So right now I’m addressing the perceived “right to health care.”

I’m against it and here is why.

When we think of our rights, we often think about the Bill of Rights and the Amendments.  The right to bear arms, the protection from unreasonable search, the right to peaceful assembly and the right of free speech.  The common thread in these rights is that they

• cost nothing to maintain or respect
• requires other persons to refrain from violating it in order to fulfill it

These are referred to as Negative rights.  If you leave me alone and I leave you alone, we have maintained these rights and violated nothing.  Now if you look at the proposed Right to Health Care, you will notice that this fails both of these standards.  It instead

• costs a great deal
• requires other persons to perform a service in order to fulfill it

These are referred to as Positive rights.  Under this right, if I fail to provide you the service of Health Care, I am violating your right to my service.  And now we reach the crux of my argument:

I do not recognize your right to my service.  I instead take this time to remind you of Section 1 of the Thirteenth Amendment which states:

Neither slavery nor involuntary servitude, except as a punishment for crime whereof the party shall have been duly convicted, shall exist within the United States, or any place subject to their jurisdiction.

Dramatic, no?  The Thirteenth Amendment is a perfect example of a negative right and I find it defensible as such.   If you’d like a more contemporary quote, you need go no further than Ayn Rand:

“I swear by my life, and my love of it, that I will never live for the sake of another man, nor ask another man to live for mine.”

I think that the goal of providing Universal Health Care ffor the United States is an admirable one, but I object to the justification used and the way people want to implement it.  But that’s for another post.  In the meantime, if a proponent of Universal Health Care cannot successfully address my simple argument above, then that person needs to seriously reevaluate their support of the idea and their attacks against physicians (both present and future) that object to it.

Though I am training to provide a service, that does not make me your servant.

Wikipedia has a great entry on Positive and Negative rights.

I have been silent in this space for a little while now but I have not been lazy. The end of my first two years is 10 days away and I will soon leave the Caribbean for a permanent place back home in the US. I have taken a comprehensive diagnostic test of my skills clinically and academically (both in-house) and I just returned from a trip to Grenada to finish work on a two-year project of mine. These are exciting times.

I’m incredibly proud of the work that’s now over. Coming in at 11,000 words, it’s about as long as an Atul Gawande article with about 1/11,000 of the readership.

“Welcome to Grenada, A Student’s Guide for Students” began in April of 2005 as a seven-page introduction to your new life on the island. It has since swelled to include information and advice for the first two years of island living. With our fingers crossed, we hope it eventually has information for the clinical years, interviewing for residency, and a guide to the match (with specifics for FMGs).

The editors believe in the power of honesty. If I told you that everything was perfect, would you believe anything I said? With that in mind, we hope you find our honest take on attending Saint George’s University to be helpful and that by showing you the rust you will appreciate the shine. For more on why we wrote this and our general mission statement, please read the Letter From the Editors.

And with that, I am exhausted. A lot has happened and the telling will all have to wait until I’m sipping egg nog, wearing a ridiculous sweater, and enjoying being the tannest man in the room.

Happy Holidays, topher.

Dr. Anonymous hosts Grand Rounds 3.09 this week.

He refused the joint. They were heading back from Prospect on Colin’s truck. He always sat on the edge of the bed, back curled forward so his hands could hold the frame and with his legs splayed for balance. It had rained earlier, and his plastic sandals weren’t much use to him against the metal. He kicked them off.

This was his third month with work. Yesterday he bought a wallet to hold his money since selling the last one some time ago. He felt worth something again to have so much. Colin and his brothers had started giving him lifts home since the second week. They were his new friends and this ride home was the highlight of his day. He knew its every inch.

He knew just where to lean. Past Git’s Supermarket there was a hard bend to the right with a pot hole. He would normally lean into the turn, but Colin had two beers tonight and would probably forget the dip. At the turn he leaned opposite as the wheel fell, dropping the weight of the car, and he kept his balance. Andrew didn’t know his brother as well and tumbled from his seat into the bed of the truck. He kept silent while the three others laughed. They teased him, “What matter wit you, boy? An’t you learn from d’old man? You don see him fall!” He had mastered these roads.

He knew the importance of details. Details mattered. He saw men with soiled clothes and recognized them. The lines of dirt on a man’s shirt shifted between begging and honest work, and he knew this. He saw it in his own sleeve slapping around his arm and he leaned his sholder forward against the wind, proud of the difference. Details mattered. His callouses were his proof.

He took the beer from Andrew. Colin was driving faster tonight and the smooth level spaces between bends and holes were shortening. He timed it to take a sip without knocking his teeth. He leaned to hand the beer back when Colin jerked the wheel. He had taken the last turn too quickly, too close to the center of the road, and swerved to avoid a car he should have seen.

He fell backwards. His bare feet lifted from the truck bed as he reached down for the lip. The beer still in his hand he didn’t think to drop it even as he balanced off the edge, half in and out of safety. Colin swerved back on course but into another hole. The dip and bounce of the bed sent him straight into the air. The truck kept moving forward while he hung there, still. He landed on the pavement flat on his back.

****************************

“Did you hear about the accident?”

“No, what happened?”

“There was an accident in Calliaqua, right by that road that forks off to our apartment. I don’t know if it was just the one car or if there was another car, but it looked pretty bad.”

“Did you see anything?”

“The cops had everything closed off and traffic was backed up all the way to Marco May’s. We didn’t get a look to see if anyone was hurt but the one car hit that concrete wall, you know, that serparates the soccer field? Anyway, it was right at five as we were coming to campus so we didn’t stop to ask any questions, but Jess saw it later and said that a bunch of people were sent to the hospital. She thinks someone died, but she’s not sure or anything. She says there was another car but it drove off.”

“Did anyone say how it happened?”

“Oh, you know, driving like fucking idiots with their brights on, too fast, and probably passing someone so they can hurry up and do nothing. I swear to God, I’m surprised there isn’t an accident every day with how dangerous they are. Serves them right. I can’t count the number of times I thought I was going to be hit head-on by one of those assholes trying to pass another car into oncoming traffic! Where am I supposed to go, buddy? The road’s only two cars wide! And it’s not like they give a damn, either. I’ve seen them just about run a Learner off the road before because they were driving too slow. I’m sorry, but with the way they drive they’re asking for it.”

“Yeah. Oh, did you hear about the truck we were behind the other day? The one with the boxes?”

“No.”

“So we’re in Georgetown coming back from the hospital and we turn onto the main road behind this flatbed full of boxes, and there’s only one string holding it to the frame and one guy sitting on top of them, like a hundred boxes, just bouncing up and down. So I said to everyone in the car, ‘Anyone placing bets that one of these boxes falls out?’ Everyone laughed but then a half-mile later I notice that the boxes started shifting, so I honked at the guy on the boxes and he looks at me like I’m crazy. Just then, two boxes fall off in front of our car and I don’t know what’s in them, so I slam on the brakes. The reggae bus behind me has been riding my bumper so he swerves into traffic to avoid hitting me. He burns the rubber on his tires and the truck in front of us stops. So we passed him and the guy in the back and the guy driving don’t say sorry or anything. The guy on the boxes shrugs his shoulders and the guy driving looks at us like we caused the fucking accident! Can you believe that?”

“Fucking idiots.”

****************************

“What hospital rotation do you have today?”

“Pathology, it’s our last one.”

“Oh, I heard somebody died last night in a car accident. I think they autopsy those people. Maybe you’ll get to do it.”

“Hope so. I’ll let you know when we get back.” I grab the keys off the doorway nail. Since our last exams, St. Vincent has looked so beautiful. Everyday has been bright blues and greens with orange at night and it has taken me longer and longer to leave our house on the hill. No one had our view. I walk to the car slowly, staring at all the ships, annoying my roommates who are sweating already. It’s so hot here.

We drive down the hill, riding the brakes. Any faster, any momentum at all, and the brakes won’t catch again. We have to always inch, slowly grinding away the brakes that already fail us. The longest sight line is less than 60 yards and most are less than 40. Coming down to the main road on rises, dips, lefts and rights with the honk of my horn the only thing saving my life, traveling ahead of me as a warning, has become mundane. The roads are all so narrow, maybe the width of two cars plus a foot, and it has made us experts at depth perception. We know down to the inch what width of our tire we can hang into the gutters. We don’t think twice about pulling in the sideview mirrors when passing. We don’t hold our breath anymore and cringe, because there’s just no point.

The polution is terrible on the roads with every other truck belching blue smoke, burning. There are no sidewalks and pedestrains share the cramped space. Nobody flinches anymore, not even when a car clips a purse. It’s expected. In the city, close to the hospital we play a game of spotting “crazies” to keep things interesting. There’s Travelcrazy, the man that walks around with wheeled luggage, his penis out of his skivees. There’s Angrycrazy, the man that walks up to any white tourist and starts screaming about his money and where is it. There’s Dancingcrazy with his bright red shorts and single flipflop who is never far from the speaker store. And our favorite, BoyScoutcrazy, with his black boots studded with pins and his revealing green shorts. His red sash is covered with badges and authority as he stands in the streets directing traffic. As a police officer chases him away we wonder where he found such a complete uniform and we take guesses at his Eagle Scout project.

“Spreading crazy,” someone answers.

Dr. Wilson takes the five of us from his office to the Path lab. We leave the hospital, down an alley towards the back. Behind Cato Hospital is the Georgetown cemetary. It can be seen from every floor of the hospital, inspiring confidence. There’s nothing here but a shed and of course this is it. It’s small, maybe 20′ by 25′. The body is on the table. Tina says she might pass out and that we should catch her if she does. We each grab a mask and start buttoning up our white coats as his assistant unzips the body.

He’s not gentle and this always bothers people the first time. It takes a while to get used to the dead as dead. As he pushes and pulls the man free, I see his sunken cheeks and grey hair. He doesn’t have a stitch of fat on him; every muscle is obvious. His right forearm is completely broken and even I cringe as the assistant grabs his hand and wrenches the arm backwards, trying to take off his shirt. His pants and underwear join the heap on the floor.

We crowd around, looking for injuries. Besides a cut lip and a broken arm, we can’t find anything. The assistant slides a block underneath his shoulder blades, forcing his chest to jut out towards the ceiling. His head doesn’t fall back immediately, but slowly because he’s cold and his neck muscles are still contracted. It almost looks likes he’s trying to keep it up. I look around to see if anyone else saw it, but they’re all looking at Dr. Wilson. Dr. Wilson picks up his scalpel and in two quick cuts, one up and one down, splays him open. Across the room you can see each mask pulled taught between our noses and jaws. We hadn’t prepared ourselves.

****************************

Wow that was fast. I think I’m going to be sick. What is he doing? Why is he hacking away at the chest? “Now, I am looking for cracks in the ribs. As a pathologist, you have to establish cause of death. The lack of obvious external injury should have you thinking of other causes such as internal hemorrhage, asphxiation, or brain damage. I am separating the pectoralis from the chest wall and inspecting each rib to rule out lung puncture and tension pneumothorax.” We never dissected like this. Anatomy lab would have been over in two days. God, it smells. Oh no. Please don’t go to the intestines. Please stay up at the chest. “Before sawing open the rib cage, we will inspect the bowel. Here is the duodenum. I’m pulling on the first part and you can see that the remainder is retroperitoneal, so I’m going to tie this off and cut it. Now we can easily pull the intestines out be cutting through the mesentery and checking for hemorrhages.” Thank God for the A/C. “As you can see, the small intestine is quite long. Here, see this hemorrhage?”

“That wasn’t the cause of death, right?”

“No, it’s much too small. This probably happened at the time of injury but didn’t contribute to his death. You see tears like this due to shearing forces from a fall or other blunt trauma. Now look here. Can you see this inguinal hernia? His scrotum contains some small intestine and watch as I pull it free…there. This bowel is not strangulated and you can see that the scrotal skin has stretched to accept it. He likely had this hernia for some time.” I can’t believe he’s dissecting with a saw. Isn’t he afraid he’ll cut something important? “Now that we’ve freed the colon I’m just going to cut around…the…rectum…there. His entire bowel is now free.” So, he doesn’t have a rectum now. He is rectum-less. This is too much. Ugh. “Now as I cut open the baldder…” Muah ha ha ha ha! “…sometimes that happens. It’s just a little urine. Was anyone hit?”

“I was.”

“You buttoned up your coat. Smart man.” He had to have done that on purpose. There’s no way he didn’t know that was going to happen. I’m standing back here from now on. “You can see that the bladder surface is trabeculated. This happens with obstruction and increased pressure. At his age you expect prostatic hyperplasia, but we should make sure to look for signs of obstruction in his kidneys as well. See this? All you have to do is cut open the prostate and you find a little stone in his urethra. Roni, can you hand me the saw?”

“Tina, are you okay?”

“Yeah, I’m alright. Thanks for asking.”

“Dr. Wilson, the family’s here to identify the body.”

“Is a police officer here?”

“No.”

“Tell them to come back in an hour. Honestly, I told them to be here at one o’clock. It’s two-thirty. I’m so tired of waiting for people to get their act together. The families are never on time. Okay, now with the ribcage gone we have a good view of the lungs and heart.”

“He was a smoker?”

“I don’t think so. His beard isn’t stained and neither are his fingers. You see a lot of this blue mottling of the lungs because of all the polution, especially in the lungs of pedestrians. Roni, can you grab me the laddle?” Oh my God that’s a lot of blood. I can’t believe how much blood there is hiding under the lungs. His lungs look so sick. They just squish as the laddle pushes them out of the way and fills again. I think I’m going to vomit. “One liter. Now you can see as we get most of the fluid out of the way we get to the clots that have congealed and settled at the bottom. Looks like red cranberry sauce, no?” I can’t take it.

“Tina, you okay?”

“Yeah, I just need a minute.”

“One and a half liters of blood on each side. Okay, now we’ll take out the mediastinum and the foregut and, Roni, can you get started on the skull?” Breath. Stand under the A/C. Keep it together, Tina. You can do this. This can’t take much longer. Just push it out of your head. This is your last day. “Now…you can separate the pharynx and larynx…from the floor of the mouth…there…” What is that in his hand? Is that a tongue? Oh my God that’s his tongue. “…and you can run the blade against the spine as you pull…and everything comes right out!” I don’t know if that was the most amazing or horrible thing I’ve ever seen. He just pulled the man’s tongue out from his CHEST and took the heart, aorta, IVC, lungs, liver, pancreas, stomach and esophagus with it. All in one piece. Everything is backwards. That was amazing.

What is that?!

“Can everyone see this? See this here? The posterior surface of his aorta is torn horizontally and you can see the massive amount of hemorrhage around it. This was the likely cause of death.”

“That’s horrible. Would he have even known? That much blood that fast you’d think he’d immediately pass out and stop breathing. Right?”

“Maybe; maybe not. You can’t know if the tear was immediately this size or if it expanded with the hemorrhage.”

****************************

“Well that was an amazing last day! Twenty-one hospital visits with a bullet!”

“I can’t believe that guy’s organs. They were perfect. No sign of any real disease. Even his aorta was pristine. Did you see a single fatty streak?”

“Nope. And his heart was fine. His liver was fine. Other than his lungs, that guy should have lived to one hundred. I wish we had seen that sort of thing at the end of anatomy; would have been a great review.”

“I kept wishing I had gloves on. I wanted to touch his organs so bad, see what they felt like before they were pickled with formaldehyde. And when he cut the organs into sections like a loaf of bread? That was awesome! I wish I could see that again.”

“Anybody catch his name? I think I want to write this up for our last assignment and all I got was ‘eighty-four years old.’”

“Nope. Did you, Sam?”

“What’s it matter? Just make up a name. Anyone else want a root beer before we head home?”

****************************

“Stop the car COLIN STOP!” Colin slammed on the brakes and the bed pitched forward sending Andrew crashing into the back of the cabin.

“Andrew, shit you alright?” He didn’t stop to answer. The old man was lying on the ground 30 yards back, his arms laying on his chest and his chin in the air. He jumped over the side of the truck and turned running. His feet were barely making contact as he closed the gap. The old man’s eyes followed him as he slid to his knees. He could barely speak.

“What’s huh huh wrong huh huh huh can you huh breathe?” The old man couldn’t. His eyes were wide and terrified and fixed on Andrew. They were pleading with him. He tried to grab onto Andrew’s shirt but couldn’t. He needed to get closer. The muscles of his neck jutted out from the skin as he lifted his head to Andrew’s. Nothing came. His lips moved but fell short of sound. All he could do was make the shape of “help.” Andrew was terrified. The old man tried again but appeared to give up. His eyes stayed fixed, his mouth still spelled “help,” but his neck relaxed.

His head cracked against the pavement.

Andrew turned to the car. “HELP!” He tried to think. “HELP!” He couldn’t see anything wrong. He didn’t know what he could fix, what he could stop from happening or make happen. He kept looking at the old man’s eyes, asking them to move when they wouldn’t. He didn’t understand. The old man had fallen but not far. It shouldn’t be this bad. The old man never fell. He shook him.

“He’s dead!” yelled one of the men from the truck. They had all stayed behind.

“Help me!”

“Get back here, fool! He’s dead and we have to get!” The car they had swerved to miss had crashed into a wall. The doors had opened and two people had stumbled out. Across the street men were coming out from the bar to watch. They were yelling at the truck full of men and coming closer. Numb, Andrew stood up and looked the men from the bar straight in the eyes. They saw him; he knew it. He looked down at the old man. He was dead. “NOW Andrew!”

He turned away running, as fast as he had come, as fast as his legs would carry him. He jumped for the bed and the other men pulled him in. He fell onto his back and laid there. Chin in the air and arms at his sides, his chest heaving away to catch every breath, he hoped there was nothing he could have done.

This last week I received over 60 submissions for Grand Rounds and included 26. This decision came after sharing some Carl Jungian vibes with Kim at Emergiblog and receiving the blessing of Nick Genes of Blogborygmi. Kim has since received a great deal of attention for her critique of the swelling Grand Rounds. According to the comments, the idea’s a hit and things may change. Next week’s host, Dr. Anonymous, has already thrown down the gauntlet:

This may be my last time hosting Grand Rounds, and I may get a lot of flack (and all my future submissions may be rejected). But, hey, I’m the editor and I’m deciding what’s in and what’s out this week. Being included in Grand Rounds is not an entitlement; it’s not a right; it’s a privilege.

Whether you agree or disagree with me, my vision next week is to put the best medical STORIES (ie – first hand anedcotes) out there for people to read.

As a host I had plenty of resources and support but as an editor I was unsure about what I could and couldn’t ask from fellow bloggers. I’m offering this post as an example of how I approached the problem of writing letters to the authors and helped a few posts that were almost there get over the edge. Accepted, rejected or edited, I sent over 80 emails and received only one response that was not enthusiastic or understanding. From this, I have to assume that people are open to the idea of constructive criticism.

If you’re an author, please don’t be put off by this. As Susan pointed out to me, “editing is also an act of love, and also a compliment on the part of the editor who spent so much time on your work.” I couldn’t have said it better and hope it’s a sentiment that every author who’s asked for edits takes to heart.

Permission was granted from Susan and the Angry Medic to show the emails below.

Letter to an author I was not including:

Thanks [author] for your submission. I have decided to not include your post in this week’s Grand Rounds. While I applaud your mission statement, I feel that the issue of prevention as the next hurdle for the medical world has been adequately covered elsewhere. For Grand Rounds I’m looking for original literary pieces about the life of medicine, patient encounters and experiences, and educational pieces aimed at those already within medicine.

Sorry to disappoint, topher.

Susan’s post went through two edits. This was the first:

Hi Susan, and thanks for your submission. I’d like to include it but feel it needs one significant change before I do. The hook for this piece is the coming analogy and your basic structure is set-up, delivery of analogy, elaboration, and finally reflection. I think it works well. However, you spend five paragraphs in set-up and five-paragraphs on the rest and this feels unbalanced. The fifth paragraph is what I would like to change.

“My vision of the afterlife is that we all wind up together, with each other and God; if we’re delighted that everyone else is there, it’s heaven for us, but if we’re appalled at the state of the neighborhood because we’re next to those people — however we define them — then it’s hell.”

It is a long sentence and a repetition of the beginning of the fourth paragraph that begins “[s]o my idea (undoubtedly heretical) is that we all wind up in the same place, and “that how we respond to it determines whether it’s heaven or hell for us.“

As repetition, it hurts the flow of your writing and offers nothing new. Rereading the entire post and skipping this paragraph gets us to the analogy faster and keeps the writing tight. Between the two, I think that the opening sentence of the fourth paragraph is stronger and should stay while the long sentence should be deleted.

Let me know how you feel about this change. topher.

The Angry Medic’s post was originally longer. We went through a few edits as well:

Angry Medic, this is much better. It’s got grit, grizzle and the honesty of frustration that makes for good writing. I can’t pick up on all the changes you’ve made, but on the whole it’s a smoother read. If you’re still up for some editing, I have only a few suggestions for the post:

“Being a puny medical student, I might sometimes not be able to fully understand the disappointment of old hands like Dr Crippen, Shiny Happy Person or PaedsRN. Now, far be it from me to suggest that a simple first-aiding assignment can fully capture the frustrations of working in the NHS, but it sure did give me a damn good picture.”

These two sentences aren’t part of your story. Your story is about your frustrations with a different style of teaching and the contrast that’s brought to bear in a clinical (football) setting. By referencing the hulking mess of NHS out of the blue, you distract the reader who’s now wondering, “Where did this come from? What have I missed?” Your writing is strong enough without it and I think you could delete it.

“Some, having suffered the tiniest of cuts, came hobbling over screaming like they’d been disemboweled by a very cranky Cyclops and demanded that we clean them up repeatedly.”

The line about convincing them that women will still scream their names is very funny and makes your point about having to “hold the hands” of certain players. This sentence makes unnecessary fun (which makes you look bad) and prevents the paragraph from ending on a joke. I think deleting it is win-win.

“I’m not convinced it’s the best way to learn medicine, but in the end I don’t think it really matters. I’ve seen great doctors from Cambridge and great doctors from Hull. And it’s convinced me that, just like any other profession, it’s what’s on the inside that matters.”

This is a big change in tone from the rest of the writing. Your finish is the last thing they read and remember and should be powerful/funny/memorable like the rest of the post. After you talk about the compromise for the coat of arms, try to finish with something slightly more edgy. “Now I’ve seen great doctors from Cambridge and Hull, so I know that none of it really matters. All the same, I’d like a little more blood on my shield/crest” or something like this. You get the idea.

All in all I think the writing is solid and I look forward to including it. Thank you for being so receptive about my editing as you’d have been within your rights to say, ’sod off.’
See you in Grand Rounds, topher.

***

Editing with Susan and AngryMedic was a lot of fun. It might look like nit-picking or other harshness, but I really liked their stories and told them so. I wanted everyone to read and enjoy them. To make sure that it happened sometimes required clipping a sentence here or moving a thought earlier or later in the post and was no different then trimming a flower to join a bouquet.

Hello there! I am A Very Famous Historian and I welcome you to the Grand Rounds. From a field of over 60 submissions, 26 authors have been chosen to seek the Grail. It will be a dangerous journey full of peril and death may await with nasty big pointy teeth. We shall see if anyone makes it out of these woods….alive. Feel free to traipse past all quotes.

A point of disclosure: Kim has written a provocative piece about how a famous historian should edit Grand Rounds for quality and content and it has informed my every decision. I have decided to change the title to Two Bloggers, Two Voices, One Opinion. On second thought — she’s a witch and we should burn her! [everything in italics will have sound in a separate window]

Jarrad at Veritography takes a break from the living to dress like a zombie for a “Lurch” on Washington. “In an interview with heavy metal rocker Rob Zombie, I once read that when his parents asked him as a child what he wanted to be when he grew up, his answer was ‘a monster’. Now there’s a kid who really chased his dreams.” Jarrad goes on to describe “switching from George Romero shambling zombie mode to ‘28 days later’ ultra fast zombie mode in order to avoid the speeding cars.” On the Virtues of Zombies is a fantastic read. Bring out your dead!

Woman: Who are the Britons?
Arthur: Well, we all are. We are all Britons, and I am your King.
Woman: I didn’t know we had a king. I thought we were an autonomous collective.

King Arthur may have benefited from a press release of some sort, but this week I’m learning that even that might not cut it. Diabetes Mine writes about The Death of the The Press Release as a tool for social (blog) marketing. Giants of the Blogosphere should take notice: the stiff, wordy offerings of old will have to go. But how should we replace them? Help Amy decide in the comments section.

Arthur: Look, you stupid bastard. You’ve got no arms left.
Black Knight: Yes I have.
Arthur: Look!
Black Knight: (looks at stumps) Just a flesh wound.

Imagine the Black Knight presenting at your hospital. Kal at Trauma Queen has no problem spotting a liar in Not As Green As the Uniform. For those of you that didn’t already know that “[b]lood smear occurs when an object contacts a body part that is already bleeding,” this post can be redeemed for CME credit. Further, the Black Knight is in for more trouble if he isn’t honest about his injuries. In the Incantations, InsureBlog relates a story of a man named “Monty” who gets caught between coverage without disclosing a procedure he had in the interim. Unfortunate stuff. For more help spotting a liar, Psychic Health has a post close to my heart. Watch out for the m00se.

I’m not entirely sure how to treat a man without any limbs (or what the Medical Coding would be) which means I’m turning to Dr. Google. This week, an article from the BMJ showed that within the first 30 results, Google catches a difficult diagnosis 58% of the time. Am I out of a job? Dr. Charles goes through the paper and runs the experiment himself revealing the limitations. Thanks, Dr. Charles, for reminding me that the study helped clinicians find the diagnosis which means (for the time being) I should keep studying. The story isn’t over, however, as Ves from Clinical Cases and Images writes that clinicians may be able to hand pick the information that Google returns for their own patients. And there was much rejoicing.

Father: Other kings said I was daft to build a castle on a swamp, but I built it all the same, just to show ‘em. It sank in the swamp. So, I built a second one. That sank into the swamp. So I built a third one. That burned down, fell over, then sank into the swamp. But the fourth one… stayed up! And that’s what you’re gonna get, lad: the strongest castle in these islands.

I still believe that we can rebuild the cities hit by Hurricane Katrina to be the strongest in the land, but the pace is causing problems. Dr. Herbert writes this week in How Slow Can You Go that of the $7.5 billion in grants allotted to help build private homes, 18 requests have been approved. Jon Schnaars writes that just because they are ignored, Katrina’s Mental Health Woes Will Not Disappear. We are inviting a public and private health catastrophe when temporary trailer homes spend five months waiting for delivery and the acute problems of “depression, anxiety disorders, stress disorders, [and] addiction” are allowed to become chronic.

[And out of the blue an arrow strikes Concorde in the chest.]

Lancelot: Brave, brave Concorde, you shall not have died in vain!
Concorde: Uh, I’m — I’m not quite dead, sir.
Lancelot: Well, you shall not have been mortally wounded in vain!
Concorde: I- I- I think I cou- I could pull through, sir.
Lancelot: Oh, I see.

Time to call a MEDIC! The Angry Medic of Cambridge isn’t seeing as much gore as he’d like from his textbook prison and decides to take his education to the pitch where he receives a ball to the face, dips blood into his antiseptic and consoles the players that a large bandage will not effect “the number of female spectators yelling their names from the sidelines.” You could say he Comes of Age. I can identify with the itch to begin but Karen Little has set me straight. With 20/20 hindsight, she offers a painfully funny glimpse of our collective future in her Years as a Medical Student two-parter. The pictures alone are worth your visit.

It’s the time of year where several people are changing roles and interviewing for their lives. BadDoctor recounts an Interview With Wolves straight from the vault of medschool myths. “I probably would have been better off telling him that Perry Mason was a filthy commie…[h]e looked at me as if he would rather see me in his headlights than in his clinic as a student.” It ends well.

Of course, there are other important interviews to be had. Nurse Ratched-Zoot writes about the successful dating strategies of doctors and suggests that all psychiatrists start off by claiming to be undertakers, since this is initially preferable to your date being “more afraid of [you] getting inside their head than inside their pants.”

With all of the forward-looking, its important to remember why we’re doing any of this. This week, Doctor Anonymous writes a great story about counseling a difficult patient to undergo a stress test that may have saved his life. The Dinosaur counters with Sigh, Just…Sigh , a story about a patient that “…is not a clinical puzzle. This is something between somatization and hypochondriasis.” Her visit length is inverse to need. Hilarity ensues.

Knights of Ni: Ni! Ni!Ni! Ni! Ni!
Arthur: Who are you?
Head Knight: We are the Knights Who Say … “Ni”!
Random background Knights: Ni! Ni!Ni! Ni! Ni!
Arthur: No! Not the Knights Who Say Ni!
Head Knight: The same!

The Knights Who Say Ni are arguably the most bizarre part of this movie (no small task) and I’ve always wondered, “What would a clinician do with them?” Certainly we could chastise them for spraying their germs with each careless “Ni!” We could sit them down and make them watch a very funny video at BreathSpa outlining the correct sneezing/coughing etiquette (I think this video could prevent The Plague if people didn’t spread so many germs laughing at it). Or we might suspect something more serious. The Tundra PA recounts her experience with an epidemic of Whooping Cough that hit Southwest Alaska a short while ago in her post, The Hundred Day Cough. Of course it was handled expertly.

God: GET ON WITH IT!

Thanks to Sid Schwab, I’m reminded that medicine is moving forward. He writes this week in You Tube, I Tube, We Tube about his experience as a medical student placing NG tubes into his classmates. Sympathetic gagging ensues while we learn that many patients undergoing abdominal surgery are now spared this invasion. MyLifeMyPace writes about a different invasion: the miserable mores of Grey’s Anatomy tainting the pool of hopeful physicians. I actually stopped watching the show because of the example she cites in So Why Do You Want To Be a Doctor?

Monk: And Saint Attila raised the hand grenade up on high, saying, ‘O Lord, bless this thy hand grenade that with it thou mayest blow thine enemies to tiny bits, in thy mercy.’ And the Lord did grin, and the people did feast upon the lambs and sloths and carp and anchovies and orangutans and breakfast cereals and fruit bats…

Should the Holy Hand Grenade blow you to bits, you could do worse than to go to Susan Palwick’s version of Heaven. She’s a volunteer ED Chaplain that sees more than a few parallels between the afterlife and triage.

While all of this has been very silly, there are adventures that bring more than a bit of peril. Paul Auerbach writes in Pilgrims at High Altitude about the “silent” deaths of pilgrims attempting religious ascents but succumbing to mountain sickness. Several good links are included. Borneo Breezes has a great post about aid to Aboriginal children and that our good intentions may not always be appropriate. “Ivan Illich said, ‘Don’t come to change us or help us. Come because you are getting something out of it. Take pictures of our wild flowers, study the animals, climb the mountains if you like, but leave us alone. We want to make our own mistakes.’ ” His pictures tell half the story in How Children Play.

…And now for something completely different.

Every once in a while, Dr. Crippen of the NHS will throw his weight behind an excellent site. I am indebted to him for introducing me to Karen Little at Just Up The Dose (showcased today) and to Abby Lee at Girl With a One Track Mind. This week he writes about the NHS’ standardization of care and lack of appropriate resources for victims of sexual abuse. At the end, he recommends the site Survivors Can Thrive. “Dr Crippen strongly recommends [her sites] but, be warned, they are not comfortable reading.” I agree. In the same vein Nancy Brown writes about an alarming ruling that “consensual sex cannot become rape.” I ask you to read these articles and see if you agree.

Finally, Julie over at Medscape has written a piece about her fight with cancer that is so amazing and moving that I find myself rereading it. Her post is a shining example of how a well-written message bores deeper and deeper into the reader. I have saved her for last to spare anyone from trying to follow — it’s that good.

And so we end. The Holy Grail is a solid Grand Rounds read in a single sitting. I hope we found it and I invite all comments from the readers and authors alike. And with that I have been sacked. Join us next week as Dr. Anonymous hosts Grand Rounds 3.09.

Cheers, A Very Famous Historian.

Heading into the weekend I have received 10 submissions for this week’s Grand Rounds, leading me to believe that the medical writers have all suffered heart attacks. Not to worry; this may advance the plot.

Nicholas Genes has the PreRounds interview posted where I answer the following questions:

1. After reading your blog, the non-US med school track is looking better all the time. You are pretty honest about not doing great in college, but you also come across as a thoughtful writer and student, an intelligent observer, and thus, probably a good medical student and future physician. Any regrets about this path so far?
2. Do you anticipate future prejudice from doctors who graduated from American schools? Back when applying, we heard some negative comments about the Caribbean; are those rumors true?
3. Your blog started out like a collection of letters home, before turning out gems like Anne and Cracked Lips. How did you get your start, and why did your writing change?

The deadline for carefully considered entries is Sunday at 11:59:59pm. Please send submissions to rumorsweretrue@gmail.com.