How to Prepare for the USMLE: Know Your Enemy

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.

Things to Come

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 Problems with the Business of Medicine

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.

Saved by Own Surgical Procedure

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.

My Best Writing

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.

The Mathematics of Packing

**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?

The Joys of Research

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.

Another Milestone in the Marathon

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.

Reason to go to Medical School: AIDS in Africa

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.

Recommended Links 01

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