Cherry Picks (3.27.07)

March 31, 2007

Once in a while, I read something that reminds me of what I’ve forgotten. Ava Dear is two posts in, cataloging a journey beginning at the first decision to leave an old life for medicine. If the rest of the writing is this good, then we are all in for a treat. Of Nodes and C Underscore.

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.

Then there is the feeling when you read someone that is making the same arguments that you are making to the same audience, but he’s just doing it better then you ever did. This is my experience reading Medical Economics by MiamiMed.

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.

I thought he had dropped off the face of the earth, but the Mexico Medical Student is back and blogging with the best post from last week’s Grand Rounds. 5/4 is so well put together, it makes me feel lazy.

More great ranting by the PandaBear MD.

  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?

I may be lucky enough to interview for transfer come June and July. This article sums up nicely the mistakes that I routinely make should avoid.

Another great post from Signout. Need to be seen.

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.”

A Farrago of Gallimaufries just returned from Spain with pictures and humor. I noticed a bit ago that the number of amateur photographers in medical school seems higher than in other groups. I hope to join the ranks of Farrago and Graham Azon on my current trip.

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.


See you in 6 weeks!

March 27, 2007

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!


Prepare for the Boards in Six Weeks

March 27, 2007

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…


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 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.


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 20th, 2007 – June 30th.


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.


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.



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.


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.

Why are they separate?

March 25, 2007

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?


Errors in First Aid for the USMLE (2007): Microbiology

March 24, 2007

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.


  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 2nd generation cephalosporins cefotetan and cefamandole. I think it’s worth changing to “(in 2nd 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

Errors in First Aid for the USMLE (2007): Miscellaneous

March 23, 2007

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:


  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, 18th, 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.

Errors in First Aid for the USMLE (2007): Reproductive

March 21, 2007

As always, comments are welcome


  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”

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Errors in First Aid for the USMLE (2007): Psychiatry

March 21, 2007

As always, comments are welcome


  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.

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Errors in First Aid for the USMLE (2007): Heme/Onc

March 21, 2007

As always, comments are welcome.

  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.

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Applications Away!

March 21, 2007

applications.jpgIt’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.