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.

Return to First Aid Errors page.

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.

Return to First Aid Errors page.

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.

Cherry Picks (3.20.2007)

March 20, 2007

thieme.jpgImagine 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.

My Hero, one of the most powerful stories I’ve read in a long time.

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.

There’s really no way to set this up without blowing the joke, so I’ll just Cue Jeopardy Music.

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

A while ago I read an amazing article on trash and recycling and discovered that what we all think we know can be bogus. I like to keep an open mind to things when I don’t know what I’m talking about, and so it is with global warming. After watching The Great Global Warming Swindle (available here through Google Video), I think what most of us think we know is hogwash. Really stretches the mind.

Blackwhite. I do love the Panda Bear’s rants.

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.


March 20, 2007

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.”

post coitus

March 15, 2007

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.

The Unexpected Suck of the Last Week

March 11, 2007

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.