PocketMod on the Wards

The PocketMod is a great way to stay organized while you're running around on the wards. It turns a piece of paper into a mini booklet that you can use to write down patient data. I use it to scribble down the Vital signs and daily information I need when I'm rounding on my patients in the morning. It's also good for writing key notes for the wards.

I have three or four different PocketMod booklets in my white coat right now:
1) Tips for the Wards (with sample admits, checklists)
2) Tips for OB/GYN (with the key parts of the SOAP for post-partum and post-op patients)
3-4) Patient logs (tracking data for the patients I've picked up that day.
* the first page always has the current date in the corner, the room # of my patients, their date of admission and other relevant quick tidbits
* each subsequent page has their patient care summary, Friedman's curve progress, daily vital signs, I/Os, H/H, Rh/Rub/GBS status, etc.

Since I've just finished with OB/GYN inpatient and I'm moving onto Psych, I'm in the process of making a new PocketMod with specific psych info. Since my Psych handbook is online, I'm toying with the idea of doing an e-version and posting it online as a sample.

Gamers ought to do SomethingWorthwhile

So I have a lot of friends who are gamers. They play games in their free time (which they have in abundance, much to my dismay) as a way to... avoid boredom, I suppose. Entertainment is an important "virtue" in today's commercialism-driven society.

Some of them play World of Warcraft. It's a role-playing game where you play a fantasy character like an elf, orc or minotaur and you run around and kill things, take their loot, get powerful gear and new nifty skills. It might sound like I'm disparaging this game, but I really like these sorts of games. I play D&D a lot. It operates on the same principles and I've often converted action sequences in movies directly into game terms.

Take the latest Indiana Jones movie for example. There's an action sequence where Indiana Jones hears a countdown after visiting a surreal little town only realize that he's in the epicenter of an atomic bomb test... and he has less than a minute to find a place to go. Hurriedly, he rushes around the house, jumps inside a lead-lined refridgerator and gets blasted like a piece of shrapnel away from the explosion. The fridge tumbles on the ground and he falls out. Climbing the hill, a huge mushroom cloud blooms up, silouetting him in the desert landscape. I was very excited by this totally impossible scene, because it makes total sense from a gaming perspective. If you throw a character into a deadly scenario, there's always a way out. Since he's a lucky sort of fellow, he made a reflex saving throw and he's got evasion so he took practically NO damage from this explosion!!!!!

Anyway, what I'm trying to say is that RPGs are a way of sharing structured dreams/fantasies/stories with your friends, be it on TV, your computer or in the theater. SecondLife has found some surprising ways of being useful in Real Life:
People can have virtual conferences with each other.
Crippled patients can experience walking and enjoy easy mobility.
People can exercise as they traverse a virtual world.
People with anxiety disorders and social phobias can interact with others in a safe environment.

-------

I know some people who like to play Pokemon. They know a bunch of random information about the statistics of Jigglypuff or Jujubee or whatever cutesy names are in the game. Each monster has a set of abilities that allow it to fight effectively against a certain foe. There are magazines dedicated to the constant updates to the card game that outline the latest strategies! People pay money to memorize random useless facts about imaginary foes battling each other?!?!?

Shoot, if people spent even a fraction of this effort learning something remotely useful during their entertainment, they'd be set! I propose that Microorganisms be introduced to the world of Pokemon. Instead of Pikachu, kids could learn about the Influenza virus and it's ability to have genetic drift and genetic shift-- requiring new flu shots every year and terrifying people with the possibility of a deadly new epidemic. Then they'd be learning about REAL monsters.

----------

People sit around and play Solitaire or Minesweeper on their computers all day at work. Why not do something constructive with your mindless puzzle gaming?

Researchers at the University of Washington came up with the idea of combining protein folding scoring and gaming... and put together a puzzle game called FoldIt!

Medgadget shares a little story about the genesis of FoldIt:

Predicting the shapes that natural proteins will take is one of the preeminent
challenges in biology, and modeling even a small protein requires making
trillions of calculations. Over the last three years, volunteers around the
globe — now numbering about 200,000— have donated their computer down-time to
performing those calculations in a distributed network called Rosetta@home.... With the inherent fun of
competition, Salesin thought a multiplayer online game was the way to go.... One
match between teams from the University of California and the University of
Illinois aroused unexpected fervor and cheering among spectators. “30 or 40
people participated,” says Baker. “The competition was very
intense.”
“Foldit” takes players through a series of practice levels designed
to teach the basics of protein folding, before turning them loose on real
proteins from nature. “Our main goal was to make sure that anyone could do it,
even if they didn't know what biochemistry or protein folding was,” says
Popovic. At the moment, the game only uses proteins whose three-dimensional
structures have been solved by researchers. But, says Popovic, “soon we'll be
introducing puzzles for which we don't know the solution.”

Is there a best pre-med school?

HalfMD responds to a reader's question:
Is there a best pre-med school?

Abstract: No! Your academic dedication (GPA, Letters of Rec), your ability to perform (MCAT), your compassion (volunteering), and your familiarity with the health field (shadowing, personal statement) strengthen your application.

However, you might want to consider one of the "Big Five" if you need someone to hold your hand for the application process (the reader's parent submitted the question....)

1. University of California at Los Angeles
2. University of California at Berkeley
3. University of Texas at Austin
4. University of Michigan at Ann Arbor
5. University of Florida

I mean no offense by that, by the way. I was completely clueless about what it took to apply for medical school and quite honestly, my first application was a complete BOMB even though I had enough of the right stuff. It would have been really nice to have a pre-med advisor. The closest thing we had was the Pre-Med Association... but really... would you expect your fellow classmates (i.e. your "competitors") to give you the best advice and review your application? That's why I'm really thankful that I had the support of a more objective and reliable group: the Medical Student Mentorship Program.

5 Tips for your Big Day

The First Aid team offers 5 tips for your "Judgment Day:"

1. Double-check your paperwork.
2. Leave your gizmos behind.
3. Bundle up.
4. Show up early.
5. Chill out!

It's a great list... especially #1! You'll have so much on your mind that it would be a shame to push your test date back because you forgot a picture ID and your confirmation code.

Test taking strategies

There's a few basic strategies when approaching questions. This works for any sort of multiple choice examination, but your results will vary. I suggest swiftly adopting one that works for you. If you run into a question where it doesn't work (and you will!) then slow down, reread the question and use a different strategy.

I've become fond of a few methods as I studied for the USMLE Step 1. I'd recommend using them in the following order:

1. Stop. Think. Predict.
2. Question-directed searching.
3. Answer-directed searching.

Stop. Think. Predict. Start at the beginning and highlight the important clues/buzzwords. Blot out the negatives. Think about the diagnosis (and some of the evident treatments.) Predict what the question will be and what the answer is. If you anticipate the right answer and it's there, BOOM! You're done. You should still review the other answers just to make sure that there isn't anything better. I love this strategy because it MAKES YOU THINK. It's exactly what you'll be doing for the rest of your life as a doctor... might as well get used to it!

Question-directed searching. This strategy is the preferred method by Drs. Walker (Tips for Taking the USMLE) and Dimov (How to Do Well on Boards). Basically, read the question first and look for clues to help guide you. This spares you the frustration of a "bait and switch" question where you read a long stem only to discover that the question is asking you about a basic science topic that's minimally relevant to the stem. I've never ran into this particular scenario myself, so I prefer to read something the way I read a novel -- skipping to the end cheats you out of the pleasure of figuring things out.

Answer-directed searching. Sometimes, you have no idea what the question is asking. Sometimes you have no idea how to guess what the answer is. I've learned a little lesson from Sesame Street. It's called "One of these things is not like the others." :) This proves that ignorance is bliss. Sometimes you can get the right answer even if you totally ignore the question and just look at the answers, isolating the one answer that's different from the others! It might be a drug from a different class than the others or a diagnosis that accounts for that one weird physical finding noted in the stem.

If you've got any other ideas, let me know. I can't think of any other ways to read a question and answers other than top-> bottom, bottom->top->bottom or just bottom...

Cognition for the USMLE Step 1

I scribbled down a few notes when first thought of this blog entry. The thinking process for the USMLE Step 1 is interesting... and the more I realized what I was thinking about (meta-cognition), the more I learned from the process of learning. It was very strange. It's been about two months since I took the exam itself. My sharp dedication to this topic is rapidly fading since I started my third year orientation today. However, I also feel a sense of urgency to at least address this topic before I ponder my clinical years on this oft-ignored-blog-of-mine (but I'd like to do better!)

In regards to the USMLE Thinking Process, consider the 4 R's:

1. Recognition/Resonance
2. Recall
3. Reword/Restate
4. Reconnect

Recognition/Resonance refers to the first part of the question stem. When you're reading, a feeling will come up. Obvious clues related to risk factors (female, fat, forties, fertile for acute cholecystitis, for example) will act as triggers. However, you should watch out -- in real clinical practice, the heuristic of stereotyping may be misleading! Stereotyping in the USMLE is surprisingly effective... and amusing.

Once you've read through the stem, you ought to Recall some basic facts about the problem at hand. This is a great exercise during your tutorial sessions as you go through questions in USMLE World... it will eat up too much of your time if you systematically quiz yourself during a timed exam. Here are some example questions: What are some causes of acute cholecystitis? (Blocked duct by a stone, either pigment or cholesterol.) Why are pregnant women more likely to develop cholesterol stones? (Answer: estrogen increases the cholesterol in the gallbladder-->hypersaturation and progesterone decreases GI motility-->stasis in gallbladder)

Next, read the question. Sometimes, it won't make sense. Restate the question, in the context of the clues given in the stem. A lot of times, certain words will be disguised and you'll have to take the extra mental effort of rephrasing them so you'll readily recognize them. Example: During the physical examination, tenderness is elicited in the upper right hand quadrant of the abdomen. Convert this long sentence to the eponym "Murphy's sign" and voila! You've created a mental shortcut.

Restating the question and the stem in your own words often helps you Reconnect with the question-writer's intent, if you didn't recognize it right away. Sometimes questions will give you a "Bait-and-Switch" and ask you about something slightly different. Sometimes it will be so painfully obvious what the answer really is that you'll wonder 'is it really this easy?!?' I felt that way on the NBME and the USMLE enough times that I felt comfortable responding with a 'Yep!' Rarely, the USMLE will disguise the question and the answer choices to such an extent that you have to rephrase everything. However, USMLE World does an excellent job disguising questions that they are all imbued with high-yield topics. They are worthwhile branches to consider even if the answer is obvious.

Take the time to figure out why every other answer is WRONG! That's more important than knowing the right answer as you study. That's not my second opinion!

Top Ten Tips for Step 1

I've been busy having a lot of fun this summer break (i.e. going scuba diving, getting a girlfriend and suffering the repercussions) so I'm sorry to all my readers out there. In lieu of a more original post, here's the list of tips I sent out to my friends when I was asked for advice about Step 1.... most of it I've said before.

1) Use USMLE World and mark the challenging questions.
2) Go through other question banks Kaplan, USMLE Rx, etc.
3) Revisit the questions you got wrong in World in random blocks and keep at it! Themes for your weaknesses start to emerge, so rehearse this material in the way that suits you best -- for me, it was silly drawings and mnemonics that I scribbled into First Aid.
4) Make First Aid your bedtime reading material. Imagine the question stems related to each subject and some of the tricky answers that typically throw you off.
5) Three weeks before, go to Prometric and take the practice. These questions are representative of Step 1 (albeit 150 questions shorter than the real thing.)
6) Two weeks before, take another self-assessment. I used USMLE World's Self-Assessment ($25, 200Qs) because it gives you the World-class explanations.
7) A week before, take NBME self-assessments to your heart's content. I'd highly recommend doing 350 questions in a day at least once.... I didn't and I found myself wishing I had more "test-stamina" as I had a series of mini absence-seizures by block 6.
8) Keep reviewing your weaker subjects in First Aid!
9) Relax the day before your exam. No matter what you think, you won't learn anything new the day before.
10) I did a quick 25 random Q block before I biked to Prometric on my final day. This warmed up my brain before the grueling 350 question exam.
11) Write down the number of blocks you have (7) on the corner of your blue laminated sheet from Prometric and knock it off as it passes. I lost track and I convinced myself that block 6 was my last one so I missed out on some vital break time.

Sorry, that list turned out longer than I expected.

Some observations I had on the real thing -- there were less calculations and more behavioral sci scenarios than I expected. Common subjects tend to cluster by block (I had literally half a dozen questions on hepatic encephalopathy in block 6 and 7!) The micro was easier than Kaplan's. Review a lot of CTs for your anatomy points. I'd estimate that the questions are 70% like NBME, 30% like USMLE World (in the thinking sense, not the obscurity sense.) Hm... there's a lot more, but the information is draining out of my head as we speak (or more accurately, as I write.)

JABSOM is not Pharm-Free

AMSA PharmFree Scorecard 2008 ranks 150 medical schools on their pharmaceutical rep policies. Only 7 schools received an A while 60 received a failing grade.

JABSOM was the first F.... shame on you, JABSOM! We failed to provide any policy whatsoever on this matter. Comments below:

University of Hawai’i John A Burns School of Medicine has implied that it is not a clinical facility and therefore it is not necessary to create policies in many of the domains on which it was assessed. It should be noted that other schools and colleges of medicine, which are not clinical facilities themselves, have created policies on conflicts of interest that apply to many of the domains assessed.

I've done s presentation about drug reps with my classmates and one of the lecturers in our EBM course expounded on the influence of drug companies in academic medicine. These are just small measures on the part of individuals though and easily tuned out as "just another boring lecture" by students.

AAMC and AMSA are pressuring schools to become more proactive in reducing financial conflicts of interest and lead by example for future doctors. This means banning all gifts and free drug lunches at University events. It means refusing industry support for CME. It means keeping our hands clean and doing our business.

There are some doctors who think that this is impractical. They think that they are immune to influence by pretty women with convincing papers on their latest drug. They think that CME will die without hefty financial support by pharmaceutical companies.

I'm not that naive.

• I know I'm easily impressionable... that's why I do my best to surround myself with good examples.
• In the long run, free samples aren't cheaper if the fancy new designer drug is 10x as expensive and just as effective as a generic drug.
• I don't fret about CME... just checking my blogroll every day is a hefty dose of up-to-date medical education.

"Bodies" exhibition in Hawaii

It's a little strange, but "Bodies... the exhibition" will be at Ala Moana Shopping Center come June 14th. A mall? Really? I guess it's a more accessible venue than a museum. I didn't get the chance to go when it was in Philly a few years ago, so I'm excited!

I'm planning on going. Feel free to come with! Cameras aren't allowed, so no pics. sorry :(

Of note: the Bodies website has a distressing disclaimer.

-This exhibit displays full body cadavers as well as human body parts, organs, fetuses and embryos that come from cadavers of Chinese citizens or residents... Premier relies solely on the representations of its Chinese partners and cannot independently verify that they do not belong to persons executed while incarcerated in Chinese prisons.

Whoa!

Put your cell phone on the dash

Last night, I called my dad to make plans for tomorrow evening. As I chatted with him, some construction workers on the side of the road shouted at me. I didn't realize why until I had finished my call and pulled up behind another vehicle.

Crap. My headlights were off!

Recent studies found that drivers (such as myself) are distracted when they are on the phone while driving. This level of distraction can be equivalent to drunk driving! There's MADD... pretty soon there'll be MACC (Mothers Against Cell Calls.)

Yet, people consider it an "efficient" use of their time when they multitask while driving.

So what can be done to ameliorate this situation?

Devoting 100% of your attention to your road is the best way, of course.

Barring that, NY Times has this tip by Amit Almor, an associate professor of psychology at University of South Carolina:

The volunteers did much better on their visual tasks when they were just
listening, as opposed to preparing to speak or speaking. When they were
listening, if the demands on their brains became too much, they could just tune
out what they were hearing.
...
It may be, the study said, that when people talk to someone
who is not present, the visual-processing parts of their brain create a mental
representation of where the other person might be. This suggests, Dr. Almor
said, that using cellphones may be safer if the sound comes from the front.

A spoonful of Obecalp

At first, it started off as a joke. I mean, it's easy to ask the question. In a clinical trial, if a placebo actually improves a patient's health almost as much as a regular drug, shouldn't we be selling placebo pills? It's certainly a funnier (and more marketable) idea than ditching the drug undergoing clinical trials... especially after the drug company forked over $100 million for research and development up until that point.

Graham at OverMyMedBody! brought the idea of Obecalp to the blogging scene earlier this year.

45% of doctors who responded to a survey said they’ve given placebos to
patients. That number certainly seems high, but sometimes patients don’t
want to hear what you’re saying–namely, that no drug will help them. ...
I’ve certainly wanted to write for “Obecalp 1 tab PO BID” (’placebo’
backwards) but I find it totally unethical and undermining of the doctor-patient trusting relationship. (emphasis mine.)

So now what?

According to the NY Times, Obecalp will now be for sale as a dietary supplement. The example cited? A child with "a nagging case of hypochondria." I'm not sure how I feel about this.

Would you have to deceive Obecalp recipients in order for it to be "effectual?" I mean, I up my Vitamin C content and drink chicken long rice soup (with lots of ginger) whenever I get sick... that's placebo and I know it! Regardless, I feel better knowing that I did something.

Why limit the marketing to harried adults with whiny kids? This drug will fit in perfectly alongside Airborne and herbal remedies. In many ways, I'd prefer something that tells you up front: "I'm completely useless!"

via The Happy Hospitalist: Ma! Ma! I Need Another Fix

image by Djenan (creative commons license)

MD Hacks (no, not that)

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Question Banks

The most important prep tool to help you with your studying for Step 1 is a good question bank. Initially, it's hard to tell what makes one question bank difficult and obscure and another, representative to the real USMLE yet challenging (read: high yield enough that you will get those 10% off-the-wall questions correct.) That's why you need to do multiple question banks! They used to come in book forms... I acquired a set of these question books from an upperclassman and then I promptly ditched them. The USMLE question and answer format has evolved over the years and your question bank should follow suit.

Here's my breakdown of the different Qbanks.

--------------------

USMLE World
By far, my favorite qbank. I call it Qworld.

• It has "world-class" explanations in their tutorial answer choices, making it an extremely good study source.
  To be honest, when I started studying for a new subject, I'd read for half a day and then just sit down and do Qworld in the tutor style. That was all the studying I needed for some subjects! No need to go back to the same old review books and fall asleep reading them if you know enough of it already. It's much better to engage yourself with active learning.
  Just take the time to read all of the answers and take notes directly in First Aid of the material you don't know. I used a fine-point sharpie so these points jump out more.
• The FRED software format seen on the real NBME is very similar to the Qworld's.
• The highlighting/greying out function is excellent! Get in the habit of using it as you read through the question. I noticed that when I faded out in blocks 5 and 6, I could still answer the questions because I reflexively highlighted the important facts.
• You can "mark" questions along the way and test yourself on this material.
• The Review tab shows your previous tests by Subject matter and Subtopic and Specific topic!
  i.e. Embryology: Cardiology: Tetralogy of Fallot
• You can also opt to review just the questions you marked, the ones you omitted, the ones you got incorrect or the ones you got correct.
  This makes it very helpful for mentally reciting the correct answers in your head during your second and third review-recall sessions.
• The only down-side (if it could really be called that) is that there is no way to electronically copy the material. You can't hit "print-screen" or "copy/paste" the text into a picture or document format, for copyright protection purposes.
  If USMLE World provided its tutorial explanations and pictures in a book format, it would surpass Kaplan by far!

USMLE Rx
By the makers of First Aid!

• Unfortunately, I don't know much about their question bank.
• It's the cheapest of all the pay-per-month Qbanks! I was surprised to learn that. I thought Qworld was the cheapest.
• I was advised to buy Kaplan and USMLE World since I had the softcover book version of First Aid Q&A. I did a few sections of the book and it was decent.
• Q&A is broken down into subsections (identical to the Subjects in First Aid) with about 25-50 questions per section. Then there are a series of random 50-block questions, for a total of 4 or 5 test blocks.
• My only regret in taking the exam earlier than my classmates was that I didn't have the time to devote to this test booklet or try out USMLE Rx.
• If you've used it, let me know in the comment section what you thought about it. :)

Kaplan QBank
This one is interesting. A representative flew in from the mainland to tell us all about the USMLE. I went for the pizza and soda. There's several programs you can sign up for with incremental costs: Qbank, IV QBank, books, lectures, whatever.

• The books are worthwhile if you don't have any other study material for the subject. I started off using them and soon drifted away as I had a whole set of High-Yields/BRS books to read alongside lecture notes, which sufficed.
• The lecture series are good if you do them EARLY. Do not wait until your final few weeks to listen to them! I highly recommend the Behavioral Science lectures (the guy is entertaining and memorable) and the Pharmacology lectures.
• The IV stuff is a waste of time, according to my friends.
• The only thing you really, absolutely need is QBank. And even there, you run into a few snags.
  Kaplan's Qbank is esoteric at times. It doesn't give you the full stem so you have to rely on the one-fact, one-answer style of recall (IMHO, this is a waste of time!)
  The software is horrible. There is a lot of lag shifting between questions. Sometimes the graphics don't load. The highlighting rarely works, I have to double click or highlight backwards half the time. And then it gets erased or random portions of the answers are highlighted. Oh and most importantly -- you cannot highlight the answers! How are you supposed to review like that?
• That said, Qbank isn't bad. However, it's not the best. I preferred Qworld because I could see the specific topic of the questions I got wrong when I reviewed (Kaplan just shows the topic header) and it's faster and more reliable.

Wiki Test Prep
The up and coming contender in the question bank world. There are a few gems here -- namely, it's free and you can find out what your score is after each test you take.

• Since it's a wiki, you have to be somewhat cautious and you shouldn't take the answers (sometimes, even the question) at face value.
• I'd say the best exercise comes from reading "Tips on Question Writing" and "See Question Template" (under the Question Body subheading.)
  Learn how question stems branch off of basic scenarios into variant physical exam and lab findings.
  Be capable of predicting at least one prompt question in each subject.
  Predict what answers will be provided alongside the real answer: similar names to confuse you? similar etiology? perhaps its the right answer except for that one (or two, or three) lab findings that don't seem to fit?
• Submit questions! I'm planning on doing that next week as I fire up SuperMemo for my computer and flip through First Aid to recall the questions (and style, mostly) I had on the USMLE Step 1.

Well, hopefully that helps. :)

I'll talk more about mental question formation, subject review and methods for recall in upcoming posts. Stay tuned!

Aimless?

The whole reason why I took my USMLE early was to go on a family vacation. My brother graduated from college and he was moving to Boston to pursue a Ph.D in Aeronautical Engineering (so in some ways, it was a "last chance" at a family trip before he got even farther away from Hawaii.) His girlfriend's family organized most of it and we spent the majority of our time at a few national parks: the Grand Canyon, Glen Canyon/Lake Powell and Bryce Canyon. There were a lot of breathtaking vistas, splendid hiking trails, interesting wildlife and great family-family bonding moments.

Now that I've settled in back at home in Hawaii and I still have another month before school starts up again, I find myself almost at a loss for what to do next.

Perhaps I'm not quite capturing the feeling exactly, as there's a lot of things that I want to do. I want to go SCUBA diving, take guitar lessons, learn how to read facial expressions and tell stories, do some ballroom/salsa/tango/swing dancing, relax at the beach, bike, hike and play frisbee more.

Why do I feel aimless?
Why have I spent my third day back in Hawaii sitting around at home watching TV?
Where has my motivation gone?

My list of things to do is a list that I wrote as a "distractor" from med school and if I can be perfectly honest... a lot of it I felt would help me branch out from medicine and ground me better. I might even meet someone nice. I'd like to have an activity partner to call me up and inspire me to go out and do something on a nice and bright shiny day like today.

However, it wasn't until I did some catch-up blog reading and came across R.W.'s note on Cognitive errors in medicine that I realized -- it's hopeless for me.

There's no escaping my enthusiasm for learning about medicine. More than my list of desired hobbies, I found myself getting truly passionate again about academic medicine. It was as if I were denying a part of myself by saying "nope! no medicine for a month, you've had enough of that already" and now that it's back, I feel joy again.

Sure, I'd still like to SCUBA and strum and sing and samba.
I'll also read and blog and celebrate my learning even if my classmates catch me and call me out on it -- "You're on break! get a life!"... this is my life folks!

I feel validated. I feel passionate. I feel... relieved. I hope I can continue feeling this way for the rest of my life.

USMLE Experience

A lot has transpired these past few weeks.

I've studied very hard for and I have taken the USMLE Step 1. Contrary to popular belief, it really wasn't that difficult. When compared to the difficult subject matter and questions asked in question banks offered by Kaplan and USMLE World, the USMLE was a cake walk. Sure, there were some obscure things that I didn't know, but I figure that's always the case and I don't beat myself up over it. The real trick in the pursuing the answers in the sample question banks is finding the patterns. Learning WHAT is important -- recognizing it, predicting the answers and selecting the right one and then -- immediately moving on.

One of my classmates was thrilled about finally getting to the good stuff. "This is what the entire first two years of medical school should be like! None of this 'PBL' BS" he exclaimed to me (on multiple, multiple occasions!) By that, he meant something along the lines of: insane study schedules, insular learning (people rarely met in study groups except to 'pimp' each other on random facts, do question after question after question after question....

Yikes! I sometimes felt as though I were half-assing it. I didn't study as hard as some of my dedicated colleagues, as I would wake up around 9am, eat a leisurely breakfast and googleread my blogs, have lunch and stroll into school around 1pm and do questions until I maxed out on my daily learning (my daily max was around 150.) I spent extra time reviewing ALL of my answers, trying to decipher why each answer was selected by the writers and a possibility. Sometimes this schedule would take me to 2am. Sometimes just 7pm and I'd go have dinner with a friend. Regardless, it was a relatively "easy" life of studying, after the rigor of Unit 4 (where I routinely studied until 2am EVERY DAY for four months straight.)

There's two basic methods in approaching the Step 1.
1) Study very hard to memorize facts and vocabulary to the point of reflexive recall between two seemingingly nonsense words i.e. cough=captopril, pigeons=cryptococcus, odds ratio=case control.
2) Love medicine and learn it.

I took the second approach for the most part. Over the past two years, I've spent a lot of my free time acquiring links to different blogs and websites that inform me about medicine. I've shared my silliest mnemonics with my study groups and I've taken extra time to truly learn the learning issues from our paper cases. For a while, I studied for the boards just by reading the old cases and thinking about them. It was a helpful exercise, especially on the physiology heavy subjects like cardiology, pulmonology and nephrology.

I found that I didn't have to learn very much new material during my studying for the boards. Most of it I had already learned along the way in our Problem-Based Learning curriculum.

There's a lot more that I'd like to say, but I would prefer to show examples along the way in an upcoming series of entries. If you want to just get a high-yield version of my message, it's this: make everything relevant to your learning. Engage yourself. Most importantly, learn about learning. The more you understand heuristics, algorithms and cognitive processes, the more powerful your pattern recognition and fact recall will be.

Recipes for Harried Students

Too busy to figure out how to eat healthy?

Let the commenters of PurePedantry @ Scienceblogs.com help you come up with some quick and easy recipe ideas to spice up mealtime. :)

Ideal Learning

Want to remember everything you learned? Surrender to this algorithm.

I stumbled across this Wired article a few days ago and I was stunned by the concept of the program SuperMemo. SuperMemo = Super Memory (not memorandum)

The concept is simple: make a series of flash cards either with questions or "cloze" statements. The program will randomize them and as you rank them based on a 6 point scale, it will reorganize them to determine (with some magical precision) WHEN you will forget this fact and it will prompt you with the flash card again at the EXACT time when you are about to forget it. Apparently this is the perfect time to relearn a fact and solidify it in your long term memory. In a lot of ways, I have been attempting to mimic this method(poorly) in my board review/study period and I wish that I learned about it earlier. It sounds like an excellent idea, even though the website is totally awful (and I assume the program is equally dense.)

I think that SuperMemo's website is very "90s" and hasn't been updated to a slick Web 2.0 edition because its Polish creator Piotr Wozniak is so focused on using SuperMemo that he puts everything at a lower priority. (The cost of dedicated brillance, I suppose.) I'd be inclined to use SuperMemo right now! if it had a better "how-to" manual, wiki-style.

Although it is too late for me to begin implementing this program for the purposes of board studying, I think I will buy it in June and play around with it to get it working for me for my third year clerkships. I agree with a lot of the fundamental .concepts that Wozniak shares on his website... hopefully I remember to blog about it in the future!

via Lifehacker

---

A side-liner to this is another program I found recently.

Wikidpad is is an outline note-taking program with a built in wiki-linking system. It can be exported to html for viewing on PDAs or online. However, I don't think it has the ability to allow you to edit the files on the Palm itself.
Dunno if I'm going to implement this system... SuperMemo sounds much more engaging (and more time-consuming.) I'll keep you updated.
via MedicalNerds.com

Touching story: Johnny the Bagger

What is it that you find most striking whenever you meet someone new?

Are you impressed by how intelligent they are?
Do you laugh at their jokes?
Do you enjoy sharing a common interest together?

For me, whenever I meet someone new, I'm struck when they treat me with kindness and respect, sometimes caring enough to really mean it when they inquire with "how are you?"

I find this sort of love and camaderie touches me most... and that's the feeling I got from this clip. Pregnant women over 40 have an increased risk of getting trisomies, which can lead to miscarriages and Down Syndrome. Down syndrome is the most common genetic cause of mental retardation, usually resulting from Trisomy of chromosome 21. Mental retardation is the combined deficit of IQ and daily functioning... which is why Johnny had a job of bagging groceries at a local supermarket.

However, a low IQ has no impact on the "emotional quotient" aka EQ. People with Down syndrome are often very loving and caring individuals. They may be naive with strangers, but their friendliness is endearing. This is the quality that enabled Johnny to touch people when he started thinking of something he could do to "make memories and motivate customers to come back."

I challenge you with this question:

How often do YOU do something simple to make memories with other people?

Yeah. Me too. Thankfully, it's never too late to start. The last time I did something super thoughtful like this was around Christmas time -- I donated $15 in the name of a bunch of my friends at school and I wrote little notes to each of them on a Christmas card. I outlined a characteristic that they possessed which I admired and thanked them for being a part of my life. Kinda cheesy and kinda difficult because I didn't want to rewrite anything for any of them... but I think they liked it. :)

via A Storied Career

Inspired

This is a letter that I've written to apply for a scholarship, something I rarely do because I hardly ever feel qualified... but it came to me in a flash of inspiration this morning and it really reflects my thoughts on a lot of different things that have been going on lately in my life.

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.”

These three rights are often quoted, but the definition of “Life” isn’t as fully explored as the idea of “Freedom.” When I reflect on it, the connection to medical ethics becomes apparent: Beauchamp and Childress’ bioethical principles of Beneficence, Nonmaleficence, Autonomy and Distributive Justice echo the same theme. I shared my ideas through an Ethics Workshop that I organized this year for the Medical Student Mentorship Program (MSMP.) The idea of “basic human rights” is a fundamental notion – treat each other with kindness, respect and love. These are very deep topics perhaps, but they are entirely relevant to why I’ve chosen to go into medicine and serve others.

The right to Life equates to a right to be healthy, in my opinion. I’ll admit, I do not know if this was the intent of our founding fathers. However in this day and age, we have the knowledge and the power to help everyone in this respect! It frustrates me how something so obvious to me could be stymied by the short-sightedness of some political parties and insurance companies. The money problems of rising health care costs cannot be solved by putting power into the hands of private insurance companies who focus solely on their bottom line and how they can cut costs and deny coverage. Only by having a huge pot and nationwide coordination may we have a basic, free healthcare plan available to everyone. Until that day, some disadvantaged populations will continue to suffer and they will never get the same opportunities as everyone else. This is why I joined the Hawaii Homeless Outreach and Medical Education (H.O.M.E.) Project where I am currently a second-year clinic manager. I volunteer at the Kaka’ako and Waianae homeless shelters where we provide free outpatient healthcare for the residents. Instead of blithely accepting an unjust system, I have sought out opportunities to be a part of something that could catalyze change and help people recognize their right to Life.

I am committed to helping the people of the Pacific region and I dream of big things for our future. As a small state with diverse cultures and strong communities, Hawaii has the unique opportunity to show the rest of the nation what Aloha really means and how we can truly care for all people. I want to be a part of that and inspire others to help as well. I feel that my current work in MSMP and HOME are only the beginning of these good things.

I hope it doesn't come off as overly pompous, cheesy or insincere because it is the truth as I see it. One of my pet peeves is when people declare something "BS" -- to me, it is only if YOU think it is and it isn't if you think it isn't. Depends on whether you have a cynical or an optimistic eye of the beholder.


^Beholder

Gems for USMLE Step 1 studying

These are a few years old... just some links I found as I browsed through blogs in my "free time" while I study for boards. It makes me feel like posting more, but I could hardly match the level of quality entertainment in these.

http://www.agraphia.net/category/zac-facts/
Zac shares some of his favorite random facts while he studied for Step 1. My favorite part is Stereotyping for the USMLE.

I mentioned that you shouldn’t stereotype… openly. The USMLE is your chance to practice. Nobody ever needs to know that the instant you see lawyer you immediately think scumbag who sleeps with prostitutes and therefore has gonorrhea, syphilis, chlamydia, and herpes. It’ll stay our dirty little secret.

http://rumorsweretrue.wordpress.com/usmle-step-1/
The Table of Contents for a series of posts on Step 1, written by one of the newest editors of First Aid for the Boards... he got the job after garnering a list of corrections for the book on his blog! Amazing. :)

My personal favorite item from this blog came up in one of the comments on micro corrections. From it, I found a great way to memorize the single-stranded, positive sense RNA viruses.
on the mnemonic for the ss(+) RNA viruses. (Wow, the list on wikipedia is impressive.)

"Happy Flava Flav is having a Retro-Toga & Corona party in Pico Cali!"

• ACE: Hep A (PicoRNAviridae), Hep C (Flaviridae), Hep E (HepEviridae, the virus formerly known as Prince. I mean, Caliciviridae.)
• Retroviridae: HIV and HTLV
• Togaviridae: Rubella, an ARbovirus (ARthropod borne for Eastern/Western Equine Encephalitis, but Rubella wants to be a PaRaMMyxovirus)
• Coronavirus: a crown is round (helical), this is the only ss(+) RNA that is helical, NOT icosahedral!

If you have HHAPPPy DNA viruses and Flava Flav down, the other ones are the other ones. Don't bother classifying them beyond segmented (Reo and Ortho) and enveloped (Naked PAP and CPR)


Some other informative links:
http://www.grahamazon.com/2006/09/grahams-guide-to-boards-prep/
-Whoa, I was the first one to comment on this entry! He has some great recommendations on books to read. Topher has a much more comprehensive breakdown. I thought about unbinding my USMLE book like some of my classmates as Graham recommended, but i noticed that they have to flip through the pages one at a time. I ended up just keeping it together (though I still have a month of studying left and if the pages fall out, I might as well unbind the dang thing.)

http://prep4md.blogspot.com/2008/03/how-to-get-99-on-usmle-step-1.html
-Y.S. links up some recommendations from people on StudentDoctor.net who scored high.

http://www.pimpnotes.com/index.php

PimpNotes.org is an open-source notes project for medical students and doctors in training. The site hosts free notes, guides, books, or any other materials created by and for medical students and residents. It currently hosts a complete systems-based pathology charts ("the grids") and pathophysiology flash cards (in progress). an open-source guide to usmle step 1 is forthcoming--created and maintained by those who are closest to the material--the students themselves."
-J. Zimmerman, MD'07, Brown Medical
School

I looked through the charts and they are very thorough -- the text is tiny on the computer screen, but it's formatted for print. So far, he's got Path, Micro and Pharm as open source notes (meaning you're free to copy and distribute them and edit them as you wish.)

Stay tuned, I'll keep updating this list as I come across new items.

Emotions and the Way

"This commercial actually made me cry a little bit.
I wish I had a family."

I was chatting with my friend tonight and he sent me a youtube link with that message on AIM. I'll let you take a chance to watch it before I continue.




----------------




Done? Good. The part at the end translates as "Thai Life Insurance."
So it's a totally fake commercial, but it made me tear up anyway. Decisions that don't make sense to doctors AREN'T bad decisions per se. Patients might have a completely different perpective that is totally valid.

If you open your eyes and listen, you might even be touched.
*sniffle*
Oh my. Sometimes I worry that my emotions will get in the way. Other times, well... allow me take the scenic route towards another conclusion.

This commercial reminded me of a class I had last year.

A guest lecturer came for a "blood banking lab" which turned out to be a confusing session on making checkboxes in the appropriate columns to "type and crossmatch" blood so we don't inadvertently kill patients in the future. While this isn't the job of a doctor typically, Dr. R wanted to impress upon us the difficulty of this task.

"Blood banking isn't as easy as 'giving them O blood.' There's a lot that goes on," he stressed. "As a matter of fact, a lot of difficult decisions are made every day. How many of you know about rationing? No? Basically, each unit of blood that is ordered for a patient is a unit of blood that CANNOT be given to another patient. If everyone demands Type O blood and we only have a dozen units, it gets used up very quickly."

"Let me tell you a story. I was called to see a patient who was delivering a baby and ran into some complications. She had Disseminated Intravascular Coagulation (DIC) and started to bleed out of almost every orifice. She was rushed into the Intensive Care Unit with nurses literally squeezing bags of blood, but she was losing blood faster than we could put it in. We might as well have opened up the bags and spilled them directly onto the floor."

"The blood wasn't enough. Platelets and Fresh Frozen Plasma too. But there was something else we could try. The magic blue juju vial."

Ok, so I made that name up. Keep in mind, that I'm recalling a story from a year ago and I haven't actually PRACTICED medicine in any hospital situation so I don't know what the indications are for using FFP vs platelets vs the magic blue juju vial (MBJJV). What matters to me is the story and the lesson I got from it.

"The only thing is, MBJJV would cost the hospital ten-thousand dollars. On top of that, she would only live for fifteen or twenty minutes, tops, even if we gave it to her."

There was a quaver in his voice and a gleam of anger in his eyes. Dr. R's voice rose to a shout.

"What would YOU do?" He challenged a few people in the class who had no idea what answer would appease this boiling man.

"What if I told you that those 15-20 minutes would give her enough time to spend with her daughter. An occasion that the husband could recall, at best bittersweetly rather than traumatically." (Ah yes, this is the connection with the Youtube clip.)

"What if I told you that the hospital had only one MBJJV and it would take months until another one came -- and another patient who could have otherwise been saved -- died because it had already been used."

"What would you do..." he trailed off, taking the time to remove his glasses and wipe his tears away.

I mustered up the courage to speak up, my own voice wobbling and wavering as I imagined the situation before me. "There's two sides to this -- payment and resources on one side and the needs of the patient on the other. When we talk about futile care, resources should not... hm, ought not to be expended if they can save a life. But in this case, we aren't talking about what best benefits the patient, are we? It's about what will be best for the husband and her daughter. Is the hospital willing to pay the money that insurance surely won't cover?"

So what happened?
She held her baby for the first and last time. She held on two hours. (Or my memory is adding in this detail for the sake of the story.)

-------------------

Afterwards, I learned that some of my classmates completely misinterpreted Dr. R's position. "That guy got really pissed off about ten-thousand dollars," someone told me. Wha? I thought his anguish over the ethical dilemma was obvious.

Do emotions get in the way? Do they cloud our judgement on what is right and wrong?
Perhaps, it's wrong to distance ourselves.
Maybe mmotions should guide us along the Way. They can reorient us to what actually matters.

Dear Congress,

Hello,

My name is Clinton. I am a second year medical student at the John A. Burns School of Medicine and I'm a minority in my class. Why is that? I want to go into a primary care field -- Family Medicine. I have long recognized the need in our country. We have a shortage of primary care physicians, dedicated people who coordinate care across our entire health care system. Family doctors have the greatest potential to impact the lives of many patients with the tools for early detection, prevention and education, in terms of cost (insurance savings) and benefits (better quality of life.)

Many of my classmates have been discouraged by the long hours, endless paperwork and low reimbursement rates seen in Primary Care. Many of them seek careers in more lucrative, more "successful" specialties. Is this really the direction we want to drive some of America's best and brightest? Is the message "We don't Care about Health Care" really an idea we want to spread?

There's something you can do to help. I'm not expecting you to change our health care system overnight; I'm merely asking for your support on a bill that will greatly benefit our Family Physicians. Hopefully, this will be a step that will take us in a new direction and everyone will have the care they deserve.

As a future family physician, I urge you to support S. 2785, the Save Medicare Act of 2008 and stop the Medicare payment cut that will take place after July 1, 2008, and guarantee an 18-month positive update so that Congress and the White House can work on fixing the Medicare payment program.

Unless Congress acts, family doctors will be hit with a decrease of more than 10 percent in payments after July 1. This sort of shifting Medicare reimbursement makes it harder for them to take new Medicare patients - do you want them to pay out of pocket to take care of patients?

Congress MUST replace the current, confusing Medicare physician payment formula that determines payment amounts. We need a NEW formula that makes sense and provides predictable annual increases that reflect the cost of providing care to patients. Family physicians deliver the primary and preventive care seniors need to stay well and to better manage chronic conditions - the leading drivers of health care spending. As the population ages, family physicians are positioned to keep seniors healthy and cut U.S. health care costs. But, they can't do it unless Congress acts now.

I urge you to help family physicians stay in business. I would like to be able to provide quality care for America's elderly without worrying about "breaking even." Please support the Save Medicare Act of 2008 to stop the payment cut by July 1 and ensure an 18-month positive update to the Medicare physician payment rate.

Change can start, here and now! Care about Primary Care, please. :)

TED Talk: Eva Vertes on Cancer

Meet Eva Vertes. In 2005, at age 19, she presented to "Technology, Entertainment, Design (TED)" on the subject of cancer. Her enthusiasm about science is really quite astounding; at 14 she decided to work in a neurology lab and in the process she discovered a purine precursor inhibits degeneration.

Discovering that guanosine protects against Alzheimer's is an impressive feat... and she's got so many more years as a researcher to learn and investigate! Cool.

She goes on to share some of her ideas about cancer cells and stem cells. Her ideas matched my own when I first started learning about medicine... I too was shocked to discover that cancer and stem cells weren't really that far apart. Both are immature tissue, but one has a purpose, the other is selfish. Perhaps cancer is a reaction to injury that just gets out of control, she proposes.

I think she's right... in part on this issue. My current understanding on cancer is that the injury causes cells to regenerate and this replication process increases THE RISK of mutations that lead to cancer. Our bodies never intend to make cancer. We are a Collective of cells that function as a group... we don't intentionally make Invasive Parasites that will kill us. So, I think the causal chain of events looks more like:
injury --> regeneration + OOPS, replication error! --> CANCER
than it does
INJURY --> OUCH, I NEED TO BUST OUT THE BIG GUNS, *fiddling around* --> CANCER.

Cancer is the dark side of stem cell therapy. Stem cell treatments just introduce something that is "totipotent", the power to become 'anything and everything,' into the body and then you sit back and hope that it will follow your directions. What if we get an OOPS moment instead? Suddenly, our most promising therapy becomes our most feared and difficult disease to treat -- ourselves.

Her questioning takes her onto the subject of muscles and cancer. Again, I asked the same question that she did. I've heard of breast cancer and lung cancer... how come I've never heard of Heart cancer? Terminally differentiated tissues that do not regenerate like muscle cells do not become cancerous. There are some embryonic cancers of the heart and skeletal muscle (rhabdomyoma/rhabdomyosarcoma), but these come from the OOPS stem cells in children rather than the damaged heart or muscle tissue in an adult.

What excited me most about her talk were her theories on metastasis and skeletal muscle's resistance to invasion by cancer cells. She offered up a few theories on inhibition of the necessary blood supply for cancer, a reorganization of the tissue or most interestingly, the skeletal muscle tells the tumor to become muscle tissue as well!

She finishes with one final thought:

When the body initiates a process and we call that a disease... it doesn't seem that elimination is the right solution. So this might sound far fetched but in the future, cancer could be used as therapy. If there are diseases where tissues are degenerating, for example Alzheimer's, where the brain cells die and we need to restore new brain cells, what if we could use cancer, a tumor, and put it in the brain and cause it to differentiate? These cancer cells are so versatile; we just have to manipulate them in the right way.

A compelling idea indeed. If we manage that, without any neurological damage like memory loss, we would be well on our way to immortality at the cancer rejuvenation clinic.

Cooking Stew

I bought some beef at the store a week back, intending to make beef curry. Instead, I had a pot of spoiled rice (that I neglected on my kitchen counter for four days as it cultured Bacillus cereus most likely) and I realized... I've never actually made stew before! I mean, I've helped my dad cook stew when I lived at home, though my role was washing and chopping vegetables, not running the show from start to finish. Then, as I dug through my closet to search for the curry packet I discovered that it was a ready made meal -- you're supposed to just toss it into hot water to heat it up and then cut it open and pour it on top of rice. Serving size: one. Lame!

Tasty Planner is a great website for recipes, meal-planning and assembling a shopping list so I thought I'd give it a go. I found a recipe for beef stew and got my shopping list together.

All I need is some beef broth, mushrooms, an onion, tomatoes and potatoes... how hard can that be?

As I wandered through Safeway, I started buying ingredients for future meals thinking to myself "Oooh, that sounds tasty!" My mind wandered through the aisles. When I got home and started cooking, I realized I was missing a few key ingredients -- namely potatoes and tomatoes! "Ah well... it'll still come out OK," I reassured myself.

As I added in all the ingredients in for my final stew, it looked more like soup. "Thickener! Oh, so THAT'S why the recipe said to roll the beef in flour before cooking it... whoops." My kitchen isn't fully outfitted, in spite of the full pantries. I knocked on a few of my neighbor's doors but seeing how it was noon, no one answered. No corn starch, no flour... what to do, what to do.

I went online to look for some ideas and someone said "add any sort of starch. Rice or potatoes are good."

Rice! I just cooked a batch of fresh brown rice to go with my meal, so I added that in. My goodness. It is the best tasting stew I've ever eaten! Of course, being the chef might influence my opinion somewhat, but the red wine certainly jazzed it up. That's an ingredient my family stew neglected to use.

The funny thing about my whole thickener experience was that when I read the recommendation to use "starch," I made the connection that oh yeah, corn starch is a starch. And hey, the reason why it thickens is identical to extracellular matrix (ECM)!

-----------------------

ECM is a mixture of polysaccharides (which includes starches) and proteins that surround cells. One of its functions within joints is to trap water and provide a cushion... basically thickening it up into a gelatinous mush.

Science to the rescue! I lack a lot of common sense when it comes to things like cooking, but boy, I like it when something esoteric like knowing about ECM actually provides an explanation for everyday things. :)

"So I'm taking these yellow pills..."

For some reason, I thought that doctors knew how to identify pills. On top of memorizing those complicationed jumbles of nonsensical consonants that pass as "names", the mechanism of action, indications, contraindications, drug interactions, side effect profile... doesn't it make sense?

I soon found out in med school that's not necessarily the case. Docs don't get hands-on with the pills. They write a prescription and the pharmacist fills it. I haven't taken very medications so... I'm not even sure I could tell the difference between Tylenol and Aspirin. Pharm-techs probably could ID the pills based on a description, but tell the MD "I'm taking something for my blood pressure. I don't remember the name, but it's a yellow pill..." you'll get a blank stare.

Surely there's some sort of resource out there for swift ID!

After a split-second search on Google, I found the "Pill Identification Wizard" over at drugs.com. It has an extensive US based formulary with pictures of various medications after you fill out a short description. Here's a sample, based on the only medication I've ever taken:

This is a service I'll definitely utilize in the future. It would be even more fantastic if you could snap a picture of it (on your cell phone, for example) and get a list of possible meds from that.

Hot tubbin'

Sundays are my work-out study days. I usually cruise down to a swanky condominium near Ala Moana Beach in the afternoon to study with a few of my classmates, J and G. We go over our cases (summarizing them and then writing up a quick review with key points) or pathology question books ("slapping in" when we've got the right answer after someone reads it aloud to make it more like a game show.)

Then we work out in the gym and have what G affectionately calls "pool time" :) The gym/pool is a big motivator for me to meet every weekend with them; the weather usually behaves and we catch the last few rays of sunshine before the golden-red glow of the sun signals that it's about time to leave the jacuzzi and get some food.

G told me about one time she broke out with a strange rash a few days after enjoying her pool time. It was like having bumpy acne from her chest down...
"G!!!! You had hot tub folliculitis!" I exclaimed, in the excited tone I adopt whenever I stumble across a surprisingly cool diagnosis.
"Whhaaaa... what's that?!?!" She said in shock.

Hot tub folliculitis is caused by Pseudomonas aeruginosa. Pseudomonas survives in hot tubs, especially hot tubs made of wood, unless the water's acid and chlorine levels are strictly controlled.

Hot tub folliculitis can be seen within several hours to 2 days of exposure. It first appears as itchy bumps, some of which may be filled with pus. It may then develop into dark red tender nodules. The rash may be thicker under swimsuit areas, where the material has held the contaminated water in contact with the skin for a longer period of time. via Medline

"Ewww!!!! Gross!"
"Yeah, I guess it cleared ok for you," I said, performing a cursory examination of her skin"
"You perv," she said, laughing, splashing some water at me.

There's another condition that's linked with hot tubs and microorganisms.
It's called Hot Tub Lung!

This 49 year old patient was admitted with several weeks of worsening dyspnoea and dry cough. He had no history of previous respiratory illness. Further history revealed that several months prior he and his wife installed a hot tub in their bathroom. His HRCT chest showed widespread areas of ground glass opacity. via Radiology Picture of the Day

Diagnosis? Mycobacterium. Not the type that gives you TB though... Mycobacterium avium intracellulare, apparently. It gets aerosolized from all the bubbles and then you get an allergic reaction from its presence in your lungs.

Don't worry, most people handle MAI just fine. It's ubiquitous... found in dirt and water everywhere. Just an activated macrophage here or there and CHOMP! The infection is handled without the breathing problems.

Education has a way of sneaking up on you...

So, it's official. I'm done with my second year as a medical student!

There's not much in that victory as the majority of my summer will be devoted to studying for Step 1. I've talked about it before here so I won't rehash all of the details of my particular situation. I have another story to share though.

After my 6 hour long multiple choice and essay question exam two weeks ago, I got a call from one of my friends living on the mainland now.
"Hey B, what's up?"

"Hey man, just landed on the island and I'm here with D. BTW, did you know that he's getting married this Saturday?"

Whoa, talk about last minute invites. Apparently D didn't have any of my contact info (or anyone in my circle of HS friends) so I made a few calls and found someone else to go with. I thought it would be a nice break from my board studies to go to the event. It was really nice; I got reacquainted with some of my old high school friends! J, my senior prom date (and a girl I had a crush on even when she was dating D), just graduated from acupuncture school and now she's working as a chiropractic assistant now. I made an effort to be open minded and ask her a little bit about her philosophy and practice and such. I was glad to hear that it really worked to help her with her pain after shoulder surgery (something that bummed me out about going to prom with her... the music really pained her having just had the surgery, so we only danced a few times.)

It's difficult for me to shut off that nagging factual scientific side of my brain that I use so much and approach things from a more nonjudgmental, holistic, cultural perspective (or what have you.)

Somehow, I opened a bag of worms by mentioning that I was in med school. After the polite round of "Oh, what kind of doctor do you want to be? (Family Medicine)" "Oh, that's nice (Yeah, I really want to be albe help all kinds of people)" One of the mothers on the table dove in for the kill.

So, I listen to this conspiracy radio talk show and they have some interesting topics. Yesterday they talked about vaccines, calling it the Vaccine Genocide. It's a shame how we have to vaccinate babies at birth! There's so many complications... How do you feel about it?

Obviously, a wedding table is no place to launch into a deep discussion about the pros and cons of vaccine administration, the benefits of herd immunity, the necessity for prophylaxis for diseases we don't have any other cures for... I was caught off guard by the sudden shift in subject matter, but I guess it was reasonable since I was inquiring about acupuncture just a few minutes earlier. How would I be respectful of her beliefs, challenge her assertions and not come off as angry, defensive, or patronizing as I do so?

"Yeah, I'm not a fan of genocide. I totally feel bad for all those all of these poor bacteria we're killing off!" I said jokingly. No one laughed. Not even a guffaw. Whoops. Time for a new tactic.

"We don't give vaccines to protect healthy people. Things like the the flu vaccine are given to protect people who are immunocompromised -- old people, young babies, diabetics, cancer patients, etc. I think a lot of people are forgetting what it's like to live in the days of infectious disease. In some ways, having vaccines makes it harder for us to understand why they are so important. Take the chicken pox vaccine for example...

"That vaccine is totally unnecessary. People who take it have a higher incidence of shingles!" retorted J, shaking her pretty blonde locks in disgust.

"Yeah, that's true," I conceded. "What I meant is this -- doctors don't even see patients with Chicken Pox anymore. Soon they'll forget what it looks like in person. I can only imagine what the general public will think."

Indeed, my personal philosophy about vaccines is somewhat cynical and harsh. In order to convince people of their necessity, they occasionally need to see the disease it would otherwise prevent... otherwise the adverse effects, no matter how rare or uncommon they may be, will be seen as PROOF that vaccines are harmful, even deadly, and doctors are killing babies. Perhaps I got through to her...

"What about the HepB vaccine?!? You give that to babies right at birth," the mother asserted.
"Yeah, the maternal antibodies protect the baby from HepB for a few months." J added.

Hm. This was an issue that required more finessing. I didn't want to tell them everything about HepB transmission, so I dropped the cancer bomb on them, a little something I had prepped a few years earlier on my blog.
"Did you know that HepB prevents cancer? Yep, that's right. We're vaccinating these children so they don't get HepB during the delivery from their mother so they don't get hepatocellular carcinoma."

I felt satisfied that I defended my profession. Still...

--------------------------
"A, what happened back there?" I said as we drove back from the beach house/wedding site. "You're a social worker, public health, natural disaster and all that business, I would've liked some support."

"You did a pretty good job," she said. "Thimerosal and autism? Where was she getting that stuff from? I thought it was disproven a long time ago."

Dang. A was right. Bush was right. Repeat something often enough, it becomes true to the American public, no matter what the facts are. Rather than submitting to this droning power of the collective, I will speak out! Hopefully in a nice and polite way that will help to put a good face on Medicine.

Is "O" the new "E"?

Have you heard of ecstacy? Also called MDMA, it is a recreational drug that was used by psychotherapists until it was US drug laws made it an illegal substance. "E" moved from yuppie bars to the dance rave scene and has since become one of the most widely abused drugs in the US. A lesser-known drug is being used in these raves too. Octium, "Oo" or simply "O" as it is called on the streets, is a chemical that was originally discovered by a Swedish pharmacist Carl Wilhelm Scheele in 1771. Since then, government scientists have been working on the uncovering the secrets of this deadly chemical. I have done some research and quite frankly the results they have downplayed to the public are absolutely shocking.

Chemistry
Unregulated by the Food and Drug Administration (FDA,) not classified as pathogenic by the Center for Disease Control (CDC.) Why not, I ask? Judge for yourself.

Effects
Extremely reactive. It can exist in a highly unstable form known as a "free radical" which indiscriminately disrupts chemical structures in your body.
Carcinogenic: causal links with emphysema and lung cancer!
Byproduct of many harmful pharmacologic and physiologic reactions!
Compounds with high octitative potentials can cause severe chemical burns.
There is a high correlation between unattended children with access to Octium in house fires.

Neurological effects
In excess of moderation, Octium can cause dizziness, weakness, confusion, and agitation.
In the anarchist movie Fight Club, this chemical was touted as a substance that "will get you high"

Systemic effects
Agitation, hyperpnea and tachypnea, chest pain, dyspnea, wheezing, dizziness, palpitations, tetanic cramps (carpopedal spasm), paresthesias, generalized weakness, and syncope

Long-term effects
deadly to many microorganisms, thought to be a leading cause in a massive "genocide" that changed our planet millions of years ago... and now an organic form of this chemical is a major contributor to the greenhouse effect, causing global warming!


Abuse as a drug
Extremely addictive, with painful withdrawal periods that cause eventual death for ALL addicts who try to quit.
produced in large amounts by ALL plant life (unlike other hallucinogenic compounds like those found in mushrooms, tobacco or Sativa cannabis.
Binging on octium is commonly called "diving". Octium abuse can lead to visual disturbances, ringing in the ears, dizziness, and severe mood swings. When Octium attacks the central nervous system, convulsions and finally coma are the result (otherwise known as CNS toxicity.)

Supply and administration
Inhalation is the common method and unbeknownst to many users, intravenous injections of Octium are highly dangerous and even deadly.
Some bars supply their customers with custom Octium, attempting to lure them in with trendy flavors. They are monitored by the FDA, but no major health risk crises have happened to spur them into action... yet.

Safety
Should you let your friends and family know about these dangers? Just think about this -- even though teenagers attending concerts and raves might be overusing Octium, they might also be using a drug linked to octium -- DHMO, aka dihydrogen monoxide.


Before you get too concerned, just take a deep breath. Whew... now that wasn't so bad, was it? Meditate on your breathing and enjoy the benefits of octium.
Similar to DHMO, octium's benefits outweigh its risks, bar none.

Happy April First :)

Are Glow-Sticks toxic?!?

MSDS = Material Safety Data Sheets

I learned about MSDS during an on-job training at my first job in high school, the brutal, dangerous environment aka McDonalds. I got splattered with oil and I burned myself more often than not (not seriously, mind you) working at the grill. When I found myself a nicer summer job at the YMCA as a camp counselor, I jumped at the chance. How cool is that, to get paid to play with kids and have fun?

It turned out to be more work than I imagined. My relationship with the kids had to swing from the Fun Guy to the Enforcer on a dime. The trouble-kids always became the ones I was most fond of at the end of the program... perhaps it was just a consequence of spending so much one on one time with them. I remember one kid had a glow stick in his mouth (for some reason) and he freaked out because it broke and he swallowed some of it. "Oh don't worry... it's probably non-toxic. I'll take you to the supervisor and we can check that. For some reason, I was under the impression that the MSDS sheets at the YMCA would have facts about glow in the dark chemicals. My supervisor gave me this weird look when I brought him in and said "what... are... you... talking about?" She was only a few years older than me, but she had mastered the ability to talk down to someone that stood almost a foot above her (taking some poetic license here.)

Still, that incident stuck with me. What IS the effect of glow stick stuff on the GI tract?

Tonight, the answer is solved, thanks to ToxNet, a resource brought to my attention by the Health Sciences Library.

Most incidences of exposure to chemiluminescent products involve asymptomatic ingestion of fluid that leaks from glow sticks or ingestion of an intact glow stick. Symptoms occur after exposure to chemiluminescent fluid and consist of transient irritation at the site of exposure.

Figures... went along with my instincts. Perhaps I'm revealing my level of hidden neuroses, but my mind feels more at ease knowing the easy way to find the answer to these questions. All I had to do was go to ToxNet and type in "glow stick" into the search box.

More and more, knowing random trivia bits will come from knowing WHERE to look... not necessarily just Knowing. The internet is very two-faced though. For every bit of information out there, there's 10x more garbage (growing day by day) Everyone should begin acquiring their set of reliable fact-checker bookmarks (like snopes.com) to combat these sorts of things.

References: Hoffman, RJ. Pediatric and young adult exposure to chemiluminescent glow sticks. Arch Pediatr Adolesc Med. 2002, Sep; 156(9):901-4.

Sleep Hygiene: a self-critique

I recently prepared a presentation on sleep apnea and sleep hygiene. I tacked on the bit about sleep hygiene because it's a concept that's quite foreign to me and I wanted to learn more about it. Quite frankly, I suck. I routinely go to sleep around 3 or 4am and I take a nap in the afternoons to try to catch up on my sleep deficits. On days when I can't take a nap, my mind wanders, I yawn a lot, I feel on the edge of nodding off around 3 or 4pm.

Here's some of the basics about it:

• Areas important to sleep hygiene:
• Circadian rhythm
• Aging
• Stress
• Common social or recreational drugs like nicotine, caffeine, and alcohol

1. Adapt your habits
   o Set a bedtime and waking time (no sleeping in more than 2-3 hours on weekends)
   o Avoid napping (if you do, make it short and before 3 pm)
   o Avoid EtOH, caffeine, heavy/spicy/sugary foods 4-6 hours before bedtime
   o Exercise! (but not right before bed)


2. Adapt your environment
   o Comfortable bed, comfortable temperature, dark room
   o Block distractions (NO TV, NO computer for at least an hour or more before, but radio is OK)
   o Only two S’s for bed
   o Proper positioning


3. Prepare yourself nightly
   o Light snack (warm milk)
   o Relaxation techniques
   o No worries in bed!
   o Pre-sleep ritual


4. Problems?
   o If you don’t fall asleep in 20 min, go do something else (like reading) until sleepy (~20 min later)

And here's my self-critique.

My waking time varies every day. Basically, I set it as late as possible so I can sleep in because it's just so hard for me to get up in the morning. I nap around 4-5pm whenever I can, which is usually 2 or 3 times a week. My naps are about 1-2 hours long, depending on what finally rouses me (usually hunger). On the plus side for me, I hardly ever snack late at night (but it's not really a problem for me to go to bed once I'm there. It's more an issue of studying when I feel most mentally alert... it's just unfortunate that it happens to be 10pm onward.


My environment for sleeping is pretty good. I actually sleep on a bed now, which different from the ~20 years of sleeping on a futon at home (the parents' place) One of my S's is lacking... I've pretty much replaced it with another S: studying.


My pre-sleep ritual usually involves brushing my teeth for close to half an hour while I browse blogs on the internet (or on especially good days, I decide to blog!) Perhaps an unwise decision, since the lights from the computer screen and the content of the blogs stimulate me and I decide "oooh, another 15 min wouldn't hurt..." and before I know it, it's 3am and I've got class at 830 tomorrow.

So my sleep hygiene is about as bad as it could be. If I want to start sleeping earlier and reset my circadian rhythm to a more decent hour, I've got to exercise more, stop my midnight blog browsing, and stop studying in bed. I should have a warm glass of soy milk, settle in with a book and read for about 15 minutes before turning in at midnight.

Ha! I wonder if that's even possible to manage, med school and beyond.

References:
http://www.umm.edu/sleep/sleep_hyg.htm
http://www.webmd.com/sleep-disorders/guide/sleep-hygiene
http://www.cdc.gov/sleep/hygiene.htm

Reproductive Issues

Today was a day of reproductive problems.

I went to the Maternal/Fetal Medicine department at Queens and I shadowed a physician there for a few hours. She was a "problem-pregnancy specialist."

The first patient that we saw was a young woman with suspected preeclampsia. It's basically a condition of high blood pressure, protein loss in the urine and sometimes accompanied by edema. It can lead to further complications like seizures, preterm delivery and stillbirth, so it can be pretty serious. She had chloasma and linea nigra, darkened pigmentation of the cheeks and a dark line down from the belly button. It was the first time I'd ever seen (or heard) of it. It's also called the "mask of pregnancy."

I had a good time chatting with her and her husband about school and their physician and such during their non-stress test (fetal heart rate monitoring) that I missed the beginning of the Dr. B's next patient encounter.

It was with a young diabetic woman who recently found out that she was pregnant. Unfortunately, she is a "RFN", meaning that she has retinopathy (can't see), ne'f'ropathy (kidney problems) and neuropathy (sensation loss in her lower legs.) These are long term complications of poorly managed diabetes and from the looks of it, she had a lot of support problems in her family that prevented her from getting quality care. It was really sad, because it meant that she had to make a difficult choice -- continue the pregnancy and risk early preeclampsia, possible miscarriage and progression of her blindness and kidney failure that would put her on dialysis... or terminate the fetus.

I... I don't know what to say about this. There were some other emotional issues that complicated her decision-making process that really surprised Dr. B. and I. I wish that Dr. B. followed up on it, because it was quite striking. Perhaps at a later visit she will. It's a tough position to put anyone in, deciding which life will suffer to ensure the welfare of the other.

Perhaps it could be a blessing for her if she decides to continue... I said hopefully. Dr. B. expressed her doubts and I can see why. She has difficulty maintaining a stable life for herself; adding a child would just be an additional stressor. The child will likely have a lot of complications due to vascular insufficiency in utero... diabetes is one of those silent systemic diseases that wreaks havoc on all parts of your body but doesn't let you know what it's doing until it's too late.

I left that obstetrics session with a lot of things to think about. How will I handle these issues with my own patients? What level of autonomy vs paternalism do they want? After all, it takes an expert's opinion in order to figure out what to do... and then the choice is left up to an overwhelmed patient. On the other hand, being harsh or judgmental affects the relationship with the patient who relies on the doctor to be their advocate... it would undermine everything to pull in biases and overrule what is in the patient's best interests.

I guess it all comes down to that. Interests. Values. Discovering what matters most to the people you see in the clinic and seeing how that affects their decisions. Helping them to understand the significance of the issues at hand and the role that they play.

---------------------------------------

Later on tonight, I went to the homeless shelter near school to help out at our free clinic.

One of the fourth year students gave a short talk entitled "Reproductive Issues in the Homeless." He shared some statistics with us, basically saying that physicians often avoid the issue of sexual matters with homeless and that limits their contraceptive use. Ironically, being monogamous and not engaging in sex trade is actually associated with lower contraceptive use since "commercial sex workers" are the types who seek out these methods of protection.

Some of my classmates, so inspired, decided to take a bag of condoms and distribute them to residents of the shelter. Later on, he told me that a lot of the women there would initially refuse to take any condoms, but when pressed, they would glance around, see if anyone is looking.... and then they'd take the entire cup of condoms being offered.

Truly there is more we can do to help these women in the area of reproductive health than just offering them a dozen condoms on a particular night. A lot of them have health insurance and just educating them about some of the options (IUDs, rod implants, Depo-Provera) can go a long way.

All in all, it's been quite a day for me.

Munchausen by proxy

I first learned about Munchausen syndrome by proxy through the movie Sixth Sense, where young Cole conquers his fears and learns why he is being haunted. A young girl shows him a videotape revealing that her mother intentionally poisoned her to keep her sick! WTF?!? People really do that?!? I felt ill. It was totally outside of my realm of comprehension. In our last Unit on Neurology and the Musculoskeletal system, one tutorial group had a running gag when they hypothesized about the diagnoses for the cases: ascending paralysis? Munchausens. bouts of mania and depression? Munchausens. kids having trouble walking? Munchausens by proxy. headache? I think you get the point.

Browsing through my blog reader today, I came across this:

A Redlands mother of four was accused of Munchausen syndrome by proxy, fabricating or inducing illnesses in her own children
-LA Times, via the Lone Coyote @ Medical Student Musings

It certainly must be frustrating to deal with hypochondriacs... even more so with hypervigilant parents! Every little cough or sniffle becomes a sign of some impending disaster to the point where the doctors become desensitized to the Truth. Just because someone is seeking attention for a medical illness that they read about on the internet doesn't mean that they are Attention-Seeking and worthy of only a cursory exam and subsequent dismissal.

Perhaps this is just my naivete and inexperience speaking, but the patients with the irritatingly vague and persistent complaints may just BE the ones who deserve the most attention and cognition. Maybe, just maybe, they have a genetic condition like Ehlers-Danlos Plus (though I couldn't find it definitively on OMIM) with a chiari malformations that could explain the seizures, centralized sleep apnea and joint dislocations.