I plan to stick to the following resources:

1. First Aid for the USMLE Step I 2011
2. BRS Physiology
3. USMLE World Question Bank
4. Robbins and Cotran Pathologic Basis of Disease (chapters 1-7)
5. All the pictures and selected readings from Goljan’s Rapid Review Pathology and BRS Pathology

I’ve always learned better by writing things out (it’s an active process, after all ), so I plan to use First Aid as my “primary textbook” and annotate it with sections from the aforementioned resources.

For those wondering what the exam format is, here’s a description from UWorld’s website.

Step 1 has approximately 322 multiple-choice test items. This is divided into seven sixty minute blocks and administered in one eight hour testing session. For Step 1, during the defined time to complete the items in each block, you may answer the items in any order, review your responses, and change answers. After you exit the block, or when time expires, you can no longer review test items or change answers.

My goal for this exam is ambitious. It’s more than just the “MCAT of medical school.” This can, in a large way, determine what I do with the rest of my life. The exam is scheduled for Sunday, March 18th giving me less than 50 days to prep… some of which I plan to use to clear my head before and after studying.

It’s game time!

A faculty member brought up an excellent point about in the post-rotation feedback session. Some medical practices are being inundated with an alphabet soup of MAs, LVNs, CMAs, CNAs, and so on. This helps reduce costs while attending to patients more quickly; however, these individuals often assume responsibilities they aren’t trained for (ie, phlebotomy, addressing patients’ questions via telephone, etc.). And therein lay one of the causes of medical error. With decreased compensation on the horizon, an escalating shortage of physicians, and more overhead… how else can we streamline private practice?

One of the nurses brought me fresh eggs laid by her chickens.

Another nurse brought me clementines from her backyard.

Now it’s time to enjoy the weekend!

I’ve seen cases ranging from acute sinusitis, cough, otitis media and musculoskeletal injuries to more advanced arrhythmias and protocols for managing refractory hypertension. In addition to this breadth, I’ve found the “continuity of care” aspect of outpatient medicine incredibly appealing. These are the physicians that most people see first for a myriad of chief complaints, so patients get to know the same provider over many years. It amazes me how my preceptor is able to recollect the nuances of his patients’ unique histories even though he sees them only a few times each year.

Roughly a year ago, I was just getting started with Internal Medicine and had no idea what I was doing. Taking histories, formulating diagnoses, consulting the primary literature, and creating a treatment plan have now become a routine part of virtually every patient encounter. Heading into some dedicated “USMLE Step 1 studying time”, this rotation has been an excellent way to apply facets of every rotation I’ve had. After all, as much of basic sciences is based on buzzwords, clinical medicine is rooted in experience.

Rather than the thorough “hospital history”, primary care outpatient visits require one to take a more “focused” history because of limited time. We covered the nuances of five types of patient encounters during today’s orientation: new problem, checkup, chronic disease, psychosocial, and change in behavior. The clerkship director has also decided to completely drop the Family Medicine shelf exam. Previously, my colleagues had to take it as a pass/fail assessment, but I’ve lucked out and won’t have to bother with that at all. The director’s justification was reminicent of my complaints - he feels our grade should be determined based on how we handle actual patient encounters and investigate questions using the literature.

So I’m off to my first day of clinic in six hours. Here’s hoping I set a good first impression.

Good and Not-So-Good Role Models

We all come across two types of people in life – those we wish to emulate, and those who, for whatever reason, we don’t. This notion applies equally to the clinical training environment. I’ve seen my superiors (namely residents and attendings) exhibit an incredible amount of medical/technical knowledge while maintaining an air of humility about their accomplishments.

Unfortunately, some prefer treating their colleagues, coworkers, and even patients in a manner which, to be politically correct, I internally question. As a student, it’s important to see both sides, differentiate good from bad, and align myself with those who promote traits I deem to be advantageous to my career.

Find Yourself In Each Rotation

I can’t even begin to count how many times my classmates and I have griped about our schedules, teams, and even patients. Someone who wants to do primary care will find surgeons obnoxious. Someone who wants to do surgery will find internal medicine too slow. The list of stereotypes and frustration goes on infinitely.

Early on, I adopted a different outlook regarding unfavorable situations – suck it up, be grateful, and find something about the rotation that you do like and can relate to; let that be the beacon upon which you judge the rotation.

Coming to med school, I had no intention of pursuing internal medicine or psychiatry, but both rotations have shown me just how much I enjoy interacting with patients. Driving in each morning, I look forward to what new personality disorder I might come across, how I’ll manage the next patient with withdrawal, how my long-term-care patients are doing and what new life stories in the military I’ll learn about. Maybe it’s fulfilling my “need to be needed”, but I’ve found a great deal of pleasure in actually interacting with patients, regardless of whatever the hours are or clinical tasks may be.

Scut Work

The term “scut work” is routinely thrown around by med students and junior residents to denote unrewarding, tedious, and often times trivial tasks assigned by our superiors. However, this is a very subjective term indeed and an individual’s interpretation of what actually constitutes scut work is directly related to team dynamics.

In general, an efficient team is a happy team… and a team which usually goes home earlier. If you’re the lowest on the totem pole (read: “medical student”) and there’s no learning opportunity at the present moment nor anything that needs to be followed up on patients, you should do whatever you can to facilitate the needs of your team. Make that run to McDonald’s for the team, get those prescriptions from across the hospital, carry those blood samples to the lab to facilitate processing, or if it’s a reasonable hour and your duties are otherwise done, ask if you can be dismissed.

The team and patients always come first – “scut work” is what you make of it.

Your Best Is Not Good Enough

I think I’m prepared for the procedure. I’ve done all the practice questions for the exam. Yet when the moment comes for me to shine, the attending/resident/shelf exam asks the one question I don’t know. I can identify all the surrounding anatomy except what the surgeon is pointing at. I know virtually everything about biliary disease except what the question is asking. Compound this sentiment multiple times through every rotation, and you’ve got a highly motivated student who has little to show for it.

With my USMLE Step 1 scheduled for March 15th, I’ve got less than 80 days to essentially make or break my career. I have to focus on my Family Medicine rotation in January, but after that, I’ll be studying more efficiently and intensely than ever. I’m motivated. I have a vision. There are no more excuses.

And I will succeed.

Thanks to everyone for their thoughtful comments, emails, and Twitter messages over the last year. I hope 2012 will provide me with more opportunities to share my experiences!

Let me construct a hypothetical vignette:

42 year old G3P2103 overweight Caucasian female presents to the emergency center with excruciating right upper quadrant abdominal pain beginning a few hours after eating dinner.

As an astute individual, biliary colic secondary to cholelithiasis (gallstones) is probably at the top of your differential. Okay, so what’s the big deal?

Medicine is a team-oriented field which places a patient’s overall wellness and health at the forefront of our objectives. We can’t address clinical vignettes without knowing other details about a patient’s labs, imaging, vitals, physical exam, etc. While shelf exams often provide the aforementioned information in question stems, in my opinion, the most important part of an encounter is completely lost  - what’s your first impression upon seeing the patient? Is the patient above constantly writhing in pain unable to find a comfortable position? Are there physical symptoms even she is not even aware of? Subtle clues often go a long way in diagnostics.

In addition, I think the process of arriving at a diagnosis is lost in shelf exams. If we think the gallbladder is involved and decide to do a right upper quadrant (RUQ) ultrasound, what’s the next step if there’s no sign of acute cholecystitis or cholelithiasis? CT abdomen? Maybe the patient is malingering? How do we justify the radiation exposure inherent to CT imaging or the implications of labeling someone as a malingerer? These are things we have to consider!

Furthermore, finding out “what it is” is just as important as finding out “what it is NOT.” Being able to quickly construct a differential with strengths and weaknesses supporting each diagnosis is a pivotal part of clinical knowledge which is difficult to test on multiple choice exams. Knowing which diagnoses are more likely will effectively guide the work-up and save tremendous amounts of resources, money, and time.

Don’t get me wrong – I’ll be the first to say that the test writers do a fantastic job in constructing questions (or rather, selecting from a circulating pool) which require higher order reasoning, but our hands are often tied when given a finite set of answer choices. Why should I be forced to select answer when I know the updated literature has either a.) completely refuted a prior tenet in the workup and/or therapy or b.) there are newer protocols available? Multiple choice exams are better suited for the objective medical knowledge we see in the first two years of training in the basic sciences.

The focus should now be on standardized patient encounters, having the opportunity to respond with short answers, creating a differential diagnosis with the ability to prioritize which items are more likely given the results of imaging and labs we order, etc. Maybe a free response section would be prudent to include on shelf exams? Of course it’s not as easy to grade, but I strongly feel our knowledge regarding the updated literature and thinking beyond the scope of the patient’s chart would be more thoroughly tested.

It’s undeniable that “textbook” medicine is different than “clinical” medicine. I’m a huge proponent of free response tests which will adequately assess the latter – the same clinical medicine we’ll actually be using as practicing physicians.

What are your thoughts?

We did lumbar punctures. We fully worked up chief complaints of ambiguous symptoms like “weakness” and “tingling.” We read countless CTs, MRIs, and angiograms. We saw Parkinson’s disease, Alzheimer’s dementia, ALS, myasthenia gravis, and a whole slew of other textbook cases in neurology. Overall, it was an incredibly laid back and enjoyable rotation.

Now it’s time to hang up my white coat for two weeks of enjoying the outdoors, attending to chores, and reflecting.

I helped the patient assume the proper position (“knees to chest”), located and draped the vertebral site, cleansed the site with chlorhexidine, anesthetized it superficially and then more profoundly with 1% lidocaine, and then grabbed the spinal needle. Telling the patient to take a deep breath, I found myself doing the same as I cautiously guided the needle in.

I first tried to “feel around”, avoiding bone and aiming the needle towards the umbilicus. I hit what I thought was bone, but based on how deep the needle was, I had a strong suspicion it could be a thickened dura. I had seen an LP done in the ER a few months ago where the resident had simply not pushed hard enough to penetrate the dura (fearing that it was bone); an attending basically walked in, pressed a little harder, and had cerebrospinal fluid (CSF) flowing within one attempt.

I tried once more and then deferred to my resident. She was also unable to have any CSF return. Our service’s chief was then called in. I shared my story from the ER, and the chief explained how dural thickening, degenerative disc disease, and other LP-complicating conditions are relatively prevalent in the patient population we’re dealing with. He simply pressed through the dura and had CSF flowing immediately – a champagne tap (no contamination of the sample by blood).

In retrospect, I’d say I did roughly 95% of the procedure properly – the 5% being deferred to someone more experienced who would cause less discomfort to the patient. I’ll take that any day.

Hopefully I’ll get to do another one in the next two weeks! Procedures are awesome.

Since this was a pediatric neurology conference, the treatment course was discussed in the context of the brain. Impaired vasodilation in intracerebral vessels has been linked to brain damage. How do we increase blood flow to prevent said damage? With the potent vasodilator, nitric oxide (NO), of course. As a biochemistry major in undergrad, metabolic pathways always appealed to me. “Oh, ‘X’ becomes ‘Y’ which becomes ‘Z’ which is shuttled inside the organelle and phosphorylated to ‘Z-P’ and…” blah blah blah. A nightmare, right?

The figure above illustrates how our body normally synthesizes nitric oxide. Of interest, according to the speaker, L-citrulline is more efficacious than L-arginine in producing a vasodilatory effect – both substrates are included in the pathway above. Patients are currently started on regimens of L-arginine, but perhaps in the future, L-citrulline will become the mainstay as more evidence emerges.

I’ve spent most of this weekend doing absolutely nothing except working on a new research initiative, playing computer games, and watching football. I have two relatively lengthy papers to finish within the next two weeks in addition to the departmental exam I need to *start* studying for, so it’s time to get focused. Winter break is two weeks away, and I want to finish the semester on a strong note!