Wednesday, December 12, 2012

How to Crush Step 2 CK

I think most people would agree that Step 2CK doesn't have near the weight that Step 1 carries towards obtaining your residency. So people tend not to stress about this exam nearly as much as they do Step 1. That's not to say that Step 2 is easy, it's pretty rough actually, but even at its best, its not Step 1. It's one section longer than Step 1, the amount of time you have to prepare is generally less, so, it is challenging in more of the deadline meeting, cramming way, rather than the sheer enormous mountain of stupid information that is Step 1. However it should be noted that most (not all) students who took Step 1 get a higher score on Step 2 on average. So one way to think about it is if you're going to try to equal your Step 1 score on Step 2CK; you could theoretically imagine a study intensity requiring about 10 points less than what your scored on Step 1 to get an equivalent score. While many of you are aware that students killing Step 1 hit around the 250's, it's not unheard of to get a Step 2 to hit the 270 range.

That being said there are a couple reasons why people do sweat bullets about Step 2 CK. For one, you may not have done stellar on Step 1, so this is the chance to redeem yourself to some extent. Some FMG or IMG programs look better if they have Step 1 and Step 2 completed with high scores thus giving the student more credibility. Finally you might just be that standard gunner who's trying to kill Step 2CK rather than chasing that blonde girl walking down the street before that last year leading up to internship (if you want my advice, chase the girl). Whatever the reason may be hopefully this will be able to guide you towards getting a score you want, and suggesting the most effective materials to do so.

I believe that there's a couple ways to approach this exam. The first way is going into it roughly trying to match your Step 1 score, which is really not the worst thing. It's the neutral approach, i.e. if you're happy with your Step 1 score, and you don't want something too competitive for residency this is totally fine to do. The other way, is to go about it like an animal and try to kill Step 2CK, which is fine, you just have to realistically determine whether you need to do this or if you have the energy to do this considering the intensity of 3rd year in general. That being said the rest of this post will be written assuming you do want to kill your Step 2CK exam.The idea of this post assumes you are starting from day 1 of 3rd year.

The fundamental problem with the approach to Step 2CK is the ambiguity. Unfortunately unlike Step 1 there is no godsend of a resource like the First Aid for USMLE Step 1. The resources available are just no where near the quality of what's out there for Step 1, so get used to this reality. Again as mentioned in my post on how to do well on Step 1, The USMLE Step 2 CK First Aid book has an appendix grading Step 2 resources on an ABCDF scale. While I think the USMLE Step 1 First Aid guide is pretty spot-on, I question some of the ratings in the First Aid CK book. There are some A resources listed, I've looked at a lot of these, and my impression is that this is not the case. There isn't one inclusive review book out there that I would give higher than a B rating, with the exception of USMLE World Step 2 and MKSAP 4 being pretty good study guides for internal medicine. Toronto Notes are also up there. I will go into which books I think are the best as you continue to read, but just to start this off, you do need to realize that to some extent the gathering of high-yield information on this exam is a lot of the time up to you and not the review books. Studying is largely dependent on what you get out of your hospital experience, don't take this point lightly because you'll regret it at the end of the year.

Getting your routine down starting with the clerkship
Step 2CK really begins with the start of 3rd year, the time of clerkship. At this point, you're fresh out of Step 1, you feel like you know a lot, but as soon as you hit the ward, you realize how much you don't know. It's almost demoralizing that the doctor doesn't really care that you know that some stupid virus is an icosohedral member of the togaviridae family. That's nice you know it, but you'll end up pissing off your attending rather than impressing him, because knowing what an icosohedron is has absolutely no bearing on the indicated management, differential diagnosis, or treatment of that virus, which is what he wants to hear and also exactly what you'll be asked on Step 2.

Second point, you're probably going to be in the wards for several hours each day. For me in internal I woke up at 5:30, and got home around 5:00 every day. It's a long day, you're going to be very tired, and the last thing you're going to want to do is study. My suggestion is to make a routine. You will have a lot of down time at the hospital, use this time to your advantage. Many doctors will be late due to their own busy schedules, have your study guides readily available and use this time to work on your board studying/shelf prep. You can get up to 1-2 hours a day of studying done just due to this. It's easy to sit around socializing with your friends because you will be tired, but your time is much better spent doing work. When you get home, you're going to want to go straight to bed. Don't do it. Sit down at your desk and study until you can't really concentrate. On a good day I can get about 2 hours out of this at most. The idea is to have at least 1 hour a day during your rotations dedicated to studying, Doctors In Traing (DIT) also recommends this. The rest of your evening might be spent doing a patient write-up, a presentation, or drinking a beer.

In my Step 1 prep-post I mentioned cutting class and self study. You don't have this luxury 3rd year, you have to go to the hospital to gain clinical experience and to learn from your residents and attendings. There's really no way around it, however that doesn't mean you can't be efficient, which is essentially what 3rd year is all about. So I'd like to re-emphasize a point from my Step 1 post. Reading Harrison's is NOT the way to prepare for the boards. If you really think you're going to digest 6000 pages in 3 months then I suggest you become president of MENSA, because it's a joke to think that you'll efficiently absorb everything in this book, or that you'll even come close to approaching the last page. This is something the residents read and are responsible to know over a 4 year period. Of course they will suggest a book like this for you to read, because it is THE premiere book of internal medicine, however it's simply not efficient, remember you have 1 hour a day after the hospital to really learn stuff, lets keep it simple and efficient all the time. That's not to say you have to ignore Harrison's - if you have a presentation, then you should probably use Harrison's but as far as board prep goes, don't be a clown and think you're going to conquer a book like that.

What Sources To Use for The Boards

MKSAP Vs. USMLE World Vs. Kaplan

These are the qbanks that I think most people use for the USMLE. By far the best one on this list is USMLE World. There's no doubt this is a refined and I think mandatory resource for the boards. The other stuff should be supplemental and is up to you f you have time. MKSAP 4 is a great question bank for internal medicine however I think it should be used more as review AFTER you have completed World if you have time at the end of your clerkship. Recall that there's a considerable amount of IM questions in World, so if you finish these, MKSAP has about 500 more to do. My suggestion is not to buy the MKSAP 4 book, but to download the equivalent computer program which is the same thing but in a format that I think is more analogous to a shelf exam format, and its really easy to find a version to download with as simple google search. Again as your doing these, you should be annotating wrong questions into your review book I would say that Kaplan and MKSAP are similar in the sense that they focus on the nitty-gritty and generally aren't as high yield as World. I have heard people say that Kaplan is way too detail oriented versus World, which is good at first but as time goes on you're going to want the big picture questions. Some people swear by Kaplan, I used a PDF version of the qbank (ie the Kaplan question book) to supplement other sections such as surgery since I think preparing for the shelf for surgery requires way more questions than what World offers (I will talk about this more in the surgery section below). Finally USMLE Rx is another resource that I don't hear used too often, again if you decide to use it I'd use it as a secondary purchase after World. The questions aren't particularly challenging, however they do follow the USMLE First Aid book very closely and almost function as a flash card recall type of exercise that could be useful later on. This would be useful if you use First Aid (for CK I didn't use the FA as I outline below). Again I don't think that the standard board prep USMLE First Aid appendix has the best suggestions for what are good sources (according to their ABC scale). So I'll first start by listing what is out there and expand from there. As far as I know there are a couple main methods for a resource that probably cover what 99% of most medical students use. Before I digress on this point, I can't underline enough that unlike Step 1 none of these sources are perfect, they only provide a skeleton for which you must supplement if you want to do well. Each has their downfall you just have to choose what is best for you. I know someone who utilized each one of the resources, and scores of those people ranged in the 250's or higher. The bottom line the people that scored 269 or around there just had a harder working schedule than most others. So choose your poison based on what source you think resonates with your study style and habits.

USMLE First Aid Step 2CK
First Aid for the USMLE Step 2 CK (First Aid USMLE)

This book is very solid because it is a complete board review book which includes internal as well as the other represented disciplines. Its pretty well organized however I'd say as far as content there's a lot of stuff missing. Many of these books don't list the gold standard for every pathology or indications for studies. They do for a lot, but not all, and it can lead to confusion. This is true not only of this book but almost all the resources, and this is why I say that there isn't a "perfect source". Some people don't like the idea of using a book like this as a primary source for medicine (ie a review book). I disagree, as I've said in my Step 1 post and as I've also reiterated in this post, you're going to be lectured all day on what's important in medicine. A book like this should solidify the important points, indications, differentials etc. Harrison's isn't going to get you anywhere fast unless you spend on taking 4 years to do 3rd year. The graphics and pictures are this book's strongest asset, but you will have to supplement with USMLE World annotations just like you did in Step 1. Again if you're using this book and are in the final stages of review and just need more questions, USMLE Rx is the qbank that complements this book, but should be used *secondary to World.

Step Up to Internal Medicine Vs Step Up to Step 2CK

Step Up to Medicine book is probably the most solid internal review book out there in other words the best summary of Harrisons. The issue is when it comes to reviewing other subjects such as OBGYN etc. you'll have to use something else. My suggestion is to use the related book Step Up To USMLE Step 2. It's by the same company, it has a more abbreviated but solid version of IM within it and it also includes all the other core clerkships. This is the book I used for my boards. The reason I like it so much is because it is the book supported by DIT. Again I don't think DIT for Step 2 is particularly good but at crunch time, it helps meter you out and review the book in an organized way. The big issue with these books is even though they are some of the better sources for reviewing the boards, there's still a lot of missing info in these books. In particular you're going to have to tackle what the gold standard is for imaging and treatment for most pathologies, please don't overlook this point because it can cost you around 15-20 point come test day if you don't have these facts organized. While it lists what all the treatements are it doesn't say what the gold standard is per se, and this is probably one of the most high yield pieces of information you need to know. So as long as your aware of the deficit going into 3rd year, you can compensate by writing in the appropriate notes from World about the gold standards etc. The other downside is that the pictures and the diagrams are not as good as USMLE First Aid. Again the reason I chose this book is because of the DIT review and because I think it is the lightest and most concise board review book. It's eerie at first how thin this book is, but as I said this is something I look for. You're brain is going to be overloaded with lots of information any ways why complicate things. Keep it simple with concise book rather than a giant thick Harrison's that you cant retain at all by the the time you're done reading the chapter. For this book I'd also consider looking up the errata because there are a couple typos that can be annoying. Take care of thee before reviewing the book so you don't absorb any incorrect information. A simple web search can bring this up, alternatively if you plan on doing DIT they have an errata built in to the curriculum you can utilize as well. I personally feel that DIT and Step Up to Step 2 is the most organized and efficient system out there.

Master the Boards Step 2CK by Conrad Fisher

This book isn't as widely used but people who use it love it. This book was authored by Conrad Fischer who is notorious for his eccentric board prep videos. This is a solid book, things are well organized, however a downfall again is that it doesn't always include the gold standards (someone correct me if I am wrong), and it also is missing a lot of information. If you've been 100% Kaplan up until now ie using Kaplan videos for step 1, this is not a bad review book. Kaplan's Step 2 Review videos are by Conrad Fischer so this is a good source to use if you want a video lecture series to complement your book. I still prefer the DIT method because its more active and has all those additional questions, however Conrad's videos are no where near as boring since he is so animated. It's really up to you but again I know people that have used either First Aid, Step Up or Conrad Fischer's book, and all have done well. Go to a book store and compare them yourself to see which format you like the best after reading through this.

Clerkship Primary Sources to Accompany your Review Book

At this point I feel like I am beating a dead horse when I say not to use books like Harrison's as your primary sources for clerkship. My philosophy is to keep things simple and dense, I don't need fluff, I need the facts and to organize them as quickly as possible so I can be prepared for my shelf and the boards. Efficiency adds points to your board score not fluff. What I would like to suggest as primary sources are merely more extensive board review systems than what I listed above. The first one is the Toronto Notes series. I think these are incredible. They are concise and list the gold standard and primary imaging studies needed for every pathology. The algorithms are great, and its a very streamlined. Again I use this for my initial read through a clerkship. My second read is with the board review book I chose above in which I add in info from the primary source. I will go into the whole system of how I do that later on, but this really constitutes as an A source for your primary texts. The best part is there's a section for each core clerkship and you can print each one out. What I would suggest is printing these books out with each clerkship, and bring them in with you to the hospital. Annotate in the book as you go through lectures and read along. This way you'll get a lot of the lecture and it will be a very active session. Bring this book home and as you're doing World questions, open your Toronto notes to the relevant page and annotate any high yield points (most importantly the gold standards). Some people do the same thing with the Kaplan note series. Again I am not the biggest Kaplan fan so I won't be talking to much about these however, I mention it just for those people that prefer this source know it's around. The bootleg PDFs for both these sources are out there circulating on the internet, I'd suggest downloading them and saving some money.

Phase 1 - Specific advice for each clerkship leading up to the Boards

Internal Medicine
To give you an idea of how important IM is for the boards, you can expect about half of all your questions to be IM. There really is no other option than to do well in this unit if you plan on doing well on the boards. USMLE World Step 2 CK has 2234 questions (as far as when this was written), 1165 of those are IM, OBGYN has 165, Pediatrics has 288, Psychiatry 126, and Surgery 128. To me that was pretty sobering the first time I saw that. Assuming that USMLE World is accurately portraying the distribution of questions on the real thing, which is pretty close, IM is obviously the most important, and Surgery (which tends to be one of the most miserable clerkships), doesn't have anywhere near the weight, in fact paying attention more in Peds would be a wiser idea than worrying about Surgery!

USMLE World Step 2CK, and MKSAP4 obviously have a lot of weight in this clerkship. These are two qbanks that are very high yield and worth doing. It can be challenging to complete both world and MKSAP 4 but if you break down a schedule it isn't too bad. If you have a 10wk schedule you could imagine doing 200qs/wk which is a little over 20 a day. Whatever you have to do but I think its very important to complete each clerkship having also completed the relevant qbank questions. I can't drive home this point enough, if you don't keep up with questions during the year, you'll be behind when its crunch time. For internal medicine you can meter out your questions according to your sub-specialties. For example when your doing cardio week, read the cardio section of your book, and do the associated answers.

As a primary text I mentioned Toronto Notes being very good but for this section it might be better to use Step Up to Medicine (as opposed to Step Up to Step 2). Bring your primary text to the hospital and annotate in it during lecture and read along with it during lecture. You're going to be tired just listening to someone talk and talk will make you fall asleep. At least this way you'll be doing some active learning using a board review style book. When you get home start doing your questions, open your primary book to the relevant page and copy the important points from your primary text (ie Step Up to Medicine) and your questions into Step Up to Step 2. This process will seem repetitive using both Step Up books at this time, but that's a good thing since you'll be crystallizing the important points over and over again. By the end of your clerkship you should have all your questions done, and you should have done quite a comprehensive review of internal medicine. If there's still time you can continue the process using MKSAP 4.

Also I'd suggest getting a tablet computer for your clerkship. You'll be rounding a lot and wanting to look stuff up. I use a kindle but now that the ipad mini is out, that's a great option too. For internal medicine the hospital reference books I'd suggest include Oxford handbook of IM and Pocket Medicine (colloquially called "cheese and onions" by the British due to its color scheme), The Mass General Hospital Handbook of IM, Tarascon Pocket Pharmacopoeia. If you can't find an ebook version I can guarantee you there's plunty of bootleg versions circulating around the internet. You might even want to put a bootleg Harrison's on there for reference. Great apps for your device include Epocrates for quick pharm information, Diagnosaurus, and obviously the Qbank World app is great to have for when you have down time. A lot of good rotation-specific advice is provided on DIT's advice page.

Surgery sucks, because you usually (obviously depending on the school) spend a long time on this rotation and as far as the boards it's just not that high yield. Recall that USMLE World has about as many questions dedicated for psychiatry as they do for surgery. Frustrating to say the least. Your time is better off reviewing internal medicine for the boards during your surgery rotation than spending all that time dedicated to surgery. Unfortunately what's good for the boards isn't always good for your shelf. So you have to weigh your personal needs (ie do you want a surgical residency -- thus doing well on your clerkship) versus do I want I high board score? The truth is, much of the surgery shelf, in fact a very large chunk of the surgery shelf is really internal medicine style questions, so mixing in some IM into your world prep for surgery is a great idea.  Thus here' a chance to catch up. If you have 8 weeks in surgery like I did, and you have only 126 surgery questions total in world, you might consider doing 500-800 questions in IM to keep yourself fresh and if you didn't finish your questions during your IM clerkship, you can now. I'd also suggest supplementing the lack of surgery questions with the Kaplan Qbank pdf file which has about as many questions as world to be prepped for the shelf. The NBME shelf was pretty rough from what I remember, so doing questions both IM and surgery during this time is pretty important.

The same system as far as preparing this section should be followed. Read your primary source and then go to your secondary source such as Step Up to Step 2 to fill in the details. If you are using Step Up to Step 2  you will notice how little is covered in surgery. Again I know it's disconcerting but you have to realize that Step 2 CK really doesn't consider surgery that high yield, that that is reflected in whatever board reviews you  use. You will have to rely on the standard of care provided by your primary text to fill in the blanks, and to annotate your secondary text. I think that DIT's clerkship advice recommendation of Surgical Recall is an expensive and relatively worthless tool for your surgery rotation. Its question answer style is good in theory, but it's pretty hard to internalize anything. Dare I say for the first time that this book is just too simple? It gives basic facts, but it misses all the stuff asked on the boards in terms of gold standards and worst it lacks organization. I think I am in a unique position to critique this book considering one of my professors helped author the book and thought himself that Toronto Notes was much better.

Again, many sources can't beat the concise but high yield nature of Toronto Notes. The surgery section of this resource is great, and you can really internalize a lot of the information in this book much more effectively  and the important points can be copied into Step Up for Step 2 for repetition. Also the whole concept of note taking into the Toronto Notes during lecture time applies here, as for all the rotations I will discuss. I will say however, DIT's study plan as far as the questions for surgery isn't bad especially with pretest qbank, but don't do this at the expense of World. Just use things like Pretest and Kaplan to supplement, especially as I mentioned in the context of the shelf.

For the sake of not sounding repetitive, the same general advice in regards to surgery applies to peds. Perhaps the only thing more I might have to add is that according to World peds is about twice as high yield as surgery, just look at the stats. Again get your World questions done, keep fresh with some IM questions, and look at some Pretest or Kaplan if you need some supplements with the q's. Toronto Notes is also very solid for Peds as a primary source. The Step Up to Step 2 section of this again is small, and probably the worst section of the book. Add what you need to from Toronto Notes to make it up to par. I know what I'm saying is discouraging about Step Up, but realize that none of the other review sources for Step 2 are that much better. Remember even though surgery is low yield, do a couple of the wrong answers in world when your doing peds to just to keep it fresh.

Again, I'd have to refer to what I said about Surgery for OBGYN. People promote the Beckmann online question bank. I really can't comment on this because I didn't utilize it, but it could be a good supplement to the world questions, I've heard it is but I can't say for sure. I did fine on the shelf just doing my same old method - Pretest is always solid too. You should be doing occasionaly wrong answers in surgery and peds at this time too.

Ok this is your big break. This is not a hard subject. The second major phase of your year has now begun, your second round on World should probably have started by now assuming that this is your last rotation like it was mine.

Phase 2 - Preparing for CK at the end of your clerkship
At this point, you've been keeping up with World all year. You should have now completed the qbank ideally.  If you haven't which is understandable, start crushing questions. This should be roughly 2 months or a little less before your exam. Your constant review should be keeping you relatively fresh. Now its time to buckle down. Spend an hour or so reading a section of Step Up to Medicine. Do a section of world related to that topic. If you have time do 20 wrong answers in random categories, that's very productive. Obviously any question you do should be reviewed if you got it wrong and review the relevant annotations in the book. As a quick efficiency tip, USMLE World Q Bank has an area in each section that allows you wrote notes. Use this section of the question to write down the page number your annotations are on in Step Up (doing this from the beginning of the year will make referring back to the book a very quick process by the time phase 2 rolls around). It will save you lots of time you'd be surprised. Doing 60-80 questions per day (and more if you feel like you can handle it) will get you doing 1800-2400 q's over the course of a month right in the range of the entire q-bank. Not easy, but doable you just have to sit down and write up a schedule that works with what you're doing at that time.

Phase 3 Final Month of Prep
At this point you have come a pretty long way. Hopefully you have these last couple weeks off, without the interference of clerkship, if not, then I suggest starting earlier for your board review. You have a month left, and you need to come up with a good schedule that balances review as well as question prep. This is where the DIT course comes into play. DIT is designed as the last push for board review. As I mentioned, compared with DIT for Step 1, this is no where near as good, however there's not many other options out there. There is Conrad Fischer's Kaplan review videos however they don't have an accompanying question book for active review, and they don't go through a board review book systematically like DIT does with Step Up to Step 2. Thus if you've been using the Conrad Fischer book in conjunction with his videos you will have to plan out your own schedule that takes into account reading the book once through, and getting through a large chunk of board questions (if not all of them) in time. I will only be commenting on the DIT method because that's what I did. If you have a month left, you're in good shape. If you do on average 2 videos per day you will have gone through Step Up one more time and doing about 2 sections of World per a day, you would have also gotten close to finishing off World again. Thus reflecting on all the work you've done so far, you've annotated your Step Up to Step 2 and read through it several times doing so. You've done it again with DIT. You've been through World almost 3 times. That's a good place to be in. There's no time to take off, remember you also have the USMLE World practice exam at the beginning of Phase 2, take this for baseline to see where you are. Realize that the USMLE World exam is slightly inflated, so its nice to take first for some ego building. By the final month take one per week. There are 4 NBME Practice exams total, one for each week of review. Some people get a lot of anxeity about taking these. Don't put these off because of that. Obviously this is very stressful, but don't let your stress interfere with what you need to do. Also note that feedback for the NBME exams are limited. There's only one with expanded feedback available meaning that it will tell you if the answer is right or wrong, but not why. If you need to look up answers, they all exist just type the question verbatim into Google, and a your results should include discussion forums debating the correct answer.

If you're keeping up with this demanding schedule, you should be pulling 12 hour-14 hour days for the last couple weeks. Its grueling, but necessary, the CK is even longer than Step 1, its 8 sections as opposed to 7 sections. You have to keep in mind one critical aspect of preparing for this exam is stamina, you will become mentally fatigued. If you follow this schedule, it will be like training with a weighted bat, once you take the weight off the real swing will be a lot easier.

If you're doing 2 DIT vids per day, you should have a little spare time in the last week. Some of these days will be taken away by doing the practice exams. With everything said and done, you should have maybe 2-3 days left. Spend those last couple days skimming through everything you just covered in DIT, run through the  Step Up to Step 2 book really quick just to keep that recall fresh. On your last day, don't think about your exam, go to the beach, whatever it is that you enjoy do that. Have a good meal. This last week you also need to get on a regular cycle. Wake up as early as you would on exam day. The night before get to bed early, even if that requires popping an ambien. Have a bag prepared with everything you need for the day. Don't eat foods with a high glycemic index, and eat small quick snacks between sections. You don't need to be dealing with a food coma in the middle of a 9 hour exam. Bring all those emergency creature comforts too Visine, Imodium, whatever it may be to ensure that your day is smooth as possible.

This whole method is loosely based off of a friend from Yale who wrote the Step 1 First Aid book a couple years back. I say loosely because DIT didn't exist when he told me his method. I think DIT incorporates the same type of last minute review, but you have the input of an expert lecturing you as well. I know this is demanding, but this is what people do to kill their exams. Take from it what works for you. However my biggest advice of all is, no matter what you decide, once you have created your schedule, stick to it. There are many people who will tell you what they are doing to study. Don't be pressured or listen to them. Be confident in your own abilities and know that this plan is a solid one. The worst thing you can do is set up a plan and then at the last minute deviate because another plan sounds better. It will end up making you feel less confident, and destroy the continuity of whatever you had already set up for yourself.

Best of luck!

Wednesday, September 5, 2012

What's wrong with the medical system of America

In general there are a couple things that people can't live without. Shelter, food, clothing, and access to healthcare are the basic necessities that I think most people would agree on. Most of these don't require training to obtain, except of course for proper healthcare.  Ask most doctors what they've been through to achieve their degree, many will say they've sacrificed quality time with their families, happiness, personal relationships, and health all in the name of helping other people.

Doctors as a group represent of body of people that are generally altruistic, selfless, and by virtue of their profession they must have a high ethical backbone. Obviously this is not true of all doctors, and if anything doctors are not put on the same pedestal they once were. Doctor's almost had a saint-like persona several decades ago, and perhaps the increase in access to information has led to people questioning them, which to some extent is a great thing, on the other hand I think this change has also pushed many people to believe that doctors aren't good people, in fact a sort of demonetization of doctors has started to occur in the past 30 years or so. Doctors have been accused of being greedy, corrupt, and people blindly believe this, without asking a fundamental question, why has this behavior started to rear its ugly head? Why in the last 30 years have doctors been documented being crooked perhaps more so than in the past? The answer lies in the flaws, and changes in the American health system as we know it, and as you read, I think these points will clarify themselves. You can almost think of this as an economical approach to medical corruption, in other words, we will analyse this problem in a "Freakonomics" sort of approach.

One of the first complaints you hear is how doctors are just making too much money, and I am fundamentally against this claim. If anything the movement to decrease the doctor's salary has fowled up the purity of medicine, leading to a vicious cycle of decreasing the quality of healthcare in this country, and the only way to see this is to understand things from the doctor's eyes, which I truly believe most people just simply don't get.

Let me start with an anecdote that might help you to "get it". I have dated plenty of girls during my course in medical school, and while I would love to give them more attention and more of my time, right now school is my priority. The issue is this, if I want to be the best doctor I can be, my education must take precedence. I'll spend several hours a day or more dedicated to this end, and when I tell a someone I care about who wants to meet up that I can't because I have to study, initially it is fine. Many people that aren't in the medical profession can't simply grasp that we are as busy as I claim to be. This eventually leads to the end of the relationship. I am not complaining, I am just merely pointing out a small aspect of the larger picture, doctors really do sacrifice a lot and even if you can appreciate the fact that they do give up a lot, it still seems to be a challenge for the outsider to appreciate the impact this causes on their own lives. The point is, to enter medical school, there is simply no way you can hate what you do. You have to have a passion for medicine, so much so that you're willing to give up a lot, whether it be a relationship etc and this in itself should give you some idea of the selfless attitude you MUST have in order to become a physician. Not only is it required, but if you don't have these qualities, the system will filter you out, and make it very hard for you to achieve such an end.

The reason I mention all this is because as I said before people get angry about the large salary doctors get. This is not out of greed. As I mentioned above, if you're just in it for the money, there's almost no way you'll be able to become a doctor because the system will remove you, its just not viable if you don't have a passion for medicine itself. So if they aren't greedy, why should they get so much money? Let's start at the begining. The doctor is groomed starting in college. Most people want a doctor who has a solid education, so a smart college student is going to try to get in the best school possible. As an example, I got into Emory University, my family gave up a lot for me to go here, because they wanted me to get a great education and enable my the best chance of being a great doctor. Oh, I forgot to mention, Emory costs $40,000.00 dollars per year. By the time I finished I was $160,000.00 in the hole. Even with my competitive resume, I didn't get in on my first shot, and considering the cut throat nature of the medical application process, I decided to bolster my resume with a Masters degree. Oh, I forgot to mention that cost me $50,000.00. I finally got into medical school, and by the time I finish, I will have reached my goal of becoming a great doctor. Oh, I forgot to mention the fact that those 4 years cost me $200,000.00. Now, if I reach my goal of obtaining a residency in Manhattan, I will start my first year by making roughly $50,000.00 pulling very heavy hours. Not only does that salary absolutely not reflect the amount of work put into the job, but in Manhattan $50,000.00 will give you a little more leeway than treading water. In essence you'll be making slightly more than you'd spend. Oh, I forgot to mention residency is 5 years, a fellowship can be up to 3 years, at this point I'm in the late 30's and because you've been treading water, it was necessary to defer loans for 8 years. If you've been keeping track, I should be close to $600,000.00 in debt due to the interest on all those nice loans. I'll be around 36 by the time I land my first fat paycheck as a fully trained doctor, and I'll most likely have started a family maybe around this time, each kid roughly costs $200,000.00 over a lifetime. I won't get to see my family as much as I would like because I would be on call all the time. So everything said and done I'll be at least 40 before I get anywhere near the positive in the bank account I've been waiting all my life to even approach. Again, I am making this sound negative for a reason, I am not trying to complain, because I've known all my life what I am getting myself into, and I am a happy person about it. My point is to show the amount of investment needed, versus when it starts paying off to show why the doctor makes "so much money" or so it appears.

Within the last 30-40 years or so, the financial vice on doctors has been becoming more and more intensified. The "demonization" of doctors (as I mentioned a couple paragraphs ago) has led to society saying wait a second, why are we paying this so much if our healthcare system (things like medicare, and medicaid) needs more money? There's a couple reasons for this.

First there's the illusion as we've already reviewed that doctor's are making a lot of money simple input/output shows why this isn't true. Secondly, doctors are not a powerful entity. If you look at similar healthcare professionals such as dentists, they have relatively powerful lobbying groups defending their rights in congress. This explains why dentists have enjoyed a relatively stable salary level over the past several decades. On the other hand, the AMA is supposedly the doctor's voice in congress. One of the first things you learn as a doctor, is this isn't really true. It turns out the AMA makes a lot of its money by helping entities such as insurance companies and big pharmaceutical companies due to its unparalleled access to information about existing doctors. This body of information affords the AMA the privilege of making a huge profit by helping organizations that don't necessarily represent the best interests of the doctors and thus the doctor's voice has been weakened as insurance and pharmaceutical companies continue to spread their tentacles into the health system.

What this means is that whenever the government needs to tighten the screws on things such as medicare or medicaid, the easiest group to pick on, of course is the weakest group, the doctors. So instead of limiting insurance premiums or lowering the price of drugs (which wouldn't be the biggest tragedy for multi-billion dollar multinationals etc.) doctors get the punch from the government, this doesn't sound like much, but doctors suffer a lot more from this than you would think.

When you wake up in the morning and go to work, there is no chance that you question receipt of your paycheck. If your boss ever pulled a move like that, you'd be enraged. This kind of thing is unheard of, and is virtually absent according to the contracting standards of American society. However, consider the following scenario, imagine you had to see 20 patients a day, and 50 percent of those patients are covered by government backed insurance (whether that be medicaid or medicare etc). At the end of the week, the doctor sends in the insurance claims so that he or she can be paid. If the government is low on funds for that month, they will simply refuse the reimbursement. This sounds crazy, but its true, and I'm not understating the significance. It's not legal but it happens all the time and it's frankly disgusting. So the doctor is angry about this and decided to resubmit his claims. Second time through, he might get paid. However what this system allows for is the following, it sets up a hard to navigate system, that's extremely time consuming (a luxury most doctors don't have), that results in many, in fact up to 40% of the doctors not reclaiming their unpaid services. This means that by simply not paying doctors the first time the government saves 40%, and eventually pays out the other 60%. This is ridiculous, should doctors really have to play a cat and mouse game just to get paid the hours they put in for service at the price that was agreed upon? On top of this, even if the above scenario is not the case, there are many ways that insurance companies skirt paying doctors, for example if a doctor happens to omit a file that they followed a certain protocol, the insurance company can deny payment simply based on omission and may be reasonably justified, but where this becomes complex is on very small points. This seems simple enough, but its not, insurance companies will nickel and dime and find any loophole to deny doctors their rightful pay even when they are following protocol. It just gets messy very fast. So you might ask, why don't they hire a lawyer? An in-house lawyer would cost about as much money as a doctor would loose to the insurance companies on a yearly basis, if not even more. On a monthly basis we may be talking about numerous different claims the insurance companies might be denying, to attack each of these individually is simply not economically or temporally feasible. The insurance companies know this, and take full advantage. Again where's the representation for the doctors here? Why should anyone tolerate such abuse?

So again going back to the original point why do people think that doctors are blood sucking and money hungry a lot of the time? One story I heard involves a neurosurgeon who is taking out bank loans just to keep his practice in order. Most of his patients are insurance referrals, and he gets screwed just like all the doctors as I mentioned before. So would someone in this position of desperation order some unnecessary tests, do something medially unethical to catch up on the hundreds of thousands of dollars in loans accumulated since college? Maybe more so than if he/she wasn't in that position.

On top of all this we now have ObamaCare. I will not begin to even claim that I understand a 2000 paged document that at most 5-10 people in all of congress actually understand fully. However I think we can all agree that one general principle is to increase access of healthcare mainly based on making it required for citizens to have medical insurance that they pay for. Ok wonderful this isn't the worst idea, I am happy that more people will be able get health care that they need. WAIT. Did you just say more insurance company involvement? Some might say ok, now doctors are going to be paid more because now insurance companies will be billing more clients. That is good, I agree, more salary for doctors. WAIT, you want the same companies that have been screwing doctors all along to be responsible for a greater proportion of their salary? Sounds like a bad idea to me. We simply can't have a law like this unless we have some type of mechanism ensuring that what this legislation intended, actually occurs. What about some laws that ensuring that insurance companies pay doctors what they're supposed to be paid without all the BS? The way I see it, the whole system will appear to work for everyone except for the doctors. Which if you're not a doctor may not concern you that much. Well you should start thinking it will, because many more apathetic doctors are going to bill frivolous tests, and do frivolous things to make up for everything they're getting shorted. In other words more doctors will practice crap medicine to put food on the table for their own families. This pattern will trickle all the way down the chain, and decrease the overall efficacy of healthcare.

Obama if you want me to vote for you, tell me how you plan to protect the doctors of America? How to you plan to ensure your entire medical system doesn't become even more frivolous if you have no way to ensure doctors won't continue to become more apathetic to the illegal practices of American Insurance companies?

Tuesday, June 12, 2012

Cigarette Culture of the Middle East Through the Eyes of the Hospital.

Walking around Tel Aviv, you begin to realize that there's basically two things that define Israeli culture. Simply put, you're not Israeli unless you have a daily coffee, and a half pack of cigs. I'd compare Israelis to America in the 80's as far as cigarette habits. While laws were recently passed here to stop smoking in public venues such as bars etc., there really has been no effect, and if anything Israelis have dealt with the law in a distinctly "Israeli" way. For example, there's a bar on Dizengoff Street has a police light that can be triggered by the bar which alerts everyone to toss their cigs when the police come to make their rounds and hand out fines.

This is just the tip of the iceberg however. I'll never forget my first day of physical diagnosis. I was nervous because this was supposed to be the first time I was exposed to patients. I had a good experience that day the first lesson in physical diagnosis was pretty memorable. However for some reason I felt the need to cough every couple of minutes and I couldn't understand why. I thought I smelled cigarette smoke but that just seemed too unlikely, so I ignored it. After several more visits to this ward, I realized this was something that was reoccurring. We were finally introduced to the professor of the ward, who came out of his smokey office to talk to us. I couldn't believe it, the head of our internal ward was habitually smoking cigarettes in his office which was adjacent to several patients. Patients who were on respiratory support, had COPD, and a host of other respiratory conditions that don't do so well when aggravated around smoke. No one cared, this .. apparently is normal in Israel, that's just how things are. (On a side note, there's an extra story worth mentioned about this professor. The ward I was in was known for having a lot of gay doctors. In the 80's my professor was facing the outbreak of HIV in Israel. One of his patients needed to be worked up, he required a list of the patient's sexual partners in order to inform them of their potential exposure. When he looked at the list, sure enough one of the patient's sexual partners was also a sexual partner of my professor. Needless to say the professor checked out clean).

The ubiquitous nature of smoking in the hospital really began to hit me the more time I spent there. When I would come down from the ward I would see a host of patients walking around with their IV-on-wheels in one hand while the other hand they were smoking cigarettes. Sometimes I would notice that the IV was filled with chemotherapy. A cancer patient smoking a cigarette? I couldn't believe it.

In my latest rotation, OBGYN, another shocker, I couldn't believe how many pregnant women were smoking. While there is no documented evidence that smoking causes deformities, it does raise the risk of several life threatening conditions for both the mother and fetus. For example, preterm labor, premature rupture of the membranes (premature water-break), and placental abruption are just a few. I walk out of the OBGYN building everyday to see at least one woman, sometimes several, gathered around smoking cigarettes.

Along the lines of smoking in the hospital, I know of some students who have smoked weed while they are at the hospital. I don't condone this, at all and nor have I ever done this myself, but it does happen, and its a lot more common than you might think. For those of you who are medical students, I can tell you that a former medical student attending a top 3 school, would smoke with several other students before rounding the wards in the hospital. He may or may not have been a co-author of the USMLE First Aid. Pretty crazy to think about. Whether you believe it or not I don't care, I don't have much to lie about or to gain from doing so, but it's definitely true.

I am doing my psych rotation now, and having been there for 2 days, I can tell you that the entire ward stinks of smoke, and most of the schizophrenic patients do as well. In fact, there's a whole reality gating theory that says that nicotine might help psychosis in schizophrenics, and this may be one of the reasons why they smoke more than most other groups of people. Anyways until next post, off to the wards ..

Wednesday, June 6, 2012

The "Pill" is not making you gain weight ladies ...

Most guys have encountered the cliche that oral contraceptives (OCPs) also known as the "Pill" make her gain weight . It's a wide spread myth that most women believe, and unfortunately it's also a belief that many medical professionals also think is true. If you polled medical students most would probably tell you the association exists.

While pathology that has high estrogen levels have been associated with obesity (for example polycystic ovarian syndrome PCOS), the estrogen itself is not the causative factor of obesity. It is true that if you have more fat tissue, you will make more estrogen because of an enzyme in the adipocytes called aromatase. This enzyme has the ability to take precursor hormones and convert them into estrogen. So to restate, if you have lots of estrogen (due to the pill, or PCOS etc.) it doesn't mean that you're obese, however, if you are obese you will have higher than normal estrogen levels.

Still don't believe? Recently in 2011, the Cochrane Review published an article explaining how OCPs do not have an associated weight gain. You can see the abstract here. This study was extensive, it is a meta-analysis meaning it pooled all the studies that are out there looking at this association, added up their data, and came up with a conclusion based on the data from all these studies. In other words this is the most comprehensive analysis to date. They started from a pool of over 500 publications, and with their exclusion criteria, they knocked down the list to 49 studies. The data pooled from these studies included several thousands of women and statistical variation was very well controlled between the studies if you look at the methods.

What are my conclusions? Ladies, quit getting lazy once you get a boyfriend ...

Friday, April 6, 2012

The importance of knowing your patient.

Life has a funny habit, when you think you're smooth coasting, no one thinks about the potential sudden turns in that road of life. For me I guess this is how I've grown as a person. I think I've lived a lot of life, probably more than a lot of people my age. As a medical student I see so many of my peers who have just coasted, never had a bump in the road, a sudden turn. I won't say it angers me, but I almost wish that some of my peers had more experience so they appreciated where they are more. It's hard for me to imagine at the age of 24-30 how some of these people never struggled. Sure they know what it means to work hard, to get a good grade, but there's so many people that have had their parents solve every little problem.

I would never be the one to hate on someone else just because they have advantages given to them all their life, that's not the point of why I am writing. I think the point is that no matter what you're situation is, don't take it for granted. Just because you have money today, doesn't mean you will tomorrow for example. As a doctor this has numerous implications. And I guess I am just learning that for myself now. My father passed away recently, and I guess what I would like to do is write about what I am learning about myself, how it can make people better clinicians in the future.

I've had a couple moments in this year that I can look back on and realize how far I've come and how much I've changed. One of my prior posts talks about a lady I took a history from. She was told that she had 6 months to live or less the day I interviewed her, a detail that I didn't know until I was walking out the door and she told me. I went through a a whole two hour history without knowing that, thus completely insensitive and unaware of her emotional state. I blame my tutor for pairing me with this patient because I feel that this was highly inappropriate to pair a medical student with someone who just got that type of news, but I also blame myself for not picking up on this sooner. As the questions rolled on, I asked her about her sisters, one of which died recently. She got very emotional, and looking back on this, I was very insensitive to her loss, yet at that time I couldn't appreciate why. The reason is I never experienced a loss like that in my life until now. And this is what's contrasts the doctor fresh out of medical school and the doctor 30 years out. 

I have several friends who have the ability to really empathize with people who had a loss. In my naivety I never really appreciated what this meant. And I guess I would have to say that my peers have the ability to truly empathize with patients in this respect have a gift, because in my case it took a horrible experience in my own life to be able to add this dimension to my doctoring abilities. The doctor 30 years out, has experienced loss and multiple challenges to that otherwise smooth road of life. He is able to feel the emotions of his patient because the same things have happened to him, and this is fundamental to building a successful relationship with your patient. 

I think the important message is that you don't have to experience loss to empathize with someone, however you do have to see it from their perspective which seems at first glance relatively easy, but it's not. The next time you hear a patient say their sibling suddenly died, pause, take a moment to think about what this really means. Imagine if you have a sibling, and what life would be like without that person. All the memories you ever had, end on that day, and you have to keep those memories. This is just a small example of what I mean, but these are the thoughts that you're patient is thinking constantly, and this is what you must be aware of, because it will change the way you approach your patient, and expand your abilities to be a great doctor. Really try to put your mind into your patients head and you will see your clinical skills grow exponentially.

Friday, January 6, 2012

First weeks of Surgery rotation

So my first couple of weeks in Surgery have been pretty interesting. I think I've narrowed down my interests even more since I've started this rotation. Internal is much more interesting to me, however Surgery I find, a little disappointing. I guess in general its a much less structured program, which seems to be inherent across all the hospitals, I can come and go as I please, no one seems to really notice or care that much. In some ways  I feel like the surgeons don't take as much interest in the education of the students as the internists do. I felt very close with my ward by the end of my internal rotation, however I have to say that for surgery I feel as though I am more of a burden rather than someone who they want to take an interest in teaching. It's hard to be enthusiastic when you feel as though the teachers aren't interested in teaching you. Also Ichilov has 18 students which can get a little irritating because everyone is trying to get into the same surgeries etc, so there's a lot of issues I am still trying to work out as far as how to maximize my experience during surgery.

I don't think I want to do surgery at this point, and I am trying  to make that decision in the most objective way possible despite my opinions of the program so far. I think the thing I like about internal is that your mind is always consumed, you're always thinking, preoccupied with some aspect of the ward. In surgery, I think initially watching these operations was interesting, however I began to realize that each one of these surgeons are specialized and have done the operation 500 times before. I think there's a level of routine to any medical profession, however I think that standing over a table and doing a surgery for the 100th time in a row, becomes less of a mind occupying exercise, and more of a muscle memory maneuver. There seems to be no differential diagnosis in tying 100 knots in a row.

Although I haven't said anything very positive about surgery thus far, I do have to say I've had some interesting experiences that I can take from my clerkship. During my first week my tutor called me up at 10:00pm to tell me there was a liver transplant procedure happening. They had already begun harvesting the organs from the donor who was taken of life support machines a couple hours before. One student who stood in on that surgery felt the heart fibrillating as it began to stop when the pulled the plugs. I cam to the OR at 3am, where they spent 2 hours prepping the liver, tying off collateral vessels that were supplying some of the surrounding connective fat tissue etc. One the liver was prepped, they started operating on the lady who has a cirrhotic liver due to NASH. She was getting ready for her 50th birthday party, when they called her up and told her a liver donor was available, get to the OR now, so ironically quite the birthday present. The surgery went until 1pm the next day, I stood in for all of it. It was my first real interaction in the OR and I was definitely fascinated by it. I thought one of the most interesting things about the whole procedure was watching the anesthesiologist manage the patient. This was obviously a major surgery and there were huge amounts of blood loss occurring as they were anatomizing the IVC and the major vessels of the liver. You'd see the hematocrit drop to 7.9 on the blood analysis and then 10 minutes to 15 minutes later when they go a new blood report you'd see the HCT go up to 10 as they added a couple units of blood. It was a marathon of a surgery but quite the education. 

Another disconcerting point is how often I've seen or heard of patients waking up in the OR. I was sitting in on one procedure where a woman was in a lithotomy  in order to close of a perianal fisutula secondary to Crohn's Disease. While they were debriding the granulation tissue, all you could see was legs starting to move in the braces, which was a bit of a crazy scene. Imagine someone in a lithotomy with only their anus exposed in the sterile field waking up .. needless to say, the anesthesiologist had to move quickly. I heard of another story occurring at Assaf Harofeh where a patient with a laprotomy woke up in the middle of the procedure and most of the intestines started spilling out of the abdomen. Another horrifying story, however one can only hope that the propofol and the fentanyl were enough to give the patient sufficient amnesia and pain control, to make the situation ok, one can only hope. Either way the surgeon that case lost it, and demanded that another anesthesiologist come in, rightfully so...

Last post about internal medicine.

This was our final week of internal medicine and even though we were crushed with work I have to say I'm really going to miss my ward. I think as time goes on a sense of family seems to develop between everyone in the ward, and it was a great feeling to earn the respect of the doctors -- and to some degree form friendships with several of them. As I said before I had a horrible experience with my professor at the beginning of internal, he literally destroyed me during rounds, made me feel so small and not confident that I didn't know how to speak around him! I thought I'd leave my ward being bitter and angry but as time went on, he warmed up, and I guess I see where he was coming from now. He is of the army mentality, break us down at first and build us up stronger than before. I have to say that I am very happy that he finally respects us and feels that we're fit enough to move on to surgery I see where he was coming from and really appreciate everything he did.

The conclusion of our internal clerkship was pretty exciting for me. I had to stay late on the last week, and the doctor I was with went out on a limb and let me do several invasive procedure in the evening. He needed to do a central line and so he let me do the entire procedure. The man was demented and all of his veins were shot. The central line was needed because there was simply no way to access him with any of the medications he needed. It was a subclavian central line so we did the usual approach 2 cm below the mid-clavicular line. We put the needle in and finally drew blood, it wasn't pulsating or bright red so we knew we were in. I put in the guide wire and catheter, and then when it was time to cap the line, blood came pulsing out bright red ... somehow what we thought was a vein, was not a vein, somehow we accidentally accessed the heart via the aorta ... not a good thing to say the least. The next morning the doctor on call tried to do the procedure again this time going in through the jugular in the neck, and this patient's veins were so bad even this attempt failed. The same night I got to do a spinal tap which was also really interesting, and I have to say this was a lot more successful!

Now that internal is over, I am pretty sure I can say its not for me, but then again we'll see how surgery goes. I am also looking forward to not having to wake up at 530 in the morning to get to school. Ichilov is right around the corner from me so life should treat me much better this time around.

Monday, December 5, 2011

Stories of the Ward: An Israeli Spy

I've had several learning experiences and interesting exposures in the ward. I'll start with a patient with an interesting social history, she's reasonably well known so I won't be using her name, but she was admitted with sub-acute endocarditis due to Strep. Bovis infection, so she is under clinical suspicion of colon cancer (due to the association between the two conditions). 

The first time I saw her, was during colonoscopy where she was diagnosed with colon cancer. Staging etc. is unknown to me in this case, I didn't follow her path work up so I don't know the extent of her condition. However her social history is very interesting. A fellow student in my ward did her intake and it turned out she was an active member of the Lavon Affair. To make a long story short the idea of the Lavon Affair was to delay the transition of the Suez Canal from the British to the Egyptians. To do this Israeli intelligence organized a group of young Zionists spies to plant bombs in various western establishments with the idea of breaking ties with both the US and England. To the outside world these terrorist attacks would show instability of the Egyptian junta and reflect anti-western sentiment on the part of the Egyptian government. The plan was partially successful until one spy had a phosphorous bomb explode prematurely. This member of the group survived the incident, which led to the unraveling of the whole plot. Several members were arrested including the patient in our ward. Some were sentenced to death, some committed suicide, my patient was jailed for 20 years along with several others involved in the plot. The result of the Lavon Affiar was a cooling in western relations for a period of 10 years and a period where Israeli diplomacy was very much questioned by western powers. Here are two links talking more about the plot:

The most interesting thing other than the history of the patient was the medical findings. Several deformities were found on the feet, she was not willing to talk about it however she referenced being tortured constantly, and the scars on her body seem to fit the description. Her x-ray showed a previously broken hip, upon questioning she mentioned how she attempted suicide by throwing herself out of a window, she nearly died but managed to survive the incident. She was sexually abused, in short jail was hell for her. 

Interestingly enough, last week we had another patient who was also part of the Lavon Affair. I don't know all the details of this other woman's role in the plot, however, when my classmate asked her if she knew the patient I previously mentioned, she said that they used to be friends. However they aren't any longer -- the reason being that her friend ratted her out thus she had to spend several years in an Egyptian jail.

So what else is new in my clinical experience? I was late for class one morning because as I was walking to the bus station to go to class, and I saw a scooter accident in the middle of the road. I guess it was one of the first times where I was needed and could actually do something to help. I was already wearing my scrubs which in an ironic way made me feel like I was dressed for the occasion! There wasnt much to due but I checked for pain in his back once he seemed that he was stable enough I turned him over, checked his pupils and cranial function. He was somewhat normal had no obvious lesions on his head, however he wanted to fall asleep. The ambulance was on the way and I told the police to make sure he stayed awake. I felt like there was nothing more to do at this point so I left the scene thinking that maybe I helped this guy out a bit, it was definitely a good feeling.

On a final note, there is one man who is 88 years old and a retired cardiologist. It turns out he is ANCA positive and has a diagnosis of Wegner's Granulomatosis. I think seeing a retired doctor in this state really makes you think about your own future as medical professional and can make you become self reflective, especially about the evolution of your own career. You have the medical students who experience everything as new and amazing, almost as though you're a baby being brought into the world experiencing all things for the first time. Then you have the residents and the first year interns who represent a spectrum of experience, some still with the same enthusiasm as the med students, some who are eager to teach us, and also some who seem jaded by the busy life that we must all succumb to. Finally you have the new doctors and the senior physicians who again represent a range of experience. However as they get older, I think medicine to them is becomes almost a grandfather-ly experience. They've seen how medicine effects everyone that's younger in the ward. They have a body of knowledge which seems mysterious to all the subordinates. I would say that all of them have a passion for medicine and really enjoy handing down what they know to the next generation, and in this sense, I think the ward imparts a sense of family among the doctors. In a weird way the transition of knowledge from one generation to the next is what really makes medicine exciting because you can see how people evolve to become better doctors on the ward. For the man I saw, I think even though he is very far in life, he still carries this tradition. As we were doing rounds he was giving us advice, telling us what he loves about medicine, again trying to pass on the pearls that he learned in his 40 years of medicine. If anything I think seeing patients like this is what inspires me to learn more, and also excites me about the future to come.

Saturday, October 1, 2011

Stories of the wards, the second half of October.

We have been doing several intakes a week now and I have seen a couple new interesting cases as we've been working in the wards.

One of my first patients was a lady with Osteogenesis Imperfecta. Something I thought I'd only hear about in the books, but it was a fascinating presentation. She was only diagnosed about 10 years ago when her grandchild had a much more severe form of the mutation with broken limbs. Since her condition is not severe, her diagnosis was only confirmed after the discovery in her grandson, since autosomal dominant transmission of the disease occurs, doctors could assume she had it. She had the classic findings including blue sclera and a history of broken bones etc. However she was in the ward for atrial fibrillation, an issue more related to age than her disease.

This was my first official intake, and when we had to present in front of our professor I was shocked. I guess I wasn't aware of the custom that medical students are supposed to be hazed in the wards. In other words, I had no idea that a lot of the big shots like to give the medical students hell by humiliation, and really intense grilling. As I presented my case, my professor mocked me, laughed at me, and made me feel like a total idiot both in front of the patient, and in the office when we reviewed the file. He got me so nervous I was forgetting simple answers and he just kept digging in. He did the same thing to another student in my ward, he took it so badly that he confronted the professor afterwards. I don't think it made too much of a difference because he still likes to destroy me during rounds. I don't think I would have been as shocked if I had the expectation of being grilled but he totally caught me off guard. I can definitely say that this guy offered me the most intense, and unpleasant experience of my professional career. However I am not thrown off by it, it's good to have someone that can light a fire under me for motivation, and now that I know what I am dealing with I can handle it a lot better.

I've seen plenty of other patients, none as remarkable as the lady with O.I. However I saw a schizophrenic patient with metastatic cancer and a couple patients with hereditary spherocytosis.

I guess the most interesting thing I've learned so far at least when considering the patient interaction is the intimate details many of these patients are willing to tell you. I've been asked about the troubles of a marriage something I have no business knowing about or giving advice. People confide and cry all the time, and it's very intense. I think internal medicine is fascinating in this respect because you really get to see people open up to you that you don't even know.