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.

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.

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:

http://www.jewishvirtuallibrary.org/jsource/History/lavon.html http://en.wikipedia.org/wiki/Lavon_Affair#The_secret_cell

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.

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.

Taking Blood from a Jailed Israeli Soldier

I had another interesting case this week that I thought was worth noting. A 20 year old Israeli soldier came into my ward, cachectic, having lost over 20 pounds in two weeks. He was put in jail and had two other Israeli soldiers armed with uzis guarding his bed (a little bit of overkill if you ask me considering this patient appeared to have the strength of a child). Anyways, I was charged with taking his blood. Such a rapid weight loss is troubling, and considering the lack of history, a broad blood screen was performed on him, meaning I had to spend roughly 20 minutes filling around 15-20 vials of blood. We talked a decent amount, I never asked why he was in jail though avoiding awkward conversation. The attendings thought he could have had anything from cancer to hepatitis, either way his rapid weight loss made everyone on the floor a little nervous as to what was going on.

One interesting thing that he talked about was the scoring system the Israeli Army uses as a means of qualifying potential soldiers on their health. A score of 21 for example automatically excludes your service requirements from the army, such a score is usually given to people that have diabetes, etc. The patient next to him was also in the army and said he scored a 64, he had a condition called hereditary spherocytosis, which was a hemolytic anemia due to a fundamental defect of the shape of the red blood cell.

There are two interesting things about this point. Many people who don't want to serve in the army try to fake being sick, so the doctors in Israel are always looking out for people coming to the clinic faking an illness. The most common being lower back pain. Performing one or two simple maneuvers is enough to figure out whether these guys are for real or not. Some people go as far as to try to fake mental illness such as psychosis etc.

The other point about the scale is that it goes from 0-97. Why 97? The answer is circumcision. Circumcision automatically takes 3 points off the score. I don't really get this because I feel like in Israel, jews consider this a good thing. It almost makes more sense to say that circumcision should give you a score of 100 and without it you get a score of 97. If you have a foreskin, do you get a 100 on this scale? I don't know. Pretty funny nuance of the medical system as far as the Israeli Army goes.

First 2 Weeks of the Wards

The first week and a half of my internal clerkship has been quite a whirlwind of experiences. There’s definitely a high to be had finally getting to do what you’ve always wanted to do as a doctor, diagnose, treat, and be part of the functional unit of the ward. While second year was exciting I think this year has even more significance because we actually get to try out our clinical skills on the patients. This obviously has a double edged sword. It’s exciting to be able to sharpen our new clinical skills, however maybe not so much for the patients when we have to fish around for an elusive vein. Today may be the perfect example, I had a very nice elderly man who I had to perform venipuncture on, and to make a long story short, after the third try he wasn’t too thrilled about my failure, “Lo Tov”.

Running through the differential diagnosis makes you feel like you know a lot, but the truth is I feel like I know nothing right now. It’s somewhat overwhelming having the responsibility of waking up at 5:30 in the morning, knowing that you can’t be tired, and that you most likely have to be on top of your game at almost all times (otherwise the doctors will eat you alive). Fortunately I’d have to say the doctors on my wards are really interesting, helpful and not too bad as far as the hazing of medical school goes. One of my most important lessons so far was learning how to use the coffee machine; it’s a matter of survival for me, and the patients.

I want to say this is like having a routine job; I used to be a high school teacher with similar responsibilities, however this is much different. Every day you have to be on top of your game much more or you could hurt someone. My explanation about my failure to take blood this morning being a perfect example; I wasn’t concentrating and the consequences are serious, I am learning not to make mistakes very quickly.

This is definitely a transitory moment of my life. I feel like I have accomplished a lot, doing well on my boards however there are certain things that I wasn’t prepared for either. Being in Israel away from family etc. can be emotionally challenging and especially last year I had a lot of time to hang out with my support system in Israel, which were primarily my friends. This year is very different. I don’t have as much time to be social as I would like and I realize that my responsibilities are much greater. I’m handling it fine, I just never realized the commitment this year would entail, so it’s exciting but at the same time having more of a personal life is something I would like, but can’t have for now.

We see remarkable cases every day, the wards have been pretty incredible. Today for example we saw a beautiful young 17 year old Palestinian woman from Nobles (sp?) in the West Bank. She had a blanket over her legs so when the Orthopedic surgeon uncovered the sheets to expose a huge basketball-sized osteosarcoma, we were all shocked. Obviously we had to hide our emotion but it was really, really sad. The girl’s leg started swelling 7 years ago, and it was diagnosed 2 years ago, the family refused to follow up. Her mother died, and her father was is a very active Palestinian activist so it was difficult for her to access the care she needed in Israel. Reviewing the case outside the room in the lounge revealed a metastatic disease infiltrating the entire viscera. This is so sad, and really underlines the ups and downs of being in the wards. Sometimes it’s very rewarding to hit a diagnosis, treat someone successfully for the first time, but the constant reminder of how bad some of these patients’ lives can be and their prognoses is an unexpected emotional factor, that while intense I am quickly coming to appreciate.

We’ve seen some other patients, most notable two Wegner Granulomatosis cases and another woman with a metastatic disease she was unaware of at the time. I saw her a couple days later, probably for a follow up that would indicate the brevity of her prognosis. Again an emotional challenge but this is just one of many that I have been exposed to.

All-in-all I’d have to say that I think this year is making me grow more as an individual than any other year of medical school so far. I really appreciate the journey, and I am excited to see where I am even in several weeks from now. I look forward to more fascinating stories, ups and downs, and the amount of clinical exposure I hate yet to gain.

Applying medical theory to conquering the drug test

To me the drug test really emphasizes exactly how much people don't research what they buy and how much the public falls prey to hopes of a magical solution. It reminds me of a similar scenario I once experienced when I worked as a teacher. I had a co-worker whose mother was dying of metastatic cancer, she set up a website raising money for a $20,000.00 treatment using massive doses of vitamin C in Mexico in order to obtain a cure. On principle I couldn't contribute, because I would be helping an organization that takes advantage of the uneducated and the hopeful. On a similar however less severe note, many herbal remedies and drug masking products do the same thing, and instead of offering a solution, they probably increase the chances of someone failing a test because they become falsely comforted by a product that advertises something that it doesn't do. Further, it may encourage using substances in the critical hours before a drug test with the promise of magical solution irrespective of risky behavior. I am well versed in the lab techniques used and will attempt to clarify what works, what are rumors are false, and give a detailed explanation of the whole process. Keep in mind the more you know about the process the more weaknesses you can exploit, so some of the discussions may be rather detailed, but what I am sharing is based on medical fact, so pick and choose as you wish, I apologize for the length so I've divided this up into sections for you to parse through and to figure out what's relevant for you.

Know what you're up against, it starts with the interview.

Worst case scenario, you landed a a dream job, you just smoked a blunt a week ago, and they slap you with the fact that in two days time you must take a drug test or risk not getting the job. Don't panic. You have a lot of research to do, but you're not SOL, so keep your cool. Chances are you have a slip of paper telling you where to go, this is the first advantage you have. 99% percent of the time you are going to have a urine test, and if you're not totally sure what type of test you're getting, call up the lab on the piece of paper and ask. You don't have to give your identification to ask a perfectly simple question like this. If you have used something around the time of when you expect to interview, the easiest way of reducing a failure is delaying your interview appointment as long as you can, not the drug test date. When you go to the interview that's when they're going to slap you with the drug test so at this point its too late because when they give you the drug test appointment, you have to show up at the designated time or your automatically fail. So to reiterate, avoid this time constraint by delaying the interview date as a method of delaying when your taking the drug test.

Figure out what type of test you're taking

You will most likely be informed if it's something else like a hair test, a blood test, or a saliva test. If it's a hair test, this is bad news, there's really no consensus on any solution that truly remedies this situation (things like bleaching have no track record and there is no reliable literature to confirm or deny such claims that it works). Shaving your head, means they'll pick it from your arm. Shave your arm they'll take it from your pubic hair. If you keep going down this logic train and shave all the hair off your body, this is suspicious behavior, and you most likely just failed. The same is true of the blood test, anything you do to change your blood will most likely kill you before allowing you to pass a drug test so call your head hunter back, because it's not going to work out. Finally, saliva tests are growing in popularity and offer a method that clearly reduces the risk of tampering, I will discuss this method later on, because its definitely a bigger challenge than the urine test. Also, blood and hair testing are extremely expensive to administer compared to a standard urine panel so most organizations opt for the urine test solely based on affordability. It's cases like applying for a CIA position where you might encounter a test like this so chill the F*** out unless you plan on being a damn spy. This being said, most of my discussion will be limited to the scope of the urine panel.

Which lab is testing you?

So now that you have established you're going to be peeing into a cup, the next thing you can consider is what  substances are you being tested for. If you are in fact this paranoid, look up the name of the lab administering the panel on your trusty slip of paper given to you by your employer and look on their website, most of these tests are outsourced to large companies that specialize in this, which makes it easier to know what you're getting yourself into. The most common testing laboratory in the USA is Quest Diagnostics so I will explain a little about their methods.

Ok I know it's a urine test, what drugs are they screening me for?

Possible tests administered by Quest Diagnostics (taken from their site).

So there are several different types of urine panels. First and foremost, if you're a health professional chances are you know what you're being tested for (which is basically every illegal drug plus every prescription drug family with a potential for abuse) so I see little point in expanding upon this, however if you do need more information here is the exhaustive list. I am reiterating what's on the Quest Diagnostics site so I'll briefly sum up the other panels. The standard urine panel which is probably what most people are being subjected to comes in two flavors the 5 drug panel = marijuana, cocaine, pcp, codeine/morphine, and amphetamine/methamphetamine; or the nine drug panel = 5 panel + barbiturates, benzodiazapenes, methadone, and propoxyphene (links have been provided for the generic names of specific drugs if one of the constituents was listed as a drug class as opposed to a specific drug). These two panels may be modified to include MDMA (ecstasy), other opiates list here (this may vary if its not Quest so make sure you know what an opiate is and if its tested for by your lab), and if you're an athlete -- performance enhancing drugs list here.  Now that you know what you're getting yourselves into, you may or may not be in the clear already. For example, if you're able to figure out that you're getting a "five panel drug test" and you're buddy passed you off a methadone tablet, you're good to go. If this is not the case, keep on reading. 

The drugs themselves.

At this point, you know what you are at risk for failing so you must educate yourself about the nature of the drug. Knowing the drug means knowing its weaknesses. There's several  variables to consider that can affect the outcome: how the drugs are broken down, how fast the body can break them down (ie the metabolic rate), how they are excreted, and where they are stored all give you clues on how to beat them.

In general, you can follow the 7 day rule. Most illicit substances are metabolized out of the body within about 7 days, so if you have a drug test, to be on the safe side, you'd probably want a week to 5 days just to be sure it's out of your system unless you're suffering from renal failure or liver failure, which in this case you're probably not in the market for a job. Below is a more exhaustive list of metabolic rates of drugs:

Taken from Erowid.com this list shows when drugs leave the system

Half Lives
As you can see there are some exceptions to the rule. First lets talk about Benzodiazapenes. The most commonly abused drugs of this class are valium (diazapam) and xanex (alprazolam). The reason it says 42 days has to do with the half life of the drug. Briefly put, the half life is the amount of time it takes for half of the drug to remain, for Benzos, the Quest diagnostic test is screening at around 300ng/mL. The half life of diazapam is 20-100 hours, meaning that at roughly 4 days half is left (5mg would be common at this time). A rough approximation using a 70kg person with 60% body water by weight, at a first half life you'd have a blood concentration of around 120ng/mL. You are safe right? Nope, they also test for the breakdown components which have a half life of 200 hours, so you can see the detectable period just increased substantially. Alprazolam is metabolized much faster so this isn't as much of a worry, but if you've taken something in this drug class what is important is to figure out what benzo you took, so you can track the half life of the specific benzo. This can be found here.

Lipid Solubility and Clearance
As I mentioned there are a couple exceptions to the rule, from the list above the most noticeable are benzos and cannabinoids. Beyond the discussion of half life with the benzos both of these drug classes have another characteristic in common. Lipid solubility. Just like oil and water don't mix, the same concept applies to drugs. Most of your body is water, so anything in your body that is made of fat, is in a sense trapped in the body, and generally tends to stay in that material for a longer period. This is part of the explanation why some benzos, cannabinoids, and also steroid based drugs (testosterone analogues for example) stay in your system significantly longer than the average water soluable drug.

So this means that if you're overweight, and a chronic user of one of the above mentioned drugs, you are at a higher risk for failing a drug test. Women general tend to have more body fat then men, so the ideal patient is to be a super lean, highly muscular male. The only thing you can do is speed up your metabolism, exercise, do some cardio. This will speed up the metabolic process of breaking down the substance, and also decrease your BMI. But again, this effect is probably minimal at best.

Using specific metabolic pathways to your advantage.
There are many ways that drugs are metabolized in the body. In medicine there are two main ways that are relevant to our discussion. Phase 1 and Phase 2 metabolism. These don't imply a sequential order, they are just general references to two mechanisms of drug clearance from the body. Knowing what drugs are metabolized by which pathways, offers you a loophole to passing a drug test. If you know for example that drug X is metabolized by a phase 1 pathway, there are substances you can take to induce the enzymes that break down these drugs. In other words, there are substances that allow you to speed up the clearance of a drug out of the system. So lets examine each drug on the general drug panel and see what affects them. There are also a couple other pathways that might be relevant and will be discussed accordingly.

Alcohol
Chances are you're not going to be screened for alcohol consumption, and that's not the reason why I made this section. What is important to know is that acute consumption has one affect on drug metabolism while chronic alcohol consumption has the opposite effect. In general acute consumption of alcohol shuts down phase 1 metabolism while chronic consumption increases phase 1 metabolism. I'm not saying to become an alcoholic, so use this information at your own health risk ... Anyways keep this information in mind as you read below.

Amphetamines
Amphetamine is metabolized by an enzyme called P450 2D6. This qualifies as a phase 1 metabolic mechanism. Two known compounds will increase the breakdown of amphetamines. Glucocorticoids are one family (this includes things like cortisone, dexamethasone, prednisone etc). These are not easy compounds to obtain, and that holds true with a lot of the compounds I will be talking about, however maybe your lucky enough to have one of these laying around. Also, some of the drugs I will be talking about must be dosed specifically, and if you don't know exactly what you're doing you could hurt yourself. The safety of these drugs is outside the scope of this discussion, however I highly suggest thoroughly researching anything you may consider taking because you don't want to end up putting your health at risk. Another drug that can induce metabolism of ampetamines is rifampicin. One other thought here is this, if you know what drug you need to take to speed you your metabolism for amphetamine, you could try faking an illness that requires the usage of the drug to obtain it. Again I am not recommending this practice, I am against this idea but I am here to tell you how to pass a drug test, what you do to your body is your choice, just make sure you educate yourself and know the risks before trying someting that could potentially be stupid. Just as important as knowing what speeds up your metabolism is avoiding substances that could slow down your metablism. The list of inducers that we just discussed is relatively short, however the inhibitors (the ones that can slow it down) is a relatively long list. So rather than list them all here, I'll provide a link that lists all of them here. A lot of the drugs on this list are more commonly consumed that you think. For example cimentidine is an anti-acid medication. My point is look at what your taking, check out its generic name and see if anything on the list matches its name. It's important to look at this list because you may be abusing or may even be prescribed one of these substances which means you need to stop taking them as quickly as possible before your test (again consult your physician before abrupt cessation of any drug). One other factor should be mentioned here. The amount of P450 you have in your body that can break amphetamine down varies with your genetics, in general if your of Middle Eastern or North African decent, your body most likely gets rid of amphetamine really quickly. Blacks have the greatest frequency of poor metabolizers, whites and asians have less of a chance of being a slow metabolizer.

Barbiturates
Barbiturates are broken down by both phase 1 and phase 2 metabolism. Ironically, they also induce phase 1 metabolism, however as far as a drug test goes, it obviously makes no sense to speed up metabolism by using a drug that will cause you to fail the test to begin with -- however, if you have been taking barbiturates chronically, you probably will get rid of them much quicker than someone who's a recreational user (the downside being that there's probably more net drug in the chronic user's body). As for what you can take to increase phase 2 metabolism you must take substances that increase the availability of the enzyme glucuronosyltransferase. A known inducer of this enzyme is pregnenalone. However there's not much literature that states that inducing this system speeds up barbituate metabolism specifically, theoretically it should work. Additionally, you can speed up the natural synthesis of pregnenalone in your body by taking ACTH, which may indirectly induce glucoronidation (by increasing the enzyme desmolase which makes pregnenalone), however again, this is a theoretical concept that not much literature has specifically proved. So the bottom line is while a lot of theory exists, its hard to do much about slowing or speeding up the metabolism of a barbituate. Once caveat, secobarbatol actually slows down its own metabolism, so avoid this.

Benzodiazapenes
If we haven't talked about this class enough, there's still the topic of their metabolism which is another important consideration. Diazepam is glucoronidated just like barbituates so the above discussion may also apply here. However, these are also metabolized by Phase 1 reactions involving the enzymes Cytochrome P450-2C19 and P450-3A4. Compounds that induce these enzymes include rifampin, carbamazepine, glucocorticoids, pioglitazone, phenytoin, and St. John's Wort. Things what will slow it down include fluconazole, azamulin, diltiazem, erythromycin, clarithromycin, grapefruit juice, intraconazole, ketoconazole, ritonavir, troleandomycin, and acute alcohol ingestion.  A confusing list to say the least, however its worth looking up to see if you are taking them etc.

Cannabinols and Marijuana
According to the research these compounds are mainly broken down by phase 1 enzymes, specifically P450 enzymes, CYP2C9 and CYP3A4. You will begin to see some patterns as we work through these drugs, and this is because several enzymes we've already listed are major metabolic pathways for many compounds that the body encounters. Thus the same inducers and inhibitors mentioned in the previous section also apply to this section. Additionally, tienilic acid and sulfaphenazole can slow the metabolism of THC (the most common active cannabinol).There have also been reports that eye drops added to the urine sample can help mask THC by emulsifying the compound, this method is more effective for acute abusers rather than chronic, and these substances will keep the urine within its physiological limits (which are tested by the labs).

Cocaine
Cocaine is a drug that is metabolized relatively quickly by enzymes that are ubiquitous, and due to how fast its metabolic profile is, there isn't much use in trying to induce enzymes etc. It undergoes tissue esterase activity, and if you want more details on the process this is a great site. However a quick search on google did yield cytochrome enzymes esp. CYP34A (as explained above) that can be speeded up.

Opiates
This describes a wide variety of drugs which have many pathways of metabolism. Methadone for example is degraded by CYP2B6, this enzyme is induced by cyclophosphamide, and inhibited by ticlopidine and clopidogrel (most likely medications you shouldn't be taking and are hard to access). Codiene, hydrocodone, and oxyxcodone are metaboliszed by CYP2D6 which has no known inducers but can be inhibited by both quinidine and paroxetine so avoid these. Fentanil and related drugs such as sufentanil are metabolized by CYP34A again this discussion was mentioned above in the benzo section.

PCP
This drug is known to be metabolized by the CYP34A system, again as mentioned above.

Steroids
Steroid drugs, usually things that are use as performance enhancers are also metabolized by the CYP34A pathway (inducers and inhibitors mentioned above). Additionally, many of these drugs are excreted from the body via bile secretion. This offers another avenue of elimination out of the body. Bile acid sequestrants offer a source of elimination for such drugs however this is a theoretical consideration and I won't claim that this method is proven, but in theory it would work. Statins offers another theoretical route of lowering levels of detectable drug in the body. By increasing the proteins that take up cholesterol and cholesterol related compounds such as steroid related drugs, you may lower available detectable levels in the body, again this is a theoretical consideration which as far as I know, does not have experimental proof, but it hasn't been disproven either. Finally, sex binding proteins (SHBG) act like mini-sponges absorbing free levels of steroid related compounds. The production of these proteins can be increased by phenytoin, primidone, carbamezapine, oxycarbazenpine, and valproate.

Known Masking Agents
Diuretics
Diuretics are commonly prescribed and include the following families: acetazolamide, thiazides, loop diuretics, mannitol, and potassium sparing diuretics. These drugs make you pee more frequently and essentially cause you to dilute your urine. Diluting your urine means that the drugs being tested are harder to detect. Many labs test for these drugs because they are used to evade drug detection, so research your lab and see if they test for this substance. What are not tested for are naturally occuring diuretics, which are easy to obtain. Caffine is pretty powerful, here is a list of some other things that can help.

Probenacid
This is a drug that is commonly used for gout. It is known to minimize the excretion of several tested compounds. Again many labs screen for the use of this drug so this is another question you may want to confirm with the lab.

Adulterants
Adding things to your urine is simply a bad idea. They test for many physiological limits of your urine, and if they are outside normal reference ranges, you automatically fail. It's just a risky and stupid practice to do. Additionally a list of common adulterants and perameters tested for are:  Nitrite, Chromates, Halogens, Oxidizing Adulterants, Creatinine, Specific Gravity, Acids, Bases and Glutaraldehyde. Eye drops as mentioned above have shown some success as an effective masker for THC.

What can be done to fake your urine test?
There are many kits out there that claim to use dehydrated urine, warming kits, and fake bladders to pass a drug test. These items may prove useful, I don't claim to be an expert in this area so I will not provide information I don't know about. However be careful what and where you get your kits because if you have urine from the wrong species, or give urine of the wrong temperature, you will fail. One thing to consider if you do choose this route is to think about what is contacting your skin. Chances are if you're using a fake set up you're nervous and you're sweating. If this sweat contacts a fake bladder that's touching your skin, the sweat will diffuse any drugs in your body through the plastic into the fake urine. I have a friend who was taking adderol and used a fake bladder and the test showed positive for amphetamine, so these tests can pick up this type of thing. Luckily he had a prescription for this so he was in the clear, but this is just an example of something you might not think of when going in. Use a diffusion barrier such as a napkin between your skin and the bladder to prevent this kind of effect.

Also, make sure your urination is not the first of the day. This urination usually contains the highest concentration of metabolites that are picked up on a drug test. Drink lots of water, use a natural diuretic, piss as much as you can, and slow this process down maybe 1.5 hours or so before your test so your test isn't rejected for dilution (determined by creatinine concentration).

Also to give you an idea of what goes on at the site, here's a link from a blog from Quest Diagnostics with some common practices used so think about these factors as well before you go in.

Drug testing solutions
About 99% of this is BS. The drinks etc that you find in head-shops make claims that haven't been proven. Many are high sugar, high vitamin B compounds that have absolutely no effect on the outcome of a drug test. Their claims are mostly false, and you're better off drinking caffeine and or some other natural diuretic rather than putting false hope into these products that just steal your money. They'll make your urine highlighter yellow, which can be cool to look at ... but that's about as effective as it gets ..

False Positives
There are lots and lots of things that can cause a false positive. Use this reference list to possibly come up with a valid explanation for why you failed, but otherwise avoid these substances if you don't have a prescription or a valid reason for taking these substances. Exhaustive list here -- this is pretty reliable and has cited sources. There are also many urban legends that relate to false positives, some of which can be found here.

The Saliva Test
This is a new animal and seems to be becoming more popular. I honestly think that this is an evolving test, in the sense that people are still trying to figure out what works, and what doesn't. Again the discussion on metabolism definitely applies to this section as well, however doping the sample is not only harder since you can't conceal the process in a spitting panel nearly as effectively as you can while urinating, so unless your slight of hand is up-to-par this isn't a viable option. Interestingly enough though, there is no discussion on Quest Diagnostics web site that I could find saying that they test for adulterants or for physiological norms as is done with urine. They did however say the following:

ADULTERATION

18) Can an oral-fluid test be beaten?

• We have not found any adulterants that can beat the test at this time. Of course, donors

may attempt to introduce something onto the pad or collection vial. This risk is

minimized because every collection is directly and easily observed.

19) How does the laboratory determine if the specimen is human saliva?

• With every specimen, the laboratory performs an IgG test. This test will determine if the

specimen is human saliva and if there is sufficient saliva to perform the drug testing. The

IgG test is a specimen validity test.

This being said if they don't test for adulterants, I see no reason why the adulterants that physically modify the specimen shouldn't work here as well. These include Nitrites, Chromates, Halogens, and Oxidizing Adulterants as mentioned before in the urine discussion. In other words the fact that Quest tests for the presence of these adulterants in the urine panel suggests that they do interfere with detection, and this has been corroborated, so this idea may be usefully applied to the saliva test. My logic has to do with the techniques used for saliva versus urine. Urine is typically done using chromatography techniques while saliva is almost exclusively with ELISA. However, the idea of using an adulterant involves chemically modifying the substance in question, so I see no reason (as long as the adulterant does change the substance) that it shouldn't interfere with both lab processes. Again this is not proven, and I invite further discussion and research into the idea. But it is important to point out that it won't hurt your chances if it does nothing so why not try it? However, I think I should restate is that the issue isn't as much whether the aforementioned adulterants work, it's more of the issue of introducing an adulterant to the sample in front of a chaperon administering the drug test ... slight of hand isn't really something I can coach you on, talk to Copperfield for this one.

Besides the discussion on the metabolism of the drugs themselves, the only other parameter I can think of is the salivary flow rate. By altering the flow rate, you can alter the composition of the saliva. This being said you can take advantage of some basic physiologic theory to help you pass. The sympathetic nervous system releases a thicker more viscous form of saliva, while the parasympathetic system makes a watery, dilute secretion. It probably makes sense to pick substances that cause parasympathetic activation versus sympathetic activation. In essence this is a way to dilute the saliva. A list of such parasympathetic activating substances can be found at this link under the heading of "agonists" while substances that slow down this system are under the heading "antagonist". In other words, use the agonists, avoid the antagonists. Also an important caveat, anytime you attempt to mess with the parasympathetic or sympathetic systems of your body, you are messing with something that won't only affect your saliva, but will alter the function of many aspects of your body. If you plan to take one of these substances, please ask a doctor or post a question here to determine if it's safe. Also recognize that some of the substances I am talking about may have abuse potential (whether that be something that gives you a high or a performance enhancing drug) thus may be screened for on a drug panel themselves, so please check this out as well.

Keeping the above points in mind you can think of activating the parasympathetic system as a desired effect. Conversely the sympathetic system has opposing actions to the parasympathetic tone of the body, so we want to stop the sympathetic system if we want watery saliva. This can be achieved using beta blockers, again if you are an athlete, this drug class can't be used because it is considered performance enhancing, a normal drug abuse panel shouldn't screen for this though. Again please be careful, these drugs can cause serious harm if your not sure about how much to take. In some disease states these can be harmful as well. Drugs to avoid activate this system and include a very large list and can be found A) here, B) here, and C) all drugs listed under indirect and mixed action. and caffeine. If you find this list a little too overwhelming, you can simplify things by avoiding any substance that also increases your heart rate, because such a substance may also cause sympathetic activation.

Finally there are substances that can alter saliva secretion that are outside the realm of the parasympathetic and sympathetic systems. The technical name for such compounds are sailagogues which increase saliva production (a desirable effect of the drug test) while anti-sailagogues do the opposite (avoid these compounds). The good thing about some of these is that they are readily available, but again some cross over into the realm of para/sympathetic effects so please, I beg you to thoroughly research any substance you may consider taking, many taken in large enough doses can be very harmful. These are not exhaustive lists, so if you are curious, inputting a google search of sailagogues etc. should bring up some more stuff. Just make sure to corroborate any potential claims that something is a sailagogue because the internet has a lot of misinformation especially when relating topics on passing a drug test.

Again, the discussion about diluting saliva by increasing secretion is not something that has been conclusively proven to pass a drug test as far as I know, however I think it follows that if you can dilute your saliva, you are making it more difficult to detect a substance in a given concentration. So I will say here that this logic is pretty sound and takes advantage of simple concepts in physiology. Additionally, it can't increase your chances of failing (unless a said sailagogue is screened for on a drug test which can be easily determined by the information provided by Quest Diagnostics), so may as well give it a shot.

This is about all I can think of, so if you have any questions please post them, otherwise, good luck.

Interesting Medical Apps for iPhone

This post integrates a little bit about what I have learned in medical school with some of the apps I have come across recently.

1. Sleep Cycle Alarm Clock
As I was studying for my boards, one thing that I really started to concentrate on was my sleep schedule. Disturbances in your circadian rhythm (your natural sleep-wake cycle) lead to all kinds of pathology including depression and a loss of concentration. It's not just a matter of the length of time needed while sleeping, it's consistency and quality that's equally important.

Sleep cycle takes advantage of the fact that your body moves differently as it cycles through the different stages of sleep. The accelerometer on the iPhone takes advantage of this variable to approximate what stage of sleep you are in. You attach the iPhone to the charger, set it face down on your bed, tell it to wake you up within a range of time, and the app will only go off when it senses that you are in the lightest sleep within the parameters that you set for it. In this way, you are never disturbed during deep sleep, and you wake up feeling refreshed and not tired. Additionally, it records your sleep patterns for the evening which allows you to analyse the quality of your sleep. A sample of my own sleep pattern is shown below.

A typical night's sleep

So this gives you the basic concept behind the app I think it's important to understand the structure of the sleep cycle to appreciate what you're looking at. Sleep structure is defined by several stages (1-4) and REM sleep (rapid eye movement sleep). These are measured by specific electric wave patterns given off by the brain measured by EEG (electroencephalogram). As you go to bed, brain waves are initially in the beta state, this is associated with being awake, with the eyes open, and alertness.

Beta Waves on EEG

Slowly, as you relax you pass into an alpha pattern, you are still awake now but the eyes are closed and you feel half asleep, many meditation techniques attempt to enter alpha wave patterns.

Alpha Waves on EEG

Finally, you enter the stage 1 sleep associated with theta waves, more commonly known as light sleep, roughly 5% of the sleep cycle is spent in this stage.

Theta Waves on EEG

The second sleep stage is roughly 45% of the sleep cycle, on EEG the pattern is described as sleep spindles and K complexes, this is a deeper pattern of sleep.

25% of your sleep cycle  is spent in stage 3-4 of sleep associated with delta waves (the slowest frequency and lowest amplitude waves).  

Delta Waves on EEG

Finally, REM sleep occurs in a beta wave pattern, sometimes it's called paradoxical sleep because as mentioned before, beta waves are also seen in the awake state. REM sleep comprises 25% of the sleep cycle and is associated with dreaming, memory consolidation, loss of motor tone, tumescence, and increased brain oxygen use. As mentioned the body loses muscle tone during REM and as you wake up, you gain it back.The sleep cycle proceeds as stages 1-4, back to stage 2, and then REM (this pattern repeating itself throughout the night). Deepest sleep (stage 3-4) is present more in the earlier portion of the night while REM increases as the night continues. The entire stage pattern can be seen below.

Compare this to the graph created by the app at the beggining and it can really clarify what's going on.

Medically relevant disturbances of the various stages

• During stages (3-4) night terrors, sleep walking and bedwetting (enuresis) occur, several drugs including imipramine and benzodiazapines (things like valuum and xanex) minimize the amount of time spent in stage 3-4 sleep in people who suffer from these conditions.
• Sleep paralysis is a common occurence in which you wake up and you can't move. This phenomenon is thought to be a problem emerging out of REM sleep. The part of your brain which turns off muscle tone during REM (as mentioned above) usually deactivates as you awaken and become aware. In sleep paralysis this part of your brain can turn off several minutes after becoming conscious, leading to this relatively frightening state. There are many theories about the purpose of REM sleep, one purports that it allows you to rehearse survival behavior (i.e. fighting etc.) while dreaming during REM. The normal loss of muscle tone is thought to stop the body from moving during such rehearsals which means you won't hurt yourself or fall off a cliff while your sleeping. 
• REM is thought to consolidate stimuli encountered during the awake phase. Studies have shown that selectively denying REM sleep can cause psychosis.
• REM decreases with age and increases in depression. In depression there is a decrease in stages 3-4 sleep, and one of the criteria for depression is an increased frequency of early morning awakenings commonly referred to as terminal insomnia.
• Narcolepsy is also thought to be a disturbance with REM sleep. When a narcoleptic falls asleep they immediately start in REM. Typically narcoleptic episodes are triggered by causing strong emotional stimuli (scaring someone for example) which is followed by immediate induction into REM sleep, which also explains why they typically drop to the floor, recall that in REM sleep, you lose all muscle tone. It's not only seen in humans, a genetic mutation in dogs has been mapped to the condition (see videos below). 

So what's a good example of how sleep cycle can measure the quality of your sleep? As an experiment, the next time you decide to binge drink the night away, set the sleep cycle app to record your sleep. Alcohol decreases the amount of deep sleep you get, and also increases the amount of time you're awake at night. Compare the sleep cycle graph below, to the normal examples I've included, and you'll get a sense of what I'm talking about.

Sleep with a night of alcohol

2. iPhone Used as a Microscope

A couple months ago, I read about iPhones being used as microscopes, which definitely qualifies as a creative way to use a mobile device for a medical application. The concept is to use such modifications to analyse blood samples in remote places. Additionally using a mobile device gives you the added flexibility of being able to send medically relevant images to pathology labs around the world. Either way, I know that's not what I'd use something like this for, I just think its a very creative application of the iPhone. The microscope on the left can be bought for $50.00, others can be found by doing a simple google search. Alternatively there have been several do-it-yourself versions of this idea, Wired has an instruction guide on how to do it here as well as other sources of development.

3. Epocrates

I think this application probably is the most widely used tool by medical professionals out of any mobile resource. Its basically an interactive physician's PDR which can identify unknown pills, check drug interactions and so much more. I use it all the time on rotations as a quick reference so its definitely important for anyone involved in the wards, and further if you have an interest in your own healthcare, this can come in handy too. Highly recommended.

4. Pocket Eye Exam

I think this is a really good application with a lot of diagnostic use in the wards. This app has a simple screening exam using the Snellen Eye Chart to test visual acuity, color blindness, and motor function. Definitely worth checking out.


5. USMLE Preparation Apps for Med Students


As your studying for your boards, or just trying to keep fresh there will be times where you're waiting on something, perhaps taking a city bus etc. where your time could be more efficiently used mastering some USMLE concepts. For me, the iPhone came in really handy. First of all I always had my Goljan audio files queued up. Some other good audio materials are the Robbin's path review audios, Pharm Recall audio, and Littman's stethascope audios (I'd post links but I don't want to be shut down, all can be easily found on torrent sites). Additionally, I think a lot of people rely on the Lange flashcard sets for revision. Lange offers the same flashcard series for Biochem, Pharm, Path and a bunch of others on the iPhone. The added benefit of this is that instead of having 5 annoying boxes filled with flashcards, you can simply have the same information put into a couple apps. Additionally they can track your progress so you can be efficient with the flashcards. Most of the major board companies, such as First Aid, Kaplan, Lange, etc. have an assortment of apps to choose from. Many people also recommend the Netter's flashcard series. I have sat in a library before and just gone through flashcards for a couple hours as a study session.

The problem is, that if you're a medical student, there's a good chance you're broke like me, and some of these apps can cost up to $75.00 which is not really an option for me. Good thing there's a way around that (not necessarily legal but, it is a way around). First of all you have to jailbreak your iPhone. Jailbreaking installs an app called Cydia which gives you functionality that you can't get on the iTunes store. To figure out how to jailbreak you need to know what type of iPhone you have, because many of the jailbreaking methods vary depending on the iOS you use and the type of iPhone you have. This site is a good place to get started, however its not too hard to figure out once you get started. After you have jailbroken your phone, you must download "Installous", to do this, click this how-to link. Once you have Installous on your phone, you're money. Basically it allows you to download any app from the iTunes store for free. In essence you have access to anything including any USMLE related resource for free. Again, this is blurring the lines of legality, however it's for a good cause, we're studying to save lives ...

6. The iPhone as an EKG pattern?

In the wards, the internal medicine docs love to blast you with EKG's. If you can't read one they will do everything short of giving you a digital rectal exam so when an unusual patern that resembled a pacemaker started showing up in hospitals around America, doctors were naturally perplexed. Finally, a recent journal article was published to increase awareness of the electrical interference that is caused by the iPhone. Check out this the article for the Emergency Medicine Journal for more info.

How to Prepare for USMLE Step 1 Starting from First Year

Having just emerged from the depths of the boards and scoring pretty well on my practice exams, I thought the most appropriate next post would be to write about what worked for me and my philosophy.

Preparing for the USMLE Step 1 is a big deal, some people are crammers, some people do better studying over a consistent and longer period of time. I would qualify myself as the latter, so if you are a crammer, perhaps this post isn't what you're looking for. While I'm at it, people learn via many different formats, all I am offering is a plan that worked best for me, and perhaps it's not what's best for you, but take from it what you wish. I am a foreign medical candidate, so for me, the USMLE is everything, it determines my residency and  really the weight put on the internal portion (my school grades) of my resume is probably 10% of the considerations that go into the process. So in some ways, I think US Medical students might have something to learn from this, because for me getting a residency is somewhat more difficult, and the USMLE Step 1 basically defines the matching process, so I dedicated the last two years to orienting myself to taking this test down the right way.

The first thing you should know about my approach to medical school in general is that its very unorthodox. I believe that the education system in general is too tied up in keeping medical students to certain standards which translates to many disadvantages when tackling the boards. For example many schools get annoyed if you don't show up to class. At this level of education if you're not self motivated, you shouldn't be here. So subjecting people to required and mandatory lecture hours to me is ridiculous - if you don't learn best from this method. Having been a teacher myself, it is obvious that some people learn better from lectures, some people learn better from books, some people learn best from videos. I believe it is the duty of the medical school to provide as many sources as possible, and give the student the tools to choose what is best for him or her. Along this same vein, I think many medical students get caught up in the "traditional" role. This is best demonstrated by the idealistic, first year medical student who plans to read everything, do everything, and basically be superman. I will expand upon this point in the following paragraphs, however my biggest piece of advice to you as an entering medical student, is this, you are obviously a smart person if you got to this level, have faith in yourself to take a chance and instead of doing everything the professor says, figure out the best way to wrangle the system and make it work for you, and hopefully as you continue to read this, you'll get a sense of what I mean.

The first and most important thing about this process starts with the course work even in first year. Having received a master's as well as a bachelor's degree I learned a long time ago that for me, I don't do well with lectures for a several different reasons. First of all, I learn best by teaching myself. Unless a professor is really perfect, no one can truly explain how something works especially addressing all the little questions that might confuse you in the middle of a lecture. Attacking the course work on your own requires you to be more responsible, you must learn how to discipline yourself to to keep up with the lectures. I pinned my study hours to the lecture hours (however my self study commonly exceeded the amount of lecture hours in a day, and if you're doing it right, it probably should). Another reason I prefer self study, is that no matter how many times I go back to the source its always the same. When you go to a lecture, you probably forget half the things they talk about, maybe their lecture is more succinct than the powerpoint, either way you have to go back and piece it together, this is not efficient. Having one good source affords you the convenience of reading through a well written explanation that you can understand the first time through, and a source that allows you to revisit anything you don't understand in a succinct way, while being able to appreciate what the important points are -- which is most of the battle anyways. Some people may argue that you lose out doing this, you miss the extra tid bits that make you the better physician. I completely disagree with this, no matter how you study, you're going to pick up unusual, and non-board related facts along the way as long as you study hard, and put in effort, you're bound to have a well rounded education.

This brings me to probably the most important point. You have to choose your sources extremely well, and it all starts with the USMLE First Aid. This will become more and more important to you as the Step1 date approaches, but it should always play a role in your education. Purchase this book before you start your first year, it has many helpful hints for you as you go through the process. The first being that in the back of this book it has a directory of the best sources to use for preparing for the boards, rating the best books as "A+" and so on. This is super helpful and below I'll provide you a list of what I used after sorting through all the A rated books to find what I thought was the best.

So when you start Cell Bio (one of the first subject usually taught in med school) I hope you didn't go to the book store and pick up "The Cell". In general this is probably the most unorthodox part of my study philosophy, I have a fear of books that are thick. Not only are they terrifying but to me its laughable to think that you can pick that book up, and think that you can discern what is important to know what is not or further, remember all those useless details and obscure proteins that no one, including the writers of the boards care about. Again this also reiterates my frustration with the professors who recommend a joke of a book like "The Cell". These guys are usually over zealous PhD's who use Cell Bio to teach you about their own research, which means that you have to learn about another set of proteins that relate to some worthless rodent model ... that no one cares about .. including the boards. I also try to use the smallest amount of sources possible. I like to find what I consider the best book, and stick to that 100% and if I need to I can build the extra meat to that skeleton as I go through the course work, but in general for me, less is more. And remember if you do have a crap professor that loves the esoteric details, almost every school has a note taking service. After studying the board related materials to master the subject, quickly review those notes to complete the gaps that might be missed for your course work -- again this is a super efficient method.

All this being said, going to the First Aid for advice, below are the list of books that I compiled and used as my primary sources for my course work.

Biochemistry
This is a very detailed oriented subject, so this actually requires a book that is a little thicker than what I usually prefer. Either way you can't go wrong with Lippencott's Biochemistry book, this is simply the best source for your first round covering Biochem. Its the most succinct out there, and I think its even listed as a top source in the First Aid. As I reviewed for the boards I used some different sources, and I will talk about this later on.

Cell Biology and Histology
This is a very low yield subject for the boards, in general, this is true of first year. Enjoy this year, there's not that much that you'll really learn from this year that has a huge influence on what's covered for the boards, for the exception of Immunology, Biochemistry, and Microbiology. I personally love the BRS series, and the BRS histo/cell bio book is awesome. Its about 4000 pages less than "The Cell" and it does a great job of outlining what's actually important to know. Also, you do need to have pictures, Wheater's Histology has good explanations and great pictures, but I would use this as a reference with the BRS being your primary.

Physiology
Costanzo. Enough said. Costanzo is a professor at Virginia Commonwealth, and her book is simply the authority for medical students. It's so well written. She also wrote the BRS, and after your first round in the main Costanzo Physiology book, this is probably the book you want to use and review for the boards. She also has a great BRS case files and question book that can be really helpful for revision.

Anatomy
This is a bit irritating. There's no one good book out there. A lot of books are needed to do this the right way. First obviously Netters is an amazing book. This will be super helpful for the practicals. I also thing Grant's Anatomy is amazing because it offers some views that aren't in Netters and also it has relevant radiographs for all the anatomy you need to know. When you're trying to master structure, I am going to depart from my philosophy and say that you need as many pictures as possible. These two sources together offer an extremely complete review of structure. As for conceptual anatomy, please, please do not purchase Gray's Clinically Oriented Anatomy for Med Students. It is a terrifyingly thick source, instead, reach for Road Map General Anatomy. This source gives you all the medically relevant annoying details that they're bound to test you on. This is more than enough. The Auckland Anatomy videos are really good too for revision and for cadaver practicals.

Neuroscience and Neuro-anatomy
Again Netter's and Grant's Anatomy are good for the structural aspects and the practicals. As for function, Costanzo's Physiology has a great chapter on this. Additionally go through the Road Map Neuroscience book for a overview of the anatomically oriented physiology that Costanzo doesn't cover. Some people use High Yield Neuro instead, I think both books are just as good, look at Road Map, look at High Yield decide what's best for you. Please don't even open "The Principles of Neuroscience" book by Kandel. This book is another 5000 paged terrifying nightmare, and was not made for a Medical Student, it was made for someone obtaining their PhD.

Immunology and Microbiology
There are two books here I'd like to recommend. First and foremost, Clincal Microbiology Made Ridiculously Simple, is amazing. Probably one of my favorite reads in med school. For Immunology I'd recommend the Lippencott's Immuno book. Its a short read and really well written.

Embryology
I hate this subject. Its the worst and relatively low yield for the boards as well. I found a great little book called Langman's Medical Embryology that's really good for a first read through. It's a lot shorter than most of the terrifying Embryology books that are recommended. For your final review, the BRS is awesome for this subject.

Pathology
This is your primary class for the entire second year, so its really important to use the best text you can find for this. And no its not Robbin's Pathology. Again this book is a reference book, 2000 pages is way way too long to read! Don't waste your time with this. Get the Goljan Pathology Rapid Review book. This is the closest thing to my bible, it was made for the Boards, and its got all the important points of all the diseases you need to know. Again Robbin's Pathology is a reference book don't waste your time reading this unless you're completely stuck on a point in Goljan that you need to clarify.

Pharmacology
Many people I know used Kaplan videos and the accompanying resources for all of school (usually the pirated book and videos). This works for many people, for me it does not. I think Kaplan is good, but it's not the best. I think it focuses on minutia most of the time rather than the big picture. But it's worth checking out, it may be what you're looking for. So the reason I bring this up is despite what I just said, my one exception to this rule is the Pharmacology videos by Kaplan. The guy who teaches this is the man. He's simply the best. This in conjunction with the Kaplan coursebook will give you a solid foundation of Pharm for the boards and for school. Also check out the Lange Flashcards for revision, they'll keep you fresh and they're a great review.

Epidemiology, Ethics, Bio stats, Psychology
I think most medical students consider these subjects jokes. Don't do it. This subjects are highly represented on the boards. They're not hard, they're just annoying subjects to recall. Learn them well, its not a lot of information. It's easy not to take these subjects seriously, but don't fall for it. There's a lot of annoying books out there that you're professors will push on you. All you need is the Behavioral Science BRS. It's really good, well written, and actually has more info than you need to know for the boards, but probably exactly what you need to know for your coursework. I've heard Kaplan Videos aren't bad for this either, but I never used them.

By the time you enter second year, you will be spending most of the year mastering the Goljan Rapid Review book. In addition, this is the integrative phase of preparing for the boards, where everything comes together. First Aid also comes into play now. Most schools approach Pathology by systems. For each system my school had 3 weeks. So I came up with what I thought was a pretty good method. The first week I would read the relevant first year subjects of that course. For example in Cardiology I would read the relevant Anatomy from Road Map, Histology and Cell Bio from the BRS, Embryo BRS, Physiology BRS, and Kaplan Pharmacology relevant to this section. I used a special fine pointed pen (a pilot .3mm) that wouldn't bleed into the First Aid page. I'd annotate the relevant high yield information that wasn't included in the First Aid (it's super important to keep this writing small and clean because you're going to be building on top of these details in the following months).

In this way, by the end of the first week, I would have finished all the first year materials that were relevant to the system in pathology that I was working on. For the second week, you must go through the relevant pathology of the course. My first review of Goljan's Rapid Review I did in conjunction with the audio files and the Goljan Pathology Slides (you can find these easily as an internet download). I would read though the chapter with the audio, flipping to the relevant path slide and writing any pearls into Goljan's book that were not included. Usually the audios don't cover everything in the chapter so a second review is necessary. For the second review, I would go to the relevant section in First Aid and copy any mechanisms and important missing diseases that  I thought were pertinent into the margins with my special pen. This is a lot of work and should take most of the second week. Finally, by the third week, I would open up USMLE World click the system I was working on and click on all the subjects relevant to that system. For example, I would check off Cardiology  and then click "all" in the other section of world (which would check off the immuno, physiology, micro etc). I would complete all the questions that were made for that section, and annotate with another colored pen all questions I got wrong into the  First Aid. Sometimes there may not be enough questions for a given section, when you encounter this problem I'd recommend the Robbin's Question Book and Webpath if your school has access to it.

The idea of this method is that by the time you finish a pathology system, you have annotated everything you need to know for the boards into one source, so you don't have to spend time referencing a bunch of books by the time your ready for your final review for the boards. Additionally everytime I annotated something into the First Aid, I'd add a code with a page number and name of the book used, that way if I did need to go back to a source and reference it, I wouldn't spend a million years trying to find it. I'd know exactly where it was instantly. Again the idea is being efficient.

A couple important points when consolidating all this information into the First Aid you have to be creative with which first year topics you choose to cover for each Systems course. Again, the idea is to be done reviewing everything by the time Systems Pathology is over so you have to be strategic, I'll give you some of the ideas I used. For Hematology, I annotated Lippencott's Immunology (my first year source) into the immunology section of First Aid, in addition to the other usual first year topics (i.e. Embryology etc). This is a a natural integration since Heme and Immuno have a lot of overlapping concepts. Microbiology is tricky, its a large section to divide up so piecemeal it together how you choose. I chose to do a large chunk of it during respiratory, and some during GI, but a little bit was done for most systems (going back and forth between Goljan, Made Rediculously Simple and First Aid for consolidating all these sources into one book). For Biochemistry I tackled it during Endocrinology but I did not use my primary Biochem Lippencott Book, I thought this would be too time consuming so I ended up using First Aid as my primary source and supplemented some sections with the BRS (however I didn't read this BRS cover to cover, I just used it to add details that I thought were important). Epidemiology, Biostats, and Behavioral science I covered during Psychiatry using the Behavioral Science BRS.

There is some logic to my fear of giant books. You can't do this method, by using a bunch of giant books like "Kandel's Neuro" or "The Cell". Additionally, look at what you have accomplished. By the time you're getting close to finishing second year, you would have reviewed all your first year sources two times, completed Goljan two times, completed USMLE World once, and have all this information consolidated into one source, the First Aid.

From here, I spent my time answering all the wrong answers on USMLE World, bringing the wrong answer count down to zero. Once this was done, I reset world. I would spend a morning reading a section of First Aid, and do two 46 question sets one related to the section I read, and one that was on any topic from world, this would take about a day if you went through each question with a fine toothed comb for review. The goal here is to be familiar with most the questions in world. At some stage you want to be able to fly through these questions be able to say that each question is at least familiar, at this point you score should be beginning to spike. After doing this for a couple of weeks, I decided to buy USMLERx question bank just to burn through as many new questions as I could. Some people elect to use Kaplan as a secondary question bank, I think this is too detail oriented, and expensive, so use what you think is best. The idea at this point wasn't for me to necessarily have the best question bank, all I wanted was something where I could practice my focusing, test taking ability, and strategy to handle novel questions that I might not be comfortable on first glance. Also Rx limits its scope to what's in First Aid, so its a good way of keeping those details fresh on your mind.

I split my last month into two halves, the first half I did the entire Doctors In Training program. I'd highly recommend it, it will make you pay attention to high yield details that you might not care to learn or have ignored up until now. Doing it in 15 days can be brutal, its a lot of work, so figure out what schedule works for you. For the last 15 days, all I did was practice questions. I simulated a full length exam every day doing 7 timed sections in a row according to the time frame of the real thing. These were done again with world, and I was able to go through world again during these 15 days. During all this time I was also doing the half exams that predict your score, these can be obtained from the NBME website as well as two that are included with your subscription of USMLE World. Do as many as you can, especially the NMBE ones -- I had several repeat questions on my USMLE from these. Additionally, NBME has a USMLE simulation test which also has repeat questions showing up on the real thing. Two days before, I downloaded a back-copies of several NBME practice tests (these are posted all over the web) and just ran through as many of the tests I did not actually do myself as fast as I could. After that, I took the following day off, and felt very well prepared for the real thing. Do this method, and I promise, if you have half a brain, you'll get a very, very solid score.

A couple final thoughts. First and foremost mnemonic devices are a method of survival on this test. If you have a hard time remembering something, make up a mnemonic don't waste your valuable time beating yourself up trying to remember something that you'll forget again in a week. If you can't think of one, there's a mnemonic for just about every topic encountered on the USMLE, use google to your advantage for this.

When you do the NBME exams, there are no answer keys, but students have developed pretty reliable keys that can be found by a simple google search. This can make a review of a test last a a couple hours as opposed to a whole day. Finally, I happen to know one of the co-authors of the former First Aid, he went to my college and below I am providing his study plan that he emailed me. Keep in mind, most people can't score in a range that even approaches a student like this, so be realistic, but at the same time, this is advice from the best so take from it what works for you:

I like to think of Boards Prep time in different phases.

Phase 1:  Systems & Modules. This is what you've been doing so far. Continue to learn the stuff using the books I told you about in my last email to you. Read Robbins, use Goljan like its Lukman's Qu'ran (well, a little more than that... you know what I mean), Robbins Review / Web Path for questions & images, and First Aid for some final touch up. And there's Pharm and Micro, of course. First Aid during Phase 1 should be the lowest priority... Do not use it to gather all the information. Use it to guide what will most likely be tested on the boards. Trust me, I know how this book is put together. You'll struggle like whoa during 3rd year if you only use First Aid. Also, don't worry about doing a tremendous number of questions. I got together with 4 of my friends once a week and did like 20-30 questions, just to get a feel for doing questions and learn from each other. Do it with friends and have a good time with it.

Phase 2:  Continue System & Modules, plus USMLE World and First Aid.  Around 4-5 months before you take your test, you should start the USMLE World question bank with the intention of finishing it BEFORE you start Phase 3 (see below). I suggest starting off doing about 20-30 per day, spending about 1-1.5hrs, making sure to go over all the right and wrong answers for each question. Have First Aid with you (the 2010 version will be out by this time and if you don't have the 2009 version already, then I suggest you buy the 2010 version -- I'm one of the contributing authors :) ), and annotate the shit out of the book with information you get from working through the question bank. You'll find this to be the most time consuming, but you'll get more efficient at it as you go along. Go through questions of systems that you covered in the fall semester first, so that you are reviewing. Don't forget that you also have to keep up with your Modules / Systems during this time, so don't spend more than 1.5hr on questions.

Phase 3:  Boards Season -- 6-7wks. By this time, you will have covered all the systems through school, read Robbins, Goljan, FA, Pharm/Micro, and USMLE World. Pat yourself on the back, you've kicked some serious ass so far, and should feel good about yourself. But, now the most intense phase begins. It's long, grueling hours and requires discipline. I spent exactly 6 weeks, which honestly was more than enough. I was starting to get exhausted by the end and just wanted the thing to be over. I've attached my overall schedule to this email. Keep in mind, take this schedule and modify it to fit your strenghts / weaknesses. For example, my strength was Biochemistry, so I didn't commit many days to it. I actually did the majority of my Biochem studying during Spring Break -- read Lippincott's and did all the Biochem World Questions.
My daily schedule was the following:
6:45am-8am -- Memorize the Pharm section from that day's FA chapter. I would make flash cards for each topic / drug in FA. Ended up with ~500 flash cards. You gotta power through Pharm, learning pertinent mechanisms, side effects, and pearls.
8am-9am -- Shower, breakfast, lots of praying.
9am-12pm -- I spent this time to either finish up leftover World Questions or redo questions. I did about 100 - 150 questions per morning. Redoing them doesn't take long to review the answers since you've already looked at it once.
12pm-1pm -- Lunch. For the first couple weeks, I used the time as a break. But I eventually ended up eating lunc with a friend and reviewing Biochem with her for like 45min. This was pretty useful for me, but be wary about studying with people. Don't let other people stress you out.
1pm-5pm -- I used this time to actually study and memorize FA as best as possible. For example, on my Cardio days, I read the FA Cardio chapter each day, and by the 3rd day, it was pretty much in my mind. I sat in a quiet place in the basement, avoided people.
5pm-8pm -- Gym and Dinner. But seriously, gotta do these. It's a stressful 6 weeks and need to take care of yourself.
8pm-10pm -- Kaplan Questions. I did about 70% of the Kaplan Qbank. Not sure how useful it was, but it was nice to see more questions. They were actually more discouraging for me, b/c I thought they were so much more detail oriented than Usmle World and the actual test. I bought the 1 month subscription and did as much as possible.
10pm-11pm -- TV/porn/whatever.

You'll see on my schedule that I have an NBME scheduled into each week. These are the practice tests available through the UMSLE website. I actually have bootleg versions of the tests and can send them your way if you'd like. I suggest you purchase at least 2 of them to see what your predicted score is. Also, if you get a 6mo subscription to USMLE World, they give you 2 World Practice tests. They are good. My score was pretty much an average of the 3 NBMEs that I bought, so its a decent predictor.

Phase 4:  Game time. Be confident in what you've done. I think I did close 6000 total questions to prep for step 1. That's an absurd number, but you get really good at deciphering exactly what the question wants. I thought the test was easier than I expected, but a lot of my friends thought it was way harder.

Let me know if you have any other questions or want more clarification. It's an intense period, but I know you'll be fine. Just stay disciplined and keep your sanity.