Scrub Notes Medical Blog: Tips For Med Students

5 Healthcare Professional / Medical Student Valentine's Day Gift Ideas

noreply@blogger.com (minava) — Mon, 06 Feb 2012 12:00:00 +0000

This isn't our first attempt at a Valentine's Day gift guide for med students, but admittedly the last one was a bit gender-biased. For 2012, we're going to try a little different approach, one that may involve a lot heart puns, allusions to cardiology, and other corniness. Or may not. You'll just have to read on to find out!

1. A Stethoscope

Yep, gotta start with the heart (for those scoring at home, that's 1 for the corny rhyme meter). Yes, I know, your loved one already has the plastic $10 stethoscope that can tell if the patient's heart is beating or not... barely. But shouldn't a quality guy or gal work with quality equipment? If they don't have a cardiology grade stethoscope, consider getting them one. It's a gift that they'll use daily in almost any specialty they go into, and one that may potentially last for decades. Read this guide to stethoscopes if you want more background info.

2. Cards... Flash Cards

And you were thinking cardiology... nope! It's bad pun #2! As much as any med student hates to study, flash cards are an effective way to cram all that information into one's brain. Getting your beloved a soon-to-be beloved set of learning tools is a productive way to help them reach their goals. The pharmacology and ID/microbiology ones are particularly helpful. For you future internists, the Pharm Cards are by the same author as Pocket Medicine (Harvard's Marc Sabatine), the essential guide for any medicine intern or resident.Although, it would be nice to sweeten that pot with....

2b. Cards... Gift Cards

Haha, kind of takes the sting off of having to study, no?

3. Listen to your Heart

And have your Valentine listen to their new iPod! The Product (RED) iPods donate a portion of the proceeds towards the campaign to help eliminate AIDS (You know Bono from U2, President Bush, and all those Gap t-shirts...)

4. Get that blood pumping

Nothing will get your lover's blood pumping faster than a plush stuffed erythrocyte! Hm, or not, but they just might get a case of the warm fuzzies!

5. Love in the Time of Cholera

And last but not least, for the literary lovebug in your life, might we suggest a non-medical novel? Sure, 100 Year of Solitude is better known, and this book arguably has little to do with infectious diseases ultimately, but it's a good read nonetheless and perhaps a welcome break from the trials and tribulations of modern medicine & medical education. Happy Valentine's Day!

Hand Anatomy: Tips For Learning The Carpal Bones

noreply@blogger.com (minava) — Mon, 23 Jan 2012 12:00:00 +0000

Learning hand anatomy is important for any medical student. Despite being a relatively small area, the hand contains many structures which leads to many disease patterns. For example, ulnar nerve injuries can cause patterns of findings like Pope's blessing. However, by learning the hand systematically, these diseases can be eventually mastered.

As far as what order to learn hand anatomy, it makes sense to start with the bones as they form the framework which all the other structures course through or attach to. The long bones of the forearm that articulate with the wrist (also called the carpus) are the radius and the ulna, which are on the lateral and medial sides of the forearm, respectively. There are two rows of carpal bones, which will be discussed in further detail below. The distal row articulates with the metacarpals, which are named by the digit they attach to. The metacarpals, in turn, articulate with the proximal phalanges (single: phalanx), which join with the middle and distal phalanges to form the rest of the digits. Note, there is no middle phalanx in the first digit (the thumb).

Proximal: A=Scaphoid, B=Lunate, C=Triquetrum, D=Pisiform
Distal: E=Trapezium, F=Trapezoid, G=Capitate, H=Hamate
Source: Wikipedia

Now about those carpal bones! Starting with the proximal row, there are the scaphoid, lunate, triquetrum, and pisiform. The distal row contains the trapezium, trapezoid, capitate, and hamate. How does anyone go about remembering them?

Simple! Mnemonics - the most common one being Some Lovers Try Positions That They Cannot Handle:

Some - Scaphoid
Lovers - Lunate
Try - Triquetrum
Positions - Pisiform
That - Trapezium
They - Trapezoid
Cannot - Capitate
Handle - Hamate

Keep in mind that the first four letters refer to the proximal row, and the second four to the distal row, both from radial/lateral to ulnar/medial side. Like every mnemonic, this one has a downside: there are THREE bones that start with 'T', two of which sound very similar to each other. How does one remember which T goes with which T bone?

For triquetrum, remember that the word in the mnemonic try sounds the same as the first syllable tri-.
Remember that, and there are only two T bones left, but they are spelled very similarly. No worries just remember that for trapezium, remember that the bone nearest the THUMB ends in -UM (say it aloud if that is unclear).
The remaining T bone has to be trapezoid.

Hopefully bearing that extra information along with the mnemonic will help you easily master the bones of the wrist. Since we're talking about the bone, here are some extra factoids to keep in mind:

The scaphoid is the most commonly fractured bone in the wrist.
Also, the scaphoid has retrograde perfusion, so if there is vascular insufficiency, avascular necrosis will go in a proximal to distal, unlike every other bone.
The lunate is the most commonly disLocated bone in the wrist. On a lateral film, it looks like a half moon (hence, the name, as luna is Latin for moon).

Once you've mastered the bones, learning the muscles, nerves, arteries and veins becomes much more straightforward. Knowing the bones is also key for learning all the eponymous fractures that occur at or near the wrist (Boxer's fracture, Bennett's fracture, Rolando's fracture, Colles fracture, Smith fracture, etc.). It takes some amount of practice and repetition, but I have no doubt you can handle it =)

Should Medical Students Buy The Kindle Fire?

noreply@blogger.com (minava) — Mon, 16 Jan 2012 12:00:00 +0000

Back in 2009, when tablets and e-readers were first becoming popular on the market, we discussed whether medical students should be required to have tablets like the iPad, or whether one should wait for an e-reader like the Kindle geared towards medical education. Now, two years later, as tablets and e-readers continue to converge and prices fall, Amazon had introduced the Kindle Fire:

What is the Kindle Fire? It is Amazon's $199 color 7-inch tablet that runs Amazon's custom version of Android for tablets. Why does this matter for medical students? Here are a few reasons why the Fire does matter:

Price - At under $200, the tablet is much more affordable than the iPad for most medical students on a budget.
Portability - At 7", the tablet is light and small enough to carry to any lecture hall, or even on wards potentially.
Color - Unlike prior Kindles, the full color screen lets students get the most out of any medical resources they find online.
Amazon - Yes, the company selling the tablet matters. Given the huge amount of content Amazon offers and the proven track record of the Kindle family, students who buy the Kindle will not get left behind, unlike, say, buyers of HP's TouchPad, who shelled out 3x as much money just to find out less than 2 months later that HP was killing the product.
Price, again - Hello, you can buy three of these for the cost of an iPad.

All that being said, the Kindle Fire is not an automatic slam dunk. Some users find the 7" screen cramped for web browsing and that the browser is slow compared to the iPad's. Also, if you are interested in using apps that only run on iOS, they cannot be used on a Kindle Fire. Even some common Android apps may not function perfectly given Amazon's tweaks to the OS.

So, where does this leave a medical student? Basically right now, first ask yourself whether you really need a tablet and what role it would play in your education. Are the text books you like to read available in e-book versions? Do you heavily use online resources? Is your campus fully Wifi-enabled? If so, a tablet makes sense. But which one? If you have the budget, certainly test drive an iPad 2. However, if your budget is a little tighter, the Kindle Fire seems to be a fitting alternative. Although, for what it's worth, the best bet may just be to wait a little while for the Kindle Fire 2!

What Medical Students (and Residents) Should Bring On Call

noreply@blogger.com (minava) — Mon, 09 Jan 2012 12:00:00 +0000

This is a guest post by Medaholic.

Essential Items to Bring when On Call

Being in-house overnight call is a rite of passage for all medical students and residents. From sleeping on old uncomfortable beds to being awoken in the night for scutwork, being on call can be miserable. However, there are somethings you can do to make your call more bearable. Having done a fair share of call, I've put together a list of items that you should pack in your bag whenever you're on call. Some are practical, some make your life more comfortable and some are absolutely necessary. Hope you find this list helpful

Must-Brings

1. Hospital ID / Access Card - Granted you should be wearing your identification normally, having a hospital ID when you're on call is a must. At night, many hospitals doors are locked and need special keycards to access. During the day, you may be able to get by without one but at night, be sure to bring it with you always.

2. Pager - As much as I hate this device, it is a must carry at night. It is often the only way someone can find you in the hospital. Worse, if you have unanswered pages from ward nurses or other health personnel, it can be considered unprofessional and have consequences.

3. Cellphone - if you're in a place with no wired telephones, a cellphone is crucial for returning pages. Similarly, lots of students, residents and staff communicate via text or direct calls to their personal phones. Also having a smartphone to look up medication dosages and references is handy.

4. Food / Snacks - It's important to take care of yourself and address your basic needs when on call. Bring a healthy dinner. Have lots of small snacks just in case you're up all night. Managing your energy levels is important for surviving busy call nights.

Useful to Bring

5.. Pocket Handbook - Whether it's a medication guide like Tarascon's or Pocket Medicine, having a quick reference can keep you out of trouble especially when you're not certain as to what's going on with a patient.

6. Money (Cash) - Most hospital cafeterias close early in the evening. You may want to grab some food from a vending machine or delivery to get you through the night. It's always helpful to have coffee money for your post-call morning.

7. Phone Charger - Most smartphones these days need to be charged daily. Nothing more inconvenient than having your phone die on you the next morning.

8. Toothbrush/Toothpaste/Floss - Going to sleep with poor oral hygiene feels terrible. Similarly, nobody likes a presenter with bad breath. Brushing your teeth in the morning is refreshing, and is a quick thing you can do to not feel gross in the morning.

9. Study Notes / Books - Some nights on call are not as busy as others. There is often some downtime if all the wards are quiet. Since you're in the hospital already, you might as well make the most of your time. Catch up on some of your studying while you're in the hospital, so you won't have to when you're post-call. If you still haven't taken Step 1, 2, or 3, bringing the relevant edition of First Aid can be quite useful. Bring a leisurely read if you want to have a bit of respite too.

10. Sleep wear - Lots of times call rooms can be quite cold - be sure to bring some warm clothing. Fleece jackets tend to be popular. Similarly, if you don't like sleeping in scrubs, real pajamas can make sleeping in the hospital a bit more bearable.

11. Comfortable Shoes - Running to the emergency room at 3am in heels or nice dress shoes is less than ideal. Bring comfortable runners like Dansko or Crocs clogs, something you're not afraid to get dirty, and something easy to slip into.

12. Alarm Clock - You can use your pager or phone to double as an alarm clock. If you would prefer being awoken by a more pleasant sound, a small travel sized alarm clock can do the trick.

13. White Coat - Some people find the extra pockets and warmth of a white coat useful. Try not to overload your whitecoat with too many tools, pens and books. Save some strain on your neck and only carry what is necessary and nothing more.

Final TipsLeave your valuables at home - jewelry, laptops, important documents. Pack only what is necessary and have a secure place to store your belongings. You are often the only one looking out for yourself when you're on call, so come prepared. Stay warm, remember to eat, rest when you can and your call nights will not be as stressful. Good luck on your next call shift!

Medaholic blogs about his journey through the Canadian medical system and offers advice for people at all stages of medical training at www.medaholic.com.

Happy 2012!

noreply@blogger.com (minava) — Mon, 02 Jan 2012 23:09:00 +0000

Happy new year! Last year was a difficult one for Scrub Notes - life got busy and challenging, and posting became infrequent. However, with a new year, we have a new plan to keep Scrub Notes active and useful for all our readers. Have any comments? Suggestions for topics you want addressed? Guest post? Let us know by contacting Scrub Notes today!

As we closed out 2011, we reviewed Atul Gawande's book 'The Checklist Manifesto' and how it could apply to medical students. After posting the review, this video clip of Gawande discussing his book and the Obama healthcare reforms was brought to our attention. The content is a little dated, but still interesting to listen to. Check it out!

Gawande is eloquent as usual, but he somewhat dodges some of Rose's questions. For example, when Rose asks what kind of system would be ideal in Gawande's mind, he simply avoids answering the hypothetical by noting its lack of basis in reality. However, that's the point: Rose wants to establish a baseline set of goals that a system should aspire to, even if it is not feasible in reality. Check it out, and let us know your opinion!

Does 'The Checklist Manifesto' Apply To Medical Students?

noreply@blogger.com (minava) — Tue, 29 Nov 2011 12:00:00 +0000

This post is long overdue, but I finally got around to reading Atul Gawande's most recent book The Checklist Manifesto: How to Get Things Right. Longtime readers of Scrub Notes are likely aware that I'm a big fan of Gawande's writing. His first book Complications has practically become required reading for pre-med students. His second effort Better continues along the same vein. However, The Checklist Manifesto is Gawande's first major effort to move beyond merely an anecdotal descriptive text on the trials and tribulations of practicing medicine into the area of shaping policy and medical practice. And, to this reader, he makes a fairly convincing argument, utilizing extended examples from diverse fields such as piloting, building construction, and finance.

Gawande's argument primarily targets his fellow surgeons. However, what can medical students learn from his text? Can the humble checklist help a medical student succeed in learning the necessary knowledge to succeed in medical school? I doubt any serious study has been done in this area, but intuitively, the answer is yes. As Gawande suggests, try a checklist.

But, what does trying a checklist mean for a student? The checklist is meant to address a systemic problem, not an individual one. Gawande targets fellow surgeons because they run the ORs: they have primary responsibility for the patient's well-being as well as for insuring that the OR runs well. A trainee like a medical student typically simply plays their assigned role. However, therein lies the problem.

By simply playing an assigned role, the student learns from their environment in a haphazard way. Some ORs meticulously run through time-outs and other preparatory procedures; others perfunctorily mention them or even avoid them except for the most necessary ones. However, the student's responsibility ultimately is to the patient, not to maintaining a culture of complacency that he or she may find herself in. By creating and running through their own mental checklist prior to any patient encounter or procedure, you can ensure that you and your team avoid making unnecessary mistakes that may cause the patient harm. Even if you feel powerless on a team or service, your personal checklist can help ensure that you are doing your utmost to serve the patient. Although this may not be the 'heroic' side of medicine, as Gawande notes, the effects can be profound in terms of safety and patient care.

Beyond patient safety, taking the time to craft a checklist can help you break down a complex procedure into simple steps. As you are learning and practicing the procedure, focusing on these simple steps will make it easier to learn the procedure and learn to do it the right way in a safe manner. Gawande emphasizes this in his subtitle: How To Get Things Right. And that's what any student wants to do: get things right.

Scrub Notes 2012 Med Student Holiday Gift Guide

noreply@blogger.com (minava) — Thu, 24 Nov 2011 12:00:00 +0000

Happy Thanksgiving! While this is a time to give thanks and count your blessings, tomorrow is a time to shop! However, most med students, residents, and other medical professionals may not be joining on these shopping trips: they're probably studying or on call! So, to celebrate their commitment to caring for others, here are a few ways to show them you care for them:

Kindle Fire by Amazon

The latest tablet from Amazon is quite a break from previous Kindles. Offering an Android-based operating system and full color, the Kindle Fire is Amazon's first foray into the competitive tablet space. While not as full-featured as the iPad, the one killer aspect of the Fire is the price: $199.

That's right, $199 - a full $300 cheaper than the iPad. For med students, the 7" form factor makes it much more portable than the iPad. While lacking 3G support, most students would likely use it in a library or lecture hall (or Starbucks), where Wifi hotspots are plentiful. And with access to Amazon's site well-integrated, it will be easy for them to purchase e-books... or TV shows whenever they need blow off some steam.

Giant Microbes White Blood Cell (Leukocyte)

A popular gift idea last year, the Giant Microbes are back! These stuffed toys are whimsical depictions of all things medical. From bacteria to neurons, check out all the options available. For the immunologically-minded, I put the white blood cell here. I can almost hear him saying, "Meep! A bacteria! Must defend!" Haha, almost like a Pokemon... but one that saves lives!

The Emperor of All Maladies: A Biography of Cancer by Siddhartha Mukherjee

This book has been on my reading list all year long and hopefully I can get to it before the year is out. However, from all accounts, the book is well-written and lives up to its subtitle as a biography of cancer. Mukherjee details mankind's history in battling this scourage and how modern science has revolutionized the fight. However, with the great advances come new challenges and new concerns in how we deal with when our bodies fail us.

Looking for more gift ideas? Check out last year's med student gift guide. And if all else fails, you can't go wrong with a gift card =)

How New Medical Students Should Learn To Learn

noreply@blogger.com (minava) — Mon, 21 Nov 2011 14:00:00 +0000

A confusing title, perhaps, but it's correct: newly minted medical students often have to reteach themselves the habit of learning medical knowledge in order to succeed in medical school. This guide from Wellness Rounds, originally intended for students entering Baylor College of Medicine, gives some good pointers for first year medical student study strategies:

Your goals

Learn material for long term retention
Pass exams
Develop skills for lifelong education & studying (nope, it never stops but it can get faster!)

1. The Basics

No magic formula for studying except for diligence and consistency
Goal is to learn and apply pertinent material – NOT perfection
Efficiency is a skill developed through practice, persistence, and reflection – not the result of drinking more caffeine or a genetic trait that skipped your generation
Studying is not a competitive sport – some student take (much) less time to learn than you will, but some take (much) MORE time than you…that’s life! Good news – in the end, we are all doctors.
Be gracious. To yourself and your peers as you pass through the basic science crucible that brings out some less than pleasant coping mechanisms. It’s normal and will pass.
You will succeed! Don’t believe us some days? Ask any of the thousands of physicians, professors and mentors around you – we’ll be glad to remind you!

2. The Specifics

Choose one way to study and stick with it for at at least 1 week
- Switching study methods costs more time than it saves and there is a learning curve to all of them
Start with the first lecture and go sequentially to be sure you don’t miss topics
For all study techniques
- Study reps: 45-50 min “on”, 10-15 min “off” (see below)
- Skim before lecture (assigned readings, ppts, syllabus, etc)
  - SKIM to familiarize yourself with how to spell new words and the general outline/concept of the lecture – this is not learning time
- Attend > stream lecture and actively listen by taking notes, drawing pics, writing qs, etc.
- Take a lunch break after lectures to get good nutrition, socialization and to recharge
Techniques for LEARNING
- Mind maps
- Review notes with ppts, syllabi and text book and create a condensed 1 page review
- Rewatch the lecture while condensing notes and focusing on main points
- Flash cards of high yield material
- Single page flow chart of material
Techniques for REVIEW
- Practice questions (online, review BRS books)
- Small group discussion, lecture by lecture (max 4 ppl)
- Small group quizzing of lecture material
- Peer or upperclassman tutoring

Study Reps: 45-50 min “on”, 10-15 min “off”

“ON”
- Close email, g-chat, FB, other distractions, put phone on vibrate/silent
- Set an alarm and STOP studying when it goes off
- Write down other tasks that come to mind on a sticky note but do NOT stop studying to do them (ex: reply to email, wash dishes, make a snack, look-up question from another lecture, chat with nearby friends, etc.)
  - These tasks can be done during your “off” period
  - You will be amazed at what distracts you and feels “urgent” while studying, but there is almost NOTHING that can’t be put off for <45 min, including perez hilton
- Don’t be frustrated if the first 15-20 min (or more) feel “wasted” bc you can’t focus – this is NORMAL and the time from sitting to focused productivity will decrease as you adjust to a daily routine (the same as exercising)
“OFF”
- Set an alarm
- Reward time! NO STUDY RELATED ACTIVITIES!
- Grab a snack, read a NYT article, catch up on the FB developments (OMG, so much happened in 45 min!!!), chat with a friend, send off a quick email, check off the list you made during your “ON” period
- Get up and stretch, walk around for a couple min – it’ll wake you up, get you out of your “study zone” (wherever you are working)
- Congratulate yourself on sticking to your study schedule and breaks
- Relax and don’t worry about how much time you have/not spent studying, let the alarm clock guide you rather than checking your watch constantly

3. The Refinement

What works for others may or may not work for you – don’t be discouraged!
Study methods evolve as you discover what sticks best in your own head
New topics/blocks may require different approaches
At the end of the week or block, reflect on what worked well (timing, setting, method)
- Adjust study methods to what works best for you – but remember, DILIGENCE and CONSISTENCY are king & queen
Exam results not reflective of your efforts? Ask for help! Professors, upperclassmen, mentors and strong peers can enhance your study skills.
STUDYING is STUDYING – it is never wasted.

4. The Balance

All work and no play makes a miserable and burned out student, resident and physician
Set aside at least 1 hour as sacred for meeting your personal needs (NOT chores)
- Examples: exercise, cooking a nice meal, calling friends and family, reading a great book, prayer or meditation
Sleep on a schedule: go to bed and get 7-9 hrs of sleep every night, your brain needs that time to literally build memory
Eat well: again, your brain and body need good protein to build synapses for memory, carbohydrates for fuel to burn while studying, and plenty of water to keep you going in the Houston heat
Break up your week: take Sat. afternoon/evening off for fun activities with friends/family (movies, restaurants, dancing, bars, parties…), sleep in Sunday morning and have time for yourself and your personal development (reading, writing/journaling, church, chats with significant other)
Schedule it: if we write it, we do it. Use your gmail calendar, phone app, planner, etc. and plot out your week including your studying, exercise, family/friends and other activities. It will give you a sense of control over your life as you plan your days, rather than your days ruling you.

5. The Non-Science Major

You’re not alone – great physicians come from a variety of backgrounds!
You may play catch-up at first, but you undoubtedly can succeed
Writing and theoretical dissection of literature/theory/philosophy/art will be applicable in medicine – but basic sciences throws you back to the forgotten days of multiple choice exams and memorization. Dusting off those skills and learning to study for regurgitation/application rather than creation may take some time, so don’t despair if you are spending longer in the library than the Bio-E major.
Link up with a science-major classmate who is good at identifying high-yield material AND explaining it.
Contact the upperclassmen study tutors – many of us had limited science exposure starting med school (“Wait, is it 2 livers or 2 kidneys – I’m not really sure?” – General Surgery Bound MS 4) and more than succeeded — but we’d love to make that transition easier for you!

For more study strategies for first years, check out Wellness Rounds.

When Should I Start Preparing For The 2012 USMLE Step 1?

noreply@blogger.com (minava) — Sun, 20 Nov 2011 03:18:00 +0000

How about... right now?

That's right: even though the exam is several months away for most students, the time to start preparing for the 2012 Step 1 is today! Why so early, you ask? Simple: USMLE Step 1 is an exam that tests your cumulative knowledge. The sooner you start accumulating this knowledge, the better. This is not crammable knowledge. I repeat, this is not crammable knowledge. Yes, I know, you're a medical student - you live off of cramming. It's worked so far, right? Why not keep pushing your luck? Trust me: this is *not* the test you want to cram for, nor is it the test to take chances with. Most residency programs heavily weight Step 1 scores when determining which applicants to interview, let alone rank. Remember, this test is a means to an end: getting into a great residency program.

Hippocrates

So, now that I've got you properly on edge, how do you start preparing for Step 1? The key is to gradually build up your knowledge in a Step 1-specific way while you are studying for your basic science exams. As I've mentioned before regarding Step 1 preparation, you should purchase a general USMLE Step 1 review book such as First Aid for the USMLE Step 1 2012 and annotate it with your own learning as you proceed through your basic science courses. Using this technique, when it comes time to study for Step 1, you are not reading some unknown professor's notes, but rather your own in a language you can understand. And, you will also become very, very familiar with the review book that you intend to use, which is quite helpful. You will start to notice certain topics end up being covered in multiple areas. For example: meningitis is both an infectious disease topic as well as a neurological topic. Both chapters will likely mention it but with a different focus. Knowing this well in advance can help you annotate one section with a note saying "Hey! Check out the other section for more info on this!" Remember, the body does not have chapters or sections. Disease is not neatly organized, so the key for your preparation for Step 1 is to be as organized as possible.

If annotating is not your thing, there are other options. You can purchase a USMLE Step 1 Qbank now and start looking at practice questions now. Simply take a section related to a topic you are working on and go through it. Figure out what your weak areas are and study them doubly hard. Whatever method works best for you is fine. It does not how you are reviewing for Step 1, but that you are doing something specific to prepare. Even doing as little as one hour per week can give you as much as a 30% head start over your peers in that final stretch before the exam. The key is to start doing something every week now so that when it is crunch time you feel prepared and confident to tackle the challenges that lie ahead. Good luck!

What The Doctor Saw

noreply@blogger.com (minava) — Tue, 08 Nov 2011 05:32:00 +0000

I recently finished reading What the Dog Saw by Malcolm Gladwell. I enjoyed the book, although it's more a collection of essays rather a unified work like his prior works. Why mention it here? Well, one chapter/story heavily involves mammography. The chapter is actually two stories in one, but both basically relate to the premise that a picture is worth a thousand words... but are they the right thousand? The other story involves the use of satellite imagery by the U.S. military to assess foreign targets. Malcolm Gladwell compares this to a mammographer scanning for tumors on a mammogram. The analogy is reasonable... but like all analogies, it breaks down after a while.

So, what does Gladwell conclude? Honestly, it is kind of hard to tell. He notes the difficulties in mammographers being over- and under-sensitive, yet concludes by noting the benefit of mammography spread across the population. What I wish he had taken more time to address would have been the nature of a screening exam. What does it mean for an exam to be 'sensitive'? 'Specific'? I'm willing to bet the vast majority of people out there don't know. Heck, I imagine many people within medicine aren't 100% clear. The recent controversy over prostate screening guidelines highlights just how controversial this subject is. If healthcare professionals are not united in how such screening is presented to the public, how can we expect patients to choose the right course of action? Furthermore, in the long run, such revisions erode the public's trust in healthcare overall.

How do healthcare professionals strengthen this trust in an era of seemingly constant changes in recommendations? Simple: focus on the underlying reasoning behind getting screened. Explain to patients that such tests evolve over time as new technologies develop. Help patients make informed decisions on their own. Ultimately, the better we communicate the need for testing, the benefits *and* the risks, the better relationship we will have with our patients, and hopefully they will enjoy better health in the long run.

What do you think? Check out the book to see Gladwell's argument yourself... you might find yourself enjoying his other pieces as well!

Just want to read the chapter but not the whole book? Gladwell has it posted on his website here.

Site Note: Regular readers may have noticed the long pause in new posts. Apologies, but sometimes life comes at one fast... and the blog got pushed to the backburner. Again, thanks for sticking with us and we look forward to putting up lotsa great new Scrub Notes stuff shortly! Happy reading!

Attending Advice On Clinical Rotations

noreply@blogger.com (minava) — Sat, 21 May 2011 11:00:00 +0000

Many second years are soon to enter the clinics and wards for the first time come June and July. Dr. Mary Brandt, a Baylor College of Medicine pediatric surgeon who blogs at Wellness Rounds, provides the following advice to medical students starting on clinical rotations:

Don’t sit in the back of the plane.

The basic sciences are important to learn the vocabulary and grammar of medicine. Clinical rotations are different – it’s where you actually learn to be a physician. If you use the analogy of learning to fly, in basic sciences you are studying the book on how to fly the plane. In your clinical rotations you are in the plane, watching and learning from the pilot. Which means you have to be in the cockpit. You cannot learn to fly a plane by sitting in the back.

In every situation you encounter in the hospital, imagine that you are “flying the plane.” When the resident starts to write the admission orders say “Do you mind if I write them and you show me how?” On your surgery rotation, be in the holding area early and ask the anesthesia resident if he/she will explain how to intubate, show you how to intubate, or even let you try. When you are writing an admission H&P on a baby in the ER, imagine you are the only doctor who will be seeing that patient. Let the adrenaline of that thought guide you to the computer to look up more about the condition, how to treat it and what you would do if you were the only person making the decisions.

Yes, you need to be pushy and, yes, sometimes it will backfire. Be reasonable, but stay engaged. If it’s not an appropriate time to be assertive, stay in the game mentally by asking yourself what they will do next, what you would do if you were making the decisions, or what complication might occur from the decisions being made. Write down questions you will ask after the smoke clears if it’s not appropriate to ask during a stressful situation.

Know what you are expected to learn before you start.

I am not a fan of “learning objectives”. If they are done well, they are very helpful, but most people don’t take the time to do them well (or don’t know how to do them). For the rest of your professional life, you are going to have to define your own learning objectives. So, in a way, learning how to do it early – during your core rotations – is also part of the skill set you need to know. (Word of advice, though – even if they are very poorly written, you need to read any objectives you are given and make sure you accomplish them.)

Start with a basic textbook. You will NOT be responsible for learning all the details in the textbook! Textbooks are written for residents and practicing physicians. But – a good textbook will give you an overview of the topics.

The strategy:

1. Make a list of the topics covered in a general textbook. There are usually 2-3 good textbooks for every specialty. Ask other students or residents which one(s) they recommend. You will probably rotate on sub-specialty services during your core rotation, but don’t get bogged down in looking in sub-specialty textbooks. Stay with the general textbook.

2. Plan to skim and make notes on every major topic. These should be “big picture” notes, not every detail. If there are 60 chapters in the book and your rotation is 2 months long, you should be shooting for one chapter a day. Keep track and make sure you get them all covered during the rotation (not after). When you are done with the rotation, these notes should be all you will need to review for the shelf exam.

3. Don’t read the chapters in order – read them as you see patients (see below). But, make sure that all the chapters are covered since it’s unlikely you will see patients with every disease in the book.

Practice being professional.

It’s really important to be professional and to be seen as professional in all your interactions. First of all, it’s the right thing to do. Secondly, a bad interaction with a nurse on the floor can lead to a poor evaluation by your attending. Make learning how to behave as a professional one of your learning objectives. Learn from those around you. Which residents and attendings are the most professional? Why? When you see bad behavior (and you will), think about it – what would you have done differently?

Learn from every single patient you see.

Use every patient to learn about their specific disease. Even if it’s the 30^th patient with appendicitis you’ve seen you’ll still learn something new. (or use it to learn about their hypertension instead)

The strategy:

1. Keep a notebook with an entry for every patient you see. You can use 3×5 cards, if you prefer. In fact, many hospitals have 3×5 cards with the patient info available in the patient’s chart for docs to take.

2. Make yourself read something about every patient you see. If you haven’t read the textbook chapter on the subject, that’s where you start. If you have read the textbook, review your notes and read something new (UpToDate or PubMed for example)

3. Make yourself write down a minimum of 3 things you learned from the patient in your notebook (or on your 3×5 card).

Be the doctor for patients that are assigned to you.

You will be assigned patients to follow during your rotations. When this happens, make up your mind that you are going to “wear the white coat”. What if you were the only doctor taking care of Mr. Smith after his surgery? In addition to reading (see above), ask the residents to help you write all the orders. Write a daily note and make sure your notes are at the level of the residents (ask them to review and critique your notes). When a drug is prescribed, know the dose you are giving, the effects of the drug and the potential side effects. When a x-ray is ordered, be the first person to actually see the image and know the result (and make sure you call the resident as soon as you do!). Don’t get any information second hand – make sure you see the results and the images yourself. At any point in time, if the attending asks, you should be able to present your patient as though you are his/her only doctor, which means how they presented, their past history, social issues, test results, procedures performed and how they are doing now.

Prepare for conferences.

Every service has at least one or two weekly teaching conferences. In most cases, the topic (or cases) are known before the conference. Ask your residents or attendings the day before the conference for the topics and/or cases that are going to be discussed. Use the strategy outlined above to prepare e.g. consider these “vicarious” patients and learn from them as if they were a patient assigned to you.

Come early, stay late and keep moving.

Taking care of patients in the hospital is a team sport. The best medical students become part of the team early and are appreciated and – therefore – taught more. It’s just human nature and it’s just the way it works. Don’t brown nose, don’t show off…. just show up. If there are labs to look up before morning rounds, be there 10 minutes early and look them up for the residents. If you don’t know the answer to a question the best response is “I don’t know, but I’ll find out!” If there is scut work to be done that you can help with, volunteer to help before you go home. Anytime you can, make the residents look good. It’s particularly important not to try to one-up the residents. You will have more time to read than the residents, so you may actually know more than they do about a specific topic. But, if the attending asks a question and the resident gets it wrong, don’t correct them in front of the attending. (Unless it’s a critical issue and you think the patient might suffer in which case you have to speak up!) Whenever you can, set up the resident to succeed. “A rising tide floats all boats” – if you help them look good, you will look good and the team will look good. Don’t ever sit in the lounge waiting for someone to come tell you what to do. There are patients to see, conferences to attend, rounds to do, labs to look up… the hospital never sleeps!

Practice having a balanced life.

Compassion fatigue is a constant threat to practicing physicians. Taking care of yourself, staying connected to family, friends and the outside work are all critical components of preventing compassion fatigue. This, too, is a skill you need to learn during your rotations so you can carry it with you into your residency and your practice.

Enjoy! You are finally a “real” doctor!’’

Your experiences on your clinical rotations will be among the most special of your life. Buy a new journal and take time to jot down the funny and not-so funny occurrences of daily life in the hospital. You will see some extraordinarily beautiful moments of human life.. and some horrendous examples of what people can do to other people. We all learn to deal with these extremes by telling stories. Write down these stories when you can. It’s also special to record your “firsts”… the first time you set a fracture or hear a murmur of aortic stenosis will be the only “first time” you have. It’s a special world you are entering. You’ll want to remember it by taking notes, recording stories and with pictures of your team and unique sights around the hospital. (No patients, though – remember HIPPA!)

Congratulations! You are well on your way to the privilege and joy of practicing medicine.

Click on over to find more practical and healthful advice from Dr. Brandt at Wellness Rounds

How To Study For USMLE Step 1 While Working Full Time?

noreply@blogger.com (minava) — Tue, 01 Mar 2011 16:50:00 +0000

I have mentioned in the past that many times, readers of this blog write in to scrubnotes@gmail.com with specific questions. However, over time, I've noticed some questions being asked repeatedly, so I thought I might answer one of the common questions on the blog itself (with permission, of course):

Q: Thanks so much for posting your USMLE Step 1 strategy. It calmed my nerves a bit to say the least. I graduated from a foreign med school in 2001, am a US citizen, took a USMLE Step 1 Kaplan Course and failed step 1. Had to start working full-time (non-medical-related field) to pay off debt. Lost my confidence but not my desire to pass the steps and utilize my education. Any suggestions for someone who must work full-time (9-5), 5 days a week and has to start from scratch for preparing for step 1? (I really liked your advice about utilizing First Aid as a primary study tool). I have not, as yet, scheduled the exam. Thanks again.
- T.H., foreign medical graduate 2001

A: Thanks for writing in! I've received many similar questions regarding Step 1 study strategies / schedule. I think what you should do is first define your goals. The strategy to study can change quite a bit depending on what your goal score is. In general, I would say give yourself double the amount of time you actually need, so you do not feel time pressure while studying. Second, lets say you are taking the test on a Saturday - make sure that you take a practice test every other Saturday for let's say, 3 to 6 months prior to the real deal. In other words, practice being in a serious testing environment. Sure, this is painful, but as you'll likely agree, it's less painful than failing. Try to match the real test environment as closely as possible - take it in a quiet place, starting at 8am, only 1 hr of breaks total. To make a practice test, just take qbank sections back to back. Lastly, don't stress too much about the outcome - if you fail again, reconsider your life goals - most people are in medicine for one of two reasons (or both): to help people, make money, or both. If you are not successful at medicine, then you can do many things to help people (teach, nursing, etc) or earn money (business, law, etc).

Hope that helped - feel free to ask more questions by emailing scrubnotes@gmail.com. Good luck!

Medical Physiology Study Tips

noreply@blogger.com (minava) — Thu, 20 Jan 2011 12:00:00 +0000

This guest submission by Igor Irvin Bussel, a second year medical student, describes tips on how to study for medical physiology with the aim of acing that inevitable physiology test.

There is no topic more fascinating in medicine than physiology. Fundamentally, it is the study of life. To be more specific it is the science of function based on integration of systems, communication of signals, and elegant homeostasis.

As a former T.A. for Medical Physiology, I want to help students appreciate and succeed in their course without stress. There is a unique best way to study for each course/professor. I aim to have you study less but in a better fashion because nobody wants to study endless hours and still not score as high as they hoped.

Medical Physiology is a unique course because it is not about memorizing facts but rather
building a mind-set and framework for thinking about the function of the human body. With that in mind, realize that you are not taking medical physiology to become a doctor-- you will learn that by doing. You are a medical student. There is no M.D. after your name... yet. Study for the exams and all else will fall into place.

Even though everyone inherently understands that they have to study for exams, they still
study to be a doctor. Let me repeat and clarify myself: You are studying for exams on medical
physiology. You are not studying medical physiology to become a doctor.

Get the difference?

Once this is clear, you can actually use your exams for what they are-- directions for how to do
well in your medical physiology course.If you just study medical physiology without looking at past exams, you will not do as well on the actual exams as you would like. The course is just too broad for you to base your studies of what you assume to be important. As long as you went to lectures or have even a remote idea of what material you covered, you should take a look at the past exams that are available. Record what topics are addressed most often in questions and hyper-focus your studies to those high-yield areas. You should review all of the material presented but be sure that you have a thorough understanding of the high-yield concepts.

Do not wait to take practice exams days prior because you are not as ready as you would like
to be. You will never be fully ready -- ever. Nor will you achieve perfection. You can however
strive to be excellent. The very act of taking the practice exams will better prepare you for the actual exams and will provide further direction regarding your weaknesses. During your study
sessions, you should be in a constant state of awareness that there are critical points you still have not learned.

When taking the practice or actual exam, always do the easy problems first. Additionally, on
multiple choice sections, your attention should be devoted to finding the wrong answers. Since
there is only 1 correct answer and 4 wrong answers, it is not only easier to eliminate wrong
choices but it also increases the probability of having to make a guess if necessary. While you
are eliminating wrong answers and picking the correct choice, it is crucial to briefly write out your rationale for each decision. This redundancy not only ensures you didn't misread but also primes memories that may be advantageously accessed for later questions. I stress proving wrong and right answers because answer choices on exams are repeated more often than entire questions. More importantly, questions are often changed while answer choices are not.

After any exam, a post-mortem type of analysis must take place. What went well? What went
wrong? Stupid mistakes? Lucky guesses? Constantly evaluate performance, analyze trends, and
implement improvements. Do not waste time engaging in debates on minutiae and rationalization battles. The reality is that most rationalizations are based on faulty assumptions and unless evidence can be provided, these communications are a complete waste of energy, air, and time.

On a final note, while all courses will promote various text books, I think the best sources, if you need them, are the following:

1. Ganong’s Review of Medical Physiology by William Ganong
2. BRS Physiology by Linda S. Costanzo

Igor Irvin Bussel is a second year medical student at Chicago Medical School. Share your passion by publishing your writing on Scrub Notes today!

Residency Interview Tips, Part 5: The Follow Up

noreply@blogger.com (minava) — Tue, 18 Jan 2011 12:00:00 +0000

So, you made it to the residency interview. You fit in well at the dinner and impressed on the interviews. Now you're walking out the door, back to your car, or to the airport, and off to your next interview. You're finished with this program til you place it on your rank list, right? Wrong! Now is the time to really seal the deal. Think about it: you were just granted this wonderful opportunity to interview for an actual job in a down economy. Not everyone is so lucky, whether they are trying to find jobs in allied health or pursuing careers in other professions like business or trying to get into law school.

There are a lot of myths out there about how to communicate with the residency program after the interview, and frankly, a lot of times, the answer is: it depends. But, there are some things you should do regardless, and here they are:

Write Thank You Notes To Your Residency Interviewers
This seemingly no-brainer move tends to the bane of the medical student after the interview. Writing thank you notes is tedious, time-consuming, and does not offer any guarantee of advantage in ranking let alone any guarantee that your interview will receive your note! Still, while this is not sufficient to gain any advantage, you should view it as necessary to avoid being at any disadvantage. The steps are simple:

Make sure to get contact information from each interviewer at the interview
Use a basic template to speed things up for yourself
Add in something unique that came up from each interview to trigger a positive memory of you when read
Do not be too verbose - keep it short and sweet
Put your contact information beneath your signature in case the interviewer wants to be in touch

One 'modern' question about the ritual: should the thank you note be handwritten or emailed?

The answer is not so simple. Handwritten notes show more of an effort and seem more personal; however, they are harder for the interviewer to respond to and more likely to go unanswered / unacknowledged. One strategy is to write a thank you note within 24 hours of your interview and immediately mail it off. Then, a week later, send a one line email stating that you hoped the interviewer received your note and that you look forward to further discussing your interest in their field in the future.

Another issue: should I thank the program director if I did not interview with them? The program coordinator?

Again, no straightforward answer, but remember that ultimately the PD is likely the one selecting residents and would be your future boss, so can't hurt to make a favorable impression there. Similarly, the program coordinator can have a huge influence on ranking decisions. Sending one or both a one-line thank you email cannot be anything but beneficial.

The Penny Black: World's First Postage Stamp

Between Interviews and Rank Lists

Some programs begin interviewing as early as October. However, rank lists are formed in February. How do you keep yourself at the top of the list over 4 months of interviews and committee meetings? Make sure to keep in touch with the PD and PC as the months progress. Keep a list of questions that come up about programs in general (things such as health care benefits or how time off is given for board exams tend to become more pressing as interviews progress) and email the qs to each program director about once a month. That way, you not only gain more specific information about each program but also keep yourself fresh on their minds as time passes.

Should I do a second look visit to a residency program?

Again, it depends. You should really do it for your own informational benefit. While some programs view such visits favorably, others are neutral, and still others view them as intrusions into the workday of active residents. You also risk reversing the favorable impression generated on interview day. Lastly, there is the cost of visiting a program a second time. One approach is to inquire discreetly with the program coordinator about the feasibility of such a visit as well as ask around to see how such visits are viewed within the program of interest.

Residency Interview Tips, Part 4: The Interview

noreply@blogger.com (minava) — Sun, 16 Jan 2011 12:00:00 +0000

Okay, the big moment has arrived: the interview. You're on! But, don't worry - this isn't Larry King and this isn't nationally televised. You should view the interview as a chance to burnish your credentials for a residency program as well as gather more information about the program itself. The interview has four main components: the first impression & introductions, interview's questions, your questions, and conclusion. We break down the interview by each part:

The Residency Interview First Impression
While many interviews run late, make sure to be early to yours. Ask the program coordinator for detailed instructions on how to find the location if it is distant from the program office. Confirm the time and location. Ask people along the way if you feel unsure. There's no worse first impression than being late.

Since you should already be wearing standard interview clothes, that shouldn't be an issue. When you enter, smile - the interview should be fun for both you *and* the interviewer! Shake the interviewer's hand firmly while saying your name slowly and clearly. Take your seat promptly and place your items next to or below you. Sit up straight but don't lean forward too much. Make sure both feet are on the ground and your arms are relaxed by your side. Basically, your posture should convey quiet confidence. And keep smiling!

Hopefully, your interviewer is mirroring your actions. As you start in on the pleasantries, take a moment to note the office. Sometimes, you can introduce mementos on the wall in order to broaden the discussion as well as show that you are perceptive. However, be careful in this regard as sometimes interviews are conducted in borrowed offices. There are many other similar interview tricks you can employ in order to relate to your interviewer.

The Interviewer's Questions
After the introductions are complete, you can expect a short blurb from the interviewer about who they are and perhaps a bit about the program. Eventually, they will segue into the actual interview questions. Typical questions are covered in many places, and mildly vary by specialty. The key here is to be clear and straightforward in your answers. You should not spend more than 2 minutes answering any particular question. Avoid rambling. Stick to your points. Don't worry if you take a momentary pause to answer a question - it shows that you are actually thinking about your response versus just spitting out whatever comes to mind or whatever you have memorized. As interviews progress, you will find that most questions revolve around "Tell us about yourself," "Why did you pick this specialty?" and "What do you find attractive about our program?" so be prepared to handle those adeptly.

Your Residency Program Interview Questions
After about 10-15 minutes, most interviewers will wrap up their questioning and ask you if you have any questions. You HAVE to ask something here, even if you have no real interest or question. Obviously, if you are curious about something the interviewer said during their portion, ask about that. Otherwise, you can go in one of two directions. First, ask questions about the structure of the program, whether it be rotations or what the interviewer views as strengths / areas that need improvement for the program. It is also helpful to ask about the future, with regards to fellowships or career prospects, or just where they feel the field is headed in general. The other line of questioning is to ask about factors outside work, such as how it is living in that city or neighborhood, or how the culture of the program is. This line of questioning is bigger risk / bigger reward. Some interviewers will view this as showing you lack seriousness, but for others, this is a good way to forging a bond that lasts beyond the interview. Judge how the interview has gone thus far before deciding to engage in this line of peripheral questioning.

Residency Interview Conclusion
Take about 5-10 minutes to ask your questions. Don't pepper / aggressively question the interviewer. If you have tough questions about say, accreditation or board pass rates, save those for the program coordinator or program director. Not every interviewer is up to speed about every aspect of the residency program. As the questions wrap up, try to leave the same way you came in, exuding a quiet confidence. Smile and shake hands firmly. Make sure to ask for a business card or note down contact information in order to send correspondence once you are done with the interview. You can frame it as wanting a way to communicate in case you have further questions. Some programs are more upfront about providing contact information, but you have to solicit it yourself in many places. Walk out the door with your head held high and move on to your interview.

By the end of the day, and certainly after several interviews, you will be a pro. Congratulations! You're basically done with all the heavy lifting of attaining a position as a resident physician!

Residency Interview Tips, Part 3: The Interview Day

noreply@blogger.com (minava) — Fri, 14 Jan 2011 12:00:00 +0000

After you have carefully scheduled your medical residency interview and done the requisite preparation, the interview day has finally arrived! Although, for most applicants and most programs, the interview day really begins on the interview day eve with some kind of meetup, which may range from very casual happy hour to a full formal dinner. The main components of the interview day consist of: getting to the dinner, putting your best foot forward at the dinner, getting to the interview, and the residency program / interview day overview.

Getting To The Residency Program Interview Dinner

As stated above, this "dinner" could really be a very laid-back happy hour, or it could be fine dining at a four star restaurant. Regardless, to partake, you have to get there first! We are presuming here that you have already used Kayak or Orbitz to find a flight to your residency program interview. Once you have checked into your hotel though, your main priority should be local transportation to the dinner. Ideally, you would have looked into this beforehand, but if you have not, here are some options to consider:

Take a taxi - the quickest most reliable way in most cities to get to where you are going, but often the most expensive, especially the further West you go, where cabs are less commonly used
Use local transportation - again, better on the East Coast. You may not have much of an issue getting there, but sometimes the dinner may run long and getting back would be a hassle or even unsafe in certain cities in the Midwest, South and West.
Find a friend - if the hotel is commonly used by interviewees, you may be able to share transportation with them to save money as well as have a more enjoyable ride over. Plus, two minds are better than one when it comes to navigation
Navigate - if you have rented a car, it may come equipped with a GPS system in which case you can simply punch in the address and drive. If the GPS is optional, I would highly recommend taking it. Better yet, simply buy your own GPS machine and bring it with you! You can use the GPS in your own car once the interview is over. Personally, I found the Garmin Nuvi systems to be quite good. Make sure to get voice navigation too.
Ask the program - sometimes, the program coordinator can arrange for one of the hosting residents to give you a ride to and from your overnight location.

Looking Your Best At Your Residency Program Interview Dinner

A lot of the advice for the interview dinner is the typical interview advice one sees dispensed in general. However, despite the ubiquity of such advice, medical student interviewees are at a relative disadvantage. We do not generally interview as much as people going into traditional jobs nor do we receive specific advice as part of our formal medical curriculum (although many schools do offer mock interviews and the like). Keep in mind the following points:

Dress For Success - Even if the interview is "casual" such as a happy hour, dress nice. Do not show up in something you would wear at the beach or to a house party. Although the phrase is used in many ways, this really is an occasion where at a minimum you should dress "business casual."
Act The Part - You are an interviewee. Even if the residents are behaving casually or speaking without minding their p's and q's does not mean you should follow suit. Do not be lulled into a false sense of comfort - order food & drink tactfully, avoid alcohol, use proper language. Don't eat or drink so much that people think you need to have lap band surgery for weight loss or join alcoholics anonymous. Some residents may seem like your friend, but they may actually be taking notes on your behavior during the dinner which can make up part of your evaluation during the interview. Don't let a lax moment at dinner jeopardize your future job chances.
Be Forgetably Memorable - While paradoxical sounding, the point of this tip is that you want to make a good impression such that everyone has a generally nice impression of you without forming any specific memory. Avoid divisive topics like politics or religion. Even if you argue eloquently or are right about something, nobody cares. The residents want to know that you are someone they can work with. Conversely, you are there to learn about the culture of the program not win debates
Gather Information - the dinner is a good time to ask about interview day specifics, such as who the likely interviewers are and what types of questions they may ask. Most residents are more than happy to volunteer such information.

Transportation To Your Residency Interview

This is even more important than getting to the dinner. Make sure you have a reliable method for getting to the interview, which is often located miles away from the dinner site and possibly even in the opposite direction. If you have a rental car, do a dry run the night before if you have time to make sure you avoid any unexpected construction or road closures. Be aware that traffic patterns may be vastly different in the morning. If cabbing it, call ahead to schedule a pickup time. I'd suggest planning on getting to your interview 30 minutes before the scheduled start to give yourself a healthy cushion. There's nothing like being late to make a bad first impression.

The Residency Interview Orientation

Most interview days begin with a light breakfast and an orientation. You should be relaxed but also be aware that you are "on stage" already. Treat everyone from the program coordinator's assistant to the program director with the utmost respect. At some programs, the non-interviewing staff have a voice in the selection process. About a 1/3 of the programs I interviewed with had the program coordinator actually conduct one of the interviews. As for the other interviewees, keep the conversation light and avoid talking about the interview itself. You don't want to the person badmouthing another program director right when the PD walks in - you never know, but they may have been med school classmates or co-residents back in the day. Assume that everyone at the site will hear every word you say during the day. A healthy dose of paranoia never hurt =P That being said, this piece is meant to remind you to be smart during your interview. Be relaxed and confident and you should have no problems acing your interview!

Residency Interview Tips, Part 2: Preparation

noreply@blogger.com (minava) — Wed, 12 Jan 2011 12:00:00 +0000

The thrill of receiving a medical residency interview invitation is quite a rush. It represents the culmination of 4 years of hard work and study. However, between scheduling the residency interview and actually talking to your interviewer, you still have some work to do! Yes, just like most of medicine, the work never ends, but the work isn't too bad here and the payoffs make it more than worthwhile. Remember, like any interview, whether it is for an ultrasound technician position or for a bariatric surgery assistant to a medical residency position, the key to success is to make the best impression possible.

U.S. Army Medical Badge, 1902

Many resources are available to read about in general how to prepare for an interview. For residency programs, books like Iserson's Getting Into a Residency: A Guide for Medical Students or First Aid for the Match are helpful. I found Iserson's particularly helpful as he walks through many scenarios you may encounter, in particular questions that are 'off limits' per the Match NRMP rules and what to do when faced with one. However, do note that the book was written a few years back and some of the information may be a bit dated (for example, you do not really need to bring extra photos of yourself to the interview).

How To Prepare For Your Residency Interview
The first step is to gather background information about your program. Possible sources of information include classmates who have interview there, friends already at the program or from prior years that may have interview there, and mentors/advisors in the field. You can also consult bulletin boards online where many applicants routinely post about their experiences (like studentdoc.com, auntminnie.com for radiology, or uncleharvey.com for neurosurgery). Lastly, consider the programs themselves. They are great resources about technical details such as the structure of rotations or board pass rates. However, take non-objective information they provide with a grain of salt because they have an obvious strong bias to present themselves in a favorable light.

After learning about the program in general, try to find out more about your interviewers. You may politely inquire with the program coordinator, but not all programs release interviewer names ahead of time. If you find out their names, try doing a search on the program site to find out more about their areas of interest. Also look them up on PubMed to find out what their research interests are. Focusing on areas of common interest can help you stand out during the interview season. Another good resource is looking up the interviewer's CV - you may find out that you share a love for comedic movies or archery or ultrasonography!

Lastly, ask around! Word-of-mouth about interviewers and interview days can be the best gauge of what to expect not only from the day but from the program as a whole. Be especially mindful of programs where the program director is about to leave or has just changed. The PD can significantly affect the culture and structure of a program so try to find out more about the new PD's philosophy on resident education.

Ultimately, knowledge is power, so the more you know about the program, the more confident you can be going into your interview. And remember, just like Obama's grandfather told him, the key to success in life is confidence! So be confident and prepare well for your residency interview!

Residency Interview Tips, Part 1: Scheduling

noreply@blogger.com (neoram) — Mon, 10 Jan 2011 12:00:00 +0000

January is the big month in the medical residency interview season. While the timeline of interview does vary by specialty, for most of them, January is the last month to schedule a residency interview! Some of you might be nervous and want to hold onto your favorite stuffed giant microbe, but never fear - a few simple tips will help you ace those remaining interviews.

"The Doctor" by Luke Fildes

Medical Residency Interview Scheduling

Unlike the interview depicted above, interviewing a prospective resident is quite a different prospect from interviewing an ailing patient. In fact, the interview begins even before you arrive on campus. It starts right when you receive the invitation to interview. After receiving the invitation to interview, enjoy the moment but do not celebrate prematurely: you still have to find an appropriate time to interview!

There are three main factors to consider when scheduling an interview: what interview dates are offered, when you have time to interview, and will you have time to travel to and from the interview site. In other words, residency interview slots x ( your schedule + travel time ) = residency interview! While this may seem overly simplistic, it becomes quickly complicated in practice when you are juggling 5, 10, or even up to 25 interviews (hello FMG/IMGs)! The key here is to be organized. Use a PDA or phone that allows you to email from almost anywhere so you can quickly respond to invitations or jump on spots that open up when others cancel.

Yes, quickly responding matters. There are a limited number of residency interview slots per residency program. Think about it: the program usually sends out a batch of invitation at the same time. Invitees will all be responding at the same time, so whoever responds first will get their choice of spots. Whoever responds last will be forced to go whenever a spot is available, or may even be put on a waiting list! So, when you get the interview dates, look carefully at when exactly interviews will be available.

Next, consider your residency interview schedule. If you already have interviews lined up, strike out those dates from the list sent to you by the program. See what dates remaining overlap. It is best to use an advanced calendar tool like Outlook or Google Calendar to keep all the dates straight. Of the dates that match, try to consider the region in which your other interviews are such that you can lump interviews in the same area together. Rank up to five dates that may work for the interview, but hold on before you send.

Don't forget to budget time for travel to your residency interview! It may take up to a full day to travel to and from a residency interview. Factor this in before you make a final determination. Once you do, rank up to 5 dates that could work for a residency interview and then respond to the program coordinator. If you are near the peak of the interview season and cannot find any free dates, do not be afraid to call the residency program coordinator. Oftentimes if you cannot find a suitable interview time, they may be able to schedule an interview with the program director one-on-one, or squeeze you onto a day that appears unavailable.

If you don't get the spot you want, don't fret: as the interview season progresses, many interviewees begin to experience interview fatigue and start to cancel interviews. Stay in touch with the program coordinator about your favored days and more likely than not, something better will open up.

As you travel, make sure to stay comfortable. A travel pillow can make a huge difference in preventing neck and back strains on interview day as well as help you get some sleep as you cross time zones! Everyone knows you can take caffeine to stay up, but if you want a gentle way to readjust your circadian rhythms after you return from a trip, consider melatonin pills. Melatonin is a natural substance that helps regulate your body's sleep-wake cycle. Travel and jetlag can affect that equilibrium; it is better to use the natural substance to readjust the balance instead of a pharmaceutical like Ambien. Similarly, make sure you dress well, especially for those January interviews in places like Chicago and Boston! And double especially for medical students from warmer places in the South and West. Consider purchasing a scarf, leather gloves, and a pea coat to look professional while you try to stay warm! The added comfort these accessories provide will be more than worth the cost of purchasing them. Lastly, make sure your luggage and other items are both professional and functional. A roller bag for travel and leather portfolio are essential to meet both ideals. The portfolio is especially helpful in managing all the papers and information you will pick up over the course of your many interviews.

Remember, residency programs invited you which means they want you to come! After scheduling the interview, you will need to focus on interview preparation, but for at least the afternoon, enjoy the accomplishment! Congratulations!

How To Become An Anesthesiologist

noreply@blogger.com (minava) — Thu, 06 Jan 2011 12:00:00 +0000

As fourth years wrap up interviews and third years begin to ponder the process, we will try to present posts regarding the career path for each specialty. Today, Scrub Notes contributor JCL, a fourth year medical student currently applying for residency programs, writes about how to become an anesthesiologist

Anesthesiology is a very demanding specialty which requires the mastery of a wide array of knowledge--from physiology, pharmacology, anatomy, to internal medicine and surgery. Anesthesiology not only challenges the cerebral arena but also requires manual dexterity and finesse. The best anesthesiologists are those who are very observant, fully utilizing one’s sensory and perceptive skills to make vital decisions that directly impact the outcome of a patient. They are also most often the calmest person in a room when something chaotic is occurring; they keep their heads when others are losing theirs. The anesthesiology profession calls on an intense but relatively short doctor-patient relationship. Do you trust a person to be your personal advocate to keep you alive during an operation which can potentially cause you death? An anesthesiologist must be calm under pressure, intelligent and decisive, as well as a team player to fully assure the best outcome for a patient, whether the patient is in the operating room or in the intensive care unit. The field of anesthesiology is a rewarding one in that one can choose from subspecialties within the area such as cardiothoracic, obstetrics, pediatrics, critical care, etc. The anesthesiologist is THE peri-operative physician. These “caped avengers” are also called upon to secure the airway in a code blue scenario or consulted on treating various acute cardiopulmonary diseases in the ICU.

One can become an anesthesiologist after going to medical school. Before doing so, one must decide if they want to become a licensed physician. Remember, nursing tracks to become a CRNA (a nurse anesthetist) are also available. CRNAs usually have some experience in ICU nursing care. CRNAs are usually supervised by MD-anesthesiologists in everyday practice and function as a part of the anesthesiology team.

To become a MD in the US, one must complete primary school, secondary school as well as college. One must take the MCAT to apply to medical school. The most important aspects of a medical school application are the applicant’s GPA and MCAT exam scores. Other things that would be extremely beneficial for a medschool application would be volunteering in the healthcare areas, research, as well as other interesting endeavors.

During medical school, it is important to decide whether a career in anesthesiology is for you. Those who seek the limelight or center of attention might not do well as anesthesiologists. Anesthesiology is considered successful when something DOESN'T happen. In the public eye, the anesthesiologist disappears from recognition. The happy anesthesiologist often recognize that the reward is the well-being of the patient at the end of the day, and that the patient made it safely through surgery.

If anesthesiology is for you, the anesthesia residency program is a total of four years of training after obtaining the Doctor of Medicine degree. To successfully match into an anesthesiology residency, the academic achievements are the most important aspects of the application (i.e. GPA, USMLE Step 1 and Step 2 scores). The anesthesiology residency has been getting more competitive in recent years.

The anesthesiology residency is made up of an intern year and three clinical anesthesia years. The first year is an intern year, which can be one of several options, such as a preliminary internal medicine year, a preliminary general surgery year, a transitional year which is made up of various areas, or some other internship year (peds, etc). The transitional year is usually a combination of medicine, surgery, ER, peds, and sometimes Ob-Gyn and elective time. Most anesthesia residents complete a prelim medicine year or a transitional year. Anesthesia residencies are either “categorical” or “advanced.” Categorical residencies are those which includes internship year in the program so the applicant does not have to apply to different programs. The advanced programs require the intern year to be completed before matriculating into a program. The average anesthesiology applicant applies to both categorical as well as advanced to maximize matching outcomes.

After anesthesiology residency, one can either go into private practice, academics, or pursue a fellowship (i.e. subspecializing). The current ACGME accredited fellowships are pain, cardiothoracic, pediatrics, and intensive care. To be “boarded” by the American Board of Anesthesiology, one must take written boards as well as oral boards. Nationally speaking, written board pass rates are about 85-88% and the oral pass rate 75%. After obtaining board certification, you have become an anesthesiologist!

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Managing Medical Residency Interview Expenses

noreply@blogger.com (minava) — Mon, 03 Jan 2011 12:00:00 +0000

Many students are in the last push of interviews before Match Day. While we have posted before on general tips for residency interview travel, the following submission by Scrub Notes contributor Shawn Kavoussi, a medical student currently applying for residency programs in ophthalmology, goes into more specific details.

The time has come for you to interview, and congratulations are in order. The hardest 3 years of
medical school are behind you. But you will hemorrhage money during the next few months if you’re
not adequately prepared. In order to prepare well and travel efficiently, consider each dimension of your travel (airfare, hotels, car rentals / transportation). Let's start with the most expensive piece: airfare.

Airfare

This is where most of your travel dollars will be spent. The more competitive the specialty you’re applying to, the more locations you’ll want to visit, and the harder it will be to coordinate them by region. If possible, try to cluster a few interviews in one corner of the country at once. This will save you the time, money and energy required to fly from say, California to Virginia. Kayak has a helpful feature that lets you plan multi-point (or non-round-trip) flights to facilitate such trips.

However, be aware that the more competitive specialties with small program sizes offer fewer residency interview days, and such a cross-country journey might be unavoidable. You also may have to visit the same city twice. For example, Tulane ophthalmology’s only interview days were November 5 and 12, and LSU’s only days were December 2, 3 and 4.

When to book: The first batch of interview invitations is usually sent a month before the earliest
available interview days. If you have two interviews several days apart in one part of the country, you can avoid flying back and forth by calling / emailing program coordinators to see if they have room to add you to their interview schedule. Start calling the program coordinators as soon as you receive the invitations, but it is okay to wait before finally picking a date. I waited 2-3 weeks before the date I picked, waiting for other invitations to come through, so that I could schedule something else nearby r and avoid paying for multiple round trips. Between a New York ophtho interview and a Yale ophtho interview that were a week apart, I was able to add on a New Haven transitional year interview and a D.C. preliminary medicine (round trip AMTRAK) interview during the gap. Just be careful... spots can go fast!

Who to book: Kayak will compare fares among the major airlines that are its affiliates. However, it is important to consider several budget airlines that do not participate. Southwest is easy to book online and pretty cheap, but like all airlines, expensive to reschedule. Similarly, check out JetBlue especially for interviews in the Eastern part of the country.

If you get a last minute interview invitation, Priceline and Travelocity can get you a better deal, but be specific about your arrival and departure times. I wouldn’t use these to schedule an interview far in advance because your interview schedule may change. When a large city has multiple airports, it’s also helpful to consider which airlines fly to the airport that will be closer to your interview.

Hotel

Hotels are very pricey in places like NY and DC. I tried to stay with friends whenever possible, and Facebook was very helpful for finding college friends who had moved to various cities. Just click the “Find Friends” tab in the upper left to reveal the drop down menu, then “See All Friends,” then find “Search By Current City” in the white drop down menu.

If you cannot find a friend to stay with, consider using sites like Priceline, Hotwire, Kayak or Hotels.com. Ideally, pick one site and use it all the time. For example, on Hotels.com, if you book 10 nights (3 nights here, 2 there, 5 somewhere else), you get an 11th night free in *any* hotel, subject to availability. There are other seasonal deals available, such as: Orbitz Winter Hotel Sale: Save up to 50%! The offer is running until January 23, 2011.

Transportation

If you can’t get rides from friends or book hotels within walking distance of the interview, Hotwire (specifically Hotwire Hot-Rates) and Priceline are the cheapest for renting cars, and this can be done in short notice. Many cities and hotels have airport shuttles that are cheaper than cabs, but these might take too long if you have an early flight for an interview the very next day. Check a city’s Metropolitan Transit Authority website or even Google Maps to see if you can plan a route by subway. Program coordinators have helped interviewers with these kinds of issues every year, and they are a helpful resource for answering questions regarding what’s practical. The main point of this section is to avoid using a cab. Try your best to get a deal, but remember: at the end of the day, the goal is a successful interview, no matter the cost!

Resources:

The Future of Medical Education: 2011

noreply@blogger.com (minava) — Sat, 01 Jan 2011 17:11:00 +0000

Happy New Year from Scrub Notes! We sincerely hope you were able to enjoy a much-deserved break from the trials and tribulations of becoming a medical professional during this holiday season. However, with 2011 now officially upon us, what does the new year have to bring in the medical education arena? As we look ahead, we see three major areas of change: the further integration of technology into medical teaching, the growth of dual-degree candidates, and the changes to resident work hours in the U.S.

Technology & Medical Education
With the rise of very powerful mobile computing, the medical establishment will have to work harder to make these tools available for young practitioners. Unlike the failed efforts a decade ago to have a Palm Pilot in every palm, students and residents are increasingly acquiring these devices on their own and demanding support for them. Whether it's an iPhone or an iPad (or even iPod Touch) or Android device, everyone wants to be connected not only to each other but to information sources like Wikipedia or PubMed. Face it, these days only doctors and drug dealers use pagers... medical schools and hospitals need to upgrade their IT infrastructure to fully support these devices. Instead of paper copies of Pocket Medicine, the future holds the promise of everyone carrying Harrison's AND Robbins in their pocket on their fancy 4G devices.

Dual-Degree Candidates
Programs such as MD/MPH, MD/JD, and MD/MBA have exploded over the last ten years. As the economy sours, job candidates have seen the dual utility in dual degrees. First, by staying in school longer, they have a better shot at timing the job market better. Why not get more education while waiting for that plum job to present itself? Second, with so many people competing for single spots, especially in competitive fields like radiology in competitive areas like New York or SF/Bay Area, having that extra degree can really make a job candidate stand out. What private practice wouldn't want more partners with some business acumen? It also helps candidates average out risk; if that whole "clinic 5 days a week" doesn't work out, you could more easily branch into alternative/associated medical careers such as healthcare management. Somebody has to run all those hospitals after all. Why not you?

Work Hour Changes
As the work hours decrease again, residency programs will have to figure out how to balance clinical duties and resident education while adhering to the new standards. Those opposed to the new standards view them as a further erosion of inculcating the idea that physicians need to put their patients' care first above arbitrary regulations. Those supporting the changes argue that better rested physicians-in-training with more balanced personal/work lives will be more effective physicians and ultimately serve their patients better, despite spending fewer hours total in the hospital. Only time will tell which view is correct, but judging by medical education systems in other countries, patient care and resident education will not change significantly one way or the other.

Whatever happens, 2011 promises to hold some significant changes in medical education. But, for the current class of MS4s, this month is that final push before the Match. Therefore, during January and February we will be publishing posts aimed at MS3s and MS4s, describing the paths to succeed in matching in various specialties, starting with anesthesia, as well as general interviewing and match tips. Good luck in 2011!

A Medical Intern's Christmas

noreply@blogger.com (minava) — Fri, 24 Dec 2010 12:00:00 +0000

As we close this week on Work & Life Balance here at Scrub Notes, we are thankful for our guest authors who shed light on some of the issues affecting doctors and patients today that are not "pathophysiologic" in origin. We have heard about how to maintain balance as a medical student, for as any provider can tell you, if you are not in balance, how can you help restore order to your patient's life, especially one that has just been thrown a curveball with a new diagnosis? At times, we fail to maintain that balance, either because we are unable to manage the stress of our profession, or we fail to live up to the high academic standards we have set for ourselves. How medical students manage stress is a key skill that is not often directly addressed within medical schools. These skills often end up being more important to a successful patient interaction than all the pathology and physiology trivia one learns, whether dealing with patients with alternative backgrounds, or just learning how to handle the stress of the first night on-call.

As we end the week, many medical students, interns, and residents will not be celebrating the holidays with their families. Instead, they will be on call, or night shifts, or just long schedules, taking care of patients. For life and death, sickness and health, do not take holidays, and nor should our compassion for taking care of those who are in trying times. I recall working last year on Christmas Eve at the VA on an inpatient medicine rotation. Trust me, the VA hospital is probably close to the last place you want to be almost any time of the year, let alone Christmas. It is strange to say that in some ways. For the most part, the patients, staff, and doctors are all nice and well-intentioned. However, the VA simply is not home, and everyone should be home for the holidays, patients and providers alike.

But, as said above, illness does not care for such sentimental notions, so we must make do. The staff had put up a Christmas tree, and many patients' families came by with gifts or just to spend time with their loved ones. For that's what we as human beings do: we adapt. We make the best of what we have. We pull together and create a sense of family and home in even the most trying of situations. A diagnosis of cancer or heart failure or AIDS is not tantamount to a diagnosis of ill spirit. Although the patient may not see the promise that their life still holds, it is up to the caregiver to gently nudge them towards making the most of their time, whether they have days, months, or decades left. To do so, we must put aside our selves and our desires and truly empathize with the patient.

To be honest, going into the hospital that day, I had no intention of empathizing with anyone. It was a pity party: who was empathizing with me, the woeful intern stuck in the hospital when everyone else was at home relaxing or making merry? Yes, the cynicism of intern year had set in. But as the day progressed, I realized some of the ideas described above. If anything, it was one of the better days of the month - there truly was a festive spirit in the air. Like Scrooge, my cold heart mellowed. What would I really have done with the day off? Likely not much, nor did I have any grand plans. Instead, I ended up spending the day casually rounding (no conferences or discharges to worry / stress me), meeting the often-mentioned-but-never-seen almost mythical family members. The patients were happier around loved ones, sharing stories and laughs, letting me peak into their actual lives. We could all put aside worrying about lab results and planned procedures, and simply enjoy the presence of being together.

And ultimately, that is what medicine should be about. It should be about providing a sense of support for those in a time of weakness, whether that be mental or physical. Being the surrogate family when one's own family is not around. Throughout that day, as the clock slowly moved forward to my own departure from the hospital, I was reminded of the transient nature of my presence there. Sure, I could bemoan my lot, stuck there, but hey, at least I got to go home at some point. None of the patients were leaving that day, and many would not leave for many more days. Whether Christmas Eve or any other day, our role should be the same: providing a supportive environment to help the patient heal themselves, both physically and mentally/spiritually, for a true physician should care for the totality of the patient, not merely their lab values or functional status. During the holidays, our goal as providers should be to provide a holiday worth remembering for our patients, which coincidentally should become a holiday we cherish ourselves.

Happy Holidays from Scrub Notes! See you next year!

What Is The First Night On-Call Like?

noreply@blogger.com (minava) — Thu, 23 Dec 2010 15:34:00 +0000

This common question is answered by an internal medicine intern's experiences on her first night. The text below is a repost of the entry "First Night On-Call", first published on the blog Life In A Q4 World.

October 7, 2010 - In our residency program, like in most others in internal medicine around the country, life revolves around a “q4” call schedule; that is, overnight 30-hour “on call” shifts every 4th night. As an intern, a first-year resident, our “on call” day starts at 8 AM, and we stay overnight in the hospital admitting patients and cross-covering for the other teams who aren’t in the hospital overnight until 2 PM the next day (i.e. 30 hours.) If we’re lucky, we can sleep for an hour or two, but usually cross-covering for 30-40 patients means getting paged constantly about every fever, request for sleeping pill or pain medication, or anything else that goes wrong in the middle of the night, and the little sleep you do get is interrupted and unsatisfying (not to mention the fact that we share a call room with the other intern on call who’s concurrently getting paged about her own separate patients.)

Anyways, the first night on call is sort of a rite of passage for interns, i.e. it will suck, but we survive it, and once that’s over with, the next 6 calls until the end of our one-month rotation (for a total of 7 calls per month) are usually not as bad, or at least not as shocking to the system. My first night on call as an intern was actually in the intensive care unit (ICU), which is generally a bit more stressful than the internal medicine wards, because the patients who are admitted to the ICU (the “unit”) are sicker than those admitted to the wards (the “floor”.) So while I was expecting that first night on call to be overwhelming, stressful, and exhausting, I was not expecting the very first patient I would admit that night to be one of the strangest and saddest cases in our residency program’s history.

She was a 23-year-old girl who came to the ER for shortness of breath, not an uncommon complaint. Her symptoms were way out of proportion to her physical exam or chest X-ray, which looked not quite normal but not like a horrible pneumonia or collapsed lung either. No matter how much oxygen we gave her through a mask, she continued to have more and more trouble breathing, and the oxygen saturation level in her blood continued to get lower and lower—not a good sign. By the time the ER doctors called us, the ICU team, about her, they already had the intubation tray set up and were planning to intubate her (put a tube down her airway so that she could be mechanically ventilated) in the ER. Given the rapid progression of her symptoms, they were able to get very little history from her, but it seemed that she had been completely healthy previously, and had not recently had any cough, fevers, or sick contacts. We gave her everything we could think of—a slew of antibiotics, antifungals, and antivirals to treat her for possible pneumonia or an early-in-the-season H1N1-type flu, all to no avail. We got a CT of her chest, thinking she may have had a massive pulmonary embolism, but that was not the case either, although like the chest X-ray, the CT wasn’t completely normal—it showed some collections of junk in her lungs, sort of like a pneumonia but not quite consistent with the classic pneumonia picture. In the ICU, she continued to deteriorate right before our eyes, her heart and kidneys started failing so that her blood pressure continued to be dangerously low even with maximum vasopressor medications and her kidneys had stopped making urine. Her husband and family members who were there with her could not give any more information about what had happened—she had been completely fine earlier that morning. The only other finding we got from examining her was that she had two cotton balls on her buttocks, covering what looked like recent injection sites. Neither her husband nor her family members could tell us what those were from—she had a couple tattoos on her legs but not recently and not on her butt.

Finally, after tracking down several of her friends on the phone, it was confirmed that she had gotten silicone injections in both her buttocks earlier that afternoon. At that point, we realized what had happened, or at least had a working theory—the injections had gone into her blood vessels and migrated into her lungs, basically turning her lungs into a solid chunk of rubber. This phenomenon apparently had been reported before, though extremely rarely of course, and was known in the literature as “silicone embolism syndrome”, which we spent the next 2 hours on Google trying to find case reports for. We looked for reports on how other hospitals had treated cases of suspected silicone embolism, only to find that basically nothing worked—it was just supportive care and waiting to see if the lungs would recover on their own, which they usually didn’t. One case report said steroids seemed to help, so we gave her a huge dose, but to no avail. She continued to worsen, and finally as the renal team was starting emergent hemodialysis on her to try to save her failing kidneys, her heart stopped beating and could not be restarted despite over an hour of CPR. She was 23 years old, had a husband and two small children, and had been completely healthy 12 hours ago before she decided to have cosmetic silicone injections in her butt.

The other wrinkle in the story was that the injections were performed illegally by an unlicensed doctor from Mexico who had been traveling around the LA area with his two Mexican assistants advertising these cosmetic butt injections. They had just been released from jail a few weeks prior, and had been posting flyers in the area, surreptitiously advertising these services for a mere $800 per injection. We were informed of this around 3 AM when a team of at least five members of the LAPD came in and started questioning us, informing us they were searching for this doctor and his two assistants, who were being charged with fraud and what it seemed like would soon be involuntary manslaughter as well. At that time we were all too stressed and exhausted to fully take in the horrible irony and moral injustice of it all—paying over $800 to die of complications from a cosmetic procedure, something that seemed almost too typical to witness in Los Angeles, especially within my first two months of moving here from Chicago. As I was writing the death summary for the patient the next day, thinking about how it would probably show up in court someday, the sadness and unfairness of it all did start to sink in some more, but I wasn’t as devastated or fraught with nightmares as I had feared I’d be. My first reaction was actually to email the story to all of my friends so that they would never get butt injections. Maybe medical school had prepared me better than I thought for psychological and emotional strains of residency.

Check out the blog Life In A Q4 World for more insights from a resident in a categorical internal medicine program in Southern California. Share your passion by publishing your writing on Scrub Notes today!

Gender Identity and Medicine, Or Why I Love Queer

noreply@blogger.com (minava) — Wed, 22 Dec 2010 06:47:00 +0000

This submission is from guest author Amanda Davis, an MS2 at Thomas Jefferson University, Philadelphia, PA

I almost took it for granted. “Do you have genderqueer patients?” I asked the physician. There
were murmurs around the room, not everyone knew what I meant, but the physician did. He
was talking about transhealth to a room full of healthcare professional students who had elected
to be there.

I didn’t take it for granted though. I asked the question because I already knew the answer was
probably yes. I asked because I knew many people would not know what “genderqueer” meant,
or had even thought about the spectrum of gender. I asked because I wanted to expose them. I
also asked because I wanted to know what the evidence shows on the safety of going on and off
hormones.

“I suspect not everyone here knows what genderqueer means,” the physician said. Some shook
their heads. It was only about two years ago that I was really introduced to the term myself.
For those who have not been exposed to this lovely idea, here is a definition from wikipedia1:

Genderqueer: catch-all term for gender identity other than man and woman. People
who identify as genderqueer may think of themselves as being both man and woman, as being
neither man nor woman, or as falling completely outside the gender binary. They may express a
combination of masculinity and femininity, one or the other, or neither.

For kicks, here is the wiki definition of queer2:
Queer is an umbrella term for minority sexual orientations and gender identities that are
not heterosexual, heteronormative or gender-binary.

I get all warm and fuzzy reading both these definitions. How lucky am I to be a part of a
community that has exposed me to these ideas, spectrums, and wonderful people?

I reflected on the evolution of my understanding of gender. I came out as bi when I was 15.
I knew one transperson in high school. I understood gender as a binary, but for a white kid
growing up in a republican suburb, I was progressive. You could identify as a man or a woman
and be attracted to men or women or both. Gender identity and sexual orientation were
separate. I was not sexually interested in transpeople, although I had thought about it. I liked
girls or I liked boys. I supported people whose bodies did not match their minds, but I did not
want to make out with them.

Fast forward to college – why do we have words like lesbian and gay for those who might
otherwise be called “homosexual,” but only bisexual for people who are attracted to more than
one gender? That emphasizes the sexual, and let’s not even talk about all the biphobia (actually
yes, let’s talk about it). I prefer to be “unidentified.” It’s about the person, not the genitals
(although, let’s be honest, genitals are fun).

Post-college: Oh yes, finally a word that makes sense to me: queer. My queer is different
from your queer. If I have to identify myself, and our culture loves labels, queer is what I am.

Sexuality is fluid. There are no absolutes. Dykes, queers, lezzies, butches, femmes, androgynous
bois or grrls, in betweenie weenies. What’s your type of girl? I just like girls, and sometimes
boys, and definitely bois, and boys who used to be girls (yeah, I got over that idea I had in high
school of not wanting to make out with transpeople).

The idea of anything more than the gender binary makes some people’s heads explode with fear
and rage. I find that so sad. Sad for all the trannies, queers and homos that cross their paths
and encounter hate. But also sad for those haters who will never know the joys of a whole range
of genders.

I only see beauty in the gender and sexuality spectrums. Beauty, sensuality, art, intrigue,
satisfaction, love. Anything else would just be… boring.

Share your passion by publishing your writing on Scrub Notes today!

How To Deal With Failure In Medicine

noreply@blogger.com (minava) — Wed, 22 Dec 2010 04:03:00 +0000

Failure is a common occurrence in medicine, but one that is far too rarely addressed. In her blog Wellness Rounds, pediatric surgeon and professor Mary Brandt, M.D., addresses the topic in response to a younger colleague's question. This is a repost of the entry "Failure".

It is part of our profession that we will never stop trying to be perfect and – just as true – that we will always fall short. As a student, it tends to be about the tests you are taking and the feeling that you will never study enough. As a resident, it’s the feeling that you don’t know enough to make the decisions you are being asked to make. As a practicing physician, you will at times stay awake at night worrying about your decisions, even when you know you did the best you could. All of this sounds like a huge downside to the profession we’ve chosen, but it’s actually a blessing. One of the core personality traits of physicians is that they care. In a way, all of the stress about not doing well enough happens only because you have empathy and compassion for your patients.

Although it’s hard to believe at the beginning, with time you will realize that the feeling of having “failed” is actually a gift. You’ll discover that “mistakes” and, more importantly, “near misses” become your most valuable teachers. What’s important is that you grasp the opportunity to learn from falling short, rather than beating yourself up. “Failing” at a task (or test) is different than being a “failure.” When you have moments you feel you could have done better, use it as motivation to study a little more, go back to the textbook, look up one more article, or review all the facts again. William Osler, in his famous book to medical students (Osler’s Aequanimitas) talked about keeping a journal of mistakes: “Begin early to make a threefold category – clear cases, doubtful cases, mistakes. And learn to play the game fair, no self-deception, no shrinking from the truth… It is only by getting your cases grouped in this way that you can make any real progress in your post-collegiate education; only in this way can you gain wisdom with experience. “

So, to answer your question about how to deal with the downfalls along the way - Start by revisiting your motivation. Remember why you started down this path in the first place. If you are trying your best to do the right thing, and are humble about the fact that you are human (and will therefore fall short) you can end every day with satisfaction and a sense of accomplishment. That being said, make sure that you work with focus – that when you study or work it is with dedication to the patients and families who are trusting you with some of the most precious decisions of their life. When you fall short, use it as motivation to learn. But, in this process, make sure you are taking care of yourself by taking time for good nutrition, exercise, social interactions and spiritual growth. The worst thing you can do when you feel inadequate is to just work more and more. This leads inevitably to compassion fatigue, which makes you less effective (and will make you suffer). Compassion fatigue is a common diagnosis for care-givers; it happens to every medical student, resident or physician at some point in time. Just like any other diagnosis, the next step is treatment. In a nutshell, the treatment is self-care.

Dr. Mary Brandt is a Professor of Surgery, Pediatrics and Medical Ethics at Baylor College of Medicine and Texas Children's Hospital. For more information and links to resources about self-care for physicians, visit Dr. Brandt's site Wellness Rounds.

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