Scrub Notes: A Blog For Med Students

Renal Failure while on ACE Inhibitor Therapy

noreply@blogger.com (Unknown) — Tue, 18 Sep 2018 19:40:00 +0000

Many chronic conditions can lead to renal failure. Hypertension and diabetes can independently cause renal failure. The effect is compounded in patients who have both. Congestive heart failure can also be present and problematic. Medications have been developed that affect the normal physiologic pathways that maintain blood flow to the kidneys in order to both maintain flow and reduce systemic hypertension. Angiotensin converting enzyme (ACE) inhibitors are one common type.

In order for the kidneys to function, blood is pumped through the aorta which supplies the paired renal arteries. Each artery branches multiple times until it reaches the functional unit of the kidney, the glomerulus. Blood flows into the glomerulus via the afferent arteriole and out via the efferent (e for exiting) arteriole. These arterioles are controlled by a hormonal regulation system that helps control how much blood flow and pressure each glomerulus sees.

The hormonal pathway is called the renin-angiotensin-aldosterone (RAS) system. When renal blood flow (RBF) is reduced, cells near the glomerulus called the juxtaglomerular apparatus convert circulating prorenin into renin. Renin catalyzes the conversion of liver-produced angiotensinogen into angiotensin I. This in turn is a precursor for angiotensin II. The conversion is facilitated by angiotensin converting enzyme (ACE) found on the surface vascular endothelial cells, primarily in the lungs.

Angiotensin II has several functions. First, it causes vasoconstriction, primarily at the efferent arteriole. It also stimulates secretion of aldosterone from the adrenal gland, which helps sodium reabsorption and potassium excretion. It also facilitates antidiuretic hormone secretion from the pituitary gland. Generally, angiotensin II wants to preserve circulating volume and blood flow.

RAAS Schematic
Source: Wikipedia

In normal physiology, renal blood flow (RBF) and glomerular filtration rate are maintained in a narrow range, regardless of blood pressure. Too much RAS activation though can lead to hypertension. Many medications affect particular steps in this pathway to disrupt that activation.

ACE Inhibitors (ACE-i) function by blocking the angiotensin converting enzyme, decreasing the formation of angiotensin II (A-II). This can maintain renal function by decreased vasoconstriction and decreased sodium retention, while increasing renal blood flow. Glomerular filtration rate (GFR) may stay the same or even decrease, due to the differential effects on the afferent and efferent arterioles. Since A-II increases GFR by constricting the efferent arteriole relatively more, blocking A-II will dilate the efferent arteriole to a greater degree. The result is more blood flowing through the kidney overall, but less of it actually being filtered by the glomerulus.

This effect on the kidney is reflected in an expected slight rise in creatinine after initiating ACE inhibitor therapy. The expected rise is usually between 10 and 20%. Acute kidney insufficiency (AKI) is defined as a rise greater than 0.5 if the serum creatinine was initially less than 2.0 mg/dL or more than 1.0 if the baseline was greater than 2. AKI is exacerbated in patients with congestive heart failure (CHF), and can occur even years after therapy was started.

Four mechanisms have been proposed for how ACE-i cause AKI in this setting. The main mechanism occurs if ACE-i cause the mean arterial pressure to decrease to a point that renal perfusion cannot be maintained. The other causes include: simultaneous diuretic use, NSAID use, or high grade renal artery stenosis.

Presuming the latter three causes have been excluded, ACE inhibitor-induced AKI can be managed with close monitoring of serum creatinine and potassium levels. Hyperkalemia is also common, as blocking A-II causes potassium to accumulate in the circulation. This is exacerbated in patients with diabetes, hyperglycemia, and on beta-blockers (which are common in CHF patients). Once adequately titrated, ACE-i therapy can continue as most induced AKI is reversible and potassium levels can be managed by reducing other potassium-retaining interventions. The long-term benefits of ACE-i should outweigh these short-term issues.

References:

Schoolwerth AC et al. "Renal Considerations in Angiotensin Converting Enzyme Inhibitor Therapy." Circulation. 2001; 104:1985-1991.

Becoming a Surgeon and Mastering the Craft

noreply@blogger.com (Unknown) — Mon, 20 Aug 2018 13:00:00 +0000

This guest post by Jenna Smith discusses the necessary ingredients for becoming a surgeon.

Individuals pursuing surgery as a career have to have what it takes to handle the job. With a lot of responsibility involved, including having another person’s life in your hands, surgeons have a tremendous amount of pressure to perform well at their jobs. Mastering the craft as much as possible can happen as long as people are willing to put in the work starting from when they’re in school and all the way through to the end of their career.

Learning How to Handle Surgical Equipment
Surgery cannot happen without the proper equipment. It isn’t possible to cut into flesh and fix broken bones without certain utensils and instruments necessary for those types of jobs. Everything from a scalpel to a surgical light needs to be well understood. Watch how others use these items whenever possible, either through video or observation. Another useful tip is to check out resources such as the Surgical Lights Buyers Guide to get acquainted with product details and better understand how to operate the equipment so it works the most efficiently.

Choosing a Specialty
Though general surgery is an option, most people opt for a more specialized field. Plastic surgery, for example, is one of the most sought-after choices in the surgical world. After graduating from college, individuals then must go on to learn at a medical school. A doctor of medicine degree is received after completing four years. During the next three years, hopeful surgeons must complete their residency training. Doctors complete general training first before getting to choose a specialty and focus on only that area. A special certification will need to be obtained to practice surgery in one particular field, such as earning certification through the American Board of Plastic Surgery.

Study, Study, Study
If students think they can go to medical school and never have to study simply because they didn’t study much at their former college, they will be incredibly mistaken. Getting through medical school and preparing to become a surgeon takes a tremendous amount of work. Individuals need to study, study, and study some more if they are going to want to remember all of the information that gets packed into just four years of classes. Medical terminology, proper procedures, hospital rules and regulations, and laws all need to be learned and memorized before school is finished. Having a study system in place will be key to being successful.

Study Some More
Studying for school isn’t the only thing to worry about. Once school is completed, students still need to become certified if they want to practice medicine. The ACLS and PALS tests are two options. If the job specialty you want requires these certifications, then it will take even more studying to prepare for either of them. Finding some good study methods that help retain as much information as possible is important for getting through these exams.

Don’t Forget to Keep Learning
Too many people believe that because they attended medical school and completed all of the required work and hours to become a surgeon, the learning is complete. They have now learned everything they need and can continue to do their job the same way forever. This is not true when it comes to surgery, not to mention medicine in general. Everything is always changing and adapting. New medicines are discovered. New machines are made for efficiency. Doctors must constantly continue learning and adapting to the world of medicine so they can offer the best care.

Becoming a surgeon takes a considerable amount of effort, patience, and desire. People will quickly find out once they start practicing medicine whether they’re truly cut out for the field. With the gruesome tasks, life or death situations, and vast amount of responsibility, only those who can truly master the craft should perform surgery.

Jenna Smith has been blogging since she graduated from the University of Utah. She finds herself spending less time writing due to a new venture called “MARRIAGE!” She enjoys her new venture very much. Lucky for us, she still finds time to write great articles, including this one.

When Breath Becomes Air by Paul Kalanithi - A Scrub Notes Book Review

noreply@blogger.com (Unknown) — Sat, 22 Jul 2017 17:24:00 +0000

"When Breath Becomes Air" is a memoir written by neurosurgeon Paul Kalanithi. The book is a poignant look at the human spirit in both the pursuit of excellence as well as in coming to terms with its own impermanence.

Kalanithi was a Stanford neurosurgery resident when he found himself becoming fatigued, with worsening pain and decreasing weight. A routine chest x-ray discovered multiple lung masses, which were soon proven to be metastatic lung cancer. The book was borne of Kalanithi's other passion, literature, as well as his unfortunately unique perspective as both a healer and now a patient at a time when he was poised to be at the peak of his talents.

The first half of the book details Kalanithi's upbringing and path into medicine. His first love was literature, which he pursued all the way to a master's degree. However, upon further reflection, he felt a desire to pursue medicine after grappling with the question of the intersection of "biology, morality, literature, and philosophy." Since he had initially pursued literature, Kalanithi took two more years to complete the pre-med requirements and then apply to medical school. Accepted at Stanford, he was a fast rising star in the neurosurgery world, despite grueling 100 hour weeks year after year.

The diagnosis, coming near the end of his training, shatters Paul's identity. After striving for close to a decade to become an attending neurosurgeon, his diagnosis is his undoing. He rapidly transitions from physician to patient, and has to learn to let go, to trust in others to have his best interests at heart. The book shows how he meditates that cancer in particular is pernicious in that it makes one mortality both immediate and yet still remote: no longer a hypothetical, but not an immediate reality. Everyone has an answer to what one would do with their last day, but what about one's last decade?

Kalanithi then details the long road back to completing his training, the successes and failures of his treatment, and how he learned to live and ultimately succumb to his fate on his own terms. He died in 2015, leaving behind his wife Lucy and their newborn daughter.

For me, the last part of the book was the most moving, an epilogue written by Lucy about Paul's last days. She charts the uncertainty of his final hours and how he was resilient even while facing the unknown. His final wish was that they see the book to fruition, in which they clearly succeeded.

The book reads like what one would expect of a memoir of a first-time author, but Kalanithi's first rate intellect shines throughout. Even though he never uses the label, it is clear that Kalanithi was a humanist at heart. He does touch upon his wavering relationship with religion. For a reader who questions both their path in healthcare or wants a glimpse of how even the best laid paths can abound with uncertainty, "When Breath Becomes Air" will not disappoint.

Do Medical School Rankings Matter?

noreply@blogger.com (Unknown) — Mon, 27 Mar 2017 13:00:00 +0000

This is a guest post / repost from Smart Money, MD on the topic of whether going to a highly-ranked medical school matters:

Some of us are overachievers. Some of us are overachieving doctors. What if you’re in-between? Let’s say that you’re an overachiever, and you want to become a doctor.

Should you go all the way up top and get that medical degree from a top private institution? Does it even matter? With tuition costs skyrocketing, you can easily spend $60,000 annually on tuition alone for each year in medical school. Add another $10-$15k in room and board, and you will be about a quarter million in the hole by the time you get out. In contrast, medical school tuition in 2016 for UT Houston for in-state resident is only about $20,000 annually. That’s a big difference.

These are considerations that are rarely taught or even discussed. If you are planning to go to medical school, it does pay to consider the consequences thoroughly before you proceed.

Does a prestigious degree help get you a better job?

It depends. It depends on where you plan to work. In clinical medicine, you can either work at an academic institution or in the private sector. Many job situations in the academic world require teaching, research, or involvement in administration. If I were a departmental chair looking to bring on a clinician-researcher, I’d want someone who not only can practice medicine well, but also has strong writing skills, coherent presentation abilities, and innovative characteristics. If two candidates had similar track records with similar recommendations and charisma, I might lean towards going for the gal with the Ivy-league degree, especially if I am running an Ivy-League department.

If I needed a doctor in the private sector, the institution that granted the degree is unlikely going to matter much at all. Yale? Great. Wayne State? That’s okay with me. You just need to be ethical, hard-working, and reasonable to deal with. For all other qualities, the verification process in each state and governing medical board can do the rest.

DO DOCTORS FROM PRESTIGIOUS INSTITUTIONS MAKE MORE MONEY?

It depends again. To understand this question, you should understand how doctors make money to see whether an Ivy-League degree will translate to higher dollars. This is also contingent upon how you are using your medical degree, whether you are practicing medicine, performing administrative work, or consulting. Remember, you don’t have to be a doctor to get rich. Or you shouldn’t become a doctor if your main goal is to become rich.

If we are considering doctor worth from revenue alone obtained through clinical practice, insurance companies make no distinction between where you obtained your degree. U.S. grad, international grad, it doesn’t matter. As long as you pass your boards (sometimes you don’t even have to do that!), you’re golden. From clinical practice alone, you’re not going to make more money having gone to a top college or medical school. Period.

Now having that special degree CAN get you more business, depending on which part of the country you practice medicine. This is particularly true (and sometimes annoyingly so) in the New England area. Patients in New Caanan Connecticut do (in general) care where you obtained your degree. They may or may not even be highly educated, but the high concentration of Ivies in that region predisposes this behavior. Unless you have significant street cred and have been working in the area for a long time, your patient may doctor shop your degree.

OKAY, I SANK $200,000+ INTO AN IVY-LEAGUE MEDICAL DEGREE, WHAT AM I GOING TO GET IN RETURN?

Many of us, under the guidance of family, friends, or schooling, end up enrolling in well-known [read: expensive] private universities and medical schools.

DESPITE the equivocal conclusion by Smart Money MD.

Don’t fret. You’re not totally screwed. If you have a good inheritance coming your way or an alternative means to fund the process, you’re actually in great shape.

If the above doesn’t apply to you, don’t fret either!

STEP 1. PAT YOURSELF ON THE BACK.

Congratulations. It is not easy getting in. It is SIGNIFICANTLY more difficult to get in medical
school than law school, business school, or college. Kudos to you.

This is a fact. By numbers alone. There are simply fewer number of available positions in medical school. The Class of 2018 Stanford Graduate School of Business has 417 new students. Last I checked, the Stanford medical school had fewer than 90 students per class. I think the acceptance rate in the medical school was about 2-3%, while the business school acceptance rate was 6%. If you compare these numbers to that of an average public medical school and public business school, you’ll see that the class sizes will be larger and the acceptance rate will also be higher.

STEP 2. YOU’VE GOT A LIFETIME OF PRESTIGE ATTRIBUTED TO YOUR NAME.

Yup, your mother can brag about her daughter at every holiday party. Your distant relatives will direct their children to you for advice. Your alma mater will also hit you up for donations every single year. You can volunteer with your local alumni group and have “exclusive parties”.
You have a lifetime of memories and connections to potentially successful friends and colleagues.
This is not a bad situation to be in.

STEP 3. CLEAR YOUR MIND AND GET TO WORK.

Get yourself back into the real world. Don’t let anything else cloud your judgment. You’re probably not even that smart. Your coworker at the hospital who came from Portugal probably is one the smartest gals in her country. She memorized Harrison’s twice to pass her country’s exams. Oh yea, she also repeated residency in the U.S. and passed all of her U.S. board exams…in English.
That’s right, her native tongue is Portuguese, and she learned Spanish as her secondary language. English was her third language.

Get yourself out of debt if you funded your education through loan sharks. If I dug myself out of debt, so can you. Save up your money. Figure out how much you are worth.

Figure out what makes you happy. Then work to get there. Easy peasy.

Smart Money MD, an ophthalmologist run financial website, focuses on proper management of medical trainee debt, lifestyle, time, and getting the most out of your hard-earned degree.

I can only second what Smart Money said above. In the grand scheme of things, getting into medical school is a much bigger deal than which medical school you get into. For most residency programs, what you get on USMLE Step 1 will carry much greater weight than your medical school. However, all else being equal, more prestigious medical schools will have more famous faculty, who will be better able to plug you into opportunities to advance your career as well as make phone calls on your behalf when it comes time for Match Day or even beyond with jobs. For more competitive training programs, specialties, or jobs, this may make a huge difference. To decide, ask yourself what type of training and career you want, then find a medical school training program that will you make you happy. Good luck!

Age-Appropriate Screening Guidelines

noreply@blogger.com (Unknown) — Thu, 23 Mar 2017 13:00:00 +0000

As you encounter patients in a primary care setting, you play an important role in preventative medicine. Specifically, you must ensure that your patients are receiving appropriate screening given their age, gender, and risk factors. Especially after the implementation of the Affordable Care Act, preventive services have taken on an even greater importance.

The main body that puts together guidelines in the United States is the U.S. Preventive Services Task Force, or USPSTF:

The U.S. Preventive Services Task Force is an independent panel of experts in primary care and prevention who systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. These reviews are published as U.S. Preventive Services Task Force recommendations on the Task Force Web site and/or in a peer-reviewed journal.

Often, the USPSTF guidelines are complemented by recommendations by specialty societies, such as the American Cancer Society or the American College Radiology. Be careful though: sometimes the guidelines may be contradictory, such as what age to start breast cancer screening with mammography. For a comprehensive list, visit the USPSTF website or download their app.

The selected guidelines below cover some of the most common recommendations:

Women

Age

Recommendation

Grade

Puberty - 24

Chlamydia/Gonorrhea if sexually active

21 - 65

Pap smear every 3 years (if combined with HPV testing, can be every 5 years after age 30)

40 - 49

Individual decision for screening mammogram based on relative benefits vs risks

50 - 74

Biennial screening mammography

50 - 75

1) Annual screening with fecal immunochemical test (FIT)
2) screening every 10 years with flexible sigmoidoscopy and annual screening with FIT
3) screening every 10 years with colonoscopy
4) screening every 5 years with CT colonography.

55 - 80

Low dose lung CT if one has a 30 pack-year smoking history, currently smokes or quit within the last 15 years.

Men

Age	Recommendation	Grade
50 - 75	1) Annual screening with fecal immunochemical test (FIT) 2) screening every 10 years with flexible sigmoidoscopy and annual screening with FIT 3) screening every 10 years with colonoscopy 4) screening every 5 years with CT colonography.	A
55 - 80	Low dose lung CT if one has a 30 pack-year smoking history, currently smokes or quit within the last 15 years.	B

Several interesting or unexpected exceptions to screening guidelines exist. For all, there is no specific recommended screening for skin cancer for the general population. That being said, one should still protect themselves from excessive skin exposure and follow up on any unusual skin findings. For men, the USPSTF recommends against screening for testicular and prostate cancer with PSA. For women, no screening for ovarian cancer exists presently. Women who have a strong family history of breast or gynecologic cancers should be screened for BRCA-1/2 and referred for genetic counseling if the tests are positive.

If there are other screening guidelines you feel should be included on here, please comment below or contact me. For more detailed information, check out Current Practice Guidelines in Primary Care for 2017:

Medical School Student Loan Consolidation And Refinancing: A Primer

noreply@blogger.com (Unknown) — Tue, 21 Mar 2017 14:33:00 +0000

Today's post is a repost from Future Proof, MD covering the basics of medical student loan consolidation and refinancing:

If you are like the majority of medical school graduates out there, you're probably saddled with a good amount of student debt. I know I am. If you are like me, you may have gathered multiple loans from several different lenders over your many years of schooling. Now that you're finally done with school and entered the workforce, you may have been bombarded with emails inviting you to consolidate/refinance your loans. So let's talk loan consolidation/refinancing.

First, let's address what consolidation and refinancing are.

Consolidation allow you to combine multiple loans into 1 loan, resulting in just 1 monthly payment instead of many. For example, if you have only federal loans and go through federal loan consolidation, you will end up with 1 bill but your interest rate will simply be a weighted average of all the different interest rates of the loans you consolidated.
Refinancing, on the other hand, allow your to consolidate your loans as above. But the difference is that your new interest rate will be dependent on your credit score and history rather than what the interest rates on your old loans were. In essence, you are applying for a new loan with new terms to pay off your old loans - analogous to a "balance transfer" between credit cards. In reality, "consolidation" and "refinancing" are used interchangeably. If you are getting an offer to "consolidate" your loans through a private lender, they're talking about refinancing. For the purpose of our discussion, I will use the term "refinance".

PROS:

1 monthly payment. This is probably the biggest benefit of refinancing your loans. Instead of making multiple monthly payments to multiple lenders, you get 1 bill and 1 payment.
You may qualify for a lower interest rate. The standard interest rate for federal student loans are fixed at 6.8%. If you have good credit and income, it's likely you will qualify for a lower interest rate. I say "may" because when I went through SoFi (the largest student loan refinancing lender) to check what they would do for me, my refinancing offer was less than generous (see figure).
You can lower your monthly payment. This can result from you getting a lower interest rate on the new loan, by renegotiating your repayment term (15 or 20 years instead of the standard 10 years for a standard repayment plan), or a combination of both.
Choice of variable vs. fixed interest rates. Choosing a variable interest rate will benefit those who are planning to pay off their student loans rapidly.

CONS:

Refinancing your loans with a private lender will make you ineligible for federal loan forgiveness programs such as Public Service Loan Forgiveness (PSLF), and other benefits such as Income Based Repayment (IBR), deferments and forbearance.
Your interest rate may go up if you choose a variable interest rate plan. Most variable interest rate loans have a cap as to how high the interest rate can reach, but it's usually more than the standard 6.8% fixed you would get through the government.
It's a permanent decision - if you ever leave the federal system, there is no recourse if you decide later that you've made a mistake.
Fees - this is a minor consideration for those with a large loan balance, but there may be fees associated with a private loan refinancing application.
So after considering many of the above factors, I ended up consolidating my loans through the government. I am currently on Income Based Repayment (IBR) with plans to eventually qualify for Public Service Loan Forgiveness.

Head on over to Future Proof, MD to see the table with statistics on medical education debt loads as well as many other great posts on personal finance for medical professionals.

For those of you currently in medical school, I would also add that I strongly encourage you to seek out grants, stipends, and scholarships to supplement your financing. There are many tied to specific student backgrounds (i.e., if you come from a minority group), or for those willing to perform public or military service for some time after finishing training. Personally, I can attest to this being a very valuable approach as a single scholarship application that I knocked out one weekend evening ended up covering my tuition for an entire semester! Another example is author Ramit Sethi who funded his entire Stanford undergraduate education on scholarship money alone. If you need a primer on personal finance overall, his NY Times bestselling book I Will Teach You To Be Rich is a great place to start:

Humerus Anatomic Neck vs. Humerus Surgical Neck

noreply@blogger.com (Unknown) — Fri, 17 Mar 2017 13:00:00 +0000

One of the most popular posts on this site was a deep dive into the difference between Pope's Blessing and Claw Hand. Who knew anatomy could be so contentious? Admittedly, today's post is likely much less controversial, but I always found the distinction between the anatomic neck of the humerus and the surgical neck of the humerus to be confusing. Well, prepare yourself for today's shallow dive into the subject. Hopefully this will help clarify the distinction between the two. If it's already clear to you, congratulations - at least one of us will benefit from this exercise!

The anatomic neck of the humerus refers to the location of the physeal plate during development. During growth, bone forms at the physeal plate as the child ages. Once the child reaches maturity, the plate closes, usually during puberty. Different growth plates will close at different ages, with well-characterized ranges known for various bony structures. This pattern of plate closure can be used to assess a child's bone age, which can then be compared to their chronological age to assess for any delay in maturation. Returning to the humerus, the anatomic neck is mostly notable as a defined landmark but has less clinical application.

The surgical neck of the humerus refers to the narrowing of the humerus in the proximal diaphysis. The neck abuts the quadrangular space, a potential space formed by the margins of the triceps, teres minor, teres major, and the medial humerus margin (3 Ts + H, as opposed to the more medial triangular space formed by those same 3 Ts, but no H). Since this region is more prone to fracture, that means fractures in this area are more likely to damage the contents of the quadrangular space, namely the axillary nerve and posterior humeral circumflex artery.

By BDB - You can find the picture here. Traced and colored the picture using adobe illustrator., Public Domain, Link

To memorize the difference between the two, you can try a few different ways. First, A for anatomic comes before S for surgical, and the anatomic neck is more proximal on the humerus than the surgical neck. Second, the surgical neck is more often fractured and more likely to have surgical complications, so the name is associated with its clinical relevance.

And that's pretty much it! For me, learning anatomy was much more helpful when I could attach a narrative about some clinical situation in which that anatomy was relevant. Start with a basic framework of the location from a book like Netter's Anatomy and then search for clinical scenarios that help solidify the terminology in your mind. Hope this helps!

ACGME Increases Shift Length For Interns

noreply@blogger.com (Unknown) — Wed, 15 Mar 2017 14:35:00 +0000

The American Council of Graduate Medical Education, or ACGME, recently announced that it was reversing course and lengthening the longest shift an intern can work in a hospital from 16 to 24 hours. The ACGME governs the structure of all accredited residency training in the United States, so this change will have broad-ranging effects. While PGY-2 residents and above were already allowed to work these longer shifts, interns had been protected from them since 2010. Here are various summary articles:

However, since 2010, concerns have arisen that the shortened shift actually detracts from intern training as they are required to hand off patients frequently in order to abide by the 16-hour restriction. Often times, a complex patient may require care past the 16 hour mark, which the trainee could not participate in while still complying with the rule.

Another concern was the hand-offs themselves. Especially in July, interns are still learning how to manage patients on a very basic level. Asking them to hand off a complex patient to another intern at the same early training stage is a recipe for error, since clinically relevant information may be omitted or underplayed, leading to errors in the provision of care.

Ostensibly, the ACGME attributes its change to the following reasons:

In keeping with this philosophy, the changes are supported by testimony from a wide range of physician specialty educators and intended to:

place greater emphasis on patient safety and quality improvement;

more comprehensively address physician well-being;

strengthen expectations around team-based care; and,

create flexibility for programs to schedule clinical and educational work hours within the maximums currently utilized in the US.

These revisions were developed as part of the ACGME’s periodic review of all program requirements to ensure that professional preparation of physicians adequately addresses the evolving and growing needs of patients.

The trade-off though is a return to the era of the over-worked, fatigued intern. Historically, residency was a brutal training process with no restrictions. The first attempt to curb work hours was set in motion by the death of Libby Zion, an 18 year old girl who was under the care of minimally supervised, overworked trainees. Her father Sidney's anger at her death led to the ACGME instituting its first series of work hour reforms. Even those changes were slow to come around: the commission formed after Zion's death recommended changes including an 80 hour work week restriction in 1989; the ACGME instituted those changes in 2003, fourteen years later.

There have been several minor revisions since 2003, including the move to the 16 hour intern limit in 2010. The debate will continue over striking the appropriate balance between clinical exposure and the physician's personal health. As a medical student, you should inquire with prospective training programs about how they plan to manage the change, as well as ask current program trainees how the program actually functions. In more demanding specialties, such as neurosurgery or orthopedics, there are many programs that have trainees working longer than the hours they actually log. Ultimately, the ACGME is not an enforcing body and cannot assess whether each resident actually works the number of hours they say they do, so it is up to you to ensure the training program you join matches your expectations.

Regardless of whether you join a relaxed program or a stressful one, your best bet to make sure you are as prepared as possible to handle patients clinically on your own. Despite different specialties, intern experiences have a lot of overlap. The following resources below should help you be better prepared for the first day when you round by yourself as a full MD:

Pocket Medicine by Marc S. Sabatine
A handy guide that easily fits into a white coat pocket, Pocket Medicine has long been essential reading for interns, especially those on medicine wards. This small book is chock full of practical tips and broad differentials for common clinic findings.
First Aid for the Wards by Tao Le, Vikas Bhushan, et al.
From the authors of First Aid for USMLE Step 1, the bible of Step 1 prep, comes this book about rotation-specific advice. While intended for MS3 students, it still contains lots of useful information for interns, especially those who will rotate among various specialties, such as transitional interns.
Intern by Sandeep Jauhar
While not a technical guide like the two prior books, this memoir by Dr. Jauhar gives a good sense of what it feels like to be an intern, especially the sense of disorientation one may feel at times.

Good luck! If you are or recently were an intern, what was your experience like? What do you think of the proposed changes?

Amazon Fire Tablet Deal

noreply@blogger.com (Unknown) — Tue, 14 Mar 2017 21:17:00 +0000

We have previously written about tablets for medical students, and why you might want one. If you're not sold on a top of the iPad Pro, consider this deal for an Amazon Fire Tablet Essentials Bundle (16GB):

Simply enter the code FIREBUNDLE at check out and get the 16GB version, case, and a screen protector for less than you would spend for the tablet itself. If you do get any kind of tablet, a case or cover is a must. Think about it: between carrying it to and from the classroom, library, or wards, the various fluids and substances in a healthcare setting, and the possibility of others using it, the tablet is prone to falls. As we discussed recently, you should also consider the pros and cons of getting a warranty.

In addition to a case, you should consider a Bluetooth keyboard. I'm personally a huge fan of the Kensington keyboard/case combo I got for my iPad Air 2, the Kensington Key Folio Thin X3:

It works great, is backlit, and last for almost a solid *year* on a single charge via microUSB. It has proven invaluable for taking notes and making the device more functional. The combination practically serves as a laptop replacement for most light to moderate computing tasks. Not to mention weighing a ton less! For any medical student with limited carrying / storage space, such a compact solution is a definite plus.

Should I Get A Warranty For My Device?

noreply@blogger.com (Unknown) — Thu, 23 Feb 2017 19:27:00 +0000

Many medical students will end up purchasing various devices such as tablets over the course of their training. When purchasing the device, a question that inevitably arises is: should I purchase additional coverage for any damage to my device? Admittedly, this topic is indirectly related to medical education. However, given that many of you are on limited budgets, it is a fair issue to consider. Buying a warranty vs. saving your money and being careful both have merit. Consider your own situation specifically before making a final decision

Why You Should Get A Warranty

As a medical student, your device is going to be more mobile and in more varied environments than someone who merely uses their device to binge on Netflix. Not only should definitely buy a case to protect your investment from minor scratches, wear, and tear, you should definitely consider a warranty in the event that your device is lost or stolen. Another major factor to consider is your own track record with devices. If you often drop items or otherwise damage them, you should be more inclined to purchase an extended warranty.

Why You Should Avoid A Warranty

Given the ever-shortening upgrade cycle in tech, you will most likely upgrade your device by the time you may incur any damage worthy of replacement. As prices are generally falling over time, the money saved up front may be enough to cover a brand-new replacement device. A rule of thumb for determining whether a warranty is worthwhile is to calculate the implied risk. The formula is simple:

100 x (Insurance Premium / Item Cost)

For example, if a device costs $200 and the extended warranty costs $40, then the implied risk is 100 x $40 / $20, or 20%. Now, ask yourself: is there a 20% or greater chance that I will break this device or otherwise invoke this policy? If so, you should buy the warranty. If not, then save your money and avoid the policy. Need a tie-breaker? Well, do you have children that will ever use the device? That alone probably makes the warranty worthwhile!

Where To Purchase A Warranty

After weighing the pros and cons above, let's say you decide to opt for a warranty. For simplicity sake, purchasing the warranty offered at the time of your purchase is probably easiest. For example, let's say you were purchasing an Amazon Fire Tablet:

You can purchase additional protection for 2 to 3 years from Amazon, provided by SquareTrade:

Looking at reviews online, SquareTrade is well reviewed with reasonable prices. Similarly, for Apple products, an AppleCare service plan / warranty is also a reasonable option.

Have you purchased an extended warranty before? What has your experience been like? Please leave comments below!

Scrub Notes Interview with Dr. James Dahle of White Coat Investor

noreply@blogger.com (Unknown) — Mon, 23 Jan 2017 14:00:00 +0000

From our recent post Financial Advice for the Future Physician, some of you may have taken the time to explore White Coat Investor more thoroughly. Those who did likely found it to be a very valuable resource in planning their financial future. Dr. Dahle, who runs White Coat Investor, was kind enough to participate in an interview with Scrub Notes about his site and other advice:

Dr. Jim Dahle
Source: WCI

SN: What inspired you to pursue a career in medicine?

Dr. Dahle: The first time I thought about a career in medicine was a career survey of some kind in junior high where "doctor" was one of recommendations it had for me. Obviously my parents were encouraging. I was very much interested in science and in helping people but I didn't really formally commit to it until it was time to study for the MCAT. I don't know how much the prestige or money was motivating for me but I was fascinated by the subject matter and I knew that I enjoyed helping others so medicine was a natural fit.

SN: What led you to create White Coat Investor?
Dr. Dahle: I started really diving deep into personal finance and investing topics midway through residency. I got sick of being ripped off by all kinds of financial professionals and decided I better start learning this stuff myself. After a few years of reading books, interacting on internet forums, and reading blogs I realized that I was spending more time teaching than learning and that I knew more about this stuff than the vast majority of my peers. That was also a period of time when I was very interested in developing sources of passive income. So the blog was started both as a hands-on experiment at generating passive income and a way to get this knowledge into the hands of my colleagues. It turned out the income, once it eventually came, wasn't nearly as passive as I had hoped, but I did end up making a big difference in the lives of literally hundreds of thousands of my colleagues, so that was rewarding in and of itself.

SN: What has been the most surprising part of running the blog?
Dr. Dahle:  I guess the most surprising thing was just how much vitriol it would attract from commissioned salesmen masquerading as financial advisors. Real financial advisors are generally very supportive of what I'm doing, but those who saw doctors as easy marks are finding them to be not so defenseless any more.

SN: What is the best piece of advice you have for medical students?
Dr. Dahle:  I have lots of advice for medical students, but I probably ought to limit this to financial advice. I guess the most important is to remember that what you do those first few years out of residency with your finances are going to determine the course of your financial life. So really focus on getting those years right. That means living like a resident for 2-5 years after residency in order to pay off student loans, jump start your retirement savings, and save up a down payment on your dream house.

SN: What are your top financial predictions for the next four years?
Dr. Dahle:  My crystal ball is incredibly cloudy. I have found predictions are extremely difficulty, especially about the future. That said, with the Republicans in control of all 3 branches of government, I expect tax rates will go down a bit. The market will fluctuate. Interest rates will change. Those who spend a little bit of time and effort learning about personal finance and investing will reap great dividends of happiness in their lives.

SN: Thank you for taking the time to chat with Scrub Notes!

For more great financial advice for healthcare professionals, head on over to White Coat Investor. You can also check out Dr. Dahle's book on Amazon:

Applying Behavioral Economics to Patient Care

noreply@blogger.com (Unknown) — Thu, 19 Jan 2017 14:00:00 +0000

Psychologist Daniel Kahneman, along with his frequent collaborator Amos Tversky, are the fathers of the field of behavioral economics. Kahneman was awarded Nobel Memorial Prize in Economic Sciences in 2002 for his work (Tversky was deceased, and thus not eligible). To bring his work to a broader audience, he published "Thinking, Fast and Slow" in 2011:

The basic premise of the book is that our brains actually function via two systems, which he terms System 1 and System 2. System 1 is instinctive, utilizing heuristics to make decisions quickly. A heuristic is a 'rule of thumb', a device to boil down complex information to a simple choice. In other words, it acts as an approximation, that is usually 'good enough' for the situation at hand. System 2 is calculating and rational; it functions more like a computer, coolly processing inputs and trying to generate the optimal decision as an output.

Kahneman's work points out the biases inherent to both of these systems. His most famous result may be prospect theory, which basically shows that humans do not value incremental changes in probability equally, and that they are susceptible to whether those changes are framed as gains or losses. Another big point that Kahneman makes is that our "selves" really consist of two separate entities: our experiencing selves, and our remembered selves. For example, think about a strenous hike or other physical activity you did. In the moment, your experiencing self may be in agony from the stress and pain; however, your remembering self may view it as a very cherished memory because of the overall payoff.

What does this have to do with medicine? Everything! Both patients and doctors suffer from these biases. While the biases are part of being human, that does not mean we should simply accept making poorer decisions because of them. As a physician, here are some things you can do to mitigate these biases from how you decide.

Gathering A History

When you first meet a patient, you will necessarily have to make an initial assessment. That 'subjective' portion, the S in SOAP note, is the lynch pin for the rest of your encounter. If you have bad information, you will order the wrong exams, make the wrong diagnosis, and implement the wrong plan.

Garbage in, garbage out.

Therefore, getting a precise history is critical. However, to do this, you must combat both your own biases and the patient's. The big one to combat here is recall bias. For example, patients with a history of cancer who present with abdominal are more likely to over-emphasize or recall factors that may suggest a mass as the underlying cause of their pain. Do not disregard this history, but do try to correlate it with objective data, such as a CBC to check for anemia, or imaging.

Ordering Tests

The explosion in objective data one can acquire on a patient has been a major boon to healthcare. However, there is a downside to such tests. This bias is on the provider's side. Whether it is an anchoring/recall bias (the last patient with shortness of breath had a pulmonary embolism, so now every future patient with SOB has a PE) or satisfaction of search (one abnormal test result precluding ordering other relevant tests), these biases can lead to either the under- or over-utilization of appropriate testing modalities.

One way to guard against this is to understand treatment algorithms at great length. While there is a tendency to avoid 'algorithmic thinking' in medicine, the notion is often misapplied. One can go beyond algorithms only after they have fully mastered them, and can confidently assess that the current patient does not fit the algorithm. This is a wholly different matter from simply ignoring an algorithm altogether.

Making a Plan

Finally, once all the history and data have been gathered, and an assessment, it is time to come up with a treatment plan. As Kahneman's book title implies, this is a good time to think slowly. Have all the patient's problems been addressed? Does every abnormal lab value have either an explanation or a plan to address it? A good treatment plan will also include some way to assess its own effectiveness, whether that is by scheduling a follow up exam or test, or some other objective measure. A plan without follow up is simply wishful thinking.

Ultimately, the practice of medicine is a human practice, subject to human biases. However, as our understanding of these biases advances, it behooves us to mitigate these biases to the best of our abilities. If we are to do no harm, we must ensure that we unblind ourselves to the harm our biases may cause.

The New and Improved Amazon Rewards Card

noreply@blogger.com (Unknown) — Sun, 15 Jan 2017 14:00:00 +0000

Regular readers of this site likely realize that we're big fans of Amazon. In addition to using e-books and being a Prime Student member, another way to maximize your Amazon benefits is by having an Amazon Rewards credit card.

Previously, the card paid 3% back for all purchases made on Amazon and 1% everywhere else. The new card now pays 5% back on all Amazon purchases for Prime members, 2% at restaurants, gas stations, and drug stores, and 1% everywhere else. It remains free, with no annual fee.

The card becomes another payment option in your Amazon account. After the monthly balance is paid off, the reward points automatically show up on the Amazon checkout page. Simple!

For a limited time, Amazon is offering a $70 instant bonus upon approval. If you are looking for a new stethoscope or maybe even a new tablet device, that would go a long way towards it! Following on the last post though, if you already carry credit card debt, make sure to pay off all your balances first before pursuing new lines of credit and make sure to pay off your balance *every* month.

This post contains affiliate links, which means the blog receives a commission if you make a purchase using those links. For more info, please read the full disclaimer.

Financial Advice for the Future Physician

noreply@blogger.com (Unknown) — Thu, 12 Jan 2017 22:25:00 +0000

Dr. Jim Dahle runs the popular healthcare-professional blog White Coat Investor. One of his posts detailed 8 Financial Tips for students looking into a medical career:

Choose the cheapest school you can get into

The decision of which school to attend will have a greater impact on your finances for the next 5-20 years than any other decision other than who/if you marry and what specialty you choose to practice. Choose wisely. I’ll give you a hint–Most medical schools in this country provide a pretty comparable education. Most of what you learn in medical school will come from what you teach yourself and the pearls dispensed to you freely by interns, residents, and other doctors you come into contact with. Little of that learning is dependent on the school you choose. Thus, choose the cheap state school if you can get into it. Don’t forget that costs aren’t limited just to tuition and fees, but also to the local cost-of-living. That school in Boston, New York, or San Francisco is going to cost you a lot more than the one in Omaha or Albuquerque.

Consider the merits of “scholarship” programs carefully

There are several organizations that would like to pay for your medical school in exchange for a commitment. The military Health Professions Scholarship Program is the best known, but the US Public Health Service, Indian Health Services, and other private deals also exist. None of these programs is a “scholarship” in the traditional sense of the word, and many a “scholarship winner” has later realized he would have been much better off, personally and financially, if he hadn’t been awarded the “scholarship.” As a general rule, use these programs only if your career goal is to be a military doctor or a rural primary care doctor. Choosing them for the money is almost surely a mistake you will regret.

Personally, I can attest strongly to his first piece of advice. Choosing a cost-effective medical school has meant the difference between graduating essentially debt-free versus graduating with loan repayments stretching out as far as the eye can see. As life progresses, your costs will increase, so that "manageable" monthly repayment will become increasingly burdensome, especially if you are interested in purchasing a house or having a children as you near the end of the long road of medical training (or already have those obligations!)

For the rest of his tips, check out Dr. Dahle's post 8 Financial Tips for Pre-meds and Medical Students.

Why Not Watching Enough College Basketball Is My Greatest Regret: Guest Post

noreply@blogger.com (Unknown) — Mon, 09 Jan 2017 20:06:00 +0000

Leah Kroll is a medical student at NYU. She writes about her life as an MS4 in this post from MotivateMD:

I made it through the rigors of pre-med. I made it through (almost all of) med school, with a few scars to show for it. And now that I’m a big, bad MS4, I finally have the time and the distance to reflect on all the literal blood, sweat, and tears it took to get here... I am a loud and proud Duke Blue Devil. It was my dream school despite my born-and-raised New Yorker parents saying, “South of the Mason-Dixon line? Absolutely no way!” My 4 years there surpassed my wildest expectations. But I failed to live all of my Duke dreams out.

I’m proud of the person that I have become as a result of persevering through the MCAT, Steps 1 and 2, clerkships… you get the picture. But throughout all of this, since the moment I decided to go into medicine, the pressure to succeed has been a heavy weight dragging me down. I had to have a 4.0 every semester in college or I wouldn’t get into medical school. I had to run myself to the bone trying to excel as a medical student or I wouldn’t be a good residency applicant. I had to get at least XXX on Step 1 or I would be worthless.

At Duke, basketball is king and I went to as many games as I could in the beginning. But as my medical school aspirations grew stronger, the number of games I attended dwindled to a pathetic 1 during my senior year season. Looking back on the night we won the NCAA tournament during my freshman year, I remember 2 things: 1. The electric rush of taking part in the ultimate Duke experience 2. Taking myself out of the party when the clock struck midnight so that I could retreat to my all too familiar spot in the library. My organic chemistry midterm was in 2 days and I had to get an A.
Every year at Duke, a good chunk of the undergraduate student body (The Cameron Crazies) sets up a tent village outside Cameron Stadium. For months, students live in these tents hoping to score tickets to the main event of the year: Duke Vs. UNC. My non pre-med friends tented every year. We pre-meds never did. After all, would we get enough sleep in the tents to study as much as we needed to? We had to keep our grades up.

I got that A in organic chemistry. But, at what cost?

We take the best care of our patients when we take the best care of ourselves. My relationships and interests outside of medicine keep me happy, healthy, and well-rounded. They help me be a better doctor. Regularly watching Duke basketball with my college friends, for example, has kept me sane as I grapple with the rigors of medical school.

If my memory serves me correctly, organic chemistry came up in medical school just once: a 3-day metabolism and biochemistry unit in my first year. Other than that, my knowledge of electron pushing has not made any contribution to my medical training. Duke Basketball, however, has come up many times with my patients. It’s something that really excites me, and the people I meet in the hospital can relate to that. It makes me stand out from the assembly line of faces and scrubs poking and prodding hospital patients all day.

Rooting for a basketball team brings all sorts of people together, and it’s that one common goal that serves as the glue. Cheering for a team is not unlike rallying around our patients to help them beat their illnesses. That’s how Duke basketball makes me a better doctor- it reminds me how to connect with almost anyone.

I only wish I had participated more in my college years. I would have been happier then and it would make me a better doctor now. As hard as it may be to remember when pursuing a profession that requires us to compete and claw our way to the next step, there is such a thing as holding on to academic excellence too tightly. Albus Dumbledore said it best: “It does not do to dwell on dreams and forget to live, remember that.” Wise guy, that Dumbledore.

Looking for more inspiration as you journey through your health professions career? Check out MotivateMD.

Medical Student New Year's Resolutions for 2017

noreply@blogger.com (Unknown) — Tue, 03 Jan 2017 18:24:00 +0000

Happy 2017! Hopefully everyone had a restful and happy holiday season. As the new year is upon us, it is commonly a time for resolutions. Some are personal; some, professional. For me personally, here's to cutting out soda! As research has shown, there is a link between sugary drinks and metabolic disease. Hopefully I can make some personal progress in that direction.

What about you? While your personal goals are unique, most likely we all share professional goals as a healthcare professional student. Study harder. Do well on tests. Figure out what we are doing with the 'rest of our lives.' Setting these goals is very important. However, that is only part of the story. A goal is nothing but a destination. What we need is a roadmap to that destination, or a plan. What would that look like? Let's take a look at the three goals mentioned above and see what concrete steps we can take towards them in 2017.

Study Harder

Ah yes, the eternal hope of the conscientious student. Study harder. The goal is omnipresent, but what does it actually mean? You could study more hours. You could isolate yourself as much as possible as you study. Both fit but is that what we want? Not exactly. What most people mean by study harder is actually to study more effectively. This will differ from person to person as everyone learns in a different manner. Some learn better by reading only, others by taking notes, still more by listening / reviewing lecture audio/video. Regardless of how you like to study, there should be two main objectives: studying for mastery, and studying for testing purposes.

Studying for mastery is a component of lifelong learning. This means that after your review, you have a deep, fundamental understanding of the concept. The upfront cost may be more, in terms of time and effort. However, in the long run, this method is more effective because once you master something, you do not have to go back and relearn it. The idea remains embedded in your knowledge base, much like riding a bike. How do you master a topic? The best way I know how is to actually teach the topic. Seek out or create opportunities. Struggling with anatomy? Volunteer to be an anatomy lab TA - the responsibility will force you to either master the material on your own, or seek out help from others so that you are competent enough to teach.

Do Well On Tests

This is also a very generic goal. Aside from a standardized test like USMLE Step 1, every medical school test will be unique. Discussing non-standardized tests first, you can of course try the steps mentioned above, mastering the entire topic. However, sometimes learning everything A to Z just isn't feasible. At this point, it is important to find out what are the objectives the course instructor wants to emphasize. Look at the syllabus, review old tests if available, and ask senior peers. If all that fails, you should *gasp* just ask the instructor what is important. Trust me, they will be happy to see you being pro-active and striving to fully grasp the essence of the material. While you cannot directly ask "What will be on the test?", you can certainly say something like "There is a lot of material to cover. What are the most important points you see students miss in your experience? What is most important practically?" Only a sadist would actively lead you away from material that will come up on the test.

Standardized tests like the USMLE are a different story. For those your best bet is to study common resources like First Aid and do review questions. Lots of review questions (such as Kaplan QBank). Ideally, you want to do these questions in a similar setting to the actual test. For example, if your test is on a Saturday morning at 8am, you went to spend several Saturdays before the test, waking up before 8, figuring out your pre-test routine, and then doing several sections to best simulate what the test will be like. Remember, for people looking at US residencies, your Step 1 score is the biggest objective determinant of how programs will assess you for interviews, for better or worse. Therefore, it behooves you to put as much concerted effort into preparing for this test as possible.

Figure Out My Career

Despite stressing about tests, they will come and go. Ultimately, the tests are simply a means to an end. It is up to you to define what that 'end' is. What type of medical career do you want? Primarily outpatient? Inpatient? Urban vs underserved community? Domestic vs. international? Medical vs. surgical? While some students go into medical school knowing exactly what they want to do, an equal number have no idea. And that's okay! School is a time for exploration. If you have too fixed a mindset, you may miss out on another opportunity that is an even better fit for you. I recommend perusing Iserson's Getting Into A Residency for not only practical tips about applying but also for a framework about how figure out which specialty you should be applying for.

Questions about the process? Please comment below or use the contact page above. Have a fantastic 2017!

Best Stethoscope for Medical Students

noreply@blogger.com (Unknown) — Fri, 16 Dec 2016 14:00:00 +0000

Ever wonder what the best stethoscope for medical school is? Before considering specific models, a medical student should consider several factors:

Quality
Anticipated Usage
Comfort
Cost
Additional features

Quality

First and foremost, the stethoscope should faithfully reproduce sounds originating from the target organ. While the majority of stethoscope usage is for the heart, the device is also used to auscultate the lungs, abdomen, carotid arteries, and other various structures as indicated. A useful device should perform well across this range of indications.

Anticipated Usage

Do you foresee using this only for required rotations and no more? Or, do you foresee doing a lot of primary clinical work, or perhaps even becoming a cardiologist? If you anticipate having a long-term relationship with your stethoscope, it is better to invest in a higher quality, more versatile device.

Comfort

This varies by individual, but if this is something you need to carry around all day, you want to make sure it's lightweight, portable, and sets comfortably in your ears.

Cost

Medical school is expensive enough. While a stethoscope is a great investment, you want to make sure it is the right one for you. The budding cardiologist is likely to get more out of the extra dollar spent than the future psychiatrist.

Additional Features

Newer stethoscopes now include various extensions, such as smartphone apps or other technology. Each person will have to decide on their own if such items are necessary.

In the US, the majority of medical students, residents, and physicians using Littmann stethoscopes by 3M. They perform well and have stood the test of time. The overall most common type is the 3M Littmann Cardiology III:

Pros:

Two-in-one tube design reduces noise interference
Dual side chestpiece for adult and pediatric patients
Two tunable diaphragms
Weight: 15.7 ounces

Cons: Cost

Personally, I have owned a Cardiology III for years and have had zero issues with it. I have never encountered a clinical situation in which the Cardiology III was not up to the task, or felt that I wish I had a different stethoscope. Littmann has released the Cardiology IV, which is very highly reviewed but looks to be mostly evolutionary changes over the III. For the future cardiologist, the Master Cardiology version is a consideration, but likely too advanced for the beginning medical student.

For the more budget conscious student, the next best option is the 3M Littmann Cardiology II SE:

Unlike the III, the II SE has slightly lower acoustic performance and a shorter warranty. However, it is a more economical choice.

Here is a table with a full comparison of Littmann stethoscopes features:

	Classic II S.E.	Classic III	Master Classic II
Acoustic Performance	7	8	9
Ideal For	Physical Assessment and Diagnosis	Physical Assessment and Diagnosis	Physical Assessment and Diagnosis
Warranty	3 Years	5 Years	3 Years
Chestpiece Design/Material	Double Sided/Machined Stainless Steel	Double Sided/Machined Stainless Steel	Single Sided/Plated and Polished Alloy
Available Colors/Finishes	6 Colors/ 2 Finishes	18 Colors/ 4 Finishes	9 Colors/ 2 Finishes
Tunable Diaphragm	Tunable Diaphragm	Redesigned Single-Piece Tunable Diaphragm on Each Side of the Chestpiece	Tunable Diaphragm
Tube Design	Single Lumen Tubing	Single Lumen Tubing	Single Lumen Tubing
Weight/Length	135 grams, 28"/71cm	150 grams, 27"/69cm	160 grams, 27"/69cm
Made in USA	✓	✓	✓

	Cardiology III	Cardiology IV	Master Cardiology
Acoustic Performance	9	9	10
Ideal For	Cardiology/High Performance	Cardiology/High Performance	Cardiology/High Performance
Warranty	5 Years	7 Years	7 Years
Chestpiece Design/Material	Double Sided/Machine Stainless Steel	Double Sided/Machined Stainless Steel	Single Sided/Cast Stainless Steel
Available Color/Finishes	16 Colors/ 6 Finishes	7 Colors/ Stainless Steel Finish	7 Colors/ 3 Finishes
Tunable Diaphragm	Two Tunable Diaphragms	Redesigned Single-Piece Tunable Diaphragm on Each Side of the Chestpiece	Tunable Diaphragm
Tube Design	Dual Lumen Tubing	Dual Lumen Tubing	Dual Lumen Tubing
Weight/Length	175, 180 grams Available in 22” / 56cm and 27” / 69cm	167, 177 grams Available in 22” / 56cm and 27” / 69cm	175, 185 grams Available in 22” / 56cm and 27” / 69cm
Made in the USA	✓	✓	✓

Source: Amazon

Have questions about your stethoscope choice? Feel free to contact us using the link at the top of this page. Happy hunting!

3 Great Reasons to Get Amazon Prime for Students

noreply@blogger.com (Unknown) — Mon, 12 Dec 2016 14:59:00 +0000

As you can tell, we are big fans of Amazon on this site. Admittedly, we get a commission from products purchased on Amazon through this site, but even if we didn't, the site is a great deal for students. Between textbooks, games, and other resources, pretty much anything a medical student would need is at their fingertips.

I still remember the days before Amazon, trying to buy books for a required reading list for school. I forget the title, but I found out the night before an assigned reading was due that I needed to have a certain novel. I called up a few bookstores, who said they carried the book generally but did not know if they had it in stock. Figuring the only way to know for sure was to check, I dragged my parents to THREE bookstores before finally getting lucky. Even then, I think we paid the cover price for a paperback, which in retrospect was outrageously expensive. While authors and publishers may not be fans, anyone who enjoys books should be very thankful that Amazon exists.

As a student, the benefits are even better. Amazon Student offers Prime services for free for SIX months. After that, enjoy a reduced rate for four years. If you refer a friend, you also get a $10 credit:

One of the big benefits of Amazon for students in general is their Kindle program. Once you download the app, you can read any Kindle title that you own on any supported device, including web browsers. Download the app today.

But wait, it gets better. If you own an actual Kindle device, you get access to two free books a month through the Kindle Lending Library, and the Kindle First program. That's up to a $480 value! I personally own a Kindle Paperwhite and am a huge fan.

For the medically inclined, many texts are available. Trust me, it's much easier to carry around one Kindle than several large textbooks. For example, I own the Handbook of Interventional Radiologic Procedures. While the paperback version is highly portable, here are some benefits of the Kindle version:

Searchable
Bookmarkable
Portable - what happens if you forget the paperback at home one day? No worries - just log into read.amazon.com from any desktop computer and boom! Your entire Kindle library at your fingertips.
You can even highlight and annotate

I cannot tell you how often these features have unexpectedly come in handy today. If you are not already part of the Amazon ecosystem, why not give it a shot? Amazon also has a large textbook exchange service, which can come in handy if you are thinking about making the switch to an all digital personal library. What have your experiences with Amazon and e-books, in particular e-textbooks been like? Comment below, or use the Contact form above to share your thoughts!

Medical Student Holiday Gift Guide

noreply@blogger.com (Unknown) — Mon, 05 Dec 2016 18:50:00 +0000

Building off our recent Holiday Book List post, and on previous gift guides, here are a few gift ideas for the medical or healthcare profession student in your life. These suggestions include both light-hearted and practical ideas, from stocking stuffer to larger items. Regardless of what you choose, your gift will show your cared one that you support them on their journey to becoming a practitioner of the healing arts.

* Giant Microbes
The always popular plush Giant Microbes are really getting into the holiday spirit this year by releasing a stocking stuffer collection, literally in a stocking! The collection includes:

Penicillin with red, green and white caps
Limited Edition Green Amoeba with scarf and ear muffs
Dust Mite with reindeer antlers
Salmonella with holly embroidery
Red Blood Cell with snowflake embroidery

Additional collections can be ordered in Christmas tree or wreath boxes.

* Brain Slice Coasters
Budding neurologist or neurosurgeon in your midst? Check out these brain slice translucent coasters. They look pretty neat, especially when stacked! The set includes ten 4" x 4" coasters, hand wash only.

* Black& Decker Personal Coffee Maker
Looking for something to put on those snazzy coasters you just picked up? How about this Black & Decker personal coffee maker with included mug? The Brew 'N Go has a permanent filter and the mug is designed to fit most car cupholders.

Other novelty mug ideas include:

* Amazon Echo
The Amazon Echo is a voice-activated speaker system that is powered by Amazon's Alexa voice assistant. While it does not have any direct healthcare application (yet), the device is useful for providing news, weather, sports, and other information. The Echo is also a pretty decent speaker and can play music from Pandora, Spotify, Amazon Music, and other streaming services. Through its skills platform (think app store), it can be extended to perform a wide range of functions like hailing an Uber, ordering a pizza, and many more. If you have a connected house (such as Phillips Hue lights or a Nest thermostat), you can use Alexa to control those devices with voice commands as well. The Echo does have some rough edges - you have to speak clearly and concisely for it to work really well. While it will understand multiple people, it's best to keep your phrasing simple. Also, don't expect Alexa to magically answer any question you through at it. The search function works best when you ask simple, close-ended, fact based questions like "What is the capital of Florida?", but not so well with broader, open ended questions like "What is the best time of year to visit Florida?"

* Stethoscope
If your loved one is new to their training, a stethoscope is a great way to both look the part and gain a useful tool. If they are already in training but have a budget stethoscope, upgrade them to a higher quality one. The Littmann line is well regarded and comes in a wide range of styles and options. For a basic choice, a Classic III is a fine place to start:

For a limited time, Amazon is offering a 10% discount off the price listed above!

And last but not least, when in doubt, you cannot go wrong with an Amazon Gift Card to let them get that perfect esoteric item for themselves:

Medical Books Holiday Wish List

noreply@blogger.com (Unknown) — Thu, 01 Dec 2016 14:00:00 +0000

Practicing medicine gets busy! Looking back at (the lack of) posts on here, I realize that I have not read a good book about medicine in a while. In fact, I don't think I've read a book cover-to-cover in almost a year! While I don't know the next time I will have enough free time to break that streak, here are a few books I would consider:

The Gene, by Siddhartha Mukherjee, MD

Written by the author of The Emperor of All Maladies, Mukherjee's new book The Gene explores both the history of the how humans considered the concept of the gene, as well as what the futures holds when we are able to edit the genetic code. Having heard Mukherjee speak in person, I can attest that he is a thoughtful and passionate believer in a deep understanding of the history of medicine in order to inform future avenues for medical research. Have you read The Gene? How did you find it?

The End of Illness, by David Agus, MD

While not new, The End of Illness re-examines what it means to be 'healthy' and what one can do to live a robust life. Agus is a professor of medicine and engineering at USC, and has written several other books about life and health, but this is perhaps his most well known. If you have read it, what did you think?

When Breath Becomes Air, by Paul Kalanithi

Paul Kalanithi was a young neurosurgeon, who has to comes to terms with his own mortality all too soon. I cannot imagine the heartache he and his family must have gone through, but hopefully writing this book provided him some catharsis.

While I used the idiom "cover to cover", the honest truth is that it's been even longer since I truly did that. In the last few years, I have started using a Kindle Paperwhite to actual read longform. While it's not a perfect substitute for the written page, I find the ability to carry many books at one time, read in low light, and look up related material very useful. A single charge lasts 30 *days*, and e-books purchased from Amazon can be read on other devices too, including any web browser. It even syncs your last read page across devices!

As the holidays approach, any of these items would also likely make a great gift for the budding healthcare professional in your life. Come across a good healthcare-related gift idea? Please share!

A Primer On The Different Types Of Medical Education/Courses

noreply@blogger.com (Unknown) — Wed, 30 Nov 2016 14:00:00 +0000

This guest post by Danielle Ward details the various options available to those interested in a career in the healthcare professions but not sure about what type of degree or what type of specialty to pursue.

The field of medical science is not just confined to physicians and doctors; there are so many degree courses and areas you can specialize in. A Bachelor’s, Master’s, or Doctorate Degree in Medicine is among the most common and popular academic course that almost every aspiring doctor wants to achieve, but there’s much more than that. You also have to crack tough entrance exams and fight through intense competition to win a seat in a prestigious medical college or institution. Most medical colleges cover major subjects, such as medicinal drugs, anatomy, and physiology

Let us delve deeper into the many different types of courses and degree option. Listed below are some practical and interesting career choices for medical students:

General physician

The most primary of medical courses, this involves studying all the different and diverse subjects in medical science. General Physicians are almost never out of work and have ample earning opportunities. It prepares you to deal with the most common ailments, such as common cold, to deadly diseases and disorders, such as cholera and jaundice. One can pursue a career as a general physician after getting an undergraduate degree in Medicine (MBBS) or a post graduate degree (MD) in general medicine.

Specialized courses

Outside the US, once you’ve achieved a bachelor’s degree in medicine i.e. MBBS, you can either start off with medical practice right away or major in a specialized field. Discussed below are some of the specialised courses that medical students are qualified to apply for:

Surgeons

Surgery medicine is one field you can specialise in. It involves learning more about the anatomy and the various intricacies of the internal organs of the body in detail. You can further narrow down your course by choosing one particular organ such as the eye or the brain and specialise in it. Your job involves examining the patient, diagnosing his condition and operating on the body to surgically remove the source of the problem. Getting a degree, MD in surgery medicine boosts your credibility and influence in the medical community.

Dentistry

Dentistry is a brand of medical science that deals with oral care and surgical treatment of teeth. From fixing the alignment to dealing with cavities you have to do it all. The MD in dentistry course involves learning all about the various dental disorders and infections that can possibly happen inside the mouth. It also covers a section about treating disorders relating to gums, and soft tissues inside the mouth. You’ll also have to study about the many surgical operations and high powered medicine.

Neurology

Neurology as the name suggests deals with nerves. The syllabus is a detailed account of the different nerves and their functions in the human body. Most neurologists are also physiotherapists who plan out proper exercises that help bring sensation back to dead nerves. Neurology also involves a bit of psychiatrist study. As a neurologist you’ll have to diagnose and treat nervous disorders relating to the brain and the nervous system.

Other areas:

Other than these major courses mentioned above, there are other equally lucrative medical fields that you can choose from. For instance, an MD in paediatrician qualifies you to treat babies and young kids. Studying cardiology trains you to identify and treat heart problems. A dermatologist deals with skin abnormalities and infections. A course in gynaecology includes diagnosing and treating the disorders in the female reproductive system. All these areas of study require a basic MBBS degree and offer high pay packages.

Medical research

There are many medical students who take up internships at established hospitals and ten join the topmost medical institutions as doctors and surgeons. But not everyone who takes up a medical course ends up being a doctor, there are students who continue their academic studies and venture out in the field of research. A relatively unknown yet interesting course, medical research involves a lot of effort and patience.

The bottom line:

Medical science is a sector full of opportunities. And there are loads of other major and auxiliary degree courses that you can opt for. Consider your field of interest and the practicality of the course before you apply for it.

Acing Your Medical School Interview

noreply@blogger.com (Unknown) — Mon, 28 Nov 2016 16:00:00 +0000

The following sponsored post discusses important considerations for an outstanding medical school interview.

Going to medical school is no laughing matter. Not only do you have to be smart and hard working but you also have to be determined, patient, strong etc. On top of that you need to have resources or the money to pay for the tuition fee, expensive books, and all the other requirements you'll need. Furthermore, you have to think a hundred times if you really want to be a doctor so that no matter how hard it gets you won't easily give up. You should also be the type who doesn’t complain when they're swamped with homework and would do every single one of them with enthusiasm. Otherwise, you'll end up like those medical students who purchase assignment just to be able to survive med school.

Having said that, you definitely won't be able to enter medical school with only good grades in hand. You must ace the interview or else your chances of getting accepted will be greatly reduced. Interviewing applicants is very important because this is where you'll get essential information that won't appear in any test and academic records. It provides interviewers with an insight on how these students carry themselves in the patient room. Their answers let interviewers know how good and comfortable you sound when interacting with other people which is very important. Since you don't want to fail, there're steps that you can take to ace the interview.

To prepare for an interview, the student should know and understand the different types of interviews. A panel interview is where you'll meet several interviewers in a single meeting and is usually a cross section of the medical school faculty and may include a medical student. A stress interview determines how an interviewee would behave under pressure and often involve personal and sensitive topics. In an open interview, the interviewer may choose the specific information to which he is acquainted with. In a blind interview, the interviewer doesn't know anything about the student and would ask him to say something about himself. Behavioral interviews operate under the theory that past performance is often the best indicator of how you’ll perform in the future.

Being well prepared is a must in any type of medical school interview. Learn and study the usual interview questions, give good answers, and practice the way you'll answer them. In preparing, you must know your strengths and weaknesses and prepare to address them. Get ready to be asked with ethical and moral questions. You should also try your best to make a good first impression. Furthermore, get ready to answer questions as to why you want a career in the medical field.

It's also essential to know the mistakes they’re usually committed so as not to make these mistakes such as answering questions too fast and not staying on topic. You should also stay positive and professional at all times. Always remember to relax and don't give out robotic answers. It's likewise important to listen very carefully to the interviewer so as to get a hint of what they're interested in. Learn about the specific programs and medical specialties the university offers and while you're on campus, talk to medical students and ask them about the program.

Radu Anthony is a blogger who writes about education, travel, health, finance and technology.

How The National Residency Matching Program ("The Match") Works

noreply@blogger.com (Unknown) — Mon, 03 Aug 2015 13:00:00 +0000

Every spring, graduating medical students in the United States stress out in the middle of March over the results of the the National Residency Matching Program (NRMP), generally celebrated by medical school as "Match Day." No other profession operates like this. Lawyers after law school, PhDs after graduate school, MBAs after business school - all enter a competitive job market. Medicine instead has a nationalized system that ostensibly relies on de jure collusion between residency programs to assure a reasonable allocation of residents to programs on a predictable schedule. How did this come to be?

The History of The Match

In the United States prior to 1952, medical students found residency positions much like their colleagues in other fields, through a decentralized, competitive market. However, as residency programs wanted the best residents, they often competed to offer spots earlier and earlier to the brightest candidates, causing undue stress. As Sara Robinson writes:

Medical internships were introduced around the turn of the last century as an optional form of postgraduate education. Because interns were a source of cheap labor for hospitals, Roth explains, slots soon outnumbered applicants and competition for interns was fierce. Salaries and working conditions of the internships were specified ahead of time, even then, and there was no negotiation in the process. Thus, the competition manifested itself in timing rather than price: Hospitals began to insist that their offers be finalized before those of their competitors. The average date for finalizing an internship gradually crept from the end to the beginning of the senior year. By the mid-1940s, internships were being finalized at the beginning of the junior year of medical school, and some inquiries came even during the sophomore year.

Recognizing that the situation was out of hand, the Association of American Medical Colleges adopted a resolution prohibiting medical schools from disseminating student transcripts or reference letters before a certain date during the senior year. This fixed the advancing-date problem but created a new one: Students tended to hold onto offers as long as possible, hoping for offers from better schools. The hospitals were unhappy with this situation; if a student rejected an offer at the last moment, the hospital might have trouble filling the slot with a desirable applicant. So the hospitals, still battling fiercely for residents, passed a series of resolutions shortening the time a student could sit on an offer. At one point, hospitals had telegrams offering residency positions delivered at precisely 12:01 A.M. on the earliest allowed day; the students were forced to accept or reject these offers within hours.

In response to this clearly unsustainable situation, all parties decided, in the early 1950s, that it was time for drastic changes in the procedure. The centralized system created as a result had students and hospitals communicating with each other as before, but it replaced the rounds of offers by ranking lists, submitted by both sides to a central authority. Following a standard procedure, the central authority then matched students with residency programs. Such was the inception of the residency-matching algorithm, although it took some fiddling (trial and error) to get a procedure that worked.

The situation improved, although economists and game theorists argued that the situation favored the hospitals.

The NRMP Algorithm

In general, the problem of matching residents to programs is one of two-sided matching, or more amusingly called the "Stable Marriage Problem." The basic problem is stated as:

Imagine a set of n boys and n girls. Each boy B ranks each girl G, and vice versa. The first boy goes to his preferred girl and proposes. If he is on the top of her list, she says 'Maybe' (for now); otherwise, she says 'No.' If she says no, he goes on to his next choice, until he finally gets to a 'maybe.' Then, the next boy repeats the same process with the remaining girls, which goes on until all the boys have paired off with all the girls.

The original research showed that while this produces a stable set of pairs such that no improvements can be made by any couple re-pairing (ie, no cheating), it was also shown that this process favors the boys (the ones asking) over the girls. Another implication was that the girls could game the system by lying about their true preferences. Economist Alvin Roth and others showed that the original NRMP algorithm was equivalent to the stable marriage problem and that it favored the hospitals. In the 1990s, Roth was recruited by the NRMP to revise its algorithm as well as make it more equitable for couples entering the match.

Despite these changes, several medical students filed an anti-trust lawsuit against the NRMP in 2002, accusing it of abetting medical schools in colluding to keep wages low. The suit was unsuccessful, but the lobbying efforts of the NRMP fared better: President Bush signed a pension law that had an attached rider specifically granting immunity to the NRMP from such claims in 2004.

Navigating the Match

In an ideal world, simply putting down your true preferences and having the residency programs do the same would lead to optimal outcomes. In reality, the process entails much subjectivity as programs want not only qualified applicants but also want to claim they did not have to go very far down their list to fill their spots. This is more an issue of vanity than practicality, but it impacts how programs structure their rank lists. Awareness of this social reality behooves the applicant to clearly state their desires for programs they are interested in during the interview process, despite not having fully considered all their options. It also necessitates clear communication with programs of interest after the formal interviews in order to ascertain if the feeling is mutual. While the degree of communication between applicants and programs is restricted per the NRMP guidelines, if any programs or applicants deviate, it is in the best interests of each applicant to also deviate (to understand this better, check out the prisoner's dilemma). Ultimately, the applicant should take whatever steps necessary to clarify his preferences with programs of interest.

If you are interested in learning more about how to navigate the match, check out:

References:

Robinson, Sara. "Are Medical Students Meeting Their (Best Possible) Match?" SIAM News, Volume 36, Number 3, April 2003
Antitrust Lawsuit Over Medical Residency System Is Dismissed - New York Times
National Resident Matching Program - Wikipedia

Being Mortal by Atul Gawande - A Scrub Notes Review

noreply@blogger.com (Unknown) — Mon, 08 Jun 2015 13:00:00 +0000

As long time readers of this blog (hi MJB!) likely know, Atul Gawande is quite popular around here. The general / endocrine surgeon at Brigham and Women's Hospital is also a well known contributor to The New Yorker and author of four books. His latest book is Being Mortal: Medicine and What Matters in the End.

Like his other books, this work is a mix of his previous pieces for the New Yorker as well as original writing. Gawande tackles an issue oft overlooked in his prior works and within medicine at large: what to do when medicine has no more to offer. The book unfolds by describing what occurs when medicine (and healthcare in general, including non-physician providers / caregivers) try to go beyond their limitations and fit patients to their models of care, instead of trying to shape care around patients. Anecdote by anecdote, Gawande describes patients, friends, and family members and their struggles with the healthcare-industrial complex. The overall tapestry is one of failure: the system did not work for these patients.

And how could it? The healthcare system is a Frankenstein collection of parts that has been optimized to fix simple, close-ended problems. The ear infection, the ruptured appendix, even the small breast cancer - all of these are easily tackled by the healthcare system. Where we stumble is when we attempt to shoehorn patients with complex or chronic problems into this model of one-and-done care. It simply does not work, and can often do as much harm as good.

In Being Mortal, Gawande attempts to show how in certain corners of the country, patients and providers are pushing back. From Oregon to Boston, initiatives have developed that attempt to create better environments for patients to live and to heal, without sacrificing overall outcomes. Surprisingly, in some cases, patients do better with less than with more care.

If one is to quibble with this book, it is that Gawande neglects to provide enough concrete, actionable advice about what to do regarding the issues he raises. For a general audience, he does not spend sufficient time discussing concepts like durable power of attorney, living wills, DNR/DNI orders, or even how to learn more about it. Gawande spends a chapter detailing his own trip down one flight of stairs to the geriatric center beneath his clinic and what he learned, but most of his readers are unlikely to have such easy access to a place like that. Admittedly, that is not the point of the book as it is not meant to be a self-help book about chronic health, geriatric, or end of life issues. Still, for a book that hopes to effect change, an appendix pointing out where one can learn more would have been nice.

Overall, the book is a worthwhile read for anyone who is elderly, is responsible for an elderly person, or cares for an elderly person. In other words, everyone should read this book. It is not a light-hearted read, but it is something better: an important read. While the ultimate outcome cannot be avoided, we can control how we prepare ourselves and each other for it, and in the process, live better, more fulfilling lives.

Other Books By Atul Gawande:

Previous Scrub Notes Reviews:

The Medical Student's Daily Bag

noreply@blogger.com (Unknown) — Mon, 01 Jun 2015 13:00:00 +0000

Much like students of any stripe, medical students often have many items they need to have on their person during their daily sojurns to lecture halls and wards. While this may be a bit dated, my go to bag in medical school was an earlier version of the Targus Checkpoint-Friendly Mobile Elite Laptop Bag. The other items I typically would have in my bag were:

Littmann Cardiology III Stethoscope - a nice gift from a good friend, and quite useful on wards
Penlight
Mobile device - at the time, a Palm Pilot, but these days I would highly recommend an iPad Air 2 due to the wide range of medical apps, light weight, and long battery life.
First Aid for the USMLE Step 1 - until I passed at least, haha
Nalgene water bottle
Clif Energy Bar - my current fav, but any snack works
Pens - always get clickable, black ink pens. And always have an extra one because they will get stolen. Trust me.
Highlighters
Pocket Medicine - probably should have carried this more during medical school, but was definitely a must-have during internship, so why not start early?
Pager - [grumbles]

Aww, I'm getting a little nostalgic thinking about my old bag. Anything you think should be in there that I missed? Please let me know in the comments below!