Home for the Holidays

Being in the hospital days before Christmas it was clear that patients really didn't want to be there. It's not their bed, their decorations or their roommate. They likely don't feel well and simply would rather be ill on their own terms in the comfort of their own home.

Deck the Halls

It was sad to see so many who were aching to be discharged from our care to be sent home for the holidays. They understood their illness was severe enough to warrant continued medical care, but like Dorothy said, "there's no place like home." For what it was worth, the halls were decorated with sparkling ornaments, holiday wreaths were hung near each door, and festive music echoed for those close enough to hear. The hospital staff were directly influenced by the trimmings and hopefully some of their holiday spirit spilled over into the patient rooms.

It made me reflect on the importance of relationships among friends and families. Being surrounded by strangers that have only known us for a few hours or days is in no way as fulfilling as family members and good friends. Cherish good health and loved ones because it is too easy to take them for granted. Despite being hospitalized, I hope those patients felt the holiday spirit even if it was briefly shared by a nurse, house keeper, medical student or other provider. May you and yours have a festive holiday season.

Question of the Week

A 26-year-old HIV-positive woman is brought into the emergency room after she is found lying unresponsive in the street. She has no recollection of what had occurred. She reports sensing a smell "like burning hair" and then blacking out. A medical history reveals that she has had a fever and a headache for the past week. An MRI of the brain shows multiple ring-enhancing lesions. Which of the following is the most likely cause of her symptoms?

A. Cryptococcus neoformans
B. Cryptosporidium
C. Cytomegalovirus
D. Pneumocystis carinii
E. Toxoplasma gondii

Answer & Explanation

Holiday Festivities

(Click image to view Doctor Fizzy's medical cartoons)

Just in time for the holidays is the spread only a physician could love. Textbook descriptions of anatomical abnormalities may not be a popular thing to talk about, but somehow they always seem to make it to the dinner table. For an explanation of these rare delicacies consult your local medical student or physician.

Holiday Cheer

Medical students usually dream of this special time when they get extra time to sleep in, experience a comatose state in front of the television, or just simply not think much at all. That is of course if you are in your first two years of medical school. The clinical years are not as relaxing; resembling something closer to a paid profession. We work all the way up to the holidays and sometimes on those special days just chugging along trying to keep pace. It continues to be rewarding, but does it really help in the long run to have one extra day of clinic...really? The break would probably be better for us mentally than stressing about a few hours of scutwork.

The cartoon depicts the feast well and I could imagine a dessert platter offering the following: cafe-au-lait spots, peau d'orange, cherry hemangiomas, or berry aneurysms. As long as you don't have any of these questionable entities yourself, your holidays are already off to a good start. So whatever your plans this holiday season, elaborate or simple, I hope you take some time to enjoy the finer things in your life - even if you have to work on a supposed day off. I hope you all enjoy the beauty of the season and stay in good health. Bon appetit!

Question of the Week

A patient is admitted to the hospital with shortness of breath and found to have a pleural effusion on chest X-ray. Thoracentesis is performed and the fluid is sent for laboratory testing. Results of the fluid analysis are: pleural protein 8.0, serum protein 6.5, pleural LDH 500, serum LDH 100. Based on these findings, which of the following is the most likely etiology of the pleural effusion?

A. Bacterial
B. Congestive heart failure (CHF)
C. Cirrhosis
D. Nephrotic syndrome
E. Pulmonary embolism

Answer & Explanation

The Choice is Mine to Make

I couldn't help but notice the mirror overhead displaying the converging intersection with an obvious "Check Out" sign. The exit always seems to be the easiest choice, because the others lead to more work, challenges and upward climb.

Uphill Both Ways

No, I'm not "checking out" of medical school, but I cannot deny the difficulty of making progress...all the time. The ascent to the finish line is steep and unrelenting. Just when you think there might be a nice little plateau ahead to cure the fatigue, you reach the bend and see the next peak in the distance. Emotionally it becomes hard to keep pace and trudge along.

This month's Internal Medicine rotation has been interesting but demanding: early morning paperwork and patient interviews to prepare for rounds, in-house nights on call, and weekend shifts. I'm still trying to squeeze in enough time to study every day and maintain some essence of normalcy. The long and early hours keep me exhausted and always looking for an opportunity to recharge before facing the next big hurdle. Driving to the hospital in the dark, rounding while the sun is out, and driving home in the dark somehow makes the days seem longer than they really are. Somewhere between sunset and sunrise, I find the needed rest to start all over the next day. Fortunately, my back continues to face the exit and my feet lead me forward despite the challenges ahead.

Question of the Week

A 58 year old man with a past medical history of hypertension presents with a cough. The medical team suspects that the cough is due to one of his anti-hypertensive medications. Which of the following is a characteristic of the best alternative drug for this patient?

A. Interference with binding of Angiotensin I
B. Interference with binding of Angiotensin II
C. Reduction of serum Angiotensin II levels
D. Decreased production of a key enzyme produced in the lungs
E. None of the above

Answer & Explanation

Regularly Irregular

Looking back, jobs with some regularity are quite nice. In a short matter of time your body gets used to the internal and nightstand clocks. The schedule can be set and forgotten as there is little variation. Medical school is not regular in terms of scheduling, not at all.

Getting Shut-Eye

Being a medical student seems to be one occupation that has regularly irregular sleeping habits. Whether there is an exam coming or a night on call at the hospital, it seems that the sleep schedule is the first thing to go. Sacrificing sleep to get an extra hour or more of study is the norm. It's no wonder caffeine is such a hot commodity among students. Now on clinical rotations I find myself sacrificing sleep so I can see patients at the hospital before rounding with the doctors. As it turns out, this is usually for my practice and there is little effect on the patient's care from my efforts. That is a nice thought to accompany the five o'clock wake up call.

Soon enough I will be sleeping at the hospital to fulfill "call" assignments. Of course it is all in the name of medicine. Certainly the culmination of stress, lack of sleep and lack of exercise is costing me to lose years from my life expectancy. How is it that a career so focused on health can be so detrimental to my own? Oddball hours here I come. I'm just crossing my fingers that when my head hits the pillow at night I can put all my thoughts behind me and actually sleep soundly until the beeper or alarm sounds the reveille.


Question of the Week

Among physiological changes in the elderly, alterations in sleep patterns are common. Which of the following best describes changes in the sleep cycle that accompany aging in the elderly?

A. Decreased REM sleep and decreased slow wave sleep
B. Decreased REM sleep and increased slow wave sleep
C. Increased REM sleep and decreased slow wave sleep
D. Increased REM sleep and increased slow wave sleep
E. Increased REM sleep and no change in slow wave sleep

Answer & Explanation

Suturing Skills

As medical students we are in the business of learning. Some things are well learned on the job, others are better honed on our own and then practiced under close supervision before getting too far ahead of our skill level. 

Tying It All Together

The baby was out, the placenta delivered, and now we had to repair the laceration. When my attending handed me the loaded needle driver, I was a little hesitant as I have not yet sutured living flesh. Without a problem, I was able to approximate the wound from one side of the tear the other. Having only practiced a couple suture ties on pigs feet, I was in unfamiliar territory and I had to let my preceptor know. Sadly he finished the job I started, despite my desire to learn.

This meant I would certainly be learning more on suturing techniques that night so I could be a little more prepared should another opportunity arise. I was happily surprised at the few things I did find and would like to share them here for those who may be a beginner at the art of suturing.

• Suture Basics - Website compiled by Boston University School of Medicine
• Suture Handling Videos - Website produced by University of Pennsylvania
• Knot Tying Kit - FREE Practice kit from Ethicon (Enter your information and they will ship it to you at no cost)
• Surgical Knots and Suturing Techniques - Book written by F.D. Giddings

With another surgery coming up tomorrow, we'll see if I get a chance to wield the needle and string. If it doesn't happen, my dental floss and fruit peels will have to hold me over until my surgical rotations come around. 

Question of the Week

A 24-year-old man is involved in a motorcycle accident and loses several liters of blood. In addition to resuscitation with normal saline, physicians decide to transfuse blood products. If the patient has blood type B, Rh-negative, which of the following blood products may be most safely administered?

A. Type A, Rh-negative red blood cells
B. Type AB, Rh-negative red blood cells
C. Type B, Rh-positive whole blood
D. Type O, Rh-negative red blood cells
E. Type O, Rh-negative whole blood

Answer & Explanation

Medical Professional Attire

First impressions can only be made once. Looking professional is important for any health care provider. As students, we are not only wanting to make a good impression on the patients we see, but we have to let our attendings know that we understand playing the part also means dressing the part. 


Comfortably Dressed

For most rotations we are dressed in modest business attire adorned with the white coat, but there are some rotations where we get to dress a little more comfortably. These times are usually reserved for Surgical, OB/GYN, and Emergency rotations where procedures are common. Most hospitals will even supply cotton scrub uniforms when sterile procedures are expected. Fortunately, even when they are not readily provided, there is an expanding market offering cheap medical scrubs both online and in local stores.

Whether you are looking for medical style attire at an affordable price or simply want some cheap scrub sets to double as pajamas you don't have to look far to find them. They are easy to clean, less restricting than business garb, and you still look professional when wearing your white coat. When I first observed physicians wearing their scrubs around the hospital, I thought it was funny that the tops were always tucked into their pants. Since then I've learned that this is a distinguishing factor among physicians. As funny as it may look, it sets them apart from the rest of the crowd and reintroduces a sense of professionalism through the threads they wear. To avoid looking like a scrub, tuck your scrubs.

Question of the Week

A 6 year old girl is being evaluated for short stature. She is at the 12th percentile for height and the 34th percentile for weight. Vital signs are within normal limits. And physical exam shows widely spaced nipples and a high arched palate. Karyotyping shows 45XO. Which is she most at risk of developing?

A. Bipolar disorder
B. Breast cancer
C. Mental retardation
D. Mitral valve prolapse
E. Osteoporosis

Answer & Explanation

Leaving the Womb

There's nothing like getting an awesome two-for-one deal. In obstetrics they seem to come with every patient visit and with few strings attached - since the majority are using umbilical cords. (My apologies for the bad humor)



Development

Having only been on the OB/GYN service for a couple of weeks now, I am fascinated by the techniques and technology used to evaluate a patient that is barely tangible...the baby. With proper prenatal care, the physician can prepare for the baby's birth well in advance, hopefully avoiding unnecessary surprises on the day of delivery.With each birth, I try to learn something new to be better prepared for the next and acknowledge there is likely no such thing as a routine delivery. Assuming the preparatory work was adequate, the delivery should just be the next step in the process.

As a student I occasionally have a hard time absorbing the hands-on knowledge as I am often listening to my attending's teachings or worse, trying to come up with answers to his questions. After our last delivery, just when I thought I was in the clear and free to synthesize the information I had just experienced, he found more fodder for questioning. "What's this?" he asked as he held up one of the used instruments. Unfamiliar with the tools, I gave each my best guess as he continued to ask the name of everything laying on the sterile field. In a way I feel like I am in the womb of medical school being tested and prodded to make certain there is positive development. With any luck, my "delivery" into the medical profession will be uncomplicated and a day of celebration.

Question of the Week

In discussing Friedman's curve (a plot of obstetric evaluation of cervical progression over time), I was surprised to get a lesson in algebra. After defining the purpose of this graph I was promptly asked, "What is the equation of a line incorporating it's slope?" I was shocked by what my preceptor was asking, and both of us were surprised I remembered it so quickly. How well can you recall it?

Answer & Explanation

A Return to Physical Medicine

My psychiatry rotation was a month of patient or family interviews that provided very little physical examination. The dialogue was our exam. I may have used my stethoscope one time during the entire month and realized at the end how much I really miss medicine.

Mental vs. Physical Medicine

To me, medicine incorporates both the mental problem solving that finds physiological pathology and having physical contact with a patient. This is commonly done as we build our differential diagnosis while performing a physical exam. I feel like a medicinal detective being able to read the various clues from the body to solve an intricate puzzle. Interpreting how a sound, feeling or observation plays into a patient's health is intriguing as well as rewarding.

This month may be a little different. I have started my obstetrics and gynecology rotation. Assuming the patients are comfortable with my participation, I will certainly learn more this month than if I were to wait outside the exam room. Their permission aside, as a male it is difficult to empathize with them, since they experience symptoms that I will never know. Nonetheless, it is a unique specialty including surgery and clinical medicine. It promises to be a fast paced month with plenty of procedures and opportunities to learn. And I can once again use my stethoscope and all the other tools in my pocket.

Of note, both Life as a Medical Student and The Differential (another blog with my contributions) have been featured in this article, "Top 50 Health and Medical Blogs by Graduate Students." Although I don't think there is any meaning to the numbers assigned, it is nice to find blog included among the bunch.


Question of the Week

A 40 year old Caucasian male with a chronic history of paranoid schizophrenia presents to the mental health clinic. He tells you that his wife stole his bottle of risperidone, which he believes caused him to experience more frequent and intense auditory hallucinations. He says the voices tell him to kill his wife because she cannot be trusted. He admits to having homicidal thoughts about his wife but denies any specific plan for harming her. He requests a refill of his risperidone. What is the most appropriate next step?

A. Admit the patient to the psychiatric ward
B. Call the patient’s wife before filling the risperidone prescription
C. Increase his dose of risperidone
D. Refill his prescription of risperidone and call his wife after he leaves
E. Refill his prescription without calling his wife as he does not have a plan to harm her

Answer & Explanation

Locum Tenens

Locum is short for locum tenens and is suggestive of a person who temporarily fulfills the duties of another. The fact that doctors, among other professions, can participate in services like this makes finding the best work environment a little easier.

A Doctor's Temp Agency

As a student I wonder what environment I'll be in and what happens if it is not the right fit 6 months after starting there. Locum doctors have an advantage in that they fill in for vacationing physicians or where there is a medical need for a temporary period of time. They can test the waters and if it is a good fit may actually be offered an extended position. The difficult part is organizing the malpractice insurance, credentials, contracts and travel arrangements. Fortunately, there are locum agencies already in place to help facilitate the process for the already busy physician.

These services provide communities and hospitals with the medical help they need while providing unique opportunities for physicians to explore different areas of the country. Locum jobs can be found in almost every state and almost any specialty. Due to the stressful nature of being transient, these positions often pay more than a permanent position would. Conversely, it can be difficult to establish a "welcome" feeling among patients and staff as locums are always on the move. In any case, the idea of being a "substitute doctor" could provide a rather interesting opportunity and is something definitely worth checking out.

Question of the Week

When getting pimped by the doctor, there's always a good feeling after giving the right answer. It's even better when you hit a home run. Apparently, no student had answered this question correctly on my doctor's service...until now. At least it made up for a few of the wrong answers I gave throughout the month.

Considering the Tricyclic antidepressants or TCAs, which are tertiary amines and which are secondary amines?

Answer & Explanation (Page 2; Heading 3)

Drawing Your Brains Out

All the psychiatric patients this month have been asked to draw a house, tree and person. Until recently I thought this was simple art therapy, but as it turns out, this is a well established test designed in 1947.

HTP Test

What was once an elementary school drawing exercise has now become a psychiatric tool for evaluating patient generalizations of the world around them and how they participate in it. The test has been detailed in a 350 page book and is estimated to take 150 minutes from start to finish. Evaluators are encouraged to ask questions about the details to really understand how the individual interprets their world.

The house tells us about associations at home including intrafamilial relationships and their attitude towards their home life. The tree and person reveal personality through body image and self-concept. Images are evaluated for line strokes, erasing, detail, proportion, and view point among other things. Everything from the roof, door, windows and smoke are interpreted. The branches, trunk, colors and person size have equal importance. Although intriguing, there is more to read than I could possibly explain here. For those who might be interested, check out the Kinetic House-Tree-Person Interpretation Manual.

I only wish I had tried my hand at drawing these before getting a run down of the evaluating criteria. It would have provided a more genuine representation of my psyche.

Question of the Week

A 47 year old woman presents with complaints of malaise and burning upon urination. She has a temperature of 39.6. Urinalysis is positive for nitrites and leukocyte esterase. A feature of the agent most likely responsible for this patient’s condition is:

A. A cell that is purple upon completion of the gram staining technique
B. A cell that is colorless after addition of ethanol during the gram stain procedure
C. An entity unable to live outside of a cell
D. A microorganism whose wall contains teichoic acid
E. A microorganism that requires an aerobic environment

Answer & Explanation

Professional Membership

One of the joys of coming home from the clinic each night used to be getting the mail. The fun has worn off as much of what fills the box are bills, political advertisements, or those pesky coupon mailers. Recently, however, I have been getting a little more than expected.

Joining the Club

A couple months ago, I signed up for a professional physician organization. My intent was to become a member so I could participate in their conference. I had no idea that I would also be enlisted to receive books, peer reviewed journals, newsletters, and more conference announcements. Since I do have some affinity to Emergency Medicine, this was a perfect organization to join. As a student it was relatively inexpensive and the resources have easily paid for themselves. My problem now is that I have little time to dedicate to their perusal despite the appeal.

From what I gather, the residency programs appreciate knowing that applying medical students are genuinely interested in their particular field. One method of gauging this interest is by learning which professional organizations we have joined. It shows a sense of dedication and desire to know more; things which residency programs tend to seek in applicants.

While my trips to the mailbox still gives me plenty to recycle, at least I now have some decent mail worth keeping. To any student who may be reading this, I would strongly encourage joining a professional organization in your field of interest. In addition to filling your mailbox with more literature than you can handle, it may actually serve you well come interview season.

Question of the Week

A 57-year-old obese man with a history of smoking, hyperlipidemia, and hypertension presents with pain in his legs while walking. On further questioning, he reveals that the pain starts in his buttocks and extends down his thighs and into his calves. Previously, the pain disappeared with the cessation of activity, but lately it persisted in his feet even at rest. His symptoms can best be explained by which of the following?

A. Decreased permeability of endothelium
B. Narrowing and calcification of vessels
C. Peripheral emboli formation
D. Thrombus formation
E. Weakening of vessel wall

Answer & Explanation

Reading - The Mental Exercise

Somehow I was lucky enough to have all the physicians that want me in the clinic 5-6 days each week and enjoy giving assignments during the time off. It's not a bad thing for learning all the material, but it has become rather draining. At least it makes time go by quickly.

Are we there yet?

There is only so much that can be learned at the bedside of a patient and in one month there is no way we are going to see everything related to a particular specialty. Hence the nightly reviews that occupy our time and remaining energy. The texts are usually inches thick and chock full of medical tid-bits. Rather than purchase a book I may never read again I access the electronic version from our online library . Now in addition to physical inactivity from hours of sitting, I am taxing my vision by staring at the glowing screen of my laptop. Yet another reason medical school has deleterious effects upon one's health.

Nonetheless, it is nice to review the materials learned in my first two years of school. Combining the black and white type with a patient who has this or that disorder turns concept into concrete explanations. For example, all the pharmacology I learned last year that slowly leaks from my mind is now coming back stronger than before. Prescribing medicine and witnessing symptom resolution as a result finally highlights some of the pesky unrelated facts associated with pharmacology. Better yet we are building a mental library of cases that will serve as examples in patient care.

Even though I may come home exhausted, at the days end, there is always more to be learned. One thing is for sure...this year, finally seeing patients, is much better than last years never ending lectures.

Question of the Week

A 22-year-old man is admitted to inpatient psychiatry after an attempt to strangle a stranger on the street in order to "squeeze the demons out" at the command of a voice in his head. He was put on a standing dose of haloperidol. Which of the following long-term adverse effects can be attributed to haloperidol?

A. tardive dyskinesia
B. Excess salivation
C. orthostatic hypotension
D. Nausea
E. Pruritus

Answer & Explanation

Rotating Rotations

The inter-rotational weekend has finally arrived. That point where exhaustion and anxiety collide to signal the change of clinics could not have come at a better time. The weather is great and I was in need of a quick breather.


Making Room for Change

Leaving one rotation and moving to the next always has a sense of tension about it. Meeting the new attending, observing clinical procedures and working with a new patient population inherently brings an unsettled feeling of the unknown. Yet as medical students, we move forward and give it our best shot. I have no idea what to expect on my psychology rotation. Maybe that's why my anxiety levels are elevated. It certainly seems fitting that this rotation elicits such an emotional reaction.

The best part about experiencing various specialties is the opportunity to really understand those patients and the doctors that provide for them. We see first hand how physical or mental illness affect the individual and learn a proper response to that condition. The attendings we work with have a significant impact on our perception of their field. Despite continued encouragement that their specialty is the best, we still have to gain enough exposure to gain an appreciation for a particular line of work. Although I am not quite sold on psychology, I will approach it with an open mind and see where I end up four weeks from now.

Question of the Week

A 6-year-old child is brought by ambulance to the emergency room following an automobile accident. She is covered with blood and unconscious secondary to hemorrhagic shock. Her parents urge the physician to do everything possible, but implore that no blood products be used to treat their daughter. What is the best course of action for the physician to take?

A. Administer blood without delay and contact child protective services
B. Convene an urgent meeting of the hospital ethics board
C. Engage the parents in a discussion of why they hold these beliefs
D. Transfuse blood as needed, explaining the situation to the parents
E. Treat the patient without using blood products, per the request of her parents

Answer & Explanation

Resident Fair

Perpetual planning is starting to get on my nerves. If it's not a test, quiz or assignment, it's setting up a rotation or more importantly the rest of my career.



Schmoozing

Normally you would think the opportunity to rub shoulders with resident program directors was a great thing. And it certainly can be in the long run, or at least when applying for programs. When I did it, my stress levels went through the roof. Putting on a best-in-show performance and asking smart questions was on everyone's mind and whether I obtained the information I needed is yet to be determined. Overall, the directors, residents and assistants made for very pleasant conversation. The type A personality in me, however, wonders how I measure up.

At least the forum lectures were exactly what I was hoping to learn; how to approach interviews, medical schools and stay strong during those crucial experiences. Despite the simplicity suggested, the emotional, financial, and time commitments are intense. Perhaps I am just exhausted from hours of study preparing for my upcoming shelf exam. Perhaps I am feeling exactly how all students would in this position. In any case, this year of planning is going to be more taxing than I initially imagined.

Question of the Week

In what state should I consider doing my residency and why? If you have the answer, I will gladly entertain your suggestions and reasoning. Otherwise, it may be some time before this question finds a solution.

Progress

Having attained a certain level of knowledge as a student, I wonder if it is adequate when the rubber hits the road. Exposure to the community and patients gives plenty of opportunity to find out what I really know.

Doctōris

It's easy to forget just how far we've come. A little over two years ago I was starting medical school and now I am being trusted enough with private medical information that leads to the decision making process in patient care. I often feel that my knowledge base is not strong enough or lacks in certain departments, and the truth is that it really does. But when interacting with the general public I realize the wealth of information that I have accumulated in such a short span of time.

It can be expected that friends, family and others will inquire about their health at any given opportunity. Just recently, during a community blood pressure screening, I fielded many medical questions. The information that I take for granted in my education is easily foreign to those not in the medical profession. From medications to physiologic processes, there is so much to know. I remember just a few years ago thinking how fascinating it was that someone could see your symptoms and differentiate between virus and bacterial origin. At the time, it was a mystery to me. Now it seems that the "secrets" are being revealed and it's my turn to share that information. This task, although daunting, is what being a doctor is all about. According to the translation of the Latin word doctōris, a doctor is a teacher. Curious to say the least.

Question of the Week

After weeks of observation, seeing patients on my own and asking my own questions my attending physician decided to "pimp" me out of the blue. Unprepared and with my head wrapped around the circumcision just performed, I failed to provide the correct answer. Introduced with discussion about the effects of injecting Lidocaine into a neonates vein, he instructed me about the risk of inducing methemoglobinemia. In his calm demeanor the question came as a surprise, "What is the treatment for methemoglobinemia?" The answer was in my head somewhere, just not where I thought I left it.

Rehabilitation

With great power comes great responsibility. Physicians are among some of the highest educated individuals and yet they are at an increased risk for drug abuse and addiction. Despite their "power", there is a responsibility to lead the way in safe practices.


Medicinal Pitfall

Employment in an environment where medicines are routinely used and available can have deleterious effects on clinicians and other health care providers. Studies have been performed to learn what fields of medicine are at greatest danger of drug abuse and the results usually show increased potential in those that distribute medications frequently. In school we are taught about the signs of addiction, where to seek help if needed, and tactics to overcome the problem. Despite this training, many physicians become addicted as a result of stubbornness, pharmacologic education, and ease of access. Check out some of these addiction facts that may shed a different light on drug abuse.

During a rotation I was surprised to work with a physician who openly discussed his past history with pain killers. He told me that the rehabilitation program he finished was one of the best things to have ever happened to him. For a long time he was in denial that there was even a problem until it interfered with his job and the patients he treated. Some addictions may seem minimal, but the psychologic drive to obtain more is very powerful. Chemical impulses can make even the most mundane stimulus phenomenal.

Addiction can happen to anybody. Fortunately, there are resources available for those who want to find freedom from chemical dependence. Whether it is a private facility, land-based hospital program or an online resource like this Vicodin rehab guide, help is available. As for physicians, most are able to keep their licenses and continue the career they have established once rehabilitation is achieved. Sadly though, it continues to be a problem. We may never know the problems others are facing, but if they come to us for help, wouldn't it be nice to have the right tools?

Question of the Week

A 35-year-old woman is found unconscious in her apartment next to an empty bottle of pills. She is brought to the Emergency Department and given flumazenil, and shortly thereafter regains consciousness. Which of the following drugs did she likely ingest?

A. Diazepam
B. Eszopiclone
C. Hydromorphone
D. Oxycodone
E. Zolpidem

Answer & Explanation

Pediatrics

There is something about the contrasting palm trees against the Las Vegas sky that makes this building look so inviting. It might be compensating for the fact that if you are a youngster, you have a good chance of getting shots here.

Youthful Medicine

The waiting room's row of low-rise chairs and toys keep the children engaged before their visit. Patient rooms are decorated with animals and cartoonistic art. This clinic is using whatever it takes to keep the young patients happy long enough to be examined from toe to head.

The change from a patient population that is older in years to one that commonly has only days or months has been a drastic one. I have to explore new methods of examination to keep the children from crying incessantly before I even touch them. Fortunately, my preceptor is a veteran in the field and has taught me some of the finer points of the pediatric approach. Although I must say that any child being circumcised is bound to have some aggression towards their doctor.

For the most part these little patients are generally happier and less demanding than the adult population. Their looks of intrigue mixed with fear are something to appreciate and more often than not, they are bewildered by the technology of bright lights and shiny objects. If they can brave the barrage of the doctor's exams, nurse's shots, and foreign environment the reward of a sticker is usually enough to encourage a return visit.

This will certainly be an interesting month. Since the pediatric population will be encountered in the majority of medical fields, it is imperative to hone my clinical skills now. I just hope we don't run out of stickers any time soon. 

Question of the Week

You went to visit your friend from college who recently had a baby. She named him Johnny. As the mother was gently letting you hold Johnny, he appeared really anxious and started crying once you reached to hold him. Johnny's age is most likely to be:

A. 2 months
B. 3 months
C. 5 months
D. 7 months
E. 4 years

Answer & Explanation

Practice of Medicine

My two month stint of Family Medicine has come to an end. Observing both the corporate and private practice side of things has offered a new perspective into this particular specialty and medicine in general.

Family Medicine

Family Medicine encompasses a little bit of everything. As a result, this leaves me a little uncertain how to best prepare for my upcoming shelf exam. There are the usual chronic diseases with a some acute illnesses, occasional small surgical procedures and the rare emergency. The clinical preferences of doctors are not always the preferred methods of diagnosis and treatment, and yet we are expected to know both. At least in the classroom setting, we knew what we were going to see on the exam. The clinical shelf exams, on the other hand, seem a bit more ambiguous.

It is easy to see a patient, ask them to explain their history, and perform a physical exam. The tough part is narrowing the differential diagnosis down to a select few pathologies, choosing the optimal tests to identify the real problem, and providing a treatment that will ultimately help the patient. On paper there is only one right answer, but in the real world the rules tend to have a little more freedom. The "practice of medicine," as students know it, is comprised of physician observation, trial, and error.

Every day I am learning more what it means to be "practicing" medicine. There isn't always a perfect solution and we may not have the answer to every patient inquiry. Nonetheless, we put our best educated guess on the table to be tested like any good experimenter would. We celebrate when we are correct in our assumptions and scratch our heads if wrong. Medicine is always evolving and we are simply trying to keep up. It is OK to "not know." Accepting that as a physician is hard, knowing that as a student relieves a lot of undue stress. After all, we are expected to make mistakes and learn from them.

Question of the Week

A 36 year old patient is brought in complaining of palpitations. Upon physical exam, you notice an irregular rate. He says he feels hot, anxious, and is tremulous. Thyroid studies yield elevated thyroid hormones. TBG is below normal. Examination of the neck is unremarkable. Which of the following is likely to be found in the patient?

A. A 20 year history of alcohol abuse
B. Exposure of the neck to radiation 20 years ago
C. A family history of heart disease
D. A personal history of Parkinson disease
E. None of the above

Answer & Explanation 

Culture Shock

Enfermera, hable por favor! 

The abrupt realization that I was in a clinic with lots of Spanish speaking patients had now become evident. The first few days had me shocked when the providers would yell those words down the hall for a translator who would arrive moments later.

Lessons in Living

Initially, I had no idea what to expect. With so many foreign patients frequenting this long standing walk-in clinic, translation was a normal part of the experience. The patients never seem to mind and usually chuckle at the doctor's attempts to communicate translated or not. His clientele of all backgrounds has come to love the medicine he practices which has been evidenced to me time and time again. When they tell me he has been their doctor since they were born, the doctor reminds them that's not long at all. He has taken care of six generations in some families!

When I'm asked what kind of doctor I want to be (usually referring to specialty), I reply "a good one." I don't think that means I will practice perfect medicine or always be right, but to me it means I will be appreciated for what I can do. The patients determine a doctor's reputation in the community, not the doctor. No matter their socioeconomic standing, they deserve adequate care and if they are satisfied, word will spread. This month in family medicine has been a unique experience in caring for patients medically and even more so in cultural awareness. All I can think is that one day it will by my turn to make a difference, will I rise to the occasion?

Question of the Week

A researcher is investigating the distribution of goblet cells in the respiratory system. She injects dye that will be picked up by goblet cells into an animal model. Where is the dye most likely to be absent?

A. Intrapulmonary bronchi
B. Larynx
C. Nasopharynx
D. Terminal bronchioles
E. Trachea

Answer & Explanation

Controversial Medicine

Microscopic science is hard to keep up with and the debate of ethical standards in relation to stem cells is still out for debate. On which side of the fence do you stand when it comes to organically derived medical procedures?

Stem Cells

I was recently asked to comment on a case between the FDA and two physicians vying for a new stem cell procedure. The orthopedists posit that they are using a procedure that implements host stem cells to repair orthopedic conditions. Their opponent, the FDA, argues that when these cells are returned to the patient's body they are considered a drug and not part of the patient's body. If the cells are to be classified as therapeutic drugs, a different set of guidelines is to be followed and FDA approval must be obtained for patient safety.

The physicians claim that the procedure is safe and has no place in the courts as the cells are simply being returned to their original host, but they are willing to fight the FDA to prove their point. Dr's Centeno and Schultz issued this press release about Regenerative and the FDA. If you knew there was a procedure that was safe and used your body to bring optimal recovery, would you be willing to take part even if it was new medical therapy? The thought of not enduring surgery to get results may actually be very comforting to some. To learn more about how patients can still avoid the need for invasive orthopedic surgery, see Regenexx SD link.

We commonly look to the FDA to recommend and ensure product safety and tend to trust their judgment both as patients and providers. In this particular case, however, their control might be infringing upon the rights patients have concerning their own body parts. Is this patient safety or medicinal dictatorship?


Question of the Week

A physician-scientist is conducting an experiment in which she tries to stimulate growth of cartilage in vitro. She wishes to use a substance to stimulate histogenesis. Which substance would be best suited to her purposes based on its stimulation of cartilage growth in vivo?

A. Cortisone
B. Estrogen
C. Thyroxine
D. Vitamin A
E. Vitamin D

Answer & Explanation

Medicine in Words

Although I never thought I would be saying this, the last two years have gone by so quickly. The new medical students just arrived for orientation and are sitting in the chairs we once occupied. My chronicled experience is but one among many fellow students.

Sharing the Journey

I can honestly say that I would still be confused if it were not for the students who went before me that took a minute in the hall to explain how to best prepare for what was to come. The confusing calendar of classwork, clinical rotations and residency that we describe to our family and friends dozens of times over was as foreign to me as a new language. The internet has made it easy to find answers in a matter of seconds, but the genuine experience can be lost along the way. For that reason I started this blog to share my experience with others who might be looking for an answer to the question, "what is medical school like?" Until recently, I had difficulty finding any such documented experience.

Not long ago, I was invited to be a contributing author on the combined blog, "The Differential." It is certainly an honor to be among students from around the world who share their ups and downs in regards to their medical education. Our blog is hosted by the well known medical resource Medscape, which increases the exposure our posts receive more than we could achieve on our own. After a little research I learned that there is an entire community of medical provider blogs on their site. At any stage in your training and for almost any specialty, there is a blog just for you. When you get a minute, I recommend creating an account and exploring some of the writings for yourself. Should you have any suggestions, I would love to hear them.

Question of the Week

A 6 year old girl is being evaluated for short stature. She is at the 12th percentile for height and the 34th percentile for weight. Vital signs are within normal limits. And physical exam shows widely spaced nipples and a high arched palate. Karyotyping shows 45XO. Which is she most at risk of developing?

A. Bipolar disorder
B. Breast cancer
C. Mental retardation
D. Mitral valve prolapse
E. Osteoporosis

Answer & Explanation

Treatment Options

The urgent care has its fair share of injuries and acute illnesses of which infections are common. It came as no surprise that my precepting physician asked me the best antibiotic treatment for specific infections. Although slow on the start-up, by the end of the month I was right more often than not.

Treatment Modalities

Bacteria have been known to take over our illness for centuries. The fight to halt their progression is still in its relative infancy as companies develop the latest antibiotics to cover certain strains of bacteria. Recently, the war against these microscopic armies has faced some retaliation via mutated strains that have developed resistance. One well known suspect is the staphylococcal organism responsible for Staph infections. Growing resistance has required a new approach to treating these infections. Despite having an arsenal of antibiotics for treating infections already in progress one company, Oasis Advanced Wellness, has a line of products that are intended to augment the immune system and avoid illness in the first place.

I was recently introduced to Oregasil, an oregano oil, that claims to have natural antibacterial properties. Its chemical component carvacrol not only inhibits the growth of certain bacteria, but it is said to taste like pizza! When was the last time you took medication that actually had a good taste? In laboratory studies, this compound was reported to be comparable to the standard antibiotics streptomycin, penicillin and vacnomycin. It is very unlikely that your doctor will prescribe a product like this, but is good to know that such formulations exist for those who prefer the natural approach medicines.

Another interesting product they offer is their Bio D-Mulsion supplement. There is a growing percentage of people who are deficient in Vitamin D. Usually we consume it through our diet, but the largest amount is actually obtained through our skin when we are exposed to the sun. For those who do not get adequate amounts of ultraviolet radiation they are at risk for health complications from Vitamin D deficiency. Thus there truly is a place for supplementing this crucial vitamin when not obtained naturally. Among its benefits, Vitamin D is known for strengthening bones, improving cardiovascular integrity, and boosting immunity. When considering your overall health, start with the basic vitamins and minerals and you'll be on the right track.

Pimped Question of the Week

A patient comes to the clinic with a 6cm, indurated, and raised lesion under the skin of the axilla that is warm, tender and erythematous. They state that they were bitten by a spider while they were sleeping, but did not see it upon waking. What is the most likely organism in the lesion and what is the initial recommended treatment?

Medical Learning

Despite the newness of the clinical setting, the challenge of maintaining a consistent growth pattern can be quite difficult. There are, however, some preceptors who are more than willing to expedite that growth process and make a point in the process. 

Getting Pimped

Whether you consider intense questioning on the spot educational or abusive, the topic is still up for debate. This direct style of discussion between student and preceptor is affectionately referred to as "pimping" although it's origins remain disputed. Students will tell you it stands for "Put In My Place" and medical journals such as JAMA suggest "The Art of Pimping" comes from a historical line that dates back to London's 17th century. If it truly is an art, then my current preceptor is a Rembrandt.

Our conversation is usually started solemnly with the question, "did you read the assignments?" After my reply in the affirmative the barrage begins. Occasionally, the questions come in rapid fire succession and at other times they are followed by informative discourse. In either case there is very little facial expression that reassures me I have done well and gleaned something of significance. I have heard stories of preceptors who voyage outside the realm of medicine to discuss mundane trivia - I feel lucky that we at least remain on topic. But there was a new first for the other providers and me when my preceptor chose to call me on his day off. I was with another physician going over x-rays on a case when my phone rang. Normally I do not answer, but since it was the man giving me a grade in a week, I thought it might be prudent to respond.

After a five minute pimping session on syncope and doing a proper patient work-up, my preceptor proceeded to share a scenario. He described a patient's age, background, history and physical and the stage was set. Until now, I followed and could discuss the principles, but when he dropped the question, I was clueless and I let him know. Alas, that is my homework for our next meeting in addition to a few other assignments. With the call now over and his coworkers shocked that he would pimp me on the phone I did a little research and found the answer to his question. It was not surprising that nobody else in the office was familiar with the answer either. At least it is something I can tuck away in my pocket the next time a preceptor wants to put me in my place.

Pimped Question of the Week

A 20 year old southeastern male comes into the office for evaluation following two syncopal episodes one week apart. Both occurred while the boy was sitting in a chair and were not exertionally induced. The last time he was unconscious for approximately one minute before "coming-to." He denies using medications, tobacco, alcohol or illicit drugs and has no underlying medical conditions or surgeries. Your physical exam is unremarkable. Following suggested guidelines, you order an electrocardiogram which is shown above. What is your diagnosis?

Urgent Care

Only a few weeks into my third year rotations and I am seeing patients on my own. This is not indicative of my level of knowledge, but because it is a lot easier to throw me into the room and then teach me when I come out.


Hit the Ground Running

My Family Medicine rotation is a little different in that it is in various urgent care facilities across the Las Vegas valley. We see every age group, a large assortment of illnesses or injuries, and a fair number of patients in any given day. With my prior work experience in the Emergency Department I am familiar with the routine, but working out the problem medicinally is a new experience all together. I can't think of a better way to learn than to go through the motions, make a few mistakes, and move forward with some correction from the attending physicians. Each case has something unique to offer whether complicated or acute.

The physician hands me a chart and I'm off to see the patient. No doubt my exams are longer and more detailed than other providers, but I make every effort to get all the information I need the first time to avoid numerous visits for forgotten questions. After obtaining a detailed history and performing a focused physical, I discuss with the patient what I think might be ailing them. I have found this useful as it helps me build the case in words and thoughts so that in five minutes I can present the patient to my attending. The art of presenting a patient is a little more difficult than I expected. So many times I fail to include all the pertinent information leaving little holes in my reasoning for a particular diagnosis. After a little discussion with  the physician, and some occasional suggestive guidance, I build my differential diagnosis for testing and treatment plans.

I know that now is the time to be learning these critical clinical skills. Mistakes will happen and they are acceptable at this stage. Without being overbearing, I ask as many questions as I can and observe or perform any procedures possible. After all, I am still a student and this part of my education is meant to integrate the textbook with actual working principles. One thing is for sure, when I make the right diagnostic and treatment decisions, it is as good a feeling as an A on any quiz or test.

Board Prep Question of the Week

A 3-month old female is brought to the pediatric emergency room by her mother, who says the baby, "just doesn't seem right." On exam, you see a tired-appearing baby lying in her mother's arms who cries weakly when you begin to examine her. You note that her mucous membranes are moist, her anterior fontanelle is bulging, and she is tachycardic to 160. She also has a rash in the distribution of her diaper. What is the most important test for you to obtain at this point?

A. Blood culture
B. CBC
C. CSF Analysis
D. Urinalysis
E. Urine culture

Answer & Explanation 

Clinical Rotations

Over the last week I have come to a few realizations; the sun still exists, taking a break can be just the right medicine, and I am most definitely a new third year medical student.

Third Year

Having no idea what to expect, I showed up in the urgent care for my overnight family practice rotation. After meeting my attending physician, we visit with a few patients and then the education begins. Questions from all angles start coming in rapid-fire succession. Without the right answers I resort to shaking my head, making an educated guess, or simply admitting that "I don't know." When all is said and done, I am humbled, corrected and educated on the spot.

Hands down this is more exciting and enjoyable than sitting in a stuffy classroom ad nauseam. Seeing a disease or injury paints a picture that so many pages in a book could not. Treatment protocols and drug regimens make sense revealing associations that were previously difficult to grasp. This is just the beginning and there are plenty of mistakes to be had along with the rewards of a job well done. In this moment of certain insecurity it is difficult to freely explore the medicine I know and stumble along the way. Fortunately, at this point in the game there are safety nets that prevent me from screwing things up too seriously. Now if I could just figure out how to quickly change my sleeping habits and consistently provide the correct answers to my preceptor's questions, I might feel a little better about this upcoming year.

Board Prep Question of the Week

A 64 year old man with a history of hypertension, well controlled on medication, reports feeling increasingly tired over the past year. He reports some weight loss without any changes in diet or exercise. He also mentions that he has been having very thin stools but no frank blood. He takes no medication. Physical exam shows a pale, thin man in no acute distress, with a mildly elevated heart rate. Rectal examination is positive for occult blood. Hematocrit is 24%, but all other laboratory values are within normal limits. Which is the best next step in diagnosis?

A. Abdominal x-ray
B. Colonoscopy
C. Esophagoduodenoscopy
D. Exploratory laparoscopy
E. Sigmoidoscopy

Answer & Explanation

Third Year Begins

With the board examinations behind me and fingers crossed tight for passing scores, I can finally look forward to beginning my third year of medical school. The word on the street is that the clinical years are undoubtedly better than the first two years of basic sciences.


Rest and Relaxation

For the first time since spring break I was really able to kick back and relax. Fortunately it falls on a holiday weekend that offers a little more meaning to my time off. With the stress back to controllable levels and a foreseeable future on the horizon, I am reveling in the lack of planning every moment. Soon I will be back on a schedule and studying again to fulfill my clinical duties, but this is a much needed break that will not be wasted.

Before sitting for the COMLEX exam, I started my rotation in Family Practice. I was such a breath of fresh air to see patients again. It didn't take long for me to realize just how much learning I have ahead of me. On more than one occasion I failed to give the correct answers to posed questions by my attending physician. I suppose those particular questions will be burned into my memory out of embarrassment. Nonetheless, the practical learning grounds beat any classroom lecture. Getting myself ready for a late night shift may take a few days, but I'm up to the challenge.


Board Prep Question of the Week

A 31-year-old man presents to the clinic for his yearly check-up and is found to have a blood pressure of 158/94. At a re-check two weeks later, his blood pressure is still elevated even though he has no risk factors for the development of hypertension. Further evaluation reveals a potassium level of 3.3 meq/L. Proper medical therapy for this man's most likely condition would involve which of the following mechanisms?

A. Agonism of the aldosterone receptor in the distal renal tubules
B. Antagonism of the aldosterone receptor in the distal renal tubules
C. Inhibition of sodium and chloride reabsorption in the ascending loop of Henle and distal renal tubule
D. Inhibition of sodium and water reabsorption in the proximal tubule and the loop of Henle
E. Inhibition of carbonic anhydrase activity

Answer & Explanation

R.I.P. USMLE

As I made my way to the testing center last week, I wanted to suppress the anxiety with a few tunes. With Queen's "We Are the Champions" blaring, I couldn't think of a better song to get me pumped for one of the most important exams I would ever take. The feeling was short lived when AC/DC's "Highway to Hell" revealed the truth of the situation. All I could do was laugh.



USMLE

Nerves on edge and adrenaline pumping, I finally settled into the exam. Question after question I tried to stay focused and not second guess myself. The barrage of random scenarios and cases certainly kept me on my toes trying not to blur them together. Surprisingly, time went quickly and it was time to call it quits for the day. Unsettled and unsure about my success, I walked away feeling accomplished in taking an exam that few get to experience. And now to wait for the results of all my efforts.

It wasn't until I started celebrating that I realized how keyed up I was for that exam. I lost my appetite and spent the next few days ill as I caught up on some much needed relaxation. Unfortunately, I still have one more exam to face. Fighting off the post-exam-information-dumping-session is difficult to avoid especially when your brain is lacking adequate nutrition. Now somewhat recovered, I am back in the saddle for another week of review to finally put this second year of medical school behind me. Despite feeling champion-like on occasion, I think it would do me good to avoid the highway to hell.


Board Prep Question of the Week

A 24-year-old male with a history of Sickle Cell disease presents to your office complaining of pain in his arms and legs of 12 hours duration. Laboratory tests identify that this patient is experiencing an ‘aplastic crisis.’ PCR tests demonstrate infection by a single stranded small DNA virus. This virus may also cause which of the following syndromes:

A. Burkitt’s Lymphoma
B. Erythema Infectiosum
C. Molluscum Contagiosum
D. Smallpox
E. Yellow Fever

Answer & Explanation

Medical Boards

I had a near death experience today, well more like this entire month. Preparing for the USMLE and COMLEX board exams has finally taken a toll, but the good news is that one test will be done in just a few days.

The Final Push

Two years of medical school, 3000 practice questions, four weeks of intense review, multiple passes through study materials, numerous white board topics and more information than I can fit in my head have come down to this. Working on 5-6 hours of sleep after studying 14-16 hours a day gets difficult with all those facts rolling around in my short term memory. From biochemical pathways and pharmacologic principles to microbiological tendencies and pathologic maladies the pieces are starting to come together.

In just a couple days I will be sitting for the first of two exams and every waking thought seems to bring me back to topics I don't have memorized. Feelings of anxiety and trepidation are fought by the thought of having all of this behind me. I can't decide what I am going to do first when it is all over, take a nap, exercise or celebrate. The catch is that when I finish the first exam and recoup, it will be time to dive back in for another week of COMLEX preparations. As if the sundae were not big enough, its cherry topper is the start of rotations the day before my exam. Fortunately I still have an appetite, does anybody have a spoon?

Board Prep Question of the Week

An aspiring medical student opens up his Step 1 score report and is elated to find that his score is 230, a 92 on the 1-100 scale! The score report indicates that the mean on the exam was 215 and the standard deviation is 15. Assuming a normal distribution, in which percentile is the student's score?

A. 63.5%
B. 77.3%
C. 84.1%
D. 97.7%
E. 99.9%

Answer & Explanation

Preparing for Boards

Before coming to medical school I had no idea what to expect other than a difficult education that would be rewarding. Now, I find it a challenge to truly convey what life as a medical student really entails. My painted picture is probably very different than that of my peers, but it's the only experience I know.

A Day of Board Exam Preparation

The alarm goes off and as I made my way to the breakfast table all I could think was "sodium stibogluconate." Too bad my recall only brought me to the parasitic infections folder in my head and the Leishmania donovani card was nowhere to be found. With my bowl of cereal prepared, it was time to make another pass at the flashcards that have been accumulating over the past year. Some days the cards are nice to me and other days they seem to be retaliating for my reluctance to review them more frequently.

After a quick shower to really wake me up, it's time to sit for the next eight hours plowing through copious amounts of information mostly guided by First Aid, the medical student's bible. In an effort to solidify the information, I found it worth my while to review the information through question banks. The results of which were not always pleasing, but usually ended in learning something new about the topic and how to incorporate the information.

On a good day, my legs would only fall asleep two or three times and I wouldn't fall asleep until after midnight. Depending on the material and how long it took to get through it, I might actually be able to get in a little exercise thus avoiding the effects of Virchow's triad and potentially deadly clots. (Who knew med school would be so dangerous?) Other times, I just needed to see the light of day by taking a walk to the mailbox or going for a drive to reward myself with ice cream. Then it was time to focus again for another few hours hoping my brain would not be too active to let me sleep. Fortunately by that time, it was willing to shut off in preparations for tomorrow's marathon of education.

Board Prep Question of the Week

A 67-year-old woman is started on warfarin to prevent embolic events from her atrial fibrillation. Four days after taking warfarin, she starts developing well defined, erythematous, indurated, and purpuric lesions on her thighs. The inhibition of which component of the coagulation cascade is likely responsible for these lesions?

A. Factor II
B. Factor VII
C. Factor IX
D. Protein C
E. Protein S

Answer & Explanation

Things I Wish I Knew - Second Year

It's that time again to take a look at what I've learned from the last year and roll it into a bite-sized post. At first glance it may not seem much different than last year's report, but with a side-by-side comparison I'm surprised I am alive to tell the story.

Looking Back

Somewhere between peaked exam weeks and the troughs of vacation, I actually found time to breath. For what it is worth I have learned a few things along the way and would love to hear from others what you have gleaned from your experience. Without further ado, he is my small list of things I wish I knew before my second year of medical school.

1. Proper repose - Some people have a knack at getting sleep and lots of it. I have never been that fortunate, but learned that a regular sleep schedule was important to staying on task during the day. I must admit though, there were days when I just had to find a spot on the floor and take a quick nap. If only our brains could burn as much energy as a full workout, now then I would be set. Make sleep a habit and take short naps when needed.
2. Staying current - I am still convinced some professors do not communicate with the others and actually understand how much information is being thrown at us. Letting too many lectures and reading assignments go unattended can lead to undue stress before exams. Pacing is crucial to really understanding the concepts despite how well you "cram." It might be difficult, but getting things done now will save the pain of not having it done later.
3. Two heads are better than one - Normally, I am not one to study in groups, but I have found this to be fundamental to my success in medical school. Where I misunderstood a point or did not have the background knowledge to comprehend, my study partners were often able to fill in the blanks. And for all those times when the stress really got to me, a quick game of HORSE was sure to do some good. Study partners help you understand what you do and do not understand really fast, get some.
4. Practice makes perfect - After being in the classroom for so many hours, it is easy to lose sight of why we are there in the first place. For some of us, it really is about helping the patient. Be sure to take advantage of opportunities that permit exposure within the community. These help make the light at the end of the tunnel a little brighter along with gained experience in practices you may intend to be doing for the rest of your career. Be an active participant outside of the classroom.
5. Surmounting the challenge - Without hesitation, I can honestly say this is the hardest thing I have ever done. Having said that, it is also one of the most rewarding. High stress conditions, little sleep, poor exercise, sparse family time and a constant query of knowledge has kept me on my toes much longer than imagined. The best part is that it is fulfilling a goal that I have had for so long, which makes it all worthwhile. Take time to enjoy one of the more difficult hurdles life has to offer.

On another note, if you are interested in what other students are saying about their experiences, my Life as a Medical Student has been showcased along with theirs in this list of 42 Medical Blogs Written Entirely by Med Students.

Board Prep Question of the Week

A 3-year old child has dyspnea, severe cough, and a fever. A chest X-ray and laboratory tests lead to a diagnosis of Pneumocystis jirovecii pneumonia. Further laboratory tests indicate abnormally low levels of the IgG, IgA, and IgE immunoglobulins. However, levels of IgM are far above normal. This patient's immune deficiency is caused by a defect in which cell surface molecules?

A. CD40 ligand
B. CD86
C. Fas ligand
D. TCR
E. TNF receptor

Answer & Explanation