Wednesday, October 10, 2012

The Final Exam

After the second year of medical school, students take the first of their board examinations, then a second board exam during the third year. A clinical patient encounter accompanies the second exam and fourth year is full of interviews which prove test enough to not need another board exam. One would think that post-medical school, the examination process ends and life returns to normal ebb and flow sans souci. Sadly, this is not the case. Enter residency...

Oiling the Rusty Mind

Months into residency and things are going great. Strolling wards, seeing patients and watching therapies take effect is a reward that hard work is paying off. But in order to pass intern year, the final round of board exams looms overhead holding in its death-grip the ability to moonlight in our post-graduate year II. This is where the intensive subject review satisfies the gap of knowledge from match day to test day. While passing scores are not required to be as high the third time around, we all want to perform well and put this exam behind us forever. It is said one needs to study two months for Level 1, two weeks for Level 2 and bring a #2 pencil for Level 3. Fortunately, many board exam resources are available so we don't have to rely on sheer luck.

With this third and final board exam I chose to prepare with the COMQUEST question bank for about one month in addition to my reading materials. One clear benefit that usually appeals to (over-worked and under-paid) residents is cost, which is generally lower than other question sets on the market. For those who might be curious what this Qbank has to offer, I have made some comments below highlighting both pros and cons. 

  • Reasoning - Each question has a detailed but brief explanation of the correct answer including information as to why the wrong answers are incorrect.
  • Comparison - Each question provides a percentage of users who chose the correct answer, thus providing you with an idea of what you should already know.
  • Suggestions - Many of the Osteopathic Manipulative Medicine questions provide special algorithms to work through confusing scenarios.
  • Images - Pathology is explained and shown to assimilate exam-like experiences.
  • Representative - These questions are very similar to actual exam questions, thus better preparing the student for exam day.
  • Calculations - Some questions use numbers that are hard to manipulate and explain that the boards will use simplified values, why not use simpler values in the questions too?
  • Video - New examination format is implementing the use of video to portray questions which could be helpful in practice questions.
  • Goal - It would be nice to know what most passing test-takers are achieving overall in the Qbank to give an idea of how prepared we are before sitting for an 8-hour exam.
  • Scores - Currently, scores are reported in small font making them hard to stand out. It would be nice if they were larger and if you could select the last 5-10 tests to see recent percentages that don't include poor scores from the beginning of practice.
  • Devices - Making a smartphone or tablet app to do questions on the go, would be really helpful.
Per the folks at COMQUEST, audio and video style questions are soon to be added to the question bank. As a gift to dedicated readers and those interested in using this resource in their board exam preparations, when purchasing your subscription, enter the COMQUEST discount code CQMED10 for 10% off until 2/28/13. Please leave comments below with your feedback! 

Tuesday, August 21, 2012

Let the Voting Begin!

More than 20 years of working towards a life dream now fulfilled, I have shared my medical school experience for four years; week by week, dose by dose, the journey has been a roller coaster of fascination. Recently nominated as one of the most fascinating student blogs of 2012, the voting process has begun and I am asking for your participation. 

1. Follow this link to the voting page today through August 28th, 2012.

2. Make sure you have Google Plus. If not, you will find the Google Plus UPGRADE Button on the Top Left of the page. Creating your profile will only take a few minutes.

3. Click on the double arrow beside "Comments" to view the entire list of nominees and look for your blog of choice...Your vote for Life as a Medical Student would be much appreciated, it's a little more than halfway down the list :)

4. Hover your cursor at the end of the blog url and click the "+1".

5. Invite your friends to cast their vote!

6. MOST IMPORTANTLY: If you cast your vote for me, please send me an email here with your name, one of your dreams and a picture of yourself to be featured on my next blog post!

Updates from residency are soon to come, so stay tuned. Thank you for coming along for the ride.

Thursday, August 16, 2012

Nominated Most Fascinating Student Blog of 2012

It is with great pleasure that I announce a nomination recently received for 2012's most fascinating student blog. Just being among the few student blogs on the internet has been quite a thrill, but this consideration is one I humbly accept. If you would like to voice your opinion and vote, the process will begin on August 21st and close on the 28th.

1. Follow this link to the voting page on or after August 21st, 2012.

2. Make sure you have Google Plus. If not, you will find the Google Plus UPGRADE Button on the Top Left of the page. Creating your profile will only take a few minutes.

3. Click on the double arrow beside "Comments" to view the entire list of nominees and look for your blog of choice...Your vote for Life as a Medical Student would be much appreciated :)

4. Hover your cursor at the end of the blog url and click the "+1". (Its in the same location where you see the votes for the other blogs.)

5. For blogs that already have votes, the  "+1" should be immediately beside the vote count to the right.

6. Invite your friends to cast their vote!

Thank you all for your support and encouragement! It has been a wonderful ride and I couldn't be happier living the dream that started so many years ago.

Monday, May 28, 2012

Things I Wish I Knew - Fourth Year

Once again, with my fourth year of medical school completed, it is time for me to break out the inner nerd and share the pictograph of my numerical note-taking. The chart above representing my fourth year of school with obvious end points when interviews finished and graduation approached.

The next chart is a culmination of first, second, third and fourth years combined. Initial observation would suggest that second year was almost twice as difficult as first year if not more so.The deep troughs usually representing times of vacation after exams or between years. The steady third year was a result of various preceptors and the work loads with each specialty. Obviously this would look different for every student depending on their scheduling. Things picked up again in fourth year with interviews, audition clerkships and the match process. Once matched, the intensity levels dropped significantly until the end of school all together.

Thoughts in Retrospection

Attempting to look back and decide on the few things that helped me along the way this last year is proving difficult, but as time passed, I have been looking forward to this post and mentally banking ideas along the way. Below are the top five things I wish I knew before my fourth year of medical school and probably could have been useful before school started.
  1. Stand Tall - It can be difficult to show courage on rotations. Many times preceptors will "pimp" students or question our thinking to the point of making us feel smaller than ever before. Standing tall, using direct answers and showing interest made the difference on more than one occasion. Confidence, even if simulated, lets others know you have what it takes when challenges come.
  2. Read regularly - Medicine is a profession of lifelong learning. Getting into the habit now of seeking the latest research in your field will serve you well when it comes time to managing your own patients. Obviously, there is more to know than can possibly be memorized, but taking an active roll in consistent reading can set you apart from your peers who only read to cram for exams. Make reading a regular part of your study routine.
  3. Follow the rules - While this might seem like a no-brainer, it is surprising how many do not. Whether an assignment to study for the next day, a sterile field you are not to touch or paperwork your school needs, abiding by given instruction will only serve to help make your life easier. You will have a lifelong career where you get to be your own boss. Save your rule breaking and adventure seeking for then. Being a student means you are still governed by the rules of those who decide the receipt of your degree
  4. Be proactive - Set up clerkships early, arrive on time ready to start everyday and actively look for opportunities to participate in patient care. Having my interview application submitted early allowed me to be on my eighth interview when some students were just starting their first. Procrastination means you may be eating crumbs
  5. Have fun - This is what you came to medical school to do. You are paying good money to make the most of a four year education, even if long hours of studying depress you. The least you can do is make some friends along the way and have a good time in the process. There are some great memories to be had in medical school, don't miss out.
Medical school is honestly the hardest thing I have ever done in my life. The journey has been amazing to say the least. To be done is not only a dream come true, but a gift only I could have given to myself. I am grateful for all the support my family, friends and readers from around the world have given me along the way. While I do not know what awaits me over the next four years of residency, I am excited to be moving in the right direction. Now to start working on that quarter million dollar student loan.

Question of the Week
A 30 year old male medical student blogger has just graduated and is moving on to residency. If he continues to blog in the little free time he will have, where can his writings be found?

D. All of the above

Answer: It will not likely be all of the above, but all those are all good places to check. I will try my best to keep this site updated with changes or news.

Sunday, May 20, 2012

Doctors at Last

From the bowels of the LVH (Las Vegas Hotel) at the head of the ballroom, my classmates and I have gathered to be hooded doctors of osteopathic medicine. Its official, we are now doctors!!!

Congratulations to all my TUN classmates and peers at other universities on a job well done!

Graduation Day Is Here!

This post comes as another milestone arrives. I wasn't certain if I wanted this to be my last post as a medical student or the first as a physician. In the end, I think this entire day is in limbo between those two phases. Today is graduation day and like many of my colleagues, I am excited to leave the last four years of medical school behind and move on to the next adventure.

THE Biggest Milestone

While trying to figure out how to wear the graduation regalia can be quite the confusing task, it is exciting to be the one donning the apparel. For years I have admired those dressed in the robes of a doctoral graduate and patiently awaited my turn. In a few hours I will be joining the ranks of those who have gone before to commemorate years of education, sacrifice and desire. All this fanfare for a little pomp and circumstance, that's worth a photograph or two.

It is likely that one of the orators today comments on the ceremony being the "commencement" of our careers as opposed to the kneel of our educational experience. As more time passes, I come closer to understanding the weighted responsibility of what it means to carry the title of a doctor. For once this really does feel like a commencement wherein there is more ahead than what the past has known. How this is possible and how I am going to make it is beyond me, but it's a new leaf in life. Today closes one book and opens another. I couldn't be happier that this day has come!

Monday, May 14, 2012

There's No Homework Like No Homework

Rotations are finished. Residency is on the horizon. I am basking in the space between...vacation-land. Although there is plenty to do in preparation for the next steps, this time is just as precious as it sounds. Letting go of the time schedule, burdens of major responsibility and trivial concerns is more relieving than I imagined it would be.

Recapturing Lost Time

While I could have been intently studying for my next board exam, reviewing the pharmacokinetics of anti-microbials or rehashing the Kreb's cycle, I chose to rest the organ I've exercised intensely for the last four years. Traveling here and there, sometimes without a phone or computer to really dive into the organic "R and R" so badly needed. Mother's Day was no exception. With no prior commitments and time to spare, I made the trek to surprise my mother even though it was the week before graduation where I would see her again. Why would I do it? Because I could. Time allowed and it makes for a better story than going to the arcade for a day.

With only one week remaining before graduation the obvious excitement has somewhat worn off since starting vacation. As it stands now, only time is between me and a degree. No more exams, interviews or documents need my attention. My vacation time seems more valuable at this point than a 4 hour meeting of name-calling and black robes. Yet we are required to attend the event, perhaps for the school to maintain its public appeal of graduating x number of doctors this year. Attending graduation will be the public culmination of all this hard work put to rest. An opportunity for close friends and relatives to say, "I know that guy, how on earth did he become a doctor?" I suppose deep down inside I want to be there too, because it is a proof-giving ceremony validating the last 25 years of my life. Something few events can do.

Here is to a lifetime of dreams, four years of hard work, relationships made and kept, mothers and fathers who support, being a medical student who experiences bipolar highs and lows, and most importantly to the years ahead. The next time I post here will be as a doctor, not that far removed from the student, but across the line a marathon winner.

Question of the Week
Was it hard?

Answer & Explanation

Sunday, May 6, 2012

Fighting for Good Health

While it seems that doctors are making buckets of money, lawyers have found a way to change this in concert with the political movers and shakers who are following suit. Many veteran physicians are encouraging young students to stay away from medicine for fear of endless paperwork, insurance battles and lawsuits. The face of medicine is changing.

Medicine Is A Business

What once used to be a profession geared towards healing the disabled and sick has now become a battle for safeguarding ones career. Often referred to as "CYA" (cover your a__) medicine, doctors are ordering more tests so not to miss pathology and treating minor ailments in vain. They put forth great efforts to serve their patients, but must protect their practice from suing patients, money-hunting lawyers and non-paying insurers. Some discussion with physicians about the subject often brings up ideas for reform with what sounds like logical plans to solve the issues at hand. In some markets doctors are paid almost 50% for their services as a result of under-insured patients or insurers who just won't foot the bill claiming there were non-qualified expenses. Since when can people utilize a service provider, demand services and pay nothing? When I go to the supermarket looking for home goods, they are certainly going to laugh when I ask them to put it on my tab.

In some places the "fee-for-service" model has done well. Patients want their health care provided and pay the provider an agreed upon fee. Both parties are satisfied and treatment is given. There is talk of requiring all citizens to have health insurance. I am still trying to understand why this would be a bad thing. I choose to drive a car; I get insured. I choose to receive health care; I get insured. Seems simple. Research has shown that people value things more when they have to "pay" a nominal fee for it. Even if there was a required co-pay, at least it would show sincerity of the purchaser to the provider that they have a significant concern needing to be addressed. It becomes taxing on the medical systems to provide free or discounted care more often than not. Perhaps that is why one third of hospital emergency departments have closed across the country in the last few years. Uncompensated services cannot last forever.

Whether paying in cash, through an insurer, Medicaid or Medicare, it seems fair to be offering remuneration to physicians for their hard work rather than trying to scheme ways to leave them empty handed. While each insurance organization has various offerings to their clients, some may come up incomplete, requiring users to seek for additive options. Medigap insurance plans for example, offer to fill in the gaps that Medicare Part A and B do not cover. It brings peace of mind to patients that experience a wider coverage of care and allows providers to give comprehensive services.

As I move into medical practice it is hard to know what medicine will be in the future. Policies are being written into law and health care reform is happening at the national level. Medicine as it is known today may be inside out and backwards years from now. Hopefully, parties on both sides of the fence find will be able to latch onto something positive so the face of medicine is tainted no more than it already has been.

Question of the Week
What are the issues, past and present including the proposed efforts of health care reform?

Answer & Explanation

Sunday, April 29, 2012

Medical Student No More!

That bitter-sweet time came at three o'clock in the morning. I had finished my last shift in the emergency department, in medical school, and in Las Vegas. My last official function as a medical student had officially come to an end. (This might be a good time to celebrate.)

The Knell of Medical School

The walk in solitude to my car in the cool calm of the morning hours was much more subdued than my nervous entry to the classroom on day one. From the first week of school, to my first exam and first patient encounter I have really enjoyed the ride getting to the final destination. With any luck, my medical knowledge has increased and I have learned how to study more effectively. Thankfully, my level of confidence continues to develop and I'm starting to get preceptor questions's about time!

I finally feel like I have something to contribute to the medical community. In due time, that feeling will be validated with my diploma. The dream of a lifetime will be a reality and yet it feels like the time went by so quickly. Residency will be a completely different animal, but at least I won't have to take out more loans to participate there. For now, I am reconnecting with my lost weekends, sleep and play time. This is the breath of fresh air I've been waiting to experience for a long time.

Question of the week
What looks like a doctor, works like a doctor and is shortly going to be a doctor?


Sunday, April 22, 2012

Chasing Zebras

This week I became fascinated again with the basic sciences, this time through physics and chemistry. The department had a Wood's lamp easily accessible and I had a urine specimen readied for testing. A patient with dermatological manifestations of a diseased state presented and according to my research, this simple bedside test would demonstrate fluorescence if positive. Shown here is my wishful attempt at something out of the ordinary, which to my dismay was negative.

Trial by Experimentation

Sometimes going out on a limb to explore a part of the differential can be illuminating to the disease process. In this case, it was more educative. Should I have a patient in the future with similar symptoms, this test will more likely come to mind than having to research it. After discussing the out-of-the-ordinary, potential diagnosis with my attending, he encouraged my investigation rather than laugh me to scorn. They told me that medical students, even in their limited knowledge can actually have a significant contribution to the patient's care. Even though we may come up with a "zebra" or two, if we didn't consider them as part of the diagnosis perhaps nobody would.

For those not familiar with the term zebra, although they appear similar and may even audibly sound similar, it is more common to come across a horse than a zebra. In medicine we use this idea to relate to diseases wherein the common things are common. We look for the obvious and common problems while considering that there may be a zebra in front of us. If we don't look for the zebras, then we will effectively miss them and erroneously treat the "horse" disease states, thus leaving the patient inadequately treated.

This little exercise was a reminder to me of how many varied sciences are included in the art of medicine. The fact that many professionals with educated backgrounds come together adding their piece of the puzzle to bring understanding to the whole picture. Whether a bioscientist, chemist, physicist, or technologist it is a team effort in creating the best outcome for a patient. On this particular day, I got to venture a little off the beaten path and was enlightened by my exploration.

Question of the Week
A 57 year old homeless male presents after a night of alcoholic binge drinking complaining of new blisters forming on his forearms. You notice that his skin appears tanned and consider the diagnosis of Porphyria Cutanea Tarda. The uroporphyrins in his urine sample appear to fluoresce under the Wood's lamp. What other finding would you expect to see in this patient?

A. Hypertrichosis
B. Melena
C. Telangectasias
D. Nail pitting
E. Cotton-wool spots

Answer & Explanation

Sunday, April 15, 2012

Planning the Fourth Year of Medical School

Blame it on the type A personality or simply a mild case of obsessive-compulsive character, but my fourth year of medical school has been so busy I needed a way to organize my thoughts and tasks. Keeping rotations, auditions, interviews and contact information accessible and managed was a priority in obtaining my residency of choice.

Peripheral Brain

Some people have laughed at my excessive use of spreadsheets to organize my homework, life and other details. For me it relieves stress, especially because I tend to forget the little things easily. These also seem to help conserve space for school related information where patient care will thrive or suffer if it is not mastered. Once the information is typed or written elsewhere, the need to constantly remember it is no longer there and I know where to turn for a reminder of things forgotten or important. The above spreadsheet image is how I managed my busy schedule for interviews and residency details over the last year. It facilitated a well-streamlined interview season and even helped me develop a rank list when the time came.

Whether you are looking to plan your fourth year clerkships, keep contact information easily available, or strategize your residency interviews, this spreadsheet may prove beneficial for you. All I ask in return is $1 donation through PayPal for my time invested in its creation. Thank you in advance for any and all donations. Here is the Fourth Year Planner. If you have any problems or questions I am just an email away. This file saved me hours of headache and stress when things really became busy, I hope it can do the same for you during one of the most excitingly stressful times of medical school life.

Question of the Week
A 12 year old male comes to you after rolling his ankle on some rough terrain during a hike. He recollects hearing a popping sound at the time of injury and is having significant pain. You notice no obvious deformities of the ankle but suspect a fracture. On radiographic imaging you note a small fracture extending distal from the epiphysis. Using the Salter-Harris classification system, this is what type of fracture?

A. Type I
B. Type II
C. Type III
D. Type IV
E. Type V

Answer & Explanation

Sunday, April 8, 2012

Trading Scrubs for Camouflage

Having spent most of my time in civilian hospitals and clinical settings, it was quite the change this month when I started my last medical school rotation in a military-run facility. Government issued footwear, camouflaged vestments and unique insignia delineating the pecking order of those in uniform.

Regimented Medicine

Hospital security started well beyond the doors of the building proper and required adequate identification through background checks and documentation. On the premise, it seems a little more like medical centers I have known with the exception of the foreign jargon and dress codes. I might add that I was happily surprised that many of the employees and patients seemed to be physically fit or at least once enjoyed a life of good health -- something that would be nice to see as the new American trend. Courtesy and manners are expressed more openly than elsewhere, likely a result of the regimented training military personnel receive.

My limited exposure to such an environment has its awkward moments. For example, the time I walked into a room and addressed the patient by a formal Mister/Missess to be quickly corrected by the patient of their notably high military ranking title. As a civilian, I had no way of knowing, nor did it change my approach to that particular patient's care. It was simply an unsettling feeling that somehow the career title with which I was unfamiliar, was expected to modify my view of that interaction. I am waiting for the time when I receive a demerit for a rule I never knew existed. Despite this unexpected occurrence, I sincerely honor and respect the service that these men and women provide or have provided to our country. It is fascinating to hear their stories and see their determination to succeed. While I may not have my stripes, I can appreciate the family bond they have created. If only more workplaces could emulate their approach, I postulate that outcomes would be favorable. Thank you troops for a job well done.

Question of the Week
A 17 year old male presents to your clinic with an apparent case of streptococcal pharyngitis by exam. You treat the patient with antibiotics and he returns a week later complaining of a diffuse erythematous rash. What is the most likely cause of your patient's rash?

A. Allergic response
B. Azithromycin
C. Amoxicillin
D. Contact dermatitis
E. Post-streptococcal dermatitis

Answer & Explanation

Sunday, April 1, 2012

Textbook Diagnosis

It's in the books. There is something fascinating when you actually get to see a "textbook" case in the clinic. Before medical school, I would have thought disease states followed some text written description or at least would present as we are taught. They don't and that is what makes medicine a "practice". Diseases don't do a whole lot of reading in their spare time.

Learning from the Patient

Earlier this month, a young child was brought to the clinic with decreased appetite and oral sores that the mother had noticed for a couple days. My initial exam suggested this was more than oral ulcers. Thinking back to the diseases with oral lesions I was excited to look for more skin changes on other parts of the child's body. One small vesicle on the palm and one on the foot confirmed my suspicion of hand, foot, mouth disease (HFMD). It was exciting to see what the books had described, albeit a mild case. On follow-up examination days later, I reached for the child's hands to see what changes could be seen, there were none. Mimicking my examination, the child's sibling did a self-exam and quickly realized he too was affected. Once a family supporter and now a patient, the sibling actually had a worse case of HFMD that would have gone undiagnosed if he wasn't present.

In a sense, the diagnosis was rewarding knowing that somewhere in my mind was stored the details to help my patient. With the vast amounts of knowledge we are expected to retain and the impossibility of doing so, I am willing to celebrate the small successes. Seeing textbook cases helps confirm my understanding of the many documented pathologies we are expected to understand. Written details are reinforced by touching, seeing and hearing the real thing in person. At least I am making progress in the right direction...and washing my hands a lot more frequently.

Question of the Week
A parent brings in their 4 year old child with what appears to be hand, foot and mouth disease. You know this is commonly associated with the Coxsackie A virus and want the parents to be aware of possible complications that may arise including which of the following?

A. Encephalitis
B. Renal Failure
C. Cardiac arrhythmias
D. Myalgias
E. Vision impairment

Answer & Explanations

Sunday, March 25, 2012

Pediatric Medicine

Likely due to language disparities, my less-than-five-year-old patient sat quietly on the examination table patiently waiting for me to start. She was smart and well-versed in the way of the doctor's office. As I approached, she knew when to open her mouth, brush her hair back for access to her ears and when to take deep breaths for adequate pulmonary auscultation. Finally finished with my exam, I returned to my documentation and in her best thespian performance let out a wee little, "a-choo," followed by a finger to the nose for good measure. [Picture: Before The Shot, by Norman Rockwell]

Child's Play

This month on pediatrics I am observing all kinds of lost treasures from childhood. From true emotions that come out in smiles, laughter and screams which somehow get tucked away when we grow older to naive playing with other people never met, ringing bells just because they are there and making sounds for no other reason than to entertain the thoughts floating inside one's head. It brings thoughts of Patch Adams gallivanting through a pediatric unit striving to see just a glimpse of a smile.

I had to laugh a little when another patient in the middle of their numerous vaccinations screamed in horror, their mother encouraging manners and to say thank you. What child wants to show appreciation for a shot and multiple at that?! Nevertheless, it brought a smile to my face when the little voice, through tears, cried out a profound, "thank you!"

Children are trying to be good even though their world revolves around them sometimes. It bothers me when their parents get cloudy vision and choose to refuse care that would easily remedy problems because they lack time or money. Taking your child to the emergency department is not just a suggestion by your doctor, it is sound medical advice that merits following. It makes me wonder why they brought the child in the first place if all they are going to do is ignore our recommendations. So who is the egocentric one now? Clearly, parents are responsible for their child's well-being. Maybe it's time for parents to have their own time out and come to their senses.

While I observe their behavior and character, I wonder what has happened to the child in me. Have I suppressed it so much that it can no longer come out to play or do I encourage its development in the hopes of a happier, healthier me?

Question of the Week
While doing a routine well-child exam you notice your 7 year-old male patient has freckles in his axilla and multiple café-au-lait spots on his torso; 3 anteriorly and 4 posteriorly. There is mild genu varus, no scoliosis and no vision abnormalities. What is the most likely condition this patient has?

A. Lesch–Nyhan syndrome
B. Henoch–Schönlein
C. von Recklinghausen disease
D. Chediak Higashi syndrome
E. Tuberous sclerosis

Answer & Explanation

Sunday, March 18, 2012

Behind the Mask

Unless you work in an operating room, the routine of what to expect may be rather frightening and foreign. The anesthesiologist makes sure patients fall asleep and somewhere between the induction agents and analgesics there is very little remembered. It's no wonder so many are mystified by the effects of a surgeon's cold steel before, during and after an operation.

The Mystique of Surgery

Surgeon David Gelber recognized he was captivated by the operative challenge that is surgery early in his career, yet so many of his patients were unawares of what to expect. In an effort to shed light on how a surgeon is capable of cutting open human flesh, repairing pathologic organs and un-opening a patient for maximized healing, Dr. Gelber has written Behind the Mask: The Mystique of Surgery and the Surgeons Who Perform Them. While doubling as his memoir, Dr. Gelber pens a thought process from start to finish of how operative cases are approached to promote a successful outcome.

Sometimes funny, at other points emotional, the reader journeys through surgical cases and how they molded Dr. Gelber's career. Life saving operations and split-second decisions are among the many stories which depict a professionally educated approach to patient anomalies and diseases. Despite an eager attempt at simplifying the language to be read by all, I felt there existed a writing style that would be better understood by medical personnel or those familiar with basic medical terminology. Commonly, definitions were given and ideas explained, but occasionally the reader may be left confused about anatomical or medical associations. Nonetheless, the text proved to be a quick read that entertained with sophistication and matter-of-fact generalizations. I enjoyed seeing through a surgeon's eyes how he performs his duties. With this piece, the surgical unknown may no longer be cloaked in mystery as it once was, rather, it brings knowledge to the lost time and memories experienced while laying on the surgeon's operating table.

Question of the Week
An 8 year old girl comes to your office complaining of a sore throat for 3 days. Her mother reports the patient had a maximum temperature of 101.5F yesterday that resolved with Acetaminophen, no wheezing, no cough, no ill contacts and no recent travel. On exam, the patient's temperature is 100.8F, tonsils are erythematous with gray-white exudate, and anterior cervical lymphadenopathy on the left. The treatment of choice is which of the following:

A. Observation with "watchful waiting"
B. Amoxicillin with Clavulinic Acid
C. Penicillin V
D. Amoxicillin
E. Ibuprofen

Answer & Explanation

Sunday, March 11, 2012

Doctoring Through Humor

Every once in a while, funny things happen. This time, brilliantly dressed man, tall in stature with half a head of blue hair paced on the stage recanting memories from his career as a medical doctor and health activist. There was no shortage of clowning, which was only exaggerated when he literally disappeared inside his over-sized pants...yes really. 

Smile, It Scares the Blues Away

Recently, I had the opportunity to listen to and chat with Hunter Adams, better known as "Patch" Adams. Most people recognize the Hollywood title, and in person, he was simply fantastic. Patch is a one of a kind personality who has established the Gesundheit Institute, a free medical clinic where health is paramount for the individual, family and community. While in his final years of medical school, Patch had a vision on how to change the world and healthcare itself by eliminating the "red tape" that is found in bureaucratic medicine. His cheery disposition, desire to spread happiness and creative outlook stoke a positive reaction in most people who have the pleasure of his company.

On the verge of practicing medicine myself as a rookie doctor, I spent a couple minutes consulting with Dr. Adams. After expressing my enthusiasm for my fast approaching residency and my simultaneous anxiety of the same, he could not fathom why as this is the best time to grow as a young doctor. His words of advice were to "never lose the humor." There are so many positive experiences to be had that it would be a shame to miss out on account of fearing the experience itself. Through his discourse, personality and example, I am reminded that we can be whoever we want and that it is acceptable to be the one who doesn't follow the norm. Compassion is a characteristic that is given to benefit the lives of others, and in my eyes, Patch exemplifies this quality with great finesse. Thank you for your words and example.

Question of the Week
What can I do to contribute to a happier me and society?

Answer & Explanation

Sunday, March 4, 2012

Medical Coding

Guest post from Deanne Hicks, Medical Billing and Coding Instructor

Greetings! My name is Deanne Hicks and I have worked in the Health Information Technology field as a certified coder for the past ten years. So, what is coding? The greatest analogy I can use to describe coding is to compare it to learning a new language. Essentially, it is the art of storytelling. A coder abstracts information from the patient's medical chart and translates that medical information into alpha or numeric codes that are up to five characters in length. There are several uses for codes, with the most common usage to drive reimbursement for providers. The other uses are for statistic collection, vital records for cause of death, public safety for communicable disease reporting, epidemic/pandemic reporting from hospital records in certain geographic areas and a host of other topics.

You may wonder how someone becomes a coder. For me, I needed a life change and decided to go back to school. Having just gone through a fairly difficult pregnancy, undergoing several encounters with a myriad of different providers over a course of almost two years, medical terminology and anatomy became fascinating to me. I wanted to learn more! I signed up for a diploma program as a medical office assistant and away I went, on a journey from which I have never turned back. I learned more about the human anatomy than I ever thought possible. When I took my medical terminology course, I was completely hooked! Once I got to the medical billing and coding portion of my program, I was on cloud nine. Although medical billing an insurance didn't interest me, I still persevered onward, patiently awaiting this thing called medical coding. Once I learned how to code, it was as if I had found my passion. For the first time in my life I knew what I wanted to be when I grew up...a Coder.

Earlier, I mentioned that coding is first and foremost, utilized in order to get the provider paid. As young medical students who dream of becoming a physician someday, wouldn't you eventually like to get paid for your time? I realize you will most likely have a hefty student loan to repay, so I suspect you will appreciate getting maximum reimbursement for services rendered. Yes, your practice will have a coder to assist you in this effort, but what you need to keep in mind is this; coders code from the medical record so the more complete and specific the documentation is, the more specific the code choice will be. In turn, the higher the reimbursement might be!

Here is a great example, hypertension. In the coding manual, hypertension is divided into three types, those being malignant hypertension, benign hypertension and unspecified hypertension. Malignant hypertension (ICD-9 code 401.0) is defined as very high blood pressure that comes on suddenly and quickly, with the diastolic reading above 130mmHg. With malignant hypertension, complications could arise with kidneys, blindness or an increased risk of stroke or myocardial infarction. If a patient exhibits symptoms such as blurred vision, confusion, anxiety, chest pain, nausea, vomiting, shortness of breath, or weakness in the limbs with a high diastolic reading, malignant hypertension needs to be considered. However, more often than not, the treating physician will simply enter the abbreviation of "HTN" on the encounter form. Because coders code from the medical documentation given, the only code choice would be unspecified hypertension (ICD-9 code 401.9). Also, benign hypertension's (ICD-9 code 401.1) definition describes this type of hypertension as slightly elevated blood pressure which, if left untreated, could cause cardiovascular and central nervous system complications.

If a physician were to document and diagnose the specific type of hypertension, this would open up the opportunity to allow a deeper evaluation of the patient with blood work, ECG if warranted, additional body systems to examine and evaluate as well. In order to code the encounter in the outpatient setting, the more body systems examined and the more test results to review on subsequent visits, the higher the level of coding for the physician's cognitive skills. All things considered, the reimbursement level for the provider will increase over a period of time, which will certainly help to make the practice thrive and in turn give the patient a higher level of care.

Everyone is a winner! Here is the successful chain of events:
  1. Medical students learn to give greater detail in medical documentation in preparation for future billing
  2. Coders and billers can code more specifically from detailed documentation
  3. Greater reimbursement can be obtained
  4. Patient's, doctors and coders are happy
So, physicians-in-training, add one more thing to your to-do list. Take a coding course offered at your local community college. Arm yourself with coding knowledge. I realize your brains are constantly being stuffed like a turkey with all that medical info, but as you know, we only use a small portion of brain power anyways. Cramming a little more knowledge into that head of yours will pay off for you big time!

Good luck!

Deanne works with Lincoln Group of Schools, a group of career training schools. She is a medical billing and coding training instructor, which is one of the various Lincoln programs available.

Question of the Week
While attending the cardiology clinic, the staff nurse measures the blood pressure of a 61 year-old man and finds that it is 182/100 mmHg sitting and 190/104 standing. He has a heart rate of 82/minute, with an irregularly irregular rhythm. On auscultation of the heart, there are no murmurs, but he has bibasilar crackles on chest examination. Which of the following pathological findings is most likely to be present?

A. Left ventricular hypertrophy
B. Left atrial myxoma
C. Occlusive coronary atherosclerosis
D. Cor pulmonale
E. Mitral regurgitation

Answer & Explanation

Sunday, February 26, 2012

The Ultimate Upgrade

This appears to be a very clean and tidy hospital room, ready for the next patient to fill its bed and utilize its healing equipment. I happened to come across it in the early morning hours on my way to see a patient assigned to my service, a patient who had occupied this bed less than 24 hours earlier.

The Morning After

I knew from the previous day that my patient was struggling to survive his declining medical condition and that it would only be a matter of time before his body decompensated. It just didn't occur to me that this particular morning would be the one I found his room void of active recovery. I was rather surprised when I passed the door mentally preparing myself to review his chart for daily rounds. This was not a novel experience for me, yet it was reason for pause in reflection of a life ended, that taught me in during his struggle to survive. Despite the frequency with which this happens, it resonates as a moment of appreciation for the health that I currently possess.

In medicine, we grapple to preserve life and health. Death is not failure in that equation, yet it is the antithesis of our goal. In fact, it may be the expectant end to the story, but our attempts at prolonging its arrival are the reason we prepare for years to work in healthcare. Sadly, it is something we have to accept as an outcome and become comfortable with despite our best efforts to thwart its occurrence. It happens and the morning I stopped in to see my patient, I could not think of a better scene than his empty bed with the light of the sun filling the corners of his room. It was serenely peaceful and appropriate. 

Question of the Week
An elderly woman, diagnosed with Parkinson's Disease, is very combative with hospital staff, refusing treatment except from her own family physician. Which of the following stages of death is she most likely experiencing?

A. Denial
B. Anger
C. Bargaining
D. Depression
E. Acceptance

Answer & Explanation

Sunday, February 19, 2012

The Match Results Are In

Sleeping the night before was not as hard as I expected it to be, but the day of the match results (February 13th) I woke up early. Before I even made it out of bed, the email shown here greeted me with very good news! In just a few months, I will be joining Arrowhead Regional Medical Center's newest team of emergency medicine residents!

Residency Here I Come!

Like many of my colleagues, I had no idea that the match results would be emailed so early in the day. Social networks were abuzz from classmates and peers around the country celebrating and spreading the news. For some it was a time of joy and for others one of disappointment that they either did not get the program they wanted or none at all. It was the major topic of discussion; sometimes surprising and often times expected. Fortunately, in the osteopathic match we do not have to wait a number of days before knowing the results, they are given in the same email. For those attending allopathic schools, they learn that they have matched and wait a few more days before learning where to and in what specialty.

I feel so very fortunate to have matched with a strong institution replete with diversity and opportunity. With the news, I can start looking for housing arrangements and vacation opportunities before everything begins. It's a relief I thought would never come when I was starting out more than three years ago. Now the looming realization of being responsible for someone's health is setting in. For now, I am just going to enjoy knowing that things are going to work out just fine.

Question of the Week
Where did you match and into what specialty?

Answer & Explanation

Sunday, February 12, 2012

Infectious Disease

One of the perks of emergency medicine, OBGYN and surgical rotations is wearing scrubs to work. Between these specialties and vacation it has been a year since I last wore a dress shirt and tie on my rotations. Despite being a little less comfortable, it brings a different sense of professionalism to the game.

Avoiding Disease

Currently rotating on a medicine specialty, infectious disease, I am learning more than ever before, the importance of antibacterial, antifungal, antiviral and antiparasitic medications. I knew there was a lot to know before, but I am now reminded of that fact where it counts, at the bedside. Every day we round on patients who have serious infections including tuberculosis, HIV, meningitis and more. When the patient's infection fighting army can no longer handle the battle, we are called in to bring the reserve armory. Donning special masks, gowns and gloves protects both the patient and ourselves from the exchange of harmful bugs during discussion and examination.

Washing hands is a necessity and stethoscopes are cleaned routinely on this service. If we are not careful, we can be the source of somebody's newest infection at which point it doesn't matter what your tie looks like -- keeping it secured is not a bad idea so it's not dragging through the patient's wounds and dressings. Medicine is a lot like figuring out a good puzzle, both in making a diagnosis and providing the right treatment regimen. Infectious disease aims to find the perfect medication for the job so we are not firing shotguns at thumbtacks every time building resistance to the arsenal we have available. It is a thought provoking field that can have a significant impact on patient outcomes as long as we don't let the disease bug them too much.

Question of the Week
Which of the following drug classes is responsible for both nephrotoxicity and ototoxicity?

A. Carbapenems
B. Penicillins
C. Tetracyclines
D. Aminoglycosides
E. Quinolones

Answer & Explanation

Monday, February 6, 2012

Words of Encouragement

Running towards the finish line, this blog post comes as the 200th, a point that seemed so far away when I hit 100 and even farther when I started writing here. As medical school comes to an end, it seems there are many things to celebrate among board exams, graduation, residency placement, friendship and family.

Fatherly Thoughts

Like a cheer from the sidelines, my father recently wrote me:

I am reminded that you are at a point in your career akin to that moment when a roller coaster crests on its ponderous first climb -- a tipping point with amazing views; where the 360 degree view is the best and breathtaking. For once, maybe only once, you find yourself at a vista point looking behind you (if you have that clarity of mind and the inclination), but especially checking out with breathless heart-pounding anticipation what's about to come. Stretched before you is a winding and precarious-looking path. You can't see it all or how it resolves itself, but you comfort yourself knowing that people survive it every day.

It's a rare defining moment where the natural course of gravity grabs the baton from a methodical and clacking power that lifts you ponderously. Gradual. Ploddingly precise. Unaffected in its destiny, but tension-inducing nonetheless. Then, in the next heartbeat, it happens. Kinetic energy takes over with free abandon with its all too familiar "here we gooooooo" careening dive. You're on a course zooming into the still-unknown hope, happiness and fulfillment on a ride that is sure to thrill and keep you on the edge of your seat.

Buckle up. Be proud. Take in the fleeting moments. Don't forget to breathe. Don't forget to cheer. Don't ever doubt that you are on the right track. And keep coming back for more of what thrills you.

It's interesting to explore the extent of the memories of your program and the interviews. For me the beginning of it all when you were young and had an eye on a frog. Heck! The entire run of you growing up and becoming Dr. Batt.

Thanks for being there for me and the family, for being the person you are and especially for the hundreds and even thousands of people who you will uplift, comfort and heal in the future.
Thank you, Dad.

Question of the Week
A 54 year old male was hospitalized for a pneumonia and placed on broad-spectrum antibiotics for 14 days. Subsequently, he developed diarrhea, fever, and crampy abdominal pain. What is the most likely diagnosis?

A. Diverticulitis
B. Colon cancer
C. Melanosis coli
D. Pseudomembranous colitis
E. Familial polyposis syndrome

Answer & Explanation

Sunday, January 29, 2012

Interviewing for Success

Guest post from Dr. Joseph Mazzei, D.O., Medical Director, BodyLogicMD of Chicago

Interviewing for residency programs can be a pressure-packed, daunting task.  Try to take a deep breath, relax and keep it simple.  The process is necessary, affording you the opportunity to find a program that fits your needs, while each program finds residents that fit their needs.  

Advice from Experience
The most important thing remember during each interview is to be yourself.  You could stress yourself out trying to determine who a particular program wants you to be or you can try to act like someone else in order to land a spot - however these tactics will not serve you well in the end.  An interview that is less than genuine will hinder your performance during the actual interview and potentially throughout the residency.  For example, if a residency program places great emphasis upon your participation in research, and you are not interested in doing research, this is not a good fit for you. You may want to be in the program because they possess a great reputation, but their reputation may not be the best thing for you. It would be best to find a program that fits you, rather changing who you are to fit the program. This does not mean, however that you should not care about what a particular program is looking for in a resident. 

Another important aspect of your interview is to be knowledgeable about their specific program. It is very important to be prepared. The more you know about the residency, the better equipped you will be to ask intelligent questions, gain information about the program and sell them on why they need you in their program. Asking questions is important. There are nuts and bolts questions, like “How much will I get paid?” or “How much call will I have?” and other similar questions. These can be answered by the human resources personnel. 

During the interview, you want to ask questions that mean something to you and the people in charge of deciding whether or not you will get into the program. For instance, you may have a strong interest in public health and are interviewing for an internal medicine program. You might ask, “I understand that you have a center for HIV treatment at your hospital. I have worked with this population in the past and have a strong interest in expanding my experience in this area. Will I have the opportunity to focus on this area of medicine during my time as a resident?” Questions like these open the door for you to talk about yourself and your unique qualities. It shows you are motivated and have taken time to learn about their program - you are not just going through the motions of multiple interviews. Interviewers see a lot of people - you need to know what makes you stand out from the other candidates and let it shine - give them a reason to choose you over anyone else. These questions also offer you the opportunity to gather more information about the program and determine if it is the right fit for you. Remember, the interview process is a two way street.  

Be certain to ask about all the aspects of the residency, such as the work environment and community.  Resident programs are trying to find people they want to spend the next several years with, i.e., people they enjoy being around. You will be spending a great deal of time with your fellow residents, therefore it is a good idea to choose residents who “play well with others.”

You may also want to consider inquiring about the social aspects of residency. For example, you might ask, “I want to work in an environment where residents are supportive of each other. Is the environment thought of as friendly and are their planned social events for residents and staff?” This shows that you want to be a part of their community. If this is important to the residency and you, it is a good question to ask. I had a buddy in medical school that was applying out west and was an avid rock climber. He asked during his interview if any other residents were into rock climbing. It turns out that the residency director was a big time rock climber and was very happy to welcome someone with common interests into his program. Again, be yourself. Be genuine.

When I interviewed with what turned out to be my residency program, the interview panel was pressing me on my grades in medical school. I was an average student with average board scores, however I had other qualities that I felt were my strong points. During the interview, several members of the interview panel, wanted to know if I had any excuses for my average grades - were there family stresses, illnesses, or other circumstances that interfered with my academic performance? I explained that I was proud of my medical school performance and that my goals were not to achieve high scores on tests, but to get the most out of my journey through medical school, which I achieved. They continued to press me on this. I knew a few things about this program. Residents were required to train at over 10 different sites at high volume emergency rooms in the Inner City. They needed someone who could adjust to new environments on a regular basis. They needed someone who was open-minded, flexible and who could learn best with hands-on experience and without rigid structure. They did not need people who only felt comfortable with their face buried in a book. They needed a person who could get along with a variety of personalities. I learned this from talking with residents within the program before my interview. I felt this would be the type of program that would benefit me the most and allow me to succeed. I responded to their questions about my grades by respectfully stating that if they are simply looking for a book smart student with high grades, then I am not the right person for their program. I then discussed what I had to offer and why I would benefit their program. There was a short silence and the next question came from the residency director. “What do you like to do outside of medicine?” he asked. I told him that I liked to brew beer, which we talked about for the next ten minutes. I was later offered a spot.  

My advice can be summed up as follows: know the program, know yourself, and be yourself. Things will work out.
Joseph Mazzei, D.O.
Medical Director, BodyLogicMD of Chicago

Question of the Week
During a laparoscopic procedure for a patient with a history of pelvic inflammatory disease and suspected Fitz-Hugh-Curtis Syndrome, what classic finding would you expect to see on the liver?

Answer & Explanation

Sunday, January 22, 2012

In Stitches

Eat, sleep, and breath medicine. That's how medical school is for so many who live through it. We get so caught up in the world of bacteria and mutant cells that we forget to live a little. The years in medical school are filled with crazy first experiences and stories that we would be wise to remember forever. Some moving, others hope inspiring and then there are those that just leave you in stitches.

Medical Memoirs

It wasn't long ago that I was traveling the country with countless hours on flights and layovers. I felt fortunate and honored that Dr. Anthony Youn had contacted me about his latest publication In Stitches, his medical school memoir. It gave me something to do during those long trips and kept me amused as I could so easily relate to his medical training experiences.

Now, I'm not normally much of a reader, but I was surprisingly drawn to the reminiscing of a fellow medical professional. A clever chronology of events, short stories and laughable themes kept me reading until I finished only days after beginning. Dr. Youn's adventure, and misadventure, portrayed the development of his character through inner trials and external challenges. As a young man slaving away to make his father happy, he realized along with his father that happiness can only come from following our own dreams. Achieving big goals requires a sense of confidence, boldness and stamina; all of which develop over time through humorous and touching events.

It was the perfect time for me to read his tales as I had been through the classwork, clinicals and would soon be starting residency. As a practicing plastic surgeon, he lives in the light at the end of the tunnel that is finally coming into view for me. No matter how difficult school becomes, at least there will be some great stories in the end. I think he sums it up well in this small paragraph:
Thanks to my small circle of close friends, my focus, work ethic, and drive to succeed, I slowly grew up. I entered medical school a shy, skinny, awkward nerd with no confidence, no game, and no clue. I came out, four years later, a man.
For someone entertaining the thought of attending medical school, current students, or one just wanting a glimpse into the life of a medical student, I would recommend this memoir.

Question of the Week
When inflating the balloon on a Foley catheter what is the proper solution to use and why?

Answer & Explanation

Sunday, January 15, 2012

Medical Sub-Specialization

Returning home to Las Vegas after touring the country means it's time to go back to rotations as usual. Fully expecting to hit some of the core specialties, I was surprised when I was assigned to urogynecology as an OB/GYN rotation.


Initially, I expected to be listening for fetal heart tones, delivering babies and controlling irregular menstrual cycles. When first learned of the specialty, there was not much guesswork as to the line of work we would be dealing with: incontinent women and prolapsed organs. It is so specialized, that it would be similar to finding a surgeon that only operates on right hands. The patients we see are generally very satisfied with their outcomes after surgery, probably because it changes their lives significantly.

It's exciting to think these last few rotations will move faster than any before as things are rolling downhill with great momentum. Experiencing sub-specialized medicine definitely keeps the study topics to a minimum when all I can focus on is the rank list and match. At least there are some aspects in every field of medicine that can be used in emergency medicine. So I am looking for opportunities to gain from this rotation those things that will be pertinent to my future specialty. Needless to say, but this has been a uniquely educational month with far fewer babies than I had imagined.

Question of the Week
What are the symptoms of urinary incontinence?

Answer & Explanation

Sunday, January 8, 2012

Residency Interviews - In Summary

Looking back over the last five months of 2011, I realize how busy life really was during that time. It seems that I was always on the road working towards the next step and getting ready to meet the next goal along the path. The bittersweet sunset to all the travels, new locations and challenging interviews has come and is now a memory.

Interview Season

Sometimes the numbers say it well:
  • 1 Board exam
  • 2 Case reports written
  • 3 Coasts
  • 4 Clinical rotation sites
  • 5 Months
  • 13 States
  • 14 Residency Interviews
  • 25,468 miles traveled

View Larger Map

It was a lot of road and air time, which I always thought would be fun. At first it was, but as time went on it became very exhausting living out of a suitcase and never in one place for too long. I met great people along the way and was able to visit some fantastic places which can be seen in the links below:
One might think from my photos that I wasn't doing much in the way of rotations at hospitals, but I would prefer to maintain some patient privacy while working. With all that excitement and stress behind me, it is time to prepare for the less adventurous yet fear provoking Match. In a week's time I will be submitting my rank list for residency programs and within a month hopefully hearing good news. It is just a matter of time at this point, but at least things are moving along well.

Question of the Week

What programs are the forerunners in your rank list?


    Sunday, January 1, 2012

    Residency Interview - The Fourteenth

    Strategic scheduling of my last interview of the season allowed me to squeeze in a Miami Beach mini vacation at Mount Sinai Medical Center. Of course I had to make a stop at the beach to recapture the benefits of natural sunlight the rest of the nation doesn't get during the winter months.

    Mount Sinai Medical Center

    Suited up for my last interview and enjoying the Atlantic coast sunrise flooding over the Biscayne Bay, I made my way to the bay-side hospital. Once a month the emergency medicine residents hold their weekly conference at Ryder Trauma Center associated with Jackson Memorial Hospital. After the guest lectures and resident presentations we stopped downtown Miami Beach for lunch with a couple residents. Once returned to the hospital, we toured the facility which has some of the best patient-room views I have ever seen!

    As the holidays were around the corner, only a couple students were being interviewed, offering more time for questions during interview sessions. I first met with the assistant program director with whom I had worked during my rotation months earlier. In addition to the generalized questions posed, I was presented with a series of clinical case scenarios. It was friendly discussion and an opportunity to see where I stand in my learning pursuits as well as my approach to problem solving. Similar scenarios spilled over into the following interview with the residents. Open communication and the welcoming attitude were greatly appreciated at this well known program.

    On this day of new beginnings, we contemplate where to direct our efforts in seeking happiness for the year to come. With interviews a thing of the past, it is time for me to focus on the decisions that will affect the rest of my career. The excitement of new adventures, challenges and aspirations is welcomed as I step forward into this time of transition, of reinventing myself. Happy New Year!

    Question of the Week
    What strong characteristics have you seen in other programs that attract you?

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