Neck Pain Treatment

One highlight for osteopathic medical students is obtaining hands-on training in Osteopathic Manipulative Medicine (OMM). Cervical spinal manipulations are among the most anticipated of techniques and thankfully have successful outcomes.

Neck Therapy

With the Hollywood stigma and the spine tingling sound of cracking, it is no wonder that we have had to wait this long to learn the mechanics associated with such treatments. As students we are just as nervous performing the technique as we are to be the patient on the table. The risk of severe damage is reported to be rather low, nevertheless, attention to properly performing these treatments is critical.

There are numerous resources available for learning the art of OMM and the American College of Osteopathic Family Physicians' website outlines a few of the more common treatments performed by osteopathic doctors. Although it is needless to say, there is more available than we students have time to consume. After learning it in the lab, we have to take it upon ourselves to make the time to practice our new skills.

In cases of somatic dysfunction, when a diagnosis is obtained, a trained DO can perform these treatments which relieve unnecessary pain and muscle imbalance. Because it is so sensitive, the neck can have a significant amount of dysfunction. Osteopathic cervical treatment is a quick way for the patient to find relief from their symptoms, and it is an enjoyably unique part of most osteopathic medical students' curriculum.

EKG Training

While working in the Emergency Department, I saw a lot of electrocardiograms (aka ECG or EKG) but did not have the training to read them correctly. Now in our second year of medical training, we are learning the basics of a somewhat complicated art.

Electrocardiogram

An electrocardiogram is a medical tool that provides an electrical reading of the heart's activity. Once you get past placing the leads in all the right places, it is a matter of understanding what the data is trying to say. With lines, spikes, bumps, depressions and what seemingly looks like cat-scratch, they can appear quite daunting to the amateur like myself. Careful observation and study of the markings can reveal a lot of pertinent information about the patient's anatomy and cardiac condition.

EKG training has branched out from the classroom to include online resources and texts that provide a quick reference to normalcy and abnormalities. As both an educational tool and reference book, Dale Dubin has published an easy to read book, Rapid Interpretation of EKG's, which I would recommend to any student of the art. Once there is a foundation of the principles, it is useful to consider a number of unique readings to see how they actually look. Dr. Wes, an electrophysiologist and cardiologist, occasionally shares EKG's on his blog for reader interpretation before posting his diagnosis. In this way, readers are exposed to various rhythms that demonstrate critical findings.

Being competent enough to know what you are seeing is a significant task when reading an EKG. With time and practice, I could be well on my way to understanding it a little better than before. Pathological indications will be jumping off the screen giving vital hints as to what treatments are required, and it's my job to recognize them when I see them. Fortunately, they will not be on living patients for another year.

Bicycle Transportation

We've only had three days of class and I already feel behind in my work. Between previewing lecture notes, reviewing lecture notes and reading the texts, I seriously wonder if I will have enough time to do anything else. At least getting to and from school will now be beneficial in relieving some of that stress. Check out my new wheels!

Scheduling Overload

Somewhere between the end of first year and the start of second year I lost a lot of important information mentally. As we cover certain subjects again, I can feel that sense of lost recognition. The professors certainly did not wait to open the flood gates and started in full force. After pharmacology and pathology were introduced, I felt my time would be well occupied. But it didn't stop there, they tacked on behavioral medicine, medical microbiology/immunology, clinical systems, osteopathic manipulative medicine (OMM), and objective structured clinical exams (OSCE).

On top of all that, I plan to squeeze in time for work-study in the anatomy lab, tutoring, several interest groups of which I'm an officer for two, and act as a "big sib" to a couple of the first year students. I smell burnout in the near future.

Stress and Anxiety Relief

In an effort to reduce some stress and use my time efficiently, I purchased a great bike at a great price thanks to Craig's List. Last year, I was in the worst shape of my life due to classroom inactivity. I'm hoping this year will be different. Amid the busy schedule, I don't see a whole lot of time for exercise and plan to ride my new bike to school instead of taking the car. Surprisingly, it takes almost the same amount of time to travel due to an abundance of traffic lights. At least this way I will be getting some movement into my otherwise sweat-less chair routine and burning useless calories in the process.

Sports Physcial

Not only is school starting in a matter of days for Touro University students, but high school students too are getting ready for the coming year. In conjunction with a local sports medicine clinic a few of my classmates and I teamed up to provide pre-participation exams for students trying out for various high school sports.

First Patient

Although our cadavers may have been our "first patients" as medical students, they were not breathing. So my first patient would have to be among the students I examined this last week. Each of the medical students were assigned an exam room where we obtained vital signs, medical histories, and performed sports physical exams.

After talking with some of my colleagues, I don't know who was more nervous, the medical students or the highschoolers. During first year, we were never instructed how to perform genitourinary exams. Given this responsibility among other tasks, we were expected to be professional and lead the exams in a timely manner. Looking back on it, it really wasn't so difficult. I assume at this point in my education, there are going to be a lot of firsts. Fortunately, this one was a positive experience.

I can tell there is a lot to be learned as the flow seemed a little choppy. In all, it was great exposure to the physical exam, younger patients, and my weaknesses as a learning student. It gives me something to work towards the next time around.

Healthcare Reform

Political propaganda just keeps rearing its face in lieu of the healthcare debate. Making sense of it all is an entirely different story and I am no where near understanding.

Healthcare Debate

With the new president and political party, we are soon to be introduced to a new form of healthcare. As medical students we may not yet be intimately involved in the business aspects yet, but we certainly will be in the future. Medicine as we know it today will change to adapt to the new policies decided in Washington.

In March, the largest gathering of osteopathic students and professionals held a conference in Washington D.C. to share their voice with politicians concerning healthcare reform. Considering the task before them, politicians may take a while before coming to a consensus, but the August deadline remains.

It is exciting to imagine how things will change by the time I and my colleagues graduate. Nevertheless, the majority of physicians are not content with the way things are moving. Understandably, the idea of doctors doing more and getting paid less is not an appealing alternative to their current standing. Perhaps if doctors were to be sponsored like professional athletes, there would be no need to worry.

Online Preparation

As new books are coming in, old books are being sold. The cycle seems a little ridiculous when we have so much technology available. How long will it be before there is an online medical degree for physicians?

Online Medical School

Although it may not be too far into the future before medical degrees come via online schools, at least online resources are a great place to study for such degrees. Whether a student or simply intrigued you can get a feel for questions that are asked on board examinations at WikiTestPrep. It is a free question bank composed to help students prepare for Step 1 (after second year) and Step 2 (near fourth year) board exams.

It doesn't take much time to answer a couple questions making this a simple addition to board prep exercises. Detailed explanations help to give a better understanding of difficult concepts. Add this to your routine as early as possible and reap the benefits when boards come around. Question banks are useful but can have expensive subscription fees which is why the above link is provided. Below are a few qbank offerings:

• USMLE World - ($185, 3 months, 2000 ?s) Good reviews
  
• Kaplan - ($189, 3 months, 2400 ?s) Most popular
  
• Exam Master - ($99, one month, 7900 ?s) Commonly free through school libraries
  
• USMLERx - ($129, 3 months, 3000 ?s) Similar to the Kaplan service but with a free trial
  
• Score95 - ($59, 3600 ?s) Poor reviews
  
• Scrub Notes - Blog post with an insightful qbank opinion

There may be other question banks available, but these tend to be the standard. I have been using Exam Master through Touro's library in addition to the WikiTestPrep just to get started. Getting in the right mindset to approach the boards has been a challenge, and the little time spent using these programs has been helpful in exploring the process. It may not get me a degree, but the internet has been my online medical school this summer and definitely keeping me busy.

Early Board Review

More than halfway through summer vacation and I can't seem to stop thinking about preparing for board exams and the second year of medical school. Despite being a year away, they loom incessantly in the back of my mind. It's time to start warming up the memory centers I turned off a while back.

Board Review Books

Since pathology is taught predominantly during the second year of medical school, it is wise to know the normal characteristics and actions of the physiological processes. Many students before me have suggested a self paced refresher course focused on physiology. For a relatively inexpensive price, I was able to procure the Board Review Series text. I figure with a couple hours every day I can at least review the important concepts so they are less foreign when we get into the material this coming year.

Many students have also recommended comprehensive books, such as First Aid for the COMLEX, First Aid for the USMLE, or question banks that will guide the study sessions towards board material. These are often used in conjunction with course materials throughout the year. In any case, there is more material available to prepare for boards than anyone has time to consume. As for enjoying summer to some extent, I think I have plenty of materials to work with and expect to see an improvement in information retention.

Clinical Corner

Home Medicine

Who isn't a fan of self-diagnosing? Admit it, you always try to guess what you have before asking the professional. I had an experience this past week where I was headed to the clinic and stopped at a book stand before arriving. To my surprise they had available a home edition of the Merck Manual. After a little thumbing, and I have to admit a selfish desire to have it on my shelf, I found a detailed description of the ailment, symptoms, treatment and more all in understandable English. For a quick reference, an abbreviated online Merck Manual is also available.

Matriculating Year Two

Hoping everyone had a great independence weekend, this blog comes to you while I'm actually out of town on vacation...enjoying every moment of it. Meanwhile back home, the school registrar is signing me up for the second year of medical school.

Registering

Registration has to be one of the simplest homework assignments I've had all year. With a quick signature, I was on my way to 45 more credits of graduate education. From what I have gathered, the first year of medical school is the most tedious as it concerns everything normal. Second year may have less credits, but a lot more material to cover in the way of pathological systems. Third and fourth years are just plain great due to the clinical experiences and freedom from the classroom.

Fortunately, some of the courses will be continued from last year so the terrain will not be foreign, but the rest will prove to keep me busy without a doubt. If Pharmacology and Pathology don't have me buried in a book all the time, I'm sure Clinical Systems will. (This comprehensive course, for example, touts a cumbersome set of notes and a lot to learn.) At least the information is becoming less dry and more interesting to learn as time goes on.

Assuming all goes well, I will be starting classes as planned in early August with adequate funds and supplies. In the meantime, I'll be enjoying vacation and honoring those who serve our country to protect our freedoms, thereby supporting my education.

Federal Student

Although I never really imagined having time to be employed anywhere as a medical student, I was happily surprised when the opportunity presented itself. This is the cadaver lab where we dissected cadavers and where I participate in the federal work-study program.

Federal Student Work

No longer a run-of-the-mill student, but a federally paid student, I reduce some of the hefty student loan I borrowed and learn at the same time. Nationally, students at more than 3,000 institutions are hired part-time to help in various operations and other positions. Almost two-thirds of the pay comes from federal funds geared towards students in financial need...for which most medical students qualify. The remaining third comes from the institution and all remuneration is tax free.

Once first year ended, I gained employment as a laboratory assistant in the bioskills and anatomy labs at Touro University-Nevada. Currently, the labs are home to 47 cadavers, the majority of which coworkers and I are preparing for the incoming DO class of 2013. Some are being prosected in preparation for allied health students within TUN's other colleges. I must admit that my job is probably one of the more unique federal student positions available.

In addition to earning a little extra among the cadavers, I will be able to brush up on anatomical landmarks and terms. This should bolster some of the already fading memories of structures once learned. Although impossible to work off my student loans in this position, if it helps when boards come around, I will be one step closer to graduating as a doctor. When that happens, no more federal student for me, instead my tax dollars will be feeding into the next generation of federally paid student employees.

Clinical Corner

Willed Body Program

The cadavers that are provided for students are obtained via willed body programs. A number of these programs exist around the country which are often associated with medical universities. An individual can specify that they would like their bodies to be used for the purpose of medical research by filing a donor form before dying. This gift to science has benefited the medical community in ways that the common public is not aware. In the university setting, these individuals are often considered a student's first patient.

Summer Exercise

We've already had a few days with temperatures above 100 degrees and Summer is officially here. It's time to enjoy this summer vacation before school starts again.

Mental Exercise

With some free time on my hands and in an effort to avert the quickly growing student loans I currently have, I tried out for the game show Wheel of Fortune. As exciting as it would have been to tell everyone I won thousands and a vacation getaway, my Wheel experience ended in the second round of auditions. Phrase, only vowels remain... B_TT_R L_CK N_XT T_M_. Left without much money and a stubby pencil as a souvenir, I am grateful for the mental workout.

Physical Exercise

High on my list of priorities for this summer has been eating nutritionally and getting in shape. Exercising right is time consuming and physically demanding. With the right tools and knowledge, workouts can be fun and rewarding.

In my search for exercise tools I have come across a fantastic website that crawls the web for the best deals in online stores. They provide definitions and guides in choosing the right product that meets your needs without the bias of commercialized businesses. With filters to narrow your search, it could not be simpler to shop the internet.

I have been looking for heart rate monitors for a while now, because meeting or exceeding 60-90% of your maximum heart rate is a significant part of an effective workout. Using a heart rate monitor will provide instant feedback that helps determine your level of exercise intensity, a major component in physical training.

When exercise intensity is not elevated, pedometers serve well to be riding your waist. They help track steps taken throughout the day which correlates with overall daily activity. Using a pedometer can help you reach the recommended amount of 10,000 steps per day by taking the guesswork out of counting the steps yourself.

What better way to model your new electronic wear than with a new pair of trail running shoes. Whether your in the gym or on a nature hike, your feet are often the most important part of your training. Recommendations are to replace your old shoes every 300-500 miles to avoid injuries from lost shock absorption and uneven tread wear.

With luck and a lot of effort, by the time second year comes around I'll be a little healthier and more prepared to take on the new year as long as I keep moving.

Discount Medical Books

It's time again to purchase the next series of textbooks and supplies. Those that cannot be found at Google Books may just have to be purchased at a reasonable price elsewhere.

Book Discounts

Fortunately, some professors reuse texts from the first year cutting down on book costs significantly. If this is not the case, here are a few learned ideas that may come in handy:

• Upperclassmen are often willing to sell used school books which would cut out the problem and expense of shipping and handling
• The school library will usually have course texts available for loan at no expense to you
• Deal Oz - Scouring more than 200 online stores, they find the best prices on the net, coupons and discounts apply to both new and used products...use it
  

Selling Used Books

If you are like most medical students, you are always looking for a little spending money, even if that means you just need to make up the difference in the cost for discounted books. It might be time for you to sell used textbooks. Honestly, most of them you will never use again and others will be outdated in no time. Rid your shelves of those that are taking up space while people still want them.

Despite the large variety of small textbook businesses, it may be wise to stick with the more common vendors; half, ebay, and amazon. If you would rather see your used textbooks go to good use, consider the incoming class, they will be looking for your great offers.

Physician Continuing Medical Education

Just when I thought my shadowing experiences had finished I was given the opportunity to explore medicine in a very different way through the Medical Education and Research Institute of Nevada.

Surgical Training

Currently, MERIN is the largest bio-skills lab in the Western United States and boasts their unique second floor observation area. Major medical companies converge on this site to host physicians from around the world for seminars and research on the latest in surgical techniques and procedures.

This well developed facility is housed under the Touro University Nevada roof, yet remains independent of the school. Willing medical students can spend a day rubbing shoulders with physicians as they learn or relearn critical medical treatments. With cadavers as patients, radiographic imaging when necessary, and the semblance of a sterile environment, the experience is the next best thing to performing the actual procedure on living subjects.

Their most recent clinic focused on pain management devices with guest lecturer Dr. James Chao from UCSD. (The subject matter was rather fitting as I recently finished shadowing a local anesthesiologist/pain management physician.) MERIN clinics host knee, shoulder, and hip surgical training to name a few. The two students in attendance moved among the stations with the doctors, networking and learning along with everyone else.

It is one of the few times, recently, that suggests the educational loans we students incur are going to be worth the pain. Although pain management may not be my specialty of choice, this experience certainly opened my eyes to the ongoing effort by physicians to maintain optimal performance and patient care through physician continuing medical education.

Shadowing

Now that school is out for the summer, we have taken to the clinics to see the local professionals in action. Job shadowing with a doctor permits medical students to learn by observation.

Job Shadowing

As I stood in the exam room, listening to the physician taking a history and performing a physical, I was impressed at how much I had learned from my first year of medical school. The terminology was not completely foreign and the medical principles behind diseases were still in my retrievable memory.

TUN students are responsible for shadowing two physicians for a period of 24 hours each. In an effort to cut down on wasted rotations, I chose to observe a gastroenterologist and an anesthesiologist. Despite some interest in their professions, I do not currently expect to choose either specialty, yet I continue to have an open mind towards both.

Thus far the experience has taken me to both clinic and operating room where I observe the doctor's responsibilities and techniques. Occasionally, the physician would surprise me with questions (known in medicine as "pimping") which often catch me off guard. If I can pull the answer out in a split second I feel pretty good, if not, they usually answer the question for me. That said, I find myself studying at home in between visits to prepare for my next pimping session.

Clinical Corner

Shadowing

My clinical preceptors have been fantastic, offering opportunities to educate and learn, they offer more to learn about their fields of practice than a book possibly could. To gain the most out of this experience, I would have appreciated a little more advice from our faculty. For what it is worth, I am listing some job shadowing tips. As usual if you have additional thoughts, please share.

• Set Appointments Early - Contact your preceptor early to set up shadow experiences (especially if it is a class assignment), there is greater flexibility and secretaries have little empathy for those who wait until the last minute
  
• Dress Professionally - This is a "no-brainer" but unfortunately there are some who do not
• Arrive Early - Plan to show up at least 15-30 minutes early, in the event a preceptor starts early or has time to talk it will be to your advantage
• Research the Position - Know a little about what your preceptor does and the educational ladder to get there before shadowing
  
• Questions - Do not overburden the preceptor with questions and carry a card to write on when they are busy performing their responsibilities so you can ask questions at more opportune times...nevertheless, ASK QUESTIONS, you are there to learn
• Shadow - Unless they ask you not to follow or copy them (hand washing etc.) you are there to experience it, do it too
  
• Study - If you have multiple days to follow a preceptor, take the time at home to study relevant terms, cases, diseases or ideas that you observed in preparation for the next visit
• Be respectful - Be nice to the other staff in the office and the patients or clients you work with, you never know when you will see them again
• Show Gratitude - Everyone deserves your appreciation for the opportunity, share it verbally and send a simple note of gratitude once you have completed your experience
  

Things I Wish I knew - First Year

After becoming a second year medical student two days ago, I looked back at the last year and gave each week a point value between 0 and 10 signifying my interpretation of medical school intensity where 10 is the greatest. Low points were often vacations (with the next few weeks prorated) and tallest peaks represent block weeks. Call me a geek if you will, but I think it's pretty cool to see the year in graph format.

Things I Wish I Knew

This last week of exams was not difficult academically, but was more so in anticipation of summer break. With one year behind me I have come up with a list of things I wish I knew before my first year of medical school.

1. Not all the textbooks were necessary - In addition to presentations and notes, the textbooks added a valuable resource, but there was simply not enough time to read every assignment. Occasionally, books were not even used. Contact current students and find out what they recommend. If possible, get used or discounted books. Often times they will already have markings of the material that is important and you save a little money too.
2. Much of the day is spent sitting - Time management is crucial to success. With excessive amounts of lecture and self study, there is little time to exercise. Elbows become sore and dry from hours at the desk, the back sore from pore posture, and the neck aching from constantly looking down. Exercise can be difficult to fit into the rigorous schedule, and it will make a great difference if included on a regular basis.
3. Organizing study habits takes time - It seems like a moot point because most people who get into medical school have some experience in studying. As one who has never used a laptop during class in undergrad, it took some time to learn how to organize my notes. When I realized that wasn't for me, I had to move back to paper. Transitioning between school and home is a challenge that requires attention. Having specific times dedicated to studying and following them will help significantly. Do what you are comfortable with, and most importantly how you learn best.
4. Associations are everywhere - At first it seems like you are struggling to get the fire-hose out of your mouth as far as information goes. Whether it is anatomical structures, terminology, or concepts it can quickly become overwhelming. For example, if you have experience with a condition you are studying (clinical, family or friends), it makes it a lot easier to remember and understand. Making associations to things you are familiar with personalizes the same message in a way you can comprehend.
   
5. Get involved - At first it was hard to imagine that there would be time to do anything but read. Initially, I was going to avoid the groups and activities until I could handle more which was not wrong thinking, and permitted proper time to habituate. Study groups are vital to bounce ideas and thoughts around. Student organizations are a great way to participate in community events and gain more experience. There is no better time to become a team player than in your first year class.

I am but one medical student in the sea of many. If you have something you wish you knew before your first year of medical school, please share.

Healthy Aging

As the semester and first year of medical school draw to a close, appropriately, we discuss the subject of aging.

Getting Older

Like a phenomenal French cheese or a well conditioned antique, aging carries a subtle tone of refinement. Unfortunately, with that comes the breakdown of tissues and a host of systemic problems. Despite being relatively young in years, it's nice to be growing older in relation to my education. I can certainly feel the tissue breakdown as my waistline and muscles tend to have a little more "give" than before. As for the systemic problems, neurologically I may have more stored away, but my brain has never been more ready for a break.

As depressing as the subject can be at times with all the diseases and disabilities that come about, there is still something to be learned. One fascinating discussion we had related to memory loss. When we learn something for the first time neural connections are made or activated allowing a short term memory to become long term. The circuitry is very susceptible to damage from a lack of oxygen or corticosteroids, which accompany increased levels of stress. That's when the light turned on above my head, "no wonder why I can't remember anything, too much stress and not enough fresh air." Well I am happy to announce, we only have one more week of educational stress and then a summer break to get the much needed fresh air.

Clinical Corner

Healthy Aging

"Use it or lose it." Eating right, regular exercise, and intellectual stimulation are exceptional ways to keep your body, mind, and spirit fit as it grows older. There are many problems that could be avoided if we simply worked hard to keep fit. Along the way we will incur our bout of troubles, but if we play an active role in our health today, tomorrow will be that much better. For more information on this topic visit WebMD's Healthy Aging Guide.

Kidney Health

What do acids, bases, filtration, resorption, and secretion all have in common? If the title and image have not already given it away, they are crucial components of the kidney's functioning.

Renal Physiology

From that glass of lemonade to micturition, we have most recently explored the kidneys down to the smallest functional unit, the nephron. Understanding how it all works can be complicated and at times convoluted (pun intended...for those who are kidney junkies). Fortunately, the internet is full of wonderful teaching aides and notes on the subject.

• Kidney Function - Flash tutorial that shows the absorption and secretion of various substances
• Mechanical Nephron - A digital video approach from the University of Hawaii
• Drawn Physiology - A collection of visual mnemonics

Although they are somewhat daunting, kidneys make sense, if studied enough. "Where sodium goes, water follows," and with that little phrase you have a lot of the kidney solved. Just make sure there is enough water in the system to begin with.

Clinical Corner

Hydration

Our bodies are composed of a majority of water, yet we don't replenish it often enough. Drinking 2-3 liters of water each day is a difficult task, but when we lose so much throughout the day it is important to replace it in order for our bodies to function properly. "Pee pale" is a suggested line that implies getting enough clear fluids so that the urine is less concentrated. This ensures a well hydrated body that can filter waste products, run vital molecular reactions, and maintain optimal health. So the next time you are about to order a fountain drink, get a water instead, your body will thank you.

Student Organizations

With the latest public health scare, swine flu, people are taking drastic measures to avoid exposure and in some cases society. There is no need to show up at work or school in your bio-suit yet.

Medical Student Organizations

I am certainly not avoiding the masses, at least not those that get together at school or in the community. As the first year of medical school comes to a close and the second year students are graduating from the classroom setting, each organization has to pass the torch to next year's student officers.

Organizations range from student government and class officers to a smattering of specialty interest groups. Recently, I was voted into office as secretary/treasurer of both the TUNCOM a cappella singing group "in TUN" and the "Emergency Medicine Interest Group." With the course load I anticipate next year, preparing for board examinations, and my involvement in another handful of groups these positions suit me just fine.

In preparation for residency programs, many students incorporate a variety of skills to better their curriculum vitae. Participation in student organizations provides opportunities for leadership, community service, and an unique way to learn a new skill or interest. Officers and members of these organizations build skills that are valuable in residency and future careers. Holding leadership positions, however, build a student's CV for the upcoming residency interviews. The bottom line is, get involved. Just like going from college to medical school, they will be looking for diversity and experience.

If your school doesn't have an organization that you think would be helpful, start one. Not only would you be a member, but you could be the founder too. If you are looking for organizations outside of school you may consider the Red Cross or Medical Reserve Corps for opportunities to get involved in your community.

The Immune System

Perhaps the denouement is behind us and we are finally on the down turn of coursework for the year. Getting out while the sun is still in the sky and having understandable lectures is a nice change for the new spring season.

Immune System

We have started our coursework in Immunity which at first seems a rather simple subject. It's not until you learn about the variability and diversity that exists when it becomes very complex. Sometimes I wonder why my immune system is just not performing so well. Does anyone know how to treat chronic rhinorrhea? Perhaps when school is out it will cure itself.

The immune system has many components that together provide a healing response to invasions. Having a good knowledge of individual parts will simplify the learning process of understanding how they interact to function efficiently. Although it is good fun learning how it all works, experiencing this process is anything but fun. Fortunately, vaccinations are available to help ward off possible infections.

Resistant or mutant strains of viral and bacterial organisms can prove to be chaotic. The common cold and flu are results of this phenomenon as well as more serious illnesses. Despite our best efforts to enhance the immune system with pharmaceuticals and exercise, it will still have the occasional bout of weakness leaving us in the proverbial pits.

Creative minds have made a variety of infectious agents available for purchase with an added sense of comfort and wit. Check out these giant microbes.

Clinical Corner

Antibiotics

Physicians prescribe antibiotics to eliminate infection. A growing concern is the resistance that develops when patients do not finish their prescribed antibiotic regimen or take it as prescribed. (Some of the bacteria that is not killed may not be susceptible to the specific antibiotic.) This leaves a window of opportunity for bacteria to alter its response to drugs creating a new strain that is more resilient. If this continues to occur in the general population, antibiotics may not work on general infections causing severe complications in public health. The moral of the story, take your antibiotics the way your doctor prescribed them.

Starting Refreshed

The taxes are filed, financial aid has been requested and the groceries have been purchased. It sounds like spring break has been a success, not to mention sleeping in once or twice.

Back to School

It was hard to stay away from the books for a week knowing full well that the next six weeks will be building upon previous information. Gearing up for the last block of the first year of medical school has taken some effort as the tank of enthusiasm was reading empty.

Fortunately, the last set of exams went well and only one exam week remains. We are on the verge of starting two new subjects Renal Physiology and Immunology. From my understanding both are rather challenging subjects. I will take their word for it as I have learned professors know how to pack a lot of information into a few weeks of lecture.

Clinical Corner

Sleep

Sleep, it does a body good. Sleep disorders can make getting the rest you need very unpleasant. Circadian rhythms help to cycle our sleep patterns which induce relaxation and waking affects. No less than 7 hours of sleep are recommended to maintain optimum health and cognitive functioning. Thanks to spring break, I think I am back on schedule.

Technology and other methods are available to help individuals who suffer from the lack of a good night's sleep. If you are having trouble sleeping or getting your child to sleep, check out the Marpac SleepMate and the Conair Sound Therapy Clock.

Spring Break

As I wait to board my plane to kick off spring break, the ringing of bells and spun slot machines echos in the background. They are one of the obvious features of the Las Vegas airport that seem to pacify impatient passengers looking for one last effort to win a buck. I'm just trying to get away from it all.

Vacation

This break could not come at a better time. I know my classmates and I were all burnt out, ready to get a breather from the books and excessive notes. The thought of getting away for the entire week and a half was tempting, but the weather in Vegas is just to nice to miss out this time of year. (I'll be back to enjoy the weather soon)

TUNCOM provides a spring break during the passover holiday, which extends beyond the common week-long break. In an effort to get my head out of the books and into the real world setting, I plan to visit the Emergency Department where I gained most of my clinical experience. This is a much needed reminder as to why I sit through 8 hours of lecture and lab every day. Being among the patients and providers has appeal that cannot easily be put into words.

Safe travels to my colleagues, Happy Easter or Passover to you, and welcome back Spring!

Choosing a Medical Specialty

After a grueling week of exams I finally had time to repose and realized it has been one year since the start of this blog. Thank you to all who read and comment, your encouragement is greatly appreciated.

Clinical Experience

With one more exam week in the past, I had time to consider my future as a physician. Knowing what field of medicine to enter is the difference between a happy doctor and the miserable one you don't want an appointment with tomorrow.

As is the case with other medical schools, TUNCOM offers students an opportunity to shadow physicians as an introduction to clinical medicine. For some, this experience can be an eye-opener to the routine doctor-patient interactions they will one day conduct. Fortunately, I have some clinical experience under my belt and will be using my shadowing experience to explore some of the various fields I may not have otherwise considered.

Although I have a few fields of interest, I would like to ensure my rotation months are spent in quality rotations that pertain to my future. Too often, students return from rotations only to realize they have just wasted a month of their time in a field that has no personal appeal. That said, I feel confident that the more clinical experience you can get, the better.

Clinical Corner

Medical Specialty

In an effort to save you precious time, I have listed a few resources that you may find valuable in your search for the perfect specialty.

• Specialty flowchart (above) - It is a quick and simple method of generally learning where you stand with an added touch of witty humor.
• Specialty flowchart No. 2 - If the first one didn't cut it, try this one.
  
• MSAT - Short for Medical Specialty Aptitude Test, the University of Virginia has compiled a simple survey that takes 10 minutes to complete. The results are ranked specialties according to the answers you provide.
• The Doctor Job - Gives a great rundown of the basics along with factors to consider when choosing a specialty.
• The Ultimate Guide to Choosing a Medical Specialty - Written by a resident for students choosing a specialty.
  
• Specialty Ranker - I have put together a modifiable document that allows you to view various aspects of individual specialties and rank them according to your interests. It covers the basic specialties and then some. If you would like to try it, click the image to the right and save it to your computer. Leave a comment or email me if you have questions. Please consider donating $1 payable through PayPal in exchange for this file...thanks and good luck!
  

Exam Week Five

One exam down, only seven more to go. Spring Break has never looked so good. If you are looking for me, I am probably under a pile of books, flashcards, notes, and other reference materials. In the meantime, check out these great resources:

• Poor MD - Great financial advice for every medical student or resident
• Health Blogs - Extensive list of 883 medical blogs
• Cases - Organized clinical cases according to system
• Test Prep - Materials to improve your board scores
  

Problem Based Learning

Like something out of an episode of "House MD", our first year medical class broke up into small groups to make our attempt at a clinical case.

Problem Based Learning

I was a little unprepared when I was chosen to be the group leader for our first case. We were asked to develop questions and an organized method of investigating a case to obtain a history and physical. Fortunately, we had a faculty physician to guide our steps in the right direction or it may have taken a lot longer to get to the treatment.

Although these are simulations, it is a great way to see how our knowledge base has advanced. The clinical skills may be lacking, but we can still apply diagnostic tests, reasoning, and questioning skills to build a case and develop a differential diagnosis.

Every couple weeks we gather again to work another case and hone the skills we will need next year when we have patient actors. Although House may be make-believe, the process of getting to a working diagnosis is still a matter of clinical processing. It is going to take a lot of practice before we feel comfortable in that position. If you have suggestions in collecting a patient history, SOAP notes or other case building ideas, please leave them in the comments below.

Clinical Corner

Hygiene

One of the easiest ways to avoid illness is to wash your hands often. It takes little time and avoids the frustration of becoming sick.

Public Health

President Barack Obama addressed improvements that will be made in the public health sector, "...Americans can trust that there is a strong system in place to ensure that the medications we give our children will help them get better, not make them sick; and that a family dinner won’t end in a trip to the doctor’s office." [Full text] Our safety potentially lies in the hands of those who regulate our foods, vaccines and medications as well as the physicians who intervene locally.

Public Health

It is nice to see correlates between medical school and the real world from time to time. We recently started a course that looks at our current public health care, how to produce the greatest benefits for the community as a physician, and how to interpret the information researched by others.

Although the system is not perfect, public health policy has an agenda to provide a safe environment from illness through detecting, reporting and treating diseases that arise among the general population. By tracking the spread of illness and providing interventions such as vaccines or prophylactic support, physicians can impact individuals and communities alike. It is important that public health research be performed in an effort to educate health care providers concerning the diseases they fight.

Clinical Corner

Disease Prevention

There are cases highlighted around the world that reiterate the importance of contributing to the overall public health in our communities. Below are some valuable resources for both the aspiring and practicing physician (most can be downloaded in portable document format):

• Center for Disease Control and Prevention - Online health resource
  
• Guide to Clinical Preventive Services - USPSTF recommendations on screening, counseling, and preventive medication topics including clinical considerations
• Morbidity and Mortality Weekly Report - CDC reports available in text and podcast
• Immunization Scheduler - Children 0 to 6 years, provides personalized dates
  
• Child Immunization Schedule - 0 to 18 years of age
• Adult Immunization Schedule - 18 years and older

If you know of other helpful resources, please post them in the comment section. In the meantime, lets do our part to be educated and stop the spread of disease. Oh, and clean your stethoscope once in a while, it will do your patients' body good.

Powerful MRI

In conjunction with our Neuroscience coursework, we integrate the use of radiological imaging to visualize cranial structures as this is how we will see them most often. As seen in the image, technology is advancing quickly permitting greater medical flexibility.

Radiology

After spending the past few months learning the anatomy of the brain, we had guest lecturer Dr. William Orrison, Chief of Neuroradiology from the Nevada Imaging Center, present on neuro-imaging and research. He was the first individual to be scanned with Toshiba's 3T MRI and is currently researching the extent of its capabilities.

The 3.0 Tesla MRI detects 320 lines of data with one turn making it quicker than older devices. Imaging studies use less contrast and produce data that is more detailed than previous machines. With all the data this powerful machine collects, 3-D images can be produced as well as dynamic motion of anatomical structures, diffusion tensor imaging (shown above), and angiography. Shortening scan times from one hour to a matter of minutes and data interpretation to a few minutes time makes this machine the new standard of care.

Despite its arrival last year, this new MRI is being used around the world to change the way physicians use diagnostic imaging. It is an exciting time to be in medicine and especially as a student. The tools of our generation will be vastly different from those of former professionals and I am certain that within the next few years advances will continue to come about, ultimately revolutionizing the practice of medicine.

Clinical Corner

Cerebrovascular Accident

A CVA or stroke occurs when the brain tissue losses blood and nutrient supply. This is similar to a heart attack and is sometimes referred to as a brain attack. Commonly this occurs as a result of blood clots that block blood vessels to certain parts of the brain. Neurological deficits result that give an individual indications that medical care is needed. There is a small window of opportunity for physicians to medically intervene and such symptoms should be treated as emergent. Diagnosis includes the use of radiological imaging to confirm the presence of a stroke. Imaging techniques may also be used to treat or remove stenosed or blocked vessels.

Conferences

Conferences tend to be a great way to gain knowledge, meet others in the field, and learn the latest skills in the field. I had no idea they give out medical degrees too.

Conference

As part of the first year curriculum, we are exposed to a medical jurisprudence course that incorporates medical law and ethical questions. Our professor is affiliated with the American College of Legal Medicine, which hosted a mock trial this past week. For someone such as myself, who has never set foot in a courtroom, this was a great opportunity to see the workings of a medically related lawsuit. It included a judge, witnesses, attorneys, evidence and the audience participated as a jury.

Certainly, the identification card which I was given is in error, but it does give me something to aspire to in years to come...the physician part anyway. And with any luck or skill, I won't be the defendant in such a case. If you are looking to attend an upcoming conference, consider these resources:

• CME Mall - One stop source for CME and conferences in the US
  
• New England Journal of Medicine - Includes a search tool for better specificity
• American Osteopathic Association - CME courses and tools
• American Medical Association - CME resources
  
• American Medical Student Association - Specific to pre-med students

Clinical Corner

Pneumocephalus

This is the condition that was in question during the mock trial which is characterized by air located within the cranial cavity. In that case it was a result of neurosurgery, but it can also arise from head trauma or basal skull tumors. When the air is trapped in the skull it is considered a tension pneumocephalus and radiology tests commonly find the frontal lobes of the brain compressed in what is known as the Mount Fuji Sign. Complications include neurological changes, therefore treatment is quick to follow ultimately removing excess air and repairing any bony defects. [Patient Case Review]

Things That Might Kill You

Exams are over and the weekend was great...for doing taxes. On the positive side, in addition to an expected great tax return, our anatomy course is complete and I think I still have a passing grade in all my classes. Spring break is really starting to look exciting though, when does it get here?

In the wake of my so called break from the books, I found this great book that every hypochondriac or medical student should add to their library, even if just for laughs.

If I remember correctly, last week I had Marfan Syndrome, I kid you not! Fortunately it probably wouldn't kill me. Taxes almost did and exams left me hanging by a thread, yet I staved them off.

Clinical Corner

Marfan Syndrome

This genetically inherited group of symptoms is often characterized by individuals who are tall and have thin, long fingers or arachnodactyly. They may have disorders of the heart, lungs, eyes or other systems. It was the pectus excavatum that convinced me I had it, but fortunately this is not definitive. Despite not having a cure, life expectancy is growing and can be supported by regular check ups for specific complications.

Exam Week Four

Stress Reduction Kit

Directions:
1. Print the image shown
2. Affix printout on FIRM surface
3. Follow directions in the circle
4. Repeat step 3 as necessary or until unconscious
5. If unconscious, cease stress reduction activity

Exams

It's test time again. This time seems a little different as I am learning to get the hang of these exams. The professors are therefore testing on more material and often it is of a more complex nature.

I want to do really well...duh, who doesn't. This week will include the first of our neuroscience exams and the last of our anatomy exams. It is hard to believe we have come this far, six months to be exact. They keep us so busy that time has flown by. That is likely why the stress is mounting as it is really difficult to keep up. I have come to the conclusion that it is only a week long, and when it is over, it's over. I can only give it my best, and in all honesty, reviewing notes that equal a ream of paper is going to take some time and a lot of brain power. I am going to find a nice textbook to keep me company until the flashcards call my name. Wish me well!

Clinical Corner

Stress

Please don't use the stress relief kit above, I would hate to be responsible for your headache in the morning. Instead, invite some eustress (good stress) into your life.

The Brain

Did you get all that? I'm still working on it myself. Neuroscience is one of the dreaded courses in medical school for good reason. We are only beginning to scratch the surface.

Neuroscience

The brain is complex, period. Pinky and the Brain make it look so easy, but keeping all the information in my head is another story. For what it is worth, they are certainly keeping us busy memorizing structures and knowing how they function.

It is amazing to think that for most of us, during our developmental stages, all the nerve fibers make it to the right location to perform their proper functions. There are so many connections, tracts, and pathways that the brain is not completely understood.

Clinical Corner

Healthy Brain Development

Unfortunately, proper brain development is not always the case and severe deformities or neurological deficits may occur. Many factors contribute to poor fetal development such as maternal nutrition, infection, trauma, and genetics. One of the easiest ways to avoid these deficits is for women of child bearing age to maintain a healthy diet. Maternal nutrition often dictates the development of her unborn child and cannot be compensated for after birth in all cases.

The Mayo Clinic lists some foods that pregnant women should avoid while the government sponsored Department of Health and Human Services provides a great resource for nutritional recommendations. As for the rest of us, here are 7 tips for increasing your brain power. For more information on nutrition check out these books.

Tax Time

Just when things start to mellow out, I can feel Uncle Sam reaching deep into my already emptied pockets. It's that time of year again when W-2 forms show up in the mailbox, numbers get crunched, and taxes get paid.

Tax

Considering all the things that taxes are used for I guess they aren't too terrible, but they certainly don't help my situation financially as a student in plenty of debt. Once all the government documents arrive and get filed we get to file even more as students.

It wouldn't be possible to pay for school without a little help from the government. Therefore, completing the FAFSA and other scholarship opportunities permits my education to continue. Considering some of the tax breaks, the process a little more bearable (thank you new house). I certainly don't mind being able to file taxes for free.

Expenses

As the numbers become quite important, I thought a running total of expenses for Touro University Nevada's College of Osteopathic Medicine would be appropriate.

• Tuition - Roughly $37,000
  
• Books - $1000.45 (Used and new)
  
• Equipment - $1,550.65 (Laptop, lab coat and diagnostic tools)
  
• Clubs - $40
  
• Extra - $202.29 (Software, vaccines, etc)

Obviously these will vary from year to year and student to student, but it is in the right ballpark. Moving, housing and food expenses have not been included. With Valentine's Day around the corner, you can help curb some of these costs and get some fantastic deals, consider some of these great gift ideas.

Clinical Corner

Epistaxis (Nose bleed)

Research says that about 90% of nose bleeds occur as a result of damage to Kiesselbach's area. It is found in the front part of the nose and has a rich blood supply. The predominant reoccurring trauma is caused by fingers that are doing too much scratching. A smaller percentage comes from the back of the nose that cannot be reached by fingers which often requires medical help. Stopping a nose bleed may take time, and is good knowledge to have if you ever need it.

Cranial Nerves

This weeks dissection finally came to a head, literally. We sawed into the skull to remove the most important and complex organ in the body.

The Brain

It was likely the most fascinating dissection yet and breaking the brain into its parts and functions has been no simple task. With a test slated early this week, we are feverishly cramming as much information, as humanly possible, into our own heads.

Specifically, the cranial nerves pose a threat to a decent grade. In an effort to help the student who has to learn them too, I have included resources that I found to be beneficial. These include memory aides, mnemonics, charts, and more. If you have suggestions of your own, please post them in the comments to share.

Cranial Nerves

• David Darling online encyclopedia - includes great links to individual nerves
  
• Chart including nerve components, functions, and pathways
• Extensive list of mnemonics
• Easy memorization technique for the nerve components (shown below) by a former student

"Great Virginia, Sweet Virginia, G Veg Save! SSA does two and eight."

The "G Veg Save" part confused me at first – obviously it helps you remember to list GVE, but then you continue onto the next line so you can finish spelling "Veg", giving you a lonely G. So you finish that line with a "SA", then put "SVE" on the line after that, so that you (sort of) spell "SAVE." Giving you:

GVA –
SVA –
GVE –
GSA –
SVE –
SSA – II & VIII

Now, which cranial nerves have a whole bunch of components in them? VII, IX, and X, right? So fill in the list like this, leaving spaces as indicated – the GVA list is complete and doesn’t need a space:

GVA – VII, IX, X
SVA – ___, VII, IX, X
GVE – ___, VII, IX, X
GSA – ___, VII, IX, X
SVE – ___, VII, IX, X
SSA – II & VIII

Now, start counting in odd numbers to fill in the spaces (you’ll use V twice, otherwise you’d be listing VII twice for SVE. So your list looks like this now:

GVA – VII, IX, X
SVA – _I_, VII, IX, X
GVE – _III_, VII, IX, X
GSA – _V_, VII, IX, X
SVE – _V_, VII, IX, X
SSA – II & VIII

Add XI to the SVE list, because it belongs there.

GVA – VII, IX, X
SVA – _I_, VII, IX, X
GVE – _III_, VII, IX, X
GSA – _V_, VII, IX, X
SVE – _V_, VII, IX, X, XI
SSA – II & VIII

So what’s missing? Of course, GSE! And for GSE, list the cranial nerves that don’t show up anywhere else in the lists, plus III.

GVA – VII, IX, X
SVA – _I_, VII, IX, X
GVE – _III_, VII, IX, X
GSA – _V_, VII, IX, X
SVE – _V_, VII, IX, X, XI
SSA – II & VIII
GSE – III, IV, VI, XII

Best of luck to all those who have to endure this complicated study. For more enlightening materials discussing the brain, consider these books.

Upon Further Examination

To fully investigate all aspects of my experience, I'd like to welcome my wife as a guest blogger for this week's post. Consideration of those friends and family members who are affected by my decision to attend medical school is important - especially since I'm married.

Willow

Thanks for the invitation, Josh. Here's my two cents on, Life as a Medical Student's Wife:

I was fortunate Josh knew he wanted to pursue medical school when I met him six years ago. Witnessing the satisfaction he received from previous involvement in the field has been crucial in helping me to be continually encouraging throughout the constant requirements and expectations that school demands. Although I'm not the one sitting in front of a book every night trying to soak in endless pages of information, medical school for me has been equally demanding of my time- and lack of time- with my husband. It has been crucial that I involve myself in my own career, community and personal interests as diligently as he is involved with school. Without my own schedule, having a husband in medical school would never work for me.

Moving to a new location, regardless of the field of study you are entering, always integrates a period of transition. Fortunately my career moved with me, so I did not have to find a new job, but socially it has been difficult to find women in the Las Vegas area who are not solely interested in clubbing on the strip, shopping or eating out for entertainment. Since I work from home as a designer for a company out of state, the ability to connect with women in the work field is difficult. So, I started teaching yoga at a gym and have found many interesting people from all walks of life congregate for fitness. Having an additional social outlet outside of my marriage has been integral in keeping my personal sanity during medical school.

In my Utopian ideals, I believe you should connect with your spouse on a daily basis. Early in our marriage I read it was important to have at least 20 minutes alone everyday with your spouse without interruption in order to maintain a healthy relationship. That usually happened. Since medical school, I have learned to be flexible regarding how, when, and where that connection happens. All the wives I've talked to dread block weeks- I am lucky if I get five minutes of undivided attention. I'm also left doing all of the "chores" on my own, and suddenly I realize just how often Josh really does the dishes. The school let us know up front that the schedule would be demanding, and our relationship has had to adjust to those demands. Having that forewarning has helped us keep the demands in perspective and adjust our needs appropriately. Sometimes this happens more easily than others.

Thanks for sharing Willow, you have been extremely supportive and flexible. To see what she has been up to lately, check out her Fresh Squeeze.

Clinical Corner

Tools of the Trade

Learning clinical skills requires knowing how to use the tools at our disposal. Diagnostic sets that include an otoscope and ophthalmoscope come in many shapes, brands, and styles. Welch-Allyn tends to hold the gold standard in this arena and rightfully so. They guarantee their products to students as long as they are in medical school or residency. With that, the prices don't seem so bad.

Although my wife is greatly supportive of my endeavors, she still has a hard time swallowing how this small package of tools can be so costly. Thanks for sitting patiently as I used my new equipment to practice my exams, did I mention how great your eardrums look?

Financial Pill Popping

With a new year comes new policy that may have significant change in how future physicians practice medicine. The Pharmaceutical Research and Manufacturers of America (PhRMA) has adopted a new code of conduct that goes into effect January 2009.

Prescription

Making drugs to fill prescriptions is a difficult task requiring years of research, money, and physicians who will prescribe them. A large sum of money is used to buy cheap pens, "free" lunches, or even more lavish gifts that entice clinicians to write a prescription for the latest wonder drug.

PhRMA has revised their code of conduct to put an end to the handouts among their distributing members. Freebies would otherwise raise the ethical question, "is my doctor prescribing this for my best interest or theirs?" Since handouts cost money, drug companies have to increase the cost to the consumer to pay for them. Why not spend the money to produce better pharmaceuticals through well funded research using the money allocated to the 'perks' column in the budget?

Medical students and practicing physicians alike will have to adjust to drug reps without cheesy stationary and edible giveaways. Perhaps the students will be fortunate to never know this ethical dilemma. Although the code attempts to curb the compensations, pharmaceuticals still remain a business that will get money in its pockets any way it can.

Clinical Corner

Blood Donation

After years of putting it off, I finally donated my blood to help the cause and it just so happens to be the National Blood Donation Month. It cost me one hour, one pint of blood and a couple signatures. In return I received one hole in the arm, a purple bandage wrap and the opportunity to help treat and potentially save the life of a patient as a medical student. Blood banks are often in great need of donors as so many patients require transfusions. If you are looking for a great way to serve, consider donating blood and helping those in need.