Practice of Medicine

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

Family Medicine

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

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

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

Question of the Week

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

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

Answer & Explanation 

Culture Shock

Enfermera, hable por favor! 

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

Lessons in Living

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

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

Question of the Week

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

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

Answer & Explanation

Controversial Medicine

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

Stem Cells

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

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

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


Question of the Week

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

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

Answer & Explanation

Medicine in Words

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

Sharing the Journey

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

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

Question of the Week

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

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

Answer & Explanation

Treatment Options

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

Treatment Modalities

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

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

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

Pimped Question of the Week

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

Medical Learning

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

Getting Pimped

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

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

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

Pimped Question of the Week

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

Urgent Care

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


Hit the Ground Running

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

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

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

Board Prep Question of the Week

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

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

Answer & Explanation 

Clinical Rotations

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

Third Year

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

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

Board Prep Question of the Week

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

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

Answer & Explanation

Third Year Begins

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


Rest and Relaxation

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

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


Board Prep Question of the Week

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

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

Answer & Explanation

R.I.P. USMLE

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



USMLE

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

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


Board Prep Question of the Week

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

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

Answer & Explanation

Medical Boards

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

The Final Push

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

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

Board Prep Question of the Week

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

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

Answer & Explanation

Preparing for Boards

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

A Day of Board Exam Preparation

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

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

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

Board Prep Question of the Week

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

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

Answer & Explanation

Things I Wish I Knew - Second Year

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

Looking Back

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

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

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

Board Prep Question of the Week

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

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

Answer & Explanation

Playing Doctor

Anticipating the start of clinical rotations, we were oriented to hospital procedures and scrubbing techniques this week. They made for long days...thankfully there won't be a test.

Sterile Technique

Despite having classes behind us and the board exams ahead of us, we couldn't quite crack the books until we were oriented properly for our rotations. This particular exercise gave us an opportunity to "scrub in" from fingernails to elbows and donning a sterile gown and gloves. It can be a challenge the first few times trying not to contaminate oneself, but the no-pressure environment was perfect for learning this skill. We may not be as proficient as some, but at least we know the basics of the surgical scrub.

It is hard to believe that the second year of medical school has passed so quickly. By keeping us busy all the time and always preparing for the next exam or quiz, we didn't have much time to really slow down. Fortunately, all the grades have been posted and I am still in "good standing" with the university. It's just a matter of time before I can say the same about board exams. In the meantime, the morale boost we get from doing doctorly things will have to feed our fires for this career we have been working hard to achieve.

Board Prep Question of the Week

An 8-year-old boy presents to your clinic with a history of nonproductive cough and recurrent opportunistic infections. His mother claims that the symptoms first arose about 2 years ago and previous physicians suspected an immune deficiency disorder. A chest X-ray reveals patchy infiltrates and diffuse clouding. Bronchiolar lavage identifies numerous neutrophils arranged in isolated conglomerates. Nitroblue tetrazolium dye reduction test is negative. Which enzyme is most likely deficient in this child?

A. Alpha-ketoglutarate dehydrogenase
B. Dihydrofolate Reductase
C. Glutathione Reductase
D. NADPH Oxidase
E. Topoisomerase

Answer & Explanation

Easing the Pain

Like something seemingly out of a torture camp the Transcutaneous Electrical Nerve Stimulation (TENS) unit is actually designed to relieve pain and discomfort through a small portable device. 

A New State of Comfort

Finally able to breath again and catch up on my sleep, I still find my back and neck sore from the long hours of hunching while studying for exams. A good night's rest and a session of yoga at the gym quickly helped ease some of the tension that built up over the last couple weeks. For some people, however, pain can be an ongoing problem that limits their daily functioning and even compromises optimal health. Recently, I heard about muscle stimulators and their non-invasive approach to easing sensory and motor deficits. Despite their evil look, some people swear by their effectiveness as adjunct to common medicine.

Although not effective in all cases of chronic pain, TENS Units are an alternative approach to the use of medications and more invasive methods of treatment that aim to reduce neuropathic pain. By stimulating nerves to release inhibitory (GABA) signals, the sensation of pain can be reduced. Among the research is a case that shows there may be some benefit to the use of such systems in restoring sensation where it has previously been diminished. For additional information about LGMedSupply's products visit their online customer blog. Otherwise, if you have used a similar device, I would be interested in hearing your feedback on the subject.

Board Prep Question of the Week

An 18-year-old girl from Southeast Asia presents with symmetric ascending weakness below her knees. She has been unable to walk for 3 days. Physical exam reveals mild hypotension and papilledema. Upon respiratory support and administration of IV immune globulins and plasmapheresis, her condition resolves after 2 weeks. Which of the following is the most likely etiologic agent of her condition?

A. Acid sphingomyelinase deficiency
B. Arylsulfatase A deficiency
C. Infection with C. jejuni
D. Infection with JC virus
E. Microsatellite instability on chromosome 4

Answer & Explanation

Second Exam Week Six

Now that our classroom career is over and the last set of exams are here, it is time to study. Fortunately for us, the first tests last week were in Osteopathic Manipulative Medicine. This meant one good corporal realignment before a week of uncomfortable postures and mental torture.

Final Adjustments

"...Take a deep breath." I then waited as my study partner dropped his weight on my upper body and we both felt the audible release of a vertebral segment that was misaligned. In no time the pain was gone and we moved on to continue our studies. As this was our last set of exams, we had the task of performing a full body evaluation and applying a specific treatment of our choice aimed to restore function. Since we were successful in treating each other in practice, our partners the next day had little to correct during the test. I think I am going to miss these little "corrective" sessions.

The thought of being finished with school is really exciting. It doesn't take long, however, to remind myself that as soon as this week is over, it will be time to dig deeper in preparation for board exams. (So much for having a vacation between school and rotations.) One thing is for sure, this experience has been so much better than I could have ever imagined. Sure, it has been difficult, but it continues to pique my interest and lift my thoughts to a better future.

Board Prep Question of the Week

A 13-year-old figure skater botches a quadruple lutz and falls on her right outstretched hand. Several weeks later a cast is removed for a healed scaphoid fracture. She begins having episodes of intense burning pain, sweating, swelling, and redness that begin in her right hand and moves up her forearm, sometimes up to her shoulder. These episodes often occur when she is angry or upset. On exam her arm shows no visible abnormalities. Which of the following nerve types are involved in the pathogenesis of her disorder?

A. General somatic afferent
B. General somatic efferent
C. General visceral afferent
D. Special somatic afferent
E. Special visceral afferent

Answer & Explanation

Fetal Development

I remain in awe that a body can reproduce its genetic code and create life as seen in this video.

The Making of Mothers

Preheat the oven to 98.6 degrees, place it in the endometrial wall and let it slowly rise over the next nine months. If only fetal development were that simple. Below are some of the highlights of embryologic formation with which most people never really become acquainted. Welcome to life as a medical student.

First Trimester - Weeks 1-14

• Week 1: Fertilization, morula, blastocyst(Day 5), endometrial implantation(6) and hCG from the syncytiotrophoblast
• Week 2: A bilaminar disc forms(8) and uteroplacental circulation starts(13)
• Week 3: The primitive streak is evident and the central nervous system begins via the notochord and neural plate; appearance of somites(20)
• Week 4: The neural tube closes leaving cranial and caudal neuropores(23), limb buds develop(28), and the heart begins to beat
• Week 5: Facial development, pharyngeal arches and clefts take shape
• Week 6: Fingers start to appear(38), endodermal derivative development (lung, stomach, pancreas, intestines, liver, gallbladder, urinary bladder)
• Week 7: Toes develop, maxillary and medial nasal swellings fuse to form upper lip
• Week 8: Fetus has the appearance of a baby and begins to move; heart sounds can be heard
• Week 9: Eyes and ears form as face and other organs continue development
• Week 10: Male and female genitalia are identifiable
• Weeks 11-14: Fine hair (lanugo) starts to appear; muscle and bones develop

Second Trimester - Weeks 15-27
The bones begin to harden, finger and toe nails form while the fetal organs continue to develop. Movement can be felt during this period as the fetus kicks, rolls, sucks its thumb and learns to swallow.

Third Trimester - Weeks 28-40
The fetus will double or triple in weight from now until birth. The skin thickens with a layer of fat to maintain body temperature. The senses of hearing, vision, touch and taste are developed and used. Repositioning in the womb is not uncommon in preparation for delivery.

Birth
All I can say is that without it, I wouldn't be here. Thanks Mom, Happy Mother's Day.

Board Prep Question of the Week

A male infant has a cleft lip on one side that does not involve the alveolar process or the hard palate. A unilateral cleft lip results from the failure of which two facial prominences to merge?

A. Lateral nasal and maxillary
B. Left and right medial nasal
C. Maxillary and mandibular
D. Medial nasal and maxillary
E. Lateral nasal and Medial nasal 

Answer & Explanation

Medical School Family

Time management is definitely an issue in medical school. Finding a balance between the books, upcoming tests and family has been more of a challenge as time goes on. Last week, one reader asked how it all comes together on the family front. Rather than imply that I know exactly how it is, I asked my wonderful wife to share her thoughts.

Life as a Medical Student['s Wife]

Without blinking an eye I'll say it's tough.  Worth it?  Of course.  Before this experience, I remember talking to a friend whose husband had just finished dental school.  She said, "I proudly wear my wife's badge for having gone through that experience."  I laughed in ignorance.  Now familiar with the battles waged through this medical school experience, I fully support her honorary wife's badge.  While Josh and I have chosen not to have children in school, (heaven help those courageous couples who do have kids) there are plenty of battles we endure.  The two struggles that seem most prominent for me this year are time/patience and emotional connection.

Last year I wrote about adjusting to the first year. This year has been most trying on my patience and I've felt like my life has had to take a backseat to his career. I've been offered many opportunities to advance in my career which I've had to turn down due to his current position and our location. I've been supporting Josh from day one of our marriage. I take that back...after our amazing honeymoon in Paris and Eastern France, I've been the sole provider. This year we will celebrate our fourth anniversary. During these four years I've worked full time as a graphic designer, part time as a yoga instructor, freelance designer, painter, letterpress designer/printer, photographer and figure skater- simultaneously. Even with all of that, Josh manages to stay busier than I and buried in books for longer hours than I work. That means when there is down time I also feel obligated to take care of everyday chores. Usually, this is what Josh and I fight about - the chores - when we're both exhausted. I think we once argued for 30 minutes about our pantry door being closed vs open until we realized the absurdity of the situation. 

This year I've felt more distance between us also.  Because of our clashing time schedules, it's difficult to connect. Last year I embraced every moment of time he had available and dropped whatever I was doing to have some time with him. My responsibilities this year are more demanding and I can't always do that. That also may have been a bad habit I enabled Josh to expect. It is difficult to feel emotionally detached due to our schedules, but even more demanding to feel compelled to switch the emotions on whenever it's convenient. In the question posted last week on the blog, the fear of affairs during long hours of study after school was addressed. Josh's study partners are two Mormon boys, so it hasn't been a direct fear I've had to face, but it would be if he were studying with the opposite sex. We've learned to put each other on our daily lists of things to do. It's important to make some sort of connection in whatever time you share, to keep the pilot light on. We recently watched a NOVA documentary called "Doctors' Diaries" that followed the lives of seven medical students through medical school. It addressed the reality of divorce, the difficulty of relationships through school and the experienced perspective of the doctors after school. I would recommend watching their stories and being honest and real about what your unique relationship requires to stay healthy.

Thank you for your thoughts Willow. I agree that this has been a trying process with moments of joy. One of the most important things I learned before coming to school was from a doctor friend. He said that as a student we can set our own schedule and if we want our family to be a priority then choose it to be such. It is crucial to work with groups, patients and other classmates, but most importantly to know that our families are standing behind us. If it were not for my wife, I would not be where I am today. Thank you for your support and encouragement, you certainly deserve a part of my degree.


Board Prep Question of the Week

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

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

Answer & Explanation

Hands On Training

Hands on training always seems to draw more interest than lecture and books. Despite the risk for injury or mistakes, it is likely we actually get more out of it than a textbook could ever offer.

Clinical Skills Lab

As I walked back to my lab station with a pig's foot cut in half, I admired the piece of anatomy and questioned how this was deemed appropriate for a Jewish institution to support. Apparently, it is "Kosher" as long as we are not eating it. Pig's feet never had the same appeal as bacon, so I don't think that will be a problem.

After creating a laceration in the foot, we learned various suture styles to close the wound. It was more of a crash course in instrument handling as I quickly learned how clumsy my rookie hands performed this common clinical task. Nonetheless, it is a skill I will be needing in the future and any exposure is good exposure.

The next station, phlebotomy, was old hat. While my partner fretted the experience, I couldn't wait to get my hands on a needle again as it had been too long since my last stick. To my surprise there were quite a few in the class who have drawn blood in one form or another. On the other hand, those who attempted it for the first time would shake at the thought of hurting their partners. Learning new skills in the classroom has obvious benefits over learning them in the clinics, fortunately it leaves room for mistakes. Even though my partner impaled me twice before striking gold, he did a great job for his first experience.


Board Prep Question of the Week

On your rotation in the intensive care unit, you follow a patient with advanced sepsis from a central line infection. On exam you notice marked petechiae on his extremities as well as some large clots around his mouth. Concerned about disseminated intravascular coagulation, you check his labs. What would you expect?

A. High platelets, low bleeding time, high PT, high PTT
B. Low platelets, high bleeding time, high PT, high PTT
C. Low platelets, high bleeding time, low PT, high PTT
D. Low platelets, low bleeding time, high PT, high PTT
E. Low platelets, low bleeding time, low PT, low PTT

Answer & Explanation

Student Loan Debt

The start of our last block sure feels good. Soon enough we will be seeing patients and interacting with physicians in the community, unfortunately that comes with a price.

Student Loan Repayment Options

Just as we are preparing to file our FAFSA for the next year we received the bad news that there will be a 5% tuition increase! Apparently this figure is low, but it still adds up. The AMA reports that the majority of medical students have more than $100,000 of debt. Ask a student and after performing the math they will tell you that their debt is closer to $200,000 or more. We have no idea how the health care reform will affect future medicine and the financial concerns it carries. From my understanding, it is difficult to be a physician and not be bothered by the monetary repercussions of business. In fact, many practicing doctors are still paying off student loans.

A growing concern is the dwindling number of family practice physicians. For many students the pay alone is a deterrent that promotes interest in medical specialties. Fortunately, there are some specialties that are eligible for loan repayment opportunities. Here are a couple resources worth investigating if you are looking to get that student loan monkey off your back and you are not interested in the military scholarship:

• National Health Service Corps - Family Medicine, Obstetrics/Gynecology, General Internal Medicine, Gerontology, General Pediatrics, General Psychiatry
• AAMC - Loan repayment/forgiveness and scholarship opportunities by state

Board Prep Question of the Week

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

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

Answer & Explanation