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CALCULATE YOUR FINANCIAL APGAR SCORE

On May 22, 2011, in General, by admin

Calculate Your Financial APGAR Score
BY: Andrew Schwartz, CPA

The term “APGAR Score” will already be familiar to anyone who has experienced the birth of a child — and to those in the medical community. Immediately after being born, every baby is evaluated by a doctor, to determine its medical condition. The evaluation consists of the following five signs: Appearance, Pulse, Grimace, Activity, and Respiration. The APGAR score ranges from zero to ten, and serves as an initial indication of the baby’s health.

Anyone looking to gain control of their financial affairs must first get a sense of where they stand. Below is a variation of the APGAR test designed to help you make an initial self-evaluation of your financial condition. The five attributes of your financial APGAR test are as follows:

1. Automobile Habits
2. Payment of Credit Card and Consumer Debt
3. Got Life and Disability Insurance?
4. Accumulated Wealth
5. Residential Equity

ATTRIBUTE POINTS
0 1 2
Automobile Habits
Payment of Credit Card
and Consumer Debt
Got Life and Disability
Insurance?
Accumulated Wealth
Residential Equity

AUTOMOBILE HABITS

Besides one’s home, automobiles are generally a person’s largest purchase. The car you drive is also perceived as a status symbol — consequently, even the most frugal person might consider being extravagant when buying a car. How long do you generally hold on to your car(s)?

• Give yourself 2 points if you keep your car(s) for more than five years, are provided with a company car from your employer, or don’t own a car and spend less than $250 per month on rentals and cabs.
• Give yourself 1 point if you generally hold on to your cars for less than five but more than three and a half years; or, if you don’t own a car, you spend more than $250 but less than $400 per month on car rentals and taxis.
• Give yourself 0 points if you generally keep your car(s) for less than three and a half years; or, if you don’t own a car, you spend more than $400 per month on car rentals and taxis.

PAYMENT OF CREDIT CARD AND CONSUMER DEBT

In this step, you will take a look at your credit card habits. Maintaining a balance on credit cards can cause your financial position to erode significantly.

• Give yourself 2 points if you generally pay off your credit cards each month.
• Give yourself 1 point if you owe money on your credit cards, but will have all balances paid off within six months.
• Give yourself 0 points if there is no way that you will be out of credit card debt within six months.

GOT LIFE AND DISABILITY INSURANCE?

Life insurance and disability insurance are keys to a successful financial plan. Generally, a person will obtain life insurance and disability insurance as part of the benefits provided by their employer, or on their own through an insurance salesperson.

• Give yourself 2 points if you have purchased life insurance or disability insurance on your own.
• Give yourself 1 point if you have life and/or disability insurance through your employer’s benefits package.
• Give yourself 0 points if you have no life or disability insurance at all.

ACCUMULATED WEALTH

In this step, you compare your net investments, your age, and your income. You first need to calculate the total fair market value of all of your investment assets, excluding your principal residence and your cars. Make sure to include non-retirement savings, retirement savings, and any other investments you may own. You should then calculate the total of all of your debts, excluding any loans on your principal residence and your cars. Don’t forget to include your student loans and your credit card debts.

You should then subtract your total debts (excluding loans on your principal residence and your cars) from your total assets (excluding your principal residence and your cars) and:

• Give yourself 2 points if your net assets divided by your annual household income exceed the sum of the following formula: [(your age - 30) x 0.2] +1. (If you are married, use the average of your two ages.)
• Give yourself 1 point if your net assets are greater than $0 but not enough to qualify you for 2 points.
• Give yourself 0 points if your net assets are less than $0.

RESIDENTIAL EQUITY

Owning a home is an essential ingredient to most financial plans. Home ownership provides a hedge against inflation and a tax-free means of accumulating wealth. For this step, you will need to know the fair market value of your home and the current balance of any mortgages and equity loans on that property.

If you own a home, you must calculate the value of your home’s equity by subtracting the current balance of your mortgage and equity loans from the current fair market value of the home.

• Give yourself 2 points if the equity of your home divided by the home’s fair market value exceeds the sum of the following formula: [(your age - 30) x .025] + 25%.  
• Give yourself 1 point if the home’s value exceeds the current balance of the mortgage and equity loans, but you don’t have enough equity to qualify for 2 points.
• Give yourself 0 points if you do not own a home, or if the amount that is owed on your home exceeds its fair market value.

INTERPRETING YOUR SCORE

Add up your total points.

If your score is 8 or higher, you appear to be on the right track with your finances. Take a look at any attribute that didn’t score a 2, and see if you should make any changes.

If your score is between 5 and 7, you have a pretty big job ahead of you. Invest some time to try and determine which of these financial attributes need work, and put together a plan to make improvements in those areas.

If your score is 4 or less, you have lots of work to do. Take a deep breath and make a commitment to getting your finances on track. Keep in mind that the challenge you face may be daunting; but it is not insurmountable.

Andrew Schwartz, CPA, partners with his brother, Rick, in the Woburn, Massachusetts accounting firm Schwartz & Schwartz, PC, which specializes in services for health-care professionals and their practices. He is also the founder and editor of The MDTAXES Network, www.mdtaxes.com, a site providing tax and basic financial planning information for young health-care professionals.

 

USMLE STEP 2- CLINICAL SKILLS

On May 5, 2011, in COMLEX, USMLE Step 2, by admin

USMLE Step 2- Clinical Skills

USMLE Step II – Clinical Skills

The USMLE Step II Clinical Skills (CS) exam was originally administered as the Clinical Skills Assessment (CSA) exam, to international medical graduates (IMGs). IMGs had to pass both this and an English proficiency test in the process of applying to residency programs in the U.S. In 2004, the CSA was made a requirement for U.S. medical school seniors as well; so all individuals who are seeking licensure in the U.S. now must pass the Step II CS exam.

The CS exam is administered at five locations in the continental U.S.: Atlanta, Chicago, Houston, Los Angeles, and Philadelphia.

When you register for the CS exam, you will be mailed a scheduling permit. You will have twelve months from the time of registration to schedule a testing date; this is your eligibility period. The specific testing date can be chosen online. You will need to bring the scheduling permit and a form of government-issued ID to the testing site. You may bring a stethoscope, but no other materials are allowed. (The examination rooms will provide all necessary equipment). Before the exam, you will sit through a short, on-site orientation.

The CS exam lasts approximately eight hours, including two breaks (30 minutes and fifteen minutes). The exam consists of twelve standardized patient encounters, each lasting fifteen minutes, followed by a ten-minute documentation session. At some stations, instead of a patient encounter, you will be required to have a telephone encounter (You will talk to a mock patient on the telephone), a caregiver encounter (as there are no young children in the exam), or a model encounter (Some procedures, like the breast exam, may only be performed on a model, not a live patient).

Before entering the room, you will be given a clipboard, paper, and pen. An announcement will be made informing you that it is time to begin the exam, after which you will have a chance to review the chief complaint/reason for visit and demographic and vital-sign information posted on the door. After reading this information, you will enter the room. Inside, you will find a standardized patient. You will have to obtain a history and perform a focused physical exam (you cannot perform rectal, pelvic, breast, or corneal-reflex exams on the live patients). Furthermore, you will need to answer any questions and address any concerns the patient may have. You should comport yourself as if you were seeing a real patient. You will receive a five-minute warning before your time is up. You may finish the encounter in less than the allotted fifteen minutes. If this happens, you may leave the room, but reentry is not permitted.

After each encounter, you will have an additional ten minutes (more if you finish the patient encounter early) to draft a patient note, either on paper or on a computer. The note will include pertinent history, physical-exam findings, initial differential diagnosis, and diagnostic studies you feel are indicated for the patient’s workup.

The Step II CS is pass/fail and scored on the basis of three components:

  1. Integrated Clinical Encounter: In this section, you will be graded on your patient note, history, and the physical performed during your encounter.
  2. Communication and Interpersonal Skills: This section is based on your professionalism, style, and the quality of your interactions.
  3. Spoken English Proficiency: This section rates how well you communicate in English.

You have to pass all three parts in order to pass the USMLE Step II CS exam. The test costs about $1,000. If you must travel to the test site, additional costs will be incurred. Over 95 percent of U.S. students pass the USMLE Step II CS exam, so don’t fret. Just remember to smile, articulate your words, wash your hands, and answer all of the patient’s questions.

 

NEONATAL JAUNDICE

On April 26, 2011, in COMLEX, USMLE Step 1, USMLE Step 2, by admin

Neonatal Jaundice
Mohammad O. Hussaini, MD

As a USMLE taker and a physician, you will need to diagnose and work-up a yellow baby. Jaundice (yellowing of the skin, eyes, and mucous membranes) in the pediatric population is either normal (physiologic jaundice) or not normal (pathologic jaundice).

Jaundice basically occurs when there is a high level of bilirubin in the blood. When blood levels of bilirubin exceed 5 mg/dL in the neonate or 2 mg/dL in others, the characteristic yellow discoloration of jaundice is observed.

Bilirubin is a by-product of red-blood-cell degradation. Normally, this bilirubin is conjugated in the liver and secreted in the form of bile into the small intestine. When there is either an increased production or decreased elimination of bilirubin, jaundice occurs.

Physiologic jaundice occurs in about half of all babies. This type of jaundice sets in one to two days after the child is born. Bilirubin levels generally peak at 12–15 mg/dL, three to five days after birth. By the end of the first week of life, levels return to normal. Reassure parents of children with physiologic jaundice that this is normal and the child should be OK by the end of the week. One should keep in mind, though, that neonatal illness could prolong physiologic jaundice. If the jaundice persists, treatment may be indicated to avoid complications.

Pathologic jaundice can be due to both intrahepatic and extrahepatic causes. Whatever the etiology, just remember that any jaundice present at birth is pathologic! Common causes of neonatal jaundice include cholestasis from any cause (bacterial or viral hepatitis, liver cancer, Wilson’s disease, cirrhosis, etc.) and extrahepatic obstruction (choledocholithiasis, pancreatitis, biliary atresia, etc.). In the latter case, the neonate can’t secrete the conjugated bilirubin from the liver, so there is buildup of conjugated bilirubin in the bloodstream. When formulating a differential for a neonate in particular, don’t forget the congenital disorders of bilirubin metabolism. In Crigler-Najjar syndrome, there is a glucuronyl transferase deficiency (Type 1 is bad, and kids die by age one). In Gilbert’s syndrome, there is a defect in the same glucuronyl transferase enzyme. And in both diseases, one will find an increase in unconjugated bilirubin. Two more congenital disorders that you should be aware of are Dubin-Johnson and Rotor syndromes. In both, there is an increase in conjugated bilirubin (implying there is a problem with excretion). Though all of these syndromes can cause jaundice, none require treatment, other than Crigler-Najjar.

There are three more causes of jaundice that you need to keep in mind for the USMLE. These should be high-yield. First is breast milk. Breast milk jaundice usually sets in about two to three weeks postpartum. Tell the mother of the jaundiced child to stop breast-feeding and to switch to a bottle until the jaundice resolves. Later, she can restart breast-feeding. Second is Rh incompatibility. If a child is born jaundiced, remember to get a Coombs’ test (direct and indirect), Hb, reticulocyte count, and peripheral smear. Treatment for hemolytic disease of the newborn (erythroblastalis fetalis) involves blood and exchange transfusions. The third cause of jaundice is drug-induced. Sulfa drugs displace bilirubin from albumin, so don’t give them to infants.

So, why do we get so worked up about neonatal jaundice? The main concern with jaundice is kernicterus. High levels of unconjugated bilirubin in the bloodstream cross the blood-brain barrier and cause brain damage, especially to the basal ganglia and hippocampus. The damage can manifest itself as mental retardation, cerebral palsy, deafness, weak muscle tone, lethargy, and seizures.

Work-up for neonatal jaundice first includes a good physical exam. Look for any abdominal pain or neurological symptoms. Get a bilirubin level (conjugated and unconjugated, of course), Coombs’ test, Hb/HCT, reticulocyte count, liver-function tests, albumin, and a peripheral smear.

There are two main treatments for unconjugated hyperbilirubinemia: phototherapy and exchange transfusion. Phototherapy is for rapidly rising or persisting bilirubin, or bilirubin greater than 15 mg/dL. Don’t choose exchange transfusion unless bilirubin levels are greater than 20–25 mg/dL and phototherapy has failed. Conjugated bilirubin treatment is targeted at the underlying disorder.

 

BEGINNING YOUR PEDIATRIC CLERKSHIP

On April 18, 2011, in Trends in Medicine, by admin

Beginning Your Pediatric Clerkship
By: Valarie Stricklen, MD

A pediatric clerkship is like no other. All the studying in the world cannot prepare you for what you will come across in the pediatric office or inpatient service. Many people say, “Children are just little adults.” On the contrary — they are very different in their attitudes, personalities, and even medical conditions. Pediatrics is also unique in that you essentially have two patients: the child and the parent(s). Are you scared yet? Don’t be! Pediatrics can be your favorite and most enjoyable clerkship, if you are prepared.

The expectations for a third-year medical student rotating through pediatrics are quite simple:

  • Do what is asked of you (history-taking, note-writing,etc).
  • Be prepared for rounds, seeing patients, etc.
  • Read about your patients.
  • Act in a professional manner.

The above expectations are quite similar to those of any third-year clerkship.

So, what makes pediatrics different from the others?

One difference applies to your history-taking technique. Obtaining a medical history from an adult is easy. You ask him or her questions and they give you answers. However, in pediatrics, your patient is often unable to speak in intelligible sentences, or even to understand you. It takes great finesse to try to obtain an accurate history from a three-year-old who is running circles around your chair while screaming at the top of his lungs. Often, distraction can be your best friend. Giving the child a book or showing them your stethoscope while you speak to the parent gives you that much-needed peace and quiet. It is important to keep in mind, however, that if the child is old enough to understand your questions and answer them, she can be a great resource. Only she really knows what her “ouchie” feels like, or how long it has been going on.

The content of the medical history is different, as well. The child’s brief medical history is only one part of the information we need. In pediatrics, we will ask questions about birth history, immunization status, developmental history, and the psychosocial history of the entire family. Learning the essentials in taking a thorough pediatric history, and being able to write information in H & P form, is key. This can be a daunting task, but understanding the basics and developing a systematic approach will make it easier and much more enjoyable. Keep in mind that it takes practice to be able to do all of this efficiently, so do not be discouraged if your attending or resident steps in every once in a while. Time is of the essence, and we sometimes need to keep things moving.

According to the Merriam-Webster dictionary, the definition of professional is one “exhibiting a courteous, conscientious, and generally businesslike manner in the workplace.” While this is an accurate description, professionalism in pediatrics requires much more. Would you ever see a “professional” playing with toys on the floor of an exam room, reading a book out loud using cartoon voices, or playing peekaboo and laughing hysterically? That is the life of a pediatrician. On your rotation, you will discover that we are looked at with respect and admiration, but we still have fun every day. That same attitude is expected of you if you wish to excel in your clerkship. Be prepared to act like the prototypical professional — but remember, flexibility and playfulness are job requisites, as well!

Valarie Stricklen, MD is an Assistant Professor of Pediatrics, and Pediatric Clerkship Director at the University of Toledo College of Medicine.


 

SURVIVAL TIPS FOR THE INTERN

On April 13, 2011, in Residency, by admin

Survival Tips for the Intern
By: Loan Trinh Kline, MD


You finally matched into residency, it is July 1st… and you’re the doctor. It’s a big responsibility, and you’re scared and clueless. Don’t worry! Take a deep breath — everyone goes through this. Here are the tips I’ve learned along the way to help me survive my intern year.

#1 – Ask. Simple as that. When you don’t know a medication dosage, where to go to get something, or how to do something, just ask! Ask your senior (they are there to help you) or an attending (if your senior is nowhere to be found). Ask a nurse, unit secretary or a colleague. They have been doing this for a long time and would rather have you do something right the first time. Plus, this shows you’re interested and makes things a lot easier.

#2 – Make lists. Have a list of phone numbers, or know where to find numbers of all your ancillary services or consults. Most of the time, the hospital will have a website where you can obtain these numbers. Know the number for the lab so that you can call them to ask what media/color tubes you need for your labs. Know the number to the pharmacy because, trust me, they would rather have you call them to ask the correct dosage of a medication, then page you to tell you that the dosage is wrong. On a related note, answer your pager as soon as you can. I know it took me a week to get used to dropping everything to answer my pages.

#3 – Own your patients. I think the best advice I was ever given as a medical student was to own my patients. This means you should know your patients. Know their history and their plan. Be thorough and complete. Update your patients and educate them. You are the primary doctor now. This may be daunting, but you are never alone. There is always a senior and an attending.

#4 – Know your limitations. If you don’t know something (i.e lab value, plan, etc.), admit that you don’t know. It’s okay if you don’t know the answer; we are all here to learn. Do not, I repeat, do not ever lie. Once you say something incorrect, your seniors, colleagues, attending and patients will find it hard to trust you again. I’ve found the best answer to give when you’re stumped is, “I don’t know the answer to that, but I will find out for you.” It’s gold. Use it, and follow through with it. Do what you say, and say what you do. Communication is key. Again, back to #1, ask someone who would know. Ask for help when you’re feeling overwhelmed. Ask your senior or a colleague for help. They are all there to provide the best patient care as a team. Finally, be a team player and help your colleagues out.

#5 – Take care of yourself. I know we hear it all the time, but seriously, sit when you can sit, eat when you can eat and sleep when you can sleep. In the first two weeks of residency, I lost seven pounds because I wasn’t eating. I remember falling asleep shaking because I was hypoglycemic. You cannot take care of patients if you are a patient yourself. Also, use the bathroom. I know it sounds ridiculous, but I’ve met residents who have had UTIs because they didn’t have time to use the bathroom. And yes, you will get paged in the bathroom!

#6 – Read up on your patients. I know it’s hard to pick up an article or a book at the end of a 12+ hour day, but try to read a little every day. You can try reading articles, but I found that, at an intern level, it’s best to get a foundation by reading textbooks. Not Harrison’s or Nelsons textbooks, but Pediatrics – Just the Facts or Ferri’s Clinical Advisor for Medicine. Something quick and straight to the point. Once you have the foundation down, you can add to your knowledge with articles, guidelines, etc. The details come later. Get the basics down first!

#7 – Residency is work. You are finally getting paid to work, so don’t complain. If you have to vent, be careful to whom you vent because rumors spread fast and the last thing you want is to build animosity within your program. You will be working with each other for the next three to five years, so be nice to each other. Be respectful. Be a team player. Everyone had to be smart at some level to get where they are, so listen to each other. Don’t be condescending. Apologize if you’ve slighted someone. If you do have a conflict with another resident or nurse, speak with them privately. If that’s not possible, speak with your chief resident or director. They are there to help resolve conflicts. The last places to engage in an argument are in the patient’s chart, in front of patients, or in your evaluation of the program. If you have allegiance to your program, the last thing you want to do is jeopardize your program with a bad evaluation. Let your chief or director know you have a problem and give them a fair chance to rectify the situation before you put it in writing.

#8 – Smile. Yes, smile. Smiling goes a long way. Be kind to nurses, LPNs, social workers, respiratory therapists, pharmacists, secretaries, case managers, environmental services personnel — everyone you meet. Introduce yourself. Remember, you’re the new kid on the block. If you’re respectful, considerate and friendly to everyone, it will only benefit you. Those around you will be more inclined to help if they know who you are. There have been countless times when nurses have gone out of their way to place IVs or check labs when I was swamped. Respiratory therapists have called to update me on my asthmatic kids and pharmacists have corrected my orders. It is just nice to know that you are not alone.

 

Is It Really Worth its Weight in Gold?
By:  Jason B. Lester,MD, MBA

As an emergency medicine resident with an interest in business, I have always wondered if the drugs I prescribe really live up to their worth. In medical school, we learn which drugs are used to treat specific conditions, and which may be more efficacious. However, in treating patients, I just want what is best for them. In real life, cost is an issue. Recently, I asked myself why I was giving one medication over another. Both seemed to help the condition I was treating. When I asked my attending for his opinion, issues regarding patient care, budgets, and doing what is right surfaced. In the end, cost came out as a large influence on decision-making.

One of the most precious and stable commodities in the world is gold. People such as Spanish explorer Hernando Cortez have traveled great distances in search of it. Many have lost their lives for a chance to own a small piece of it. It is the theoretical basis for our modern economy. We watch prices in the newspaper and always seem astonished by the cost of gold. I wondered, “How does it compare, weight-to-weight, to the drugs I prescribe?”

Let’s take a look. On November 1, 2006, the price of gold per troy ounce was $619.30. To compare apples to apples, we have to convert the troy ounce to milligrams. One troy ounce is 31.1034768 grams. After the conversion, one milligram of gold costs roughly two cents. In light of this, a milligram of the “most sought-after” commodity does not sound like much.

Now, let’s look at how much we are paying for drugs that we sometimes prescribe, without a second thought, to our patients. With varying costs due to contracts, sales, and other market forces, I went to the Internet to find prices for some common drugs. For one subset, I chose drugs that treat nausea and vomiting; the other subset consisted of “luxury drugs” for hair loss and erectile dysfunction. The search date was November 1, 2006, the same date I searched the price of gold.

Three drugs which can be used for nausea and vomiting are: Phenergan, Reglan, and Zofran. Clinical practice and patient response may vary with these drugs. For our purposes, I will assume that one dose of the drug will provide symptom relief. According to the website Drugstore.com, the going rate for a 25 mg pill of Phenergan is $0.599, or about $0.0239 a milligram; just slightly over 2 cents (remember, gold per milligram is slightly under 2 cents). Reglan, offered in 5 mg pills, is about 15 cents per milligram. Lastly, Zofran, offered in 4 mg pills, is $23.20, costing $5.80 per milligram, or 290 times the value of gold.

For patients using luxury drugs, the treatment options vary, and the cost is surprisingly lower than one might expect. For help with erectile dysfunction, Cialis is available for $12.10 per 5 mg pill, or $2.41 per milligram. Its rival, Viagra, comes in a 25 mg pill, costing $9.99, or $0.40 per milligram. For hair-loss sufferers, finasteride, which is sold under the name Propecia, comes in 1 mg pills for about $1.99 each. Interestingly, finasteride is also used in a higher dose of 5 mg, to treat benign prostatic hyperplasia (BPH), and the cost per 5 mg pill is $3.10, or only $0.62 per milligram. Makes me want to cut up the 5 mg pill for those savings, or better yet, buy gold, because my hair will probably fall out eventually!

In then end, I was looking for some sort of perspective, which I believe I have found. Imagine Cortez sailing for the New World, not to find El Dorado but “El Zofrano.” We treat gold like gold. We keep it in safes and in banks, heavily guarded. However, we prescribe medications at times without even looking at how they compare to other things in life, business, and society. Perhaps we should protect these medications more carefully, since many can be worth their weight in gold, or maybe even much more.

 

THE WAY TO STUDY MEDICINE

On March 31, 2011, in COMLEX, USMLE Step 1, USMLE Step 2, by admin

The Way to Study Medicine
By Stephen Goldberg, MD

The following suggestions about how to study medicine are not the result of scientific survey, but reflect my own experience in teaching medical students for 25 years. The suggestions also arise from my service as President of the MedMaster Publishing Company for the past 27, years and from the feedback I have received from students and instructors throughout the world.

The biggest problem in medical education today is an old one: There is too much to know, and not enough time to learn it. The problem is more acute today than it has been in the past, because of the great increase in medical information and even the addition of new courses in medical school. How can you digest and remember so much information, whether it’s for your general medical education or your USMLE/COMLEX review?

While memory aids such as mnemonics and humor certainly can help, it is more important that you really understand the material rather than just memorize it. Understanding it is key, because you can apply the information to a great variety of medical situations instead of using a cookbook approach that lacks understanding and applies to only a narrow spectrum of textbook medical cases. Moreover, once you understand, it becomes much easier to pick up and remember more esoteric facts, as opposed to just trying to remember isolated bits of information.

Despite the importance of reference texts, it can be difficult to go through them in the short times allotted for medical-school courses. Also, the information can be so overwhelming that it becomes difficult to see the forest for the trees, and acquire an overall understanding. While it is important to have the reference text, the initial phase of acquiring understanding is best achieved through the small book that helps you see the big picture. Once you’ve managed that, you can delve into the reference texts or elsewhere in greater detail as time permits, and you’ll have greater success than just trying to memorize information.

Your time to study for the USMLE/COMLEX may be limited, especially since studying often needs to be done while other medical school courses are underway. While you could review a book that contains isolated facts that may appear on the boards, you won’t acquire an understanding this way. While passing the boards is important, so is having the understanding necessary to be a good clinician. Ideally, you should have this before you review isolated facts for the boards. Such understanding can be achieved through the small book that focuses on clinical relevance and overall understanding, ideally read at the time the course is taken, but later if needed. The focus of the USMLE/COMLEX is on clinically relevant material, so that small book will likely contain the most relevant facts for passing it.

Once you’re on the wards, the question is how to make the most efficient use of your time in continuing your medical education. Not only is your time limited, but you’ll often find yourself fatigued from long periods on call. Trying to study a book like Harrison’s Medicine from cover to cover is likely to be futile. You need a more efficient method of learning. Reading journals can help you keep up on current information, but your primary focus in the medical-school years should be on acquiring the general broad information that is common knowledge. This in itself is a very large task. It has often been said, and I agree, that the best way to learn and retain medicine is through patient interaction. But to supplement this learning experience, it is important to do a certain amount of critical reading. Learning from your residents can be very useful, but the literature is more likely to be accurate. The most efficient way to do this reading, in my view, is to ask specific questions about the patient conditions you’ve seen during the day, and then seek out specific information in your reading. You should have specific questions to research, and then look for specific answers. In that way, over time, you will have learned the most important information related to the common diseases you are likely to encounter.

In the old days, such research would mean either having the necessary reference texts at hand, which might not have the information you need, or which might be several years out of date, or going to the library to search through heavy tomes of Index Medicus for pertinent references, and then hoping the library had the corresponding journals for review. This could be time-consuming, though, and difficult to accomplish when you’re already fatigued from a busy day. Today, the Internet provides a much quicker and more efficient way of searching for information. By using a general or medical-specific search engine, it is now possible to find important current and practical information about virtually any medical condition.

The ideal way to learn medicine, then, in my view, is to:

• Learn from the patient.
• Acquire a general understanding through the small, clinically relevant book that provides the overall picture, so you can see the forest rather than the trees. Humor and mnemonics can help, but understanding is key.
• Seek out particular points of information through the Internet.
• Keep a reference text at hand.
• Read journals as time allows.

Stephen Goldberg, MD
Professor Emeritus, University of Miami School of Medicine
President, the MedMaster Publishing Company
www.medmaster.net
Author of:
Clinical Neuroanatomy Made Ridiculously Simple
Clinical Anatomy Made Ridiculously Simple
Clinical Biochemistry Made Ridiculously Simple
Clinical Physiology Made Ridiculously Simple
Ophthalmology Made Ridiculously Simple
The Four-Minute Neurologic Exam
Differential Diagnosis (CD part of Clinical Pathophysiology Made Ridiculously Simple)

 

RESIDENT WELLNESS

On March 24, 2011, in Residency, by admin

Resident Wellness
By: Paul O’Leary, M.D.

Healthy residents care for their patients. However, multiple studies focusing on stress, burnout, and well-being demonstrate that the opposite may also be true. Burned-out, unhealthy residents simply don’t do as well at caring for patients.

The study of stress and well-being aids our understanding of how to quantitatively improve the work environment using multiple models and validated scales that measure burnout. Initial studies in the late 1970s focused on how stress affected hotel staff and nurses. Then, in the early 1980s, studies about how stress affects resident physicians began to appear in publications, as well. These publications assisted efforts, during the late 1980s and 1990s, to legislate improvements in resident work environments, culminating in the 80-hour workweek that began in July of 2003. Now, researchers are broadening their focus to include resident well-being and quality of life, as well as including ‘well’ residents and ‘stressed’ residents.

As a resident, I became very interested in improving the well-being of my fellow residents. I understood that even with the changes in the work hours and the oversight of the GRE, residents were still at risk for burnout. However, workload is not the only thing that can affect one’s risk. Research shows there are six major aspects to work satisfaction, and  the combination of these factors can lead to either protective or detrimental effects.

Naturally, workload is one of the factors, as being overworked can lead to burnout. Another important factor is the amount of control a resident has over their workload. By having the resources necessary to do work efficiently, and by having flexibility in one’s schedule, residents may protect themselves from burnout. The third factor is collegiality, or how well one gets along with others in the workplace. Fourth is rewards, not only through financial compensation, but also in recognition of a job well done. Fifth is fairness — whether tasks are divided fairly, and everyone is expected to meet the same requirements. The sixth factor is personal values; it is important that residents share the same values as the group for whom they are working.

By discussing these six aspects of work with the Residency Director, we were able to make changes to the program, which reduced the stress and level of burnout a lot of the residents were feeling. As we learn more about how to create a healthier workplace for residents, we create a healthier environment for patients, too. And that makes everyone feel better.

Paul O’Leary M.D.
AMA Psychiatry Section Council
Resident & Fellow Section Delegate
1225 50th St. South
Birmingham, AL 35222

 

Falcon Faculty Member Featured in New York Times
Dr. Michael Rafii’s Research into Alzheimer’s Disease makes Front Page News

At Falcon Reviews, our faculty members are more than top-quality PhD and MD professors with USMLE experience — they’re also experienced in real-world science and research. Falcon staff member Dr. Michael Rafii’s research into Alzheimer’s disease was recently featured on the front page of the New York Times.

A neurologist at the University of California, San Diego, Dr. Rafii is also an investigator in a large federal study exploring the early signs of Alzheimer’s. New diagnostic tests, including spinal taps, M.R.I.s, and PET scans, have made it possible for doctors to recognize the disease in its very early stages, before it manifests through observable symptoms. The advanced knowledge that an individual may be at increased risk for Alzheimer’s has led to a moral dilemma regarding whether or not to share this news with patients. The New York Times article, titled “Tests Detect Alzheimer’s Risks, but Should Patients Be Told?” is part of The Vanishing Mind series, focusing on the disease.

While it’s exciting to discover new advances in disease detection, the information can be devastating for patients — especially when there may not be an effective treatment. Will patients benefit from the information, or will they be harmed by the certainty of an impending disease, over which they have no control? In a study conducted by Boston University, nearly a quarter of patients requested their diagnosis be revealed. So far, the psychological impact has not been negative. In fact, many patients with high-risk diagnoses responded by increasing exercise, and beginning vitamin and nutritional supplement usage, although these measures have not been shown to reduce Alzheimer’s risk.

If your doctor knew you had a degenerative disease about which you could do nothing, would you want to know? As doctors, what is the greater responsibility to our patients — to inform, or to do no harm?

Click here to read the full article, and learn how a Falcon faculty member is making a difference in the world today. And be sure to explore our “Faculty” section to learn more about Falcon faculty members and how they’re contributing to the world of medicine.

 

WAS

On March 7, 2011, in COMLEX, USMLE Step 1, USMLE Step 2, by admin

Wiskott-Aldrich Syndrome
By: Nathan York

Wiskott–Aldrich Syndrome (WAS) is a primary genetic disorder that results in a combined immunodeficiency syndrome in children. It is a rare disease (four cases per million live male births), with a characteristic clinical presentation, making it a good case for the USMLE. It is characterized by the triad of eczema, thrombocytopenia and recurrent fungal, bacterial and viral infections. This disease is caused by a mutation in the gene that encodes Wiskott–Aldrich syndrome protein, or WASP, which is located on the X chromosome. This gene is expressed in all hematopoietic stem cells and appears to be involved in cytoskeletal functions. Dysfunction of this protein results in progressive decrease in the number and function of T cells. This lack of functional T cells also causes an inappropriate B cell response, due to the lack of necessary cytokines for activation and class-switching. The result is an ineffectual response to foreign antigens. Interestingly, these patients develop allergic reactions and eczema as a result of elevated IgE levels in the blood.

Presentation
As an X-linked disorder, this disease will only appear in males. It can manifest itself in several different ways, because of its effect on hematopoietic development. Within the first few months of life, gastrointestinal bleeding can be detected due to thrombocytopenia, and is often the first sign of the disease. This bleeding tends to become less severe as the child matures. Other early signs include the appearance of purpura and excess bleeding from circumcision. As maternal IgG decreases in the infant’s blood (around six months of age), recurrent infections begin to occur, with particularly poor protection from polysaccharide and protein antigens leading to pneumonia and meningitis. Recurrent infections of any kind should automatically suggest some sort of immune deficiency in the differential diagnosis. As the child approaches one year of age, eczema and food allergies develop (See Figure 1). Remember, for the USMLE, WAS presents as the classic triad of immunodeficiency (recurrent infections), eczema and thrombocytopenia.

Figure 1: Atopic Eczema

Diagnosis, Treatment and Prognosis
Diagnosis of WAS can be made by the following criteria:
-Demonstration of thrombocytopenia (platelet count of 5,000-10,000/uL)
-Presence of small platelets by histology (see Figure 2)

Figure 2: Microplatelets in Blood Smear

-characteristic of WAS

-Progressive decline in T cell number
-Immunoglobulin profile (decreased IgM, increased IgA and IgE, normal IgG)

Treatment of WAS includes the following:
-Bone marrow transplant (reconstitution of T and B cells)
-Splenectomy to manage thrombocytopenia
-Prompt treatment with antimicrobial agents upon infection

Prognosis of patients with WAS is bleak, if not detected. Without treatment, the average life span is approximately three years. With aggressive treatment, the average life span increases greatly, with some living more than 30 years. However, long-term survival increases risk of malignancies, especially within the lymphoid compartment.

References:

1.  Coico, R., Sunshine, G., Benjamini, E.  Immunology: A Short Course (5th edition).  2003.  John Wiley & Sons, Inc.  Hoboken, NJ.

2.  Gupta, K., Pulliam, L.  Concepts in Microbiology, Immunology and Infectious Disease.  1997.  Parthenon Publishing Group.  New York, NY.

3.  http://www.emedicine.com/med/topic1162.htm