Saturday, December 26, 2009

How To Eyeball A Patient

Gestalt View
As you walk into the room is the patient appear sick or not sick? Distressed? Obtunded? Comatose?
Does the patient oxygenate and perfuse?
Vital signs
What are the specific numbers, how was it assessed, and does it correlate with the picture above?
Find abnormalities. That's really what you are paid for. Some people always have high creatinine or low hemoglobin or whatever, so don't focus on the population mean abnormalities, focus on the patient's abnormalities.
Will tell you a lot about the protoplasmic substrate (except cancer as chemotherapeutic agents generally don't show up on medication reconciliations) and look out for side effects of therapeutic intervention.

Thursday, June 4, 2009


I have actually taken the USLME Step 1 Examination twice, having failed it the first time, so I have a slightly unique viewpoint regarding this exam. There is a multifactorial explanation/excuse/reason as to why I did not pass, but it did give me a lot of experience preparing for the exam. I do not believe that this an examination that tests basic medical science but rather tests your ability to take a huge multiple choice test. Yes there is a significant amount of information you must know, but rote memorization will not get you through, to quote Goljan ( you must understand mechanism, not only of the underlying physiology and pathophysiology, on both micro and macro scales, but of the mechanism of the test questions themselves. The resources I found useful for information review were:

Gold Standard Board Review System (
Kaplan On-line lecture series (
USMLE Step 1 Made Ridiculously Simple (

The oft touted Step Up ( and First Aid ( were not of great help to me, but if your mind wraps well around such outlines then it may be of benefit.

I split my days into a morning of questions (minimum 100) and an afternoon of lectures. I took at least one weekend day off per week. Approximately every two weeks I would do 8 hours of questions to simulate the exam, out of a book of written examination questions. Make sure that you reverse engineer the questions, I noticed that there were certain types of questions that I missed. I just kept doing the questions until I had done them all right. In all I did over 3700 different questions between all my resources, which included Q-bank, Q-Book, and other test question repositories.

Since then I have been introduced to the Goljan lecture series, while I didn't use them I believe they would be of benefit.

Do not let the cost of a prep course discourage think of it as a $1000 to $3000 investment in your future. You will carry a failure or a low score on USMLE Step 1 for a long time, it is not the end of the world but it will make you work harder for residency and it may keep you from getting your foot in the door.

Thursday, April 23, 2009

White Coat Ceremony Talk 2008

I gave this brief talk to the medical students in 2008, I thought it was pretty good:

This is not a white coat.

This is a superhero’s cape; a knight’s tabard; a wizard’s robes. Not convinced? Where else but in comic books and medicine can grown-ups wear the equivalent of pajamas and be taken absolutely seriously. Who else but a paladin or a physician would be on a quest to help people. What else but the magister’s raiment or the white coat symbolizes knowledge and the hope of miracles.

Despite its mystic origins, the white coat is a poor insulator against the freezer they call the cath lab and attracts tomato sauce. It will snag every exposed door handle and makes a barely tolerable pillow. Its carrying capacity is significantly less than the mass and volume of assorted pocket references, peripheral brains, pagers, and diagnostic gadgets required of medical students.

The mark of a physician, however, is not in their sartorial splendor but in their desire to help people through their compassion, intellect, and work ethic. The white coat symbolizes the best qualities of a physician. They are the vestments of medical knowledge and the license to alleviate suffering. They command both power and respect while demanding duty and service. Today these medical students begin their clinical apprenticeship, they become squires to Sir Osler and side kicks to Hippocrates.

These student doctors will find that as soon as they don their crisp white coats that they will be looked to for answers regarding simple analytical diagnosis to the difficult decision of whether to allow a fellow human being a glass of water. From a simple piece of cloth they will be privy to a person’s most intimate secrets and exposed to a patient’s greatest moment of weakness. They will find that no matter how much they load the straining pockets of their uniform they will never carry enough resources to have all the answers.

This coat will be your introduction to clinical medicine, sometimes frightening but always rewarding, it is by interacting with patients as a student doctor that you will learn to be a physician. This white coat is your passport to that experience. Welcome to the most fun part of medical school.