Spotlight on Specialties-Neurology

Spotlight on Specialties-Neurology

Nature of the Work
Neurologists focus on the diagnosis and treatment of diseases and/or impaired function of the brain, spinal cord, peripheral nerves, autonomic nervous system, and muscles. Therefore they may be involved in dealing with tumors of the PNS and CNS, degenerative disorders of the nervous system, strokes, as well as various multi-systemic disorders that affect the nervous system. Neurologists may sub-specialize in:

• Child Neurology
• Clinical Neurophysiology, using clinical evaluation and electrophysiology tests such as EEG, EMG and nerve conduction studies
• Pain Medicine, providing advanced care to patients suffering acute, chronic or cancer pain

Training
One year of internship with a minimum of eight months in Internal Medicine, plus 3 years of neurology residency. Sub-specialization requires an additional 1-3 years of fellowship training.

Demand/Salary
The Bureau of Labor Statistics indicates that supply and demand is currently in rough balance in this specialty and likely to remain so for at least the next few years. The annual salary for a neurologist ranges from $152,000 to $221,000.

For More Information
Visit any of the following organizational websites:

• American Academy of Neurology www.aan.com
• American Board of Psychiatry & Neurology www.abpn.com
• American Neurological Association www.aneuroa.org

Choosing Action Over Reaction

Steven R. Daugherty, Ph.D.
Director, Education and Testing
Kaplan Medical

We all like to know and feel confident that we know. We load our brains with facts and details to be sure that we have the ones we need when we need them. Learning begins with exposure to important details and sets before us the task of making these details our own. On exams, we prove to ourselves and others what we have learned by being able to state the relevant fact when it is called for. In short, we see; we respond. And having the right response gives us the feeling of competence and satisfaction of mastery.

But this kind of learning, this sort of knowing, has one strong limitation. We are only able to respond to what we have already seen. When confronted with something novel, we are unlikely to have the required response. In the face of uniqueness, we search our responses and find ourselves deficient. The sense of deficit leads to uncertainty, uncertainty to frustration, and frustration to paralysis. In this situation we see, but do not know how to respond, and our sense of mastery dissolves to leave us with a growing fear of incompetence.

At its best, the USMLE* confronts you with things you may have never encountered and asks you to look at things in ways you may not have anticipated. Even those students who have studied well and taken in a host of details often find themselves surprised, and consequently frustrated. Many students try to overcome this by seeking to find out as much as they can about what has been tested and how it have been presented on previous exams. But this strategy inevitably comes up short. New questions are constantly being developed and novel presentations are continually being invented. Students who focus on what has been tested in the past will find themselves behind what is being tested in the present.

Doing well on the USMLE, therefore, depends not so much on having the right responses memorized, but being able to reorganize those acquired responses and refashion them to solve a new, unanticipated problem. Knowledge is the springboard for answering USMLE questions. But being able to reconstitute and think with that knowledge is the actual leap that carries you to success. Success depends not so much on having a pre-programmed reaction, but on being able to stop, think, and select the right action to respond to the novel situation presented. Mastering the exam rests not on programming your reactions to the questions you encounter, but on learning the right mental actions you take to arrive at the best solution. Thinking, not knowing, is the key.

The mental processes here are far more complex than the simple stimulus-response of a reaction. USMLE requires us to make new responses on the spot to cope with fresh, unanticipated scenarios. This is not mere temporal lobe recall, but frontal lobe problem-solving. The central issue is not do you know the right facts, but can you do the thought processes required to find the best answer.

But, having the right cognitive processes is just half the battle. Optimal performance also requires the proper emotional state. The question is, can you maintain your confidence long enough to let this essential problem-solving cognitive processes happen before uncertainty opens the door to anxiety and emotional escalation? The virtue of a pre-wired response is that it fixes emotionality. A pre-wired reaction means that little time is available for self-doubt, and that emotions remain in contained. Thinking takes time and doing the thinking that action requires allows time for emotions to run free elevate to a level of performance interfering anxiety.

As always, the secret to mastering the thought processes required by the USMLE is practice. Not practice in memorizing content, but practice at using that content in exam-parallel problem-solving situations. Mastering these thought processes means that you will have the essential skill the exam requires, but also that you will have the confidence that you can handle whatever the exam may throw at you. In the end confidence comes not from a sense of knowing everything (something that is not humanly possible), but in a practiced ability to think on your feet and arrive at a best solution to a any presented problem. The solution comes from thinking, not from knowing. And self-confidence arises from the ability to act to solve any problem, not merely from having the right pre-programmed reaction.

Remember that the USMLE is not only testing to see is you have the knowledge required to be a physician, but whether or not you can make use of that knowledge the way a physician’s have to use it. Knowing facts, but not knowing how to solve the problems that patient’s present makes you smart, but ineffective. What separates physicians from simple technicians, what makes you a professional, is that you know more than how to react to set scenarios, but that you can think and derive the right course of action to whatever situations you encounter. Knowledge is the foundation, but being able to think and apply that knowledge is what truly makes you a physician.

Can You Name It?

Mechanism of Action:

• This is a synthetic version of a substance made and released by the thyroid gland
• It is converted intracellularly to a substance that enters the nucleus, and binds to a receptor protein, leading to increased production of mRNA and protein synthesis.

Indications:

• This agent is indicated as replacement or supplemental therapy in congenital or acquired hypothyroidism of any etiology, except transient hypothyroidism during the recovery phase of subacute thyroiditis.
  Specific indications: primary (thyroidal), secondary (pituitary), and tertiary (hypothalamic) hypothyroidism and subclinical hypothyroidism.
• This agent is also indicated in the treatment or prevention of various types of euthyroid goiters.

Route of Administration:

• Oral Tablets – Strength in mcg (25, 50 75, 88, 100, 112, 125, 137, 150, 175, 200, 300)
• Parenteral: 200, 500 mcg/vial

Selected Adverse Effects:

• Cardiac: Palpitations, tachycardia, cardiac arrhythmias, angina
• CNS: Tremors, headache, nervousness, insomnia
• GI: Nausea, vomiting, diarrhea
• Miscellaneous: Weight loss, fever, menstrual irregularities

Selected Drug-Drug Interactions (Drug + Other medication =):

• + Cholestyramine = Dramatic decrease in drug absorption
• + Estrogens = Increased estrogen levels
• + Anticoagulants = Increased anticoagulant effect
• + Beta-Blockers = Decreased beta-blocker effect
• + Digoxin = Decreased digoxin levels
• + Theophylline = Decreased theophylline clearance in hypothyroid patients
• + "Fasting" = Increased drug absorption
• + Food = Decreased drug absorption

Special Considerations:

• Contraindications: Hypersensitivity to this product; thyrotoxicosis uncomplicated by hypothyroidism and the presence of BOTH hypothyroidism & hypoadrenalism
• Warnings/Precautions:
  • Obesity: Use in euthyroid patients is ineffective and may cause serious life-threatening toxicity, especially when given with sympathomimetic amines (such as anorexiants).
  • Cardiovascular disease
  • Endocrine disorders (Diabetes mellitus or insipidus; adrenal insufficiency (Addison disease)
    • Exacerbation of the intensity of symptoms of these disorders may occur
  • Pregnancy category A
  • Decreased bone density
  • Tartrazine sensitivity
  • Monitoring: Periodic assessment of the patient’s thyroid status can be achieved by means of appropriate laboratory tests

Drug of the Month: Levothyroxine sodium (Synthroid ®)


Endocrine Enigma

A 34-year-old woman presents to her doctor with complaints of anxiety and general nervousness. She states that she had been in her usual state of health until 3 weeks ago when she caught a cold. On physical examination, she is a slender, anxious-appearing female. The only significant physical finding is slight tenderness during examination of the neck. This pain is made worse when she swallows. Thyroid function tests are drawn, revealing high serum T3 and T4, and low TSH. Antibody assays are pending. Which of the following is the most likely diagnosis?

(A) De Quervain thyroiditis
(B) Graves disease
(C) Hashimoto thyroiditis
(D) Lymphocytic thyroiditis
(E) Myxedema


The correct answer to the question above is: A.

1. CORRECT: Subacute granulomatous thyroiditis is a painful inflammation of the thyroid gland. It is thought to be secondary to a direct viral infection or a postviral inflammatory phenomenon. The inflammatory process leads to the release of the stored thyroid hormone from the follicles. The patient has increased levels of T3 and T4. TSH is down-regulated. This is usually a self-limited disorder that may or may not be followed by transient hypothyroidism. The classic clinical features are painful postviral hyperthyroidism. The pain is exacerbated by swallowing. Patients are anxious, emotionally labile, and have heat intolerance.
2. Graves disease is characterized by the gradual development of hyperparathyroidism and an ophthalmopathy.
3. In Hashimoto thyroiditis, patients are hypothyroid.
4. Lymphocytic thyroiditis is painless.
5. Myxedema results from long standing hypothyroidism.

One Tool to Use in Assessing the Quality of Internal Medicine Residency Programs

One Tool to Use in Assessing the Quality of Internal Medicine Residency Programs

If you plan to apply for training in Internal Medicine, there is a website that you should know about. The American Board of Internal Medicine (ABIM) site publishes the passing rates for all accredited Internal Medicine training programs, and the information is searchable by state. Because passing rates on the specialty certifying board examination is one measure of the quality of the training provided to residents by programs, this is very useful in researching specific programs in order to determine if the residents trained by that program were properly prepared to pass their IM specialty boards. While factors outside of the control of a program can sometimes affect passing rates, prospective applicants to programs should investigate the success of programs in preparing their residents to become board certified, and this online searchable database provides an important tool for doing exactly that. Once you have identified Internal Medicine programs that you are interested in and are considering applying to, visit the following website to locate the IM Board pass rates for each program.

http://www.abim.org/resources/states/

The ABIM database contains information about the internal medicine certifying examination performance of programs accredited by the Accreditation Council for Graduate Medical Education (ACGME). For each residency program listed, the American Board of Internal Medicine (ABIM) reports the cumulative pass rate for the 2002 to 2004 certifying examinations in internal medicine.

What data are reported?
For each program, the number of candidates that took the examination, the number who passed, the percent that passed, and the 95% confidence interval is given.

Which residents are included in the calculation of a program's pass rate?
Candidates are included in the computation of a program's passing rate if they meet the following four conditions:

1. They are first takers of the 2002, 2003, or 2004 certifying examinations in internal medicine (repeat takers are excluded)
2. They completed training in the year of or the year before the first attempt (i.e., a candidate who took the 2004 certifying examination for the first time must have completed training in 2003 or 2004)
3. The final year of training is in internal medicine or a combined training program such as pediatrics and medicine
4. Candidates must have received their satisfactory final evaluation of clinical competence from the training program

Incremental versus Insight Learning

Steven R. Daugherty, Ph.D.
Director, Education and Testing
Kaplan Medical

Why is it that some people seem to get so much more out of their USMLE* study time than others? Why is it that although two students spend the same amount of time preparing for the USMLE, one gets a top score while the other barely passes? Students often tell me how hard they try as they prepare for the USMLE. I've seen their preparation and know what they're saying is true. Yet, some students do not seem to get the improvement one would expect from the time and effort that they put in. Why does effort sometimes not equal success?

The short answer is what matters most is not the time you put in, but what you do with that time. No one gives you credit for effort. No one cares about your struggles. All that anyone will care about is the score you get. Stop focusing on working hard and focus on getting results. Hard work without results means nothing.

You reap the benefits of your efforts by using your study time to gain the level of insight that the USMLE requires. This process is often very different from the one needed for your exams in medical school. USMLE learning is different than medical school learning.

Learning takes place by two distinct processes: the accumulation of details and the organization of those details into a systematic whole. The accumulation of details is incremental. Piece by piece, step by step, you commit the essentials to memory. Brick by brick you collect the critical pieces out of which you will build your intellectual home. But just having the bricks is not enough. At some point you must actually build the house. Accumulation of the parts means little unless they are assembled into a coherent whole.

The organization of knowledge requires a different process than the accumulation of the pieces. No longer are you engaged in a search for the pieces of the puzzle. Now you must fit them all together into a systematic whole. This process is not one of incremental accumulation, but of insight, punctuated by the flash of the emotional "Aha!" Insight forms the pieces into patterns. And the pattern, once understood, gives a context by which all of the pieces are seen in a new light. The difference here is gathering information vs actually getting the point.

You have all had this experience at some point. Think about the time you struggled with your study material, trying to remember the details. And then, suddenly, it all made sense. The details all link up and everything comes into focus. No longer where you concerned about remembering the individual details, because the pattern, once recognized, holds the details in place for you. Once you get it at this level, you "have" it. And the knowledge stays with you even with the passage of time.

The USMLE is not testing whether you have gathered in the necessary knowledge, but whether you have achieved the requisite level of insight so that it all makes sense. USMLE questions are problems that need solutions, not questions in need of remembered answers. Insight allows problem-solving. Without it, you are merely guessing.

All of this means that the study methods that may have served you in medical school may not get you to the level required by the USMLE. Medical school exams are about demonstrating that you have accumulated the bits and pieces of knowledge the professor wants you to master. Multiple-choice exams in medical school expect you to recognize the correct facts on a presented response set. As you study you memorize the required content, bit by bit until you have a storehouse of the things your faculty wants you to learn. You answer their questions by searching that storehouse and finding just the fact needed to answer each question.

Success in medical school depends primarily on the incremental accumulation of knowledge. Success on the USMLE grows out of the insightful assembly of these bits of knowledge into a lucid whole. Learning is not nearly as hard as unlearning. The real struggle in getting ready for the USMLE is not learning the knowledge you need, but learning to use that knowledge, to think about that knowledge differently that you did in medical school. The hardest part of your preparation is learning to leave your old habits of incremental accumulation behind and take on the new processes of insight.

Why do some people get more out of their study time? The long answer is those who gain the needed insight walk away with the information in a mental form that sticks with them, while those who are locked in the incremental accumulation of facts are vainly trying to hold on to the individual pieces that keep slipping away.

Students learn facts for exams. Doctors have that knowledge organized in a way that allows insight to solve clinical problems. Strive for insight. Spend study time not just reading, but thinking about what you have read. Take time to talk to yourself and others about the core concepts and ideas. Your self-confidence will soar and you will achieve a USMLE score that demonstrates that your study time has been well spent.

Can You Name It?

Mechanism of Action:

• This agent is delivered in an enteric-coated delivery system that is able to resist gastric inactivation and deliver enzymes into the duodenum. Once delivered to the duodenum and when the duodenal pH reaches approximately 5.5, the enteric coating begins to dissolve and release of the enzymes is initiated. These enzymes act locally in the gastrointestinal tract and catalyze the hydrolysis of fats into glycerol and fatty acids, protein into proteoses and derived substances, and starch into dextrins and sugars. Once their digestive function has been completed, the constituents may be partially absorbed and subsequently excreted in the urine. Undigested enzymes are excreted in the feces.

Indications:

• This agent is indicated for the treatment of steatorrhea secondary to pancreatic insufficiency such as cystic fibrosis or chronic alcoholic pancreatitis.

Route of Administration:

• Oral capsules: 4,000 units; 10,000 units; 16,000 units; and 20,000 units

Selected Adverse Effects:

• General: diarrhea, abdominal pain, intestinal obstruction, vomiting, intestinal stenosis, and constipation.
• Other: dermatitis, hyperuricemia, hyperuricosuria and fibrosing colonopathy primarily in cystic fibrosis patients.

Selected Drug-Drug Interactions (Drug + Other medication =):

• + indomethacin or ibuprofen = intestinal and liver lesions in animal studies

Special Considerations:

• Contraindications: Hypersensitivity to pork protein or any other component of this product.
• Warnings/Precautions: Cases of fibrotic strictures in the colon have been reported primarily in cystic fibrosis patients with the use of this product; any change in drug therapy should be made cautiously and only under medical supervision; pregnancy category B

Drug of the Month: pancrelipase (Pancrease MT ®)



Diagnostic Dilemma

A 34-year-old male body builder collapses during a particularly strenuous workout. His trainer accompanies him to the emergency department and is able to provide information regarding the patient. He denies any significant past medical history except for a torn biceps tendon 2 years previously. The trainer, however, appears hesitant when asked about illicit drug use. Physical examination reveals a hypotensive, tachycardic patient in moderate distress. Radiologic examination reveals a subcapsular mass within the liver and a large amount of blood within the abdomen. The patient is taken to the operating room in which a 14 cm subcapsular solid yellow mass is removed. Which of the following is the most likely diagnosis?

(A) Focal nodular hyperplasia
(B) Hepatic adenoma
(C) Hepatic cyst
(D) Hepatic hemangioma
(E) Hepatocellular carcinoma

The correct answer to the question above is: B.

1. Focal nodular hyperplasia leads to well-circumscribed liver nodules, classically with a central scar. The nodule is made up of disorganized liver parenchyma. It is important to note that all components of the liver parenchyma are present, albeit disorganized. These are usually discovered incidentally and are not prone to hemorrhage.
2. CORRECT: Hepatic adenomas are commonly seen in young female patients taking oral contraceptives and in those patients that are taking anabolic steroids. Although these are benign tumors, they can rarely undergo malignant transformation. The greatest risk, however, is not in terms of their neoplastic activity, but in the risk for subcapsular lesions to rupture with resultant hemorrhage. This may present with right upper quadrant pain, but if severe enough, it can lead to hemorrhagic shock (as in this patient). Histology reveals a solid yellow nodule with hepatocytes. Other hepatic components (Kupffer cells, bile ducts) are not present.
3. Hepatic cysts are cystic rather than solid, and not a likely source of hemorrhage.
4. Hepatic hemangiomas are the most common benign hepatic tumor. The size and clinical presentation is highly variable, with the most common being asymptomatic. These lesions can rupture with significant blood loss; however, the histology would demonstrated large vascular channels.
5. Hepatocellular carcinoma usually appears in the cirrhotic patient after many years. Although they may bleed, it is an unlikely diagnosis in this case.

The Osteopath Option

The Osteopath Option

Did you know the M.D. is not the only medical degree out there? The D.O. (Doctor of Osteopathy) degree entitles a physician to all the same rights and opportunities as an M.D. Furthermore, the D.O. education focuses on preventive health care, the role of the musculoskeletal system, and treating the patient as a whole person. Sound interesting? Note that, compared to a list of allopathic (M.D.) schools of the same average U.S. News Primary Care ranking, the top osteopathic (D.O.) schools had 68% more graduates choosing careers in primary care (49.4% vs. 82.9%).

This statistic reinforces the claims of osteopathic institutions that, compared to traditional medical programs, their students receive more personal attention and are more likely to become primary care physicians. Furthermore, osteopathic schools receive 3.5 applicants for each person admitted compared with 2.4 for allopathic schools. This may be due to the fact that osteopathic school admissions are more geared towards identifying other variables besides grades and test scores, a process intended to produce more empathic physicians.

D.O. vs. M.D.

The field of osteopathy was pioneered in 1874 by Andrew Taylor Still, a religious medical doctor who became fed up with traditional medicine. He purported the idea that diseases were curable by manipulating the "deranged, displaced bones, nerves, muscles—removing all obstructions—thereby setting the machinery of life moving." Since then, osteopathy has made significant strides, most of them away from "alternative" methods and towards traditional medical practice. D.O.s these days are very similar to M.D.s. Consider the following:

* Both typically start with a scientific 4-year degree.
* Both undergo a four-year medical program.
* Both complete a residency afterwards (osteopaths can enter traditional residencies).
* Both can specialize, although a lower percentage of osteopaths do.
* Both take state licensing exams.

Read more about the Osteopath Option.



Verbal Strategy

Don't Expect an Entertaining Read

The passages you'll confront on test day probably won't be fun to read. Odds are, they'll be boring.

As a part of the challenge, you must be able to concentrate and glean meaning regardless of the nature of the text. This will involve working through your resistance to dry passages and overcoming any anxiety or frustration. The more control you can muster, the quicker you can move through each passage, through the questions, and to a higher score.

Remember, Verbal Reasoning isn't there to entertain or provide relief from the science sections, but to put you through a mental obstacle course.




MCAT News Update! The MCAT Test Change Resource Center

Have you visited our new MCAT Test Change Resource Center recently? We've updated our site to include the most recent information about the computer-based MCAT, 2007 MCAT test dates, CBT FAQs, and even a fully working sample test in the format of the new 2007 version of the exam! Plus, you can see Kaplan's course schedules for the 2007 MCAT. Visit the MCAT Test Change Resource Center now and take control of the new MCAT.




Pop Science

Laughter and Health

We've long known that the ability to laugh is helpful to those coping with major illness and the stress of life's problems. But researchers are now saying laughter can do a lot more—it can basically bring balance to all the components of the immune system, which helps us fight off diseases.

Laughter reduces levels of certain stress hormones. In doing this, laughter provides a safety valve that shuts off the flow of stress hormones and the fight-or-flight compounds that swing into action in our bodies when we experience stress, anger, or hostility. These stress hormones suppress the immune system, increase the number of blood platelets (which can cause obstructions in arteries) and raise blood pressure. When we're laughing, natural killer cells that destroy tumors and viruses increase, as do Gamma-interferon (a disease-fighting protein); T-cells, which are a major part of the immune response; and B-cells, which make disease-destroying antibodies.

Laughter may lead to hiccupping and coughing, which clears the respiratory tract by dislodging mucous plugs. Laughter also increases the concentration of salivary immunoglobulin A, which defends against infectious organisms entering through the respiratory tract.

What may surprise you even more is the fact that researchers estimate that laughing 100 times is equal to 10 minutes on a rowing machine or 15 minutes on an exercise bike. Laughing can be a total body workout! Blood pressure is lowered, and there is an increase in vascular blood flow and in oxygenation of the blood, which further assists healing. Laughter also gives your diaphragm and abdominal, respiratory, facial, leg and back muscles a workout. That's why you often feel exhausted after a long bout of laughter—you've just had an aerobic workout!

The psychological benefits of humor are quite amazing, according to doctors and nurses who are members of the American Association for Therapeutic Humor. People often store negative emotions, such as anger, sadness, and fear, rather than expressing them. Laughter provides a way for these emotions to be harmlessly released. Laughter is cathartic. That's why some people who are upset or stressed out go to a funny movie or a comedy club, so they can laugh the negative emotions away (these negative emotions, when held inside, can cause biochemical changes that can affect our bodies).

Increasingly, mental health professionals are suggesting "laughter therapy," which teaches people how to laugh—openly—at things that aren't usually funny and to cope in difficult situations by using humor. Following the lead of real-life funny doc Patch Adams (portrayed by Robin Williams in a movie by the same name), doctors and psychiatrists are becoming more aware of the therapeutic benefits of laughter and humor. This is due in part to the growing body of humor and laughter scholarship (500 academics from different disciplines belong to the International Society for Humor Studies). Here are some tips to help you put more laughter in your life:

* Figure out what makes you laugh and do it (or read it or watch it) more often.
* Surround yourself with funny people—be with them every chance you get.
* Develop your own sense of humor. Maybe even take a class to learn how to be a better comic—or at least a better joke-teller at that next party. Be funny every chance you get—as long as it's not at someone else's expense!

Adapted from howstuffworks.com.





School Spotlight
Wake Forest University School of Medicine

Location: Winston-Salem, NC
Website: http://www.wfubmc.edu
U.S. News rank (research): 41
Average GPA: 3.63
Acceptance rate: 4.7%

Average MCAT score
Composite: 10.1
Verbal reasoning: 10.1
Physical sciences: 10.1
Biological: 10.1
Writing: P

2005-2006 Expenses
Tuition: $34,006
Required fees: $0
Room and board: $15,040

Celebrating 100 years in existence, the Wake Forest University School of Medicine (WFUSM) is the centerpiece of Wake Forest University Health Sciences, a $100-million research community that maintains nationally recognized research centers in cancer, human genomics, investigative neuroscience, stroke, women's health, and many other disciplines, including the newly established Maya Angelou Research Center on Minority Health. This stimulating environment provides an ideal situation for the study of medicine, anchored by a renowned medical curriculum and a commitment to endow students with an understanding of the awesome role and responsibility of physicians in society.

WFUSM students study the basic and clinical sciences in a variety of settings including classroom lectures, core clinical clerkships, small-group problem-based learning, laboratory sessions, and more. Acclaimed nationally as a model for medical education reform, the WFUSM curriculum aims to educate students according to seven core goals: 1) proficiency in self-directed learning and lifelong learning skills, 2) appropriate core biomedical science knowledge, 3) clinical skills, 4) problem solving/clinical reasoning skills, 5) interviewing and communication skills, 6) information management skills, and 7) professional attitudes and behavior. Community-based clinical experiences in the first year, as well as a focus on general population health, are hallmarks of the curriculum. Furthermore WFUSM, recognized as one of America's "most-wired" campuses, integrates information technology into its program, and all incoming students are provided with a laptop computer.

WFUSM students have access to a number of cultural and athletic resources in the Winston-Salem, North Carolina area. Winston-Salem is located less than an hour from the mountains, has a vibrant science and arts community and is right in the center of ACC basketball and football, as well as world-class golf.
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Tips to Improve Your Clinical Relationships and Evaluations

Whether you are a medical student doing rotations and electives, or an international medical graduate doing a clinical observership, you will be evaluated by attending physicians and chief residents. This is a common source of concern as these individuals are potential sources of letters of recommendation for residency applications. Here are some tips for increasing the odds that you will receive positive comments.

• Much friction comes from misunderstood expectations. So as soon as the clinical experience begins, seek out the person in charge and clarify what's expected of you.
• Ask for feedback—don't wait until the end. This way, you can work on any deficit areas and demonstrate that you want to learn and are eager to improve.
• Approach interactions with superiors with respect. If you express that you value what they want from you first, they are more likely to listen when you follow this with your own concerns about fulfilling what they request.
• Avoid comments on personalities when discussing issues. Instead, state the specific facts leading to the problem and, whenever possible, suggest a compromise or solution to the problem.
• Before going over a superior’s head, take a step back and ask yourself how important the problem really is. One bad evaluation is unlikely to hurt your career, but negative comments about you made by multiple evaluators will raise the concern that you may be the problem.
• Associate with colleagues as one way of putting your problem in perspective. Others may have found ways to address the issue that you hadn't thought of. And even if you only hear your experience validated by the experience of others, your feelings of being singled out or isolated will decrease.

Increasing numbers of court cases have been brought against employers by employees who feel they have been treated unfairly. As a result, many employers now very carefully document how they deal with employee problems. There is a diversity of opinion about whether such protections should apply in the same way to medical residents. With which of the following statements do you most agree?

1. Residents' mistakes can cost lives, so the same legal protections shouldn't apply.
2. Residents' problems and mistakes should be dealt with in the same way as other employees.
3. If a resident is careless or negligent, then the consequences deserve to be harsher than if the error was due to inexperience.
4. The attending/supervising physician should be held accountable instead because they are supposed to be supervising the residents.
5. Unfair treatment of residents when something goes wrong happens all the time, so the real solution is for residents to unite in order to get the protection they deserve.

Think and Know versus Grab and Go

Steven R. Daugherty, Ph.D.
Director, Education and Testing
Kaplan Medical

Who is in charge when you take you exam? Do you control you exam, or does the exam control you?

The USMLE* requires you to be able to think on your feet. The exam is not testing your knowledge, as such. Rather, each question is designed to assess your ability to sort out what is important, integrate the relevant concepts and solve the problem presented. You do not master this type of question by memorizing a lot of facts and spitting them out. USMLE questions require you to decide early what is relevant, ignore what is not, and pick the option that offers the most optimal solution. Grabbing for the first answer you see will not get you the score you want. You need to learn to think with what you know and come up with the very best choice.

Mastering this thought process for the USMLE is difficult for two reasons. First, much of medical school education is oriented towards strict memorization. Testing in medical school, whether by oral or written exams, often focuses on the subtle details and minute distinctions which demonstrate an in-depth exposure to the material of interest. When you show that you know these details on an exam, the faculty member feels confident that you have spent adequate time and attention on the content of most concern to them. But, being good at memorization and being good at thinking are two separate things. Even if you can think clearly and efficiently, medical school often rewards you for memory, not thought. And after spending time getting good at the processes of memorization, you may have lost the impulse for and habits of thinking well.

Second, the time pressure of the exam forces even those students who have retained the skill of thinking to abandon this higher intelligence and hope for salvation by reaching for the first option that looks familiar. Time pressure degrades our willingness to spend the moment thinking requires and induces us to value speed over effectiveness. We short-circuit our thinking processes by using what cognitive psychologists call "heuristics." Heuristics are ways of generating an approximate answer without fully considering all of the information presented. The two most common heuristics are Availability, where what comes to mind first is given most credibility, and Representativeness, where things with similar features are deemed as being the same in all respects. Both of these heuristics serve you well in medical school. What is most available mentally is likely to be what you just studied as you crammed for an exam. What you have just learned is what will most likely be on the test ( Availability). When you crammed for your exam, you were required to know a finite set of information. All you had to do on the exam was know a relevant detail that let you discriminate within this finite set of material (Representativeness).

But, the Availability and Representativeness heuristics, so valuable in medical school, interfere with the core thought processes essential to do well on the USMLE. The breadth and depth of the content covered by the exam you will face on the USMLE convert these mental heuristics from valuable short-cuts to disastrous dead-ends.

Most medical school exam are about "grab and go." You see an answer that looks familiar and reminds you somewhat of the issue presented in the question, so you grab for it and go on to the next question. A good USMLE score, by contrast, depends on "think and know." You must think about what is presented, compare this with your knowledge base, and reason though to the best possible answer. Sometimes the answer is something you have already seen and already thought about. These are the easy questions. However, increasingly, students say that USMLE questions present material in unique ways, from a perspective they never really considered before. These questions are harder, but are becoming the backbone of the exam. You must answer these integrative questions by applying your knowledge in new ways to situations that are distinct.

The key issue is this: The knowledge needed for the USMLE is the same as that you learned in medical school. What sets the USMLE apart is its insistence that you learn to combine the different threads of the knowledge you have learned and weave them into a new pattern. Doing well depends not on grabbing all the right treads, but learning the art of weaving. On the USMLE, you will be asked to use your knowledge in ways that you may never have before. Not grab and go, but think and know.

The exam is not a quiz show where you get points for spouting esoteric facts. The USMLE is a screening test to see if you have mastered the perspectives and thought processes essential for medical practice. A physician, a good physician, makes a living by thinking and reasoning. Take the time to relearn and practice this art of reasoning and you will reap the reward of a higher score.

Can You Name It?

Mechanism of Action:

• The most accepted explanation of its mechanism of action is that it causes relaxation of vascular smooth muscle, producing dilatation of peripheral arteries and veins, especially dilation of veins.
• The therapeutic effects include: dilatation of veins promotes peripheral pooling of blood in the extremities as well as decreasing venous return to the heart. The net result is a reduction in left ventricular end-diastolic pressure and pulmonary capillary wedge pressure (preload). The arteriolar relaxation decreases the systemic vascular resistance, systolic arterial pressure, and mean arterial pressure (afterload).

Indications:

• This agent is indicated for the prevention of angina pectoris due to coronary artery disease.

Route of Administration:

• Oral Tablets (30 mg, 60 mg and 120 mg)

Selected Adverse Effects:

• General: chest pain, edema, fatigue, fever, flu-like symptoms
• CV: hypotension, angina pectoris aggravated, heart murmur, abnormal heart sounds, myocardial infarction, Q wave abnormality, arrhythmias, extrasystole, palpitation, tachycardia, ventricular tachycardia
• Nervous system: dizziness, headache, paresthesia, vertigo
• GI: abdominal pain, constipation, nausea, vomiting
• Metabolic: hyperuricemia, hypokalemia
• CNS: anxiety, concentration impaired, confusion, decreased libido, depression, impotence, insomnia, nervousness, paroniria, somnolence

Selected Drug-Drug Interactions (Drug + Other medication =):

• Other vasodilators = Increased vasodilation and increased adverse reactions
• Alcohol = Increased vasodilation and increased adverse reactions
• Calcium channel blockers, organic nitrates = profound orthostatic hypotension

Special Considerations:

• Contraindications: hypersensitivity or idiosyncratic reactions to other nitrates or nitrites
• Warnings/Precautions: severe hypotension, use with caution in patients who may be volume depleted, paradoxical bradycardia, increased angina pectoris, aggravation of the angina secondary to hypertrophic cardiomyopathy, development of tolerance with time

Drug of the Month: Isosorbide mononitrate (Imdur ®)

Cardiac conundrum

A 54-year-old woman with a history of valve replacement visits her dentist for a routine cleaning. Two days later, she develops a severe fever, has small hemorrhages on her fingers, and funduscopic evaluation reveals the presence of retinal hemorrhages. She becomes hypotensive and is rushed to the emergency department. Which of the following is the most diagnosis?


(A) Acute bacterial endocarditis
(B) Acute rheumatic fever
(C) Libman-Sacks endocarditis
(D) Nonbacterial thrombotic endocarditis
(E) Subacute bacterial endocarditis


The correct answer to the question above is: A.

1. CORRECT: Previously damaged heart valves or prosthetic valves are susceptible to infection. Bacteria seed the valves in this case after dental work. The rapid decline of the patient and the peripheral and retinal hemorrhages reveal the likely diagnosis as acute bacterial endocarditis. In mechanical valves, if there is infection around the valve, it can lead to its possible dislodgement.
2. Acute rheumatic fever may lead to fever. If the myocardium is affected, conduction abnormalities may result. Repeated bouts affecting the myocardium lead to its scarring.
3. Libman-Sacks endocarditis presents as sterile vegetations on both sides of the heart valves. Fever and peripheral hemorrhage are not seen. These vegetations are seen in systemic lupus erythematosus.
4. As the name implies, nonbacterial thrombotic endocarditis is characterized by accumulation of small thrombotic emboli on the heart valves. This condition is associated with chronic diseases such as cancers.
5. While a normal heart valve is not usually susceptible to the less virulent organisms that give rise to subacute bacterial endocarditis, those with a prosthesis are. The important distinction is rapidity of the onset of symptoms.

Residency

Plan Ahead for the Costs Involved in Applying for Residency! If you are planning to enter the NRMP Match for 2007, it is wise to understand the costs involved early on so that you won't be surprised once you begin the process. To give you an idea of these, here are the fees which applied during the 2006 Match cycle. Additional expenses associated with travel/housing for interviewing at programs are not included since the costs involved will vary with the number of interviews offered to and accepted by applicants. Below is a summary of 2006 fees involved in residency application: The ERAS application process requires three separate fees: $75 ECFMG Token Fee $60 ERAS Processing Fee $50 USMLE™ Transcript Fee You will also incur fees based on how many programs you decide to apply to: Number of Programs Per Specialty AAMC Fees Up to 10 $60 11-20 $8 each 21-30 $15 each 31 or more $25 each You will also need to register with the National Resident Matching Program (NRMP): $65 NRMP Registration Fee $50 Late Registration Fee (after December 1) $15 Additional Registration Fee for each registrant participating in the Match as part of a couple $30 Fee for each program ranked, above 15 programs International medical graduates may be subject to additional fees to the ECFMG. See www.ecfmg.org for details.

Who is in Charge on Your Exam?

Steven R. Daugherty, Ph.D.
Director, Education and Testing
Kaplan Medical

Who is in charge when you take you exam? Do you control you exam, or does the exam control you?

The USMLE is not only testing your content knowledge, but also your ability to problem-solve on your feet. In spite of distractions, are you able to contain your anxiety and focus on the pertinent issues before you? Do you approach each question with a confident curiosity? Or are you hoping that things will be easy; that you have seen the problem before; that you will get lucky and see a question focused on content you recently studied? Do you approach each question with quiet confidence or uneasy hope?

Success on the USMLE depends on identifying issues and thinking clearly. Yes, you must have memorized essential content. But, the exam wants more from you than a demonstration of what you have memorized. The exam wants you to show that you know how to use what you have learned.

To accomplish this you must be more than a recoding and playback device. You must be more than a machine. You must be a person who can assess, think and decide. In short, you are being tested on who you are as much as what you know. The USMLE expects you to be in control of yourself and to demonstrate that by your control of the exam.

Gaining the control you need for the exam begins with your preparation strategy. In the long process of exam preparation it is easy to lose perspective. Over the course of weeks and months it is easy to feel overwhelmed and buried under the material you must master. Once lost, you feel like you are playing catch-up, and you never quite catch up. To avoid playing continual catch-up, take charge of your USMLE preparation from the very beginning.

Begin by making decisions and taking action based on those decisions. Decide what is essential and what is lower yield. Decide what study material resonates with you and helps the content to make coherent sense. And then, plan your study to cover the material you have selected. Avoid the temptation of asking everybody else what you should do. Yes, listen to advice, but then make your own decisions as to what works for you. Be especially skeptical of advice from parents and family members who do not have first-hand knowledge of the USMLE. Family usually advises you to work hard and spend long hours at study, but they rarely can give you critical insight about what to do with that study time.

You have to live with your exam results, so you need to take responsibility for deciding how you should proceed. Make a study plan that maps how much time you will study each day and then follow it! Avoid studying “every waking minute.” Treat study time like a job. Put in your time, mentally clock out at the end of the day and give yourself a chance to rest each evening. Tomorrow you must get up and do it all again. Make sure your strategy is one you can maintain long term, not just over a couple of days.

When your study turns to questions, stay in charge by avoiding excessive focus on you percentage correct. Each question is a chance to test what you know and how you think. If you get a question right, congratulate yourself on your progress. But never forget that it is the questions you get wrong that will really improve your performance on the actual USMLE. When you get a question wrong you have uncovered a deficit. Use this knowledge by taking direct action to resolve the deficit. Diagnose why you missed the question. Was it because you missed something when reading the question or because you did not know the content? If you missed something when reading, pay attention to what you miss and you will discover patterns of errors you can correct. If you did not know the content, go back to your study material and go over it again.

Don't just react to questions, act on them. Don't simply feel good or bad about your question results. Make use of the information you have gained and do something about it!

By making decisions all the way through your study preparation, you are not only going to do a better job of learning, you will also be teaching yourself the mental set and the self-control the USMLE requires. You know how to take charge because you have learned to take change of yourself. We want doctors who have the self-control and the aplomb to handle whatever patient care issues with which they are confronted. Your final USMLE score is a much a reflection of you control of the exam as it is your memorized knowledge. Take charge of your preparation and you will take charge of your exam.

Can You Name It?

Mechanism of Action:

• Acts on hematopoietic cells by binding to specific cell surface receptors and stimulating the proliferation and differentiation commitment of these cells. In the human body, this agent is produced by human monocytes, fibroblasts, and endothelial cells. It stimulates the production of neutrophils within the bone marrow and affects neutrophil progenitor proliferation and differentiation.
• This agent is produced by recombinant DNA technology.

Indications:

• This agent is indicated to decrease the incidence of infection in patients receiving a variety of myelosuppressive anticancer drugs associated with a significant incidence of severe neutropenia with fever, as well as use in patients receiving bone marrow transplantation.

Route of Administration:

• Solution for injection

Selected Adverse Effects:

• General: nausea, vomiting, bone pain, diarrhea, fatigue, sore throat, generalized pain.

Selected Drug-Drug Interactions (Drug + Other medication =):

• Drug interactions between this agent and other drugs have not been fully evaluated.
• Drugs that may potentiate the release of neutrophils, such as lithium, should be used with caution.

Special Considerations:

• Contraindications: Hypersensitivity to this product
• Warnings/Precautions: Allergic reactions, splenic rupture, adult respiratory distress syndrome, may enhance the growth potential of malignant cells, leucocytosis, immunogenicity, must continually monitor blood counts, pregnancy category C.

Drug of the Month: Filgrastim (Neupogen ®)



Mysterious Malady

A previously healthy 23-year-old college student is preparing to take a 3 month trip around Asia. He has received most of his vaccinations, including the full course of the hepatitis B vaccine. He also started to take his malarial prophylaxis 2 or 3 days ago. He now reports to the emergency department with jaundice, pallor, dark-colored urine, weakness, and back pain. Blood tests indicate a profound anemia. A blood smear reveals multiple fragmented red blood cells. Which of the following is the most likely diagnosis?


(A) Autoimmune hemolytic anemia
(B) Glucose-6-phosphate dehydrogenase deficiency
(C) Hereditary spherocytosis
(D) Paroxysmal nocturnal hemoglobinuria
(E) Sickle cell disease

The correct answer to the question above is: B.

1. The development of antibodies to red blood cells and their subsequent destruction has been noted to occur 1-2 weeks after the administration of antibiotics and antihypertensives.
2. CORRECT: The presentation of acute hemolytic anemia a few days after starting antimalarials (such as primaquine) is classic for glucose-6-phosphate dehydrogenase deficiency. Red blood cells deficient in this enzyme are unable to regenerate NADPH. NADPH is, in turn, required to convert oxidized glutathione to reduced glutathione. It is the generation of reduced glutathione that allows cells to resist oxidative stress. Older red blood cells in which the stores of reduced glutathione are depleted are more susceptible. Sources of oxidative stress includes the consumption of fava beans and antimalarials. Viral hepatitis and pneumonia can also elicit massive hemolysis.
3. As the name implies, blood smears would have shown spherical cells in hereditary spherocytosis. Furthermore osmotic, not oxidative, stress promotes their destruction.
4. Paroxysmal nocturnal hemoglobinuria is caused by a red blood cell membrane defect. Most patients do not have hemoglobinuria, and those that do, have it at night. It is not related to anti-malarial medication.
5. Sickle cell disease is an inherited disorder that certainly would have presented earlier.

Deciding to Succeed

Steven R. Daugherty, Ph.D.
Director, Education and Testing
Kaplan Medical

Succeeding on the USMLE means making decisions. The exam does not ask you to tell what you know, rather it asks you to make decisions based on that knowledge. It is decisions that are tested. Knowledge is assessed only by inference. You must know critical details; however, these details are means to an end, not the end in themselves. At the end of each exam question is a decision. Your performance on the exam rests not with what you know, but how you make decisions.

Decisions on the USMLE have some essential parallels with medical decisions in the real world, but also some critical differences. Real world medical decisions and USMLE questions both involve some of the same knowledge. Both require the integration of content of a number of subject areas to solve the presented problem. Both require the capacity to sift presented information to decide what matters and what does not matter.

But real world medical decisions and USMLE decisions are vastly different in their consequences. In the real world, if you make a bad medical decision, you could kill a patient, or at least cause avoidable pain and suffering. If you make a bad decision on a USMLE question, then you simply get the question wrong. Now, getting a question wrong is something you want to avoid, but you must admit that the consequence is a lot less traumatic and a lot less enduring.

Because the consequences of your decisions are different on the USMLE, your decision processes must be different than those in the real world of medicine. In the real world you must strive for certainty. If you are not sure, get sure. If you need more information, get it. Because life and death may be hanging in the balance of your decision, it is vital that you seek as much certainty as possible. In the real world you strive to get as close to 100% certainty as possible in order to assure yourself that you are making a decision that you and your patient can live with.

On the USMLE, you will rarely attain this level of certainty. You simply do not have the time. You must learn to make decisions you can live with without having the time you would like to allow that feeling of certainty to emerge. On the USMLE you must learn to make decisions, not when you are 100% sure, but when you are 51% sure. Fifty-one percent sure is when you think maybe you have the answer but you are still not sure. That "maybe" IS the decision! The added time you spend on the question after that point is not going to improve your score, but simply allow you to feel more comfortable with the decision that you have already made.

Train yourself to make a decision and move on. Do not wait for certainty. Read, decide, and move. There is another question waiting for you. Remember that, at the end of the day, what matters is not whether you get this particular question correct, but rather your total score across all the questions you face.

If you find yourself short on time during the exam, you will not gain speed by reading faster, but by deciding sooner. Your reading speed is essentially a constant for the exam. No matter how much you may want to read faster, you really can't. You can't read faster, but you can decide faster.

The time we spend making decisions is really composed of two parts. The first bit of time is about thinking and choosing. The second bit of time is simply dedicated to feeling good about the decision we have already made. This second part of the process does not make our decisions better, but merely helps us feel better. Forget about feeling better. You do not need to feel better to do well on the exam. You need to make a decision, live with it and move on to the next question.

When you think that you may have identified the best answer, you most likely have. Make the choice and stick with it. Stand with the courage of your convictions and in the confidence of your ability to decide. Learning to make these kinds of decisions is the key to attaining that USMLE score that truly reflects your abilities.

Can You Name It?

Mechanism of Action:

• This agent is a nondepolarizing neuromuscular blocking agent with a rapid to intermediate onset depending on dose and intermediate duration. This agent acts by competing for nicotinic cholinergic receptors at the motor endplate. This action is antagonized by acetylcholinesterase inhibitors, such as neostigmine and edrophonium.

Indications:

• This agent is indicated for use in inpatients and outpatients as an adjunct to general anesthesia to facilitate both rapid sequence and routine tracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation.

Route of Administration:

• Solution for IV injection: 5 mL and 10 mL multiple dose vials containing this medication for injection (10 mg/mL)

Selected Adverse Effects:

• CV (arrhythmia, abnormal electrocardiogram, tachycardia); GI (nausea, vomiting); Respiratory (asthma, bronchospasm, wheezing, or rhonchi); and General (rash, injection site edema, pruritus)

Selected Drug-Drug Interactions (Drug + Other medication =):

• + Inhalation anesthetics, enflurane > isoflurane > halothane = enhanced activity of other neuromuscular blocking agents
• + Aminoglycosides; vancomycin; tetracyclines; bacitracin; polymyxins; colistin; sodium colistimethate = enhanced neuromuscular blocking action
• + Quinidine = recurrent paralysis may occur

Special Considerations:

• Contraindications: Hypersensitivity to this product.
• Warnings/Precautions: Only administer under the supervision of experienced clinician; use carefully in patients with myasthenia gravis or myasthenic (Eaton-Lambert) syndrome, possible anaphylaxis, long-term use has not been studied; Pregnancy category C; Dosage adjustment may be required in patients with clinically significant hepatic disease, use cautiously if used for rapid sequence induction in patients with ascites; malignant hyperthermia may occur.

Drug of the Month: Rocuronium bromide (ZEMURON ®)


Researching Which Programs to Apply To

Once you have decided on a specialty, it is time to begin looking at various sources of information about programs within that specialty. Many specialty organizations maintain databases on accredited programs, searchable by state/location. Often, the listed program names are links to individual program websites. Alternatively, you can use the official database, called FRIEDA, which lists all accredited programs in all specialties and is searchable by many criteria. The data in FRIEDA is always fairly accurate, but is updated most frequently during the active months of the matching cycle (September-March).

Another source of information about good programs to apply to is your own network of IMG physician colleagues and the staff at your Kaplan Center. These individuals usually have a working knowledge of where other IMGs found program interest, either in the form of offered interviews or where they actually matched.

Your own research can lead to other prospects by making use of the Unfilled Position lists from previous cycles of the NRMP match. We suggest that you limit this to the 3 most recent match years because program policies and their openness to IMG applications do change over time. Most medical school reference libraries will have copies of the Unfilled Position List booklets, or the booklets may be ordered online at the www.nrmp.org website. Once you obtain the lists, scan within your specialty of interest to find programs that have not always filled in the 3 previous matches. In the lists, this is indicated by subtracting the program Quota number from the Filled number listed for each program. Programs which have experienced problems in filling all the positions offered in the match are often more receptive to considering internationally trained applicants.

Once you have identified a number of programs that look interesting and potentially open to IMG applicants, visit their individual program websites to read about what they offer.





Musculoskeletal Mystery

A 21-year-old college football player complains of pain and swelling in his left thigh. He states that his thigh has been swollen ever since he was tackled hard at a football game 4 weeks ago. Evaluation at the time revealed mild bruising but no fractures. An x-ray performed now reveals a circumscribed radiodensity with central lucency in the distribution of the vastus lateralis muscle. This ossific density appears to be distinct from the femur, and no fracture is identified. A follow up x-ray performed 4 weeks later showed more ossific material centrally with no fracture. Which of the following is the most likely diagnosis?


(A) Extraskeletal osteosarcoma
(B) Lipoma
(C) Malignant fibrous histiocytoma
(D) Myositis ossificans
(E) Stress fracture

The correct answer to the question above is: D.

1. Although important to exclude, extraskeletal osteosarcoma occurs in older individuals, is not preceded by trauma, and does ossify initially at the periphery.
2. Lipomas can develop in the young adult, but not so rapidly and do not ossify.
3. Malignant fibrous histiocytoma is a soft tissue tumor with a variety of cell types. The angiomatoid variant occurs in young adults. It is an unlikely diagnosis given the history.
4. CORRECT: This is a classic presentation for myositis ossificans. As the name indicates, it is formation of osteoid matrix within the muscle. Although often associated with a preceding traumatic event, this is not always the case. In the initial stages, myositis ossificans presents as an area of soft tissue swelling. As the bone matrix is laid down and the trabeculae are mineralized, the lesion becomes visible on radiographs. The process of ossification begins peripherally and progresses centrally until the entire lesion is ossified. Excision is usually curative.
5. Stress fractures may initial be radiographically occult, but are usually seen on later films. They are also not associated with soft tissue lesions.

Answering from Fear vs. Answering from Confidence

Tips and Trends:
Answering from Fear vs. Answering from Confidence

Steven R. Daugherty, Ph.D.
Director, Education and Testing
Kaplan Medical

Emotions are the motive force that guides our actions. What we feel has an awful lot to do with what we do. And in few places is this as true as when answering questions on the USMLE.

For some people the looming exam evokes fear. "How will I be judged?" "Am I up to the task?" "What if I fail?" For others the coming of the USMLE is a challenge that energizes. "Here is the chance to show what I have learned." "This is the forum in which I will show myself and the world that I deserve to be a physician."

Many people preach that the goal of the student during the exam should be to be calm and as emotionless as possible. Many people will tell you that during the exam, emotions are a stumbling block. Nothing could be further from the truth. The fact is that the exam will evoke strong emotions. Making the best use of your emotional reactions to the exam has a great deal to do with your final outcome.

Strong emotions are not bad. Emotions serve as the gateway to the cognitive processes demanded by the exam. The right emotional set lays the foundation for optimal cognitive processes. Emotions are the physiological backdrop within which our thoughts and mental processing occur. To do your best you do not want to be emotion free. Rather, make it your goal to harness those emotions you feel. Emotions provide the energy to keep you going when you are tired and to maintain your focus when you are distracted.

All decisions are emotional. Without emotion no decision would ever get made. The key to successful decisions is not a lack of passion, but having the right emotional basis by which cognitive decision-making can proceed. Doing well on the exam is not just about knowing, but more fundamentally, about being able to act, to make decisions. Answering the each presented question requires you to break free from the mere facts to the level where you understand what is being presented, what is most important and, therefore, what must be done.

Think about your preparation for the USMLE as essentially a contest between fear and confidence.

Fear is aversive. We don't like fear and usually act to get rid of the feeling as quickly as we can. Because fear is aversive, it leads to thoughts of escape. In the face of fear we do not want to engage and solve, but disengage and run. Fear causes us to make impulsive choices to feel better, not thoughtful decisions which stand the test of time. Fear drives us to act, but drive out rational cognitive analysis at the same time. Driven by fear, we seek to get an answer in order to get rid of the question. And our whole motive changes from getting the great score to simply getting rid of the bad feeling.

Confidence is positive. Confidence has us jumping into the problem with the anticipation that we can handle whatever is presented. When we are confident a problem is not a burden, but something which energizes us as we seek to understand and to master. From this perspective, each question becomes a challenge. And our goal is transformed from avoidance to one of mastery. Confidence gives us a solid emotional platform on which we can build with our recollections and thoughts. Confidence takes the first step to success by assuming that we will succeed.

The difference between fear and confidence rests with a simple thought. If you think you can handle the exam, you are confident. If you think you can not, you will be afraid. Please note that which ever stance you take is not based on rationality, but on what you assess reality to be.

Can you handle this exam? The fact is that of course you can. You would not have made it this far in your career if you lacked the capacity. Perhaps you have not done everything right or perfectly you entire career. That does not matter. No one expects perfection. All anyone expect is for you to be the physician you are. A physician does not walk into the examination room with fear and trepidation, but with confidence. Each patient is not a problem. The patient is your job. Tending to the patient is you calling.

How do you get to confidence? What makes the difference between the disruption of fear and the energy surge of confidence? It's all about preparation. Confidence does not come from simply reading the content, but from doing things with it. Confidence is born in the flash of insight, in the ability to face something new and figure it out.

When you are well prepared, you are confident. When you are not well prepared, you fear. It's really as simple as that. Put in the time learning to think and not just memorize and you will no longer fear the outcome, but rise to the challenge. That is the confidence that leads to success.

	Residency
	2007 Match Applicants Advised to Get Step 2 CS Test Date by July 1, 2006 International medical students/graduates planning to participate in the 2007 Match are strongly encouraged to apply for Step 2 CS and to schedule their testing appointment by July 1, 2006, according to a notice posted March 3, 2006 on the ECFMG's official website (www.ecfmg.org). This recommendation stems from the need to have taken the Step 2CS exam before Dec. 31, 2006 in order to ensure that the score is available before the Match deadline in February, 2007. This does NOT mean that you must take the exam before July, but rather that early registration is the best way to secure a testing appointment at one of the national CS testing Centers. As of March 2006, the earliest available test dates at any clinical skills evaluation center is in late May or early June 2006. The demand for test dates during the second half of 2006 is expected to be particularly heavy. Similarly, the demand for Kaplan's Step 2 CS preparation courses is also expected to be heavy in the latter half of the year, making it a wise move to register and schedule early in order to ensure that you will get a slot for both the Kaplan CS preparation course and for the Step 2 CS examination as soon as possible. Early registration and scheduling offers several benefits: Only registered applicants can access the Step 2 CS Scheduling mechanism showing the available dates. Scheduled testing appointments may be changed without cost with more than 14 days' notice. Applicants who take Step 2 CS early but fail are more likely to be able to retake the exam in 2006 and still receive their result in time to participate in the 2007 Match.

Renal Riddle

A 13-year-old girl is brought to the doctor’s office by her anxious parents. They are very concerned about the change in her urine color; in fact, it seems that there is blood in it. The child has been in good health except for a recent respiratory tract infection. Physical examination reveals mild edema in the lower extremities and increased blood pressure. Examination of the skin is normal. Serum creatinine and blood urea nitrogen are also normal. Examination of the urine reveals gross hematuria and elevated protein. Antistreptolysin O assays are negative. Histologic examination demonstrates mesangial proliferation. Immunostaining is positive for deposition of IgA, C3 and properdin. Which of the following is the most likely diagnosis?

(A) Acute post streptococcal glomerulonephritis
(B) Alport syndrome
(C) Berger disease
(D) Henoch-Schönlein purpura
(E) Minimal change disease



The correct answer to the question above is: C.

1. Post streptococcal glomerulonephritis is a distinct disease from Berger disease. It is mediated by the formation of IgG antibody complexes deposited in the glomeruli. Serum tests reveal antibodies to several streptococcal proteins. These patients only rarely progress to chronic renal failure.
2. Alport syndrome is an X-linked disorder in the alpha-5 chain of the collagen type IV molecule. This disorder is associated with deafness.
3. CORRECT: Deposits of IgA, C3, and properdin in the mesangium occurs in IgA nephropathy, also known as Berger disease. Berger disease initially presents in children, most commonly, following a respiratory tract infection. It can, however, occur following urinary or gastrointestinal tract infections. Patients may have a mild nephritic syndrome with edema and some proteinuria. The proteinuria is not to the level seen in nephritic syndrome. The gross hematuria only lasts a few days but often recurs a few months later. Although initial serum creatinine can be normal, chronic renal disease can occur in up to half of the patients after several decades.
4. IgA deposits are seen in Henoch-Schönlein purpura; there are, however, purpuric lesions.
5. Minimal change disease is the most common cause of nephrotic syndrome in children. It is not associated with deposition of IgA.


Can You Name It?

Mechanism of Action:

* This agent is an IL-2 receptor antagonist, which binds with high-affinity to the Tac subunit of the high-affinity IL-2 receptor complex and inhibits IL-2 binding.
* The therapeutic effects include inhibition of IL-2-mediated activation of lymphocytes, a critical pathway in the cellular immune response involved in allograft rejection.

Indications:

* This agent is indicated for prophylaxis of acute organ rejection in patients receiving renal transplants.

Route of Administration:

* Solution for IV injection: 25 mg/5 mL (a clear, sterile, colorless concentrate for further dilution and IV administration)

Selected Adverse Effects:

* Most Common: immunosuppression and development of immunosuppression
* Other:
o Gastrointestinal System (constipation, nausea, diarrhea, vomiting, abdominal pain, pyrosis, dyspepsia, and abdominal distention)
o Central and Peripheral Nervous System (tremor, headache, dizziness)
o Urinary System (oliguria, dysuria, renal tubular necrosis)
o General (posttraumatic pain, chest pain, fever, pain, fatigue, hypertension, dyspnea, pulmonary edema, coughing, impaired wound healing without infection, insomnia, back pain, tachycardia and blood disorders (Bleeding and Clotting Disorders).

Drug-Drug Interactions:

* cyclosporine, mycophenolate mofetil, ganciclovir, acyclovir, azathioprine, corticosteroids = increased incidence of adverse reactions.

Special Considerations:

* Contraindications: Hypersensitivity to this product; past history of anaphylactic or severe systemic reactions to human globulin.
* Warnings/Precautions: Immunosuppression; Development of Infections; Pregnancy category C; Dosage adjustments necessary in pediatric patients and geriatric patients.


Drug of the Month: daclizumab (Zenapax ®)