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.