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Episode 91: There aren’t enough residency positions for graduating medical students? It depends on the state; the forecast is grim. Download transcript: Stop Cutting Residency Positions  More Medical Students Than Residency Positions As you may know and have probably heard there is becoming an increasing discrepancy between the number of graduating medical students and the number of positions available for internships in residences. It’s a terrible thing to be in medical school graduate and be unemployed and not be able to get a job. This is a disturbing topic. I’ve had a considerable amount of fought before doing a podcast because I wanted to make sure I got my numbers right. [ad#300×250] Texas’ Medical Student Projection Now, I’ve finally found a graph. It’s not national but it will give you an idea. I want to give you a sample from Texas and if you could find a better reference nationally to give you this specific data please give it to me and I will certainly share it again with the podcasted community. The text is hospital association in Texas Higher Education coordinating board. Hosted a forum, they got a couple of million dollars to establish new first year residency positions. In 2012, they had a report that is available online and they said it already in 2014 there were 63 less slots available for graduating medical schools compared to the number of 4th year graduating Texas doctors. Let me be real clear what I’m saying here. A lot of people will go to a different state to apply and attend a residency. A lot of U.S. citizens or even foreign nationals, they go to medical schools outside of the United States. What we’re talking about now is a coming crisis where people graduating in medical school within their own state can’t even get a job. Even if they all stayed in the same state, they’re being forced to go elsewhere. Florida Grows Medical Schools – Not Residencies Florida is actually the worst. There are medical schools popping up everywhere and this goes back several years when the AAMC said, “Hey, we need to boost the number of medical school graduates by 30%.” Texas did that but the residency growth is much slower and more expensive, believe it or not, than a medical school and its rate has only been 15% growth since then. It’s outpacing it by twice as much and the number of graduating medical schools is quickly overtaking it. This is projected to happen nationally. This is alarming. You may be experiencing this already, but this has real life implications such as the number of applications you should put in for your residency and the number of interviews you should go to. I think everything is going to start doubling. If you aren’t already just a stellar student then I think you need to double everything right off the bat. I’ve been down that road, had to switch programs. I know what it feels like to not match. I know what it feels like to match to your number one choice. Man, you need a lock and load on this and go to a lot more residencies if you are below average in your medical school class. That is my advice. Projections of Unemployed Doctors By 2016, the number is projected to jump to almost 200. 180 it says here, but I’m looking at the graph that I will include in the show. It’s for this episode. I’ve researched the actual 69 page paper that this council put out and this has happened before which id surprising, a little bit in 2007. It was about 112 more graduates than there were residency slots. That’s not that long ago. It’s happened a little bit before then, but the trajectory from 2014 and 15 and what’s projected on our into the future is much worse. A lot of this corresponds with the economic recession, that when it dovetailed. The problem is that the government is broke.

Episode 90: USMLE Step 3 is changing in 2014 and the rest will follow suit. Learn about the changes and new structure in this episode of the Medical School Podcast. Download transcript: USMLE Changes in 2014 and Beyond View image of changes: USMLE changes Dr. Dan:           Welcome to the Medical School Podcast. I’m your host, Dr. Dan, and this is Episode 90. In this episode, I will be discussing the evolution of the United States Medical Licensing Exam. There are a number of important changes which I am sure you’ve heard about, but I want to clarify and notify those that did not know about this stuff. Let me set the background a little bit with the USMLE. In the early 1990s, the USMLE exam for the allopathic schools replaced the NBME, the National Board of Medical Examiner certification examinations and the Federation Licensing Examination program called FLEX. It’s been around for a long time as a standalone. That’s gone on 20 plus years now. [ad#250×250] Of course, in 1999, they began those computerized patient simulations in Step 2. Standardized patients were introduced in 2004. That’s only about 10 years now. They’re making a lot more changes which is the purpose of this episode. Also in 2004, the USMLE undertook an in-depth review of the program. Everything is moving towards evidence-based. That’s the underlying theme here with what’s going on with the USMLE. They’re doing feedback on the test to make sure that it’s valid and actually measuring what it’s supposed to measure and that what their targeting is actually relevant to clinical practice today. There were 5 major recommendations that came back and were adopted in 2009. The first one is to make the USMLE focus on assessments to support state licensing authorities’ decisions about a physician’s readiness to practice patient care at entry into supervised practice, which means beginning a residency, and entry into unsupervised practice, potentially after internship when you get your license and begin [moonlighting 00:02:15]. They’re trying to dovetail with the licensing exam to provide them feedback. That might mean that your individual state board might look closer at the USMLE scores themselves, particularly if they are scrutinizing you for some other kind of behavioral, personality, or disciplinary problem. They might look at your USMLE scores and require some remediation. That’s all down the road. Those aren’t current changes. I’m just trying to set the five major recommendations now as a backdrop and we’ll get to the one big change that they’re doing to the Step 3 examination this year, 2014. That’s going to be their first big kickoff to implement all these changes. The second big recommendation is to adopt the general competency schema that is consistent with national standards for the overall design, development, and scoring at the USMLE. It looks like they want a competency-based schema. They have, of course, adopted the ACGME core competencies schemas, that is, there are 6 competencies the Accreditation Council for Graduate Medical Education. That is the group that licenses or accredits the allopathic residency programs. When you become a resident, you will know about that. Those 6 competencies include medical knowledge, patient care, communication and interpersonal skills, practice-based learning and improvement, professionalism, and systems-based practice. They’re trying to get all four of these USMLE Step scores to be ultimately organized around these 6 core competencies that fit in directly with the ACGME competencies. On a side note,

Episode 89: Tips for saving money in health care. And, calling all 2nd year medical students! It’s your time for a USMLE score boost! Download transcript: How to boost your USMLE Step 1 score and save health care costs The Dark Side of Medicine Today I’m going to be talking about the unveiling of the dark side of the medical-industrial complex and how the institutions and boards that run the hospital systems can often times have a different agenda than you the physician, the one charged with taking care of the patient. Calling All Second Year Medical Students Before we get into the meat of that discussion today I want to put a call out to all second year medical students.  I have an IRB proposal that I’m putting together for a research project.  This about the fifth one I’ve done now on medical students or pre-meds or residents and such.  This one is specifically looking at mood states prior to taking the USMLE Step 1 or the COMLEX Part 1 if you go to an osteopathic medical school.   Then I’ll do a mastermind intervention and re-survey students to see if their mood states change. [ad#300×250] If you happen to be a second year medical student you could benefit be participating in the intervention.  Of course we’ll do official informed consent and all that stuff to tell you what’s expected and what you get out of it.  The bottom line is I want to survey some students about 40 questions.  How long does that take you, a couple minutes at the most then give you a three week, twice a week teleconference style delivered mastermind meetings to boost your USMLE study plan, to decrease your anxiety and help you get better organizational skills.  I don’t need to go into all the details here, but if you will visit medicalschoolpodcast.com, sign up for the email list. That will instantly send you some speed reading videos, but that’s beside the point, just get on the email list because very soon I act fast, I’m telling you.  I’ve written most of the IRB proposal today with some spare time.  I am going crazy with research.  I’ve got all kinds of stuff going.  I’m about to have a gig in Philadelphia at a sleep conference.  I’m going to have a paid trip to Berlin to speak on military research that we’ve been doing here.  Everything I’ve touched is turning to gold in the research department and I would like to bring you in along for the ride and I hope that you’re enjoying the podcast. Perhaps you’ve noticed I have a different little swing in my step, a little bit more boost of energy and reinvigoration of the medical school podcast.  That’s in large part due to getting my medical license and having the horror and black smudge of pain in my life from my previous emergency medicine residency experience wiped away with my medical license and it also has to do with being finished with my current residencies, nights and weekend call.  It’s just done.  I have a day job now (laughs). Physician Ethics Today the idea is that you start out in medicine, you take a Hippocratic Oath, you put on the white coat, you’re here for the patient first.  Many times you hear the term medico-legal, you hear ethical, you hear law and ethics often times combined as topics for presentations.  You’ve been beaten to death with this stuff like patient autonomy, justice, beneficence, non-maleficence, first do no harm.  Of course you have law and often times laws can be unethical.  I don’t even need to get into that here.  As a healthcare professional, specifically as a physician you have one bent, to take care of the patient, that’s my point. Today I wanted to highlight a problem.  Especially as healthcare systems are being squeezed for finances in The Affordable Care Act is crushing smaller practices and hospitals as we have a payer shift to more public ...

Episode 88: It’s a kiss because it’s something nice that you can frame and hang on your wall. It’s death because you’ll never be able to work as a doctor. Download Transcript: Kiss of Death Today’s episode is all about the kiss of death when it comes to a residency training.  You never heard of this before.  I can guarantee it.  Let’s get started.  I just got out of a meeting called the Residency Training Committee Meeting, and I learned about a particular action that a residency program can take toward a resident that they feel Is not doing well that is essentially the kiss of death for their medical career. [ad#300×250] But let me set the stage first.  Residency training hearkens back to the days of like 1904 when Nathan Hale brought his ideas from Germany about the way medicine should be taught in America, and they were tough.  They never left the hospital. Burn out, and difficulty, depression and stress is a part of our medical training heritage here.  It was done that way by design.  It’s not an accident.  We go about 80 years in history until 1980, it was either ’84 or ’86 when Libby Zion died and her intern hadn’t slept very much.  Her resident was fatigued back in the good old days up in New York where they just ground residents into the ground. Her husband was, I believe, a New York Times writer or something big, big writer and editor, and had a lot of connection and made a big media and legal case out of it and the upshot of all that is what you now recognize as the ACGME Duty Hour Restrictions on residents.  ACGME is the Accreditation Council for Graduate Medical Education. You’ve heard of OSHA probably, the Occupational Safety Health Administration?  That group is generally responsible for safety in the workplace, but when it comes to physician training they have stayed out of the argument so all of the typical OSHA requirements like having to get a lunch break and different stuff like that don’t apply to doctors at all. The limited scope that the ACGME has is simply what they’ve made for themselves, in other words, duty hour restrictions, time off between call shifts, etc.. That’s it.  Residency programs can do anything they want to to residents besides violate those things on any kind of consistent basis or they face losing accreditation. That’s kind of the backdrop is that it’s a difficult place.  In the old days, residency meant residency.  You actually lived there.  At the DeBakey Center in Houston, Texas, at Baylor, those residents never left the hospital.  They literally when they did a rotation with Dr. DeBakey did not leave the hospital for 30 days.  That’s what we have come from and you already know, I’m sure, about the duty hour restrictions.  That’s kind of where we are, but understand that at its root it’s a place where they’re supposed to train you and teach you. That brings us to today’s topic because some of us don’t take the lessons very well.  We get too comfortable.  We get cocky.  I’ve mentioned that recently on a podcast.  It goes to our head.  We get some criticism.  It can sting, but what about when you are felt by a particular faculty member to not be cutting the mustard, not be measuring up to your restrictions, or to your requirements and they want to fire you?  Or they want to remediate you? Let me give you a few definitions of some words.  What you have to correct folks is monthly evaluations.  That’s the simple stuff.  I generally say keep it clean unless your trying to stack up documentation to keep somebody fired.  Yes, you will be filling out evaluation forms on your peers, and they will be filling them out on you.  If there is a consistent pattern, which means two or more times you mess up doing ...

Episode 87: Doctor Dan shouts the triumphant praises of one who is done with overnight call…forever. Hi, It’s Doctor Dan. I just wanted to record this brief special episode about my last call shift ever. Call is of course variable depending on where you work whether it’s night float system or twenty-four hour call in our program. We do six months of night float and then a year and a half of calls kind of front loaded and three night ago I did my very last call of all now that the last year and a half of my residency in psychiatry. There’s no call nights or weekends. I mean I can still work in ER during the day but I just consider that a part of our regular job, just very excited. I think that as this [inaudible 00:46], you know I got my license; I got another milestone of having passed the six months; I’m done with call now; I’m getting back into pod-casting, my passion, I love this stuff. [ad#336×280] I got a new iMac, kind of celebrated and I had to get the new iPhone 5c you know just to kind of get updated and upgraded and it’s definitely a passion in pursuit of my … So so many good things are all happening, that’s not half of them that I sometimes can forget the importance of one of those little milestones of my last call shift. I wanted to share a little experience with you as that stress kind of rolls off my back and goes away. It encourages you, it is definitely worth waiting for, hang in there because one day you’re last call shift will come and it will be worth it for you, I guarantee it. Honestly the harder it is, kind of the more you’ll enjoy it. I’m in the kitchen, I get home from work, not a bad day at all, of course I chose psychiatry partly because of lifestyle balance also because I love it and we’re sitting there thinking about dinner and planning meals and when we’re going to cook what. I like to grill a lot, chicken, fish, and stuff. The first thing I do In my mind automatically is sit there and start playing the rolodex. Okay, what day of the week is it, when’s my next call, what day’s this week to I need to take … wait a minute, there’s no call, I mean it was just like that. It was really kind of weird, I just had to stop and go. You know I don’t think I realized how much the work schedule and the residency schedule affects you. Especially trying to get in shape which I did, I was able to loose over thirty pounds as a resident and work out. You have to plan so much, you have to be proactive about your shopping. You know what it takes to always have healthy food with you, at least I hope you do. By the way, let me know if you want to … If you want me to kind of get into the area on a pod-cast at all about how to loose weight in residency. I’ve thought often about the whole fitness aspect. Anyway, I just wanted to give you a brief encouragement and to say hang in there. If you have a question for me I’d be happy to put together a pod-cast or some other kind of answer for you if you need some help and you can’t find it anywhere else. I just added a tool on the website where there’s a bar along the right side it says “Record a question for the post-cast.” You literally can … If you want to hear your own voice on this pod-cast, you can click on that, put in your name and email I think and I haven’t used it yet. I encourage you to use it, if you like it let me know, it’s right there. It’ll make a recoding for me and send me an email notification then the next time I put together a pod-cast I can have your voice actually play. Obviously in these past post-casts I’ve been reading emails, that’s not as fun to listen to so if you’re not too shy and you’ve got a question you haven’t heard anywhere else, i’d be happy to try and answer it for you.

Episode 86:  Four categories of shock intuitively with respiratory and metabolic acidoses. Shock A. Causes of hypovolemic shock Diarrhea, blood loss, cholera, sweating, not DI (b/c losing pure water, and not losing Na, total body Na is NORMAL! Losing water from ICF; no signs of dehydration; when you lose salt, show signs of dehydration). Cross-Synaptic Learning Principle = Epidemiology. Other examples include most common causes of death by age group (MC genetic cause of MR = Down Syndrome, MCC of MR = Fetal Alcohol Syndrome, MCC death in youth = accidents). [ad#300×250] Example: lady with hypovolemic shock – when she was lying down, her BP and pulse were normal; when they sat her up, the BP decreased and pulse went up. What does this indicate? That she is volume depleted. This is called the TILT test. Normal BP when lying down b/c there is no effective gravity, therefore normal blood returning to the right side of the heart, and normal CO. However, when you sit the patient up, and impose gravity, you decrease the venous return to right heart. So, if you are hypovolemic, it will show up by a decrease in BP and an increase in pulse. Cardiac output is decreased, and the catecholamine effect causes this scenario. How would you Rx? Normal saline. Example: pt collapses, and you do a tilt test: 100/80 and pulse of 120 while lying down. Sitting up, it was 70/60 and pulse of 150. The pt is severely hypovolemic, therefore Rx is normal saline. Treatment: One liter in, showed no signs, put another liter and the BP becomes normal, and is feeling better, but still signs of volume depletion (dry mouth). We have the BP stabilized, but the pt lost hypotonic salt solution, therefore we need to replace this. So on IV, give hypotonic salt sol’n (b/c was losing hypotonic salt solution). We do not give 5% dextrose and water b/c there’s not any salt in it. Therefore, we will give ½ normal saline. The treatment protocol is: when a pt loses something, you replace what they lost. And when pt is hypovolemic, always give isotonic saline. Example: DKA, have osmotic diuresis; tonicity of fluid in the  urine that has excess glucose is hypotonic. Hypotonic fluid has a little more fluid than salt. So the pt is severely hypovolemic; therefore the first step in management is correction of volume depletion. Some  people are in hypovolemic shock from all that salt and water loss. Therefore need to correct hypovolemia and then correct the blood sugar levels (DKA pts lose hypotonic solution). Therefore, first step for DKA pt is to give normal saline b/c you want to make them normotensive. Do not put the pt on insulin b/c it’s worthless unless you correct the hypovolemia. It can take 6-8 liters of isotonic saline before the blood pressure starts to stabilize. After pt is feeling better and the pt is fine volume wise. Now what are we going to do? The pt is still losing more water than salt in urine, therefore still losing a hypotonic salt solution, therefore need to hang up an IV with ½ normal saline (ie the ratio of solutes to water) and insulin (b/c the pt is loosing glucose). So, first thing to do always in a pt with hypovolemic shock is normal saline, to get the BP normal. Then to correct the problem that caused the hypovolemia. It depends on what is causing the hypovolemia (ie if pt is sweating, give hypotonic salt solution, if diarrhea in an adult give isotonic salt sol’n (ie normal saline), if pt with DI (ie stable BP, pt is lucid) give water (they are losing water, therefore give 5% dextrose (ie 50% glucose) and water). B. Four kinds of shock: 1. Hypovolemic shock: Blood loss, diarrhea (adult or child), basically whenever you are lose salt, you could end up with hypovolemic shock. Give volume. 2. Cardiogenic shock: MC due to MI. Right Ventricular Assist Device and await transplant. 3. Neurogenic shock: Assoc. with spinal cord injuries.

Episode 85: This begins the audio series with the Cross-Synaptic learning approach. USMLE topics are taught while universal principles are pointed out that refer to other topics or physiologic processes. These lectures will be saved online in the MMC and are expected to be completed in 2014. Cross-Synaptic Learning approach for the USMLE Step 1 To get other USMLE titles, get a password/login and visit http://medical-mastermind-community.com/med-students/usmle-comlex.  USMLE Step 1 Endocrine Disorders Primary vs Secondary vs Tertiary: Cross-Synaptic Principle of “Structural” Learning Process. These correlate to the processes type of information and the graphical content study approach taught in the MMC Exam Prep modules. * Hashimotos = destruction of the thyroid gland = PRIMARY hypothyroidism (the gland screws up the hormone) * Hypopituitarism and hypothyroidism = SECONDARY hypothyroidism (no TSH to stimulate) * Hypothalamic Dz = Sarcoidosis destroying TRH: TERTIARY (no TRH) * Example: adenoma on parathyroid producing PTH leading to hypercalcemia = primary hyperparathyroidism * Example: have hypocalcemia/vit D def, and asked the parathyroid to undergo hyperplasia, that is called SECONDARY hyperparathyroidism * Example: what if after a long time PTH keeps being made = tertiary hyperparathryroidism (rare) [ad#300×250] Overactivity vs underactivity of glands: Cross-Synaptic Learning Principle of “Interference Tests”. These refer to a physicians alteration of the ‘natural’ (or in this case unnatural) process. Other areas include ECT and the use of adenosine in supra ventricular tachycardia. Stimulation test: if pt has underactive gland, would use stimulation test to see if the gland is working. Supression test: if pt has overactive gland, would use suppression test to see if gland will stop working. Most of the time, things that cause overactivity, we CANNOT suppress them. There are 2 exceptions where we suppress them, and they deal with overactivity in the pituitary gland 1)prolactinoma can be suppressed bc it can prevent the tumor from making prolactin; bromocriptine suppresses it (dopamine analog – normally, women do not have galactorrhea bc they are releasing dopamine, which is inhibiting prolactin (therefore dopamine is an inhibitory substance – bromocriptine is also used for treating parkinson’s because bromocriptine is a dopamine analog (which is what is missing in parkinsons dz) 2) Pituitary Cushings: b9 tumor in the pitiuitary that is making ACTH – you CAN suppress it with a high dose of dexamethasone. These are the only two exceptions for a tumor making too much stuff. (There is no way to suppress a parathyroid adenoma making PTH, or an adrenal ademona making cortisol, or a an adrenal tumor from synthesizing aldosterone – these are AUTONOMOUS). Example: pt with hypocortisolism – lets do an ACTH stimulation test – will hang up an IV drip and put in some ACTH; collecting urine for 17 hydroxycorticoids (metabolic end product of cortisol) and nothing happens – so what is the hypocortisol due to? Addison dz – gland was destroyed – therefore, even if you keep stimulating it, you will not be making cortisol. Example: Let’s say after a few days you see in an increase in 17 hydroxycorticoids, then what is the cause of hypocortisolism? Hypopituitarism – in other words, it’s atrophic bc its not being stimulated by ACTH, but when you gave it ACTH over a period of time, it was able to regain its function. So, with that single test, you are able to find cause of hypocortisalism. Can also look at hormonal levels – ie Addison’s causing hypocortisalism, what would ACTH be?

Episode 84: You aren’t going to believe how simple it can be to decrease stress during exam week. Seriously, you’re not going to want to hear this. Be Prepared For Tests Despite all you may have heard about how to decrease stress during exam weeks, I have a theory. See, I believe that if you’re actually prepared to the level that you need to be – and you know it – then your stress relief will be automatic. In fact, I used to be able to guess my score and be accurate within 2% most of the time. No surprises. Much lower stress – that is the Mastermind Way.  [ad#300×250] Stressed About Exam Stress? How To Find Your Inner Calm At A Testing Time Examinations can be, if you’ll pardon the pun, a very testing time. Months, or even years of preparation, study and revision all boil down to this moment – time to show the examiners the extent of your knowledge in a limited amount of time. There is often a lot riding on a successful outcome – with places at top medical schools, universities or even internships at stake. So how can you get a handle on your stress levels and so enable yourself to perform at your very best? First of all, you need to understand what it is you’re dealing with. What is stress, and how can I recognize the symptoms? Stress is a perfectly natural response to pressure. The body senses the pressure as a physical threat and releases chemicals into the bloodstream that can make you feel jumpy or on edge. Your muscles tense in readiness for a ‘fight or flight’ reaction, while your mouth becomes dry and your breath quickens. Not very nice. Plus, other signs, such as headaches, sick feelings, lack of sleep, unexplained aches, inability to concentrate and bad temper, all add to the general discomfort and inconvenience of stress. It can lead to panic, producing alarming symptoms, such as chest pains, breathlessness, dizziness or fainting if it is not identified and managed at as early a stage as possible. What are other common triggers of stress? Obviously, the very fact that you are preparing for an important exam will be enough to start your stress levels rising. However, other factors can play a major role. Addictions, such as alcohol or drugs can prove a major distraction, which also produce yet more physical symptoms that your body will need to deal with. Cutting back, or seeking professional help to deal with such an addiction is a crucial step to take if you want to do well in your exam. Family disputes can be another area for concern – here a quiet word or two might be needed to make your loved ones aware of the pressures your exams are putting you under to see if they can find better ways to support you, or even simply back off from you for the revision and examination period. Always make the educational institute aware of any serious problems that might impede your studies; they are there to help you do the best you can and can often be flexible in their approach. Finally, money worries affect us all – not least when we are struggling students. The current rise of debt counseling services is no coincidence in this age of heightened stress and financial instability. Yet there are still several solutions out there. Student loans still exist, and there are a fair few credit cards with cashback available that can help you plan your repayments while gaining access to immediate cash for short-term purchases. See what your bank can offer. How can I deal with my stress and reduce its impact on my studies? Put simply, you need to learn how to relax. Your doctor or health worker should be able to give you some breathing techniques and simple relaxation routines to try. Physical exercise can help lower stress, as well as provide a welcome break from your studies.

Episode 83: This is the second in our series of Gold Standard USMLE Audio Reviews covering the antipsychotic medications.  Let me know if your medical school uses a systems-based curriculum; if so we’ll organize the DVD-ROMs according to your block schedule if you’re interested. History of Schizophrenia  [ad#300×250] I. Brief History * Kahlbaum ———Catatonia * Hecker ————-Hebephrenia * Sanders————-Paranoia (“absent mind”) * Morel ————–Demence Precoce * Kraepelin ———Dementia Praecox or Precox (Catatonia + Hebephrenia + Paranoia) * Bleuler ————Schizophrenias (” splitting of the mind”) * Langfeldt———-Schizophreniform Disorder II. Essential features of Schizophrenia Characteristic signs and Sx (+ and -) that have been present during a one-month period or shorter period if successfully treated …………(involves active psychosis w/ delusions & hallucinations) ……with some signs of the disorder persistent for at least 6 months These signs and symptoms are associated with marked social or occupational dysfunction The disorder is not obviously related to organic causes (drug-physical illness) or mood d/o (these options must be eliminated) III. Symptoms at Onset * Somatic Manifestations, changes in the ability to work- vague; ie headaches * Anxiety * Perplexity – “what did you say? I did not hear you.” (they are not mentally there) * Abstract ideas (philosophy, occult, religion, etc.) * Peculiar Behavior- not bathing; justify it by saying only dirty people bath and kept rationalizing it * Trema (fright) – realize that something is wrong * Apocalyptic- person falls to pieces * Vegetable-like phase- pt had no pain with a horrid abdominal abscess IV. Diagnostic Criteria (according to the DSM-IV) * Characteristic symptoms- 2 or more of the following, each present for a significant portion of time during a one month period (or less, if successfully treated) – Delusions – Hallucinations – Disorganized speech (frequent derailment or incoherance) – Grossly disorganized or catatonic behavior – Negative symptoms (affective flattening, alogia, or avolition) Only one of the above is required if the delusions are bizarre of hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other * Social/occupational dysfunction- significant declining performance at work or in relationships since the onset of symptoms; or when the onset is in childhood, the child fails to achieve the expected levels of interpersonal, academic, or occupational achievement * Duration- continuous signs of disturbance persist for at least 6 mos – 6 mo pd must include at least 1 month (or less is successfully treated) that meet Criterion A (active phase Sx) – May include pds of prodromal/residual Sx during whichsigns of disturbance are manifested by either Only negative Sx or 2+ symptoms listed in Criterion A present in the attenuated form (odd beliefs, ususual perceprtions) * Schizoaffective and Mood Disorder (w/psychotic features) have been Excluded – Ruled out b/c either: 1. No major depressive, manic, or mixed episodes have occurred concurrently with acute phase symptoms 2.

Episode 82: Sample the Gold Standard USMLE Audio Reviews in this episode – decide for yourself if you like this Pharmacology of Asthma sample from a professional audiobook. If you do, we have an entire collection for every USMLE and medical school you take! Listen to the podcast here… I. A-a gradient – know how to calculate: Alveolar O2 and arterial pO2 are never the same. The difference between the two is called alveolar arterial gradient. [ad#300×250] Reasons for it: (1) Ventilation and perfusion are not evenly matched in the lungs. When standing up the ventilation is better than perfusion in the apex, whereas perfusion is better than ventilation at lower lobes. This explains why almost all pulmonary infarctions are in the lower lobes – perfusion is greater there. Also, this explains why reactivation TB is in the apex – TB is a strict aerobe and needs as more O2, and there is more ventilation in the upper lobes (higher O2 content). Normally, alveolar O2 is 100 and the arterial pO2 is 95. So, normally, the gradient is 5 mmHg. As you get older, the gradient expands, but not that much. Most people use their upper limit of normal – in other words, have a very very high specificity of 30 mmHg. If you have an A-a gradient of 30 mmHg or higher there is a problem. It is very high specificity (aka PPV – truly have something wrong). The concept is easy – you would expect the gradient btwn the alveolar O2 and the arterial O2 to be greater if you have primary lung dz. What will do this? Ventilation defects (produces hypoxemia, and therefore prolongs the gradient – dropping the PO2 and subtracting, and therefore a greater difference btwn the two), perfusion defect (ie pul embolus), and diffusion defect. But the depression of the medullary resp center by barbiturates does not cause a difference in A-a gradient. So, prolonged A-a gradient tells you the hypoxemia is due to a problem in the lungs (vent perfusion/diffusion defect). A normal A-a gradient tells you that something outside the lungs that is causing hypoxemia (resp acidosis – in resp acidosis, PO2 will go down). Causes of resp acidosis: pulmonary probs (COPD), depression of resp center (obstruct upper airway from epiglottitis, larygiotracheobronchitis, café coronary (paralyzed muscles of resp), Guillain Barre syndrome, amyotrophic lateral sclerosis, and paralysis of diaphragm. These all produce resp acidosis and hypoxemia, but the A-a gradient will be NORMAL). So, prolonged A-a gradient, something is wrong with the lungs. If A-a gradient is normal, there is something OUTSIDE of the lungs that is causing a resp problem. Few things must always be calculated: anion gap (with electrolytes) and A-a gradient for blood gases – all you need to do is calc alveolar O2. We can calculate the A-a gradient = 0.21 x 713 = 150 (0.21 is the atmospheric O2; and 760 minus the water vapor=713). So, 150 minus the pCO2 (given in the blood gas) divided by 0.8 (resp quotient). So, normal pCO2 = 40, and 40/.8=50 and 150-50 = 100; so, now that I have calc the alveolar O2, just subtract the measured arterial pO2 and you have the A-a gradient. This is very simple and gives a lot of info when working up hypoxemia. II. Upper Respiratory Disease: A. Nasal Polyps: 3 diff types of nasal polyps – MC is an allergic polyp. Never think of a polyp in the nose of kid that is allergic as an allergic polyp. Allergic polyps develop in adults after a long term allergies such as allergic rhinitis – Example: 5 y/o child with nasal polyp and resp defects, what is the first step in management? Sweat test – b/c if you have a polyp in the nose of the kid, you have cystic fibrosis; it’s not an allergic polyp. B. Triad Asthma – take an aspirin or NSAID, have nasal polyps and of course have asthma. They don’t tell you the pt took aspirin and that the pt has a polyp. The aspirin or NSAID is the answer but this is how they will ask the question: 35 y/o woman wi...

Episode 81: Match Day is around the corner and your certified rank order list is almost due. Do you put every program you interviewed on your list? What happens if you don’t get your first choice? Should you put a very competitive place as number 1? At the time I published this podcast (Feb. 3, 2012), certified rank lists were due in 2.5 weeks. This audio podcast explains the way the “magic computer” decides who get’s an allopathic residency in the US and who does not. [ad#300×250] This information is based on the National Residency Matching Program’s statement from September 2010; it’s been unchanged since then. General principles are outlined in the figure below. Click here to download the NRMP Match Day Algorithm.    

Episode 80: Learn how to maximize your clinical experience for test day. In this episode you’ll learn one of only two study goals during residency. Also, discover which phase of the exam cycle people are neglecting and a new resource that will help you maximize your clinical experience for test day. “Research shows that only 28% of residents are pursuing their clinical questions.” Evidence-Based Medicine training is simply not being translated into real life on the wards. And you know why! Time. Case in point: what is the primary factor affecting your ability to memorize the Gold Standard in the Clinical Science years compared to the Basic Science years? Time That is why the Golden Summary book is necessary. I’m about to unveil a systematic approach to overcome the time barrier. And it’s as simple as 4 Steps to Maximizing Your Clinical Experience. I’ve now bridged the gap between study approaches of Pre-Med/Basic Science and the mind-bending art of studying on clinical rotations. Let me show you when it works: 5 phases of the exam cycle: learn to maximize the Latent phase 1.      Test day 2.      Post-test break 3.      Latent phase 4.      Study plan 5.      Test prep Dichotomize information into Foreground and Background Board review binder Foreground journal Sign up for instant access to this course now! Product Features: * 5 video tutorials streaming from Amazon, totaling nearly 2 hours in bite-size format for you to do at your own pace. * In fact all of the video tutorials in the Medical Mastermind Community now stream live from Amazon – no more downloading them and finding the right player. * Step-by-step checklists for each tutorial in PDF format for you to print. * Clearly delineate a paradigm shift that happens in your study goals when you reach the end of medical school – which persists throughout your training and career really. Without the rapid cycle of exams, learn how to use the 80:20 rule to your advantage. (Hint: there are only 2 study goals in the Clinical Science Years and you won’t believe how simple they are.) * The learning science behind it centers around the Information Processing Funnel, based on a specialization of David Allen’s technique, which I coined. This truly will teach you how to maximize your clinical experience and turn that trash in your white coat pockets into points on your in-service and USMLE exams! * No more feeling lost or overwhelmed, or at least helpless about it. I will teach you how to create 3 distinct study resources that will keep you feeling confident and in control! ANY MEMBERSHIP TYPE GRANTS YOU ACCESS!! You can forget about 90% of what you learned in your Problem Based Learning classed in medical school about how to do Learning Issues – those approaches simply don’t pan out when you’re working 12-30 hours shifts in the hospital. You need real-world, practical solutions that will enable you to metabolize board-testable material at the bedside while simultaneously building an evidence-based bibliography of your own – written in one-liners in your own words! Learn how the majority of residents are thinking too small during the early part of residency with regard to choosing the study resources to use. Just like I’ve been teaching pre-meds and Basic Science Years medical students for years, I will convince you of the utility of using a Golden Summary book. Now, unless you’re already Mastermind Community trained, I know I’m using terms you are not familiar with. In fact, a few of these resources are brand new to even long-time members. Don’t fret. I’ll give away one of the ONLY TWO study goals for the Clinical Science years right now,

Episode 79: Experience second-hand what it’s like to go through the first month of medical school. This podcast hits the highlights of a live teleconference of our Mastermind Community. Listen in… In September, 2011, two Mastermind members that are First Year Medical Students that took time on a Saturday morning to share their early experiences of medical school – while it’s still fresh. Watch the entire video here:  Medical School Burnout Prevention Top 10 Tips To Survive The First Month Of Medical School: * Don’t think you’re unique if it only takes a few hours on your very first day to feel overwhelmed. * Pre-matriculation programs help with establishing relationships before school starts and familiarity/orientation to the facilities. * “The Slump” is alive and well and Medical Mastermind Community membership may not be preventative – only therapeutic when you get on a live teleconference. * Review the Mastermind Study Techniques (tab #2) the week prior to medical school starting. * Set your overall goal for medical school academic achievement and arrange your social schedule (what’s left of it) accordingly. * Self-Testing is an indispensable study technique. (see the Mastermind Study Techniques program for further details). * I highly recommend the Board Review Series of books for all of the classes for the entire first 2 years’ of classes in medical school. * Active learning will help you digest difficult content. * Take notes in a USMLE review book (i.e., First Aid for the USMLE Step 1) as you go through your first 2 years. Don’t read the book itself unless it’s the week before final exams. * If you can get your hands on old medical school exams, use them to complete your learning objectives (see what all is testable) and to practice figuring out why each incorrect answers choice is incorrect. FEATURED RESOURCES: * Mastermind Study Plan CHEAT SHEET * PreMed Listener Questions podcast  

Episode 78: Did you know that without a Right of Sepulcher a gay/lesbian partner can be excluded from end-of-life care decisions and even funerals? Medical Ethics for Gay and Lesbian Couples * Wills * Parental rights * Gay/lesbian/unmarried legal issues in time of incapacitation or death

Episode 77: Discover sage advice you can use to counsel your patients with difficult family circumstances, end-of-life issues, and non-traditional “families”. Medical Ethics Welcome to Part 1 of this 2-part series of interviews with Attorney Dara Strickland. * Advanced directives * Medical power of attorney * End of life issues * release of body at time of death