Patient Stories: Cancer & The Caregiver

If you’ve been around here long you know that my love of social media goes beyond tweeting pictures of the most adorable twins on the planet and talking #meded with others in the healthcare world, it extends into the world of patients and their stories. Social media is fun, it’s interesting, and it’s a good way to interact, but more importantly social media is a teacher. I’ve learned more about how to be a compassionate doctor by listening and interacting with patients who share their stories online than I ever could have learned from a textbook.

So, when Cameron contacted me and asked if he could blog about his experiences as a caregiver for his wife who has mesothelioma I was ecstatic. The chance for my readers to hear a story about how medicine doesn’t stop at the door to their clinic – invaluable.

Let me introduce you, this is Cameron, his gorgeous Mesothelioma-butt-kicking wife Heather, and their adorable daughter, Lily.

Cameron, Lily, and Heather

And here’s what he had to say about how becoming a caregiver for his wife in her fight with Mesothelioma gave him a new perspective and mission in life:

My wife, Heather, knows that I went through a great deal after she received her diagnosis of mesothelioma. Although I briefly told her about my experience, this information will show her, and anyone else currently struggling through a similar difficult situation, more about my emotions as I cared for her.

We were blessed with the birth of our daughter Lily three months before the devastating diagnosis. Instead of being able to celebrate such a joyful event, we were instead plunged into misgiving and trouble when the doctors gave their diagnosis. From that first moment, I had trouble imagining how our family would be able to get through this time.

While I mostly wanted to take time to process my emotions, the doctors required Heather and me to begin making important decisions regarding her healthcare and treatment. This was a small portion of what I could expect over the coming months, as I would continually be needed to make more choices that were demanding.

When I was able to process my emotions, I found myself full of vexation, frustration and uncertainty. I displayed these emotions outwardly in much profanity. I was only able to curb this when I remembered that my wife and daughter needed me to be their steady support. While I certainly failed at times, I always tried to be positive for my family.

Another part of the process for me was learning how to deal with such a large number of tasks. Besides work, I also had to care for my family and pets and coordinate traveling schedules. This caused me a great deal of stress in the beginning, but I soon found that tackling one important task at a time was vital. In addition, I readily accepted the help of family and friends who graciously came to our aid during this time when I do not believe that I could have made it by myself.

The hardest time was the two months when Heather and Lily were staying in South Dakota with Heather’s parents. Heather took this time to rest after her surgery and to prepare for further mesothelioma treatments. However, I was only able to see my family once during this period.

The weekend that I visited was a snowy one. In fact, I had to wait out part of the 11-hour drive in my car as I waited for the snowplows to clear the roads. Once I arrived in South Dakota, I had a little over one day with my family before I had to return to work.

I readily admit that while the decision to be apart was hard, it was completely necessary for all of us. I needed to work while Heather needed to rest. I see this, as well as all the other exacting choices that we made, without any dissatisfaction because they were vital to Heather’s health. Through all of our struggles, Heather is still here and still healthy over six years later. I hope that our story can be a source of hope and help to those currently battling cancer, as well as those battling alongside them.

CameronBio Continue reading “Patient Stories: Cancer & The Caregiver”

Medical School in Denmark

Today we have a wonderful guest blogger, Andy Skovsen, with us to talk about medical education in Denmark! Andy lives in Copenhagen, but seems to have been a bit of a nomad having lived in the US a while and just returned from working in South Africa! He has also spent some time in the Danish Military and still works part-time with them. I must say, I’m a little jealous of all the great culture and scenery he seems to have experienced. Andy graduated from medical school in 2008 and has been pursuing a career in Surgery, with a particular interest in trauma and emergency medicine. He has a great blog called Doctor’s Without Filter, which is co-authored by himself and two others in Danish (Go-Go Google Translate). Andy got married last summer (Congrats!!) to a doctor who is currently pursuing a career in Cardiology and in his free time (which sounds like it might be severely limited!) he enjoys sports like skiing, mountain biking, diving, and surfing! I have to admit, I want to be friends with Andy – he sounds like tons of fun!

 

Getting In:

How old is one when they begin medical school?

Usually around 18-20. Some gain entrance through a separate set of university specific merits and tests, and are usually a couple of years older.

What exams does one have to take to get in?

Entrance is granted through application. You take finals from “gymnasium” (roughly equivalent to last year of high school and first two years of college in the US). Entrance is based on your GPA after this. Approximately 10% gain entrance through a separate quota system, which is defined by each of the 4 universities in Denmark offering a medical education and usually involves testing as wells as merits.

Is there any required pre-requisite coursework?

Certain levels of Maths, Danish, English, Physics and Chemistry are required to apply. These can be supplemented post-gymnasium graduation.

Is it a competitive occupation?

Very competitive. The number of applications far exceed the number of places. At the moment, it’s the most sought after university degree in the country.

What are you called at this stage of training?

Medical student.

 

Being In:

How long is it?

6 years. After 3 years, you are given a Bachelors diploma, which is pretty much useless unless you want to transfer to a different Masters degree.

How are the years broken down?

This varies from university to university, but generally broken into 12 semesters with the first 6 being pre-clinical, and the last 6 being clinical.

Describe your typical day.

Varies immensely for each semester/rotation. The common denominator seems to be end-of-semester exams, which increases workload and hours hitting the books to all waking hours and eliminating partying to zero.

If you choose a specialty, when do you have to decide by?

After graduation you do one year of internship, then you apply for positions in your specialty.

What are you called at this stage of training?

Medical Student

 

Getting Out:

What exams do you have to take?

Once you take your final exams from medical school, you’re pretty much done with exams.

Do most people graduate?

Students drop out of medical school mostly to switch to other degrees. I remember starting medical school, during the first lecture, we were told to “look to your right and look to your left, those two people will not be here when you graduate.” A rough estimate tells me that about 1/4 to 1/3 of starters do not finish.

When are you finally considered a “doctor?”

After passing the final year of medical school you get your diploma, then you sign the Hippocratic Oath and become a doctor.

Do you have additional training after MS or do you start working immediately?

One year of internship is mandatory. The internship is split into two 6-month positions, the first usually being in a hospital, and the second often (80%) being in primary care/family medicine. Each year is a lottery, where all graduates are assigned a random number correlating with the amount of graduates is a number internships. The graduate that received number 1 in the lottery gets first pick and so fourth. Positions are all across the (small) country. The system is perceived as unfair by many, but is not looking to be changed any time soon.

What’s the average debt for attendance?

None! Medical school is paid by the state. When attending university, you also get a small allowance (about $750/month) to live on, but books you must pay for. Living expenses are rather high, especially in Copenhagen, so many students work and may also take loans.

What are you called at this stage of training?

Doctor, Intern or Resident.

 

Being Out:

What’s the average salary?

Salary is fixed. Currently base salary is around $4,500/month on top of this you get a small remuneration for being on call, etc. Usually comes to around $5,000/month. On top of this comes taxes (50%+). Through your career your salary increases in increments.

Is the job security good?

It’s good. 100% of graduates are employed in internships. In the long run, some specialties are very difficult to get into and others you can walk right into after internship.

Can you switch specialties?

Yes, you can switch, but you start back from the first year after internship.

What are you called at this stage of training?

Doctor or Resident

 Image By Andy Skovsen | Available on Flickr

Very interesting! Thanks so much for sharing, Andy – I really enjoyed reading about medical education in your country and I know these posts are some of the most popular on Mind On Medicine, so I’m sure others enjoyed the information as well.

Other Medical Education Monday posts can be viewed here!

Medical School in Indonesia

Today I’m excited to introduce to you Anna, a 22 year old medical student from Bogor, West Java province in India. She is in her last year of clinical clerkships at Universitas Pelita Harapan medical school, a bilingual (Indonesian and English) open to both local and foreign students.

Currently, Anna is undecided on a specialty, but is interested in both Neurology and Emergency Medicine. She has five more rotations before she finishes, so it will be interesting to see what she decides on! She blogs at Surreal Hours and you can catch her on Twitter @a_elissa.

She contacted me a few weeks ago asking if I was still open to having more posts in the Medical Education Monday series. I’m so thrilled that y’all find medical education in various countries as interesting as I do…it’s certainly been great to hear about all the different systems.

If you are (or someone you know is) a medical student or physician in a country not yet covered, please have them contact me! Here’s what Anna had to say about Medical School in Indonesia:

Getting In:

How old is one when they begin medical school?

We begin medical school directly after high school. However, some schools are open for students who already have an undergraduate degree, this is usually the case for foreign graduates.

What exams does one have to take to get in?

  • Public Schools: National exam called SPMB that is designed for a specific major, but is valid for any universities. This exam is not the actual entrance exam, it’s only for filtering out students who are academically eligible for a certain major, in this case for medical school. A prospective student sitting the medical school SPMB also needs to fill out a list of schools of their choice. The result of the exam is then sent out to those schools, and he will receive a notification about his acceptance. There is then another exam and an interview from each school that he has to complete and pass before being formally enrolled.
  • Private Schools: Each school has its own entrance exam, usually consisting of basic science focusing on human biology and chemistry, and an interview. Students applying for scholarship may be required to sit an additional exam.

Is there any required pre-requisite coursework?

The national high school system divides the curriculum into two major programs: Ilmu Pengetahuan Alam or IPA (Natural Sciences), and Ilmu Pengetahuan Sosial or IPS (Social Sciences). One has to do the IPA / Natural Sciences program to be eligible for medical school. If a student graduates from a foreign curriculum, like Cambridge or the International Baccalaureate (as in my case), then he must have taken at least biology, chemistry, and maths.

Is it a competitive occupation?

Very.

What are you called at this stage of training?

A high school graduate.

Being In:

How long is it?

5 years.

How are the years broken down?

  • The first 3 – 3.5 years are pre-clinical years. Using the new block system, we learn basic anatomy, physiology, biochemistry, and immunology for the first year, then system-based approach for the remaining pre-clinical years. The actual division of the organ systems depends on each school. In my school, it is musculoskeletal, cardiology, pulmonology, gastroenterology, genitourinary, endocrinology, neurology, obstetrics and gynecology, dermatology and venereology, tropical medicine, hemato-oncology, and emergency medicine.
  • Students who have completed the first 3.5 years are considered graduates already, and are granted the title “Sarjana Kedokteran” (Bachelor of Medicine). They can quit at this time and start working non-clinical jobs.
  • The last 1 to 1.5 years are clinical/clerkship years. We do 9 minor rotations and 5 major ones. They differ by duration: minors last 4-5 weeks, majors last for 10-12 weeks. Minor Rotations: Neurology, radiology, psychiatry, ophthalmology, ENT, oral medicine, dermato-venereology, anesthesiology (including critical care), and forensic medicine. Major Rotations: Surgery (including emergency medicine), internal medicine, obs/gyn, pediatrics, and public health. Upon completing the clerkship, we then graduate as Medical Doctors.

Describe your typical day.

  • Pre-clinical: Class starts at 7:30 AM. Some days start with lectures, some with PBL discussions. Labs are usually in the midday. On the last period every Friday, there is a plenary session where the PBL case study that week is discussed with an expert. The day usually ends at 3:00 PM.
  • Clinical: In my hospital, office hours start at 7:00 AM and end at 2:00 PM, while outpatient clinic starts at 9:00 AM. The first thing we do in the morning is write SOAP notes of ward patients, then wait for the attending physicians to come for the morning round. After rounds, activities vary according to department. We may have academic activities, like tutorials or case study presentations, or we may go to outpatient clinic and have academic stuff later in the day. For surgical specialties, most operations commence at around 10:00 AM, depending on the number and difficulty of the cases that day.

If you choose a specialty, when do you have to decide by?

There’s no requirement for that. Age-wise, residency programs only require applicants to be less than 30 years old by the time of entrance.

What are you called at this stage of training?

  • Pre-Clinicals Years: Medical Students.
  • Clerkship Years: Our formal name is “dokter muda” or junior physicians, but we are more often called with our colloquial names, “co-ass”, from the Dutch word co-assistant. We still use a lot of Dutch medical terms in spoken conversations.

Getting Out:

What exams do you have to take?

The law is changing as I’m typing this. There used to be no exam getting out, as each rotation in clerkship already has its own exam. However, the new bill proposes for a national board exam. It is still undecided whether the exam will be a test for theory or clinical skills, or both.

Do most people graduate?

Yes.

When are you finally considered a “doctor?”

When we have taken our Hippocratic Oath at the end of clerkship (and after the board exam, if the new bill passes).

Do you have additional training after MS or do you start working immediately?

Again, the law is under some changes. The new law requires an unpaid 1-year internship in a hospital chosen by the government. After that year, doctors can work independently.

What’s the average debt for attendance?

There is no debt, except for scholarship students. Regular students pay the full fee. Scholarship students will pay back by working for their universities or teaching hospitals immediately upon graduation for a certain period of time, usually 2n + 1.

What are you called at this stage of training?

A doctor. More formally, a general physician.

Being Out:

What’s the average salary?

Depends on where you work. The general rule is the same everywhere: it’s higher in private institutions than public ones, and is also higher in bigger cities than in rural communities.

Is the job security good?

Yes. There is a high demand for doctors throughout the country, especially outside the main islands of Java and Bali.

Can you switch specialties?

Yes, but people rarely do this.

Can you go back and choose a different specialty?

Technically, yes, as long as one has not reached the age of 30 by the time of entrance. However, I have never heard of anybody doing that.

What are you called at this stage of training?

A specialist.

I Love My Job – Medical Educator Edition

As a first year I began working alongside a Pediatrician who would become pivotal in shaping my view of doctors and specialty choice. The way she loved her job shined through every single day (and still does as I work with her in third year) and the example she was to me became key in my discovery of the importance pursuing a career in a field you love holds. She showed me how important it was to choose a specialty you are truly passionate about…partly because it benefits you, but mostly because it benefits your patients.

As I mentioned a few days ago, residency applications are looming on the horizon and, with that, comes the promise of graduation (uhh…I hope, anyway) and “the real world.” As I struggle to decide what I want to be when I grow up I find that speaking with people who truly love their job is not only incredibly eye-opening, but exceedingly inspiring to me. Last semester I began asking around to find some healthcare professionals who love what they do and are willing to tell y’all about it. I hope to build a resource here so medical students struggling with post-graduation planning can get a look into the day-to-day life of various areas of medicine and, hopefully, find a piece of themselves in one of these inspiring stories.

I started by asking Dr. Michael McKenna, pediatrician and pediatric program director at Indiana University, what he loves about his job as a medical educator and how he ended up in the position.

Here’s what he had to say…

J. Lo in The Wedding Planner, when asked why she is a wedding planner:
“Y’know, ‘Those who can’t do, teach?’ Well, those who can’t wed, plan!”

While the above quote is a common phrase, I wholeheartedly disagree. People who teach don’t do so because they can’t hack it otherwise. They do it because their passion for their field is so great they can’t help but spread their knowledge, experience and passion to others.

I am a pediatrician, but the reason that I have been asked to write for Mind on Medicine’s “I Love My Job” series is because I teach newly minted doctors how to be pediatricians.

I am a Medical Educator.

I initially thought I was going to be a Pediatric Endocrinologist because it was the only organ system that made sense to me.

But before I had a chance to go on to fellowship, I had to pay my time to the State of Indiana.

No, I wasn’t making license plates in a minimum-security correctional facility. In medical school, I participated in a tuition payment program to serve in a medically underserved area. After residency participants needed to payback their time before doing any kind of fellowship. So, Endocrinology would have to wait.

Luckily, this did not preclude me from receiving the greatest honor of my career, serving as a Chief Resident of my residency program. Most residencies have one or more Chief Residents leading during their last year. In our program, Chiefs are expected to create the schedule and call schedules for the year. They also do a great deal of problem solving. Most importantly, Chief Residents teach residents and medical students. It was this aspect of my Chief year that changed the direction of my career.

Ever since I was a kid, I considered being a teacher, but being young and foolish, I didn’t consider it “cool enough”. These thoughts came flooding back during my time as Chief, as I realized medicine and teaching could be combined into one career. Ever since, I’ve had one all-encompassing (albeit cheesy-sounding) goal… helping residents become the best pediatricians they can be.

You don’t have to be Chief or take special classes to become a medical educator. The main quality needed is passion. I encourage everyone to incorporate medical education into every career path. 

The best medical educators I know, just like the best doctors, are always adding to their knowledge base. For educators, this means attending workshops about giving feedback or creating curricula. You can even get a Master’s Degree in Medical Education.

The day-to-day flow of a medical educator varies depending on specialty and  interests. The main question of career medical educators is, “Who is paying for your time?”

In medicine, you pay for your time by seeing patients in order to bill and generate revenue. Teaching doesn’t generate any revenue. Instead, I have to convince the Chairman that I am worthy of receiving money from the budget to teach.

Medical education is a great way to keep your career exciting. Each day is different. I might be mentoring a resident, seeing patients, developing a new workshop or a myriad other tasks on my “to-do” list. More importantly, being around learners all of the time constantly exposes me to their thirst for knowledge, keeping me excited about medicine.

Many students and residents are paralyzed by the perceived gravity of choosing a career, believing that once they choose their path, they are committed to it FOREVER. That is not true. Your MD (or DO or MBBS) opens many doors. If you ever get stuck in a rut, you can always find a new adventure without up-ending your life with a new residency. Bring a learner into your practice, teach at a nearby medical center, be a mentor. Be a medical educator!

Because of the way my clinical time is set up, no one is ever going to say that Dr. McKenna is my doctor. I am sure this sounds like a sad statement. Isn’t that why most people go into medicine in the first place? Yes, on occasion I long for that, but I have something much better. If I do my job right, I will have hundreds of pediatricians that will proudly (at least I hope!) say, “Dr. McKenna taught me how to be a pediatrician.”

That is why I am a Medical Educator.

Michael McKenna is Associate Program Director of the Pediatrics Residency at Indiana University. He conducts scholarly work in the areas of social media and medicine as well as mentoring of chief residents. More importantly, he blogs about pop culture, academic medicine and history (occasionally all 3 together!) at Mamihlapinatapei (ironsalsa.wordpress.com). You can also follow him on Twitter @IronSalsa or email him at mpmckenn@ iupui.edu.

Image 1: sakhorn38 | FreeDigitalPhotos.net
Image 2: scottchan | FreeDigitalPhotos.net

Mind On Med Ultimate Guide to Studying for USMLE Step 1 and COMLEX

A couple of months ago I asked a few of my favorite online medical students to answer a few questions about their experiences preparing for Step 1 and COMLEX. They gave me some very insightful answers, so I wanted to share them with you. This post is simply to create a comprehensive answer to the question we all have as second year med students, holymaterialexcessiveness how do I even begin to prepare for this? Believe me when I tell you that these 4 students have amazing advice & guidance. I’ll answer the same questions from my point of view in another post. For today, though, let me introduce you to my guests:

            

Step 1: June 14            Step 1: June 24             Step 1: Early June         COMLEX 1: May 27

Blog: APM                   Blog: MD2B                  Blog: Lancet                 Tw: @endlessrant

Tw: @astupple             Tw: @grecoa3               Tw: @michaelbmoore

 

I’m ecstatic with my score.

 

I am very happy with my score. I originally set my goal around average – which is 220 or so. After taking a few practice tests, I realized I could aim a little higher and ended up surpassing the new goal as well. I used this score calculator online. It factors in UWorld, NBME, and practice questions to give a score estimate and I found it very helpful for setting my goals.

In general, I am very happy with my score. It wasn’t perfect, but it wasn’t ugly either and really, unless you are shooting for something super-competitive, that should be your goal. The test is a reflection of how serious you are and the effort you are willing to put into a task, but it is also a measure of your ability to answer arbitrary arcane of standardized multiple choice questions on a specific day in May, June or July. For me, it’s like running a marathon in under 4 hours – not going to get you into the Olympics. It’s my best. In retrospect, that sounds like a total rationalization, but hey…it’s my rationalization.

Yes & No. Going into the exam I had determined a score range that I would be happy with. My actual score ended up being the literal bottom of that range. When I got my score, I started laughing. One point less & I would have been in tears. So yes – I’m happy, but (as always) I would have liked to done better.

 

No formal prep classes. My school had a week of formal review in late May provided by one of the prep companies with a wonderful live lecturer. I was happy with it and the videos provided with it were good, but if you hadn’t done a lot of prior prep-work it wouldn’t have saved you.

Doctors in Training. I highly recommend it. I was reluctant to use it, because it’s essentially a guided tour through First Aid, but it really keeps you going at a fast pace for 15 days (the length of the program).

 

I used two books: Goljan Pathology and First Aid, and supplemented with the classic textbooks from each supporting discipline. Goljan Pathology is not for everyone, but it is worth taking a serious look to see if it suits you. I found it ideal because it was clinically applied pathology, written with STEP 1 in mind. I did all of USMLE World, taking time to read through the explanations. Also, I listened to the Goljan audio recordings of his STEP 1 review several times through during the year to learn pathology in general.

I predominantly used First Aid for Step 1 and UWorld question bank. I also used specific books for weak areas – Rapid Review Biochemistry, BRS physio (super high-yield) and Microbiology Made Ridiculously Simple.

Book: First Aid for USMLE Step 1 Resource: Kaplan Q-Bank (on PC/Android/iPad). A note on Qbanks, your choice of Qbank is not as important as your discipline in using them. If you are a MSII you should be deep into a Qbank – start as soon as you can and use it often. A month with the best Qbank is not going to make up for lost prep time.

First Aid for Step 1 + Saverese OMT Review = The complete COMLEX study package. Practice Questions – COMBank & COMSAE

 

I studied non-stop for five straight weeks after second year was over. Prior to that I thoroughly read through Goljan and First Aid once with friends as a study group before the end of second year classes. We started this before Christmas break, meeting roughly once a week. The group wasn’t a huge time investment and it paid off tremendously because, when full-time studying came, I knew where to look to sharpen areas that I’d become rusty on.

I ended up studying for 4 weeks and a few days. After formal lectures ended the school gave us a maximum of 6 weeks to study for the test. I tend to get distracted very easily when I’m studying, so I knew that a schedule would be important to keep me on track. I would wake up around 7 and get to the library by 8. I would study until lunchtime, when I would walk back to my apartment and grab some food and take care of other errands. I’d get back to the library around 1 and study until 5 or so, when I usually took a class at the gym. At night I’d eat dinner and do a set of practice questions out of UWorld, and get to bed around 11 or so. I used a systems-based approach to studying. Our curriculum was systems-based, so it made sense to me to review the material the same way I learned it in the first place. I didn’t even start studying for the USMLE until our last class ended in May. Instead, I focused on the coursework and doing well on my tests, since these covered each topic more in depth than Step 1. You only have a few weeks to study before the exam, which isn’t nearly enough time to re-learn everything from the start of 1st year, so learning the material well the first time through is key.

 My school did not give me time to prep – our classes ended a week before our mandatory live prep course. I tried to get 2-3 hours of prep a day regardless of my class schedule. I would use the review materials/Qbank pertinent to the organ system/specialty we were studying at that point. It’s not as hard as it sounds.

I started studying concurrently with classes in January 2011. This might seem early, but I consider myself a slow reader & my weakest subjects were biochem & micro (2 BIG subjects & sections of FA). I used the Taus Method where you annotate each section of FA using a review book. Study time varied by week & topic I needed to cover, but I aimed to put in 4 hours/week of board prep on weekdays & at least 4 on the weekends. I then studied for 2 weeks after classes ended. During that time I’m guessing I studied 10-12 hours/day.

 

The day before the test, I broke the rules and did some reading. Personally, I feel more relaxed just reading stuff. That way, I don’t have to convince myself that it’s okay not to do any preparation. I’m not a hyper-focused person who’s too neurotic to relax, it’s just that I prefer to read over material rather than not.

I still had some questions left to do in UWorld, so I finished them early in the day. I spent the day packing to go home for a few days, cleaned my apartment, hit the gym, and went to bed early.

I reviewed my ultra-high-yield/most commonly asked questions…Brachial Plexus, Dermatomes, Cranial Nerve Exams, Characteristic Drug Side Effects/Reactions. Mainly for nerves and to give me something to do.

I got a massage, ate a great lunch, watched Inglorious Basterds & reviewed FA. Everyone says “Don’t study!” I disagree. Don’t try to learn anything new, but do set a cut off time – mine was 6pm. I went to bed at 11pm.

 

Take some time preparing a lunch that will be tasty, you’ll actually want to eat, and that’s easy to store in a 1 cubic foot nonrefigerated locker. Figure your lunch out the day before and don’t forget napkins and all that. Also, pay attention to what foods make you tired an hour after eating and avoid those.

I took the exam early in the morning (it’s an 8 hour exam). I recommend taking lots of sugary snack and caffeinated drinks, because it’s a marathon of a day. The exam has a tutorial section and a lunch break built in, but you can skip both. I wouldn’t skip the tutorial, because there are a few ways that the test software differs from the practice tests. Also, the lunch break can be split up. I took breaks in between each of my exam blocks to stay fresh.

Bring snacks, one for each break and your own water. Sounds dumb, but make sure you do it. Make it tasty, but not too tasty, with a good mix of complex and simple carbs (Power Bar). If you need caffeine, re-caffeinate at lunch. A day long test is as much a physical challenge as a mental one.

Make sure to have a snack during your breaks. You won’t be hungry during your break, but you will be 15 minutes after it ends.

 

The one thing that I regret is not taking more full-length practice tests. I don’t think I ever sat for 8 hours straight during my preparation and the fatigue definitely got to me on tst day. I consider myself kind of tough, used to working 8 hour days and longer, but I was surprised at how my focus was off. If I were to do it again, I would have done two or three 8-hour practice sessions, just like the regular test day; get up at 6AM, make a quick breakfast, and then go to a room and do nothing but questions for 8 hours. It sounds awful just writing it, but considering all the work invested, this time developing test stamina might have had a big impact. Last comment: I would seriously consider not taking ANY notes or doing ANY highlighting. Just read and do questions. Your brain is amazing, and trying to force it to remember stuff with notes and highlighting just gets in the way.

Most of my classmates took about 5 weeks to study, and began Monday after our last final exam; this gave them a week or so afterward to travel and relax before third year began. Hands down, the best decision I made was taking a week off to go on a trip BEFORE I started studying. Most of my classmates thought I was crazy, but when I came back I was fresh and relaxed. My other biggest strength when it came to studying was that from the beginning I wouldn’t let myself get freaked out by what everyone else was doing – some friends would literally do nothing but eat, sleep, and study. I didn’t get bent out of shape about it, because I just can’t study that way. I made sure to take time for the gym, and my favorite TV shows. I took weekends off from studying and did fun things. I think it helped keep my mind clear and stress level down.

Great question. I waited until January before my test to make a freaked out OCD schedule for my prep. I wish I had done that sooner.

QBanks – if you are only taking the COMLEX, a 3 month subscription to COMBank is all you need. The questions are indicative of what’s on the actual test. If you think you want to take the USMLE as well, then stick with UWorld & get a 1 month subscription to COMBank. Take a practice test. There are several available on the NBME website for $50 each and they are definitely worth it. They are made of retired questions and it is exactly how the actual test will be (but only 200 questions instead of 400). My suggestion is to take one about 2 months before your exam so you have a baseline & then another 1 month before so you can see how you would do on a real exam. The downside to the COMSAE is that you don’t get an answer key. They score it for you & give you a breakdown, but not explanations so they aren’t really helpful for learning – just assessment. I took 2 & my actual COMLEX score was 60 points more than what COMSAE predicted.

Santo Domingo Children's Hospital

Medical School in the Dominican Republic

Medical School in the Dominican

Today I am honored to be continuing our Medical Education Monday series with Medical School in the Dominican Republic. Our Mind On Med guest blogger for today is Vera, a 21 year old medical student in the Dominican. She’s starting her 5th year of medicine and is still wide open on the specialty front, but has a special interest in Neurology. She loves blogging, snail mail, singing and coffee (would we even call her a med student if she didn’t love coffee? I think no, but that’s likely the addiction speaking). And, get this, Vera is a Latin dancer! How cool is that?! We should get her to do a vlog lesson for us. Feel free to contact myself or Vera with questions about Medical School in the Dominican! My additions are in orange.

Santo Domingo Children's Hospital
Children's Hospital in Santo Domingo, photo by RIGHT TO HEALTH.

Getting In:

How old is one when they begin medical school?
A regular student who never repeated courses in high school graduates of at the age of 18. You start pre-med after that – when I started pre-med was one year, but now it’s two, so you enter properly to med school at about 20 or 21 years old.

What exams does one have to take to get in?
We actually just have to take the general exam everyone takes to get into college, it consists of questions on Spanish, Maths, Logics, and English.

Is there any required pre-requisite coursework?
No, there isn’t (just the two years of pre-med course work described above).

Is it a competitive occupation?
No, there is a place for everyone interested; the only requisite is to maintain a scoring upon 2.5/4 while you are in premed in order to get in to the med faculty.

What are you called at this stage of training?
Premed Student.

Being In:

How long is it?
6 years

How are the years broken down?
When I started: One year premed, two years basic sciences and three years of clinical training.
Nowadays: Two years premed, two years basic science and two years of clinical training.

Describe your typical day.
Every semester is different. In the current unit I’m on classes begin at 7:00 am with a 2 hour theorical class. Everyday it’s a different subject, this semester includes Peds and childcare, Endocrinology, Gastroenterology, Imaging and Clinical Pathology, Family and Community Medicine and Preliminary Research. After that I go to the assigned hospital for that day and take a 2 hour practical class, again the subject is different each day. About 11:00 am we have a two hour break for lunch, I usually get the chance to go home and eat. At 1:00 pm we are back at the classroom and get out by 4:00 pm, which is when our college and hospital hours end and our duties begin. We are now working in our thesis, so we have about two or three meetings a week (an important amount of hours of work) and the rest is dedicated to study. Usually I stay in week nights (like a little kid =P  [nah! like any dedicated medical student, if you ask me :)]), I’ve learn to value my sleep and I know I’ll do it even more in a few months and years. Weekends are pretty diverse, depending on what’s going on.

If you choose a specialty, when do you have to decide by?
You can have an idea of what field you preferred, but it’s after you graduate that you can start a specialty. You have to take an exam and attend to an interview at the hospital when you are planning to get in; if you are accepted you are good to go. At the interview, besides your personality, the interviewers notice the points you have accumulated along your career as doctor (you win points by papers published, hours in hospital work, an internship year for the government, your graduation scoring, being part of the national medical association and, of course, the interview itself).

What are you called at this stage of training?
Medicine Student. In two semesters I’ll be called Medical Intern (middle of 5th year of med school).

Getting Out:

What exams do you have to take?
To be a doctor you don’t need to take any exam, but to opt for a residency spot you must take a national exam, it is based on a 100% and the minimum to pass it is 70%.

Do most people graduate?
Yes, most people certainly do.

When are you finally considered a “ doctor?”
Right after finishing the one year Internship required in med school and then get your diploma, which gives you the title of Doctor in Medicine (so, if I’m interpreting right, that would be about 7 years into your training including pre-med, medicine and intern year).

Do you have additional training after MS or do you start working immediately?
Doctors have to work a year for the government after graduation (another one year internship, now as a doctor and not a medical intern, in whichever hospital they require you to go to)* in order to get their exequatur (a written official recognition and authorization by the government to which one is accredited to work as a doctor in medicine).
*(The further the hospital, the greater the points you get).

What’s the average debt for attendance?
Well, the cost of medicine career here is about 500,000 RD$, that number into dollars must be around $13,158 USD.

What are you called at this stage of training?
Doctor

Being Out:

What’s the average salary?
The average salary of a resident is about 34,000 RD$ ($790 USD) per month.

Is the job security good?
Jobs have a great availability in our country, the opportunities are better for doctors who work in private clinics or hospitals, although private offices are kind of expensive. Doctors who want to work at a private level have to have the resources or help themselves by loans, which actually pay off when they get established and start working. Not everyone finds opportunities, though.

Can you switch specialties?
Yes you can, but only if it’s related to the field your currently on.

What are you called at this stage of training?
It depends on the years that the specialty you’ve chosen lasts. The word “Resident” adds an R to the name and later the year you are currently on. Ex.: R1, to the residents that are on their 1st year. R2, R3… you guys get the point =P. (This is quite similar to US residency training where we are called “physicians” or “doctors” during our residency training years and PGY1, PGY2, PGY3, etc. to denote our year of residency training. Although, in the US your intern year is equivalent to PGY1). 

Previous Medical Education Monday Posts

Medical School Around the World:

Full Body Physician

My Doctor Has A “DO,” What Is That?

I am honored to have @DrJonathan, a Family Medicine resident from Chicago, guest blogging this week for Medical Education Monday on what exactly a “DO” degree is. After receiving questions on Twitter from two separate people asking if it was “ok” to continue seeing their physician who had a “DO” degree, I knew it was time for this post. Before applying to medical school I truly had no idea there were two types of physicians in the United States and it was interesting to me to learn about Osteopathic degrees. @DrJonathan graduated with his degree in Osteopathic medicine this semester and is now attending residency. Today he has written a wonderful article about DOs geared towards info useful to the general public and next time he will be explaining the differences in licensing and training for students who may be trying to decide between the two paths into medicine! He is a superb writer, you won’t be disappointed.

”Photo

What Is Osteopathic Medicine?

    Despite all the different types of medical professions in America, a physician is the most universally recognized medical profession. Most people associate the word “physician” with an individual who has an MD (Doctor of Medicine). Although most physicians are MDs, they only account for a portion of medical doctors in America. The other type of fully licensed medical doctor in the US is the Osteopathic Physician (DO). Currently, there are over 80,000 practicing Osteopathic Physicians in the United States. They account for almost 10% of all practicing physicians and nearly 20% of current medical students are in Osteopathic medical schools. Osteopathic physicians can be found in any medical field from Pediatrics to Family Medicine to Dermatology to Orthopedic Surgery. Their training includes all the training MD receives: they attend 4 years of college, 4 years of medical school, and at least 3 years of residency. Although they also have their own types, they can complete the same residency training programs, same medical board exams, and earn the same board certification as MDs. They are fully licensed physicians and surgeons in all 50 states, prescribe medications, perform surgery, and independently practice medicine. DOs and MDs work alongside one another in all areas of medicine. They are separate, but equal in their medical practice and theory. The difference lies in the Osteopathic medical philosophy.

    Osteopathic medicine was founded in 1874 by Andrew Taylor Still, a MD. He felt that the medical practices of the day were suboptimal and thought physicians should promote the body’s innate ability to heal itself, prevent disease, and maintain health. He emphasized the muscuoskeletal system in understanding how illness or injury in one part of the body affects another. Osteopathic physicians are taught from the first day of Osteopathic medical school to treat the entire person – not just one body part or system. Their training focuses on the body’s inherent ability to heal itself. They look for ways to restore and maintain health, not just eliminate disease. In addition to learning all that MDs learn, DOs are also trained in the practice of Osteopathic Manipulative Treatment (OMT). OMT is predicated on the theory that structure and function are reciprocally related. Without optimal structure and function, the health of the body suffers. OMT consists of hands-on therapy that helps remove restriction, encourage blood and lymphatic flow, alleviate pain, and return the body to its original state of healthy functioning. Osteopathic physicians can use OMT in every field of medicine in order to restore and maintain health. This additional skills that DOs possess enables them to bring an extra dimension to quality patient care.

    DOs play a vital role not only in helping reduce the physician shortage in America, but especially in meeting the need for primary care physicians. Given the holistic, patient-centered view of Osteopathic medicine, it is not surprising that over 60% of DOs practice primary care in fields such as Family Medicine, Internal Medicine, Pediatrics, and Obstetrics and Gynecology. DOs are also notorious for practicing in rural, underserved communities. Primary care is most conducive to the Osteopathic philosophy of holistic, preventative, patient-centered healthcare.

    The differences between DOs and MDs are subtle, but deep. That does not, however, minimize the fact that they both work for a common purpose: to ease suffering, promote health, prevent disease, and improve quality of life in patients. Osteopathic physicians, however, use their unique philosophy, additional skill set, and all other available medical options to provide patients with the highest quality, most comprehensive healthcare available.

MomMD.com Announcement – I Need Your Help!

A few weeks ago, while I was consumed with memorizing what causes a left shift on the O2 Dissociation Curve, I received an email that made me giddy with excitement and overwhelmed with gratitude. MomMD.com, a site I’ve frequented many times since deciding to apply to medical school, contacted me asking if I’d consider coming onto their team as a weekly blog contributor. I am ecstatic to have this opportunity and can’t wait to get started over there.

The blog there will be separate from Mind On Medicine and, among other things, I’ll be writing more about topics related to being a woman in medicine. Don’t worry, though – this blog isn’t going anywhere! This is still my personal outlet and I’ll be here just as much, but I’d love to have your support and encouragement as I get started as a contributor for this rockin’ resource.

In the mean time, I would love it if my awesome Mind On Med readers would help me choose a name for the new MomMD blog! Vote for one of the options below, or add a new one. If you come up with something great, I’ll definitely add it to the options!

Later on I’ll announce the winner and let y’all know where you can find me on MomMD!


[polldaddy poll=5261349]

Medical School in the UK, Residency in the US

Today’s Medical Education Monday post is one I have been looking forward to reading since he offered to write it for me a few weeks ago! Nick Bennett (@peds_id_doc) is a Pediatric Infectious Disease Fellow in Syracuse, NY and he has a very unique perspective to share with the Mind On Medicine readers today. Dr. Bennett went to medical school (and got his PhD…overachiever…does that mean we call him Doctor Dr. Bennett? I think it does.) in Cambridge, UK, but chose to do his residency in the United States. Medical school in one country, residency in another – what a unique and valuable addition to to this series!! In addition to being a bug-killer extraordinaire, he is interested in teaching communication skills, antibiotic stewardship and software-driven data analysis (from what I’ve gathered on Twitter he’s the owner of some geeky computer skills – something I’ve come to regard highly after marrying a software developer – that stuff is no joke). I hope his information can help someone looking to do something similar, but I can assure you that his story is a great read even if you never plan to practice medicine somewhere other than your country of training…actually even if you never plan to practice medicine at all.

I’m in the interesting position of someone who went to medical school in one country (UK) but completed residency in another (USA). My reasons for doing so are, on the surface, fairly simple (my wife is an American) but it goes a bit deeper than that. One issue that was important was the fact that in the UK the junior doctor jobs often involve moving from hospital to hospital, spending only a few months in the same place. The alternative was to move once and stay at the same hospital for several years. It seemed like a simple decision!

The problem I immediately ran into was – just how the heck do I do this? There was absolutely no careers advice for those of us who wanted to leave the NHS (National Health Service). I’d even been to careers advice forums where the speaker opened with, “This is really for all the scientists here, as doctors have it pretty much sorted out.” Yeah, thanks.

Searching online revealed two basic hurdles – exams and visas. The US assumes that every other medical school in the world has exams that aren’t reliable. You not only have to graduate from your medical school (if it is on the list of acceptable schools!) you have to pass US medical school exams as well – the USMLE Step 1 (the test I take Friday
and 2. For most people this is an annoying formality, but there are two issues here: Step 1 is basic science – you may be many years from your pre-clinical training and hence quite rusty (as I was) by the time you take it – and Step 2 has a heavy US bias, so you have to re-learn minor facts of epidemiology as well as have a basic knowledge of US geography and the medical conditions, typically infections, that are more common in certain states.

The exams are required for certification by the ECFMG – the Educational Commission for Foreign Medical Graduates. Along with your medical school records, passing the Step exams is needed to obtain ECFMG certification, which is required to start a training program in the US as a Foreign Medical Graduate (FMG). It is quite expensive in terms of fees and exam costs, but if you want the training you have to invest the money.

The second issue of a Visa was one I was thankfully helped with by marrying an American! The more typical approach is to obtain a H1B or J1
training visa. These are sponsored by the residency program or the ECFMG, so you have to have been accepted by the program before that can move forward. Not every program will sponsor training visas so focus your efforts on those that do. FMGs are often at a competitive disadvantage compared to US graduates, but some programs are very supportive so it can pay to do your homework about a particular place to find out how they stand on that issue. If you have contacts in a residency program in the US that’s probably the best way to get the inside scoop.

I was very lucky in getting the program I wanted – I was taken “outside of the match” which means I didn’t have to deal with the NRMP (National Resident Match Program), which I gather can be quite stressful and complex, especially for non-US graduates. As such, I’m rather odd in that I can’t offer any advice on visas or matching! I did it through networking and spending time here as a student doing an elective. That kind of exposure is priceless when it comes to applying for a residency position (spending time doing away rotations in places you want to do residency is sound advice for ALL medical students, not just for those looking to go to a new country to finish their training)
.

There are a few websites out there with advice on moving to the US. They’re worth reading to be prepared for some of the inevitable culture shock. Oddly enough, the effect was perhaps weirder coming from the UK. Enough of the lifestyle and society was similar to the UK that when something WAS
different it seemed more of a surprise. Silly things like having to add sales tax onto prices and paying for checking (current) accounts were hard to get used to,  you get used to it, though.

Once I was here a few things became quickly apparent. The first was that although it seemed as if my medical school training gave me an excellent basic medical science background, but I felt wholly unprepared for actual patient care. The US students were given more responsibility and seemed more involved in patient care that I had been. The other FMGs that were starting with me tended to have already completed a residency in their own country. I was lucky in having a graded experience working up from the newborn nursery to the ER and excellent senior residents, but I know that had I started out in the ER things might not have gone so well! My learning curve was near vertical, but I kept my head above water enough to keep going. Once I was settled in it was also clear that despite all I had heard about the “evil US profit-driven healthcare system”
, the actual practice of medicine was basically the same as it was in the UK. Docs still made decisions based on best practice and in the patient’s best interests, at least in the academic setting. Only rarely did insurance ever come into play – usually when patients didn’t have any and we had to cut corners to save them some money.

Later, as a Fellow, I ran into the issue far more frequently, when having to obtain “prior authorization” for treatments that insurance companies would rather not pay for. I’ve also heard and seen more discouraging practices from the non-academic world, which although not unique to the US are far less likely in the system I came from. Everything from pharmacy costs to malpractice premiums is shifted upwards, and it’s easy to see how the US ends up spending twice as much as any other developed country for no additional benefit.

There were several advantages to coming here that I really didn’t anticipate. Back in the UK I recall asking my research supervisor how I could get to be someone like him. He replied that I should focus on medicine for the first 10 years or so before trying to come back to research. When I asked the same of my mentor here in the US he said “Well, you’ll have to wait until at least the second year of Residency…!”  As it happens, in my Intern year I started writing online medical review topics, helped out with clinical trials and started a new medical education initiative for the students. It seems as if people are very willing here to support junior doctors in the kinds of extra-curricular activities that would otherwise have to be put off for years in the UK. That’s not to say that every FMG becomes a world-famous clinical educator or researcher, but that it just seemed to me that the opportunities were better for me here. In addition, it’s very clear that people do all kinds of things with their medical training here. In the UK I felt as if I was being channeled into the NHS and it seemed there was no way to easily merge education or research into my daily activities. In the US it is equally valid to choose private practice as it is to choose academics, industry, or government work – in fact, many mix and match.

I think I got a great education from the UK, and I didn’t leave specifically because I couldn’t get what I wanted there – it was for personal reasons, but it turns out that making this move to the US was a really great professional decision, too.


Past Medical Education Monday Posts

Medical School in the UK Post

Medical School in The Caribbean

Over the course of this series it has become very apparent that medicine is a competitive occupation no matter what country you live in. This holds true to higher degree in some countries more than others. Brenda, a Canadian in the midst of getting her MD from a Caribbean medical school, was nice enough to do a write up for me on what it’s like to get your medical degree from a school in the Caribbean. The Caribbean school route is becoming extremely common amongst American and Canadian students and I felt it was an avenue that definitely needed to be covered in the Medical Education Monday series. I’m really excited to have Brenda’s information to share with y’all today. Please feel free to email me with questions and I will make sure she or I finds the answers for you. As always, comments I’ve added are included in orange font.

Picture I took last summer of St. Matthew’s University residence hall in Grand Cayman.
It literally backs up to crystal clear water & white sand beaches, not fair!
Medical schools have been popping up in the Caribbean for many years now. These institutions offer the opportunity for individuals who have not been able to get into a Canadian or American school a chance to still persue their dream of becoming a doctor. Each school is slightly different, so please do your research when thinking of applying. Also, be wary that some schools are not exactly permanent – they get built and try to get as many students as they can and then shut down. In addition, some schools are not approved by all governing bodies, so please do your research! There are some really good ones that have been around forever and are getting to be as competitive to get in as an American school, but before you apply you need to figure out which ones are appropriate. (Click Here for information on Accredited  Caribbean Medical Schools).

My journey was tough. I went back and forth with several options. When I finally decided to pursue my dream of medicine I didn’t have the time to go through all the required courses in a Canadian university. I did my research and found a school where they offered a pre-med program where, for 8 months, we covered the basics – anatomy, chemistry, medical terminology, etc. With a good GPA I was automatically admitted into the MD program at this school. Attending a Caribbean medical school is slightly more difficult because we are seen as international medical school graduates, but I think in the end it’s all worth it.

Getting In:

How old is one when they begin medical school?
With the Caribbean schools the average age is slightly higher because most individuals have pursued other careers before starting. However, there are also those coming straight from undergrad. For pre-med programs, you need as little as 2 years of undergraduate work to get in.
What exams does one have to take to get in?
Each school in the Caribbean is different. Some require the MCAT and some do not. For the pre-med program, it is not required.
Is there any required pre-requisite coursework?
The required courses to get in are very similar to the US schools.
Is it a competitive occupation?
It is beginning to become a little more competitive to get into these Caribbean schools. Some are becoming as good, and very close to being as competitive, as US schools. The required GPAs are getting higher and higher each year.
What are you called at this stage of training?
Pre-Med

Being In:

How long is it?
Four years
How are the years broken down?
Two years of basic sciences on the respective island. Two years of clinical training in the United States. There are some clinical rotations where the Caribbean students are learning right alongside American students.
Describe your typical day.
Semesters 1-3: These are purely basic science. Beginning either 8 or 9am and going all the way to 4:00pm, you sit in a classroom where the professor lectures. Each semester has 4 subjects. After classes, you study. There are “blocks” which are computer-based exams every 3 weeks for each class. At the end of the semester you take a shelf exam that is written. This exam contains old USMLE Step 1-type questions and it is the same exam written by the students in the US. (These are exams written by the National Board of Medical Examiners, or NBME, and they are what my US medical school uses as block finals as well).
Semesters 4-5: Book-type lecturing is decreased at this point and students are doing more hands-on training, like learning to take histories and physicals. We also go to the local hospital.Comprehensive Exam: This is written at the end of Semester 5. It is basically a cumulative shelf exam. It is required in order to go on to take USMLE Step 1.
3rd year rotations: Family Practice, Ob/Gynecology, Internal Medicine, Psychiatry, Pediatrics and Surgery rotations with a shelf exam at the conclusion of each clerkship. Most accredited schools have students do 3rd year rotations at their affiliated US hospital, not in the Caribbean. (Not surprisingly, since many of the Caribbean med students are American, this layout is almost identical to the layout of medical school in the US).
If you choose a specialty, when do you have to decide by?
Most people will decide what specialty they want to go into by the end of their 3rd year rotations.
What are you called at this stage of training?
Medical Student

Getting Out:

What exams do you have to take?
To work in the US we are required to pass the United States Medical Licensing Exam (“USMLE”). We take “USMLE Step 1” after our second year, it is an 8 hour exam covering basic clinical sciences. “USMLE Step 2” has a clinical knowledge part and clinical skills part that has to be passed before graduation at the end of your 4th year. “USMLE Step 3” is taken at the end of your residency training.
Do most people graduate?
Because of the intensity of basic sciences not everyone graduates this portion of the training, each class loses around 1/5th (20%) of their students.
When are you finally considered a “doctor?” 
After your 4th year of med school you graduate and are offically an “MD.”
Do you have additional training or do you start working immediately?
To work in the US you must do a residency in the US. Getting a US residency as a graduate of a medical school in another country is tough, but not at all impossible. Everyone applying to residency in the US must be a medical school graduate (or soon-to-be graduate) and must have passing scores on the USMLE Step 1 and Step 2 (Clinical Knowledge and Clinical Skills portion). However, passing is not usually good enough to get you the residency you want – it’s competitive and the higher your score the better your chances. 
What’s the average debt for attendance?
Each school is different but it can range anywhere from $98,000 to $212,000. Of course, this is only the tuition and you must factor in the price of housing, which can vary substantially. Also, the cost of plane tickets to and from the island when you want to visit your home. 
What are you called at this stage of training?
After graduation you are officially a “doctor.” For your first year of residency you’ll be considered an “intern” and for the rest of your residency training you will be referred to as a “resident physician.”

Being Out:

Most of these students are working towards a career in US medicine and their salaries/schedules/licensing/etc. will not differ from physicians who graduated from a US medical school. For information on physician salaries, job security, specialities, licensing, etc. in the US, see Medical School in the United States.

Past Medical Education Monday Posts: