Monthly Archive: September 2011

2011 Residency Duty Hour Restrictions: An Intern’s Perspective

Taken from

In a recent post I explained the differences between the old ACGME duty hour restrictions and those implemented in July 2011.  The main difference is that first year residents (i.e. ‘interns’ or PGY1 residents) are now limited to 16 hours shifts, with a mandatory 10 hour break between shifts.  All residents are still limited to the 80 hour work week that has been in place for nearly 10 years (2003).

I heard about the new restrictions while I was a fourth year medical student.  At first, the idea sounded fantastic, both for the resident and the patient.  However, a few months into my internship and I am already starting to see some potential downsides to these regulations.   Lets look first from an intern’s perspective.

  • The new duty hour restrictions leave no option to residencies but to start a large night float operation.  This means that a large subset of your interns will be working nights for 2-4 week intervals.  Rather than just being on call every fourth night, interns must now switch from nights to days to nights frequently.
  • With the 80 hour work week remaining intact, but the shift limit being decreased to 16 hours, you can imagine that interns are not working any less, they are just working more shifts.  So, rather than having ‘post call’ days, or a ‘golden weekend’ (Saturday and Sunday off), I am in the hospital nearly every day.
  • In addition to the hours, there is a HUGE loss in patient continuity.  I feel like I never know the patients I am covering.  This is detrimental to the doctor-patient relationship and also to my learning.

Now, from the patient’s perspective: imagine you come to the hospital with acute pancreatitis. You are admitted by the night float intern and resident, who sign you off in the morning to the primary team and never see you again. You are taken care of by the primary team intern and resident during the day, who then sign you off to a totally different intern and resident when they leave for the day.  This is the normal cycle in most US teaching hospitals in 2011.  A patient will have been taken care of by 3 different interns and 3 different residents in their first 24 hours of admission.  There is no continuity, and a very high rate of patient ‘hand-offs’.

I do now know the answer, but I know what question we all must answer.  If you are a patient in the hospital who all of the sudden develops septic shock at 9:00am in the morning, who would you rather rush into the room?

  • An intern who has been working for 28 hours straight who knows you well but is very tired, or
  • An intern who had a full night’s rest but doesn’t know you from Adam and has only heard one sentence about you?

Which would you choose?

New 2011 ACGME Duty Hour Regulations

As you have all heard, the new ACGME duty hour regulations began at this year.  In this post I discuss the confusing changes that have been made; in a separate post I discuss how these changes have affected me during internship. In 2003 the Accreditation Council for Graduate Medical Education (ACGME) adopted new rules that limited intern and resident to 80 work hours per week, averaged over a four week period.  In addition, the 2003 regulations limited residents and interns to 30 continuous hours of work and stated that no new patients could be accepted after 24 hours.  Residents were limited to no more than 1 call night in every 3 days (Q3). These restrictions included all clinical, surgical, didactic, and moonlighting activity.  Click here to see the full list of 2003 regulations on the ACGME website.

In 2011 the ACGME added additional regulations, aimed mostly at first year residents, also known as ‘interns’ or post graduate year 1 (PGY1).   The duty hours per week has remained the same at 80 hours, averaged over a four week time period.  The continuous hours on service, however, was decreased to 16 hours with a mandatory break of 10 hours between shifts.  What this means is there will be no more 24+6 = 30 hour call days for interns.  Upper level residents (PGY2 and up) are still able to work 24 hours shifts, but the 24+6 strategy is no longer listed in the regulations and they are still restricted to no more than Q3 call.  Additionally, interns and residents may not be scheduled for more than 6 consecutive days of ‘night float’. Click here to see all the new 2011 regulations on the ACGME website.  Additionally, you can access ACGME’s main webpage for the new 2011 regulations which offers FAQ, a glossary of terms, and the committee’s letter of intent on the new regulations.  Link to ACGME main 2011 regulations webpage.

These are the most dramatic changes, though the ACGME implemented a number of other “strategies” and “professionalism” comments to the new regulations.  The ACGME website has produced a great chart comparing the new regulations to the old regulations.  Click here to view the regulations comparison chart 2003 vs 2011.



How to create a great research poster

Taken from University of Michigan Center for Research and Learning

Your research is only as good as you can present it.  Presenting a poster at a conference is an important way to gain experience presenting research and is a great way to demonstrate your motivation to medicine or your specialty of choice.  (It also looks good on your CV, but you knew that already).  There are a couple steps required to presenting research at a conference


  1. Conduct good quality research
  2. Submit an abstract to the conference of your choice (make sure you know the deadlines, as these are sometimes nearly a year prior to the conference)
  3. Design a high quality poster
  4. Present your poster at conference

In this post I will only touch on #3 and a tiny bit of #4, conducting good research and writing an interesting abstract are topics for another day.

I recently came across a great article which touches on the specifics of poster presentation: formatting, fonts, graphs, colors, sizes, logos, etc.  (link)  The author explains in detail how to grab viewers attention.  I will not go into that much detail, so please see the link for specific information.  I use that article as a reference whenever I work on a new poster.

Click here to go to an indepth article about creating a great research poster

Also, if you are looking for a generic poster template that you can start with, click here.  This is a standard, three column template that is clean and organized. Be sure to customize it so it does not look like a generic template when you are done.

Click here to download a generic poster template in powerpoint.

The most important thing to remember when you are designing your poster is this: KNOW YOUR AUDIENCE.  Most of these people are not really interested in your research, no one can read every poster at these conferences so it is up to you to grab their attention.  With this in mind, here are my top five recommendations…

  1. Learn from the Experts: peruse award winning posters from previous years at the conference you will be attending.  Often conferences will make these posters available to the public.  There is no better way to learn than to use ideas from those who are already succeeding
  2. Keep it Simple Stupid: No one likes a busy poster, passerbys will simply pass her by.  Keep the format clean with regular sized text (size 20-40 depending on font).  No tiny text and no crazy fonts.
  3. Know the conference standards:  It is really hard to take a poster seriously when it is 4′ by 6′ but needed to be mounted on a 3′ by 5′ presentation area.
  4. Know your Research: You will often be asked to summarize your poster.  Why can’t they just read it themselves?  I have no idea.  Be prepared to summarize quickly or more in depth, depending on what the individual is looking for.
  5. Dress for Success: If you look professional and attractive, you are bound to attract more business. If I see an individual who can not present himself or herself well, I certainly am not going to take the time to figure out if they can present their research well.


Goljan Audio Lectures and High Yield Notes

As you begin to prepare for USMLE Step 1 you will likely something about the Goljan lecture series and the Goljan pathology review book.  Dr. Edward Goljan is a pathologist at Oklahoma State University Medical School (you can read more about him at his university website or on Wikipedia.) In my opinion, there is no one in the country who knows more about what student need to learn for Step 1 than Dr. Goljan.  There are currently a number of board prep materials available to medical students thanks to Dr. Goljan, let me discuss a few of them.

1. Audio Lectures: Years ago Dr. Goljan taught a prep course for both parts of the boards, both Step 1 and Step 2. Somehow, these lectures were recorded and are now shared between medical students across the country and across the globe.  While I do not endorse illegal file transfers, these files are available for download on the internet and there is no other possible way to obtain them.  From everything I have read and after countless requests of my own, I do not believe it is even possible to purchase the audio files. I will provide a couple of links, but they will, inevitably, not always work.  

Your best bet is to google "Goljan Audio" or ask students in your school if you can use their copies.  As you know, it is always risky to download data from websites you don't know. Link 1: This is a skydrive directory that seems to have all the lectures available for download individually Link 2: I used this website,  It looks a bit shady but it worked well for me. Again, the best method would be to find some on a friend's computer. I wanted to mention what makes these lectures most useful.  I do not believe that listening to them early in your first or second year of med school is helpful.  They are not a great review for your school tests because they are only an overview.  Also, when you begin to make your study plan for Step 1 you are not going to have 40 hours to sit and listen to lectures.  Frankly, you will fall asleep and get nothing out of it.  I found that listening when I exercised every day was a fantastic way to use them.  That way I didn't feel guilty about taking an hour to exercise (which, by the way, is the best thing you can do when you are studying 10 hours every day) and I surely learned more from Goljan than I would have from Eminem and Coldplay.  In fact, I know that just listening in the car and while running picked me up a good number of questions on Step 1.  I still remember, word for word, one question that I absolutely would not have known if not for Goljan's lectures. I have heard that there are 'new' Goljan audio lectures since I took Step 1.  I can not verify this, and I search using my usual websites only found the same audio files that I used 3 years ago.  If anyone knows more about this, please leave a comment.

2.  Dr. Goljan's Book, Rapid Review Pathology: There is ongoing debate about what is the best pathology review book for USMLE Step 1.  The debate usually comes down to Dr. Goljan's Rapid Review of Pathology, and BRS Pathology.  Dr. Goljan's book tends to have more images, a more modern layout, and does not rely solely on text to teach pathology while the BRS book is a no-nonsense text book which attempts to teach the most important points of pathology quickly.  So, the choice depends on how you learn. While the issues at the heart of that debate will have to wait for a different post, we can all agree that BOTH books are very good.  Links to the newest additions of both books on are shown below.  I used primarily the BRS Pathology book, but I have only ever heard great things about Goljan's book. In fact, some students believe it added double digit points to their board score.  Link to and the newest editions of both the Goljan's Rapid Review, and the BRS book are shown below.

Dr. Goljan's Book 

Dr. Goljan's Competition

3. High Yield Notes: Less known are the Goljan High Yield Pathology Notes.  The format that is available on the internet is not ideal, but I do think that these notes can be very useful.  The document is a very rapid review of the pathology associations that are most common and most important to Steps 1 and 2.  It is long (30-40 pages) and very dense (no pictures, small font size, all pages are full of text) but it highlights very efficiently the high points of pathology for the USMLE. Again, you can search the internet for "Goljan High Yield" and you will be inundated with places to download the file.  Alternatively, I will attempt to keep my copy on my website until someone tells me that it is illegal, which I do not believe it can be as this, too, is not available for purchase anywhere else. Click the link below to download the pdf. Goljan High Yield Pathology Notes  

Which doctors get sued the most?

Have you ever wondered which physician specialties deal with the most malpractice lawsuits? While I was in medical school I often heard physicians discuss the rising costs of malpractice insurance and the lack of tort reform.  I knew that OB/GYN doctors had to deal with a lot of lawsuits, but I had no knowledge of which other specialties faced frequent lawsuits.  The New England Journal of Medicine recently published a great paper identifying which medical specialties are sued the most frequently.  The paper can be freely accessed by anyone (click here to see the full article).

The most interesting results can be summarized by the graph below, which demonstrates the percentage of physicians sued in a calendar year, separated by specialty. As you can see, neurosurgeons and cardio-thoracic surgeons lead the list with nearly 20% of all physicians in these specialties sued each year.  Wow, that seems excessive!  On the other side of the graph, only about 3% of psychiatry and pediatric physicians deal with lawsuits each year.

Taken from NEJM, click the link below to see the full article

See the full article here

The article also presents data that demonstrate the cumulative probability of being sued during your career.  They find that by the time physicians in ‘high risk’ malpractice fields, such as general surgery and neurosurgery, reach 55 years of age nearly every singly physician has been sued at least once (95-99%).

Malpractice lawsuits are an important topic, especially when choosing a medical specialty during medical school.  Students need to know what problems the every-day doctors face so that we can make informed decisions.  If someone went into neurosurgery without knowing that nearly 100% of all neurosurgeons will be sued by the age of 55, this might result in a very unhappy professional life.  On the other hand, if you love neurosurgery and you are informed about this problem, you will be able to weigh all the pros and the cons of the specialty before making your decision.  When you know what you are getting into, you always have a higher chance of success.

Carlos Pestano Surgery Review Notes

If you have not yet heard about the Pestana surgery review notes (download), these are a must have.  There are a number of good review and question books for your surgery rotation, but nothing as useful and high yield as the Pestana notes.  I read through these two days before my shelf exam and I know for a fact that it got me 4 or 5 questions that I would not have known otherwise.  They are extremely high yield; almost universally, students admit that questions were asked on their surgery exam that seemed to be taken right from the Pestana notes.

Click the link below to download the .doc file.

Pestana Review Notes for Surgery

As nearly every medical student in the country is currently using these review notes during their surgery clerkship, I though the least I could do was recognize the physician who provided them to us.  Click here to see a recent award given to Dr. Pestana, MD, PhD.

He has also published a number of books including the Manual of Surgery and Fluids and Electrolytes in the Surgical Patient (amazon links below).

The University of Utah Anatomy Tutorials

I recently posted about a great radiology website that is also a good study tool for gross anatomy.  It is i

mportant to remember that most anatomy tests will include a few questions using radiology images.  However, I found that the best way to study anatomy was through anatomy dissection websites.  The University of Utah provides a great website to their students, and it is open for public use too. Their anatomy website is broken up by organ system and features hundreds of images and quizzes.

They have an entirely different site dedicated to neuroanatomy.  This is the clearest and best organized review I could find on the internet. 

In addition to the basic anatomy website, they also have many histological and pathological slides and quizzes.  The histology review on their website was one of the best I could find.  The pathology slides are equally worthwhile, though they are likely more useful for courses other than anatomy.