Monthly Archive: July 2015

Basics of Fundus Drawing

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Ophthalmology

July 7, 2015

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Few ophthalmology residents today learn the art of color fundus drawing. This used to be a fundamental skill required by all ophthalmologists. With the advent of electronic medical records, wide angle fundus photography, and the never ending push to see more patients, the art has nearly died. However, there are a number of reasons why the art should not be ignored by ophthalmology residents; allow me to try and persuade you.

Why should I still be drawing the retina?

First, you will need to be able to read old medical charts; some of which have only fundus drawings without text descriptions of the retina. No matter what form of ophthalmology you practice, you will need to read and interpret these intricate fundus photography. Second, many retina specialists suggest that taking time to produce a proper fundus drawing is the best way to coerce residents and ophthalmologists into a proper, complete retinal examination. Retina specialists in particular have been known to spend more time on a colored pencil drawing of the retina than on the retinal exam itself. Finally, if you are at all interested in a retina fellowship, there are few better ways to impress your old-school retina faculty than to produce great fundus drawings. So, with that in mind, here is a quick primer.

The Fundus Skeleton

A true retina drawing will contain three concentric circles. The first represents the equator, the second represents the ora serrata, and the third represents the pars plana. There should also be 12 tick marks indicating each clock hour of the retina. (See a great example here). 

A Work of Art

Next come the colors. A normal retina should have a red hue and most ophthalmologists will color in the entire first two circles (out to the ora serrata) with a light red color. The image on the left is representative of how to draw most common findings in the retina. Feel free to download and print this image, I have found it very useful. Let's break up the details by color.

Color Fundus Drawing

Click for full size [large] image file

Brown:

Any alteration in the choroidal pigment. Brown is usually reserved for a nevus or melanoma.

Black:

Any alterations in the retinal pigment including pigment mottling, lattice degeneration, dark retinal pigmentation (CHRPE), or laser scars.

Blue:

A sign of fluid, blue can represent veins, sub retinal fluid surrounding a retinal tear, retinal or macular edema, or a frank retinal detachment.

Red:

As previously stated, normal retina is red and most ophthalmologist paint the entire fundus with a light red color. Arteries are also red and any retinal neovascularization is red as well. A darker red is used inside of a blue outline to demonstrate retinal holes or tears. 

Green:

Anything in the pre-retinal space. This includes media opacities, vitreous hemorrhage, pre-retinal hemorrhage, pre-retinal gliosis, epi-retinal membrane.

Yellow:

Exudative processes including retinal exudation, drusen, retinal scars, emboli, choroidal neovascular membranes.

Good Luck!

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Tips for the USMLE Step 3

Categories:

Step 3

July 6, 2015

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Master the Boards Step 3

 

The USMLE Step 3 represents an interesting paradox in medical education: it is the board exam whose results are the least important, but whose content is the most important. Maybe we medical students and medical educators have our priorities backwards? Here we have an exam that determines if you can competently diagnose and treat patients, and it is an afterthought when compared to an exam that tests whether or not we can memorize with perfection the Kreb's cycle. Does anyone else see a problem here? The truth is, you can not completely blow off Step 3 or you are in for trouble. Here are a few pointers on how to prepare for the exam

 Scheduling

Ideally, everyone should take Step 3 in the second half of intern year. This will give you ample time to hone your inpatient hospital skills, something that will be critical for the new Computer-based Case Simulations (CSS), but not too much time to forget everything you learned in medical school and internship. Too often I meet specialists who are taking Step 3 at the end of their residency. There is nothing about a 5 year orthopedics residency (or any other residency) that will prepare you better for Step 3. To put off the exam for many years of residency will leave you unprepared and you will have lived with a weight over your head unnecessarily. 

Remember, USMLE Step 3 is written specifically for the broad training culminating at the end of your internship. Technically, after your internship, if you pass Step 3, you can be licensed to practice medicine in the United States. Do whatever you can to get the test done during your internship.

Studying

You are going to be busy as an intern. If you have free time, you will want to sleep or relax; the last thing you will want to do is study for another board exam. You will not need much time to prepare for this exam, but you cannot completely blow it off. You need to find a way to reject the old saying, "two months for Step 1, two weeks for Step 2, two pencils for Step 3". If you think this way you are likely to waste your time and money. Let me illustrate two reasons why you should consider a small amount of studying: 

  1. Most of you will focus either on children or adults during internship. You must be prepared to answer difficult questions about all age ranges on Step 3. If you are out of practice in pediatrics, study up.
  2. Very few of you will take care of OB/GYN patients during your internship. This is something else you will need to study
  3. The CSS is unique and has many quirks that you have not experienced yet. You MUST take the time to familiarize yourself with the format and how to succeed. If you do not prepare for this strange new testing format, you could make some logical choices during your exam that will not count. You simply need to spend a couple of days learning about the test itself and taking some of the CSS practice questions through the ACGME website. There is a great review of the CSS format and some of its nuances here. 

Questions

As I have said before about other USMLE board exams, there is no substitute for a great question bank. Both Kaplan and USMLE World have great Q-banks, though I tend to prefer USMLE World. If you spend a solid week or two on questions, you will be more than ready.

Books

I think that one or two good review books can help a lot. The main goal of a review book will be to re-familiarize yourself with the specialties that you have not thought about in two years (pediatrics vs. adults, medicine vs. surgery, OB/GYN vs. everything else). Below is a list of books that I found useful. Again, you probably only need one or two of these.  

  • Updated June 2015

1. First Aid for Step 3:

I am a sucker for the First Aid series. Even for Step 3 I think they produce a fantastic review book. You should know, there are many residents who prefer the two books below (or others) to the First Aid for Step 3 book. What draws me to this book is that it contains a brief review of all required specialties and a great review of the CSS format with great CSS practice questions all in the same book.

 

2. Master the Boards USMLE Step 3:

I have always been impressed with review books written by Conrad Fischer, the author of this book. Master the Boards for USMLE Step 3 is no different, it is a great review of the entire exam. I also highly recommend this book.

3. Crush Step 3:

Many residents swear by the Crush series for Step 3. One downside is that they seem to be branching into two separate books, the main Crush Step 3 book for the clinical content, and the new Crush Step 3 CCS book as a primer on the CCS question system. So, you might end up buying two book if you go with this brand, but I have never met someone who regretted studying from Crush Step 3. 

 

 
 
 

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Interview: The in’s and out’s of radiation oncology

Categories:

Radiation Oncology

July 6, 2015

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radiation oncology

 

A Radiation Oncology Attending's Perspective: From an interview with a radiation oncology attending.

Part of an interview series entitled, "Specialty Spotlights", which asks medical students' most burning questions to physicians of every specialty.  See what doctors from every specialty had to say about why they chose their specialty and how to match in their residency.

 

  • What attracted you to radiation oncology?

I realized that a radiation oncologist has a unique opportunity to serve as a physician for patients at a very difficult time, and I appreciated the emphasis on shared decision making and communication skill by my mentors in the field. I also enjoyed the emphasis on anatomy and imaging.

 

  • Describe a radiation oncologist's typical work day?

I typically arrive at around 7am when treatment begins for the day. Most of a radiation oncologist’s work is in an outpatient clinic. The day is spent seeing new consultations, follow-up visits, and evaluating patients who are currently under treatment. When you aren’t seeing patients, your time is usually spent creating individualized radiation treatment plans for new patients, which includes doing a CT simulation, contouring, and planning with a dosimetrist and physicist.

 

  • What type of lifestyle can a radiation oncologist expect?  

Nearly all of a radiation oncologist’s work is in an outpatient setting, which means that nights, weekends, and holidays are usually free. This is one of the more attractive features of the specialty.

 

  • What is the potential salary of a radiation oncologist?

The average salary varies significantly between academic settings and private practice. There is a wide variety of compensation agreements depending on each unique situation.

 

  • What is the job market like for radiation oncology?

Radiation Oncology is a very small field. For example, in some less populous regions, an entire state might have around 16 radiation oncologists. Because of that, it can be challenging to find a job in a specific geographic region. If it is essential for you to live in a certain region, be aware that it might be difficult to make that happen, and that you might have to accept significant compromises to get a job in a given area. This is one of the drawbacks of radiation oncology. If geography and flexible location are important to you, other larger specialties might make for an easier job search (e.g. internal medicine, anesthesiology, etc).

 

  • What can you tell us about radiation oncology subspecialties?

Most radiation oncologists complete their training after the 5 year residency without doing a fellowship. A fellowship can sometimes help to bolster academic credentials if needed or be used as a segue into a job at a desirable institution. Common fellowships include pediatric radiation oncology and proton therapy.

 

  • What are the potential downsides of radiation oncology that students should be aware of?

If you have academic aspirations, it can be difficult to find protected time as a radiation oncologist. Geographic limitations are an important consideration (see above).

 

  • How competitive is the radiation oncology match?

Very. Radiation Oncology attracts students with great boards scores, strong letters of recommendation from mentors, and ample research experience.

 

  • What must a student do to match well in radiation oncology?

Students must obtain great board scores, demonstrate research productivity, and produce strong letters of support from mentors who know you well.

 

  • What are residencies looking for in a radiation oncology resident?

Strong credentials will open the door for an interview. Beyond that, programs are looking for someone who can carry on a normal conversation and has a pleasant personality.

 

  • What should students be looking for in a radiation oncology residency?

It can be interesting to look at where graduates end up after residency. There is a wide variety in the quality of didactics, with most radiation biology and physics courses being something that you just have to endure no matter where you match.

 

  • What else would you tell medical students who are considering radiation oncology?

While radiation oncology offers a desirable schedule and good compensation, it is important to go into the field for the right reasons. Keep in mind that as a radiation oncologist, you will be taking care of patients who are very ill, and are often approaching the end of life. To be successful, you will need to develop the skill of navigating these sensitive discussions with agility, and sometimes it can be emotionally exhausting. At the same time, helping patients and their families work through these scenarios is very meaningful and fulfilling work.

 

Editor's Note: For more help choosing a specialty in medicine, I highly recommend one or both of these two great books. I found both very useful.

 

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Best Books for USMLE Step 2 Clinical Skills (CS)

Categories:

Fourth Year, Books, Step 2

July 6, 2015

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This list is part of a series of articles about the best books for medical students. Click on the Med School Books Main Page to see other lists including the best books for each year in medical school, the best books for each clinical rotation, and the best books for USMLE Steps 1, 2, and 3.

As many of you know, the pass rate for USMLE Step 2 CS is very high, usually 97% or 98% for first-time test takers from the USA. Many will take that to mean that they don't need to study, but I think it means something slightly different. Here is a 2% that you really don't want to be part of! Studying for Step 2 CS is really not difficult, you already know the material, you just have to learn about the test. I don't think you need to spend much time studying, but reading one or two review books will prepare you in three ways 

  1. what the test will be like,
  2. what you will be tested on (it's NOT just the medical content!)
  3. a review of the most commonly tested cases. 

I will list the two most widely used books and highlight some subtle differences. You really only need one of these. Good Luck.

  • Updated June 2015

1. First Aid for Step 2 CS:

This book will prepare you for what to expect in the testing center. I felt much more comfortable just know what was going to happen, step by step, after reading this book.I think this is the strength of this book, it lays out the nature of the exam very well. There is also a good review of some of the highest yield cases you might encounter during the clinical skills test. This book prepares students very well for the Integrated Clinical Encounter (ICE) portion of the exam. For most people, reading through this book one time would be sufficient prior to taking the USMLE Step 2 CS.

 

2. Kaplan USMLE Step 2 CS Core Cases:

Like the First Aid book, Kaplan's USMLE Step 2 CS book is a great resource and one quick read through it would be sufficient for most students. The one thing that Kaplan's book has is a better explanation of how to act during the exam so you can maximize Communication and Interpretation Skills (CIS) portion of the exam. Browse the format of each book, you probably just need to choose one.

 
 
 

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When should I schedule USMLE Step 2?

Categories:

Fourth Year, Step 2, The Match

July 2, 2015

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Calendar

One of the important questions all medical students have to answer in their fourth year of medical school is when to take the USMLE Step 2 exams. The answer to this question depends on each student's individual circumstances. Let me list a few pointers that might help you in making your decision. At the onset let me state that I do not know of a good reason to not release your scores to residency programs. Everyone should release scores, to do otherwise suggests you are hiding something. If you don't want your scores to be known by potential residencies, you simply need to schedule the test after your information is sent to programs, this is a much better alternative. 

After you have decided on a time to take the test, check out my list of the best resources to study for Step 2 CK.

  • The only nationwide deadline facing medical students is that prior to obtaining a license and starting internships and residencies, students will have to pass the USMLE Step 1, Step 2 CK, and Step 2 CS. So all medical students will have to pass these exams before July 1st after their fourth year. However, most medical schools have their own deadlines. If your school requires both Step 2 exams to be done before January 1st of your fourth year, you need to plan accordingly.
  • The next question you must answer is whether or not you need your Step 2 CK score to be available when you are applying for residency. There are two situations where this might be the case. If you are applying to a competitive residency and your Step 1 score is not impressive, most people recommend doing everything you can to obtain a great Step 2 CK score to send to residency programs. Alternatively, no matter what residency you are applying to, if your Step 1 score is below the national average (usually ~218 or below), most people recommend sending a Step 2 CK score to potential residency programs so they know you have passed the boards and will be eligible to start residency on time. If you fit into either of these situations, you should take Step 2 CK before the end of September in order to have the score available during residency application.
  • If you have a deadline from your school but you do not need to send a Step 2 CK score report to your potential residency programs, there are still some scheduling conflicts to consider. Students applying to early match residencies or other competitive residencies will spend most of the months of November and December interviewing. Available interview dates in these situations are usually sparse and difficult to manage. The last thing you want is to miss the only available interview date at a top choice residency because you have Step 2 CK or Step 2 CS scheduled the same day. If you can move your Step 2 dates earlier or later, I would recommend doing that. If you have a January 1st deadline like many schools but will be interviewing in November/December, consider taking your Step 2 exams in the September/October time period.
  • It is important to remember that Step 2 CS is not a very important exam for most fourth year medical students. The vast majority of students pass the exam and there is no numeric score released to students and residency programs. Therefore, it is in your best interest to simply schedule this exam when it interferes the least with your interviewing and clinical rotations.
  • If you are trying to cram your Step 2 CS or Step 2 CK in December before a deadline, beware of unpredictable winter weather. I have known a number of students who missed clinical duties or interviews as they were stuck in the airport after the Step 2 CS exam. Many of you will be traveling to cities prone to snowfall (Chicago, Philadelphia), so bear that in mind when scheduling.

If you have any other advice for the four year students reading this, please post below. Good luck to everyone and don't forget to check out my list of the best books for Step 2. 

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