Category Archive: Third Year

Spotlight Interview: Why did you choose psychiatry?

A Psychiatry Resident’s Perspective: From an interview with a psychiatry resident at UC Irvine in Irvine, California

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 Psychiatry?

I like the idea of working with the whole person. I feel like in psychiatry you address a person’s social, financial, and relationship concerns, which in my mind are the most important part of life.

 

  • Describe a Psychiatrist’s typical work day?

There are different fields in psychiatry, but what I’m interested in is private practice. I’ll probably end up splitting my days between therapy and medication management appointments. Therapy appointments usually go an hour, med management about 15-20 minutes. In those visits the person already has a therapist but consults a psychiatrist for medications.

You can also work in an inpatient setting in a hospital, work for the prison system, do telemedicine (something else I’m interested in), work with children, geriatrics, forensic, or almost anything else you want. I like the variety of the specialty.

 

  • What type of lifestyle can a Psychiatrist expect?  

Psychiatry has the big advantage of being a less demanding specialty. Depending on your working situation, you might be on call once a week or so. Even the psychiatry residency usually has weekends off! Most private practice psychiatrists work around 30 hours per week.

 

  • What is the average salary of a Psychiatrist?

Again depends on your situation, but you’ll see something like $200,000 as an average. In California, psychiatrists generally take cash only and charge around $300 an hour.

 

  • What is the job market like for Psychiatrist?

There’s a big need for psychiatrists. In particular, child psychiatry needs more people.

 

  • What can you tell us about Psychiatry Sub-specialties?

Child psychiatry: 2 extra years after residency (but you can eliminate your 4th year of adult and make it 5 years total for adult and child). There is more demand for this field. The salary is generally higher. The lifestyle is about the same for this and all the others.

Forensic psychiatry: 1 extra year. Harder to get a footing in this one, but pays very well once you do ($1000 per hour for testifying in court). Custody hearings can be part of this specialty.

Geriatric psychiatry: 1 year. Not too sure about the job market. I imagine it’s in high demand. Probably similar salary to adult.

 

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

It definitely takes a certain personality to do the job and do it well. You need to be able to separate yourself from some of the sad stories you’ll come across. You also need to be able to set boundaries well with people.

 

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

It’s a great job and something to definitely consider. Some people say there’s not much medicine involved, which is as true as you make it. You can definitely go a more therapy-centered route if you prefer. But, if you love the medicine and research side, there’s plenty of opportunity for that as well. The brain isn’t very well understood.

 

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.

 

Top Ten Books for Third Year Medical Students

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. 

Choosing a top ten list for the third year of medical school was a lesson for me in biting off more than one can chew. I will soon be compiling top ten lists for each of the core rotations in medical school, which will be a more manageable list. However, there are common themes during this very important year of training, and you will be testing the waters of many potential future specialties. I think these books will help with these endevours. 

  • Updated April 2015

1. First Aid for the Wards:

Beginning the third year of medical school is a daunting task. I shook like a little kid the first time I had to present on rounds. In retrospect, I wish I had read this book before I ever started third year. It provides great advice about prerounding, rounding, presenting patients, and working with your clinical team. It also gives rotation specific advice for each of the main third year clinical clerkships.

2. Pocket Medicine:

I consider pocket medicine a must-have for all students and residents. I used it during medical school and am still using it in residency. It highlights all the most common clinical illnesses and presentations. For each illness it describes the clinical presentation, signs and symptoms, diagnostic tools, and treatment plan.

3. Maxwell Quick Medical Reference:

A small book with a big role. Nearly every medical student I know carries this book in their white coat. It contains clinical pearls and references that are very high yield. Additionally, it contains sample notes (progress, transfer, procedure, admission, etc).  It is about the best $10 you can spend.

4. Case Files:

The Case Files Series (Amazon link) is my favorite clerkship study series. Similar to the Pretest Series (#5) and the Blueprint Series (#6), Case Files publishes one book for each medical student clerkship. The book teaches principles through a series of 50-60 cases.  After each case is presented, the relevant clinical teaching points are discussed and followed with a series of questions. For my style of learning, this was the ultimate study tool during third year. I particularly recommend Case Files Neurology and Case Files Family Medicine. .

5. PreTest:

Another series of books for each medical student rotation, the PreTest Series (Amazon Link) are simply question banks in print form. Their questions are very good and hit on relevant material. Although I prefer USMLEworld as a straight question bank tool, the Pretest books allow you to always have questions at your side for bus rides, downtime at the hospital, etc. Along with many medical students, I particularly recommend PreTest Pediatrics, which was eerily similar to the shelf exam.

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6. BluePrints:

The BluePrints Series is a third series with one book for each medical school clerkship. Unlike the case-based presentation of Case Files and the q-bank format of PreTest, the Blueprints series are more like textbooks. They aim to teach the most pertinent clinical facts without becoming too dense. Each book is about 300 pages and contains a wealth of information…if you can get through it. Blueprints Obstetrics and Gynecology is widely considered the most useful; I used it and did very well on the shelf.

7. Surgical Recall:

If you are interested in surgery or just interested in obtaining a good grade in your surgery rotation, you need to know what is going on in the OR. Surgical Recall provides step-by-step details of surgical procedures including surgical indications, pre-operative management, intra-operative management including a walk-through of the surgery, and post-op management. It will really help you shine in the OR.

8. First Aid for the USMLE Step 2 CK:

Yes, you will probably find a 'First Aid' book in each of my Top Ten book lists. This is because I have found them to be the best tool at solidifying the most important points of each phase of medical school. During third year the First Aid for Step 2 CK (Clinical Knowledge) was a great way to make sure I knew the most important facts. It is certainly not sufficient to study alone.

9. Dr. Pestana's Surgery Notes:

Dr. Pestana's notes are an absolutely necessary resource for students on the Surgery rotation. The notes provide real-world examples that combine pathophysiology with surgical patients. Complications, surgical decision making, and post-operative care are all addressed. I was shocked at how high yield these notes were when I took the shelf exam.

10. Step-Up to Medicine:

You will also find this book at the top of my list for the the internal medicine rotation. However, it is so good that I thought I should mention it here too. The book comes highly recommended by nearly every student that has ever used it. It will give you a great base to study from and find out what you need to study more.

 
Honorable Mention:
  1. I can not create a list of study tools for third year medical students without mentioning USMLEworld.  After using many Q-banks, many question books, and other resources, I have concluded that USMLEworld provides questions most consistently similar to the real shelf exams and boards as well as provided the clearest explanations.
  2. Success on the Wards: 250 Rules for Clerkship Success is a highly rated book for third year students
  3. 250 Biggest Mistakes 3rd Year Medical Students Make and How to Avoid Them is written as the same authors as "Success on the Wards" and also comes highly recommended.
  4. The Ultimate Guide to Choosing a Medical Specialty. Really, this books should be in the Top Ten.  I left it off because it is not specifically for third year medical students. However, it is one of the best resources available for deciding what is important to you in a specialty, and comparing variables across all medical specialties. I highly recommend it.
 
 
 

Is the Patient’s Device Safe for MRI?

MRIsatety.com is a great resource for medical students, residents, and all medical personnel.  We all know that when a patient has a pacemaker from 2004 that they can not get a thoracic MRI. However, what if the patient had a recent shoulder replacement? What if the patient has a port for chemotherapy? What if the patient had recent spinal surgery? No matter what the circumstance, you can search this website for the patient’s device and find out if it is safe for an MRI.

The main website is…
http://www.mrisafety.com

Or, the searchable list of implantable devices can be found directly at…
http://www.mrisafety.com/list_search.asp

The list of all searchable products includes:

  • Pumps
  • Aneurysm clips
  • Bone and Nerve stimulators
  • Cardiac Pacemakers and AICDs (defibrillators)
  • Breast and other soft tissue implants
  • Coils, Filters, Stents, Grafts
  • Dental Implants and Devices
  • Catheters
  • Clips
  • Foreign Bodies
  • Ocular Implants, lens
  • Sutures
  • Etc.

 

Spotlight Interview: Why Did You Choose Neurology?


 

A Neurology Attending's Perspective: From an interview with a neurology attending at the University of Michigan, in Ann Arbor

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 neurology?

The subject matter was, and still remains, the most interesting part of medicine to me.  I love figuring out where the problem is—the “localize the lesion” question that is the heart of neurology.  But perhaps the most important is that I enjoy the day-to-day interactions with patients:  the types of questions they have, the exams I have to do, the problems we have to deal with…  I saw what it was like in med school, and realized this was my favorite by far.

 

  • Describe a neurologist's typical work day?

A clinic day is 8-5, with fairly long visits for each patient.  I get 30 minutes for a follow up and 60 for a new.  Most of the visit is getting the history.  In the hospital (teaching hospital with residents), rounds are usually mid-morning, consults in the afternoon.

 

  • What type of lifestyle can a neurologist expect?  

There are a few neurological emergencies, which are uncommon but usually end up going to an ICU right away.  You can pick a subspecialty that has minimal emergencies.  Most private jobs I see have call q 4-6.  However, call is usually from home, answering questions.  The biggest determinant of lifestyle is reimbursement.  If you have a billable procedure like EMG, botox, EEG, sleep studies, you can pay your salary quite easily and have a very relaxed schedule—probably 50 hours a week at most.  Without a procedure, much more time is necessary, as the visits can last a long time so you may have long clinic hours.  60 hours or so.  Call may be q4-6 but I rarely see attending neurologists in the hospital after 9 PM or before 7 AM.  Usually call is handled from home.

 

  • What is the potential salary of a neurologist?

A private neurologist will start at about $200-250K.  They will need some procedure (EEG, EMG, sleep studies, botox, etc) to be able to maintain that without a terrible clinic schedule.

 

  • What is the job market like for neurology?

I get advertisements for neurology positions all over the country, all the time.

 

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

Seeing patients in clinic takes longer than most specialties but bills the same, which can hurt the reimbursement a lot. Most neurologists need some sub-specialty training to get a procedure like EMG or EEG.  In a private hospital, you stand the risk of being consulted on every mental status change, which is rarely neurologic.  They are easy consults, but could make call very annoying.  Most neurologists just tell the consulting team to get a bunch of tests that night and then see the patient in the AM.

 

  • Every specialty has a reputation, how do you respond to the reputation of neurologists?

There are two.  The first reputation is that neuro cannot fix anything, only diagnose it.  This is now an archaic idea, since we now can treat almost every disease to some degree: we have acute stroke treatments (tPA), many MS treatments, and neurological diseases are one of the top areas of drug research in all companies.  The second is a reverse reputation (one that we notice ourselves about other physicians):  most physicians are terrified of Neurology, and would often much rather consult us than do a neuro exam.  This is a shame, and leads to some disappointing situations.  But it also generates a bit of an “outsider” image between us and all other specialties, somewhat similar to the disconnection between medicine and surgery.

 

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

If you like figuring out problems like a medical detective, and if you are a very observant person who likes little details,neurology should be at the top of your list.

 

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.

 

Pre-operative Clearance Checklist

A frequent question in the outpatient setting is whether or not a patient is optimized for surgery. There are a number of things that a physician must check in order to properly send a patient back to a surgeon with a gold star. I recently used the Johns Hopkins Internet Learning Center (HopkinsILC) to study the basic pre-operative evaluation and I highly recommend it (requires access from your school or hospital, many hospitals have access, ask your librarian).  There is a great review pdf available from HopkinsILC which details some of the highlights of the lesson.  Below I will summarize some points from the pdf. To learn more, you should ask for access to HopkinsILC, it is a great resource.

 

  1. If the patient has any active cardiac issues, surgery should be postponed.  This includes…
    1. Recent myocardial infarction (<30 days)
    2. Active cardiac disease (unstable angina or worse)
    3. An uncorrected arrhythmia
    4. Severe aortic stenosis

 

  1. The patient must be able to complete 4 or more ‘metabolic equivalents of task’ (METS).  This includes
    1. Climbing a flight of stairs
    2. Walk for 30 minutes
    3. Play tennis, bowling, or other more intense sports
    4. Able to vigorously clean a house (scrub floor, move furniture)

 

  1. There are a few medications that must be stopped prior to surgery. Some examples (not an exhaustive list) include…
    1. If the patient is on blood thinners (coumadin) or anti-platelet drugs (plavix, lovenox, etc) these may have to be stopped and the surgeon will have to be part of the discussion
    2. Diuretics, ACE-inhibitors, and ARBS are usually held
    3. Oral hypoglycemics are usually held for 1-2 days
    4. Insulin is usually decreased by 50%
    5. Sedatives are usually held

 

Again, here is the link to the pdf explaining the above points. And here is the link to the HopkinsILC website.

 

 

American College of Radiology: Appropriateness Criteria

Have you ever wondered what imaging test should be ordered for your patient? What radiologic test would be most beneficial in this situation? What imaging test should I order first? If a patient comes in with a painful knee, should I get an x-ray or go straight to MRI?  If a woman comes in with a non-tender breast mass should I get an ultrasound before the mammogram?  These are difficult questions; luckily The American College of Radiology (ACR) has our back! The ACR publishes a fantastic online resource they call the “Appropriateness Criteria” which details the best imaging tests for nearly every presentation.

http://www.acr.org/ac

They website allows the user to choose between a variety of organ systems (e.g. women’s health, urology, gastrointestinal).  In each organ system the user can then choose a specific complaint (e.g. breast mass, hematuria, dysphagia). For each complaint, the ACR then allows the user to choose what specific patient presentation is occuring (e.g. 35 year old woman with a new breast mass vs. 35 year old woman with a mass seen on mammogram vs. 70 year old woman with a new breast mass). In each circumstance, the ‘Appropriateness Criteria” explains what is the best radiologic test to help diagnose the patient’s problem.  They explain in detail the advantages and disadvantages of each test (MRI, CT scan, ultrasound, x-ray, etc) for each specific problem.

The criteria are updated every few years, the most recent data comes from 2009. One of the best parts about the ACR Appropriateness Criteria can be found at the end of each section. Not only do they make suggestions about which tests will be most useful in diagnosis, they also provide a literature review for EVERY SINGLE patient complaint which outlines what research and studies they are using when making their suggestions.

I HIGHLY RECOMMEND this website. In fact, there are few resources that I can recommend higher. I have used this many times and they intricacies and precision of the criteria still surprise me.  There is NO BETTER RESOURCE available to determine which imaging tests are indicated for a specific patient presentation.

 

EKG Basics PowerPoint

I recently started a rotation in cardiology. It has been nearly 2 years since I have worked on a heart service and I was looking for a quick refresher on EKGs. Luckily, I found a great powerpoint review on the Standford website. There are only 20 or so slides and they cover major topics such as: review of heart conduction system, EKG lead placement, determining the heart rate, and determining the QRS axis.  They review both the ‘quadrant’ approach to axis determination and the ‘equiphasic’ approach. If you are going to be starting a rotation in cardiology or if you just want to refresh yourself on EKG basics, I suggest you take a look.

You can click the link below to download the PowerPoint directly from this website or you can go to the Stanford website listed below.

EKG Basics – Long

http://medresidents.stanford.edu/TeachingMaterials/EKG%20Basics/EKG%20Basics%20-%20Long.ppt#34

Internet based paging system

howstuffworks.com

If you need to send numeric or text pages to medical students, residents, or attendings Telepage Web Pager is the best website. Most hospitals have a built in method to text page anyone with a hospital affiliation. However, this web based paging system allows you to page anything you want to any pager in the country.  Try it, it’s free!

http://www.telepagewebpager.us/

Procedure Notes: Central Venous Catheter (CVC) Placement

Central Venous Catheter (CVC, Central Line) Placement

Date: <____>
Time: <____>
Indication: Hemodynamic monitoring/Intravenous access
Resident: <____>
Attending: <____>

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a dependent position appropriate for central line placement based on the vein to be cannulated. The patient’s <right/left> < neck/shoulder/groin> was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the surrounding skin area. A triple lumen <9-French> Cordis catheter was introduced into the the <subclavian/internal jugular/common femoral vein> using the Seldinger technique <and under ultrasound guidance>. The catheter was threaded smoothly over the guide wire and appropriate blood return was obtained. Each lumen of the catheter was evacuated of air and flushed with sterile saline. The catheter was then sutured in place to the skin and a sterile dressing applied. Perfusion to the extremity distal to the point of catheter insertion was checked and found to be adequate. <Attending/Resident> was present for the entire procedure.

Estimated Blood Loss: <____>
The patient tolerated the procedure well and there were no complications.

Other procedure note examples:

Also, thank you to my two favorite websites for helping me write notes in the hospital:

Procedure Notes: Lumbar Puncture

Lumbar Puncture

Date: <____>
Time: <____>
Indication: Altered Mental Status
Resident: <____>
Attending: <____>

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in the <LEFT/RIGHT> lateral decubitus position in a semi-fetal position with help from the nursing staff. The area was cleansed and draped in usual sterile fashion. 1% lidocaine was used anesthetize the surrounding skin area. A <20-gauge 3.5-inch> spinal needle was placed in the <L3-L4/L4-L5> interspace. Clear cerebral spinal fluid was obtained and the opening pressure was noted to be <?cm>. Four tubes were filled with 4 mL of CSF. These were sent for the usual tests, including 1 tube to be held for further analysis if needed. <Attending/Resident> was present for the entire procedure

Estimated Blood Loss: <____>
The patient tolerated the procedure well and there were no complications.

Other procedure note examples:

Also, thank you to my two favorite websites for helping me write notes in the hospital:

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