In english, please

So here’s the update- after the ECFMG declared paper war on me, I won an important battle (yes!) Unfortunately, my application is still being “processed”, which means I can’t schedule an exam date yet! Ahhhhh! I thought I could take the stupid thing by now. I figured I want to take it mid-September, latest (and avoid my birthday if at all possible, because no amount of chocolate could make up for that kind of misery). The stupid website says it could take up to 3 weeks to process- which would be Sept 10th, the exact day my UW subscription runs out… and cash is running low… The only good news is that with all of these stupid paperwork-related delays, my eligibility period is automatically extended to november. Neat. How many times did I write the word “stupid” above?

Anyway, as I still don’t know when my oral exam date is, I can’t schedule the USMLE 2 for after the written HEX. I really don’t want to do that anyway, I think it would feel really nice to have all of the written stuff over with. However, if I’m not sure if I even can take it before the HEX, it’s not worth me spending $45 to take another NMBE to see where I stand!?

This is really frustrating. I think I will take a practice HEX tomorrow- then I will know what topics are weak that I will then try to review with internal medicine in the next few weeks. Hopefully I will be able to schedule soon- as soon as I find out I’ll take the NMBE practice test to see if I would probably surely pass- then I will just schedule it as soon as possible!

I am slowly become more emotionally labile, sugar- and coffee-addicted and ridiculous in general (the other day the phone rang while I was doing practice questions and I stared at the receiver for a good 20 seconds trying to figure out what I was supposed to do… press the “ON” button, duh!)

<sigh>

It seems that “counseling” your patient is an American buzzword. I have rarely come across the same emphasis in Germany. In the States it is felt that giving your patient advice- especially on certain key topics- is not only important but mandatory. In fact, some USMLE questions (as I assess from the USMLE study tools such as Uworld and First Aid) ask you what the “appropriate response” in certain situations is- and they often involve counseling.

What do I mean? For example, I recently came across questions about sun protection (sun lotion vs. clothing, especially pertaining to fair-skinned children). By far the most important topic for counseling is to QUIT SMOKING. In fact, you will lose points (according to the FA for the step 2 CS) if you don’t “counsel the patient about smoking cessation” in a patient encounter for the oral exam.

I have to say that my experiences in the US and Europe differed significantly in this respect. I regularly encountered doctors who actively and consistently asked their patients to stop smoking. When I talked to a patient in Germany about quitting, a doctor STOPPED ME and said he likes to smoke too, I shouldn’t “stress the patient out”. Hmmm. I thought that was maximally uncool. I think the problem is that smoking is “cooler” here in Europe. It is just as much of a health hazard, though, especially for COPD patients. One doc once asked his patient when the last cigarette was and explained to me later how important it is psychologically for the patient to know when his last cig was.

On a rotation in an E.R. in the States, a physician had to examine the genital area of a young boy (in the presence of his parents). The doctor explained that he was allowed to touch the boy there because he was a doctor and because his parents knew about it and reminded the boy that otherwise, adults shouldn’t do that. I have to say I was impressed!

It takes time, time we don’t have, it often falls on deaf ears, I know that, but take time to counsel- it CAN make a difference!

Oh dermatology. Not really my thing- I’m not going to lie. But I made an effort and have been doing pretty well on practice questions. Luckily, most of the basic vocabulary in derm is the same in English (macules, papules) but there are some disorders that have slightly different names, and there are a few types of pathogenic molds that occur in the U.S. and not in Europe (though they are more relevant for pulmonary, I will mention the one here). So here’s an ecletic collection of important dermatology terms common in English derm textbooks:

-Ludwig’s angina – bilateral submaxillary/sublingual cellulitis, usually due to a tooth infection. Symptoms =fever, dysphagia, drooling and erythema of the larynx.

-Comedos are most commonly referred to as “blackheads” in everyday language!

-”Yeast” infections are candida infections (usually referring to vaginal infection)

-The ABCDEs of melanoma (because they are so important): Asymmetric, Border (irregular), Color, Diameter (>6mm), Evolution (change/new)

-Blastomycosis: a fungal infection (Blastomyces dermatitidis) endemic to N. America (esp. central USA) that causes infections involving lungs, bones, joints, prostate and *skin: verrucuous, violet lesions. Treat with itrakonazole

-Sporotrichosis (“rose gardener’s disease”): a fungal infection with Sporothrix schenckii that most often occurs after minor trauma from a rose thorn, it starts as a small, painless, pinkish lesion that progresses to a boil, and ultimately to an ulcer if left untreated, treat with itrakonazole (alternative: potassium iodide solution)

-Herpetic whitlow: HSV-1/-2 infection of the hands often found in health workers who have continuous exposure to oral mucosa (dentists!), present as small, painful vesicles, often surrounding the nail bed, usually self-limiting, otherwise topical acyclovir

-My favorite way to remember the key diagnostic test for herpes infections? “Tzank heavens that I don’t have herpes!” (Feel free to laugh out loud)

Whereas I had trouble falling asleep in July, I have turned into a narcoleptic in August. I am so exhausted and I can’t get out of bed! Motivation = 0.  I guess I’m a little overwhelmed because I started reviewing internal medicine on top of the regular study schedule- it’s just too much!

Like now I’m doing pharmacology (few subjects can make me so aggressive). The especially annoying part is that guidelines change (though the Examen Online is pretty good about mentioning that) and a lot of drugs have different names in the States…

My studying for the USMLE has been tough anyway. I thought there would be more in common. While I do feel that there are synergistic effects from doing both German and American questions, it is demotivating to realize how long I’ve been out of the American system. There are so many little details I just don’t know because I have only done a few rotations in the States. My percentages on the USMLEworld question bank aren’t getting any better, either! Many claim this is normal, but I am starting to get panicky. Maybe I should reassess with an NMBE.

Ugh… it’s Friday. I would so much rather curl up with a book and my dog on the couch or go for a run! Well, I guess I need breaks anyway… it’s like I’m reasoning with my inner 6-year-old child. Tomorrow is officially a “study day” for me, but I’ll keep it light but just reviewing the stuff I wrote down that I didn’t know from questions.

T.G.I.F.!

I was able to review Uro in 1 day- some topics were pretty easy, some were pretty intense! Here are my fav acronyms for urology:

-”Can’t see, can’t pee, can’t climb a tree” – to remember the triad of symptom’s in Reiter’s disease = uveitis, urethritis, arthritis

-”Point and Shoot” – the Parasympathetic nervous system regulates erections, the Sympathetic nervous system regulates ejaculation

-DD for hematuria: S2I3T3 = Strictures, Stones, Infarction, Inflammation, Infection, Trauma, Tumor, Tuberculosis

And the most common abbreviations:

-BPH = benign prostatic hyperplasia

-DRE = digital rectal examination

-ED = erectile dysfunction

-UTI = urinary tract infection

-VCUG = voiding cystourethrogram (to diagnose vesicoureteral reflux)

-ESRD = end stage renal disease

-TMP-SMX = trimethoprim-sulfamethoxazole

I had to pee at least once an hour while working on Uro- how ironic! Am I the only one that happens to?

Obstetrics is filled with fun acronyms! Some are useful to remember important diseases- some are just part of the “lingo”:

-FHR (fetal heart rate), NST (nonstress test), CST (contraction stress test), Quad-test (AFP, estriol, beta-HCG, inhibin A** all four are low in Trisomy 18, AFP/estriol are low and beta-HCG/inhibin A are elevated in Trisomy 21), IUGR (intrauterina growth restriction), SGA (small for gestational age), GTD (gestational trophoblastic disease), STD (sexually transmitted disease), ROM (rupture of membranes), PROM (premature rupture of membranes), UTI (urinary tract infection), UA (urinalysis), GBS (group B Streptococcus)

-The HyPE about preeclampsia  = Hypertension, Proteinuria, Edema

-HELLP syndrome = Hemolysis, Elevated Liver enzymes, Low Platelets

-ToRCHeS common congenital infections = Toxoplasmosis, Rubella, CMV, HSV/HIV, Syphilis

-The symptoms that PAVE the way for diagnosis of ectopic pregnancy = Pain, Amenorrhea, Vaginal bleeding, Ectopic pregnancy

-How to be a HELPER in case of shoulder dystocia: Help reposition, Episiotomy, Leg elevation (McRobert’s), Pressure (suprapubic), Enter the vagina and attempt rotation (Wood’s), Reach for the baby’s arm

- The 7 Ws of postpartum fever (one of my favorites, very similar to the causes of post-op fever) = Womb (infection), Weaning (mastitis), Wind (pneumonia), Water (UTI), Walk (DVT), Wound, Wonder drugs

-And finally, one random fact I forgot in part I – it comes up a lot, “fibroids” are uterine leiomyomas (not some made-up disease, but most women aren’t familiar with the term leiomyoma)

Let’s first go over the vocabulary for the gynecological review of symptoms:

-Abnormal vaginal bleeding (how often are your periods*? how long do they last? how many tampons/pads do you use each day? do you have bleeding between your periods? are they any clots of blood?)

-Dysmenorrhea (how long have you had pain during menstruation/have there been any recent changes? what do you take for it? = self treatment regimens such as OTC or over-the-counter pain meds, heating pads, etc.)

-Masses/lesions (have you noticed any sores or bumps? if you suspect VD = veneral disease – ask: have you had unprotected intercourse? for the breasts- ask about self-examination: how often, what time in the cycle, any changes, etc. **however, this practice is no longer recommended!**)

-Vaginal discharge (any changes? is there an odor? what does it look like? any pain on urination?)

-Dyspareunia (this can be a hard topic to broach as this symptom most often has no underlying pathology- maybe start with an open-ended question like: what is going on in your life right now?)

-Abdominal pain (is it related to your cycles? urination? bowel movements? any history of VD?)

-Urinary symptoms (pain on urination? for younger kids “when you pee”? to inquire about incontinence: do you lose your urine when coughing? laughing? straining? do you have to press to void? = empty the bladder, do you have to wear a pantyliner for leakage?)

-Catamenia = menstrual history (age at menarche, cycle length, flow length) including current LMP = last menstrual period

-Obstetric history: Gravida = nr. of pregnancies, parity = nr. of deliveries: F-P-A-L (fullterm, premature, abortions/miscarriage, living)

The “lingo” is so important in this area – many women are embarrassed to talk about these things or might use slang. It’s important to understand certain terms and to know which terms are appropriate/professional. For example, when you begin the exam you should tell the patient to “relax” her legs or “let them drop to the sides” whereas “spread your legs” is completely inappropriate!

*Some patients say they are “on” their period rather than “having it”. Some people say “I fell off the roof” or “I’m raggin’ ” (though it’s more slang). I once heard a doctor ask a patient with a strong Southern accent “how’s your flow?” and she said “carpet, why?”

Psych is another one of those subjects for which a comprehensive understanding of the language- including idioms, cultural references, slang, moral norms, and word choice nuances- is essential. You can use common sense, a medical dictionary, and some good mnemonics to get through the psych part of the USMLE – but I think you would need to spend a year or two in America to start to understand the culture to become a psychiatrist.

First- for the exam:  there are a lot of questions on the USMLE that ask “what is the appropriate response”- i.e. they want you to choose the sentence that you should say as the doctor in that very situation. That sort of thing doesn’t come up in the German exam. There is a high emphasis on maintaining professionality and you mostly need common sense for those questions. A few are about whether minors can have an abortion or take the pill- which are more about medicolegal issues that psych issues- but those rules are easy to learn.

2 great mnemonics for 2 important disease complexes: depression and mania:

Depression: SIG E CAPS = Sleep (hypersomnia or insomnia), Interest (loss of interests), Guilt, Energy decrease, Concentration decrease, Appetite (up or down), Psychomotor agitation/retardation, Suicidal ideation* (this term refers to concrete plans for a suicide) (diagnosis is made with at least 5 of the above symptoms plus a depressed mood for at least 2 weeks)

Mania: DIG FAST = Distractibility, Insomnia, Gardiosity, Flight of ideas, Activities/Agitation, Sexual indiscretions, Talkativeness (three symptoms plus an elevated or irritable mood for at least one week suffice for diagnosis)

Lastly, 2 drugs that you need to know if you go to the States (not just for a rotation- but also for party chitchat and jokes):

-Xanax (Alprazolam)

-Prozac (Fluoxetine)

Neurology is one of the most complex subjects – and a subject helpful for just about any branch of medicine you go into! There’s no shortcut for sitting down and learning all of the pathways and terminology- but I will let you in on my secret: acronyms! There are so many in English and they help me a lot! So forgive the random nature of the following, but here are some of my favorites!

-Cranial nerves: In order to remember the cranial nerves, there are several funny and/or “R-rated” sayings (no need for me to post, just google them…) But there is a “harmless” saying that helps you remember whether tehy are “sensory”, “motor” or “both”:

Some Say Marry Money But My Brother Says Big Brains Matter Most

**Very important! English doesn’t distinguish between “sensibel” and “sensorisch” – both are described as “sensory”!!!

-STROKE:

The deadly D’s of posterior strokes = Diplopia, Dizziness, Dysphagia, Dysarthria

Noninfluenceable Risk Factors: FAME = Family history, Age (>60), Male, Ethnicity (African-American, Hispanic, Asian)

Contraindications to Lysis: SAMPLE STAGES = Stroke/head trauma (3 months), Anticoagulation, MI (recent), Prior intracranial hemorrhage, Low platelets (<100,000), Elevated BP (>180/110), Surgery (2 weeks), TIA, Age (<18, very old with many comorbidities), GI bleed/ulcer (21 days), Elevated glucose (>400 mg/dL also very low <50), Seizures (current)

-NPH = normal pressure hydrocephalus = The 3 W’s: Wet (incontinent), Wacky (dementia, personality changes), Wobbly (ataxia)

-Guillain-Barré-Syndrome: The 5 A’s = Acute inflammatory demyelinating polyradiculopathy, Ascending paralysis, Autonomic neuropathy, Arrhythmias, Albuminocytologic dissociation

-Status epilepticus Treatment: “First ABCs, Then Begin Giving Naloxone” = Fosphenytoin, ABCs (airway-breathing-circulation), Thiamine, Benzodiazepines, Glucose, Naloxone

-Differential Diagnoses for Dementias (although I think this is a good one to remember for all pathologies!): DEMENTIAS = neuroDegenerative, Endocrine, Metabolic, Exogenous, Neoplasm, Trauma, Infection, Affective dissorders, Stroke/Structural

Last week I decided I needed a break from studying alone all day, reading every morning, getting lunch from the grocery store down the street, doing practice questions in the afternoon, taking  breaks to run and/or read… Same thing every day! My dog was even getting bored (even though I talk to her A LOT). So I decided to meet up with a friend. Our plan was to review some tough topics with each other, we each chose a topic to prepare, and then do cases (which would be good practice for the oral exam, even though it’s early) and then maybe do some practice questions together. We had studied together occasionally for exams before, so I thought things would go really well.

Honestly, I ended up being really frustrated! We both seem to have expected to get more done- somehow we held each other back. Instead of building each other up- it felt like we were dragging each other down. The one problem is that it is frustrating to do cases. I think it’s really important, because you realize how many things you have just memorized and just recognize associations instead of really understanding the material and being able to organize it and explain it yourself. That can be a depressing realization. It also made me think back to a seminar I had in high school about studying effectively. I remember the speaker saying how you have to be honest to yourself and learn how to test what you really know. He said most people only study what they already know- it makes them feel better.

So I ended up getting behind on my study schedule- but I learned a few things that I didn’t expect to. Group study is just very different. It will help me for the oral exam, but I need to have the freedom to organize my own time for the written part. I need to change my daily routine so that I don’t get bored- I’m more effective when I vary things (just the change from last week motivated me to do more and better this week). Finally, I need to check myself when I’m reading and practicing questions and make sure I really understand the material- I will imagine someone is asking me about the topic.

Enough stress for now- time to relax and enjoy the evening!