Med Student

2nd year med student

[thedisagreeabledoctor]

3rd Year Struggles: How to Look Less Stupid than You Are

Dear rising MS3s,

Welcome to the big show - sorta.  Third year is this magical time where you are expected to know how to take care of real patients.  Rather than worrying about that, I am sure you are busy taking selfies with your white coat on and stethoscope around your neck while tweeting about how early you have to start getting up, #medschoolproblems.

This may come as a shock, but you are a clinical moron.  The sooner you accept that, the sooner we can move on to improving it.  I don’t care if you are coming off your 260 step 1 score, real patients don’t present with multiple choices.  All that score means is you are good at diagnosing and treating paragraphs of words, not people.  I am only saying this from experience.

When you start your first day on the wards you are going to realize you got pushed into the deep end of the pool, sans floaties.  Like someone truly drowning, you will be tempted to flail about, reaching out for anyone to save you.  Don’t.  No one has time to hold your hand, and you will quickly make people hate you if you constantly beg for advice/help/guidance, etc. 

Have no fear, I am going to give some tips to make the transition easier and help you look semi-competent.  Behold my list of life-saving resources for third year. 

1. Scut Sheets (http://www.medfools.com/downloads.php) - you will likely follow 1-5 patients while on the wards.  This sounds easy, but things move fast and you don’t want to be presenting old data on rounds.  Scut sheets allow you to organize your patient information in a way that is easily accessible and portable (iPads are great, but in my experience you can’t beat good old paper).  Further, the H&P sheets help to remind you of all of the things you need to examine/inquire about.  You don’t want to be the student who comes back to report on a patient with epigastric pain in whom you never examined the cardiopulmonary system.  Print a couple of each style to find one you like.

2. Stanford 25 (http://stanfordmedicine25.stanford.edu/index.html) - remember that time before step 1 studying, when you had to practice actually touching people?  That was called the physical exam, and you are expected to actually do that… on every patient… everyday.  Better refresh on it so you don’t look like a fool palpating the thyroid over the thyroid cartilage.  Go to the website, click “The 25″ button and see the 25 physical exam skills every student should know, along with detailed explanations.

3. MedCalc (http://medcalc.medserver.be)

Enough said.  Qx Calc is also worth downloading (http://www.qxmd.com/apps/calculate-by-qxmd).  

3. Journal Club (http://www.wikijournalclub.org/wiki/Main_Page) - I guarantee that during the year some jerk-off attending is going to ask you, “what is the best NOAC for atrial fibrillation?”  Obviously, like most, you will stutter because all you know to use in Afib is warfarin.  Then he or she will smile, knowing they have established their superiority, and tell you to look it up and do some sort of presentation.  Welcome to the best tool ever for such scenarios.  This wiki is run by a team of physicians who synthesize large trials into digestible snippets.  The app is well worth the money too. (The answer to the above question is apixaban, by the way, as determined by the ARISTOTLE trial; not that this scenario is based on a real event that occurred to me or anything). 

4. Smart Medicine (http://smartmedicine.acponline.org) - this app is amazing.  Seriously.  It is free to American College of Physician (ACP) members; and membership is free to students.  You should join just for this app.  This is much less cumbersome than UpToDate and will will make you shine when you present your assessment and plan (also, rumor is that DynaMed and ACP have teamed up to create an even more amazing tool that is coming out in August, also free to members).

5. Medscape (http://www.medscape.com) - this is an awesome resource that is free. Medscape is one of my go to apps for understanding disease pathophysiology.  Another feature, which most students don’t realize, is the articles on surgical procedures.  This is HUGE for your surgery clerkship.  You can read over the procedure, see relevant anatomy and know just enough to be one step ahead of this guy:

Plus you get updates on medical news, have access to practice questions, etc.  Get it, use it, love it.

6. Online Med Ed (https://onlinemeded.org) - aside from learning real medicine, third year is about preparation for the step 2 of the USMLE.  I advise finding a question bank and organized program to keep your studying on track throughout the year.  Enter God’s gift to med students.  This is one man and a mystical dry erase board that will make learning clinical medicine easier than cooking a Totino’s pizza.  And it is one of the few things cheaper than a Totino’s!   

So there you have it.  You now are better equipped for the coming onslaught of pimp questions.  My suffering is your gain.  Below I will list a few other apps I have used this year that were less important to my success.  Happy studying.

ASCVD Risk Estimator (http://tools.cardiosource.org/ASCVD-Risk-Estimator/) - I believe there is an app in the app store as well.

Anticoag Evaluator (http://www.acc.org/tools-and-practice-support/mobile-resources) - see the risk factors for coagulation

CDC vaccine schedules app (http://www.cdc.gov/vaccines/schedules/hcp/schedule-app.html)

Read by QxMD (https://www.readbyqxmd.com) - allows you to get medical articles directly to your phone using your institutional access.

Sensitivity and Specificity (http://lifeinthefastlane.com/techtool-thursday-055-sensitivity-and-specificity/) - link to the app and review 

Pap Guidelines (http://appcrawlr.com/ios/pap-guide) - a free version of the ASCCP app and a life saver while on Gyn. 

[docitaliana]

Don’t forget epocrates for looking up meds and doses!

Also… get a power brick for your phone.

[emt-rj]

Me watching nearly any medical show or movie: YOU. DON’T. SHOCK. ASYSTOLE.

(via emt-rj)

Also… “WHAT ARE THOSE COMPRESSIONS?? ARE THEY EVEN TRYING??”

(via part-timemedstudent)

The weak compressions always bug me the most.

(via dxmedstudent)

[whatshouldwecallsunyopt]

When classes & labs are cancelled but you have clinic

[savinggrades]

was studying for sat when suddenly pretty pretty light filtered through my window. i couldnt resist so here it is yall

[a-joyfuljourney]

[ambivitie]

Started bullet journaling this year and it’s working out pretty well… now time to follow through for the rest of the semester

[studierr]

4/11/17 | two posts in one day??? what’s going on lmao. i had a fun day exploring london with pals on thursday - the natural history museum is so beautiful! ft. bujo spread from this week :^) (click for better quality)

[howlsmovingdesk]

20th Nov 2017 —

I should really be more active here ohmy;;;

[fuckyeahyoga]

[morebaffledlessbrooklyn]

Getting a Thorough History Pt. 1 - Defining Words

One of the most common problems I come across as I work with residents in my office is that they don’t ask the right questions and as a result miss important details that make developing their assessment and plan a more difficult job than it needs to be.  I’m not talking about the basic OPQRST type questions.  Most residents have memorized some form of that mnemonic and get the basics.  It’s filling in the details that most people miss and getting those details can make all the difference.  Especially in pediatrics, getting a thorough history can be the key to an accurate diagnosis.

When a patient or parent uses any term with a specific medical definition, always ask them what they mean.  

A big example is wheezing.  Parents love to tell you that their small child is wheezing, but if you delve in further, most people really aren’t talking about actual wheezing.  They’re talking about noisy breathing most commonly due to upper airway congestion.  True wheezing is generally not heard by people other than the patient without a stethoscope (Unless there is SEVERE respiratory distress).  So when someone tells you their child is wheezing ask them what they mean by wheezing.  What kind of noise was it?  Are they making that noise now?  My pulmonology mentor used to say you should always have parents try and make the noise for you, but I don’t know that going that far is necessary.

Another medical term that folks like to use is fever.  If a parent tells you the child has had fevers for the past 2 nights, there is a whole list of questions you need to ask.  How did you measure the temperature?  What was the reading on the thermometer?  Asking these follow-up questions to all my patients has taught me 2 things:  

Most people don’t know that 99.9 is not a fever

People who don’t use thermometers will give you a specific number anyway when asked because… well… I have no idea why but it happens all the time.

(Note that there is some data to suggest that subjectively reported fevers (i.e. He felt hot) are somewhat reliable, specifically when reported by the mother, but it shouldn’t carry the same weight.)  Also, don’t just ask if they gave any medication for the fever, always ask which medicine they gave ( Name and formulation), the exact dose given, and when they gave it to the child.  People give their kids all sorts of crazy wrong doses of tylenol.  Under-dosing acetaminophen and ibuprofen is a major reason people report their fevers didn’t go away after taking medicine.

Constipation is another term that always needs defining.  When was the last stool?  What is the child’s normal stooling frequency and what is the frequency now?  Babies have stooling patterns that evolve over time.  Newborns sometimes stool with each feeding, but some stool as infrequently as once every 3-4 days.  “He normally poops 3 times a day but for the past week he’s only going once,”  isn’t necessarily constipation.  Often its just a benign change in stooling habits.

Just because the parent tells you the kid has a barking cough doesn’t mean the kid has croup.  I mention it because barking isn’t really a medical term, but it’s being used as one in this context and lots of residents fall into the trap and diagnose croup in kids who don’t have it.

There are many other examples I could go through but I think by now you get the picture.  Always ask all the questions and define all the terms.  Residents often worry about time efficiency when getting H&P’s in the office setting.  My advice for this, and if you take nothing else from this post take this, is to first worry about getting all the information THEN worry about getting it efficiently.  Getting out of the room in 5 minutes doesn’t mean anything if you missed key information.

As always, feel free to drop any questions or comments in the ask box.

[wayfaringmd]

Solid advice. Also applies to adult patients, especially the elderly.

I’d like to add diarrhea to the terms that need defining. For some people, having 3 bowel movements in a day is diarrhea. For some, it’s a loose stool. What doctors mean is watery or liquid stools.

[msterimd]

“he’s had a fever for three days now”

“how can you say he had a fever?”

“he says he felt hot, and he felt hot”

“did you use a thermometer?”

“…no. But he really felt hot!”

Me, taking history: .-.

[medblues]

[lbriscoe]

[supagirl]

[okayysophia]

[bluefigs]

productivating: when you procrastinate by doing other productive things, but you’re actually just avoiding that One Thing you really don’t want to do

[birdkoskincare]

( 1 4 . 1 0 . 1 7 ) i didn’t have classes yesterday so today feels like a sunday! i’m feeling this desk situation but my yankee candle is dying, it’s my fave scent and it makes me a lil sad bc i can’t get a new one for now :’c

[pro-autistic]

It’s okay if you learn slower than your peers.

It’s okay if you need things explained in other ways than your peers do.

It’s okay to learn differently.

It’s okay to study in your own way.