Dr. Thinker: Phone interview

-          Some programs might do a phone pre-interview first before they select you for an actual in person interview.

-          Otherwise, phone interview is common during SOAP.

-          It’s just like a regular interview. It’s a little easier as you don’t have to dress up, don’t have to worry about your expressions.

-          But, you have to take care about the length of your answers and your tone.

Dr. Thinker: Interview season and FAQs related to interviews

1.      When should you be in the USA?

-          I would advise you to be in the USA, at least from the 1st of Oct until end of Feb (Rand order list submission) or Match day ( if things doesn’t go as planned, it’s better to be in the USA for SOAP).

-          If you are in the USA, you can contact programs by telling that you are in the vicinity and so can make it to the interview at a moment’s notice.

-          Even in February there are chances to get an interview due to last minute cancellation by others.

Dr. Thinker: Contacting the programs after Sep 15th

1.      Can you contact the programs to review your application? If so, when is the right time?

-          Of course, you can contact the program coordinators to review your application.

-          One of the biggest misconceptions during the interview season is to NOT contact the program early (like until end of October).

-          You will see a lot of people especially on facebook pages and usmle forums strongly advising you not to contact them. Don’t believe them. Most of those, especially the ones with fake identities would be just trying to screw with you. They would mislead you to cut down their competition.

-          You can start emailing program coordinators from the end of September or preferably

first weeks of October.

-          The tone of your email should be in a requesting manner.

-          You can even call the program coordinators. But, before you rub your information on them, first enquire if they are free and comfortable to talk about your application. Proceed only if they say yes.

-          I just stated this from my own experience. I am just clearing the misconceptions. I am in no way forcing you to do it.

Dr. Thinker: NRMP registration

-          Register as soon as possible, before the end of November to avoid late fee.

-          NRMP registration is a must to be able to participate in the MATCH.

Step 2 CS: How to introduce yourself

"Mr. XXX?"

"Hi. I am Dr. _______. I am the attending physician today and I am here to take care of you."

"Are you comfortable in the room?"

"Let me put this drape on you to make you more comfortable."

"Is it okay with you that I take some notes while interviewing you just so I don't miss out on any important points?"

"So tell me, what brought you to the clinic?"

Dr. Thinker: FAQs related to programs

1.      When to start searching about the programs?

-          The best time is from July as most of the programs update their requirement info by the end of june or start of July.

Dr. Thinker: ERAS CV

-          It is automatically made as you fill your details on ERAS.

-          Make sure you make no grammatical errors.

-          DO NOT LIE about anything on your CV.

-          Present mailing address: Give your US address. Sometimes programs like to call those that live in the same region.

-          Permanent mailing address: I would suggest US address for this too, for the same reason as above. Programs would prefer those who have family or familiar to that region/state.

-          Medical school honors/Awards: Mention the awards you got in medical school, like distinctions or gold medals.

Dr. Thinker: MATCH season

-          Application for the Residency match starts on 15th September.

1.      What all should you ideally keep ready by the end of August?

-          Make sure your LOR’s are uploaded. Waived LORs take longer to get processed than the unwaived ones.  The processing time can be anywhere between 1 day to 2 weeks. The closer it gets to sept 15th the longer it takes.

-          Have your final draft of PS ready.

-          Have your MSPE/Dean’s letter uploaded (Dean’s letter can be a substitution for MSPE)

-          Your profile photo – keep it as professional as possible.

ERAS CV, PS can be uploaded or updated even in the last moment. There won’t be any processing time for this.

Dr. Thinker: Stay/Accommodation

Short duration: Especially when attending interviews.

1.      Airbnb: It’s a website where you can get rooms for a cheaper rate than the hotel. It’s the best option for a one night or a couple of nights stay.

a.      The rooms are usually in an apartment or a house and most often the owners live in the other room.

b.      You can search for shared or private rooms.

c.       You can search for the rooms according to the distance from the hospital.

d.      You can see the photos of the room and house before you book.

e.      You can read the reviews and then decide whether to take it or not. YOU MUST read the reviews.

f.        It is usually safe. I used it many times without any trouble and so did my friends.

           You can use this referral link to sign up in order to get 35$ off on your first booking. You must sign up clicking this link in order to get it.

            Link: www.airbnb.com/c/rchandra40?s=8

2.      Couch surfing: Like literally renting a couch in an apartment.

a.      Much cheaper option.

b.      Read reviews before you book.

https://www.couchsurfing.com                   

Longer duration:

During electives: It’s best you ask the coordinator to send a list of places where students usually live.

Dr. Thinker: Travelling in the USA

-          You would be spending a lot of money on this. So, always look for a couple of options and choose the best alternative.

Dr. Thinker: Letter of Recommendation (LOR)

FAQs

1.      How to get a good LOR?

-           It’s very simple.  The doctors in the USA are very friendly. They just expect you to know basic knowledge.

A.      Be on time – very important.

B.      Come to the hospital at the same time your resident or fellows come and leave along with them, even if they ask you to leave early.

C.      Read a topic, or something related to the cases you see and ask your resident or the attending some intelligent doubts in that topic. This way you are building up a rapport without sounding dumb when they talk about that topic.

D.     Volunteer to take a case or present a topic. Don’t wait for them to give you work.

Dr. Thinker: Research

FAQs  

1.      What are the types of visa on which you can join research?

A.      Research Volunteer/Intern: B1 visa

-          It is an unpaid position.

-          Your visa could be B1/B2, but at the port of entry the customs officer usually stamps B2. So, make sure you ask him to stamp  B1 if you are going for this kind of research.

B.      Research Assistant: J1 visa

-          This could be paid or unpaid position.

C.      Post doc: J1 visa

-          Paid or unpaid depending on the funds.

-          They usually have a commitment for 2 years. But, sometimes you can break it after an year depending on your attending.

Dr. Thinker: United States Clinical Experience (USCE)

USCE – United States Clinical Experience

Types of USCE:

A. Clerkship: It is considered hands on clinical experience.  You MUST try your best to do this no matter what.
Eligibility: You should be a medical student and not graduated yet.
(For Indians: Internship period is still considered as not yet graduated.)

- The best clinical experience.

- This is what the programs look for.

- The LORS from this have a great value.

B. Observership: Not a hands on, just shadowing another doctor.

Eligibility: Either a medical student or after graduation

- Not considered as a USCE by most of the programs.

- Some hospitals might let you touch and examine patients, but legally you are not supposed to.

- Best to fill the gap between graduation until residency application or end of the season.

- A reasonable time spent a big university or a community hospital that takes IMGs into residency is fruitful.

C. Externship: Hands on clinical experience.

Eligibility: After graduation

- Some programs doesn’t consider it as USCE as this kind of experience is mostly offered by private agencies or at private clinics.

- The LORS can mention it as hands on.

- Best to do if you haven’t had any clerkships

Dr. Thinker: USMLE STEP 2CK and STEP 3

I am not going to explain this in detail as I already did it for USMLE Step1. The approach is the same. Once you are done with Step1 exam, you will get a hang of it and you are going to become your own master of USMLEs.

USMLE STEP 2 CK

When is the ideal time to give it? – It’s best given asap after USMLE step1. It will save a lot of time as your basics would be strong and fresh.

Duration: 3 months if given immediately after USMLE STEP1. Otherwise 4-6 months.

Resources: MTB 2, MTB3, Uworld

Practice Tests:  1. UWSA    2. NBME forms 1-7

Dr. Thinker: USMLE STEP 2 CS

When to give it? 

1.      Ideally give it after your clerkship or observership, as you will get to know how to talk to patients in the USA.

2.      It can be given before step 1 or after. It doesn’t matter. I gave it before step 1.

Dr. Thinker: USMLE STEP 1

USMLE STEP 1

Ideal Duration: 6 months (But, remember it varies from individual to individual)

Resources: Kaplan notes, Kaplan Videos, First Aid, Uworld

 Alternative resources:  If  you are aiming for high scores    

Dr. Thinker: FAQs regarding the application for USMLE Step exams

These are some of the questions I had encountered on multiple occasions from many people.

1.      Can we change the testing center from some country to the USA or from the USA to some other country?

-          Yes, you can change from any country to another country.

-          Just call ECFMG customer care. They will give you a number to which you can fax your request. You will just have to write your details and the request “Please, change my testing center from “current country” to “the country you want”, on a white paper and sign at the bottom.

-          If you change your testing center from any other country to the USA, then you will get a refund for the testing center surcharge fee(150$) that was earlier charged in your country.

-          If you change your testing center from the USA to any other country, then you will be charged a testing center surcharge fee depending on the country you are changing it to.

Dr. Thinker: My journey

I am sharing my story mainly for those who go unmatched or thinking of giving up at
every hurdle that comes in the USMLE path. I didn't match at my first attempt, too. We may not
have the same problems overall, but I totally understand what you would be going through. I
didn’t have any financial troubles ( thanks to my parents and brother), but emotionally it was a
nightmare until Mar 14, 2016, considering the fact that even my family wouldn't have been
happier with me giving it an another try( can't blame them).

Journey: We think we need some help or seniors for securing electives and all. In reality- it’s
just an excuse we give ourselves. Of course, having them will make it easy, but not having them
isn’t the end. I did it all by myself with the help of google. That's one reason I keep answering
queries on usmle pages, as not everyone has someone to back to them up. Remember -
Contacts don't just happen for everyone, you make them!!

Dr. Thinker: Note

DON’T GIVE UP

 You may not match this year,

 you may not match the next year.

 But, you will have to and for sure will match one season.

 As, matching can only be delayed and not denied.

 Provided, you don’t GIVE UP.

Dr. Thinker: A path to USMLE contents page

Hey everyone!

Our new awesome author Dr. Raja Chandra (Pen name: Dr. Thinker) is going to share his USMLE experience with us in the next few posts. He is also planning to write a few funny posts. Who is excited? :D

He took out his precious time and wrote everything he had come to learn about USMLE in the past couple of years. This is a contents page that helps you navigate so that you can read what is pertinent to you at this stage :)

Hope it helps! Good luck.

Thanks a lot for sharing this with us, Dr. Thinker! :D

Step 2 CS: Writing examination in patient note

Hello! In this post, I'll be noting some points how to write a patient note for step 2 CS. Especially, focusing on short forms that can be used in the exam.

I have noticed that writing the note in ALL CAPS is better and it does save a lot of time. Similarly, instead of using the "colon : " you could use the "dash - " and it'll make life simpler.

Step 2 CS: Loss of consciousness

Differentials:

Seizure - Ask for shaking, tongue biting, rolling of eyes, incontinence

Hypoglycemia - Sweating, fatigue, excessive hunger

Orthostatic hypotension - Ask for palpitations, positional syncope or hypotension associated with large meals. Medications can cause this. Counsel this patient properly by warning them and ask them to get up slowly, etc.

Vasovagal syncope: What were you doing when you lost consciousness?

Step 2 CS: Amenorrhea

I am just trying to set a sequence of questions to ask in the exam, tests to order and examination to do so that I am not all over the place in the exam.

So here's what I am going to do if a case of amenorrhea shows up - Ask about general menstrual history and then go to symptoms specific for differentials:

Anatomy and Neuroanatomy - How to Study

Hi guys, I'm Jay once again, and I passed my Anatomy and Neuroanatomy subjects today in my first year. yayyyy!! :D

So I thought I'd share some facts about how I studied anatomy in my MS1 or First year of Medicine.

First, which books to read?

Is Homosexuality a disease? Is Gay a gender? (Sex, Gender and Sexuality)

We got these questions, many times in our Whatsapp study groups! No, is the answer to both questions. Let's find out why and lets find out much more information about what is Sex, Gender and Sexuality(Sexual Orientation)!

Neonatal screening test mnemonic

Hello! The mnemonic for neonatal screening test is:
"BCG PH"

Mucosal edema and effect on absorption of diuretics in CHF

Say, a patient comes in with exacerbation of heart failure. He was previously well controlled on a good drug regimen including oral lasix. It is a tendency to give diuretics (Like furosemide) in the ED intravenously (Even though they can tolerate oral meds). Ever thought why?

Step 2 CS: Noisy breathing

I think mnemonics aren't required for every case if you have the correct thought process, you will ask the right questions.

Hyperkalemia

Hey everyone! Here are some review questions about hyperkalemia:

What is the physical examination finding you are likely to see in a patient with hyperkalemia before you order an ECG?

Antibiotics that can penetrate pancreas mnemonic

Hello!

There are only a few antibiotics that can penetrate infected pancreatic necrosis, a complication of acute necrotizing pancreatitis. These are carbapenems, quinolones and metronidazole.

How do I remember these antibiotics? Mnemonic!

Diagnosis of celiac disease

So today, we were discussing differentials of weight loss when someone mentioned celiac disease. What tests do you usually order to diagnose celiac disease?

We answered:
IgA endomysial antibody (IgA EMA)
IgA tissue transglutaminase antibody (IgA tTG)
IgA deamidated gliadin peptide (IgA DGP)

But there is something else which also needs to be ordered if these tests are negative. Do you know what it is?

Long term high dose steroids - Prevention of complications

Today, my staff asked - What are the conditions you can do prophylaxis against in a patient with long term steroids?

Guess before you read the answers!

Zones of MI, leads and ECG mnemonic

Hey!

Warning: This is an over simplified post. 

If you are the kind who has a tough time remembering changes in "which lead" correlates with the "where" the heart is injured, this post is for you xD

Elevation of ST segment indicates zone of injury, diagnosis is supported by reciprocal changes, ST segment depression in the leads facing the opposite wall.

For precordial leads, I use the "SAL" mnemonic.

V1 Septal

V2 Septal

V3 Anterior

V4 Anterior

V5 Lateral

V6 Lateral

Step 2 CS: Writing patient note

Patient note tips:

1. Write the chief complaint in brilliant detail
2. Write findings consistent with diagnosis #1
3. Write findings consistent with diagnosis #2
4. Write "denies" (Negative findings associated with particular dx)

Step 2 CS: Do you think I have cancer?

Counselling a patient who says, "My father died of lung cancer 10 years ago. Do you think I have cancer?"

How to study for final year MBBS

"IkaN, can you write a post on guiding a final year MBBS student who has just started and already feels burnt out? What books can I use? How should I organize my notes? How can I balance my posting with learning for theory? How can I maintain the right attitude and avoid feeling overwhelmed? I tend to compare myself with others as in how well they get along and why I can’t do the same? I feel negative already. Please help me. I idolize you a lot and I really need you to give me a path to follow!"

- Asked on Tumblr

Packing for electives

I had made a list for "What to pack" for electives before leaving. My friend is leaving this month and I wrote this blog for her and everyone else who is planning to go for electives and need help with it :D

Packing is tough because you've got limited space and weight. I carried a 23 kg big bag. My carry on was of the appropriate luggage compartment size. They do not weigh carry on bags if they are in the dimension range. I also took a bag pack for my laptop and a hand bag for work. You can carry the coat & umbrella with you, they don't mind. Do not put food / sharps in the carry on, they'll remove it.

One of my friends luggage bag got misplaced during his flight change. He only had his carry on bag with him for the initial 2-3 days (Till the airlines resent his bag!) So make sure you have at least a few set of clothes and necessary documents in your carry on, in case this rare incident happens to you.

Here's a list of what I packed and suggestions on what you should pack. You can use this list to guide yourself and make sure you don't forget anything!

Clothes and linen: 
1 warm coat, 2 gloves, 2 scarves, 2 thermals, 1 knit winter cap, lots of socks, umbrella.
I didn't carry blankets because I knew I would be provided with them.
(They say you should buy winter wear like coats and snow boots in America but I advice you to carry it from your home country anyway in case you can't go shopping immediately.)
8-10 formal shirts, 3 pants, 1 lab coat with long sleeves.
1 formal shoes, make sure your toes are covered. (You can wear sports shoes with scrubs in surgical rotations.)
3 track pants and tops to go with it
2 hoodies, 2 sweaters, 2 jeans
1 pretty dress (My birthday was around that time so :D )
1 big towel, 1 small towel
1 semi open shoes for wearing at home. (I didn't pack flip flops because I knew I would wear socks most of the time due to the cold.)

Documents: 
Passport copies (Keep one copy in each bag)
Visa copy
Step 2 CS exam copy
Immunization
Health insurance
Malpractice insurance
Acceptance letters

Medicines:
Paracetamol
Allergy medication
Cough medication
Antibiotics
Vicks balm
Bandages
Anything you can find at home
(It's important to carry medicines because they are really expensive in the US)

Skin care:
Vaseline
Moisturiser
Cold cream
Sunscreen
Make up

Optical stuff:
2 Glasses
Lens solution
Lens

Academics:
First Aid for Step 2 CS
Pens, pencil, sharpener, eraser

Electronics:
Laptop with every ebook ever
Phone charger
Universal adapter
Pen drive
Iron (I didn't carry it because the clothes dryer doesn't leave a lot of creases and you don't really need to press any clothes)

Crockery:
1 mug, 1 big spoon, 2 small spoons, 1 butter knife, 1 sharp knife, 2 plates and 2 bowls. Everything microwavable, unbreakable and not too heavy.
Apartments that you rent may give you utensils for cooking, so don't carry too much like frying pan and heavy utensils.
I think you should also carry a water bottle and a tiffin box. Sometimes, it is easier to carry a lunch box with home food than to eat from the canteen.

Toiletries:
Tooth paste and tooth brush
Shampoo, oil, conditioner
Comb, Hair ties, Clips
Bathing soap, perfume, body spray
Washing powder, soap for clothes
Soap for utensils, utensils scrubber
Sanitary napkins
Mug for water (Because there are no jet sprays here)

Others:
Scissors
Nail clipper
Safety pins
Wrist watches
Needle and thread
Weighing scale
Stethoscope
Hammer (If neuro rotation)

Spiritual:
Diary
Religious books
A photo frame :)

Food: You don't need to carry them from India because you will get most of the food in America as well. I think tea bags are hard to find. Also, I froze a few home made chapatis so I had something to eat if the weather was too bad and I wouldn't be able to make it for groceries in the first few days. It was a good decision.
Tea bags
Milk powder
Sugar
Salt, pepper
Ghee
Frozen franks
Frozen chappatis
Nutella
Peanut butter
Honey
Biscuits
Soup
Chocolates

You can always buy stuff from here even if you forget a few items here and there. So don't stress too much like I did :D

Milrinone in congestive heart failure

Today, my resident was teaching us about different drugs used in heart failure when he started talking about ionotropes like milrinone and dobutamine.

For those of you who don't know, Milrinone is a phosphodiesterase inhibitor and it enhances cardiac contractility by increasing intracellular levels of cyclic AMP.

Milrinone has a lot of beneficial hemodynamic actions short term. It can provide acute hemodynamic and symptomatic benefit in patients with advanced heart failure with reduced ejection fraction, improving functional status and reduce hospitalization [1].

BUT long-term therapy with oral milrinone increases the morbidity and mortality of patients with severe chronic heart failure [2]. The mechanism by which the drug exerts its deleterious effects is unknown.

Milrinone causes more harm than benefit in patients with ischemic cardiomyopathy [3].

That's why, like my resident called it, milrinone is also known as Killrinone! I just like how he made the kill pun, so I wrote about it and wanted to let you guys know :D

To summarize: Even though milrinone is used in patients with refractory heart failure for symptomatic relief, it has no long term mortality benefit.

That's all!

If you've noticed, I am trying to level up my blogs by referencing articles, I won't get too technical and you will still see the smiley faces. But I think it's time for Medicowesome to grow up and be more evidence based :)

-IkaN

References:
[1] Safety and clinical utility of long-term intravenous milrinone in advanced heart failure.
AUMehra MR, Ventura HO, et-al. Am J Cardiol. 1997;80(1):61. PMID 9205021
[2] Effect of Oral Milrinone on Mortality in Severe Chronic Heart Failure
Milton Packer, Joseph R. Carver, et-al. N Engl J Med 1991; 325:1468-1475 November 21, 1991 DOI: 10.1056/NEJM199111213252103
[3] Heart failure etiology and response to milrinone in decompensated heart failure: results from the OPTIME-CHF study.
Felker GM1, Benza RL, et-al. J Am Coll Cardiol. 2003 Mar 19;41(6):997-1003. PMID: 12651048

Ibutilide

Hey guys.

So here is a random fact. Ibutilide is the only drug that converts atrial fibrillation to sinus rhythm.. All the other drugs..propranolol, verapamil, digoxin etc reduce the ventricular rate only.