Post-Residency Review

Tl;dr: Residency sucked.

On a more detailed review.

Regarding Internal Medicine residency.  

From a mostly in patient perspective.

The way a lot of medical education, in medicine specific training, as opposed to surgical which I'm not as familiar with, gauge you is through the RIME scale.

R - reporter

I - interpreter

M - manager

E - educator

As reporter, you're able to reliably obtain information from the patient and chart, and present it correctly, or give the needed information reliably when asked for something.

This is something you must be able to do by the end of medical school without any issues.

As an interpreter, you need to make sense of the information you're gathering and present it in a way that makes sense.  

-For example:  If you have a patient with fevers, right upper quadrant pain, and jaundice, you must interpret that as ascending cholangitis.  A reporter wouldn't quite make the diagnosis but present the patient's findings plainly.

As a manager, you need to make a plan to take care of the patient.  Regarding in-patient, the way I recommend you think about it is, "Why is this patient admitted to the hospital, and how can I get them to the point where they can be discharged."

-From our above example, you need to treat the ascending cholangitis.  A good starting plan is probably antibiotics and fluids.  But which antibiotics and fluids? What dose, how much?  

Finally, as an educator, you will be able to clearly explain, and teach, to your teammates and medical students your medical knowledge.

First year:

This year is essentially your free pass to come off as sort of dumb, for the first few months.

Do not continue to be dumb beyond that, because I saw it keep a couple people back a few months before they could start second year, and one person got kicked out, for not being adequate.

To be successful, put in the work during your third and fourth year of medical school.

I recall reading on reddit.com/r/residency, and on the SDN forums, during my third year of medical school, that you should take it easy in fourth year.

THIS IS WRONG.

Yea, I had a chill time in my last few months of medical school, but it led to me being chronically behind my peers in residency by about 3-6 months.  By the end of second year, I closed the gap, but it was a very not fun struggle.

Expect half of your year to be inpatient rotations, with one or two months of ICU.

Make sure to do one or two ICU rotations during medical school.  

Make sure to do one or two ICU rotations during medical school.

Note that I wrote the above line twice for good reason.

By the end of your first year, you need to be at least in the lower end of the manager part of our grading scheme above.

Second year:

Finally, your chance to lead the team.

Depending on your program's culture, this could be that interns present to the attending, or that they present to you, with the attending essentially as the team's consultant

This year of residency, you need to start learning and knowing medical guidelines.  

With the goal that you can treat patients according to medical guidelines, where medical guidelines exist.

Not every medical issue has guidelines, but those that do, mean that there is a standard of care, and you must follow it.

For example.  It is generally accepted how to treat septic shock.  We'll use septic shock secondary to pyelonephritis as our example.

If an elderly patient is brought in with blood pressure 80/40, fevers, malodorous urine, and poor oral intake, they likely have septic shock from pyelonephritis.

What I would do in this situation, is obtain IV access, start giving the patient fluids, obtain blood and urine cultures, and start broad spectrum antibiotics.

This is a simple plan above, but some details, are that a generally accepted guideline is to give 30cc/kg of the patient's weight (consider doing ideal bodyweight if they have something like heart failure), as a fluid resuscitation for their blood pressure.

Third year:

In short, you need to be able to function independently by the early to halfway mark of third year.

Start interviewing for jobs in the Fall.  People who don't match into fellowship will start interviewing, and you will have more competition for jobs if you wait.

This whole post was a draft for the past few years.  

Posting it now, late 2024, as I'm resuming this blog.

-Be Good.

Promotion to Financial Freedom

What should a physician's goals be?

What should anyone's goals be?

A: To achieve financial freedom.

What's my deal?

The slog through college, medical school, and residency felt like a prolonged indentured servitude.  I am approaching solvency in terms of my finances.  In retrospect, becoming an attending physician has been quite sacrificial.  Yes, this is obvious and known with respect to becoming a physician.

What I wasn't expecting, was how much of myself I would sacrifice, as I guzzled down the Kool-Aid to get to where I am.  That is, academic medicine is an exercise in self-immolation to obtain accolades that nobody really cares about.  I didn't write anything on this blog for years, because I didn't want to be doxxed while in training, or in the military.

The goals I have now are no longer "prestigious".  I don't want a prestigious specialty, a high military rank, a nice car, a nice house, a nice watch, a nice suit, or anything material.  Except for healthy food.  That is the main material thing I want.

What I want is "F U" money, my health, the health of my family, and free time to pursue interests and relations.  

Medicine is set up to prevent people from getting F U money and free time.  It takes too much debt, and too much time.  Once you have come out of the other end of the mold, you are so bogged down in debt, and have done nothing else, that you just keep up the Sisyphean work because you know nothing else.

The BEST doctors I have ever worked with were the ones that had no family, and no spouses.  They were the perfect employees / citizens.  Creating health and wealth for their patients, employers, and the IRS.

Yea, they made a lot of money, but I've seen enough palliative care patients on the backend of middle age to know that none of this "hustle culture" matters.

Do what you need to do to get to where you want to be, while still living life.  Don't forgo life for trinkets.  You can't take them with you.

For those of you who are fortunate to be wealthy enough to not have to grind, please don't lose the wealth.  I've seen distant relatives squander fortunes on wasteful things.  

"Take only memories; leave only footprints."

-E. F.

Internal Medicine Clerkship Tips

Oh yes, the internal medicine clerkship rotation.  Where you will go to learn that you don't know shit about some arcane thing about an organ system you brushed over in physio because you were gonna pass the class anyways and had to bust your butt on biochem just to pass.

But really the best way to impress is to show up early, and be eager.  Yes, eager.  That's how my resident told me I can get a good grade.  When I say eager though, don't be overbearing and annoying.  There's a fine line between the two.  You need to show interest, be happy to help, and bring a positive attitude to the team you're working with.  This, along with trying your best, will be enough to get you good feedback.

Don't worry about having to know certain things and details.  The knowledge you need to know will come from your shelf studying.  More important for your clinical grade is being able to write good notes, and being able to present well.  That is, presenting with confidence and conviction.  You'll get better at these things as time goes on.

Make sure to use some kind of MS3 survival guide to focus your efforts.  I used this one: http://som.uthscsa.edu/StudentAffairs/documents/MS3_Survival%20Guide.pdf


Here are some general topics you WILL encounter in your medicine rotation.

Know the majority of the chest pain differential.
- MI, esophageal rupture, pneumothorax, pericardial effusion, PE, aortic dissection.
- These 6 are potentially fatal chest pains you must rule out.

Know the shortness of breath differential.
- PNA, PE, pneumothorax, asthma, copd are obvious ones

Know the abdominal pain differential.
- This is more prevalent for surgery, and I'll address it in the surgery post.

And finally, know what to do in certain emergencies, such as hyperkalemia.
CBIGKDie
C - calcium gluconate - stabilizes cardiac membrane
B - bicarb or beta agonist
I - insulin
G - glucose to go with the insulin
K - Kayexalate
D - Dialysis

You'll need to know more than this stuff of course, but for some reason these stick with me over a year after the clerkship.

Internal Medicine Shelf Exam

I would love to tell you how to do well on this exam, but instead I'm going to tell you how I did, which is average, and how little I had to study.  My scaled score was a 75.

Now, I would have liked to do better, and I missed honors on this shelf by a few percent, but I'm here to set your expectations based on how I studied, so that you can do better.  Like I've been saying before, I'm a pretty average student, so most of you readers should get some benefit.  So here's what it takes to get an average grade.

First, start off your clinical year with internal medicine.  You won't know much of anything outside of step 1 material at this point.  Tell yourself how you're going to study really hard to do well on the shelf.  Start off strong by doing Pretest questions, and some Uworld questions.  Consider watching the Emma Holliday review video (link), and then don't actually watch it.  Consider watching the onlinemeded videos (link), and then don't actually watch it.

So far you're doing great, it's halfway through your clerkship, and you've done about 200/1200 of the medicine uworld questions, and about 1/2 of the pretest questions.  Most of your learning is being done at the hospital based on your patients and researching stuff on uptodate.

In other words, you need to kick it up a notch.  At this point you should get serious about studying.  Start breezing through uworld, and if you get something wrong, then learn that topic, and learn it well.  The books I used to learn stuff well was Case Files Internal Medicine, and Kaplan Step 2 CK.  I didn't even bother with Stepup, it's too dense for my liking.

Finally, you're in the last 10 days before your shelf exam.  You have about 300 uworld questions left, you stopped doing pretest, and you're only going to do the Emma Holliday review video because it's short.  Great! Now finish the questions, do 3 nbme practice exams, and watch the review video two times.  Take your test, and get an average score.

Next time:  How to honor your Pediatrics shelf because all it is is an internal medicine shelf.

Preclinicals and Realistic Step 1 Expectations

Alright, I never update this blog, and all you care about is what I titled this post.  So straight to the point.  My step score is in the 230s.  A good score, but still not good enough for anything real competitive like ortho, ent, derm, or uro.  Guess those are more than likely out.

You are most likely an average student like me.  Pretty good, but not stellar.  Good, this post is for you, because you also likely won't get 250s, even if you try all the things people with 250s do, you will end up having a score wall like I did.

To do well on step the number one thing is to do well in your preclinical classes.  I got a few questions right only because I remembered random shit from first and second year.  My friends who crushed step were rockstars in years 1 and 2.  I'm serious, try very hard to do your best.

My second year progressed like this leading into step:

• First half of year, don't even think about step.
• I used PATHOMA for my pathology course.  This is the NUMBER ONE way to study for step indirectly.
• I also used sketchy micro,  and sketchy pharm.  NUMBER TWO way to study for step indirectly.
• Second half started uworld.  I got through half of it before dedicated.
• Also tried starting first aid, but it was HELLA boring. (You can use a one year old first aid by the way, though I wouldn't go further back than that.)
• Just before dedicated.  You will have finals for your second year courses, and so you WILL KNOW pathoma and sketchymicro and sketchypharm very well right before dedicated.
• Dedicated (5 weeks):
• I took an nbme to see where I stood.  (Don't get discouraged if you do poorly.  It is a challenge to your psyche to kick ass when you get a shit practice score.)
• I focused mostly on uworld questions, and I tried to study first aid at ~2chapters/day.
• I did ~120 questions/day, with one block focused on material I read in First Aid that day, rest random.
• First aid soon fell to the wayside about 2 weeks in, and it became a reference instead.  
• Each week on the weekday I was set to have my test, I would take an nbme.  I did this every week leading up to the test, improving a little bit each time.  My step score was within 5 points of my last, and best test.  (Do newer nbmes last since they'll be most like the real thing.)

There you have it.  If you're an average/above average student, and try as hard as you can, you will get at least an average/above average score.  But to really get a high score you have to do as well as you possibly can in years 1 and 2.  Comment if you have questions on anything.

First Year Update 1:

It's currently Thanksgiving break, and I actually have some free time to make a Blogger post!

So, I'll just start from the beginning of the year.  In August, we basically had very little studying to do (relative to now that is).  There were also a bunch of social events with free food before classes started.  Note, FREE FOOD.  Needless to say you should attend these.  Not only is there free food, but they're one of the few times that you can really have a shot at meeting new people before everyone's core group of med school friends start to form.

Now, on to the school work!  At my school they started us off with Biochem, Genetics, Microanatomy, and some not so science based physician skills classes.  As the weeks went by though they added Gross Anatomy, Physiology, Nutrition, and Immunology to the mix.

When you first start med school you'll likely do one of two things: study too much, or study too little.  And you'll most likely not know what you need to know.  This is a skill you will learn as you go through med school.  

To be clear, the hardest part of med school is NOT being able to understand the material; it's getting through the large amounts of material, and picking out the high yield material for exams.

On our first set of exams, we were only tested on Biochem, Genetics, and Microanatomy.  The averages were in the 80s, but there were quite a few people that didn't pass (below 70% score).  As for myself, I studied way too much.  I did well, but not much better than the average.  Since then we've had a ton of exams and material.   

Also, I've learned some more effective study habits these past few months.  Such as don't study too much, study more effectively, and make time where you don't study at all.  If you study non-stop for hours without any breaks, the material won't stick.  And make sure you get enough sleep.  The people that study straight through depriving themselves of breaks, sleep, and other hobbies simply don't appear as confident coming out of exams, and personally I didn't do much better studying that way.

With that stuff said I've found I'm an average/sligthly above average student at my med school.  I'm not particularly annoyed by it because I'd be happy with a midrange competitive specialty like internal medicine, and I'm not sure I'm capable of gunning for 100s on every exam.  I don't really feel like studying that hard at times anyways.

Instead I'm going to continue to enjoy my time by participating in extracurriculars, spending time with friends and family, and keeping up with my hobbies.  Or in other words, I'm enjoying living a healthy life and not making studying my life.  If you do this though make sure you pass everything.  School is still my top priority.  Good luck!

HPSP: Health Professions Scholarship Program (Army, Navy, Air Force scholarships)

Figure 1: 'Nuff said.

Intro

Hpsp is the health professions scholarship program from the military. You can apply for one through the army, navy or Air Force, or all of them at once, and pick from whichever branch awards you one. It pays for all tuition, fees, books, and some equipment needed while in med school. They will NOT pay for a computer though.  You also get a $20,000 signing bonus, and a $2,100 per month stipend as a student.  The bonus gets paid out in installments three installments, starting on your first month of medical school.

Years owed to army

You owe the army one year for each year of school paid, or one year for each year of residency. Whichever is greater. Then you owe a few years of inactive ready reserve, where they only call you up for work if absolutely needed. This all has to total eight years. So if you do a 5 year Ortho residency, you owe 5 years active duty, and 3 years inactive duty. 

Why I signed up/ Residency stuff

I signed up for it because med school is expensive, I want to serve America, and I don't want to deal with the cons of the civilian healthcare system (ex: you don't need to buy malpractice insurance as a military physician). With that said, it has it's cons. If they critically need more of some type of doctors, it is ultimately their decision which residency I can do. If they need you to go somewhere foreign, like Germany, Japan, or Korea, you need to go. Also, during your inactive ready reserve period, they can call you up if there is a major conflict with another country.  This is unlikely because it apparently didn't happen with the last two wars.

I also did it for the chance to travel, and do something different from the pack. I'm honestly really excited to learn more about, and become a part of the military.  Furthermore I really do love America, and I want to support the country in this way.

I want to do something with surgery or procedures. I'm thinking Ortho or EM. On that note, the military residency match is in the early Fall. So you'll know where you're going before everyone else's match day. You CAN do a civilian residency in something if they need more of it. It's kind of a gamble though, because if you don't match they have you do primary care work or something for like 3 years. I haven't really looked to to that too much though. 

It's really up to you if you are into it.  People on the internet say to do it only if you are serious about serving the USA.  I am serious and want to, but at the same time, I do not want to have $350,000 (65 for my undergrad + 4*70 for med)  of student debt at ~7% compounding interest.  Doctors don't make as much money as they used to, and tuition is only going up, while pay for doctors is going down.

Pay in the Army