USMLE Day #3: UWorld and I Are Fighting

Me:  Okay!  I’ve successfully studied ALL of molecular biology in 3 days!  It was hard but by God, I have gone through everything that could possibly be tested!  TRY ME NOW, UWORLD.

UWorld:  Cool.  Let me give you this DNA strand, okay?  It looks like this:

3′ ———- ATCTGTTAATCGGATATC —— 5′

 Me:  Huh.  Okay.

UWorld:  Now, what’s the last amino acid in the resulting protein? waiting expectantly Me: … aha.  I see what you’re doing..

UWorld:  ?

Me:  You want me to get tripped up on the 3′ – 5′ thing.

UWorld:  … Hmm?

Me:  And on top of that, you expect me to confused about the DNA versus RNA thing.

UWorld:  Ah.

Me:  Too bad for you.

UWorld:  … Oh?

Me:  YES.  Because I studied this stuff.  I literally studied it backwards and forwards.

UWorld:  I see.

Me:  Right.  Oh, and the transcriptions versus translation thing?  I’m onto that, too.  That’s totally MCAT material.  So nice try there, but better luck next time.

UWorld: Because..?

Me:  Because I can confidently say the answer is “B”.

UWorld:  *snort*

Me:  …….?

UWorld: ohnoyoudontUWorld:  Hahahahahaha, NO.  So sad for you.  There was a “UAA” in the second codon.  That’s a stop codon.  Cute try, though.

Me: ………

UWorld:  Hey, maybe you should make a little mnemonic for yourself:  We stop at the stop codon.  Pro tip.

Me: buffy face slow closeup samuel jackson

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USMLE Day 1: Biochem Makes Me Feel Like Michelangelo

If you hired me solely to draw biochem pathways all day, I would buy the fanciest set of Staedtler pens and use only the heaviest of heavy-weight paper and I would buy a beret and no one could stop me from wearing it indoors, no one.

… luckily, when planning my Step 1 schedule, I grudgingly acknowledged this and gave myself an entire 48 hours to live out the dream, guilt-free, under the clever guise of “making flashcards”.

Urea Cycle(No, but seriously, I did really make flashcards – I just drew each pathway and saved it with different words blanked out.  I swear to god the effort was semi-productive.)

TCA Cycle alpha ketogultarate dehydrogenase

Actually, artists working on their Art and med students working on Step 1 are pretty damned similar.

Both artists and USMLE-studiers get to feel like nobody understands you, nobody really gets the true magnitude of what you’re attempting, or how it requires you to work through the night and not pay attention to trivial, mundane details like “dishes” and “laundry” and “social interaction”, god, can’t you see this is important?  

glycogenolysis and synthesis FULL

Also, both artists and USMLE-studiers get to drop a lot of humble-brags while being generally insufferable to everyone else around them and going through a lot of expensive paper and inner turmoil about how to color-code co-factors.

… I imagine.

… Hypothetically.

… I don’t actually know whether artists have inner turmoil about co-factors, I guess that one’s a bit of a miss.

USMLE Step 2: Summarizing Stuff That’s Made More Complicated Than Necessary

1.  Antiarrhythmic Drugs:  Atropine speeds shit up. Adenosine slows it down. Amiodarone fixes anything, but kills your lungs. Everything else is 6th line.

2.  Antipsychotic Drugs:  All that’s worth knowing about the 2nd gens are their major side-effects, which luckily mirror their names: Olanzapine causes weight gain cause “o” is the fattest letter. Aripiprazole and Ziprasidone sound zippy and thin, and are both weight-neutral.  (Ziprasidone is, in fact, so zippy that it can cause arrhythmias).  And finally, Quetiapine sounds like “quiet”, which is appropriate because it has the quietest side-effect profile (the least risk of extrapyradimal S/Es or increased prolactin).

3:  Sensitivity of a test vs its Positive Predictive Value:  Tricky because they seem so similar, so the temptation is to think of them as the same exact thing.  Textbooks do a crappy job of explaining the difference, I think, so here’s my attempt at it:

sensitivity vs PPV

Say your friend makes an instant swab test for The Bubonic Plague.  The test correctly catches all but 1% of her PI’s Yersinia Pestis Orientalis samples at the expense of also catching 5% of the perfectly healthy controls- so her screening test is 99% sensitive and 95% specific.  You are impressed.

She swabs your cheek with it to while she’s explaining the test to you.  If the test then gives a positive result, how worried about imminent death would you really be?

Answer: you shouldn’t be worried at all, because The Bubonic Plague is so rare that the odds of you being one of the 5% false positives vastly eclipses the chance you are the index case of a modern pandemic.

So despite being an extremely sensitive test, it has a low PPV… in the modern population.  The key point is that if you were a medieval European peasant getting that same swab and testing positive, you’d correctly be far, far more worried.  The Positive Predictive Value of the exact same test would be higher in the 14th century.

And that’s the point: sensitivity & specificity depend only on the test, whereas PPV and NPV also depend on the prevalence of the disease of the population being screened.

Potassium Limericks

Based on the premise that it’s easier to memorize rhymes than kidneys.

In hypOkalemia, medics
should first suspect loop diuretics,
steroids used thoughtlessly,
Magnesium paucity,
Or any cause hyperemetic.

Total parental nutrition
or maybe C.A. inhibition!
Villous adenomas
or DKA comas
Or hyper-adrenal conditions.

For excess potassium terror,
It’s renal OR adrenal failure
Succinylcholine, most types of gangrene,
or a digoxin OD (though that’s rarer).

Or SHH syndrome which can be treated
with fludrocortisone taken as needed!
In long-term; kayexalate
But now, Ca+ gluconate
And furosemide here can’t be beat..ed.

(… okay, I know – but hey, I tried.  HUMANITIES IN MEDICINE, folks.)
*drops mic, spreads arms wide, walks out backwards*

Social drinkers, problem drinkers, and high-functioning alcoholics

I know nothing about anything other than AA.  And I know next to nothing about AA.  So psychiatrists, doctors, med students with a clue, people who have ever had a drink in their lives, whoever – please explain.

Yesterday I finished reading Drinking: A Love Story.  The author said that reading A Drinking Life by Pete Hamill was a major factor in her sobriety, so I bought and read that book last night.

I just finished the last chapter, and am sitting in bed with the cat, thinking about it.

Both authors talk about how muddled the line is between a “problem drinker” and an “alcoholic” – and both had convinced themselves that because they were achieving and maintaining successful careers, they couldn’t possibly be the latter – even though they knew they drank more than most people.

Both authors define themselves as “high-functioning alcoholics” and admit it’s a troubling category.

I agree, it’s troubling.  The DSM doesn’t currently recognize “alcoholism” as being a thing – just Alcohol Dependence and Alcohol Abuse, which is – to put it mildly – completely confusing.  Alcoholism itself doesn’t fit neatly into either category.

But alcoholism, at least, can be shoved into one of those umbrellas – as long as you acknowledge that the patient has genuine social or work problems as a result of their alcohol abuse.

But high-functioning alcoholics don’t.  So what do you call that?  They’re still dependent on the alcohol, and that’s still extraordinarily dangerous.

So how do you draw the line between being a social drinker, a problem drinker, and a high-functioning alcoholic?  

Here’s why I think that’s an important question, and not just a word game:  All of the psychiatrists I’ve talked to about this have said that recovery doesn’t necessarily mean abstinence. Abstinence isn’t even included in the new SAMHSA definition of recovery.

I’m guessing that has more to do with methadone treatment for heroin addiction than it has to do with alcoholics eventually drinking moderately – but the possibility is there.  Moderation Management seems to have been accepted as a legitimate form of cognitive-behavioral therapy, albeit one that doesn’t seem to work in the most severe alcohol abusers.

Is alcoholism so ingrained in genetics and environment that an alcoholic should never have had their 1st drink to begin with?  Or is there a straight line of progression in alcoholism, from “social drinker” to “problem drinker”?  Is “high-functioning alcoholic” a step along the way, or an end-point alternative to true alcoholism for some people?

And if it is a straight line of progression, is it possible to intervene with a Moderation strategy before they hit the alcoholic state?

If so, shouldn’t this be the sort of thing we’re billing to problem drinkers?  “If you keep on the way you are, you may have to go into AA and never drink again.  Sound scary as hell?  Maybe you should learn strategies to cut back now to avoid it, then.  Here’s a pamphlet, here’s a website, here’s a Moderation hotline.”

Seems like it’d be easier to get someone to agree to that then to agree to abstinence.  But would that just inevitably be a speed bump on their way to complete abstinence or death?

The founder of Moderation Management ended up joining AA, relapsing, and killing two people in a drunk driving accident.

Where’s the line, and – in light of the above example – is it worth finding?

Why are Heberden and Bouchard’s nodes named after 2 different people?

(In osteoarthritis, enlarged DIP joints (knuckles closest to the end of your fingers) are called “Heberden’s nodes” and enlarged PIP joints (knuckles you use to knock on doors) are called “Bouchard’s nodes”.  And yes, I really am going to complain about it.)

Medicine is moving away from most eponyms, since they’re generally undeserved and were also inevitably given to some sketchy doctors who didn’t deserve to be immortalized (case in point: Wegener’s granulomatosis.  He was, it turns out, a nazi.

So that led to a 50-year-long awkward moment in medicine.  A moment which has only been extended by trying to rename the disease “granulomatosis with polyangiitis”).

To be fair, some people will try to tell you that, actually, medicine is moving away from eponyms because they’re “so difficult to memorize” – a viewpoint that’s, at best, pretty damned optimistic.  (Fun game:  Go find a physician, resident, or M4 and ask if they think organic chemistry was helpful.  Then, after they finish laughing, ask them if they’d be in favor of dropping it as a pre-med requirement.

… Yeah.  Spoiler alert: they’re not for it.  Neither am I. “Medical education” is practically synonymous with “Sure, some of it’s inefficient, but if my generation had to do it anyway, so do you.”   People who say that “medicine eats its young” aren’t kidding.)

Heberden’s and Bouchard’s nodes seem even sillier than most other eponyms.  Getting credit for seeing some weird manifestation of a disease, I understand.  Getting credit for some weird “you can only see this part of the anatomy if you cut a person open and squint at them sideways” piece of organ anatomy, I understand.

But getting credit for the fancy notion that sometimes when your knuckles are inflamed, they’re enlarged?  That’s ridiculous.  You may as well call a sore throat “Heberden’s throat”.  In either case, regardless of how fancy the pathogenesis is, I’m pretty sure people already knew the symptom was directly related to the disease.

So I looked it up.  Heberden was a fancy London physician from a good family, who wrote a chapter on arthritis in the medical book that was most in vogue at the time.  So they gave him the DIP-joint-is-inflamed eponym.  Okay, fine.

But nearly one hundred years later, the PIP -joint-is-inflamed symptom was – it appears – randomly assigned “Bouchard” as an eponym.  Bouchard was a French pathologist who studied under Charcot and doubtless did a lot of interesting things, but none of them seem to be related to arthritis.  I guess medicine felt like he was such a stand-up guy he deserved an orphan eponym?

If that’s a legitimate action to take when confronted with an awesome pathologist and an unnamed disease, Wegener’s Granulomatosis should just be renamed Goljan’s Granulomatosis.  TWO BIRDS. ONE STONE.

Goljan is a champion arm-wrestler. Hand over the eponym and no one gets hurt.

Bouchard’s nodes are less common than Heberden’s nodes, so maybe we should give Heberden a pass on not noticing that the swelling sometimes happened on the PIP joints. But I’m honestly not convinced that Heberden didn’t notice the “Bouchard’s nodes”.

You know what I think?  I think he was just like, “meh, it’s exactly the same thing in a location just centimeters away, no need to write about these nodes like they’re any different.  It’s not like they’re going to give it someone else’s name.”

Well, the joke’s on you, Heberden.

Joke’s on you.

The Science of Babies

Tonight’s Netflix suggestion:  “The Science of Babies”!

6:50pm:  Fantastic. I had no idea this existed. With a title like “The Science of Babies”, I expect a 3 year neonatalogy fellowship condensed down to 30 minutes. Do not disappoint me, Netflix.

6:51  WILL SOMEONE PLEASE PICK UP THIS POOR CHILD.

"Babies: They come into this world alone."

6:55:  … No?  No one?  We’re still narrating things over a lonely baby?

Correction!  A lonely, CRYING baby.

7:00:  “A human will likely take over 6 million breaths in a lifetime.  But the first is by far the most difficult – AND DANGEROUS.”  Shit is getting real.

7:05:  “Two thirds of baby deaths occur in the first month – a rate not equaled again until the 7th decade of life.”  Poor babies!

7:07:  “A newborn’s vision is cloudy, and therefore limited to about 12 inches.”  POOR BABIES.

7:10:  “Babies know intuitively to hold their breath under water.”  Poor ba- wait, what?

And then there was a bunch of stuff about neurons and synaptogenesis and synaptic pruning, which is all well and good, except facebook.  (Don’t worry, I periodically checked back into the Netflix tab to see if anyone ever picked up the crying theater baby.)

7:30:  (They didn’t.)

I don’t think I got a neonatology fellowship out of this, so in that sense, the documentary was a disappointment.  However, a counterpoint:

Vowels!

… I think the counterpoint wins.

Anatomy: Take Two

After college anatomy, med school anatomy, and several patients with knee problems, I have finally sat down and learned my knee anatomy – but only because I knew I’d have to teach it to the first years tonight.

And in retrospect, I don’t know what was so damned hard about it.

It’s like doing your laundry.  You put it off for weeks, thinking it’s “too much work”, and then you do it and you’re like, “Oh, wait, no – I’m just lazy.”  (… No?  Just me?)

I suspect it seemed too hard because 1) all the initials make it seem like there’s more ligaments than there really are, 2) no one ever shows any simplified diagrams before jumping right to the 100% anatomically accurate stuff and 3) people teaching the knee tend to forget how confusing it looks at first.

Professor:  Just like the ACL, MCL, and LCL – the action of the PCL obviously makes sense.  Any questions?
Me:  Yes.  But only about the stuff that “obviously makes sense”… because I’m an idiot.

But to be fair, I used to teach MCAT classes and I did the exact same thing.  That’s just what happens when you have to cover 3.5 hours of material in 3 hours – you inevitably assume you know which parts are easy for your students, and if you get it wrong, you feel like a total jerk.

Me:  Look at how clear that passage was, especially when there’s so many difficult ones on the test!  This is exactly why you NEED to triage the verbal section.
Students: … *panicked expressions*
Me:  <– in all of test-taking history, never once actually “triaged” a verbal section.
Me:  <– what a jerk.

While we’re on the subject of anatomy, here’s a slide that was actually included in the 1st year’s foot lecture.

I like how nicely it sums up absolutely everything you need to know about med school lectures.

Happy International Brainstem Day!

Last night I studied neuroanatomy until I started feeling a strange fondness for it.  (“Aw, look – the spinal trigeminal tract again!  Bless its heart, it just keeps going out of its way.“)

Then I woke up surrounded by flashcards and with the vague sense that I may have studied myself into some alternate universe where neuroanatomy makes sense, because I still feel like it’s fascinating.

It’s like there’s a magical switch that gets flipped 3/4 of the way through memorization – a switch that makes you realize how everything acts in relation to everything else.  This must be what drugs feel like.  

(Did I finally lose it?  I don’t know.*  Possibly.  DARE to keep kids off neuroanatomy.)

But as long as I feel this optimistic, I’ve decided to declare today to be International Brainstem Day.  Maybe that’ll keep me in the right frame of mind to dedicate today to all the neuroanatomy lectures I’ve been avoiding.

(Actually, I was originally going to only suggest that someone official should declare this holiday.  But then the internet told me that yesterday was Wrinkled Raincoat Day**, and I decided I have to have at least as much power as that person did.)

(Let’s face it – the founder of Wrinkled Raincoat Day was probably a frustrated fashion school student posting on their fashion school blog, and then some “Weird Holidays” website put it on their calendar and legitimized it through the magic of google.)

I bought you a new holiday, and it's AWESOME.

…  Speaking of being legitimized through the magic of google:  just in case some holiday-cataloguing website owner does come across this page, I’d like to assure you that this is Totally A Thing.  I didn’t make it up at all.  It’s heavily observed in Metropolis.  We have.. traditions, and everything.

For example, traditional gifts given on International Brainstem Day: Coffee, unsentimental cards, and sympathetic looks.

Traditional International Brainstem Day activities:  Memorizing the brainstem.

*  Yes.  The answer is “Yes”.

**Plus, according to the same website, today is apparently National Student Day, which is practically International Brainstem Day already, right?.