On the road to Dartmouth for the 4th interview this week and 5th overall. Very tiring. Trying to write down thoughts on programs before I forget.

Lots of questions asking "why did you apply here." Never answered "rather be here than Witchita" which would've been closer to the truth.

Kicked off the interview season today. What an awkward/interesting process. 5 interviews in 5 hours, with 60 students for 4 positions. Good to have one done.

Orthopedic Pimp Questions

Here is a list of questions that I'll add to from time to time of ortho pimp questions I have been asked/heard people asked.

What is the innervation of the three muscles that insert as the pes anseurinus?

What are all the muscles that insert on the scapula?

What is the muscle belly of the iliotibial band?

What is worse regarding ROM lost, a subtalar or talonavicular fusion? (TN)

What composes the nucleus pulposis and annulus fibrosis--in detail?

In the OR:

What nerve is in danger with this incision?

What is the innervation of this muscle? As mentioned before, much more rarely are questions re: origin and insertion asked-- don't waste your time knowing the 3 main arteries to the knee if you don't know the innervation of the tensor fascia lata.

What muscle is this?

Why can't I use the cautery on the Mayo stand? (Only patient is grounded)

What are the layers that I will be cutting through? More commonly asked in gen surg than ortho

As always, feel free to add other questions you have been asked in the comments.

Secrets to Orthopedic Away Rotations

Here is a quick rundown of what I've learned and been told about how to thrive while on an orthopedic away rotation.

First and foremost, as I'm sure you already know this is a tryout. It's a chance for you to try a program on for size, but moreso it is a chance for them to see what kind of resident you might be in their program. It's easy to slip into the mindset that just because you graced them with your presence for a month that they are going to think better of you. Not so. In fact that is why on average it is a lot easier to hurt your chances of getting into a program by doing an away than it is to help your chances. The all encompassing first rule of away rotations is: always work hard.

What are some of the ways you can shine? You can prepare the notes before the resident's arrive in the morning. Perhaps it is just where I am at, but unlike general surgery, it seems that the residents do not care (and may even prefer otherwise) if you see a patient in the morning before they get there. They seem more concerned that the actual rounding process is streamlined. Regarding the OR and pimping, the most important thing to know is anatomy. Most commonly you'll be asked questions such as "What nerve is in danger with this incision," "What muscle is this," etc. Expect more nerve-muscle questions than insertion, origin and action questions.

When in the operating room, assume that once you are given a role once, they expect you to fill it from that time onward. For instance, some common tasks are adjusting the lights, sponging up blood in the field, and using the suction. Additionally, one should be familiar with deep tissue, subcutaneous, and skin closure so that when the attending asks if you are comfortable doing so you don't respond by saying something like "we'll I only saw it once..." Another thing to mention: when the resident or attending moves towards where you are standing, you should move to the other side of the table, they won't always take time to say "Hey can you switch positions with me."

Another OR tip: when retracting don't worry about them repositioning the retractor frequently. It is likely nothing but them wanting it in a specific place and not a commentary on how you are doing. You'll likely notice them doing the same thing with the residents.

The biggest thing that programs are looking for is hardworking, teachable medical students that appear to be engaged in the case or lecture, with whom they can get along with on a day-to-day basis. Most of the time they would rather have the above student as a resident than one that is just the best at answering all of their pimping questions.

Hiking Mt. Olympus

After hiking Mt. Olympus (Utah) today and nearly requiring LifeFlight to get me off of the mountain, I thought I might share a few thoughts that you will not easily find on SummitPost or other similar sites that dramatically oversimplify some of the challenges that you will face. But before I get ahead of myself, here is the rundown of what happened and the mistakes I made.

Starting out around noon (aka the "Hottest Time of the Day"), I parked just down the street from the trailhead, along Wasatch Blvd. I had read on a few pieces on climbing Olympus that there were more cars broken into in the parking lot that there were windows shattered along the street--a rumor that was denied by several people that I met on the trail. But going back to the start time, if you are from a humid state such as the southeast or midwest you will be unpleasantly surprised at how hot it is. The temperatures were in the mid-90s, but because it is so dry here it felt like high-70s and I thought nothing of it.

After starting out at a decent grade out of the parking lot, you enter a series of open switchbacks with low vegetation and great views of the valley. There are a few spots with minimal exposure, but for the most part the trail is extremely safe. In my mind the trail has four segments: the first segment contains mostly scrub brush and grasses.

In the second segment, you enter an area of low trees mixed with increasing amounts of rock that you have to navigate as you climb. In the middle of the summer, this segment also contains your only source of water on the hike in the form of a small stream. Many other sites talk about how it is a steep hike that is only 3ish miles each way, but you would be surprised how fast you go through water, especially if you have not fully acclimated to the altitude.

The third segment of the trail has higher trees, steep grades and significant amounts of rocks in the trail that will slow you down. Many times you are walking in a tunnel of foliage with increased humidity.

The final segment is what I found to be the most grossly underdescribed in other websites. This is the segment of the hike above "the Saddle," a flat segment of ridge that gives great views to the east.

First of all, if this is grade 3 climbing then it's 3.9. The last 45mins or so of the climb is a lot closer to grade 4 climbing than it is grade 3. When I think of grade three climbing, I think of the kind of climbing that is necessary near the summit of many Colorado peaks where you are going up and over some low boulders but would not fall/roll more than 20ft in a worst case scenario. The last bit of climbing on Olympus has significant exposure in several spots and requires at least minimal vertical climbing skill, more than your average mountain hiker may be comfortable with, especially considering many hikers on Olympus are lugging decent sized packs up, which significantly alters one's center of gravity. Never mind my biggest pet peeve about this segment.

Utah. I get it. You are all about the "go for it, and if something goes wrong, maybe we'll be able to help you before it is too late." I also understand the massive amount of wilderness in Utah. But this is probably the second most popular hike in the SLC area! This is a trail that has 12 year olds and 70 year olds on it. And yet there are zero markings as to the trail above the saddle! Not only is this incredibly dangerous, but it also means that you waste large amounts of energy coming back down as nearly everyone takes different paths and has to double back when they hit a 10 foot drop off. In other words it's manageable on the way up but can be disastrous on the way down.

I got in a situation where I was so low on energy that I had to continue down despite the fact that it was much much more dangerous and exposed than the path that I went up on. There were times where a slip backwards would have almost certainly meant broken bones and likely worse. Not only is the trail marked at all, but there is a grand total of two cairns to help one navigate down, and one of them is next to the mailbox at the summit! It's no surprise that in the past few years a number of people have died.

To wrap up my meandering story, although I brought plenty of water I quickly dried up the available calories in my body and became so nauseated that I could not get a dry granola bar to go down--so I called for help. Luckily as the trail is mostly on the valley side, you should be able to get help if needed. I had become so weak that I was afraid of falling down the trail, even though I was back in the 3rd and slightly less steep stage. I had to just sit and wait until my friends could help me by bringing some zofran (anti-nausea) and some liquid energy.

Was much of this my fault for leaving on a hot day at the hottest time of day? Yes. Should I have brought more calories with me? Yes. Are there dangers inherent to climbing Mt. Olympus that are not described on other sites? Yes. I hope that if you are like me and searching out info about the climb that you be sure to start early, budget extra time, and take extreme caution above the Saddle area if you plan on summiting. Multiple people die here every year, if you are like me you may underestimate how difficult the grade is, especially if you are used to the typical Colorado 14er which rises a mile in 7 or more miles walked. Feel free to share your Olympus stories in the comments section.

PS these images are my own, please do not copy them onto other websites without permission as they are protected.

Last Objective Medical School Ranking

Here is the last time that the NIH compiled statistics regrading research dollars to specific medical schools. Harvard ranked 26th... I'm sure they have a great personality.

Medical School Rankings / Top Medical Schools

Every year US News and World Reports ranks medical schools based on a complicated process of assigning varying values to different criteria. For instance, how much research is performed at a given institute is put on a scale of 1-10. Quite frankly, this is a very asinine way of going about things.

What they really did was determine what schools would be considered the consensus top 5 schools based upon reputation alone (Harvard, Hopkins etc.) and then devised a system where these schools ended up on top and the rest of the medical schools fell into place somewhere behind.

Does anyone look at these from year to year? Oh look! Harvard is back in first this year! Hopkins sure had a good run going! How ridiculous! But they can do one better!

Now the braintrust over at US News has created a ranking system even more backwards. Did your 2 years of advanced chemistry during undergrad foster an interest in Geriatrics? Better find the best school for preparing you for your future career! Never mind that 99.999% of students either change what specialty they were interested in or seriously consider other options.

And how would you rank medical schools for how they prepare you for a career in geriatrics. Do some medical schools have especially old cadavers? Is the average age of the faculty >65?

Here are my thoughts: talk to medical students, talk to doctors--evaluate the advice they give you and see if it applies to you. At the end of the day it really doesn't matter where you end up. Got into Hopkins, Penn or Harvard. Congratulations! Now whenever you introduce yourself people are going to think that you are either grandpa gave a sizable donation to build a new library, or that you sold yourself as some oppressed Eskimo-Latino who grew up as the son of toilet assembler only to survive mean streets of Malibu and USC.

In other words, you are probably better off going where you know nothing is going to be handed to you. Newsflash: in California they won't know the difference between Wright State and Wayne State, so you better spend your time in med school wisely, e.g. study hard for Step 1 and get some research done during your four years.

Your thoughts?

A Funny thing Happened on the Way to the Cadaver Lab: An Open Thread of Interesting Hospital Occurrences

I've mentioned a few stories that have stood out to me in my four years of medical school. Now it's your turn--through the years hopefully we'll come up with some good ones. Other health-care workers feel free to share your funny stories.

Saving Money In Medical School

In medical school one is given large loan "disbursements" at two times every year. Because very few people have any other source of income, you can minimize the amount of debt that you end up with by following several rules. I'll list them from most-to-least insightful:

1. Invest Extra Loan Money

At every disbursement, transfer 50% or so of the money into a brokerage account. This helps in many ways. First, since the money is no longer in your bank account, there will be a psychological effect of thinking that there is less money for you to spend. In effect, even if you aren't one to make a paper budget, we all still spend with an idea of how far we need to stretch out our money.

The second benefit is that many of these brokerages, such as TD Ameritrade (which I use), will give you 5 free trades. What this means is that you can transfer your money into a short term CD, safe stocks, or a mutual fund without paying $10 to put your money in and take it out.

Of course, they hope that you fashion yourself Gordon Gekko and move your money in and out of different stocks, thereby making 6+ trades and giving them money. You are smarter than that. Additionally, if all you do is move 50% of your money into the account at the start of the year, you will get close to 1% in interest, which is better than you would get from a bank's savings account.

In short, if you can put the money into a CD or mutual fund you may even be making money on the loans (depending on the interest rate), which is much better than losing 4-6% as the interest piles up in a checking account.

Feel free to compare TD Ameritrade to other sites, I like them and they are not giving me anything to push their site over any other.

Not a good idea with loan money:

2. Make a "Per Day" Budget

Take all of your monthly expenses: rent, car payments, gasoline, groceries, cell phone bills, etc. and put them in an excel spreadsheet. Then divide them by 4.3 (or whatever Google tells you is the number of weeks in a month) to show how much each thing costs per week. Then break that down into per-day expenditures.

Not only will this give you a rough idea of how much discretionary money you have on a day-to-day basis, but it may also give you insight into areas where you can save. For instance, my wife and I found that we could save close to $3,000 if we were able to pay off our car loan early.

You may find that you are saving more, if only to see the amount that you could be saving per day increase. In other words, it can become a game where you are rewarded for saving, by picturing what you could do with that money, e.g. spring break trip or new bike.

Hope these are helpful, they have both helped me tremendously, feel free to post other tips in the comments section.

Can I Get Into Medical School? An Open Thread

I thought I'd make an open thread for prospective medical students to ask questions and I'll do my best to answer them a-la Dear Abby. Feel free to post other experiences/frustrations you have had in trying to get into medical school.

If Shelf Exams Actually Were Representative of What You Saw in the Wards

Pediatrics

1. A 7 year old female presents to the clinic with a three week history of looking "not quite right." This is her third visit in the past four days. The patient's mother is on disability due to cologne exposure at work, and the patient is uninsured. Her mother states that she has been having fevers as high as 37.2 (99) degrees and has been having early morning awakenings, e.g. 8am. Physical exam, family history, and past medical history are benign, but limited due to the patients use of her Nintendo DS during the exam. Her mother states that she had a cousin who was sick with HIV that felt better after receiving antibiotics. What tactic might keep the patient from returning to the office in the next 24 hours.

a. Give gentamicin, hope for an adverse effect that requires a ENT consult

b. Tell the patient the office will be closed for the next week

c. Give the mother a prescription for Valium

d. Put them in the waiting room for 4 hours before telling them their rapid strep was negative

Surgery, Medicine, Neurology, Family Medicine:

2. A 46 year old male presents to the clinic with unbearable pain. He leapt unto the exam table like a Russian gymnast when no one was looking but now winces and moans in pain when the stethescope is placed on his chest, despite the fact that he complains of knee pain. All radiographic studies have been negative. He begins the interview by offering that he "isn't looking for pain meds or anything." In fact, he's never been better--in order to keep feeling better he just needs a few more vicodin to get him over the hump. When you ask how much he would need for a month he says "I don't know man!" When you write a prescription for sixty 5/500s he goes ballistic and accuses you of not "understanding" how much pain he is in. His unkempt wife sits in the corner shaking her head scoldingly. What is the next step.

a. Keep the patient from getting between you and the door

b. Refer to chiropractic care

c. Give daily cortisone shots for a week

d. Recommend physical therapy

to be continued...

Amazon Seller's Account (or The World's Worst Customer Service)

Being a medical student, you go through a lot of books. From the first day of school when you are told to purchase a dissection guide, Grey's Anatomy, Netter's, and a book of pictures of dissections, we collect lots of books that are nice to have for the 4 months of the course but have little value otherwise.

I thought I would be forever condemned to keep bookshelves full of useless materials--then I found the Amazon Seller's Account, but first a little background.

I've been buying books off Amazon for years. I'd estimate that I've spent a couple thousand dollars, both on books for myself and medical books that I've needed for courses. So you can imagine how excited I was to find a seemingly easy way to resell the books.

So within a few minutes I had opened an account and listed all of the old books that I wanted to get rid of. Keep in mind I had never opened an account before. Imagine my surprise when I received this email from Amazon within 6 hours of opening an account.

Hello from Amazon.com.

We are writing to let you know that we have blocked your selling account. Your open listings have been canceled and you may no longer sell on our site. Any subsequent selling accounts that are opened will be closed as well.

We took this action because it has come to our attention this account is related to an account which has been previously blocked for performance issues or violations of our policies. While we do not provide detailed information on how we link related accounts, we have significant evidence that this account is related to a previously blocked account.

While we appreciate your interest, please understand that the closure of an account is a permanent action. Thank you for your understanding with our decision.


Regards,

Seller Performance Team
Amazon.com

First off, who's idea was it to send out form emails like this to valuable customers, especially if there was a chance they could do it in error. For someone who puts value in their word in commitments they enter into, it was very offensive to hear these baseless acusations.

Clearly Amazon had made a mistake as I had never opened an account in the past. I expected that a quick email would be all it would take for them to correct what must have been a clerical error--how wrong I was. Here's the next email that I received in response.

Greetings from Amazon.com

I have verified that your account has been blocked by our Seller Performance team on January 30, 2010. Please e-mail them at seller-performance@amazon.com regarding the status of your account. You may also reply to the block notice in the Notification page of the Customer Metrics section in your selling account

For more information, see our Help page on Appeals for Suspended or Blocked Accounts:
http://www.amazon.com/gp/help/customer/display.html?nodeId=200370580

Questions about your funds should be directed to our Payments team at payments-funds@amazon.com.

These departments do not offer telephone support. However, they will respond to your e-mail as soon as possible.

For more information on your Seller Performance ratings, please visit:
http://www.amazon.com/gp/help/customer/display.html?nodeId=12880481

Thanks for being part of the Amazon.com online community. I do hope this message finds you well and I wish you all the best in all of your future online sales.

Best regards,

Carlos V.
Amazon.com Seller Support

Clearly this was another form email--Amazon may not have any problem accusing people of wrongs they haven't done, but I guess they have difficulty actually responding to emails sent in response.

In my final email I stated that because my issues were in no way addressed I would be canceling my Amazon credit card and never purchasing from them again. Here was their response (note: in my email I never mentioned being "singled out" this must've been their email they send out to people who don't just give up and allow their name to be dragged through the mud..

Hello from Amazon.com.

We apologize that you feel singled out by our actions, but want to assure you that is not our intention. Be assured that our policies apply to all sellers.

We regret we are unable to provide further information on this situation. Further correspondence regarding the closure of your selling account will not be answered.

The closure of this account is a permanent action. Any subsequent accounts that are opened will be closed as well.

Best regards,

Seller Performance Team

Needless to say, if others are dealing with this problem, Amazon is going to have some PR difficulties in the future.

Update: This is the 5th ranked site in Google when one types "Amazon Seller's Account"! Which is great! I feel like in some small way I am "sticking it" to "the man," for how despicably they treat their customers. If reading this and having a similar problem, please share your story in the comments section so as to help get the word out.

Young Hearts and Lauren Hill

Yesterday we had a review of EKGs. When discussing EKGs the cardiologist mentioned that "Young hearts may demonstrate U waves." All I could think about was asking him if young hearts beat free tonight.

A week ago a woman named Lauren Hill came to the hospital to teach as about diversity. I wanted to ask her if she was familiar with the fact that: girl you know you better watch out, some guys, some guys are only about. That thing, that thing, that thiiiing.

I'm easily distracted.

The Ambiguous Psychiatrist Sound

What do you do when your goal is to elicit as much information as possible from a patient while neither supporting nor condemning their thoughts/actions? The answer is the ambiguous psychiatrist sound.

It's somewhat hard to describe if you have never heard it firsthand, but I'll do my best.

It somewhere between "Mmmm" and "Hmmm" but it isn't just the combining of the two sounds "Mmmmhmmm" because if you aren't careful "Mmmhmm" can come off as sounding condescending or disbelieving.

Instead it is almost an impossible fusion between the two sounds. As if you could be saying both Mmm and Hmm in the very same instant. It's best used with a gutteral, breathy not to disguise any possible inferences that a patient could possibly derive from the sound. Additionally, the best psychiatrists can include an almost imperceptible rise in pitch at the end of the sound to further confuse the patient as to whether it was questioning or affirming.

It's like saying "I respectfully want to inform you that I'm listening but I want you to clarify, if you are able" but with the simplicity of one syllable. In short, it is the perfect sound in the hands of a skilled practitioner and it can work wonders on the psych ward.