The Final Countdown

So, I wrote my Step 1.

You know, in retrospect, it sounds like an fitness instructor certification exam.

Step 1

Once my scores come in, my opinion may change drastically to one of the following:
1) Well, at least its average
2) WOOOHOOOO
3) WHAT IN THE &*$&#@$#

That being said, considering I must have set some kind of record for time spent studying in prep for the step 1, the exam wasn't that bad. At least, not until the 7th hour. But I digress.

First: neither Uworld nor Kaplan Qbanks quite match the Step 1 in terms of capturing the essense of the Step 1 questions. More so than I expected, Step 1 questions included many that were either sincerely simple, or were deceptively simple. Several questions were often presented in a way that appeared difficult (ex: having multiple graphs in a single question) while actually asking for a very simple analysis. Compare this to Uworld, where I would diagnose 35 cases of rare cancers in a single block of randomized Uworld.

Second, I was much more calm than I had expected. Over my first two years, trouble sleeping and pre-exam jitters were the norm. Even before my Comp exam, despite spending a generous amount of time studying, I still had trouble sleeping. But I was calm as a cucumber on the day of the step. Even did a tiny block of 10 questions in the morning just to get my brain churning (8/10, baby!). I looked over First Aid in a coffee shop while waiting for the exam room to open up, and while I would have thought that detrimental, I actually had 3 problems come up on things I just reviewed that morning and may have otherwise forgotten. Why so calm? Probably just the vast amount of questions I had done. While I had done some blocks before the Comp, it was still a smaller number than I would have preferred otherwise. However, I left a lot of time in between the two for me to go through question banks.

"Do questions" is advice I have often heard. My first try at it, which was right after the basic sciences, was one of confidence. I felt as if my base knowledge was so full of misconceptions or gaps that doing questions did not aid me. Learning nit-picky details and unexpected drug interactions (EBV + penicillin causing a rash, or the opioid Meperidine contributing to Serotonin Syndrome, etc...) was knowledge, but it seemed like facts heaped upon a larger pile of unsteady facts. I was lacking in confidence in my own knowledge of these pharmaceutical products. After taking a Kaplan course, and doing lots more questions (both Kaplan and Uworld questions) I started seeing archtypes of questions and presentations. Sure, there was the oddball here and there, but just getting used to the common types of questions helped immensely. Additionally, my recall of key facts increased in speed and accuracy, and I ironed most of the misconceptions I had.

 Will simply running through thousands questions help, then? Probably not. Having spoken with IMG colleagues who did into the exam after racing through question banks (4 blocks a day?!?) their performance was average at best. Having a deeper understanding of the answers requires time and patience. Additionally, simply memorizing First Aid or DIT may not help.

The Step 1 was, unexpectedly, a much more conceptual exam than expected. Thinking about the big picture is required, though I have never come across any resources that could reduce the idea of thinking "conceptually" to a few core points. I'm not sure how it can be taught, if that is even possible. I want to expand on this, but my memory has already of those questions has already started fading. Sorry :S

Finally, the last two blocks. Wow. After having a few minutes left over at the end of the first 6 blocks, the seventh was when I started running out on time. I could both see and feel myself slowing down, and my anxiety rising. I normally skip a few questions in each block that are either long or tricky, and return to them and spend more time on these. But by block 7, I started skipping a lot more questions. After reading question 46 on the block, I looked back and noticed that I had flagged many, and left many others blank, with only minutes left to spare.

Typical anxiety reaction.

Why do I think this is typical? Because a study buddy of mine with anxiety issues displays the exact same behavior. It takes a lot of concentration and coordination (which are not exactly plentiful after 6 hours of exam writing) to force yourself to slow down, take your eyes off the screen for a bit, breath, and realign both your body and mind. It was not my recall that was hampered; rather, I lost the ability to hold all the facts in my head and approach the problem from different angles. I forced myself to start reread words three or four times for it to stick and actually click.  ("despite not changing habits, patient has weight loss. weight loss. weight loss. weight loss. oooh maybe its cancer"). However, these two blocks felt significantly more difficult than the rest, and had some presentations that I would be hard pressed to narrow down even on a good day.

I finally walked (more like hobbled) out of there. Never to return.

And at least it is over now.

What do you mean 'Step 2'? What the hell is a Step 2?

No. NO. NOOOOOOOOOOOOOOOOOOOOOOO.

Best of luck on your endeavors .

-Arthur : )

Adventure Time

a) Regarding the recent Obamacare/Affordable Care Act rollout:

b) Everything else
Weeks of my life are melting away like ice cream on a hot waffle.
Money runs out of my pocket like ice cream running down my cone and staining my clothes.
Its 9:30 AM and I really want ice cream for breakfast.

Since last we spoke intimately by a fireplace (through laptops that signal each other using both wireless and wired connections), my attention span and energy had dropped. Perhaps its because I have been studying for this test more than three times as long as the average student. The post-comp efforts waxed, then waned. But as soon as I set my Step 1 date, everything changed.

Just having that set date in the future alters your perception of the world. The work becomes finite, within reach. I have been going through Kaplan Qbank, and plan to finish USMLEworld a few days before my exam.

Dear Step 1:

In the meanwhile, I have been trying to collect paperwork for my post exam residency, mostly in the form of health documents. For the uninitiated, the $900 step 1 results take about a month to process (because multiple choice questions were obviously not designed to quickly and cheaply transmit results). After that time, my med school will verify all my documents and send me on my merry way.

Unless, of course, my other documents are not ready.

Among the documents required:

a health assessment form
PPD (tuberculosis) test (~$40)
flu vaccine
signed certificates for i) ACLS ii) BLS
HIPAA certification (via METS inc.)
Infection control certificate - ICC
passport photocopy (for canadians)
passport-sized photo
CV/resume
titers to check for my immunity against MMR, VZV, Hepatitis B
health insurance

So yes, I have been running around trying to get everything ready.
The ACLS/BLS/HIPAA/ICC were simple, as my school had organized them and delivered the documentation to us. After signing the ACLS/BLS, scanning, cropping, and saving the photos, I had to go to Myross.rossu.edu portal, upload them into the 'askross' system under clinical rotations-->health documents, and pray to various deities that the faculty does not misplace them (because THAT HAS DEFINITELY NEVER HAPPENED BEFORE THREE TIMES DURING MY ADMISSION CYCLE. ARTHUR, YOU ARE BEING ODDLY SPECIFIC. REALLY I HADN'T NOTICE).

Passport sized photo should cost $10 to get at Costco/Shoppers. I had an old one but...well....the photo looked like I had just been arrested for a felony bad hair day. I might just do this at home.

The titers...no please anything but this again.
As a Canadian, you should know that only Public Health (a government body) is licensed to test for titers in Ontario. Thus, every lab in Ontario sends their blood samples to Public Health. When I last spoke with my doctor/nurse/lab tech, they told me that Public Health only does qualitative testing--->goddamn it.

Qualitative testing means that your results come back as "Positive" or "Negative" for immunity against whatever antibodies you test for. Ross (and likely most american institutions) require Quantitative testing, where it gives an actual number to represent how many antibodies you have, instead of just a 'positive' or negative'. Its not that important a distinction in the long run, but the school has stated a number of times that qualitative tests are insufficient.

So herein lies the problem. I was hoping to do what I had done last time I was in Miami: go to a medical laboratory, have my blood drawn without needing a prescription (and paying out of pocket because my Aetna insurance wouldn't cover it).  But that's not happening. All the US states within driving distance all need prescriptions. Also, almost all the medical laboratories in those nearby states are run by people who want to run their business into the ground.

Over a period of two days, I found out:
a) 90% of those phone numbers are disconnected
b) 80% of the connected phones did not have anyone there to speak with
c) 100% of the people that picked up could not give me any information on pricing

So, just as I was about to start planning my trip, a friend advised me that her doctor in Ontario was able to specify to Public Health to give quantitative results.

Hold. The. Expletive. Presses.

So does this mean my doctor just doesn't know how to specify this? Or maybe I wasn't clear enough last time? This comes as a shock, because every other Canadian student at Ross that I have spoken with was not able to get their results done quantitatively in Canada. So, now to follow up on that.

Anyway.

Other problems: Aetna insurance is only valid for students that are currently enrolled. Like a large number of students studying for the step 1, I am in temporary withdrawal status, which means I don't have my schools valid insurance, and won't until the spring term. BUT in order to complete applications for track rotations for the coming term in February 2014, I need to have a photocopy of an insurance card by a November 29 2013 deadline. Catch-22. So I suppose I will need to buy temporary insurance (goodbye, money), until I can get an application in (which won't actually guarantee anything), and IF I get a rotation anytime soon, THEN my school insurance kicks in. But to be honest, I don't even know where my school insurance plan stands.

If you ever wonder why, despite all the numerous grants and plentiful forgiving bank loans, there are so few med students from lower income families, feel free to mention the odd costs aside from tuition/rent/food/textbooks that other people forget to consider:

-examination costs (a little under $900 for the Step 1, much more for Step 2 and 3)
-health care documentation (~$80, depends on your doctor)
-PPD test (~$40)
-flu shot (free if you have OHIP, the standard medical insurance residents of Ontario have)
-titers (probably a little under $100)
-US health insurance (I have no clue)
-study aids ($200 for Uworld alone, up to $7000 for top-tier review courses)

So realistically, expect to spend $1500 just to be allowed to take a test and send in a bunch of applications.

Until next time!

Fix it FArthur

My current hobby: keeping track of each error (or potential error) I come across in the Kaplan USMLE Step 1 textbooks (copyright 2011).

At the moment, across 6 texts, I've come across 24 potential errors. The majority are typographical errors, a few formatting, one error that gave an incorrect fact, and one question whose explanation continues to evade me. I know that First Aid gives monetary compensation for every error in its book. I've inquired Kaplan, and they've sent out mixed messages ranging from "no" to "free review book". So, we will see.

So I finally finished all of the histology that wasn't covered by Kaplan professors. It took...uhh...longer than it was supposed to. ie all the time I wanted to give towards actual anatomy that I've studied before went into histology. That isn't doing wonders for my current Kaplan-endorsed schedule.


Edit: found another factual error

Bad Title

It's been a while since I've posted anything.

It will likely be a while longer until I post anything substantial.

Kaplan was a decent course.

Main things I noticed:

• There is information covered in Kaplan that did not appear in First Aid, and vice versa. 
• This is supplemented by the fact that Kaplan suggests spending 30 minutes each night reading First Aid
• I can't speak for the content of the course. It seems good enough, but what degree of that is tested is anyone's guess.
• My main complaint was from rescheduling. It only happened a few times, but keep in mind that I only have 1 day off per week, and a good chunk of that is supposed to be mental recovery. So when that becomes booked off, I can't suddenly make up the time out of nowhere.
• The course is nicely integrated to the same basic level. One professor's explanation of some mechanic in one subject did not contradict another professors explanation in a different topic, which did occur at Ross a few times. In a few instances, one prof would even mention a concept taught earlier by another prof. They knew each other's material well, and the textbooks were also consistent.
• I had heard complaints from one or two students that certain professors didn't spend enough time explaining the process behind diseases, but in all honesty, there is only so much time.
• Things I would hope: Kaplan would integrate their book into some flashcards. Or rather, they wouldn't try to sell the flashcards seperately after I dished out a significant amount of cash.
• Pharm has never been my strong suit, but after making some of my own cards and going over them all (which caused me to be 3 days late into my schedule) I finally improved my pharm score, which has been one of my bigger weaknesses. Having cards I could alter would have saved me a lot of time. I'll probably post them up here when I've gone through them a few more times and caught any big errors.
• The next big weakness is to finish biochem, as I couldn't catch up to the last 3 big chapters in time. Which Kaplan shovelled all into one day, after mentioning they were the most high-yield chapters. And also re-learn all the first few chapters >.>

But the current task at hand: finish all of anatomy. Today. No clue how :P

Feeling: not much at this point. Just focus on the goal at hand. My spirit feel blunted, but then again, this might just be what I've always been. Its been a long time since I've felt joy. I think it was when I was on a boat.

Probably the more annoying thing is the general pain. Muscle pain is most places. I feel weak. I'm so flabby I could have been a stand-in for Flubber. Living isn't necessarily something you work towards, as much as it is something you do. If I was spending a longer time studying, but also had a decent quality of life, I wouldn't have much to complain about. But this....this is something else entirely.

Probably the more annoying thing is the general pain. Muscle pain is most places. I feel weak. I'm so flabby I could have been a stand-in for Flubber. 

My only hobby in the last while spending the occasional hour trying to fix broken things in the family car. 

After a week of not having a single error light on the dashboard (yeah, I patted myself on the back), 2 lights both popped up again. (I had to shake the aforementioned pats off the back. They were dirt on my shoulder).

I feel like my good intentions in January-March back may have cost me a few months of my time. My time spent studying pathology on my own felt like I finally began understanding much of what was I didn't understand before, but it didn't translate to increased test performance. Physiology received the most time, and likewise the greatest boost to my score. Cardiovascular also improved slightly, but not enough. It seems like everything else was a waste of time.

Thus far, I've probably spent more time studying than 2 students combined, and my schedule predicts I won't be ready until I pop a third student under my belt (awkward phrasing). Then again, as an IMG, I probably need it. Not unlike Kaplan, Ross keeps cutting here and there, but there's only so much fat you can trim before you are left with meat, and then only bone.

When the going gets tough, I try to remember a quote attributed to Marcus Aurelius:
"What is there in this that is unbearable and beyond endurance?"

I have it printed and taped up to my wall.
Just dive back in there, amigos.

Aplan-K

It has been a loooong time since I've written anything.

It has also been a loooong time since I've spent a day off in front of a computer. I tend to actually just leave the house on that one sweet day off per week.

So what happened to me? I bit the bullet (is that phrase appropriate if its in the past tense?) and enrolled in a Kaplan course. The lack of significant upward progress in my score after months of study was worrysome, as were disappointing results from friends that had taken the Step 1 with the same amount of I had to study, but had received lackluster scores. I would like to imagine that the Kaplan course was just a small sum of money, and that the time investment is minor in the long run....actually, I'd rather continue believing that fantasy for the moment. I do know most of my friends will begin their rotations before my course even ends, so...I guess that clocks me in as studying nearly 10 months for the Step 1. Wow. That has got to be a record. Guinness Book, anyone? (I'll also settle for a Guinness)

Kaplan itself isn't a bad course by any means. Having studied a good chunk of the material before, the lectures alternate between "uhn, he has been on this topic I know back to front for 30 minutes" to "wait wait slow down." Often switching between seconds. The Classroom Anywhere option was a nice option at only 4 hours lecture per day, because I absolutely hate 8 hour days where I am too tired and just disgusted at the thought of revisiting material. Heck, I've even got a study partner that uses Skype. (Though, at the moment, she took a nap and her computer has shut off without a means of my contacting her. And class starts in 5 minutes. Oh boy.)

Not much else is new. After having to stop attending exercise classes in the evening due to scheduling conflicts with the Kaplan course, I have yet to partake in any exercise, which annoys me to no end. After dealing with a scummy gym recruiter, and realizing I barely have enough hours in the day to review the previous days material, I have been hesitant to drop cash for a subscription. The only positive note to look for is a slight interest in improving my physical appearance as of late, be it through new clothes (purchased for the first time in two years!), cologne (not quite yet), and even some skincare products (soap!).

So...blah. What are my lady and gentleman readers busy with these days?

Its been a long time since I've written anything.

I flew back home, having grown tired at the lack of good progress I had expected from living at my own place in Florida. I settled into a study schedule. Started taking some exercise classes at night. Started working with more practice  questions (which I still despise doing).

And finally, I took the comp. I felt pretty good going in, despite not being altogether confident in a few of the low yield subjects. And I walked out feeling like a squadron of pigeons had just completed the death star trench run and released a poop missile straight into my forehead.

Its odd. Uworld supposedly has questions very similar to the Step 1, and the NBME is supposedly very predictive of overall step 1 performance. Yet, with the exception of two questions, I felt that the comp questions were unlike most that I have been practicing over the last few months.

Similarly, I felt that this newest comp was more difficult than the last. Or maybe I just had a better idea of what answers I knew, and what answers I knew I didn't know. There were definitely oddities, like the lack of any questions on diseases typically covered in biochemistry (ie Pompeii's, Galactose metabolism, lysosomal storage diseases, etc), instead opting for somewhat more bizarre topics.

I haven't received the results of the test yet, but I know they are arriving any day now. In the meantime, just focus.

Focus.

Focus.

and breath.

https://sites.google.com/site/microbeinvader/

This is a step in the right direction: making learning fun and with more short-term benefits.
I can't vouch for correctness, but the game seems well-designed.

Now, I don't know if studying for the Step using a videogame is a particularly good idea. But its definitely a novel one.

Foodie

I've been lying in bed for 2 hours now, waking up with what feels like a grade D hangover. Tired, feeling like my house suddenly came to life, and its rectum is situated directly over my bed (On a completely unrelated note, a bird shat on my yesterday morning. Not a great way to start the day). The thought of reviewing another organ system was about as appealing as peeling an eel.

My current mood probably has to do with the fact that I didn't have enough to eat last night.

Thinking back, my food situation in my new apartment has been rather inefficient. Unlike my last apartment, the additional roommate meant even less space in the fridge for food. More of my food gets lost in the vortex of hidden fridge space until it goes bad, or it has to sit out on the counter. Additionally, the pots and pans here are much smaller as well, which means I can't prepare enough food for a week in one sitting. I've essentially had to prepare between 1-2 meals at a time, which takes up a lot of time. And finally, my preferred grocery store is now a few minutes away. This wouldn't be a problem, save for the fact that I don't have a car. I simply pack as much food into my backpack as humanly possible, and then carry it all home. Occasionally, I have to make 2 trips, and my last attempt at grocery shopping was so frustrating that I never bothered to come back for the second round of shopping.

Ergo, I am currently alternating between breakfast and lunch continually.

Anyways

In other news, the laundry situation has been an improvement. I replaced my last detergent with something that doesn't seem to cause my skin to explode. I don't know how much of my clothes I'll be able to bring back to Canada, as my books already exceed my luggage weight limit. When I return to the states, I plan to supplement my 8 pairs of mix-and-match socks with just a few pairs of new sock/underoos. The following are pricier than what I usually go for, but have great reviews in terms of comfort and durability.

Socks

Undergarments

Finally, tomorrow is Valentine's Day. You know what that means? Next week, I'll have access to a ridiculous amount of discount chocolate. For those of you that have a significant other, I would recommend a holiday card from the heart.

Uberty

I'm at a wierd place in life. My body is changing. It yearns for lofts, and steamer trunks, tables made from salvaged wood, and color schemes. It demands better coffee and clothes that exist outside of the category of "hoodie". I fear I might be going through Urbanuberty, puberty's lesser-known cousin.

Looking at some pictures today:

 I came across this textured wallpaper

as well as these invisible bookshelves

and this...whatever its called. Vanity tray? Club bathroom imitation?

All three seem easily doable. The bookshelves are from a Norwegian (autocorrect is having a fucking field day with that word) company, but it doesn't look like it would be hard to weld something similar. The textured wallpaper is the only thing that can't be scrounged together from spare parts of goodwill.

Anyways. (and yes, I use anyways as often as Kurt Vonnegut "so it goes".

a) I am out of food. I need to go grocery shopping.

b) I noticed that I can have a very tough time getting started some mornings if I don't talk to someone. Its very odd. All it takes is a 3 minute conversation and I'm good to go.

c) I've had trouble with waking up early in the morning for the last week. Yes, pretty much the entire week. Probably because of stress. A friend suggested that instead of sticking to strict schedules, I should just start working when I feel like it. Its been somewhat helpful, if not in sleep, at least in motivating me. I started getting work done for the first time in 3 days. Then again, it might have something to do with the fact that I took 2 days off.

This actually reminded me of a conversation I had with another student. It seems to me that among Caribbean med school students, I've come across a few groups of students that applied. The following two were the more interesting. 

One group was impatient. I don't mean to say that they suffered from a personality trait; rather, due to various life circumstances, going through the traditional route to a North American med school was not feasible. Truth be told, many people can go through 6 years of studying and waiting just for their application to hold any potential.

Notable examples:

• One student was a fully licensed doctor that wanted to specialize in a new field after practicing for +20 years. His university credits were no longer valid, and thus he would need to go through an additional 4 years of undergraduate college/university just to apply to a US med school. 
• One student had applied for 2 years in a row, and while getting an interview to a US med school, her MCAT scores were about to expire and she wanted to move on with her life instead of being stuck in limbo.
• Several students had families, and were unwilling to have them spend years waiting while the application inched forward

A second group just had problems. Bright students, but with factors beyond their control. For some, that meant financial issues or difficulty accessing a loan for a US medical school. For others, it meant psychiatric or social issues that prevented them from excelling all the time. A history of anxiety/ depression/ ADHD/ bipolar disorder/etc...  likely affected their performance in undergrad and kept them from having a competitive application for a US med school. Regardless of whether the issue was under control or not, the rest of their life was derailed by something beyond their control. Ross has a hit-or-miss in terms of addressing some of these issues. They do have staff dedicated to helping students with certain issues, as well as counselling services, but they are limited in high quality staff.

So maybe I don't function well with only 1 day off per week. I'm just inefficient like that. Oh well. 

I'm sure there are other groups, such as those that were pushed into the field by their parents, but I haven't directly observed this phenomena at Ross.

So it goes. Uh. I mean, 

Anyways...

Interesting read, in case you want to keep procrastinating.

Rxercise!

The cycle seems to be repeating again. Woke up at around 6:30AM today, despite alarm being set for 7:30 AM. Blarg.

Looking at possible causes:

-I exercised later at night than preferable
-
-
-yeah that's all I got

Asking a doctor about my observation

I blame my decision solely on my preference to go gymming at 8PM. Why, you may ask?

To ask "Why?", press 1 now.

To just sit there and keep reading, stay on the line, and a representative will be with you shortly.

We are expecting longer than normal call volumes. Just stay on the line and we will be with you shortly.

How I Met Your Mother airs on Mondays at 8. That's the reason. Yes, I watch the show. Yes, its suffered somewhat in quality. Yes, it makes cardio workouts a lot less boring.

Anyways, after the cardio I tried doing a few squats. I've been on an endless quest to try and squat with proper form. My first attempts in university used videos and advice given by people who sadly didn't know what they were talking about. The advice "don't go below parallel" contributed to an annoying amount of knee pain I've felt over the years. Poppycock, I say! My attempts on the island's gym were thwarted when I began focusing on continual increments in weight plates, as opposed to how my body felt. After some back and knee pain, I finally stopped following sharp right-sided abdominal muscle strain, which I feared was a hernia at the time. In Miami, I came across a fellow that gave one or two suggestions, and also purchased a better book.

Each time, I try to incorporate the previous lessons I have learned. It actually reminds me a lot about medical education. Some facts/advice comes easily and a student understands and integrates into the thought process, and others are read but not consciously incorporated. Facts/advice that is easily understood usually forms the backbone of our understanding of topics, but at a cost that students may rely on this information at inappropriate times. Sort of like using a hammer that I understand well (hit the small pointy thing into the not-pointy thing) when what I read is a screwdriver.

A Uworld question comes to mind that asked about maximum pulmonary vessel dilation in relation to the respiratory cycle. I thought back to the cardiovascular cycle, where during inspiration, pulmonary vessel dilation reduces the blood going into the left atria, causing a decrease in heart rate. Thus, I assumed that pulmonary vessels would be maximally dilated during inspiration. The majority of other students chose the same response as I did, and similarly got that question wrong. The correct response involves understanding the pressure/volume curves of the lung/chest wall. This is why doing questions are an important part of many sciences. Its not that one fact is wrong, but rather, not all facts are equal, and thus the right fact is necessary for the right process, to answer the right question. I believe this is all part of the meta-test; you aren't simply learning pathways, processes, facts and associations; rather, a lot of the implied training is having your thought processes line up with those of the test-writers. 

Anyways. I wonder where others are at incorporating sensors to help visualize and keep track a body while lifting. Seems like a fun project for when I get back home.

Oh, nearly forgot. I was musing on Kessler Syndrome yesterday (a potential phenomena involving debris flying around earth). Creating a hypothetical solution to this also sounds like a fun problem.

So many decisions...

No, not the movie Ted

Came across this Ted Talk by chance. He mention some of the stuff I've discovered on my own, or have read about from earlier readings, but also incorporates the tiniest bit of new physiology I hadn't come across before. Of course, physiology is a giant box of blarg that he barely touches on (with the exception of cardiovascular physiology) and I wish there was more on this.

 Parts of his talk do seem gimmicky and oversimplified. Then again, packaging and simplifying is all anyone sells these days. Nonetheless, he message across to a lay audience. The biggest downside to this talk is that the presentation ends just when it starts to get interesting. Mentioning other methods of improving physiology would have also been nice, as far as improving upon my last post.




In other thoughts, I really feel as though my GI physio (secretin? CCK? VIP?) and reproductive physiology  (specifically hPL) isn't up to par. Similarly, there is a huge bucket of liver that I haven't touched with a 10-foot pole, including: cholesterol and bile synthesis/excretion/reabsorption, genetic pathologies (Dubin-Johnson, Rotor, etc) and lipid-lowering agents (High Yield). Oddly, I feel as though I understand respiratory physiology, but my performance on Uworld indicates otherwise. I'm hoping to take a good chunk of tomorrow just revisiting the material I've studied this week and trying to re-commit it to memory and do more practice questions.

Update: reviewing bile synthesis and excretion proved relatively painless. The only thing that I seem confused about is whether there is a biological reason for the reabsorption of urobilinogen into the portal vein via the enterohepatic circulation, or whether this is coincidental. I suspect this fact is taught for diagnostic purposes, to distinguish between causes of jaundice based on laboratory values of serum/urine Unconjugated bilirubin/Conjugated BR/urobilinogen and symptoms (pale stools/dark urine/etc).

Double Update (Dubdate!): I really need to review the whole ALT(Alanine Transaminase), AST (Aspartate Transaminase), ALP (Alkaline Phosphotase), and GGT (y-glutamyl transpeptidase)

Cycling

Yesterday, I started packing my bags. Besides the few clothes and toiletries I have, my few remaining items include books, more books, some binders + pens, an Aeropress and Contigo mug, a B&D clothes iron...and thats it. Oh, I almost forgot: I have even more books. Too many to fit in one piece of luggage (and yes, its overweight). I'll probably need to buy a carry-on

This morning, I set my Comp retake date for April, and bought my plane tickets home. Currently on my third bowl of oatmeal. I really hate oatmeal sometimes.

I'm sitting back and looking at the last few days of work. It started out, predictably, with a lot of disorganization. By the next day, I had straightened up and was able to manage the urge to distract myself. I could write a thousand words about how it feels at times, but why bother?

One biochem pathway later...

Suffice it to say, the act of studying causes me stress and discomfort. I don't know why. Some people are distressed by spiders or dogs or falling out of an airplane (or possibly some combination of falling out of an airplane full of spiders and landing on an island inhabited by wild dogs). And so my first thought is to do something besides work. Maybe check my email, or look up a webcomic, or (the nuclear winter scenario) log onto Reddit. 

The stress continues as long as I study, and the urge to relieve that stress is endless. On days that I have slept well, I have more self-control and can march forward with less stress-relief interruptions. 

This describes the first 2-3 days of a new study session. 

Then, the unhappyness starts piling on. Going to the gym for an hour daily or every other day doesn't relieve the physical pain associated with desk-work. My sleep worsens, as I both tend to sleep later in the night (usually in search of things that will cheer me up) and wake earlier in the morning (because fuck you, circadian rhythm). My hobbies are reduced to snacking, or going to the empty fridge to remind myself that I don't have any food left. This might continue for 2-3 days of declining accomplishments.

Finally, I reach Minimum Effective Concentration. A day flies by and I'm a whole chapter behind schedule. 

Then I take half a day off to watch some TV, sleep in, or make food. 

Of course, there are times when its not as much about stress as it is about boredom. Hearing about a topic for the 5th time can be only so interesting. In this case, I can sometimes increase my level of interest by increasing the speed of the lecture (if its audio/video). 

Other things I've done in the past that have marginal benefits: 

-have my bags packed before I sleep, with a plan for the next day

-turn off distracting skype/cell phone/other ways for people to break one of my few minutes of concentration

-change study areas

-change my study sources (rotate between questions, books, lectures)

(Pomodoro and flashcards did not show signs of effectiveness, but perhaps I didn't do them properly the first time. )

In the past, I've focused on trying to reduce the urge to slack off. However, this all seems to stem from the fact that studying causes stress. Is there a way that I can dissociate the two? Maybe cognitive behavioral therapy?

More to follow once I've had a real lunch. I really hate oatmeal right now

26

For the better part of a day, I was 26 years old. But that was yesterday. And probably again tomorrow, once I slip back into the comfortable and unproductive life I've established for myself.

But today, I am (X-Y) days old

Let X represent the total number of days I'll be alive (and will be determined experimentally).
Let Y represent the number of days I've currently lived (easily determinable).

I'm currently at X-9498. That clock is moving forwards whether I like it or not, so I better do something with it. Make a difference with the difference (I sincerely apologize for that pun). Because life is like a gym membership. No matter what you do, you're going to be charged. Who knows, maybe I'll fix up a fun little digital clock with an Arduino one day.



Anyways.

I've had a growing interest in the Minimalism subreddit. As with many internet communities, noone can agree on what the subreddit represents. Some believe its simply about getting rid of possessions that detract from your life. Others believe its simply about getting rid of as many items as you can and having only a few things define you (such as the 100 Item Challenge). Some believe its a design aesthetic,  others believe its about maximal efficiency, and still others believe its a buyer's guide. Some people post pictures of their bedrooms, looking for feedback or praise. A few harken back to the Minimalist art movement, while others try to create minimalist art or suggest music.

Whatever your definition, I find many of these things calming, especially in a period where I have increased anxiety due to upcoming exams. I have come to appreciate the work it takes to avoid non-food purchases for the last few months. I'm absolutely floored by the minimal work it takes to keep my room tidy (one of the benefits of owning few things). I've learned one can't simply buy a few "zen" things and stick them on a wall and feel at peace. Similarly, I feel that just getting rid of items may help, but it doesn't really give the room 'flow'. It seems that a lot depends on the architecture of the room (big windows being a plus), the landscape, and low background noise. The solution is simple: I need to build a glass cabin in the woods.

Life just feels simpler. Granted, this subreddit hasn't helped with my motivational drive, but I'm hoping my new method of age-counting will help a bit with that.



Anyways.

Pterodactylus has lost the second run fight. That makes me the current champion of legs.

Anyways.

Retractions and Reactions

Retraction: My last post erroneously stated that no-one reads this blog. In addition to myself and web crawlers, both people and magical wooden puppets read my thoughts. The Arthur at Ross U Blog regrets the error.




There are some sayings I dislike. The phase "Bad news comes in three's" is one of them. Not because bad news usually comes in one's, but if they occur in a short enough time-span we lump them together into triplets. Not because bad news usually has some silver lining.

Its pretty simple: Bad news actually comes in four's.

Firstly: Christmas cards and gifts that were mailed from Canada have yet to arrive to my domicile. There is a good chance they will never arrive.

Secondly: I received the score for my Comp test and received a 64, when the passing score is a 65. Ouch. Right in the kidneys. More on this later.

Third: I'll be celebrating yet another birthday far from friends and family.

Fourth: Awkward conversations with disappointed parents for the foreseeable future.


I started writing this post several days ago, focusing on post-exam breaks. However, as I began to tease apart the finer details of the causes of exam stress, the whole of the universe began to unravel. Or at least that's what I tell myself when I start writing pages of incoherent rambling. Instead, I've combined parts of that post with thoughts on the Comp examination and studying in general. If it feels disjointed, it only appears so because I applied crazy glue between different paragraphs, thoughts, and recipes for tomato sauce.
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Among topics studied for medical examinations, the Law of Diminishing Returns applies. One can attempt to memorize every protein, cell type, mechanism of action, etc... but:

• only so many questions can appear on a test
• some knowledge is considered more pertinent than other knowledge, depending on the scenario
• examiners tend to ask questions on what they consider more pertinent

Every student takes the Test. In school where grading hierarchy exists, there may also exist the Meta Test. Here, student's efforts are additionally spent trying to determine which topics are High Yield ("HY") and thus most likely to show up on a test. This may includes trying to obtain copies of previous year's tests, leaked concept sheets, 'remembered' questions from previous students, and even behavioral analysis of professors.

Among the many pieces of advice I've heard, the most memorable include:

• "If Prof P steps away from the podium while speaking about a topic, its HY"
• "If Prof. Y reads it directly off a slide, its HY"
• "If its a behavioral problem, always pick the mushiest answer choice possible"
• "Prof Z typically tests only first-line drugs"
• "Prof B personally said he would be testing from one of these 4 things..."
• "Prof A tells pretty girls whats on the test, so we usually send M every semester to talk to him"

Besides the fact that I'm running out of variables and pseudonyms,  some of these pieces of advice were highly suspect (typically the former), while the latter tended to be pretty accurate. Other methods violate the student honor code (but in the case of a high school classmate breaking into a locked office, they may also break local laws). Perhaps expecting a group of intelligent and competitive students to only compete ethically is unrealistic, because in the world of professional [anything], ethics doesn't win you gold medals; it only keeps you from losing a gold medal. Maybe the fact that these students are all competing in the field of medicine (which I've been told holds ethics highly in present day) means that winning shouldn't be everything.

Before I received my Comp score, I personally tried to distance myself from relying on concept sheets and 'remembered' questions, because I believe they interfere with true learning and education. Everything could be important in the right circumstances. But in my observations, friends that utilize these tools have performed well (and even better than I typically do), often for a fraction of the effort. I am (rightfully) an idiot for ignoring all these tools available to me. But are they worth it?

Perhaps raising my grade to an A- would have felt like a nice pat on the back. It would have let me apply to the leadership position in certain clubs and groups, which is a nice talking point when applying to future residency spots. It would have let me apply to do my fifth semester in the Saginaw, Michigan campus instead of the default Miramar, Florida campus. It may have gotten me into one of the more highly coveted track programs that is offered by Ross U. And most importantly, simply having a high grade would be a talking point on my future applications for residency positions. 

I do somewhat regret the choice I made in the past to ignore concept sheets. Residency spots for IMG's don't come easy, and any strong asset in obtaining future positions should be fought for, tooth and nail. My decision in the past were made because of the benefits I saw at the time; however, many of the benefits of a high grade were only gradually revealed. For example, I only found out about the minimum requirements for being a student group leader in third semester, while applying. Track programs were only recently instituted by Ross, in my fourth semester, when they decided that both GPA and Comp performance would play a role in student placement. Faculty only revealed in fifth semester what sorts of information appears in the Dean's Letter.

Do I regret not utilizing concept sheets and remembered sheets for the present? Once again, yes and no. The thought of spending an additional 3 months studying for the Comp is not appealing. Watching friends move on and start rotations 2 months before I do is a righteous bummer. Having to live at home again is like spiritual flatulence: noisy, socially disruptive, and associated with a diet high in beans. But on the bright side, I've completely revamped my knowledge of many biological and disease processes. What was once full of holes and misconceptions from 2 years of studying, forgetting, studying a different emphasis under a different professor, forgetting again, getting disease processes and proteins confused, seeing contradictory lecture notes vs study notes vs textbooks, memorizing associations simply because a professor said to memorize them...I can finally start anew. And I have. My knowledge of the core P's (physiology, pharmacology, and pathology)  has never been stronger, and this is still just the beginning. I have many months ahead to hammer out all the kinks in my memory.

So, applying this pseudo-science and learning about HY topics has its benefits, both for that student's present (allows maximizing time spent studying and minimizing the effects of the diminishing returns) and for that student's future (increasing competitiveness for future applications). But if you are OK with being an ethical 'loser' that ends up happy in less competitive positions, then be ready to live contently, albeit with some regrets.

As a side note: I have read that under our new Dean, Ross is looking to remove the use of the Comp as a barrier to writing the Step, and simply use it to help students identify weak areas. I believe this to be a step in the right direction, but this is only a tiny cog in the machine, and is not unique to Ross by any means. I've spoken with students in other medical schools where the sharing of concept sheets and the like is also commonplace. This report suggests that the problem continues even in the future down in a medical career.

Are there solutions to this problem? Alarmingly, I ask you: do you think this is a problem?

Even more alarmingly: DO YOU THINK THIS IS A PROBLEM?!?!?!?!

Maybe another day, my disembodied readers. For now, enjoy a story being written by a friend of mine, entitled Lovers in a Dangerous Time.

Gasp!

Egads!

After accepting an invitation to dinner last night, I went to bed feeling like I had forgotten something important. And I had.

Pterodactylus is the winner of the first Run Fight. She runned me right in the run-glands, and I lost after going three days straight without a proper workout.

Her prize: everlasting glory on a blog that noone reads.

I ran on Monday (500C), and got through only half of Tuesday's planned run. Took Wednesday off (because lazyness). My Thursday run was replaced with...a movie.

Pterodactylus ran on Monday, and also ran for half an hour today. As well as some muscle-busting arms workout.

Run Fight Progress #2

Arthur ran today!
Pterodactylus ran today! and apparently worked out her arms.

DID YOU WORK OUT TODAY?

FFFFFFFFFFFFFFFFFFFFF-

So.

My alarm goes off at 6:30AM. My test is at 8:00 AM.

Its currently 1:30AM.

I have been in bed, trying to fall asleep for 2.5 hours. But my brain won't shut up.

Shut up brain.

One thought after another flies through my head. Randomly. I'm not every worrying about any of the thoughts. I quiet the image of a sock, and instead a coconut takes its place as something to think about.

Breathing techniques have been useless.My usual focusing techniques were useless. But then my overactive brain helped me recall a certain graph involving benzodiazeepnies, barbiturates, and anxiolysis.

And after my third shot of vodka, I'm really feeling a lot less inhibited.

Yeah, this is not a long term solution. Don't try this at home.

Also, the anxiolysis kicked in. Success!

The thoughts no longer race in my mind. Its nice and quiet. I'm still not able to go to sleep, but at least my brain has shut up.

Run Fight Progress Report 1

Wednesday January 9t
Arthur: no run
Miss Pt: ran

Thursday January 10th:
Arthur: no run
Miss T: no run

Friday Janury 11th:
Arthur: finally ran! And then went to bed early! And then a bug kept flying into his ear and kept him awake for an hour until he found it and smote it!
Ellie: skated with gym class (I'll allow it)

So far, Ellie is winning the run fight by 1 day's worth of run! I'm winning in the study race.

Enjoy some Cool

The Missing Link

Despite my respect for the human brain, there are times when I just drop the ball and miss the most glaring connection. Take Silicosis, for example. Its an occupational hazard involved in sand-blasting, and I just memorized that fact 3 months ago without really bothering to understand why. (Well, keep it mind, it was right next to a disease called Pidgeon Fancier's Lung, which looked way more interesting).

But yesterday, while going through another pathology resource, they laid it out for me. Sand-blasting blasts walls with sand. Silica is a major component of sand. HOW COULD I FORGET THIS? And this isn't the first time. But I'm too embarrassed to post the rest. Fun fact: Silica inhibits phagolysosome fusion-->this increases your risk of Tb!


Unrelatedly, here is a list of drug names that I commonly confuse:

Imipramine
Indapamide
Amiloride
Amiodarone
Amlodipine
Amantidine
Rispiridone
Reserpine
Clonidine/Clozapine

The Phen 4 (phenylephrine, phenoxybenzamine, phentolamine, and phenylzine)

and just as a review:
Imipramine: tricyclic antidepressant (along with clomipramine and amitryptiline). Blocks reuptake of NE. uses include depression.
Indapamide: a thiazide diuretic
Amiloride: K+-sparing diuretic
Amiodarone: a class III antiarrhythmic. AE include pulmonary interstitial fibrosis (not unlike Bleomycin)
Amlodipine: a CCB, similar to Nifedipine. acts on vasculature.
Amantidine: an anti-viral that happens to include dopamine and decrease acetylcholine (hence its use as an anti-parkinson's drug)

Clonidine: a2 agonist in CNS, causes decrease in NE release
Clozapine: 5HT2 antagonist and D2 antagonist

Phenylephrine (a1 agonist),
phentolamine and phenoxybenzamine (non-specific a1 antagonist),
Phenelzine (MAO inhibitor of both MAO-A and MAO-B.

While this isn't wholly correct, its easier to remember MAO as such: MAO-A mainly degrades 5HT and NE, whereas MAO-B mostly breaks down DA. Selegiline is an inhibitor of MAO-B, used in Parkinson's. Phenelzine and tranylcypramine are an inhibitor of both. Used in depression.

Rispiridone is a serotonin 5HT2A antagonist (not unlike Clozapine, Olanzapine, and Aripiprazole). Might see it used in psychosis.
Reserpine, however, prevents the storage of NE in vesicles.

Run Fight

Welcome, weary travellers, to this most ancient of battles. Our two Champions will begin a long, possibly fatal, run to the death! but more likely, until one gets lazy and doesn't run for 3 days straight.

In this corner, the proud host of this blog, who will probably lie to you about his progress! Arthur "The Golden Legs".

And our opponent for the near future, the proud host of "Hip And With It, the Mighty Pterodactylus!

Day 1 (January 8, 2013):

Today, I ran for my daily 500 cals.
Pterodactylus also ran for the day.

Tune in tomorrow to see who's given up!

Check out these pipes

Fun fact: exposure to vinyl chloride increases your risk of angiosarcoma of the liver.
Vinyl chloride is commonly found making PVC pipes.
Angiosarcoma is a metastatic cancer of the blood vessels (which are essentially pipes).
If you make PVC pipes, you'll break your own.

aaaand that's enough mind-wandering for one day.

2013

I tend to hate New Years Eve. Its usually filled with some combination of disappointment, boring parties, and  signals the upcoming end of my holidays. This year's party was so enjoyable that I thought the tide had changed.

Nope.

On New Year's day, I wrote an NBME test to gauge my estimated USMLE Step 1 score. The results were abysmal. Even in topics I had been studying for weeks, I was below average. I spent more than an hour just panicking. Keep in mind, I have a similar exam that needs to be taken in 10 days that my school has deemed mandatory. Furthermore, I am not allowed to write the Step 1 until I pass that exam.

I made a plan. *Cue training montage*

1) Since writing tests appeared to be my biggest weakness, I would do practice questions every day. This is something I tried to implement weeks ago, but the test results were consistently in the range of 50%, and my ego couldn't take that day after day, sooooo I stopped writing them altogether. Yes, I'm apparently not immune to the "if I ignore it, it'll obviously go away" thought process.

2) Finish my study of physiology, which although slow, was taught by the only educator I can rightfully call a teacher in the last 2 years. I have been instructed by many doctors and professors, and while many have been decent educators in their own right and built the stepping stones, only Dr Wazir Kudrath was able to take those stones and build a path. Its unfortunate that this will likely be his last semester teaching UMBR at ross, and even more unfortunate that he is unable to teach in Dominica, where his approach to basic science is needed.

3) Begin studing a combination of the pharmacology out of First Aid (2011) that I have yet to approach. Other students have suggested that First Aid covers all the pharmacology that shows up on Step 1. Dr Kudrath had already covered cardiovascular, renal, respiratory, and neurological pharmacology, but there are additional drugs in each of those respective fields that weren't covered due to limited time. I will add oncology and clotting cascade drugs to go over, as I feel they are important for future use. Finally, I want to review my antimicrobial pharmacology. I have studied these in the past, and I've heard recommendations that antimicrobial pharmacology is best studied in tandem with microbiology, but the limited time means that might not be possible before the Comp.

*I'm just going to interject with a note about how I got another flat tire due to a piece of broken glass, and if I find you throwing glass out of your car, I'm going to find you and make you eat it.

4) My weakest subject by far is pathology. Pathology questions are the largest percentage of questions on the comp and Step 1 (close to 25%), and my score is abysmal in it. I'm not sure what resource to utilize, as going over the entirety of pathology in ~7 days seems impossible. Especially when it involves a 600 page study guide like Rapid Review (compared to THE textbook on pathology, the fabled 1400 page Robbins & Cotran's Pathologic Basis of Disease). I've had friends recommend Pathoma videos, and while I find it somewhat scarce in details and inappropriate for the Step 1, it might do well enough for the Comp. They are pricey, however.

5) Even if I pass the Comp, my estimate of writing the text near the middle of March is going to be pushed back till the end of April. On the plus side, I'll have an excuse to move back to Toronto right as it starts warming up.

6) I'll make adjustments to my Comp date in order to reach my target score of 250. Yeah, 250. If your going to aim, might as well aim high. Unless there's an orphanage at the top of a hill or something.  

*Addendum: actually, my weakest subject is more rightfully anatomy, but it is long, detailed, and has very few questions show up on the Step 1, so while I do plan to master it in the near future....it can wait till April.