Med School Confidential

by Robert H Miller

  CHAPTER 14

  The Second Year: Disease and Medicine

  The good physician treats the disease;

  the great physician treats the patient who has the disease.

  —SIR WILLIAM OSLER

  AT THE DAWN of the second year, you will make the transition from studying normal Anatomy and Physiology to studying disease and its impacts on the body. Your course work now will focus on Pathology (a study of the impact of disease on anatomy), Pathophysiology (the impact of disease on the body’s function), and Pharmacology (the basics of how we treat pathology and pathophysiology with medications). You will also take Microbiology, in which you will cover the broad spectrum of bacteria, fungi, viruses, and parasites that can wreak havoc on the human system.

  Most important, it is during the second year that you will begin to develop the essential framework of clinical decision making and differential diagnosis.

  We are taught medicine in the form of lists and tables from the annals of various specific subjects like Anatomy or Microbiology. Patients, on the other hand, know nothing of the science and give us only constellations of symptoms. The art of medicine is in recognizing the patterns of symptoms, knowing the mechanics and progression of diseases in the body, and correctly identifying your patient’s illness. These skills will be emphasized during your clinical rotations in the next two years. But it is during the second year that you will begin to develop your clinical decision-making ability by considering differentials as you learn the basics of disease.

  Finally, the spring of second year is when you typically take the first step of the U.S. Medical Licensing Exam (USMLE Step 1). This is a major rite of passage and a major undertaking. Hopefully you’ve followed our advice and have been slowly accumulating study materials with each class you’ve taken. This will make your preparation for the test infinitely more efficient and enjoyable. Chapter 15 will deal with preparing for and taking the Step 1 Exam in detail.

  “Differential diagnosis is the key to life,” Deb advises. “Start thinking about this early in your training! Ask why and how about everything you can. I think medical school trains us well to memorize details for multiple-guess questions or to expand on the minutiae of a single disease process quite well. Patients, however, rarely present us with a single disease. More often, they present us with multiple vague symptoms and we must pick one of the several things that may be the cause.

  “For instance, in the anesthesia world, a patient under general anesthesia may be hypotensive, but why? Is it because they are dehydrated from being without food or water for the last twelve to twentyfour hours? Is the patient suddenly losing a lot of blood from the surgical field? Are the medicines we are giving, such as the anesthetic gas, vasodilating the patient? Is the patient having an allergic reaction to the antibiotics he is receiving? There are many different choices for the cause of one symptom, and in order to treat the problem correctly you must know the cause. Turning down an anesthetic gas when you haven’t even thought of treating the patient’s anaphylaxis won’t necessarily help you. The larger your differential, the less likely you are to miss something.”

  THE SECOND-YEAR COURSE WORK

  Microbiology

  Infectious disease is at the core of many, if not most, human diseases. Even some cancers are thought to have their origin in earlier viral infections. Understanding the spectrum of agents that can affect and infect the human body is critical. The discipline is inherently broad. We are continually discovering wholly new pathogens and observing old pathogens evolving to take on new characteristics.

  Your course work in Microbiology will be divided along taxonomic lines. You will have sections on bacteria, viruses, fungi, parasites, and atypical agents. In each section you will learn the members of the group, their mechanism and manner of infection, their lab identification, and the drugs potentially used to combat them. You will also have a lab section that requires you to grow and evaluate microorganisms, and to develop a familiarity with at least the basic lab techniques like Gram staining and microscopy.

  The key to mastering microbiology will be . . . you guessed it . . . memorization. If you understand the organizing framework early and start memorizing aggressively, you will develop a structured perspective on the discipline in addition to the specifics of each organism. An excellent reference book by Mark Gladwin and Bill Trattler called Clinical Microbiology Made Ridiculously Simple has been the bible of this course for years. Flash cards are also immensely helpful here.

  Don’t sweat the lab stuff too much—unless you’re going to be an M.D/Ph.D. or otherwise have the opportunity to conduct research, you’ll probably never use these skills again. Clinically the important lesson will be knowing which tests to order on a given sample and why. Go over your Step 1 review book to get the proper perspective and to help you handle the challenging microbiology questions on test day.

  Pathophysiology

  In Pathophysiology, you will examine the impact of disease and dysfunction on human physiology. Your mind should still be fresh with your understanding, gained during your first year, of how the body is supposed to work. Now you must examine the impact of infection, metabolism, trauma, environment, failure, and aging on these processes. Why does the impact of diabetes extend well beyond high blood sugars? How does cholesterol play a role in heart disease? Why do alcoholics suffer from liver failure?

  Your Pathophysiology course work will probably follow the same general sequence you followed in your Physiology course. Obviously this course forces you to review your normal Physiology as well, so take advantage of the opportunity to fill in any gaps or weaknesses and review concepts for the Step 1 Exam. Make sure you have a clear framework for the broad range of diseases presented here. You will rely and draw on the complete spectrum of information you garner in this course for the rest of your clinical career.

  This is a key subject in which to use your Step 1 board review books and develop a set of flash cards or another study method that you can rely on to review for the Step 1 Exam.

  Pathology

  In Pathology, you will review each organ system you learned in Anatomy and begin to understand how it can be affected by disease and dysfunction. You will be investigating the impact of infections, toxins, genetic diseases, injury, and metabolism on the structure of the organ systems. Your lab work will focus on reviewing histologic slides under the microscope and looking at specimens.

  This course will review the major anatomic systems and the disease states that affect them. You will learn the microscopic and macroscopic impact of disease on the various organs and tissues. Your didactic review of the material will be supplemented with lab time spent examining whole organ specimens as well as thin sections under the microscope. If you’re lucky, you’ll also have the chance to observe an actual autopsy—and probably be surprised by how different the newly dead, unpreserved body looks from the cadaver you became so familiar with during Anatomy.

  Pharmacology

  This class will be your first major foray into therapeutics—treating disease and healing patients. You will start with an introduction to basic pharmacologic principles on how drugs function and how they are distributed in the body. Then you will step through each major drug class, reviewing the different drugs in that class, their therapeutic goals, mechanisms of action, side effects, and appropriate dosing regimens.

  There is a massive amount of memorization here. Flash cards are virtually imperative. You will have to review and rereview, test and retest before all the different drugs become familiar enough for you to be able to apply them. Take the time to do this right the first time, as any lingering uncertainty about what a drug class does will be a serious handicap next year when you hit the wards.

  That being said, it is also true that these days there are more drugs than any single person can possibly remember, and there’s just too much information on each drug to have it all available for immediate recall. There are, however, several useful pocket, PDA, and computer
resources that let you instantly look up drugs in the clinical environment (see appendix, page 271). You will come to rely on these tools once you’re on the wards. For now, however, good, oldfashioned memorization will provide the conceptual and factual underpinning you need to be effective in the clinical environment. Not surprisingly, this area is also tested heavily on the board exams, and no outside resources are permitted—so you simply have to master as much of this material as you possibly can. Enjoy your drink from the fire hose.

  Human Behavior/Psychiatry

  This is primarily a clinical rotation in your third year, and many schools now include a didactic curriculum in basic human behavior during the second year as well. This course is concerned with defining what is generally considered normal behavior and the principles that govern it. You will also spend a significant portion of your time learning how to take a detailed family and social history, and how to develop a basic psychosocial profile of any given patient.

  There are really no tricks to mastering this class. The workload is typically low, and the performance is primarily clinical. Enjoy a nonmemorization class and an opportunity to explore some of the leftbrain concepts in medicine. A healthy appreciation for what drives us as humans and how we react to events in our lives will be an important weapon in your clinical arsenal.

  CHAPTER 15

  Bringing It All Together: The USMLE Step 1 Exam

  By failing to prepare, you are preparing to fail.

  —BENJAMIN FRANKLIN

  YOUR PRECLINICAL STUDIES will culminate in the mother of all exams—the USMLE Step 1 Exam. This exam will be unlike any exam you’ve ever taken before—it is longer, more comprehensive, more detailed, and, frankly, more difficult than anything you have ever seen.

  AN OVERVIEW OF THE STEP 1 EXAM

  The USMLE Step 1 Exam confronts you with approximately 350 multiple-choice questions in seven one-hour test blocks. And the questions aren’t unidimensional like “What nerve innervates the heart?” They are primarily clinical vignettes that force you to pick up on anatomic and physiologic clues that subsequently relate to pathophysiology or pharmacology. Thus, a typical question would be something like this:

  “The patient has had two heart attacks and is on a cardiac medication regimen. She presents with right upper quadrant abdominal pain and jaundice. The drug most likely causing her jaundice is . . .”

  Your response would require you to know that since she has known heart disease, she’s probably on a standard regimen, which would include a cholesterol-lowering agent. From this assumption, you would recognize that among the common drugs in this class (known as the statins) are a group of drugs that lower cholesterol by inhibiting the synthesis of cholesterol precursors. They also tend to cause liver dysfunction and muscle pain as common side effects. In fact, these are some of the most common reasons for patients’ intolerance to this class of drugs.

  PREPARING FOR THE STEP 1 EXAM

  The USMLE truly does require you to bring it all together—that is, synthesize all the information from your preclinical studies into a one-day checkpoint. That being the case, you’re probably wondering how you should approach studying for an exam of this breadth and scope.

  The old adage is “Two months for Step 1, two weeks for Step 2, and a number-two pencil for Step 3.”

  This may not quite hold true, but in general it is true that Step 1 is far and away the hardest, Step 2 builds on more clinical data and is easier to approach, and by the time you take Step 3 you’ll have enough experience under your belt that you’ll find the exam to be fairly straightforward.

  If you’ve followed the advice in this book you should already have a huge head start on most of your colleagues. By the spring of your second year, your classmates will be frantically buying board review books, streaming through the pages, and crying in desperation as they realize that (1) half the stuff they studied and memorized for their class work over the last two years is not on the Step 1 test, and (2) the other half that is relevant could have been prepared for contemporaneously with their classroom study of the individual subjects—which would have saved them an incredible amount of time and effort.

  Now aren’t you glad you bought this book?

  As you stride into the library, past carrel after carrel of red-eyed, stressed-out students, you’ll be confident that that large bundle of your previously prepared flash cards and the well-annotated board review book you’ve been working with during the past two years as you covered each subject will have you doing just what you should be doing—reviewing for the boards, not learning for the boards.

  An organized and dedicated study plan, however, is still in order.

  Most med schools offer some protected time to allow second-year students to focus on studying for the boards. If yours doesn’t, make sure you plan out a lighter course load or a period of time off to dedicate yourself solely to studying for Step 1. You need to capitalize on the advance work you have already done and identify your areas of weakness.

  Listen up, though—and heed this advice.

  Take all your class notes, bundle them up, and put them on a high shelf in the corner. Reviewing entire subjects from your notes and outlines is not an efficient study strategy.

  Not unlike the MCAT, your goal here is to study to survive and thrive on this particular test, not to remaster the subject matter. Thus your study strategy must focus on how to beat the particulars of the test.

  You must learn to study smart—not just study hard.

  Start with a solid general boards reference book like McGrawHill’s First Aid for the USMLE Step 1. The First Aid series does a nice job of concisely providing the factual information you need to master in order to compete on the boards. The series has been the most popular with medical students for some time, and the authors continue to refine and update the material to stay current with the test.

  The book offers little in terms of explanation or context, and its approach is somewhat fragmentary. However, it’s an excellent place to start because you can review the material and assess what’s familiar and what’s not.

  Simply put, you need to know everything in this book.

  At first this will seem like an unreasonable, unwieldy, impossible task. But once you wade into it, you will discover that you already know much more than you thought you did. Go through the flash cards you made in each class and organize them according to the outline of this book. Now review all your flash cards and go through the material in the book at least once. Make a running list of areas in the book not covered by your note cards. This will be your subjectreview list for further study.

  The next step is to begin testing yourself. Get yourself one of the many board review question banks. You can purchase these either in book form or on CD-ROM. Since you’ll be taking the actual test on the computer, we advise you to train with the CD-ROM. Tote around your laptop and work through question sets at your favorite bookstore or coffee shop, at the library, or at home on the couch. Be sure to acquire a test set that has complete explanations of all the answers. Set aside time at the beginning to take at least one complete test block under real-time conditions. Don’t cheat and look at answers as you go. This is your self-evaluation.

  When you complete and score the test, don’t be dismayed by your score—you’re only just starting your preparation, and you’ve got to start somewhere. Now you have a baseline.

  Next, go back through the answers to all the questions. Make sure you got the correct answers correct for the right reasons, and make sure you understand the reasons for all the wrong answers. Make note cards to memorize the questions you got wrong. Incorporate these cards into your growing set from the board review book and your previous classes. As you discover subject areas where you exhibit weakness, add them to your subject-review list.

  Now take that subject-review list and begin filling in the holes. At this point, if you can’t restrain yourself from doing so, you can pull down your course notes and review them. However, a good s
ubjectbased board review book will likely do a better job of providing the same context and structure with, again, a specific focus on what’s going to be tested on the boards as opposed to what your professor was interested in teaching you.

  There are many different series of books available. As mentioned, the First Aid series offers a detailed review of most of the major review books with letter grades reflecting the quality and usefulness according to the editors and prior students, so consult that resource first. Don’t get bogged down in reviewing an entire subject unless you really feel you need to. The goal here is to fill in the gaps to round out your complete spectrum of knowledge for the boards. Attempt to be as focused as possible in your subject reviews. Make additional note cards as needed to ensure that you capture and master the material you review.

  From this point on, you simply need to keep repeating this same cycle until test day. You should see progressive improvement in your mastery of the material on your note cards, the subject matter in the Step 1 review book, and in your actual sample test scores. You should hit fewer and fewer questions that are stumpers or seem foreign, and you should find your subject-review list shrinking down to none.