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Episode 67:  Heather De Anda got accepted to her number 1 medical school yesterday and granted us an interview. She shares her “classic mistakes” in previous application years and provides great advice to the struggling premeds, though these principles can be applied to all of us – at any level!

Classic Mistakes in Medical School and Residency Applications:

Here are some classic mistakes (Heather mentioned a few and Doctor Dan added some more…):

* Assuming you’re competitive

* Not applying to enough schools or programs

* Not keeping an open mind and positive attitude while on the interview trail

* Not asking for, or accepting, help in the different domains of academics, essay writing, mentorship, interview skills and the success story format.

* Not thinking of how your experience can benefit others (Mastermind Principle)

* Being stingy with your money and not investing in your preparation

Episode 66: Discover the dark side of medicine with this insightful podcast. Learn a useful tool to help you make decisions when you’re burned out. And learn how to find out where Dr. Dan will be interviewing so you can meet him when he’s in town!

The “5th Step” comes from the 12-Step community and is essentially a written tool to help an individual gain perspective on a complex, often emotional, experience. Hmmm, sound like residency?

You can follow my journey on Facebook as I travel the country doing 21 interviews at Psychiatry Residency Programs:

http://www.facebook.com/#!/pages/Medical-School-MasterMind/112410748822927

Episode 65: This episode covers atrophy, hypertrophy, metaplasia, dysplasia, and hyperplasia.

Listen to the podcast here…

Adaptations to environmental stress: Growth alterations

A. Atrophy:

Diagnosis: the decrease in tissue mass and the cell decreases in size. The cell has just enough organelles to survive, ie less mitochondria then normal cells, therefore, just trying to ‘eek’ it out until whatever it needs to stimulate can come back.

1. Example: hydronephrosis, the compression atrophy is causing thinning of cortex and medulla, MCC hydronephrosis is stone in the ureter (the pelvis is dilated). Question can be asked what kind of growth alteration can occur here. Answer is atrophy b/c of the increased pressure on the cortex and the medulla and produces to ischemia, blood flow decreases and can produce atrophy of renal tubules.

2. Example: Atrophied brain due to atherosclerosis (MC) or degeneration of neurons (Alzheimers, related to beta amyloid protein, which is toxic to neurons).

3. Example: In muscle, many causes of atrophy – ie Lou Gehrig’s Dz (amyotrophic lateral sclerosis) knock off neurons to the muscle, so it is not stimulated, leading to atrophy.

4. Example: Endocrine related:

a) Hypopituitarism will lead to atrophy of adrenal cortex: the zona fasiculata and retiucularis layers of the adrenal cortex; NOT the glomerulosa b/c ACTH has nothing to with stimulating aldosterone release. The fasiculata is where glucocorticoids (cortisol) are made, while reticularis is where sex hormones are made (17 ketosteroids and testosterone). ACTH is responsible for stimulating these, therefore zona fasiculata and zona reticularis are atrophied.

b) Taking thyroid hormone will lead to atrophy of thyroid gland. This is due to a decrease of TSH and therefore nothing is stimulating the thyroid gland which leads to atrophy.

5. Example: Slide showing a biopsy of a pancreas in a patient with cystic fibrosis. What is growth alteration? Atrophy, b/c the CFTR regulator on c’some 7 is defective and has problems with secretions. The secretions become thicker and as a result, it blocks the ducts and so that means that the glands that were making the fluids (the exocrine part of the gland) cannot make fluids b/c of the back pressure blocking the lumen of the duct, which leads to atrophy of the glands, which then leads to malabsorption in all children with cystic fibrosis.

6. Example: Slide of an aorta, with atherosclerotic plaque, which leads to atrophy of the kidney and secondary HTN (renovasuclar HP, leading to high renin level coming out of the kidney). In the other kidney, it is overworked, therefore there is hypertrophy (renin level coming out of this vein is decreased and suppressed).

B. Hypertrophy

Increase of the SIZE of cell, not number Scenario: A cell biology question: what is the N of this? Hypertrophy of a cardiac muscle (permanent muscle), suppose there is a block just before the G2 phase. What is the number of chromosomes? Answer: # of c’somes is 4N, b/c it already underwent synthesis: already doubled.

1 N = sperm (23 c’somes)

2 N = normal (diploid cell)

3 N = trisomy

4 N = double the number

C. Hyperplasia

Increase in the # of cells. In normal proliferative gland, there are thousands of mitoses, therefore see more glands with hyperplasia.

1. Example leading to cancer: With unopposed estrogen, you may end up with cancer, b/c if you didn’t have progesterone (undoes what estrogen did-counteracts the estrogen), you will get cancer. The cells will go from hyperplasia, to atypical hyperplasia to endometrial cancer. Therefore hyperplasia left unchecked there is an increased risk of cancer. One exception: benign prostatic hyperplasia; hyperplasia of the  prostate does NOT lead to cancer; just urinary incontinence.

2.

Episode 64: Doctor Dan interviews Kasey Gahler, an independent financial adviser with experience in physicians’ financial concerns. Learn how contacts can possibly affect your financial planning decisions in the future.

Contract Reviews For Physicians

Disclaimer: this is NOT legal advice; always review contracts for legal aspects with your lawyer.

Physician Salary

* Is the offer competitive with other offers in your geographic area?

* Can be determined by:

* Yearly American Medical Association book with general ranges per specialty and area; Also the Medical Group Management Association.

* Simply talking with others going in to practice

* Hospitals/practices using a past/recent contract and replacing the name can be commonplace

* The practice may not know your fair market value

* Discussion point for later on in the interview process

* If too low, can usually be remedied by simply letting the practice know your fair market value

Physician Benefits

* Health insurance and group Disability Insurance (DI)

* Most are pretty standard.

* Typically not a “negotiation” point

* Remember your group DI is taxable since the practice/hospital is paying the premiums

Retirement

* Also fairly straightforward

* Most practices will help you get to the full amount of pre-tax savings. This can be done through 401K and profit sharing, SEP IRA’s, 457 plans, etc.

* Some practices allow you to put more away than the pre-tax maximum through deferred compensation, etc.

* Most practices and hospitals now have Roth IRA availability. Something to keep in mind for the future. Might have another pod cast on taxation and retirement issues in the future, etc.

Physician Concerns About Leaving Their First Practice

* About 40% of physicians stay at first practice less than four years

* Non Compete/Liquidated Damages –

* This is a very often overlooked area of contracts that can affect your family.

* Importance depends on whether you plan to practice in this specific area long term. If all of your family are from this area, might be a determining factor in your decision to practice there, if you would leave the area anyway this is most-likely a non-issue and not a point of negotiation.

* Can be geographic in nature, monetary in nature but typically a combination of the two

* In the past contracts typically stated: “If you leave our practice, you cannot practice within a 50 mile radius, etc. of one of our hospitals”. Since this has been difficult to enforce at times, most contracts have moved to the following: “If you leave our practice, and  choose to practice within a 50 mile radius, etc. of one of our hospitals, you will owe us $200,000 or two times your annual salary, etc.” These tend to be enforceable by the law.

Tail Coverage

* Covers your malpractice claims after you leave the practice.

* Two different kinds: Occurrence based and claims based (Claims based way more expensive)

* Can amount to as much as 2 – 3 times your yearly malpractice premium

* Not as big of an issue as in the past as many new employers will help you buy purchasing a “nose” policy at the new practice/hospital

* Something to be aware of as it would be financial funds out of pocket if you change practices and most young physicians might not be sitting on that amount of money right away. (Don’t want to take out even more loans to leave first employer)

Demographics of the Medical Practice Group

* Too old — Could change the way business is done once those partners begin to retire.

Episode 63: Learn how to ace your interviews for medical school and residency program admissions. Doctor Dan speaks from a lot of experience to bring you this concise volume. From saving money and resting to practicing your Success Stories and being up on current events, your mind will be fully armed to take on the all-important task of selling yourself on that fateful day.

Introduction to Interview Skills from the Medical Mastermind Community

Hello and welcome to the Episode 63 of the Medical School Podcast. I’m your host, Doctor Dan.

I’m here to bring you in to the Medical Mastermind Community, a fellowship of hundreds of like-minded medical and premedical students helping each other achieve success in a spirit of harmony.

MCAT & USMLE Podcasts

We have completed hundreds of hours of science podcasts for every test! From the MCAT and USMLE Step 1, all the way to the USMLE Step 3 and residency board preparation.

You have to join the Medical Mastermind Community and listen immediately through the web. Or, download all the MP3’s you want. Simply right-click and save them to your computer. Then, drag them to a Playlist in iTunes or other MP3 player device. They are yours to keep forever.

Please note, except for the Lifetime Membership option, all memberships have recurring, monthly dues that must be paid by you until we receive 3rd party funding.

Interviewing Skills

After you’ve submitted all of your secondary applications, AMCAS> TMDSAS, & ERAS applications, you’ve entered The Gap. This is a period of time when all of your work leading up to this point in your career is out of your control.

Self-esteem and doubts

Fear of not getting emailed or called

There are a number of things you can do to prepare, however. Listen to the above podcast to learn all sorts of helpful tips.

Click here to download the Medical School and Residency Program Comparison Sheets.

Episode 62: What is the evidence for acupuncture, Yoga, and vitamin therapy? Doctor Dan interviews Dr. Ronald Stram, founder of the Center for Integrative Health and Healing.

Integrative Medicine Training

After becoming board certified in Emergency Medicine, Dr. Stram did a fellowship at the Arizona Center for Integrative Medicine.

Evidenced-Based Holistic Medicine

Here are two databases that organize research by the strength of their evidence:

* The Natural Standard

* Natural Medicine Database

Episode 61: Doctor Dan interviews co-founder of MommyMDGuides.com, Jennifer Reich. Learn how women physicians balance motherhood with medical practice.

Pregnant Physicians

It is estimated that some 20,000 women have a child at some point in their medical education and as many as 50,00 men and women become parents during this process. Parenthood is clearly an epidemic!

Medical Careers

Having a child can definitely change your life priorities and, sometimes, cause you to want a different lifestyle. This can lead to a change in medical specialty.

Once you look into the eyes of your newborn, your world will change. This is not something to fear, but to embrace!

Best Time To Have A Child In Medical School

There is no “right” time, which means that ANY time is the right time! See, the responsibilities and stress always seem less desirable when you’re talking about someone else’s child. When it’s yours, it’s entirely different.

Is it tough? Sure, but you better listen to the podcast and let Jennifer answer that question from a women’s perspective.

Special Mentions

* Jennifer’s Posiblog

* Dr. Kristie McNealy’s blog

* Christy Valentine, MD

Episode 60: This is Part 2 of the very long Cancer Podcast. Dr. Dan covers Grade versus Stage, paraneoplastic syndromes, and a high-yield list of the most common causes of the various cancers.

Cancers and Associated Diseases – Part II

Xeroderma pigmentosa – sun exposed areas, auto recessive, can cause all skin cancers (BCC, SCC, and melanomas), and the defect is in DNA repair enzymes. Other DNA repair defects are associated with BRCA1 and BRCA2, p53, they splice out the defects, this group is called the chromosomal instability syndromes – Wiskott Aldrich, Blooms, Ataxia Telangiectasias, and Fanconi’s, all have probs with DNA repair.

Basic rule of thumb for BCC and SCC:

* Upper lip and up is basal cell carcinoma;

* lower lip and down is squamous cell

(therefore, lesion on lower lip = sq cell; lesion on upper lip = basal cell)

Example: inside nose is BCC, b/c above the upper lip

Example: keloid – sq cell carcinomas and 3rd degree burns and sq cell carcinoma developing in areas of drainage from the sinus and ulcer that doesn’t heal from antibiotics. So, wherever there is constant irritation, and division of cells related to irritation, there is an increase susceptibility to cancer. This does not hold true for scar cancer tissue related cancers of the lungs or adenocarcinoma (just applies to things on the skin – ie burns and draining of sinus tracts). Only bacteria assoc with cancer? H. pylori – adenocarcinoma and low grade malignant lymphomas.

XII. Grade vs Stage

A. Grade = what does it look like? The term well differentiated means that the tumor is making something like keratin or glands, and if it’s identifiable it’s called low grade. When the cells are anaplastic, poorly differentiated under the microscope, and if you cannot tell what it is, then it’s called high grade.

Example: sq cell carcinoma can see keratin pearls; can ID it, so it’s a low grade cancer.

Example: see gland like spaces, can ID so its low grade

B. Stage = (TNM) MC staging system; goes from least imp to most imp (TNM)

Example: breast cancer with axillary node involvement; therefore, the N=1, but the “M” is worse, b/c it indicates that cancer has spread to other organs like bone, etc. Just b/c it goes to lymph nodes doesn’t mean it is the most imp prognostic factor.

T=size of tumor; if tumor is over 2 sonometers, it has a chance of mets

N=nodes (next most imp for prognosis)

M=mets outside of nodes (most imp prognostic factor)

Stage is more important than grade for prognosis; and within staging, M is the most imp factor for prognosis.

Example: pt with prostate cancer, which of following has it the worst? The answer choices were cancer limited to prostate, it went into seminal vesicles, it involved the wall of bladder, went to lymph nodes, or bone? Answer = bone (bone represents the “M” of the TNM system – this is stage 4 by definition=mets)

Example: a slide of a colon cancer and a lymph node: what is most important – size of tumor or lymph node involvement? Lymph node. If it was also in the liver, what is most imp? Liver specimen is the most imp prognostic factor.

XIII. Host defenses – most important is Cytotoxic CD8 T cell

Others – NK cells, Ab’s, macrophages, type 2 HPY. In hospital, they look for altered MHC class I Ag’s in the cancer pt, b/c cancer wants to kill T cells; they do this by putting in perforins, which activate  caspasases, and this leads to apoptosis (the signal, from the perforins, activate the caspasases, which have proteases, which break down the nucleus and mitochondria, and cell dies, without any inflammatory infiltrate).

XIV. Other diseases seen in malignancy:

A. Cachexia – cause is TNF alpha; it is irreversible. Once you see a pt with disseminated cancer about to go into catabolic state, can give then total nutrition, but still won’t help.

Episode 59: Doctor Dan interviews Dr. Fardad Forouzanpour, a Cosmetic Surgeon. Dr. Fardad is a Board-Certified surgeon and one of only three physicians authorized to run his own Surgical Fellowship in Southern California. He has trained surgeons from all over the world. Dr. Fardad is also the inventor of the Umbilical Locator which was designed to help plastic and cosmetic surgeons locate the umbilicus when performing abdominoplasties.

Plastic Surgery Fellowships

Traditional Plastic Surgery

This is the most well-known. It covers a lot of burns and reconstructions, even trauma.

Cosmetic Surgery

As the name implies, this separate fellowship opportunity allows surgeons to focus on mostly elective, aesthetic surgeries and procedures. Most patients pay cash, are often quite needy, and aren’t affected by the Health Care Reform.

Words to the Wise:

* Choose a specialty that you feel comfortable with, even if you had previously wanted to do something else.

* Don’t do procedures unless you’re fully trained to do them and deal with the complications.

* Not all surgeons’ personalities fit well with the often wealthy clients that have elective cosmetic surgeries.

Episode 58: Doctor Dan interviews Oleg Reznik, M.D., author of The Secrets of Medical Decision Making. He is an expert in Mind-Body medicine and is currently faculty at The American Institute for Mental Imagery.

Medical Decision Making

When we seek medical advice we’re hoping that a physician will always offer us what is in our absolute best interest. Indeed many physicians attempt to do that and some actually do. It is my perception however that great many physicians are bound by what I would call the Four Corners of the Medical Box.

Physician Pressures:

* Fear of litigation

* Financial and time pressures

* Guidelines of Health Care Authorities

* The current Medical Model

What propels a physician to leave this box by going beyond the boundaries of personal security?

The Medical Decision-Making Solution:

* Genuine compassion

* Desire to do what is in patient’s absolute best interest

* Courage to take the necessary risks.