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Bonus Episode: What do you think of these new USMLE Podcasts? Doctor Dan teaches pathophysiology and physiologic responses of the kidney to various disease states, including primary aldosteronism, DKA, SIADH and diabetes insipidus as examples.

Listen to the podcast here…

Renal Physiology

A. ECF/ICF

ECF (1/3) = extracellular fluid of two compartments – vascular (1/3) and interstitial (2/3)

ICF (2/3) = intracellular fluid compartment

Example: how many liters of isotonic saline do you have to infuse to get 1 liter into the plasma? 3 Liters (2/3:1/3 relationship); 2 liters in interstial space, and 1 L would go to the vascular space; it equilibrates with interstial/vascular compartments.

B. Osmolality =

Measure of solutes in a fluid; due to three things: Na, glucose, and blood urea nitrogen (BUN) – urea cycle is located in the liver, partly in the cytosol and partly in the mitochondria; usually multiply Na times 2 (b/c one Na and one Cl). Normal Na is 135-140 range, times that by 2 that 280. For glucose, normal is 100 divide that by 18, let’s say it’s roughly 5, so that’s not contributing much. BUN:  located in the liver, part of the cycle is in the cytosol and part of it is in mitochondria. The urea comes from ammonia, that’s ammonia is gotten rid of, by urea. B/c the end product of the urea cycle is urea. The normal is about 12; divide that by 3, so we have 4. Therefore, in a normal person Na is controlling the plasma osmolality. To measure serum osmolality: double the serum Na and add 10.

C. Osmosis =

Among intracellular, intravascular, and interstitial spaces, 2 of these 3 are limited to the ECF compartment. One can equilibrate between ECF and ICF across the cell membranes – urea; therefore, with an increased urea, it can equilibrate equally on both sides to it will be equal on both sides; this is due to osmosis.

B/c Na and glucose are limited to the ECF compartment, then changes in its concentration will result in the movement of WATER from low to high concentration  (opposite of diffusion – ie in lungs, 100 mmHg in alveoli of O2, and returning from the tissue is 40 mmHg pO2; 100 vs. 40, which is bigger, 100 is bigger, so via diffusion, O2 moves through the interspace into the plasma to increase O2 to about 95mmHb). Therefore, in diffusion, it goes from high to low, while in osmosis, it goes from low to high concentration.

1. Hyponatremia

Example: In the case with hyponatremia – water goes from ECF into the ICF, b/c the lower part is in the ECF (hence HYPOnatremia); water goes into the ICF, and therefore is expanded by osmosis. Now make believe that the brain is a single cell, what will we see? cerebral edema and mental status abnormalities via law of osmosis (the intracellular compartment of all the cells in the brain would be expanded)

2. Hypernatremia

Example: hypernatremia – water goes out of the ICF into the ECF, therefore the ICF will be contracted. So in the brain, it will lead to contracted cells, therefore mental status abnormalities; therefore, with hypo and hypernatremia, will get mental status abnormalities of the brain.

3. Diabetic ketoacidosis

Example: DKA – have (1000mg) large amount blood sugar. Remember that both Na and glucose are limited to the ECF compartment. You would think that glucose is in the ICF but it’s not. You think that since glycolysis occurs in the cytosol therefore glucose in the ICF (again its not) b/c to order to get into the cell (intracellular), glucose must bind to phosphorus, generating G6P, which is metabolized (it’s the same  with fructose and galactose, which are also metabolized immediately, therefore, there is no glucose, fructose, or galactose, per se, intracellularly). So, with hyperglycemia, there is high glucose in the ECF, so water will move from ICF to ECF. Therefore, the serum Na concentration will go down – this is called dilutional hyponatremia (which ...

Episode 30: Learn study techniques to use DURING an exam. This is a nice adjunct to the CD of the Month Club’s Comprehensive Study Techniques, because that CD focuses on techniques to manage a semester or test cycle – not really a single exam!

Listen to the 16 minute podcast here…

When the test starts:

Start your exam with a topic you are familiar with. This will tend to have you feeling good about the exam. This will build up your confidence to be able to answer those questions that you really find it easy. This builds confidence on your part.

Make time for Matching. Knock this one out first if you see it. Often, there are many easy questions in there that people often run out of time to capitalize on.

When answering LONG question stems:

Read the last sentence first. When you see a lengthy question that looks like a paragraph or half-page, the best thing to do is to read the last sentence of every question to find out what they are looking for. Then, read the question and you will be more focused. That is incredibly important.

Look for hints. Questions may contain 5-7 hints so look for it and circle keywords as you read through. When you read those long questions you don’t know the answer, don’t read it again because you still won’t know the answer. Remember it’s a time constraint test and you don’t have the luxury of 5 minutes looking at one question. So that you can get an educated guess on and KEEP MOVING.

Should you ever guess on a test?

Yes, but not in the setting that you may think. Here are some techniques that might help you navigate shelf exams:

Only guess when you really don’t have any idea. When you read questions you have no idea about and you simply don’t know a thing, and then guess.

When guessing, let it be an educated guess. First look at answer choices that are remotely familiar answer, take it. This is probably the answer. Certainly don’t randomly choose one favorite, pre-determined letter B or C and stick with it – this is a bad idea! You’ll hear all kinds of advice similar to this, but test writers hear the rumor mill too.

Patient management decisions:

For the USMLE Step 2, think cheap and use your common sense. When dealing with management, find the cheapest “next step”. Often, the gold standard is not the first step on the USMLE, or in real life.

P.S. Happy Birthday to me!

Episode 29: Learn how to help your patients’ healing by acknowledging their spiritual beliefs, staying emotionally vulnerable, and even being open to a spiritual journey of your own.

Listen to the podcast here…

In the last podcast, we discussed the contrast between out perfectionist, type-A personality and the objective information overload that exists in medical education.

Internally, we’re continually striving and conniving to find a way to rationalize and sync our ambition and good motives with the reality that we can’t remember everything. What’s more, there will be some patients we cannot save.

Ok, let’s assume thought like this occur to you occasionally. How do you respond when a patient wants to pray with you, or is much less worried about their loss of life than you are?

The fact is that there are several billion people that profess religious convictions globally. All of these worldviews converge in the patient care relationship.

With 2/3 of U.S. physicians entering medical school with degrees in science, there is often disconnect between the religious convictions, and ardent living out of those beliefs, and the patient populations for which they care.

I’m not suggesting that scientific education precludes belief in God. In fact, recent scientific evidence is increasingly demonstrating that the two are very mutually compatible.

Practically speaking, we as physicians need to learn how to be supportive our patients and respect the healing power that is known to come from spiritual convictions and a healthy outlook on life.

In terms of the patient-physician relationship, connecting with our patients has the best therapeutic effect. Staying emotionally vulnerable ourselves will guard against pessimism and desensitization.

What’s not usually taught is that the value of spirituality is that it adds much needed meaning to life and everything that happens within it.

From the simplicity of looking for a reason why things happen and “looking on the bright side”, to physical healing and the supernatural, you will see it all during the course of your medical career.

The question, as I see it, isn’t “do these things happen?”, it is “are you paying attention?”

Are you spiritually awake?

A major reason why I left my first residency was because I was too fatigued to maintain my spiritual fitness. I even did an entire Anatomy of Malignant Residency Program course to make sure that my experience wasn’t wasted.

As I agreed to in my last podcast, I’m going to be extremely vulnerable in this second podcast on this subject of inadequacy as a physician.

Here is the exact same list of internal questions that so many student-doctors carry with them:

* I am not perfect. In fact, I’m prone to do the wrong thing when left alone.

* Of myself I don’t have the intellectual power to remember every single detail that will be important one day to a patient.

* I will make mistakes.

* I have to find a way to be happy with whom I am even though I can’t live up to the unspoken curriculum that states I need to remember everything.

Now here are the same ideas conveyed in total transparency. If I did not share this with you, then you wouldn’t know who I really am. I think like this every day and it is unfair to both of us, if you’re interested in my story at all, to leave out such a crucial part of me – my faith!

I’ll now go over the same list and overlay my convictions:

* I am not perfect. In fact, I’m prone to do the wrong thing when left alone.

Episode 28: I’ve heard of perfectionism, but is the Imposter Phenomenon like being abducted by aliens? No, most medical students do it early in the first year of medical school and Pre-Meds usually live that way!

Listen to the podcast here…

If a physician is honest with herself, she will have to admit that sometimes medicine isn’t enough to care for patients.

There exists a chasm between the volume of information that one can apply in medical practice and where we live.

Medical students realize this in a matter of weeks once medical school starts – there is simply to much to learn!

In this podcast, I discuss perfectionism – a disposition to feel that anything less than perfect is unacceptable. The result of a perfectionistic internal dialogue in medical school is a conflict with reality.

There are only a few categories of responses to the overwhelm in medical school.

* Honesty with yourself

* Honesty with others

* A bring-it-on attitude (necessary for the most competitive residencies)

* Denial

A majority of medical students, I believe, are honest with themselves about this, but don’t like to talk about it with others.

Often, there is a delay in talking about struggling academically in medical school. It was astonishing to see the personality of my 225-person medical school class switch from being like regular, idealistic Pre-Meds, to being quiet about their grades overnight.

After the first set of tests came out, no one talked about them. I had a friend that aced all the tests and people got mad when he told them about it.

The opposite was more often true: students don’t want to discuss their mediocre grades.

The result is the Imposter Phenomenon: occurs when high achieving individuals chronically question their abilities and fear that others will discover them to be intellectual frauds (1).

So, what is a mature, healthy response to this type of stress? How will you get through it in a way that will leave you happy and whole all the way through the medical education journey?

This is a very personal struggle for everyone, and there a lots of things people do to cope. It’s easy to cite research articles that discuss every step of the medical education journey, but how does Doctor Dan really feel internally?

I have decided to be increasingly vulnerable in this podcast, so I’ll actually answer this question publicly. I’m about to lay out more than I discussed in the private burnout MP3 that I made available for members only years ago.

Here’s how I reckon all of these points in my own, spiritual life:

* I am not perfect. In fact, I’m prone to do the wrong thing when left alone.

* Of myself I don’t have the intellectual power to remember every single detail that will be important one day to a patient.

* I will make mistakes.

* I have to find a way to be happy with whom I am even though I can’t live up to the unspoken curriculum that states I need to remember everything.

This mindset fluctuated so often in medical school that I felt like I had Multiple Personality Disorder.

It wasn’t until residency that I came to terms with where to find that sort of strength – in spirituality, a Power Greater Than Myself.

Episode 27: In this episode, Doctor Dan pours out his heart in order to save heartache for hundreds of medical residents and students every year. This passionate topic is very controversial, so he uses statistics and the scientific method to make an argument for the existence of malignant residencies.

Listen to the 12 minute podcast here…

Every year, the Accreditation Council for Graduate Medical Education (ACGME) releases minimal statistics on the overal health of the medical residency training industry.

In 2008 they provided the most recent statistics regarding the amount of medical residencies, programs and the number of medical residents who got fired.

Here is a relevant summary for our topic today:

31,609 Total Residents

–  280 Dismissed

0.9% Get “dismissed”.

Let’s give the benefit of the doubt and say that all residencies are wonderful. This will be our null hypothesis.

Then 0.9% of residents should be “bad”, right? So a program should fire about 1%.

Therefore, programs that have 10 residents accepted per year, should fire an intern once every 10 years! Programs that have 20 residents, should have one “bad apple” every 5 years., and so on…  Pretty rare!

So, why do some programs never fire and some always fire residents!

My was in a residency program that fired 1-4 people every year and they only accepted 10 per year – that’s a 10-40% fire-rate!

Either…

* they’re choosing all the bad residents, or

* there’s something wrong with the program itself – both possibilities are a problem with the residency!

I believe that the problem lies with the program, in most cases! So, the number of “bad” residents is much lower than 0.9%.

Forums may answer the reverse stat. Do a search in StudentDoctor.Net for malignant residencies and have fun reading!

How can I avoid choosing a bad residency?

I just developed the Anatomy of a Malignant Residency Course, subtitled:

How to choose a residency that delivers on leadership and commitment to your training:

In this comprehensive course, I cover The Players’ WANTS, FEARS, & SECRETS from every perspective in a fair and balanced way:

* US government

* AAMC, AACOM, & Medical Schools

* ACGME

* Residencies

* The residents

How do you define a Malignant Residency Program?

In the comprehensive course, I define leadership based on the US Army’s proven formula and apply it to health and malignant residency programs.

The course ends with 26 Questions to ask, some of them you’ve NEVER thought of. They are specifically constructed so that you can gain insider access, in a non-offensive way, to the way things really work at the program.

This course is included in Disk #2 in the CD of the Month Club and includes the 26-Point Residency Comparison CHEAT SHEET.

Specifics To Ask AHEAD OF TIME

Episode 26: Dr. Dan interviews Dr. Ken Lin from MedFools.com. This is a great Mastermind community Spirit because he helped students coming up behind him all the way from medical school and even now as a practicing physician.

Listen to the 30 minute podcast here…

Dr. Ken Lin has been devoting countless hours to helping students through www.MedFools.com

From scut sheets and personal essays to career advice and medical school book recommendations, Dr. Lin has it all.

I used his scut sheets extensively during medical school and found them invaluable. It was a regular part of my routine to print out some copies every morning before rounds.

In the full-length interview, we discuss the best way to use sample personal essays. Learn shocking news that some medical students actually copy/paste lines from sample personal essays and put them into their real residency applications. Sounds like a MedFool to me, but in the wrong sense of the word!

Dr. Lin reviews personal essays, as do I. It’s a great idea to  have a physician review your personal essay, especially if you’re a premed!

In the podcast, I hint about a new course I’m working on called Anatomy of a Malignant Residency Program. Sign up for the free Speed Reading Course for Medical School and I’ll notify you when it’s ready.

And we’re doing product reviews – so WE’RE saying what will help us best on our NIH grant. Now your CD of the Month Club membership includes access to full USMLE and MCAT study resources.

Bonus Episode: In this unscheduled episode, Doctor Dan outlines his entire 12-part video series detailing everything you need to know about getting a medical residency in the United States. Learn all about match statistics, Caribbean versus International Medical Graduate comparisons, and USMLE competition. There’s simply too much to describe in words.

Listen to this podcast here…

It took me 5 days and 130 PowerPoint slides to put together this Video Series on the Match and Scramble.

Starting on March 31, 2010, I will begin releasing all of these videos on this podcast channel so stay tuned.

Here are some of the topics I’ll cover:

* How to Match Successfully

* What are your chances of Matching?

* Match Day Schedule and Scramble Week

* Residency admission requirements

* How to rank choices for the Match

* USMLE competition and program credibility

* Required documentation – IMG emphasis

* The Scramble – filling slots after the match

If you don’t already know, “The Match” this where senior medical students usually begin the application process of applying into residency, these may took place in the fourth and final year in medical school. After applying, the next step will be the interviews this will be held between October and February. Soon after the interview is over, students submit a “rank-order list” to a centralized matching service.

You should submit it by the second month of February. Residency programs will also submit a list of their preferred applicants to the same service as same as you are. The process is hidden from both parties, so neither you nor the program will see each other’s list.

To follow what I am using watch this videos so you can learn more and get the right information to able for you to know what to do when applying for residency.

Episode 25: There’s nothing like block exams, with 2-4 weeks straight of tests. How do you cope? Learn where to get real exam questions to use for practice so that you can adjust your study techniques ahead of time and predict how well you’ll do on the real exam.

Listen to the 23 minute podcast here…

Medical school exams are different than anything else.

The testing schedule can be grueling.

The content of the exams can be surprising, but not for everyone. If your medical school allows it, you may be able to get copies of old exams and enjoy a tremendous advantage over fellow students that don’t manage their time well enough to get to use them as practice tests.

Do you ever feel ready to do practice questions in medical school? No. At best you’ll begin to trust that the discomfort of starting free recall before you’re ready is a powerful instrument for developing medium- and long-term memory.

My medical school offered an Exam CD Program and they charged $60. I still remember getting that letter in the mail after I got accepted to medical school, but before it started. I quickly wrote the check and mailed it to make sure I had insider access; a genuine look at what was really expected of my by my professors.

Months later I was immersed in the dregs of medical school life and found the medical school exams essential for success – so essential that I later included them as an important tool in the arsenal of my Study Techniques Course.

Episode 24: The Medical-Mastermind-Community.com survey results are in! In this episode, Doctor Dan answers listener questions and directs you to resources that will further help you in your medical education journey. Do you have a question for Doctor Dan? If so, please submit your questions on the new “Request Topics” link, below in the show notes.

Listen to this 19 minute podcast here…

Thank you for your participation in the surveys that I email out through the Medical School Newsletter. Your comments are very much appreciated.

I use your comments to direct the show’s content, so you DO have a voice!

There are several themes that I see emerging after nearly two years of podcasting, conducting Mastermind Teleconferences, and getting AMSA‘s Mastermind Program off the ground:

* Medical students are excited to find hope through Mastermind Support Groups.

* Making money in medical school is of huge interest (stay tuned for a future Medical School Podcast on the subject).

* How To Study Medicine and manage all of your responsibilities in medical school is universal.

If you have a question you’d like covered in a Mastermind Group Teleconference, here’s a new web page that is designed for just that: Ask Doctor Dan.

Let me know how I can help you,

Doctor Dan

* 3rd Annual Medical School LIFE Conference will be May 29-30, 2010. The first one was a weekend series for the American Medical Student Association chapter at the University of Houston. Out of those conferences, the Pre-Med DVD Course was build as a sort of basic training. The following year charter members of the Medical Mastermind Community met for a weekend conference in which we led a Service Learning Project. The result was a grant proposal submitted to the National Institutes of Health to enrich students’ medical education journey and encourage service to the medically underserved.

* All 200 of the peer-reviewed, scientific journal articles were posted inside the web site for members only. They outline every facet of the medical education journey and correspond to the 5 Phases in the Evolution of a Physician in Training, which is my Physician Wellness Initiative. The idea is to increase awareness, receive validation, and try suggestions from others to find relief. So, just read the articles as you face the different ups and downs along the way.

* All of the medical school exams were also uploaded to the website. Previously they were only available as part of the CD of the Month Club, but we found it was inconvenient not knowing which tests covered specific material. The web outline breaks down each block exam by the topics covered on each set of tests. You can check out the navigation without logging in.

* Facebook 30-day challenge. If you’ll make a video about the Medical School Podcast or Speed Reading for Medical School course, I’ll give you a free, 30-day account tot he Medical Mastermind Community online – a $27.99 value. This includes our biweekly conference calls, from which video archives are now all updated.