Books And Resources For USMLE Step 1

Every U.S. medical student must take and pass Step I prior to becoming a licensed physician. Although Step 2 and 3 are also important, Step I ends up being *the* major test since it is the one residency programs look at when a student applies for a particular program. Having recently taken Step I, here are some resources, both online and books, that I found useful:

Books:
First Aid for USMLE Step I 2008 - An ABSOLUTE essential. This book contains the basic information for the entire test. If you can memorize this entire book, you are almost guaranteed a 240+ score.

BRS Physiology - A solid review of all the physiology you need to know for the test

BRS Pathology - A good companion to the physiology book

Microbiology Made Ridiculously Simple - A good review of microbiology. It probably has much more detail than you need for the test, but combine this with First Aid's microbio, and you're golden.

Pharmcards - Probably more detail than you need for pharmacology, and does contain some errors, but overall, if you know these cards, you're set for the pharm parts of the test

There are several other potentially useful books, but if you use the ones listed here and master them, you will do very, very well.

Online:
Ace Step I Without Becoming a Hermit - another guide to books for Step I written by a HMS student

Goljan Notes - the mythical Dr. Goljan apparently runs Step I review courses. His notes and mp3 lectures are heralded by some. I listened to most of the lectures, but looking back on it, they're probably best started early and listened to in one's spare time

Kaplan QBank - Almost every student will end up doing practice questions in addition to studying. There are several QBanks out there, but Kaplan has a reputation for good results. Try it before you buy it:

The Challenge consists of a sample set of questions to let you assess how your studying is going, as well as give you a taste of what Kaplan's questions are like. I used them in my preparation, and definitely found it worthwhile. 


Feel free to comment on other resources you find helpful!

Medical Marvel: Sternal Foramen

Image courtesy of Radiology Picture of the Day

I suppose a sternal foramen isn't so impressive, but I found the accompanying blurb to be funny:

A sternal foramen is a round or ovoid congenital bony defect that results from incomplete fusion of the sternal ossification centres. The estimated prevalence is 4.5%. It is typically asymptomatic and of no clinical significance, except in the setting of sternal acupuncture due to the risk of pericardial puncture and tamponade. There have been two such reported cases in the literature, one of them fatal.

Oh the accupuncturists! I feel bad for them. Can you imagine how they felt after learning what happened?


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Better Know A District - Glaxo-Smith-Kline

Stephen Colbert has a series called 'Better Know A District,' where he interviews various members of Congress. This week, his piece featured Pennsylvania's 7th Representative Joe Sestak. I just found Colbert's riff in the middle of this clip on the drugs he's on to be funny:

For even more Colbert, you have to read:

Myths About Medical Myths

A recent article "The top medical myths" on a British newspaper's website left me perplexed. While some made sense, a few were questionable and one was just flat out wrong. Sure, maybe sex is not really exercise, and it's true that most hypertension does not cause headaches (although, if it does, that's a very bad sign). However, I thought this was just ridiculous:

YOU SHOULDN'T MIX ANTIBIOTICS AND ALCOHOL

How wrong is this? Totally, with the exception of the antibiotic metronidazole.

What are the facts? Any interaction of alcohol with virtually all antibiotics is nonexistent, or so small as to be irrelevant. Metronidazole, an antibiotic used for a variety of infections, is the exception to this rule. When mixed with even small amounts of booze, it causes vomiting.

Any related myths? That you should always finish your course of antibiotics. It usually makes little difference.

You may agree with the alcohol part, but not finishing antibiotics??? That's just a bad idea - not finishing courses of antibiotics is what leads to drug-resistant bacteria. It's one thing if some blog said this, but a newspaper (and its website) should be held to a higher standard. I always thought the arguments against socialized medicine were a little bogus, but after reading this, maybe there is some merit to them...

Tier 4 Drug Pricing

As a follow-up to my post last week about the economics of drug dosing, the Times has published another piece looking at the growing popularity of Tier 4 drug pricing among insurance plans.

"With the new pricing system, insurers abandoned the traditional arrangement that has patients pay a fixed amount, like $10, $20 or $30 for a prescription, no matter what the drug’s actual cost. Instead, they are charging patients a percentage of the cost of certain high-priced drugs, usually 20 to 33 percent, which can amount to thousands of dollars a month."

As I've previously argued, private insurance fundamentally makes no sense:

"But the new system sticks seriously ill people with huge bills, said James Robinson, a health economist at the University of California, Berkeley. “It is very unfortunate social policy,” Dr. Robinson said. “The more the sick person pays, the less the healthy person pays.”

Traditionally, the idea of insurance was to spread the costs of paying for the sick.

“This is an erosion of the traditional concept of insurance,” Mr. Mendelson said. “Those beneficiaries who bear the burden of illness are also bearing the burden of cost.”"

Any reasonable analysis of the insurance system should have predicted that this would occur. It was only a matter of time.

Medical Marvel: Lithopedion

Image courtesty of Radiology Picture of the Day

If it's Monday, it's Medical Marvel time. Well, as long as I keep finding interesting stuff, I guess. Today, we investigate lithopedions. According to Wikipedia, a lithopedion is:

A Lithopedion (Greek:litho = stone; pedion = child), or stone baby, is a rare phenomenon which occurs most commonly when a fetus dies during an ectopic pregnancy, is too large to be reabsorbed by the body, and calcifies on the outside, shielding the mother's body from the dead tissue of the baby and preventing infection. Lithopedia may occur from 14 weeks' gestation to full term. It is not unusual for a stone baby to remain undiagnosed for decades, and it is often not until a patient is examined for other conditions or a proper examination is conducted that includes an X-ray that a stone baby is found. The oldest reported case is that of a 76 year old woman, whose lithopedion had probably been present for 46 years.

There is one case report discussed on Radiology Picture of the Day. What surprises me about all this is that I always thought ectopic pregnancies had a high mortality rate. However, this condition, especially given the size of the lithopedion, makes me wonder about that. I should note, I have not taken my ob/gyn rotation yet, so maybe I am mistaken about the nature of ectopic pregnancies. At any rate, can you imagine living with a lithopedion inside of you for potentially several decades? Strange, no?


Looking for more marvels? Check out craniofacial duplication, or fetus in fetu.

Memory Chips For Humans?

Ever considered having a memory chip implanted in your head? As much as I would want one, I've never given it serious thought, but one psychology professor does not think implanted memory chips are so far-fetched. Gary Marcus, professor of psychology at New York University, argues that we suffer a severe deficit in how we retrieve memories relative to what is possible:

All this becomes even more poignant when you compare our memories to those of the average laptop. Whereas it takes the average human child weeks or even months or years to memorize something as simple as a multiplication table, any modern computer can memorize any table in an instant — and never forget it. Why can’t we do the same?

Much of the difference lies in the basic organization of memory. Computers organize everything they store according to physical or logical locations, with each bit stored in a specific place according to some sort of master map, but we have no idea where anything in our brains is stored. We retrieve information not by knowing where it is but by using cues or clues that hint at what we are looking for.

But, of course, the idea of some kind of androidization of human beings is off-putting. Dr. Marcus feels differently:

Would this turn us into computers? Not at all. A neural implant equipped with a master memory map wouldn’t impair our capacity to think, or to feel, to love or to laugh; it wouldn’t change the nature of what we chose to remember; and it wouldn’t necessarily even expand the sheer size of our memory banks. But then again our problem has never been how much information we could store in our memories; it’s always been in getting that information back out — which is precisely where taking a clue from computer memory could help.

That makes some sense, but sometimes, our ability to forget also serves a protective purpose, by insulating us from memories of unpleasant experiences, for example. By doing so, our forgetfulness to some degree allows us to attempt things that may not have been so pleasant the first time around. Plus, how do you feel when someone remembers everything a little bit too well? Frankly, it can be a bit annoying. Memory chips may work well with computers, but I am not sure how well humans would truly fare with them.

A Second Opinion on Second Opinions

The idea of getting a second opinion makes a lot of sense, especially in complex cases. However, in practice, it is difficult to broach the topic as it feels like a violation of the trust one hopes develops between a physician and their doctor. However, a recent article on second opinions in the NYTimes shows that second opinions deserve a second look:

Some studies have examined the frequency and efficacy of second opinions related to invasive procedures like biopsy and cancer surgery. Rates of discrepancies between doctors vary, and for the most part they do not lead to changes in treatment. For 30 percent of patients who voluntarily seek second opinions for elective surgery and 18 percent of those whose insurance companies require it, the second doctors disagree with the first.

Thirty percent? That's pretty high, but it makes sense given how complex cases can become. I think one way to approach the problem would be to make second opinions a standard requirement for particular diagnoses that are more likely to have ambiguities, such as how to treat complex hematologic cancers. Doing so might make the practice more acceptable.


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Whizbang Stuff To Image Coronary Arteries

Imaging the coronary arteries is difficult, but a new technology may soon make the process much simpler. The method, called optical coherence technology, has been used previously in ophthalmology, but with certain modifications may now be applied to coronary vessels as well. What is OCT though?

OCT works by projecting a beam of light onto a surface, which then reflects a small amount of light back to the device. Due to the high speed at which light travels, reflection time is too brief to be measured directly. Instead, OCT relies on an interferometer, which measures the interference of noncoherent light. Because these light waves have a short wavelength, high-resolution images can be generated. (Intravascular ultrasound (IVUS) could also be used, but it typically has a resolution of 80 microns to 130 microns. OCT devices already on the market are able to measure down to the 15-micron level, providing far more detail.)

Nerdy, yes, but kinda neat too. The potential for the technology seems appealing:

The increased accuracy of OCT technology allows doctors to observe how well the stent is adhering to the arterial walls and to track small amounts of endothelial regrowth that would go unnoticed by IVUS. It could also be used postoperatively to check healing. The resolution of this scan is fine enough to allow doctors to identify small but significant plaque deposits that existing technology might overlook. The technology could also be used to carefully target biopsies, as cancerous cells could be identified in much smaller quantities than currently possible.

No, I don't have anything to gain financially if this becomes the new standard, but it just gives me pause as I try to imagine how medicine will be when I actually am out there as a full practicing physician. Neat stuff.


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The Economics of Drug Dosages

I recently read an interesting article on the economics of drug dosing. The article discusses the medication used to treat Gaucher Disease, the most common lysosomal storage disorder. If untreated, the disease can cause many problems, including severe bone/joint damage. The drug costs over $200,000 per year! I must admit I have never really given it much thought, but if a drug can cost, but at those prices, it definitely gives one pause:

The drug in question, Cerezyme, is used to treat a rare inherited enzyme deficiency called Gaucher disease. Some experts say that for most patients, as little as one-fourth the standard top dose would work, saving the health care system more than $200,000 a year per Gaucher patient. “It is economic malpractice to give a much higher dose of an expensive drug than is required,” said Dr. Ernest Beutler, an authority on Gaucher disease at the Scripps Research Institute. Some other Gaucher specialists argue otherwise, saying that skimping on the medicine could endanger patients.

The economics of this drug are staggering:

With Cerezyme, which is made by Genzyme, the profits are sizable. Gaucher disease, which can have complications like ruined joints, is rare; only about 1,500 people in the United States are on the drug and about 5,000 worldwide. Sales of Cerezyme totaled $1.1 billion last year, making it a blockbuster by industry standards.

A BILLION dollars from a drug used by at most 5000 people? I am willing to bet that most of the people outside the U.S. do not get the medication, meaning that in the U.S. the cost of the drug may be even higher than the value quoted above. To be fair, here is Genzyme's defense:

Genzyme, which became a leading biotechnology company because of Cerezyme, says that it has raised the price only once — 3 percent last year — since introducing the drug in 1994. The company says it needs the high price to make a sustainable business of serving such a small number of patients and to pay for research on new products. Genzyme also says it provides the drug free, if necessary, so that no one goes without the product because of its cost. But critics say the company’s development costs were minimal, because the early work on the treatment was done by the National Institutes of Health, which gave Genzyme a contract to manufacture it. And analysts estimate the current cost of manufacturing the drug to be only about 10 percent of its price. Insurers generally cover the drug because there are so few patients. But finding or staying on insurance can be difficult.

The collective costs can be staggering:

Ms. Mangum began treatment in 2000, at a cost of more than $400,000 a year. The next year, the premiums for everyone in her insurance pool went up by $180 a month.

I am not sure what can be done about this under the current system, but if one thinks about the true purpose of insurance, I think it becomes clear that a national healthcare system is necessary to protect and cover the costs for individuals who have these rare but treatable diseases.

Medical Marvel: Craniofacial Duplication

Perhaps you saw the news last week, but if not, here it is: a two-faced baby was recently born in India. The condition is known as craniofacial duplication or diprosopus. Apparently, the condition is not due to abnormal twinning, but rather a protein abnormality in the SHH (Sonic the Hedgehog) Protein that leads to facial features being duplicated.

Image courtesy of The Huffington Post

Interesting stuff, but again... why India? Why?

Medical Marvel: Fetus In Fetu

My friend sent me an interesting story about a man in India who was found (at the age of 36!) to have his twin living inside of him:

At first glance, it may look as if Bhagat had given birth. Actually, Mehta had removed the mutated body of Bhagat's twin brother from his stomach. Bhagat, they discovered, had one of the world's most bizarre medical conditions -- fetus in fetu. It is an extremely rare abnormality that occurs when a fetus gets trapped inside its twin. The trapped fetus can survive as a parasite even past birth by forming an umbilical cordlike structure that leaches its twin's blood supply until it grows so large that it starts to harm the host, at which point doctors usually intervene.

A fetus in fetu is quite rare. In fact, when I first read the article, I thought the punchline was going to be that he had the world's largest teratoma or something. As often as humans are called 'parasites' metaphorically, I guess this is a literal case of a human being as parasite. One other point: why does stuff like this seem to always happen in India?

A Shortage of Primary Care Physicians?

A recent piece in the NYTimes discusses Massachusetts' experience after enacting its health insurance reforms which mandated coverage for all its citizens. The article discusses how the structure of reimbursements has shifted how many people enter into primary care. It's little surprise that this is the outcome, given situations like this:

Dr. Atkinson, 45, said she paid herself a salary of $110,000 last year. Her insurance reimbursements often do not cover her costs, she said.

“I calculated that every time I have a Medicare patient it’s like handing them a $20 bill when they leave,” she said. “I never went into medicine to get rich, but I never expected to feel as disrespected as I feel. Where is the incentive for a practice like ours?”

I imagine some politicians out there believe that the "magic of the market" can solve this problem. To a certain degree, as the supply of PCPs shrinks, salaries should rise, but given the way the private health insurance system works, this "market correction" does not seem likely. Doctors are too weak in the system, and the insurance companies end up looting both them and their patients. Think about it: the insurance company not only sets the "price" (the premium / deductible) for the patient, but also for the physicians (in terms of reimbursement rates). Why should this be the case? Can you imagine if your auto insurance company charged you to let you buy a car and then decided how much to pay the car dealership when you went to get that car? It's just ridiculous.

Jenny McCarthy's Anti-Vaccine Autism "Bulls**t"

Jenny McCarthy was recently on CNN's Larry King Live to talk about her experiences raising a child with autism. Apparently, it was Autism Awareness Week on CNN, and she is the national spokesperson of Talk About Curing Autism. Needless to say, she blamed her child's disease on vaccines. To be honest, I only watched the excerpted portions, not the whole program. However, from what I caught, McCarthy seemed to be relying on her personal story, stories from other parents, and uncited "statistics." I suppose this is a problem with cable news in general. In an effort to show both sides of any issue and have "balance," both parties are reduced to using sound bites without citing any true data, and viewers are left without any sense of which argument actually made more sense.




In the second half of the program, two pediatricians came on the program to discuss their viewpoint that there is no such link. That's when McCarthy unleashed her vast parenting and medical knowledge on them:

In the second half of the program, two pediatricians joined the program who didn't believe that there was a link between vaccines and autism, and McCarthy wasn't having any of it. "Are we considered acceptable losses?" she asked dangerously after a point was raised on the cost-benefit of vaccinations, and what they offered in terms of prevention. "Give my son the measles! I'll take that over autism any day." It was also around that point that she called the standard vaccination program "bullshit" without missing a beat. CNN deleted the expletive in the transcript but not on air, because they don't call it "Larry King Live" for nothing.

Hmm... who are you going to believe, two pediatricians with decades of experience, or a woman who is famous for showing her hoo-ha's in magazines and hosting a TV dating show and dating Jim Carrey (I think?). It's sad that I know that much about her actually. While her child's condition is unfortunate, McCarthy's lashing out at pediatricians and vaccines is a sign of denial and a desire to assign blame. The very idea that measles is somehow vastly preferable to autism makes no sense. Clearly, McCarthy is not familiar with some the complications of measles, like
subacute sclerosing panencephalitis. While the rise in autism is a cause for concern and further serious study is required, such sensationalization does more harm than good.

Still not convinced? Keep reading about the crusade against vaccines, or other interesting articles related to autism spectrum disorders.

Projection: The Politicians' Defense Mechanism

Projection is a type of psychological defense mechanism. According to Wikipedia, it is defined as:

In psychology, psychological projection (or projection bias) is a defense mechanism in which one attributes one’s own unacceptable or unwanted thoughts or/and emotions to others. Projection reduces anxiety by allowing the expression of the unwanted subconscious impulses/desires without letting the ego recognize them.

For some reason, this seems to be a fairly popular defense mechanism among celebrities, especially politicians. Here are a few notable examples:

Eliot Spitzer

The former New York Governor recently resigned after he was found to have frequented prostitutes. Why projection? Prior to being elected governor, Spitzer had served as New York's Attorney General, and was particularly aggressive in enforcing the law. Seems like he was projecting his own moral failings on others.

Larry Craig

The former Senator from Idaho resigned after he was caught in an investigation about male prostitution in the Minneapolis Airport. Why projection? Prior to this discovery, Craig was outspoken in his opposition to same-sex marriage.

Gary Hart

The former Presidential candidate and Senator was found to be having an affair after claiming not to be involved in one and challenging reporters to follow him around. I suppose this isn't really projection, but the hubris of such a challenge is something to behold.

History is filled with many more such examples, such as Henry Hyde leading the impeachment hearings against President Clinton, even though he had engaged in an affair years before himself, or noted segregationist Strom Thurmond having fathered a child with an African-American woman. I suppose there are many more politicians who have no such failings, but it almost seems like projection is part of the job description.

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