Thursday, October 30, 2008

Medic Ride-Around

I just returned from 10 hours on a paramedic rig in San Francisco. This is part of the emergency medicine rotation at San Francisco General. It was a rather interesting day. Not very busy, but busy enough that I only napped for 10 minutes around 1:30 PM.

The cases included:
  1. A morning commuter who fell in a crosswalk, skinned her knee and was bleeding from the head.
  2. An older gentlemen one week out from a prostate surgery who had bloody urine and pelvic pain.
  3. A kid who fell in gym class onto a tennis court and had midline neck and back pain.
  4. An eleven year old who was post-ictal from his first seizure.
  5. A different eleven year-old who konked heads with a classmate playing football.
  6. An elderly diabetic woman who fell at the food pantry and incurred a non-bleeding scratch on her knee. She later offered to dance for us - for a fee.
Three of these went to a hospital. The medics apologized for not having any 'interesting' cases, but one pointed out that his favorite kind of day is one where no one gets hurt. It was interesting to me to see what people call 9-1-1 for, and the expense incurred for it. That's a difficult thing to get my mind around. And I'll have to think about that a little more.

Wednesday, October 29, 2008

Hello. I'm Thomas. And I'm a Blogaholic.

Okay.  It's time to dive head-first into the medical blogging controversy.  One of my colleagues at the University of Washington is interacting with administration there to possibly set guidelines and recommendations for medical blogging.  He's got me thinking again about this issue.  As you recall, I thought a lot (and still do) about the line between sharing a patient's story (anonymized) and respecting her rights.  I settle with asking patients or masking identifying facts so much that the patient would not recognize the account as his own.  You can imagine there are a lot of people who have things to say about this.  I respond to my professional society's position in this week's article for The Differential.  Check it out if you have the chance.

Regarding blogaholism, I actually do score positively on the CAGE screen for blogging (A and E).

Tuesday, October 28, 2008


Warning: humdrum domestic details ahead!

My first shift is today from 1400 to 2200. Last night I prepared by staying up until 11:00 PM. Today, I tried to sleep until 8 or 9:00. This morning, I'm reading emergency medicine stuff for a few hours, am soon going to track down some biking shorts (be very afraid) and a reflective vest, and will head over to the San Francisco General around 1:00 so I have time to shower and get my hair done. Then, since I have tomorrow off, I think I'll head over to the East Bay to get some computer work done. Now I just have to find a library where I can set up shop working on my various writing projects...

Saturday, October 25, 2008

Next Stop: San Francisco

Well... actually, I'm flying into Oakland, staying with my parents in the East Bay and then heading over to SF proper to get the lay of the land before Monday's orientation to the San Francisco General emergency medicine clerkship. I'll pick up my brand new Trek 7.3 this weekend!!! My first shift is on Tuesday, I'll be riding along with medics on Thursday and much more. My overnight shifts are all grouped in my third week, which is nice, and I have scheduled my residency interview the last week of the rotation.

Now if I can just figure out what I need to pack...

Friday, October 24, 2008

Last Day

Today is going to be crazy. Just like the last 70 days.

After ten consecutive weeks of psychiatry, I'm going to miss hour-long interviews, the wait and see approach to care, the challenge of nurturing behavior change and all of the talking. I'll also miss the daily case studies of brain pathology.
  • The amazingly disorganized schizoaffective homeless man who saluted me every time I asked him a question and could recount amazingly accurate historical accounts of the Pacific Theater in WWII.
  • Entering into the dark, empty, wide-open room at the edge of a cliff and offering one pinhole of light (i.e. Washington Sate Law) to move a suicidal patient to the next day.
  • Having to stand back when an extremely psychotic patient is immobilized for her own safety and then being there when she is able to speak in cogent sentences.
  • Seeing the effects of drugs and alcohol that all of the commercials warn about.
  • Learning that it's actually not uncommon for a manic person to be found naked, directing traffic. In fact, it's pathomneumonic for mania.
Psychiatry, you've been good to me. I'll see you again soon.

Wednesday, October 22, 2008

Diagnose This

For no apparent reason, I've woken up at 5:15 or 5:30 without an alarm for the past week.

I wonder if this application process is taking a toll on my sleep architecture.

Tuesday, October 21, 2008

Clinical Knowledge

My USMLE Step 2 Clinical Knowledge score came back in record time. As you will recall, my score on the costly sandwich (CS) exam was PASS. Today, three weeks to the day after taking the 9 hour computer exam, I received my score report. I PASSED, and scored higher than I did on Step 1 (which I took back in 2003).

Since my score was higher than I expected, and lower than most of my peers, I've decided to share some data about how well the USMLE World practice software package prepared me and the accuracy of one practice exam score predictor, provided by Those who know I'm an engineer at hear will not be suprised by the following chart.

Plotted on this graph are score estimates from sequential practice exams I took using the USMLE World software. That software grants you acces to a couple thousand practice questions and prepares exams composing of 46 questions each. I averaged the raw scores of the six most recent exams made of questions I'd never seen. That average was input into the tool and plotted on the date. The averages are rolling. The turnover was 4 exams (adjacent data points share from 1-3 individual scores in their average. On the scale above, the horizontal line is 184, or passing. You can see that my trend was dangerously close to that cutoff. But considering my poor showing on Step 1 back in '03, I knew I needed to buckle down.

Shown in red is my actual score - a 209. This is below the national mean, but right about where I'd hoped to be. The one data point immediately before the exam - that was the free USMLE practice exam provided by the exam company. I recommend you take it. not only, will it make you feel better, my experience was that combined with the score estimator, it was a better predictor of my actual score.

Finally, you may ask: why is he advertising such a low score? Well - there's a good chance that residency programs already know my score. If you're reading this because Google brought you here, maybe you'll appreciate seeing a self-reported score that isn't in the 240 range. If you're reading this because your my friend, thanks for being my friend!

If you haven't taken the exam yet, hang in there. Take some time to focus on the material, practice with question sets, and try to take some time off to prepare. I wouldn't, for example, recommend studying at the same time as taking a required psychiatry clerkship.

Jump Into Sound

One of my patient's chief complaints today currently tops the list of titles for my first book, should I ever get to that point. The phrase carries multiple meanings ranging from dark to playful.

Jump Into Sound

What do you think?

Sunday, October 19, 2008


I've another article up at The Differential today. This one's about the anxiety associated with interviews. Not interviewing patients - interviewing at residency programs. Except that right now, my anxiety is centered on waiting for interview offers. For those playing along at home, I'll be updating a list (on the panel at right) of which cities you may be able to find me over the next few months. I'm linking the programs' websites, too (as much for my own utility as for your curiosity). Next week, I'll fly to the Bay Area for a month-long emergency medicine clerkship at San Francisco General Hospital.

Physician Heal Thyself

I've been a bit under the weather lately, and considering that I currently cannot see more than 50 feet out my window which can typically see mountains 50 miles away, that's saying something. Getting sick as a health provider adds conflict to the first directive of "do no harm" and lumps additional irony to the proverb, "Physician, heal thyself." Medical student status adds another wrench to the mix. I've written more over at The Differential.

Powell Endorses Obama

This entire segment on Meet the Press is worth watching, but I want to direct your attention to the part of his statement beginning at minute 4:27.

Right on, General Powell!

"What if he is?" and "Is there something wrong with a 7 year old Muslim-American kid who believes he or she could be President?"

These are the questions we SHOULD be talking about. And "Muslim-American" in that question should be interchangeable with atheist or agnostic or Hindu or Jewish...

Sunday, October 12, 2008

2008 FOSEP Enegy Forum

In 2004, Seattle's Forum on Science Ethics and Policy (FOSEP) hosted an informational event about stem cells that attracted more than 700 people to the University of Washington Campus. This election year, a new group of graduate students has put together what promises to be even more timely. If you are in or near Seattle on Thursday, October 16, this event will be worth your time. Check out more at FOSEP's web site, or click on this poster for more information.

Take This Class

Click for a larger image. Email me with questions.

Tuesday, October 07, 2008

Clinical Skills

I am pleased to report that the United States Medical Licensing Examination has found me:
  • capable of integrating a clinical encounter
  • competent with communication and interpersonal skills and
  • proficient with spoken English.
In sum, I passed the clinical skills portion of USMLE Step 2. Step 2 CS. The CS stands for Costly Sandwich. As in $1500. Or in my case, $500 each. For those outside of the medical education circle, this is the exam where senior medical students (or international medical graduates) fly to one of 5 American cities to take an 8 hour examination that consists of interviews with 12 standardized patient actors. The closest spot for me was in LA. The exam costs about $1200 not including lodging and airfare. There is a "free" lunch.

Monday, October 06, 2008

Register Today!

Have you registered to vote yet?

If not, today is your last day to do it if you want to vote in the most important election in my lifetime.

Rock the Vote has a really easy online registration in whichever state you're in.

Just Do It!

Sunday, October 05, 2008

Going Crazy in the PES

Lately I've been thinking a lot about what the difference between psychiatric illness and normal variation. Admittedly, this is due to my frequent proximity to mental illness with my clinical rotations. My latest post to The Differential could blur the line a little more than usual. It's a must-read for my family and close friends. Can you figure me out?

Role Model

I'd someday like to be a Caleb Burhans of science, medicine and society. Don't know who that is? I didn't either until I read today's New York Times feature of him. Or, if you're oriented more to screen than print, watch this clip:

I found it an inspiring example of following one's interests and passions.

Saturday, October 04, 2008


My fellow bloggers,

Are you looking for some carnivals to showcase your best writing? Listen up!

Like so many of my extra-curricular interests, blogging has fallen a bit behind in the face of licensing board exams, finals, and long hospital work hours. It doesn't help that my current bus lines do not have wireless... But you've seen an increase here and at The Differential of late. I am really excited about what is going down over at Clashing Culture in the next two weeks. Thanks to the strong work one of my co-bloggers there (Mike, also known as Tangled Up In Blue Guy), Clashing Culture will be hosting not one, not two, but three carnivals in the next two weeks.

On deck over there is:
If you want to submit to any of these, click on the links above to either connect to a web form or to email the host.

Wednesday, October 01, 2008

it is finished

Step 2 Clinical Skills is in the rear view mirror, and I'm driving the speed limit. Which is only 55 on the freeway passing though my municipality.

Why only the speed limit? It's all those gruesome traumas I've seen in the ED were for folks driving ABOVE the limit...


I'm pretty sure I won't have to take the exam again.