Medical Thread

[BarakzaiAbdali]

I want to amend what I wrote above. Someone pointed out to me via pm that the usage of the word dumb might be construed as offensive. I want you to know that when you read the sentence, I am not in any way implying any applicant to any pathway is inherently "dumber." I thought the language indicated that I knew these folks going through the DO pathway were of great intelligence, but just that the only reason they did not get into the MD pathway may rest in the mistake of not realizing that about 50% of the application process is "fluff" and business. That is with the caveat of if they even ever wanted to go the MD route.

However, Qunduz khoraay, I talked to some osteopaths and got some more information for you.

So the DO degree pathway and training is generally indistinguishable from the MD training pathways. However the DO pathways emphasis holistic approaches a bit more. More DOs, as I stated, do go into Primary Care... but over the years, similar to their MD colleagues, they are branching out into more selective fields.

I still do note that the majority of the hospitals I have worked or studied in do have more MDs in the competitive specialities though.

There appear to be special residency programs that only DOs can attend if they want to. However, they can all sit for the same USMLE Step Exams we sit for.

Regarding Admin Khan's question of preparation... usually a good curriculum and some hard work are more than adequate prepartion.

For USMLE step 1: Most folks swear by the Kaplan Q Bank and First Aid for the Boards (A review book). Its wierd because that formula does work for some reason...

For USMLE 2: USMLE World Q bank is pretty much all one needs.... just repeating questions and clinical scenarios again and again.

USMLE 3: Practice USMLE world cases from a Q bank + some Kaplan notes suffice. The internship year usually is great preparation in and of itself and some people take it blind and do great.

Bottom like Kunduz Khoraay here is the pathway I generally advocate so one can practice completely autonomously without inhibition around the world and in the US:

Go for the MD route. If you cannot pursue this, get the DO degree and sit for the USMLE. If not, then pursue the PA route.

If you go DO, then talk to me and maybe I can try and help you so that you develop a competitive application for applying to residency of your choosing. My kid sister is nearly on the cusp of applying, but she goes to an MD school. She is a bit closer to the process and I can gauge what changes may have occured.

The good news for youngins is that the system is changing in the coming year or two and the internship year is going to be a bit easier with 12 hours on and 12 hours off (no overnight call anymore). So the general MD route should be more reasonable for even conservative Afghan girls who want a family life.

Good luck and know I am here as a resource if you need me. As always, use what you gain in the service of Islam.

[BarakzaiAbdali]

I was at an interview today and really reminded myself of why it is so important to keep your ears open. You can really learn to word things from these masters of the realm (the old school cardiologists). You can then use this information on subsequent interviews. So for example, I have always found it difficult to explain how clinical pursuits and research interests mirror eachother and that the thought processes behind both can help one be a superb academician-clinician. The problem is that you can get pigeon holed either way.

So the attending, a big member of the American College of Cardiology noted that the research problem starts with some scant data and a series of hypothesis just as a clinically challenging patient in the ED presents with limited data and you have to generate a series of possible differential diagnoses to investigate. In both situations you have to understand which data is important.

So now, when this question comes up regarding how I justify research acumen supplementing the ability to clinically care for patients, I will craft these words into a formidable answer.

Remember, listen in all that you do and you can really develop your speaking capabilities.

[qunduz92]

I want to amend what I wrote above. Someone pointed out to me via pm that the usage of the word dumb might be construed as offensive. I want you to know that when you read the sentence, I am not in any way implying any applicant to any pathway is inherently "dumber." I thought the language indicated that I knew these folks going through the DO pathway were of great intelligence, but just that the only reason they did not get into the MD pathway may rest in the mistake of not realizing that about 50% of the application process is "fluff" and business. That is with the caveat of if they even ever wanted to go the MD route.

However, Qunduz khoraay, I talked to some osteopaths and got some more information for you.

So the DO degree pathway and training is generally indistinguishable from the MD training pathways. However the DO pathways emphasis holistic approaches a bit more. More DOs, as I stated, do go into Primary Care... but over the years, similar to their MD colleagues, they are branching out into more selective fields.

I still do note that the majority of the hospitals I have worked or studied in do have more MDs in the competitive specialities though.

There appear to be special residency programs that only DOs can attend if they want to. However, they can all sit for the same USMLE Step Exams we sit for.

Regarding Admin Khan's question of preparation... usually a good curriculum and some hard work are more than adequate prepartion.

For USMLE step 1: Most folks swear by the Kaplan Q Bank and First Aid for the Boards (A review book). Its wierd because that formula does work for some reason...

For USMLE 2: USMLE World Q bank is pretty much all one needs.... just repeating questions and clinical scenarios again and again.

USMLE 3: Practice USMLE world cases from a Q bank + some Kaplan notes suffice. The internship year usually is great preparation in and of itself and some people take it blind and do great.

Bottom like Kunduz Khoraay here is the pathway I generally advocate so one can practice completely autonomously without inhibition around the world and in the US:

Go for the MD route. If you cannot pursue this, get the DO degree and sit for the USMLE. If not, then pursue the PA route.

If you go DO, then talk to me and maybe I can try and help you so that you develop a competitive application for applying to residency of your choosing. My kid sister is nearly on the cusp of applying, but she goes to an MD school. She is a bit closer to the process and I can gauge what changes may have occured.

The good news for youngins is that the system is changing in the coming year or two and the internship year is going to be a bit easier with 12 hours on and 12 hours off (no overnight call anymore). So the general MD route should be more reasonable for even conservative Afghan girls who want a family life.

Good luck and know I am here as a resource if you need me. As always, use what you gain in the service of Islam.

this is so helpful barakzai wrora. thanks a lot for this.

[BarakzaiAbdali]

Here is an interesting article regarding the changing culture across 3 generations of American Medical Physicians. I think there is a very astute quote from Osler, the father of modern residency training:

http://www.nytimes.com/2011/04/02/he...ewanted=3&_r=1

"The culture of medicine at the time was decidedly macho. Residents routinely worked 120 hours a week, often staying at the hospital for days at a time. Indeed, the term “residency” comes from the first such program at Johns Hopkins University, established around the start of the 20th century, where doctors lived in a dormitory next to the hospital, a monastic life inimical to women who wanted children. As the residency requirement took hold nationally, the share of female doctors, already low, fell further. Dr. William Osler, the founder of the residency program, celebrated such sacrifices.

“What about the wife and babies if you have them? Leave them,” Dr. Osler wrote. 'Heavy are the responsibilities to yourself, to the profession and to the public. Your wife will be glad to bear her share of the sacrifices you make.'"

Now contrast Osler's attitude (that attitude that made American medicine what it is today and subsequently had an impact all across the world), with more recent developments:

"Pregnant residents are another sign of medicine’s shifting culture. Residency hours and practices were once so grueling that few doctors deliberately became parents during those years. But in an effort to reduce fatigue-related errors, residency hours were reduced in 2003 to 80 per week. Last year at Johns Hopkins, the birthplace of the residency program, more than a third of the women in one internal medicine residency program became pregnant or were the mothers of young children — an outcome that would have been unimaginable to William Osler."

So for my female future colleagues on here... or for those of you females with strict parents who want to join the ranks, referring your parents to this New York Times articles might just allow them to reflect on the new culture of medicine and its flexibilities.

I tend to think that Osler had certain things correct... in order to master disease states, their presentations, and their treatments you have to see them again and again. Reading about them in Harrison's only goes so far.

Moreover, hearing various giants in the field talk about their days of every second to third night on call and open Medical ICU protocols is a crazy experience because of descriptions of just how rigorous their days were. Yet these folks have the details hammered into their brains. Some argue that knowledge has exponentially increased from their time. As an example, all you could really do in the 1980s when a person was having their heart attack was give them some aspirin and watch the heart attack complete itself. Maybe you threw some Lasix their way. Now, we have an arsenal of protocols are our disposal with a number of additional medications we implement. With this in mind, the learning curve has steepened.

So in the long run, I am not sure what will be better for the field, the new restricted work hours or a more rigorous system similar to what Osler proposed.

What I do know is that the ACGME changes that are coming our way in the next year will open the field wide to women such as yourselves from more restrictive environments. As an intern, you will likely see overnight call only in the cardiac and medical intensive care units.

Being informed about such matters and changes in the field will make you sound much more academic at interviews and such.

Best of Luck.

[qunduz92]

salam barakzai wrora

what activities can we, as students, engage in in the afghan refugee camps?

[BarakzaiAbdali]

salam barakzai wrora

what activities can we, as students, engage in in the afghan refugee camps?

So from what my sister experienced, you need a male family member there. There are legitimate NGOs that are involved there. My wife's family members have some links that we can utilize if you decide you want to go that route. The camps still operating in Pakistan are much safer for you.

There are also refugee/tents/camps set up near Kandahar now as per the infrastructure devastating attacks that the Surge has produced. Another option is Mir Wais Hospital in Kandahar.

You do not have to worry about "looking like a doctor." Your simple presence and desire to lend any helping hand is a huge deal. The other option is the Afghan Refugee Clinic that I run here at Yale.

Give me a heads up either way.

[Admin Khan]

BarakzaiAbdali,
How can I support the Afghan Refugee clinic you run?

[BarakzaiAbdali]

BarakzaiAbdali,
How can I support the Afghan Refugee clinic you run?

Salamoona,

The current organization of the clinic is under IRIS:

http://www.irisct.org/

So the general funding for the clinic comes from various donors and Yale itself now after we lobbied it to include it as a general subdivision of the Primary Care Center. The issue with this structure is that all refugees are lumped into one "refugee" clinic with myself heading up the Afghan portion of it in coordination with some very generous Iranian doctors who are helping to stave off the massive influx.

I may try to see if the clinic can function off of some exclusive funding meant for the Pashtuns/Afghans. The hardest part of it is that when something is prescribed, these folks have limited access to medications at first until they get reclassified in some way by Connecticut State. Even then, the medications and associated costs tend to be an issue.

Most of these refugees are given about a month of two of funding and are then expected to find their own way.

I will gather more information regarding actual logistics to see what we can do.

There is a young Wardak boy who still comes in from Massachussetts, a really good guy in my estimation, who helps out with translation when I am gone/not around/on the unit. From what I understand, because of medico-legal issues, translaters have to be registered through the hospitals they participate at. My idea for folks like Qunduz would be to accompany me into the clinic. I would allow them to play a role (since no one really monitors me at this point) via me coaching them on what to ask and then asking the questions, etc. If we do any procedures, like knee taps or other primary care oriented procedures they could assist. I would likely hook them up with the director of the whole refugee clinical subdivision within the Center for future recs and stuff that they might benefit from (because I am still classified as a trainee my rec doesnt mean much until I become an attending level physician status post heart failure fellowship).

[qunduz92]

barakzai wror you are so helpful.

the clinic idea sounds good. i am interested in helping you with that.

as far as the refugee camp ordeal is concerned, i would be with male relatives. i was not planning on going alone so try to help me find my way with that. its true some people say they can be an unruly bunch but i always give our people the benefit of the doubt. where is this camp you speak of located? i am going to be in the area during the summertime though so it would work out. thanks a lot.

[kakargirl]

wror mashallah great information you put up, i don't know how you do it wror ,as i know your busy life ,its amazing mashallah i'm so proud of you and i'm not being bias by blood or anything, you truly are a genius wror.

[BarakzaiAbdali]

Another great forum that is well known to American Medical Graduates and Foreign Graduate alike:

http://www.studentdoctor.net/

It also provides a wealth of information for folks interested in everything from a career in the PA business to Dentistry to Pharmacy School.

Folks come on here to provide interview related information and specific questions they were asked, techniques to prepare for standardized testing ranging from the MCATs to the DATs to the USMLE exams to the ABIM board exams.

Various program directors are also hosted from time to time to comment on current affairs in medicine as they relate to seeking a career within the medical field.

[BarakzaiAbdali]

Obamacare. Its a word floating around these days in the Afghan community as well when kids are bringing up a future in medicine. The assumption is that doctors are going to starve now. This is not at all true. In fact, the practice of medicine may change quiet a bit for the better in advertantly (I say this because I do not agree with all the facets of Obamacare).

For instance, many hospitals these days are instituting performance measures. As an example, if a patient comes in and is diagnosed as having a heart attack, the hospital has a check list that is sort of mindless that entails physcian trainees check off whether the optimal cocktail of medications to potentially save the patient from future events, improve mortality/morbidity is on board. This is sort of stupid because the pathophysiology of a heart attack is complex. If the patient has an inferior wall myocardial infarction we need to determine whether the right coronary artery has been hit or not. It feeds the conduction system of the heart and if you reflexively provide a beta blocker (a type of medication) to such a patient because a nurse runs up to you demanding that you institute performance measures for some idiotic paperwork (at 3 in the morning when you just want to fall over and sleep) you may inadvertantly harm the patient by adversly affecting the heart rate. You will look smart when you actually pause and document why you prefer to reevaluate 4 days out or so after the catheterization is done to determine whether the Right coronary was involved.

With eletronic medical record systems coming into the foray, this sort of algorithmic thinking is going to increase.

However, with medicaid and other sources of funding limiting nonevidence based practice, my hope is that trainees will be taught to practice with much more logic and will really truly understand when too much imaging is wasteful, etc. As a result, the American medical system may begin to rely more on the basics as the British system does. As an example, a nuclear stress test is expensive per the material that is required for the exam. So the British are pushing cardiac MRI, a potentially less harmful approach to such diagnostic workups (more importantly, their logic behind pushing it makes complete sense).

Also, primary care physicians are experiencing a potential rebirth of their field with this new approach to healthcare. They are going to become a more prominent gate keeper.

From what I hear, my field may get pushed into the hospital arena and out of the private practice arena. This may not at all be such a bad thing.

The bottom line is that American Medicine is not going to collapse any time soon. Academic funding is going to get tighter. All of this may lead to an improved state of practice though, where grant money is alotted to stuff that actually is worthwhile. As an example, a lot of money is getting thrown at adult stem cell therapies (as opposed to embryonics). However, the adult stem cell populations have not been proven to become heart cells and may just function, at best as a sort of pharmacological vehicle. Therefore, pushing adult stem cell therapies and throwing money at it from all angles may be a bit useless.

[BarakzaiAbdali]

Electronic Medical Record Systems:
Think programs like EPIC Medical, the Veterans Administration's CPRS, sunrise medical systems, etc. With the healthcare plan, eletronic medical record systems are going to actually become more abundant. To the budding computer scientist, this is a lucrative option to chase and very worthy of looking into in terms of generic programs that can be implemented in grass roots environments. In my opinion EPIC and the US government developed CPRS are excellent systems and are very user friendly. These systems have multiple specifications for design that we physicians demand:

1) The ability to access eletronic healthcare records
2) The ability to document during encounters (inpatient and out)
3) The ability to see bloodwork/labs/rare studies and imaging studies (e.g. pull up a patients MRI
4) An ability to enter in orders to be executed

There are others, but I put this this out there because these companies are going to experience a boom in the coming years as the hospital systems across the country get linked up.

It may be many decades from now, but as we attempt to build that cross border hospital system in Pashtunkhwa/Afghanistan that we talked about, I am going to need to coordinate with young talent here to come up with in house record systems.

For instance, Vanderbilt University has its own medical record system (STARLink I think it was called on my recent visit) that it modifies and was developed by the school of engineering. From what I understand it is superb. I think that EPIC and these other programs are going to be way to expensive to implement in the Afghan healthcare system.

We will need to model ourselves off the Vanderbilt University Paradigm and develop in house software cheaply at each hospital that serves local purposes initially and then allows us to link up with the above design specs in mind.

I wonder what Rehman Medical institute utilizes at this juncture. My hope is that it has gone digital in all aspects, including echocardiography, as this allows loading into such electronic medical record systems.

In medical jargon these record systems are called
EMRs (eletronic medical record systems).

[Admin Khan]

BarakzaiAbdali,

Today I had the honor in speaking with a Professor from Harvard medical school. To be honest with you, he wasn't so optimistic about the medical field. His argument revolved around the fact that there are way too many doctors in the US, and since the US economy isn't as strong as it once was, many people can't afford to pay high medical bills which in result equates to payments not being paid on time, etc. He also mentioned that the US needs to stop permitting foreign doctors to the US because:

• Most of the time, they aren't as well-trained as their American counterparts. He was speaking about how they are just good exam-takers, and how they are good at memorizing concepts without understanding them. He also mentioned that he doesn't want to generalize, but it's the truth from his experience.
• They take away from the local homebrew. And in result, they are many young doctors who have enormous debts, and they are unemployed.

Looking forward to your response. Your thoughts are as always valued and appreciated.

[BarakzaiAbdali]

BarakzaiAbdali,

Today I had the honor in speaking with a Professor from Harvard medical school. To be honest with you, he wasn't so optimistic about the medical field. His argument revolved around the fact that there are way too many doctors in the US, and since the US economy isn't as strong as it once was, many people can't afford to pay high medical bills which in result equates to payments not being paid on time, etc. He also mentioned that the US needs to stop permitting foreign doctors to the US because:

• Most of the time, they aren't as well-trained as their American counterparts. He was speaking about how they are just good exam-takers, and how they are good at memorizing concepts without understanding them. He also mentioned that he doesn't want to generalize, but it's the truth from his experience.
• They take away from the local homebrew. And in result, they are many young doctors who have enormous debts, and they are unemployed.

Looking forward to your response. Your thoughts are as always valued and appreciated.

I find that foreign graduates can be very capable if they are acclamated to the American environement and communication mentality. Here at Yale, the directors were telling me that in the coming years even in NYC they are going to clamp down on foreign grad admissions to residency. Word on the street is that the noose is already tightening.

Regarding the professors commentary, I would caution you about relying too much on the medical professional's own assessments if they are not involved in MPH level work. Take for example the fact that about 10 to 15 years or so ago, surgeons across the country were clamoring for a massive clamp down on the number of surgical residency spots. The College of Surgery and the AMA are notorious guild/lobby style interest groups that raise such red flags and alarms every few years. Or take for example the claim that gastroenterologists were going to be in overabundence. In both situations, they created an artificial supply and demand mismatch so much so that there is actually going to be a surgeon shortage in the coming decades.

What Peter Herbert, the CEO/Head Cahoona here at Yale told me was that as Cardiologists and other specialists are more highly regularted, their capability to do procedures at their own whim, without relying on evidence based practice will cut into lucrative private practice modalities. This will then force most of them into academia/hospital practice. His joke was that they will go from earning $400,000 to 500,000 in the private sector to 200,000 to 250,000 in the hospital set up (he meant that they still wont be starving).

http://www.usatoday.com/news/health/...shortage_N.htm

"The predictions of a doctor shortage represent an abrupt about-face for the medical profession. For the past quarter-century, the American Medical Association and other industry groups have predicted a glut of doctors and worked to limit the number of new physicians. In 1994, the Journal of the American Medical Association predicted a surplus of 165,000 doctors by 2000.
"It didn't happen," says Harvard University medical professor David Blumenthal, author of a New England Journal of Medicinearticle on the doctor supply. "Physicians aren't driving taxis. In fact, we're all gainfully employed, earning good incomes, and new physicians are getting two, three or four job offers.""

http://www.usatoday.com/news/health/...shortage_x.htm

"Most worrisome, the retirement of baby boom physicians means the number of doctors will start falling just as the first baby boomer turns 70 in 2016, says Ed Salsberg, a workforce specialist at the Association of American Medical Colleges."