Monthly Archives: August 2011
To complement the recent release of our book recommendation for Ob/Gyn clerkship and Step 2 review, we offer the below experiences in hopes that rising medical students can learn from past mistakes and successes. Obstetrics and gynecology is usually perceived as one of the more labile rotations you will face in medical school. While there are clear differences between hospitals across the nation, and even great variability between teams within the same hospital, this tends to generally be the case with respect to other rotations.
In distinction to many other clerkships, most medical schools rotate students through a number of different ob/gyn sites and settings, usually highlighting outpatient gynecologic exams, inpatient or surgical gynecology, outpatient obstetrics, and labor and delivery. This generally prohibits cohesive or longitudinal teamwork, and leaves residents and attendings with very little exposure time from which they must draw their evaluations. As such, the first piece of advice is to pre-read before starting obstetrics and gynecology. This is in distinction to other stable rotations where reading can be done along the way. You will get pimped on day 1, and have few days past that to redeem yourself. Come in knowing your basic terminology and abbreviations.
Outpatient ob/gyn clinics are usually mixed. Some will probably be shadowing, while others are primary care based, where focus should be on prevention and good planning. For gynecology, you should know your in-office STD and vaginosis screenings, what to look for on microscopy, and how to treat each. Every exam should have a complete history on sexual partners, obstetrics (G’s and P’s), contraception, pap smears, STDs, vaccinations. If you’re uncomfortable talking about these topics, now is the time to get over it. Be sure to bring your stethoscope.
For obstetrical checkups, you should go in knowing your screening tests, timeline, and the most common reason for first and third trimester bleeding. Presentations should always start with something sounding like “28 year old G3P1011”. G (gravity) stands for the number of total pregnancies. P (parity) has four numbers which correspond to full term pregnancies, pre-term pregnancies, abortions/miscarriages, and live children, in that order. You will be commonly treating bacterial vaginosis and trichamonas with flagyl (metronidazole). You should remember this medication has a disulfiram effect, so it should not be taken with alcohol. Some patients will actually forego treatment until the weekend is over because of this unwanted reaction. Yes, really.
Experiences are usually divided between benign and gynecology-oncology. You should have a pair of gloves and lube packets in your back pocket at all times. Each surgery will start with a pelvic exam on your unconscious unconsenting patient. When the resident lubes up, extend your pointer and middle fingers towards them like a handshake for a “high two” to share their lube. This is how Ob/Gyns bond in the wild, along with matching surgeon caps, black zip-up tops, and playing their favorite game: “find then avoid the ureter.” The pre-op exam is a great opportunity to get your pelvic exam down, so don’t pass it up.
You will most likely need to be able to gown up yourself. If you haven’t had surgery, ask an intern or fellow med student to teach you on the first day of your rotation, regardless of whether you’re starting on something surgical. You should also come into this rotation knowing basic knot tying techniques, regardless of whether you’re going into anything surgical. It’s just a good basic skill to have throughout medical school. If you aren’t familiar with knot tying, a quick search on youtube and spare string or sutures will be helpful. If you have these basic skills down, you will be allowed to do a few things aside from retract. Remember, if you are down below, it is considered “dirty” even though you are in sterile garb. Never move from pelvis to abdomen without changing gloves. Crazy pimp question: most med students are taught in anatomy that nothing runs with the round ligament, so naturally many attendings love asking about it. The correct answer is the Sampson artery.
If you are interested in catching babies, try to take shifts when there are minimal residents, such as nights. If your hospital has private attendings who allow medical students with them, jump at those opportunities. They’re the ones who will let you actually deliver, whereas many of the interns (especially new interns around July) will soak up the opportunities with staff attendings. A lot of labor and delivery is just going into rooms and asking “is there anything I can get you?” and then fetching ginger ale. However you should push into the action when it starts.
The best way to learn how to deliver a baby is to find someone who will let you put your hands on top of theirs for a few deliveries so you get an idea of just how much pressure and movement is needed. Next step up is having your hands under theirs. Once you have a good feel for that, you’re good to deliver with observation. This technique isn’t necessarily offered or known to many residents, so be sure to ask, but it really works well. Be careful when you put on gloves in the room, because it is not uncommon to get surprise-lubed by one of the nurses, whether you wanted it or not (although you almost always want it). If you have the opportunity, try to spend a little time on triage (be sure you know the signs of labor!).
If you have tips or suggestions you would like added to this article, please add them in the comments.
While this site had previously reported on the vast shortcomings of Blueprints Pediatrics, the writers of Blueprints Obstetrics and Gynecology, now in its fifth edition, have thankfully delivered one of the best ob/gyn review resources for medical students who are not going into obstetrics and gynecology. The book itself follows the same format and design as the others in the series, but don’t judge the book by its cover.
The major strength of Blueprints Ob/Gyn is that it is specifically streamlined for NBME exams, which means it strips down all the unnecessary detail and presents the core topics that will aid you in rocking the shelf, as well as the ob/gyn questions on Step 2. One of the tough areas of ob/gyn is learning all new normal anatomy and physiology while currently learning the pathophysiology. The book does a good job of breaking this up into an easy to read flow, with chapters that have a manageable length. This includes both big-picture overviews (e.g. things that go wrong in third trimester) as well as drill down topics (e.g. preeclampsia). Furthermore, the book also has its own question sets which further solidify the topics as you go. This book also doubles as a great guide on Family Medicine as well.
Specific chapters include Pregnancy and Prenatal Care, Early Pregnancy Complications, Prenatal Screening/Diagnosis/Treatment, Normal Labor and Delivery, Antepartum Hemorrhage, Complications of Labor and Delivery, Fetal Complications, Hypertension in Pregnancy, Diabetes in Pregnancy, Infectious Diseases, Other Medical Complications in Pregnancy, Postpartum Care, Benign Disorders of the Genital Tract, Endometriosis and Adenomyosis, Pelvic Relaxation, Urinary Incontinence, Puberty and Menopause, Amenorrhea, Hirsutism and Virilism, Contraception and Sterilization, Elective Pregnancy Termination, Infertility and Assisted Reproduction, various Cancers, and Breast Disease.
Keep in mind that this latest fifth edition has very few changes compared to the previous two versions. If you can pick up the older copies for cheap or free, they will provide the same knowledge.
This is the sixth and final part of a series of posts on comparing Welch Allyn products that will help incoming first year medical students learn about and select different medical instrument components to construct the right Welch Allyn diagnostic set (otoscope and ophthalmoscope).
By now, you should have reviewed the other five articles in the series, and noted your preferences:
Compare Welch Allyn Series: How to Pick the Best Battery and Handle
Compare Welch Allyn Series: How to Pick the Best Case
Compare Welch Allyn Series: How to Pick the Best Light Source
Compare Welch Allyn Series: How to Pick the Best Otoscope
Compare Welch Allyn Series: How to Pick the Best Ophthalmoscope
Trade-offs of Pricing and Usage
It is important to remember that many medical schools only require use of personal diagnostic sets while learning how to perform a physical exam during preclinical years. Many rotations will either not require use of these instruments, or provide them to medical students and staff if needed. You should contact senior medical students at your school to ascertain the usage of these instruments when considering the price. For minimal use, you may want to consider purchasing from another manufacturer entirely. It is also a common mistake for incoming med students to assume these instruments will be used after med school. Specialties that use these instruments have more expensive versions or wall mounted models, and many specialties won’t need them at all.
Selecting Your Model
Most retailers do not carry all diagnostic kit combinations of the above Welch Allyn components. Most local companies will carry about 4 of the 75 total diagnostic kits manufactured by Welch Allyn, and that is actually sufficient for the large majority of med students. It is not uncommon for retailers to highlight the more expensive components, such as the PanOptic ophthalmoscope, and to list all other options by their model number. This can be a rather confusing selection process, which can be remedied below.
The following application is designed to assist in putting it all together and selecting the Welch Allyn diagnostic kit that is best suited for your needs and desires based on the results of the above articles. You may input your selections and the application will output the specific model number for your use with retailers. It will also output a list of the closest matches to your selection, in case your first choice is not carried by your retailer.
Please click one of the following from each category:
Recommended Diagnostic Kit Model Number:
Many will argue that the first mistake third year med students make is buying this book, while others will claim that it is an essential and invaluable survival guide. 250 Biggest Mistakes 3rd Year Medical Students Make and How to Avoid Them by Dessai and Katta is the semi-popular successor of the 101 Mistakes book. As the title suggests, it reviews all of the big issues bound to cause trouble on the wards. But how helpful is it really? The answer depends upon the direction and perspective from which the book is examined.
If an attending were to be pulled aside and asked to write a list of all the things that bring down 3rd year med student evaluations, it may very well produce this book. Therefore, many reason that the opposite must be true: buying this book prevents students from making these 250 mistakes, thereby instantly increasing their grades. That’s essentially the fear hidden in the title of this book: buy it or you won’t get good evals.
Looking at the same scenario from the medical student’s point of view produces different results. If a fourth year medical student were asked to write a list of all the things they wish they knew for themselves coming into med school (one of the very goals of MedStudentBooks.com), only a small portion of this book would be reproduced. The reason for this distinction is because the large majority of “mistakes” in this book are common sense items that the large majority of medical students either don’t make, or adapt to with effortless efficiency.
So why the discrepancy in appreciation of this book from readers? For medical students who have worked in “the real world” or have been held to rigid professional standards previously, pieces of advice such as “show up on time” or “dress professionally” or “get your work done on time” come as an expectation. Others however need gentle reminders that there is a clear distinction in the environment between preclinical and clinical med school years. The majority of medical students come directly from college, and may face an actual professional setting for the first time in their lives at third year. This latter group comprises the students who would most benefit from the nuanced recommendations of 250 Mistakes.
The big picture consists of the following. First, med students should be professional. Second, they should ascertain the characteristics on which they are evaluated by directly asking residents or attendings at the start of each rotation, and reevaluating methods based on feedback along the course of the rotation. It can be an intimidating process for someone unfamiliar with the culture of medicine, but such open communication is a common occurrence. Most attendings at teaching hospitals are happy to help, and do not mind offering feedback. It should be noted however that this falls under a common rule of medicine: don’t ask the question if you don’t want to know the answer. Feedback is only helpful if it is used, and being defensive about feedback is looked down upon.
If you can accomplish these goals of professionalism and open communication that seeks out feedback for improvement, there’s not much else this book has to offer. If however you are new to the working world or want a few gentle pushes in the right direction, this can certainly help. Despite it’s 200+ pages, it’s a rather fast read with big bullet points. The book itself is relatively cheap (compare prices below), but it can usually be found at your local medical library, or borrowed from friends or student lounges.
Another common mistake new medical students make is securing a medical dictionary. Usually these are used as incentives for signing up with one of the medical societies that want your money, but as a whole, they are not needed. That’s not to say they are inaccurate or unhelpful, so much as outdated. If you need to look up the definition of a specific medical term, chances are you will be effortlessly turning to Dr. Google or Wikipedia, instead of digging out a book from your shelf and using your mastery over alphabetical order and small print font.
With that being said, there is a small sub-population of people who will argue over which medical dictionary is the best out there. The fact is, they all get the job done to about the same degree and ease. If you have to pick one because your medical book starter set wouldn’t be complete without it, I would say go with Stedman’s Medical Dictionary. It’s the one that has been endorsed by the American Medical Association (AMA), and is one of their incentives for joining (as referenced above). This not only means that you have the opportunity of obtaining it at no additional cost if you were to sign up with them anyway, but it also usually means that they are plentiful and freely given away by other med students who didn’t want it.
Again, it’s a common mistake to buy a medical dictionary. They just aren’t needed. But if you insist on getting one anyway, grab a copy of Stedman’s.
As a complement to the latest post on ophthalmoscopes, we are happy to share an excellent online resource for medical students to learn about ocular findings and signs that may pop up on physical exam: The Eyes Have It, from the University of Michigan’s Kellogg Eye Center.
The Eyes Have It is a site that provides a split instructional and quiz portion to both review and solidify ophthalmology knowledge. The information is straight forward, and creates a great overview for med students in the primary care settings, and a starting point for ophthalmology clerkships.
For the first-year medical students, after you purchase your ophthalmoscope for the first time, take a good hard look in as many eyes as you can. When something looks weird, this is the site to go to as your first step. For the third year medical students, here’s a pimp tip that will make you look like a rock star: involvement of herpes zoster on the nose is known as Hutchinson sign, and is a good clue that the eye is involves in the outbreak as well. Bonus points are given to anyone who can comment on the pathology of the above two images from The Eyes Have It.
This is the fifth part of a series of posts on comparing Welch Allyn products that will help incoming first year medical students learn about and select different medical instrument components to construct the right Welch Allyn diagnostic kit (otoscope and ophthalmoscope). The focus of this discussion is on Welch Allyn diagnostic kit ophthalmoscope heads.
This is the topic that will have the most options and provide the basis behind one of the larger price differences in your diagnostic kit. Ophthalmoscopes, as the name suggests, are instruments used to look at the eyes, specifically the retina. Some med students will get through all of medical school without learning how to actually perform an exam using their ophthalmoscope, let alone utilize many of the bells and whistles that come with it. As with otoscope heads, all of the below ophthalmoscopes are the 3.5 volt version, which refers to the standard power handles, and are in contrast to miniature “pocket sized” versions of these instruments. If you’re interested in the bottom-line short version, scroll to the bottom.
We’ll start as usual by reviewing the baseline model, seen right. This has the basics that any med student would want, and will allow for visualization of the retina. It feels and looks just like any other ophthalmoscope you would see in clinic, which means learning on this will prepare you for whatever you may find along medical school, with three additional filters you will most likely never use.
Aside from being able to change the light size or dim the light, this ophthalmoscope allows the user to change the light into a slit beam, for easier visualization of objects on the surface of the eye, as well as the depth of the anterior chamber. It also comes with a fixation aperture, which basically turns the light into cross hairs in case you want to double your ophthalmoscope as a sniper rifle scope. The actual reason for this configuration is for relative measurement and assessing blind spots. This feature is rarely used even by ophthalmologists, usually in the setting of hospital consultation when there are limited instruments. The final added feature is the red-free filter, which is a funny way of saying “green light” used to contrast structures in the back of the eye from the otherwise red background on which they reside. Again, chances are you won’t use any of these, and they won’t be taught in med school physical exam classes.
The key component that will be used and comes standard on these types of ophthalmoscopes are the focusing lenses, which allow the user to adjust for the physical size of the eye and focus on a crisp image at the back of the eye. This will come up in subsequent models.
Overall, this is the model of choice for the average med student looking to purchase a quality instrument without the markup associated with unneeded features. However, many retailers do not offer Welch Allyn diagnostic sets with this lower-priced option, even though such sets are manufactured.
The next step up is the coaxial ophthalmoscope, which is commonly one of the two models offered by retailers as an ophthalmoscope option in a Welch Allan diagnostic kit. Like the Standard Ophthalmoscope above, it has the same number of focusing lenses, and includes all of the above apertures, plus the cobalt filter. This is a blue light used in conjunction with fluorescein stain placed in the eye, which produces neon green or orange concentrations of the dye within scratches or irregularities on the surface of the eye. The idea is that it highlights lesions on a clear medium that are otherwise difficult to visualize. This is helpful in field work during emergencies, but will not be a needed skill to use as a medical student, or a necessary tool in the middle of an actual emergency room that has full slit lamps with this feature.
Welch Allyn claims, in their usual fashion, that this upscale model provides less glare, superior visibility, and a larger field of view compared to the standard ophthalmoscope. While bad or broken ophthalmoscopes are indeed a detriment to an ophthalmoscopic exam, I doubt anyone would be able to practically tell the difference between the coaxial and standard Welch Allyn ophthalmoscope.
For completeness, I will also mention that Welch Allyn manufactures the AutoStep Coaxial Ophthalmoscope, which is the exact same instrument, but with additional focusing lenses for super-fine tuning. This model is not offered in any Welch Allyn diagnostic kit, and would need to be purchased separately. However, as you can imagine, these additional focusing lenses are not a significant improvement and in no way recommended for medical students (or anyone else).
The final Welch Allyn Ophthalmoscope to review is the PanOptic Ophthalmoscope, also known as the bazookascope. As you can see from the image, this is in a different league as the other varieties, as its price tag will also prove. Like the above opthalmoscopes, the PanOptic also fits on any standard Welch Allyn 3.5 V power handle.
Welch Allyn states the advantages of this scope include a five-times greater view of the back of the eye, and 26% increased magnification. As mentioned in the otoscope review, an oddly specific 26% increase in magnification is unnoticeable. The PanOptic Ophthalmoscope does however provide a significantly larger view of the retina, with significantly less skill required to use the instrument compared to the learning curve of the above models. Simply holding this up to a patient’s eye will produce nice results. Less time spent figuring out how to use the instrument means more time dedicated to figuring out what you’re looking at. This is an underestimated double edged sword.
As long as a PanOptic is used, better visualization will be acquired. However the large majority of clinics and hospitals in this country do not have this expensive piece of equipment. It is exceedingly common for a medical student who learned on a Welch Allyn PanOptic to subsequently have no technical ability to use a standard ophthalmoscope in a practical setting, placing them at a severe disadvantage without their own instrument.
One of the main reasons med students purchase a diagnostic kit is to learn the technique of using these instruments, more so than to use them throughout (or after) medical school. Most clinics will provide med students with wall mounted versions of the standard ophthalmoscope, making it unnecessary to haul around a personal set. Due to the shape, these are also bulkier items that weigh down white coats and do not sit well in soft cases. Given all of the above, as well as the price below, it is exceedingly common for med students to attempt to sell their PanOptic ophthalmoscopes, finding them unnecessary. Nonetheless, some percentage of students will continue to purchase these instruments to ensure they have the best possible view of the back of the eye. This is one that definitely has its trade-offs.
In summary, the direct comparison is as follows:
|Cobalt Filter||Ease of Use||Exposure
||$170||No||Learning Curve||5 degrees|
||$190||Standard||Learning Curve||5 degrees|
|* prices are for the ophthalmoscope heads only. handles are sold separately.|
Prices are higher if you purchase components separately, so try to buy a value meal (a complete diagnostic kit sold as a single unit) unless you can find a really great deal. With that being said, the above three scopes were added to the price-check plugin as a reference.
Still can’t decide? Let us help! Check all that apply:
|My med school requires infrequent usage of diagnostic kits.|
|Money is of no concern in the purchase of my instruments.|
|I have a habit of losing things easily.|
|I want to learn physical exam techniques using equipment that will best prepare me for practical clinical settings.|
|I want to learn physical exam findings using the absolute best equipment at my disposal.|