Do you have a dumb question that you're kind of embarrassed to ask in the main thread? Is there something you're just not sure about?
This is your opportunity to ask questions. No question too simple or too silly.
Culture war topics are accepted, and proposals for a better intro post are appreciated.
Jump in the discussion.
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Notes -
I went blind again. Before anyone panics, it was for less than an hour, and I'm fine now.
I was previously diagnosed with a condition known as central serous chorio-retinopathy, where fluid leaks out of the vessels below the retina and makes it bulge out. It is usually due to corticosteroid consumption, which I've never done, but also due to prolonged and severe stress. Guess what I'm experiencing?
This isn't the first time. In keeping with a now-obvious pattern, it happened to me before a high-stakes exam. Once before the PLAB 1, again before the MSRA. And now, the MRCPsych Paper A looms ahead of me.
My stimulants might contribute (they're stimulating the sympathetic nervous system too), even if I take very reasonable doses. Unfortunately, my ADHD is not an affectation, I can't study without my meds, let alone pass exams. Especially exams that require months on end of grinding and memorization, when is rather be doing anything else.
So yeah, same choice as usual: lie flat, or keep fighting. I'm inclined to do the latter unless the attacks become so severe that I'm at great risk of permanent visual damage. I did see a doctor once, and it was decided that a waitful watching system was appropriate, instead of jumping to options like intravitreal injections or lasers. It's been a year and a half since then, and this attack was mild, so I suppose it wasn't the worst advice.
Anyone else have a few dangling Damocletian swords above them? Aimed at their eyeballs? Alternatively, what's the best way for me to manage my stress, when giving up or foregoing my meds isn't an option I'm willing to consider?
(I'm going to order myself some green tea. It helped in the past.)
See if you can find the right kind of downer? Sure, it might sound like a bad idea, but so does being on stimulants your whole life. I think the ship has sailed on that particular kind if worry.
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When I was a first year in med school, staring at the sheer amount of knowledge I was supposed to cram into my brain, I would get too anxious and stressed out to even concentrate enough to study. So my girlfriend suggested I take some of her Xanax, which calmed me down enough that I could hit the books. The next day though I would have forgotten everything because as you know (and I had not yet learned at the time) benzos fuck with your hippocampus and it's harder to form memories. I did this three times before I recognized the pattern enough to bother googling it. So uh, don't do that.
What ended up working out for me was getting plenty of daily exercise. I was basically trying to study for 14 hours a day, then I'd watch a movie to unwind, then go to bed. Cutting that back to 13 hours of trying to study and one hour of exercise in the morning made me a lot less stressed out. And of course commiserating with people in the same boat as me. The worst thing you can do is not talk to your friends and colleagues about this.
Now, the thing that tends to stress me out the most is parenting. I am fully confident at times that I am fucking up my kids and they're going to need a lot of therapy in their mid-20s when they realize how much damaged my wife and I caused. But, and maybe this makes me look silly, I find the sycophantic nature of ChatGPT as well as its always available-ness is perfect for stopping me from spiraling.
Anyway: physician, heal thyself and so forth.
Another doctor here? Good, please unlurk yourself! That's a genuine request. We're up to 5 and change, depending on how you count med students who may or may not be hiking naked in Alaska.
Evidence that pharmacology should be shoved into the first year syllabus haha. You'd have been better off drinking alcohol to steady your nerves, since (paradoxically) alcohol increases reteograde memory retention, while hampering it anterograde (at reasonable doses).
https://www.nature.com/articles/s41598-017-06305-w
For anyone else reading: don't do this.
I'm in awe. I couldn't study for 12 hours a day if my life depended on it, even on medication. I feel utterly burnt out after 4-6 hours of actual study (not just sitting there with the book open, or procrastinating, as I'm doing now). This was true even before I had a job. Well, apparently that has been enough so far, and I try to keep up the habit.
I did. I still feel bad about it, my dad is always stressed when he hears of such episodes, and he's the old-fashioned type of doctor who believes I don't need stimulants because ADHD isn't a real condition. He loves me, so I look past that. They know, they care, but they're a continent away.
Friends? They get it, sometimes. I had a good buddy who was a bit older and burdened with kids, he passed the exam during the previous window, so I suppose I have no excuse.
I suppose it's my turn to reassure you, though I have no kids of my own. Donald Winnicot was on to something when he came up with the concept of the "good enough mother" (and father).
Once you're past levels of effort above outright neglect, the returns to additional parental effort decline steeply or become outright flat. Parenting is not a video game where grinding extra hours levels your kid up faster. When it comes to variance in life outcomes, heredity is king, non-parental environment is queen, and “parenting” (once you’ve cleared the bar of “not abuse or neglect”) is a minor courtier at best.
https://www.nature.com/articles/ng.3285
I have seen a full writeup somewhere, but I've lost it. I can look harder later.
In other words, you don't have to worry too hard. You've done the important things, like giving them your genes, amassing wealth, not abusing them (I hope, but feel free to disabuse me if you disagree) etc.
They're good genes! You're a doctor, hardworking, and probably more conscientious than is good for you. In all fairness, so were my parents, but you can't help some things. I turned out okay. I love my parents despite their minor failings, and I'm sure your kids will love you too. If you’re worried you’re messing up, that’s actually evidence you’re not the type who would really mess up.
Thank you, I mean it. I've been through worse, both in terms of academic load and blindness. I'll live, and if I ever become a consultant, I will dedicate my life to involuntarily commiting some of the exam-designers. Oh, and if your kids end up needing therapy, I'll offer a steep discount as a professional courtesy.
I mostly lurk because I don't feel like I have much to contribute and everyone around here seems to know what they're talking about, or at least is good enough at rhetoric to fool me. And then I have this really bad habit of needing social approval in a way that downvotes cause me mental distress, even if I am positive I'm right. I'm kind of a coward online like that in a way that I am not irl.
And my study habits were probably unhealthy. I had a few friends in med school and was generally very well liked by people who knew me, but I had more than a few people say to me at some point in our 4th year "damn wsgy why weren't we better friends? You're a great hang!". I had kind of partied way too much in university and overcorrected. My (now) wife even mentioned what it was like to date me those first two years at our wedding. The rule was she could have me for an evening and overnight either Friday or Saturday and had a blanket invitation to stay over at my place on other days but I wasn't going to talk to her until 8pm and we had to be in bed by 10:30. Like she'd be hanging out on my couch watching TV while I ignored her with earplugs in my head. It got a laugh, appropriately.
I'm not actually too worried about the kids in the grand scheme of things. But it's like having one of your vital organs removed from your body and giving it a mind of its own. You can't help but get at least a bit neurotic about it getting damaged.
Maybe post more so that eventually your thin skin gets bruised into thick calluses.
Same boat here - fellow medico, don't post much here since i also feel not much to contribute.
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Honestly I've used the downvotes from my sometimes half-cocked healthcare economics rants as part of exposure therapy for fear of online censure.
Our people pleasing and neuroticism needs treatment!
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Hey, having nothing useful to contribute doesn't stop some people! Don't let it dissuade you, you're probably wrong on that front.
But yes, having thick skin is a major benefit when it comes to regular participation on the Motte. I would encourage you to dip your toes in the water in the less contentious threads, like you're doing right now.
Such a shame. My parents would have loved to have you instead of me. Well, not because I partied too much (I didn't, at least in med school), but because they wished I'd studied.
A fair point. It's easy for me to talk about adopting a laissez-faire attitude towards children I don't have. The changes parenthood provoke are scary, but also strangely comforting. One's own struggle and strife seem so inconsequential when there are little people who need you. Yours will turn out great!
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I've found that prioritizing sleep above all other things helps to keep my stress in check. In school, I would sleep immediately after class to ensure I got enough and I'd fit homework and studying in the hours that remained between waking and having to be in class.
I wish I could do that dude. The stimulants already muck up sleep cycle, and I've never been the kind to be able to cat nap.
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First of all, sorry to hear that and all the best with the tests.
Secondly, about:
I’m curious about these medical exams and studying. Are there some candidates you’ve met that can just ace them without studying, based solely on general medical knowledge and above average recollection from both medical school and hands-on training in the years before their specialist qualification? Or is it like some legal qualifications, where even a towering intellect needs to rote memorize that the answer is a section 37 part 3 form and not a part 4 and that a certain period is 13 working days and not 12?
My recollection of medical school was that almost all of the stellar students and smartest students were the same people. You did have a pot of smart bad students but usually they had something like ADHD and couldn't keep up with the study demand. Although I find that the smart people who didn't do well were better at retaining information years later than the not as smart but better students (this retention being in reference to things like other people's specialties).
However, "bad student" for medical school in the U.S. is a god outside of it - things like pre-exam crams and all nighters are flat out impossible. It isn't uncommon at the start of first year to be basically learning multiple undergrad classes worth of material in a week, every week. Almost all exams are incredibly high stakes and some are full days in length or more etc.
The material usually doesn't require much beyond an above average IQ to learn but the amount of it is vicious - the classic statement is "like drinking from a firehose" and then you do that for years.
No amount of pure horsepower can do it - you also need the effort.
That said an interesting part of how this has gone in the US is that the rote memorization component of medical education has become more or less solved, and since they need to do some candidate discrimination..... they've worked very hard to dial in on the "thinking" parts instead of pure memorization.
A question might be - patient with x disease has y side effect, which of the following medications most likely caused the side effect? And then all 6 meds cause that side effect - they want you to know that one of the medications is overwhelmingly likely to be prescribed because of a practice guideline, causes the side effect at a much higher rate, or something else like that.
15-20 years ago the standardized tests were hard because the way medical knowledge has exploded in recent years. Now they are actually fucking hard and require much more in depth understanding.
This may be a bit US specific though, as the population of students here is generally neurotic passionate about care people or money seekers looking for the best gig (which also requires high performance).
EDIT: An added layer of problem is that the exams have no constrained syllabus, the best you have is weights. The contents is usually "everything." Nephrology in Ortho boards? Sure. A modality that hasn't been used outside of Eastern Europe for 30 years? Sure. A drug that just cleared clinical trials five minutes ago? Yeah.
The secret is that all of the questions are fair or at least important (ex: new drug is actually the first in a new class of medications that they've been trying to get off the ground for decades), but as a student you don't know that until years later, so if you want to do well (and people do) you have to know absolutely EVERYTHING.
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Thank you.
I don't think that it is possible to pass just about any medical exam with zero studying, in the literal sense. But I definitely know or have heard of people who can get by with much less of it in the way of "total hours of effort". The very best young doctors I know (in terms of academic performance and successful entry into difficult specialties) were both very smart and very hardworking.
There are people who have retained far more than I did from med school, which definitely came in handy for them. I wasn't the most motivated of candidates back then (because my performance didn't matter as long as I passed, and I only ever failed one minor exam in the last decade), but I put far more effort into career-defining or gatekeeping exams later.
For example, the very first exam a foreign doctor needs to clear to get a license to practice in the UK is the first PLAB exam. It was always oriented around a UK curriculum, but now is/will be entirely subsumed into the same British end-of-medschool exam that is the UKMLA. A British med student would have a very significant innate advantage simply because that's their default curriculum, whereas a foreign grad would need to learn additional information about UK guidelines (holding all else equal, which I will happily grant isn't true, British med students are very good on average).
Once the PLABs were done, I had to give another exam called the MSRA, where the advantages for the locals diminish. The exam has roughly the same core topics as the PLAB/UKMLA, but will drill much harder into the nitty-gritty details. These details aren't comprehensively covered in med school, so that's when your own effort begins to come through.
The next step is usually the membership exams of one of the Royal Colleges. In my case, the MRCPsychs. At that point you are well beyond "innate" or general knowledge. Almost everything is new.
Not all RC exams are made alike:
Something like the MRCPsych Paper A heavily rewards rote memorization. There's no exam where it isn't important, but some others will test your practical and critical thinking skills harder than others.
You would have to be God to derive medicine from first principles. For mere humans, no matter how smart, there's no choice but to resort to empiricism and knowing what works. Medicine, for all its scientific underpinnings, remains a deeply empirical and at times atheoretical field.
For example, why do antipsychotics increase the risk of pneumonia? Nobody knows. Why do clozapine and olanzapine cause the most weight gain (within antipsychotics)? Fuck knows. There is no logical chain that leads from the pharmacology of clozapine to it causing more weight gain than ziprasidone. We only know these things through observation.
The exam questions reflect this reality. They do not ask you to model the interaction of dopamine antagonists with hypothalamic appetite centers. They ask: "Which of the following drugs is most associated with weight gain?" This is not a test of your reasoning. It is a test of your internal lookup table. You either pass the herblore skill check or you don't.
And that is a good question. It's information that is in some way relevant to clinical practice.
Freud's nonsense isn't. Neither is Monkey Business. I don't know why I need to learn the name of the dude who invented modern antipsychotics, or why I'm being asked that. Yet those make up an unfortunate amount of the syllabus.
Sure, but I would classify this closer to the ‘classical’ examination than the rote legal memory check where, you FOOL, you forgot that it was actually a class 5(a)i notice and not a class 5(b)i one even though you actually! In the sense that I would imagine that smart and well-read psychiatry students would probably know that antipsychotics increase the risk of pneumonia and so on. Even moreso for Freud’s ‘nonsense’.
I... uh... didn't know that until I opened my revision notes to look for examples. You are welcome to update on how smart or well-read a psychiatry student I am. In all fairness, that knowledge is irrelevant in clinical use, I've never seen or heard of a psychiatrist not prescribing because of pneumonia risk from an antipsychotic.
But, in general, my main source of frustration is irrelevant information gumming up the syllabus rather than the fact that a lot of memorization is involved. If what I have to memorize a lot of facts to be a good psychiatrist, then that's just what I need to do. But I don't enjoy, and in fact, hate quite a bit of what I'm forced to learn. Physics majors aren't grilled on their knowledge of Aristotlian mechanics, nor are chemists asked to produce the schematics of the alembic necessary for transmuting lead to gold. It's all so tiresome.
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Fuck, I’m sorry.
I have stress-provoked tachycardia which is less crippling but certainly unfun and produces perhaps a similar ‘I need to do important things to have a good life but not too many things or else my body will go wonky’ dilemma.
I’m sort of failing to manage it at the moment but generally I would advise trying to separate out one’s stressors a bit. Don’t go drinking the night before the marathon. Try to have specific study times that don’t coincide with your worst work shifts. If possible, try to have the confidence that you can take a break every so often without fucking up your life.
Thanks my dude. Misery loves company!
(Also, I will probably be in London sometime between Monday to Wednesday next week, let me know if you're free. We can be miserable together in person.)
I presume you've gotten that looked at? My impression is probably anxiety, and CBT or the drugs would help if that's the case. Maybe even just a beta-blocker for symptomatic relief if it gets bad.
I won't be drinking before the exams, and I've already cut it down to a single night of dissolute enjoyment at the pub. They miss me, but I actually need to lock-in.
I try to study at sensible hours, but easier said than done.
That's true. This exam isn't the end of the world if I fail, just £500 I won't be getting back. But I do very much want to pass it in one go - deferring it is an option, but I'll only be getting busier in the future and I'm already a bit overdue for an attempt.
To moan in general, the exam is designed by sadists, with much of it of limited/negative utility in actual psychiatric practice. But I am not credentialed enough to be consulted on such topics, so I'm dealing with it. It's also pointlessly hard, but eh, I can manage that too.
Thank you for listening, it means something to me.
Cool! That's today to Weds, or next week?
Had keyhole surgery (catheter ablation) a couple of years back when it flared up to multiple several-minute bouts of 180bpm a day. Much better now, only once every few months, but I live in fear of it getting worse and needing surgery again. Realistically could be a lot worse but it's made me risk-averse in a way I dislike.
Good to hear that it's not do-or-die, at least. Worst comes to the worst, spreading the study out over a longer period will make you much more likely to retain the knowledge.
Best of luck!
Now that is far more serious than I'd like. Did they not give you beta blockers for as-required symptomatic relief? Did the surgeons or cardiologists not give advice regarding lifestyle modifications or exercise tolerance? This is far out of my wheelhouse, but I don't want you to be unduly anxious, even if you are right to worry.
Next week! I'll DM you closer, once I know the exact dates.
Thank you again!
I've got a tab of verapamil, which is similar to a beta blocker. In practice they've usually died down quickly enough that I don't have time to fetch and take it, which is good.
They did, in Japanese lol. Broadly they said, "Look, just don't worry about it. Do whatever exercise you like - it won't help but it won't make things worse. In practice go on living your life the same as ever." Which is... nice and all, and better than the alternative, but somehow less reassuring than 'eat salad, never let your heart get above 160, and we want you to wear a 24h ECG once a year' or whatever. I try not to think about it too much, or else I will turn into a hypochondriac.
It seems to be genetic (at least one of my elderly relatives used to have it I think) and to die down as you get older.
Verapamil is a calcium channel blocker, and a good option. I don't recall off the top of my head whether it's superior to something like metoprolol, but it is very reasonable to prescribe.
I'm sorry, I had to laugh. This is a good reminder that patients are not made alike, some of us need gentle reassurance, others desire bright lines in the sand. In all honesty, I think telling someone not to let their HR cross 160 either won't work or will be counterproductive. The anxiety of watching it maybe go to 140 might easily cause it to spike.
Something like an Apple Watch with ECG tracking might be good just for the peace of mind. I told my dad to get one, and even offered to pay. Unfortunately, despite getting a heart disease so rare it was until recently thought to only happen to the Japanese (coincidence?), he's proof that doctors make bad patients.
If you want to DM me the exact diagnosis, I can probably give you better advice, but I am still a psychiatry resident and I am blissfully forgetting everything about cardiology other than measuring QTc elongation on a trace.
If they lived to be elderly, don't you think that's a good sign?
Much appreciated! I'll take you up on that and DM you if I ever need a serious talk, but I'm quite all right for the time being. I'm not worried about dying per se, but the original surgery was very much Not Fun for various reasons (I woke up during the operation) and I'd like to avoid being in that position again if I can.
Very useful in some ways, surprisingly un-useful in others. It lets you have a look and get an idea of what is 'normal' and what is 'not normal' on a moment to moment basis. It's less useful in that many conditions produce the same biomarkers. For example, low heart rate variability can either be a sign of relaxation and recovery (good, go and get some exercise) or your body desperately trying to relax and activating the parasympathetic nervous system after serious exertion (maybe not good, you need to relax and not do anything strenuous). Low stress just before you wake can be a sign that you're well-rested (good) or that you're very tired and your alarm woke you in the middle of a sleep cycle (less good). And so on.
Ideally sensors are a good way to sort through the psychological chaff such as excess stoicism or excess hypochondria/anxiety and get a good idea about what's actually going on with people, but it doesn't seem to work that way. There also seems to be a dearth of individual high-detail studies, just very specific medical studies on unusual cohorts or vast field surveys.
I imagine this comes up a lot :) But for certain types of people saying 'I would love to do X with you but the doctor says I can't because of Y, what a joyless bastard he/she is amirite?' can be much easier than saying 'I'd like to do X but it makes me nervous'. I don't know how you'd go about finding which patient responds to which approach except through experience and stereotyping, but I bet it has a big payoff especially if you ever go private.
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