4th Term Information and Advice, Saint George's University School of Medicine

Nutrition – 1 unit

This two-week nutrition class was not difficult. You do not need any additional material other than the two packets provided.  Your grade is based on one exam.  I thought this class would provide an understanding into the fundamentals of nutrition and various ways to tailor nutrition for patients...sadly…this was not my experience.

The class was broken up into two sections.  You will learn about nutrition in health and diseases during the first week.  Topics covered include host response to trauma/infections, inflammatory responses, and various nutritional needs throughout our lifecycle, pre-/during/post- pregnancy, fetus in utero, and the basis of a healthy diet.  Most of the information you will learn during this first portion is pretty common sense (eat fruits and veggies, limit intake of saturated fats, folic acid supplementation to prevent neural tube defects, benefits of omega-3 fatty acid).

I found the second portion more informative compared to week one.  Topics covered included nutrition during intensive care, under-/over-nutrition and associated diseases, malnutrition, and the relationship between vitamin D to bone health.  Studies were included in each lecture topic to highlight certain points.  We were not asked any specifics in regards to the numbers found in these studies. Knowing the general results/conclusions of each study for the second portion was sufficient for our exam.  However, you do have to memorize specific numbers for the first week’s material.

This class offered a chance for recuperation after the microbiology final.  The exam for nutrition was not too challenging and I personally found most answers pretty easy to pick out (Find the odd one out: Eat a well-balanced meal, increase omega-3 fatty acids, increase fiber intake, increase saturated fatty acids).

Communication and Physical Diagnosis – 3 units

I personally found this class disorganized and quite frustrating.  Most lecturers read word-for-word from PowerPoint and did not offer any additional insights into the material.  Most students in my class felt that lectures were mundane, a waste of time, and only went because of mandatory attendance via clickers.  I believe we needed to attend 16 lectures to receive full credit for professionalism (5 percent of grade).

You are required to bring your PD kit during each laboratory session.  Lab groups that consisted of 6 students (assigned based on first names) met twice a week with a different clinical tutor every few meetings.  Your group will meet either from 1-3 or 3-5 and will switch after the microbiology final.   The change in time threw off many students studying routine they developed throughout the first half of the semester.  My experience with the quality of instruction from the various clinical tutors ranged from 10/10 all the way to 1/10. Some clinical tutors had magnificent teaching skills and could properly introduce the material to the group in a cohesive manner. Other tutors sat and kept silent the entire time offering no additional guidance and told our group to read the manual for explanation. The most frustrating portion of lab sessions was that different clinical tutors would teach different techniques on performing the exact same physical examination.  This inconsistency was also represented in the physical exam videos that we watched at the beginning of each lab session (15 to 30 minutes).

You will receive a total of 14 laboratory manuals covering topics from vital signs, global assessment, head and neck, ENT, eye, heart, peripheral vascular disease, respiratory, abdomen, musculoskeletal, CNS, breast, and female/male genitalia.  This was the sequence we were presented with for the course materials.   Each lab manual presented topics starting from relevant anatomy, followed by physiology and/or neurology, then ending with proper techniques needed to perform the given physical examination.  I would highly suggest reading each packet before going to lab as some clinical tutors will teach improper techniques.  You will be graded on the OSCE based on the specific manner in which you perform a physical exam according to the manual, not according to the lab videos or clinical tutors.

There were two in-lab quizzes and one case write-up.  You will pick the quizzed physical examination from an envelope and perform it in front your group.  The clinical tutor will then ask two questions based on information found in the laboratory manuals.  You will have a real patient for the case write-up.  Your group will interview the patient and perform the necessary examinations.

The Objective Structured Clinical Examination (OSCE) I and II will represent approximately half your grade.   The first OSCE will have three stations: one interview, one major, and two minors.  The second OSCE will have four stations: two interviews, one major, and two minors.  You will have a total of 8 minutes to perform the skills asked in each station.  Your clock will countdown from 10 minutes during the first OSCE but not the second OSCE.  This threw off many students in their first station because exam time ended when 2 minutes were still on the screen.  Feedback was given during this remaining period.

Best advice I can give is to practice with a partner or in a group.  It helps to watch somebody else perform various exams while you try to catch the mistakes and/or omissions.  First learn the proper techniques then begin timing each other for 8 minutes.  Some physical exams (eyes, ears, mouth, abdomen, peripheral signs of various systems) require you to memorize a list of things to inspect for.  You need to have these memorized for the OSCE because the examiner has a list and checks off specific things you mentioned during inspection.  Make sure to practice your interviewing skills in various clinical situations.

The written midterm covered introductory materials to respiratory and the final was cumulative with an emphasis on the second portion of class.  Both examinations did not include any materials from lectures that were not in the laboratory manuals provided. The only exception was for Intro to communication skills, the difficult patient, patient education, physician anxieties, and the glossary. WARNING: Our examinations did however ask questions that were not found in the lab manuals but introduced in other classes.

OSCE examples
(This list was meant to give you an idea of how OSCE instructions are written and is by no means complete.  You should create your own list based on your version of the laboratory manuals.)

Major:
Examine CN 5,7,9,10,12
Percuss and auscultate the heart including special positions
Examine joints of wrist and hands
Inspect, palpate, and percuss the posterior chest
Central visual acuity and peripheral field testing
Examine the parietal cortex and cerebellum
Examine external ear and perform the 3 hearing tests
Examine and palpate the abdomen, including tests for ascites
Examine lower limbs for peripheral vascular disease and do special tests

Minor:
Examine peripheral signs of the thyroid

Examine epitrochlear and axillary lymph nodes
Perform the 4 tests for extraocular eye muscles
Fundoscopy (verbalize what you are looking for)
Evaluate lumbar spine, special tests sciatic nerve pain
Peripheral signs of abdominal disease
Tests for acute meningitis
Test meningitis, hypocalcemia
Peripheral cardiovascular (excluding fundoscopy) and examination of internal/external nose

Perform vital signs
Examine the oral cavity
Examine the salivary glands
Examination lymph nodes of head and neck
Superficial and abnormal reflexes
Superficial and deep tendon reflexes
Test for motor power
Test fluid in knee and collateral ligaments
Test for JVP and hepato-jugular reflex
Perform Allen's test and Buerger's test
Palpate and percuss the liver and spleen

Interview scenarios:
Hint: Don't only focus on PAIN!  "SOCRATES" will NOT work in every scenario (Severity, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating/Relieving factors, and Severity).  I personally did not like this acronym because it does not follow a natural progression of asking questions.  I preferred using OPQRST which stands for Onset, Palliative/Provocative, Quality, Region/Radiation, Severity, and Timing.  However, try to use more open-ended questions (Tell me about your XYZ, Can you describe your XYZ) when possible instead of close-ended ones like the acronyms above.  Think of various common situations for doctor visits and time yourself for 8 minutes when practicing.

Nausea and vomiting

Colicky pain in LLQ that fainted
Burning urination and increase urinary urgency, herpes
Infertile female because of PID with previous history of STD
Diabetes
Thyroid disease with associated symptoms
Throat infection with associated symptoms
Menopausal women
AIDS with severe diarrhea and cramping
Acid reflux
Lower GIT infection
Stomach ulcer and dark tarry stools
Sexually transmitted disease
Ruptured ectopic pregnancy
Benign prostate hyperplasia
Urinary tract infection
Headache
Vision issues with arm numbness
Possibly pregnancy
Healthy patient

Microbiology – 5 units

Microbiology was an intense ten week course.  Some students recommend getting Clinical Microbiology Made Ridiculously Simple. I believe this was a great book but many students did not have enough time to read through it.  Pre-midterm consisted of general introductory material into microbiology (microorganism, parasite, fungi, virus), lifecycles, classifications, methods of control, pathogenesis, and diagnosis followed by a list of microorganisms to memorize.   Post-midterm information was presented by organ systems (CNS, respiratory, genitourinary tract).  I found this method of teaching microbiology extremely ineffective because instead of learning about a specific organism in its entirety, we were introduced to that microorganism in various organ systems with one or two slides pertaining to it.  This fragmented approach in teaching microbiology made learning the material extremely difficult.

Microbiology lab was only during the first week of class.  It was not mandatory to attend the two lab sessions.  Students learned various plating and culturing techniques throughout the two days.  We had the chance to go around campus to take sample swabs of doorknobs, handles, and various other objects.  You will be shocked with what was cultured should you do decide to join the two-day lab session.  I will never look at a water fountain the same ever again.

Some students printed out the note version of the handouts instead of using the slides to study.  I felt the notes were easier to read and seemed more organized (especially in the GI portion where you must associate the clinical symptoms, types of food, time and duration of presentation with the agent).  Many students neglected this class until the weeks prior to examination.  The pathology exam is usually on Monday and microbiology exam on Friday.   It’s very tempting to put off studying because you see that three day gap in-between.  But trust me…there is simply too much information to cram in that short window if you want to do well.

The best advice I can give is to make sure you study microbiology at least an hour or two each day before starting on pathology. EVERYTHING said in lecture and written in the handouts is fair game.  Make sure you know the specific categories and shape of each microorganism.  You must also learn the mode of transmission for each one.  Knowing the clinical presentations often narrows the answer choices down to two.  Knowing the exceptions and/or stains along with specific environments and/or drug sensitivity/resistance needed to culture the microorganism often narrows the answer choices down to one.

There were 5 in-class quizzes that consisted of reading journal articles with topics ranging from influenza vaccine, hand-washing, and various other microorganisms.  To the best of my recollection, each quiz consisted of 5 questions.  The lowest of all your quizzes will be dropped.  Quizzes are an easy twenty points so make sure you study the articles and know them down cold.  A unified exam was given during the first few weeks of the semester with questions on microbiology and pathology.  Microbiology was more heavily weighted (6.8 percent) as compared to pathology (2 percent).  Microbiology questions were not nearly as difficult compared to pathology.  The material at this point was not too dense, but you must know the different plating techniques, mode of transmission, and shape of the organisms that you have covered thus far.

I am afraid that I cannot provide any more insight into this class because I contracted dengue fever post-midterm and was unable to concentrate for a month.  I still can’t fathom how I passed the microbiology final given that I only studied for one night.  Our class of approximately 600 students had roughly 20 A’s, more C’s than B’s, and a few dozen students failing the course.  Anyhow, I wish you the best of luck for this one.   Let the bug parade begin!

Pathology – 13 units

I personally felt that pathology was by far the most interesting topic…right alongside with physiology.  With that being said, this pathology course was the most challenging and frustrating experiences of my life.   Challenging because you cover so many diseases in such a short period of time and frustrating because of the department.   You must have the required textbook, Robbins Basic Pathology (baby Robbins), or an electronic version to use as reference throughout the course.  Robins is a reference book, not something you read from cover to cover throughout this course.  The book goes into too much depth at a level that is not required to do well and may perhaps hinder your performance.

Pathoma was THE MOST invaluable resource that I used throughout this course.  I cannot overemphasize this enough.  Dr. Sattar does such a magnificent job at simplifying concepts in pathology.  I would suggest reading through the relevant chapters and watching the videos in Pathoma PRIOR to attending lectures/sonic.   Pathoma does not go into as much detail compared to class but does a superb job in laying the groundwork needed to understand pathology.

You will have a different visiting professor each week throughout pathology.  Quality of professors ranged from being truly exceptional all the way to downright bad.  Some will take the time to explain concepts while others will read off their notes verbatim.  The pathology department took down the slides on sonic halfway during the semester due to copyright issues and/or HIPAA violation. This made it very difficult to sonic for obvious reasons.  There were three equally weighted exams along with a unified exam in this course.  The first third of class covered general concepts and the remaining two-thirds dealt with system specific pathologies with each midterm reflecting said materials respectively.  The pathology portion of the unified exam was worth 2 percent of our total grade. I felt the questions were more difficult in the pathology section as compared to the microbiology portion.

Pathology lab sessions were four times a week from either 1-3 or 3-5 and switched after the microbiology final.  It drops to three times a week towards the end of the semester.  A maximum of 12 people are allowed in each lab group.  I believe you submit a list of group members during third-term.  It is better to have the maximum allotted number so that workload is more distributed than would be otherwise.  Your group will receive a set of slides each weekend and each member will present a given amount throughout the week.  It typically took me about two to three hours per slide…sometimes four… which I think was a bit excessive.   This was the biggest mistake I made during pathology and I urge you not to repeat it.  Looking back, I personally felt this was not an efficient use of my time and would suggest that you try to spend no more than an hour and a half for your slides.  The only benefit I received from taking that much time was that I knew my slides inside and out and could focus on other topics come exam week.

Print out the pathology slides beforehand (4 or 6 slides per page) and take notes on it during sessions.  These slides (or some variation) were on our exams…I think it was 35 image questions on each test that were from the slides.  Pay special attention to EVERYTHING the clinical tutors say because some information they highlighted were not found in the lecture notes but were on the exam in some form.  You will have a different clinical tutor every week and again, the quality ranges from really good to okay. Clinical tutors arrive about 30 minutes after lab has started.  Try to ask your clinical tutor if there is anything they feel is important for each slide.

Focus ONLY on the general principles (cell adaptation, necrosis) for slides you receive during the general pathology section.  DO NOT focus your time researching/presenting the specific pathologies (benign prostatic hyperplasia, esophageal cancer).  You will revisit those during the systemic pathology section.  Make sure to learn and understand the general concepts in the first third of the course because all pathologies stem from those very concepts.

I think reviewing normal histology helped me prior to starting pathology.  I say this because I believe knowing what normal looked like allowed me to better differentiate abnormal.  You need to understand what is happening at a cellular level to appreciate pathology at a macro level.  This is especially true for the second midterm since it focused heavily on the histological aspect of various diseases. Not only will you need to learn the buzz words (monospot positive, M-spike, target cell, Heinz body), but more importantly, you MUST learn what those words actually describe.  This is very, very important because most questions on the exam will not mention buzz words specifically but rather describe them histologically.

I felt constantly pushed up against the wall throughout this semester.  I did not have much steam left in me after the microbiology final (even more so because I contracted dengue fever).  However, I remember the last two weeks of material (childhood pathologies, forensic pathology) for the third exam was not dense.

You will need to turn in 10 concept maps throughout the semester.  A concept map is like a brainstorm covering a specific topic (necrosis, cytokines, cancer) of your choosing.  You need to connect each word to as many topics as possible (draw many interconnecting lines).  This will make sense after the lab tutorial on how to draw concept maps.  There are also 5 clinicopathological cases (CPC) that you are required to turn-in each week near the end of the semester.  Your group will discuss the case and go over the answers with the clinical tutor.  You are not graded on whether the answers are correct but rather on participation during group discussion.  I mostly used the Robbins pathology book and Wikipedia to answer CPCs.

My advice for this course in a nutshell would be:
1) Get Pathoma – read and watch the videos BEFORE lecture
2) Don’t spend too long on lab slides and assignments
3) Learn the histological changes for every disease
4) Learn the buzz words and what it actually describes
5) Focus on your notes rather than using too many resources
6) Form an awesome group~!!!