Ben White

Applying for a Medical License in Texas

03.07.14 // Medicine

Update 11/2015: Essentially, things have gotten cheaper (crazy!). New costs reflected below.

Update 1/2016: I wrote a JP exam review book (more info here), which you could buy.

Update 9/2016: DPS numbers are no longer a thing, because Texas finally realized it was stupid to essentially duplicate the DEA number everyone needs to have anyway.

As with most things that really matter, the website, process, and wait for obtaining a medical license in Texas is less than ideal.1 And then, once you have paid for and subsequently obtained your medical license, you will still have to wait your DEA number (if you don’t already have one) before you can actually do much with it. The whole process from start to finish will likely take you somewhere in the neighborhood of six+ months.

Applying for your license

The application checklist is exhaustive and wordy to the point where a run-of-mill US-trained physician may not be sure if they’re eligible. In Texas, you must have completed your internship (but not your residency) prior to applying for your medical license. As part of the application process, you will need to supply both proof of both your USMLE Step 3 success and a “Form L” from your internship or residency signifying your successful completion of this task. So, if you take Step 3 during your intern year, you can apply for your license on July 1 of your PGY2 year. You also need to pay for, take, and subsequently pass the Texas Medical Jurisprudence exam. Of course, you can’t do that until you fork over the initial application fee.
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Steps

02.02.14 // Reading

Yesterday I read and finished the short novel Steps, which had been recommended to me specifically because it is composed entirely of short vignettes. What I didn’t know at the time was that Steps, which was published in 1968, won the National Book Award for Fiction, and that its author, Jerzy Kosinski, was a Polish Jew whose family survived the Holocaust by posing as Catholics with the help of sympathetic local villagers in central Poland. Like Primo Levi, he also committed suicide later in life.

The vignettes in Steps are anchored by an extremely uncomfortable and disturbing eroticism. The prose is elegantly terse. Details of character and plot are obfuscated by the allegories of the individual vignettes, but the narrative arc does at times become more distinct. The book left me feeling disturbed, confused, and thoughtful. It’s quietly poetic without being indulgently lyrical.

Oddly, as a coincidence of sequence, in my mind Kosinksi’s unyielding depiction of amoral sexuality and intimacy as power is an even starker than it might otherwise be. Because last week I read Veronica Roth’s completely unrelated Divergent series, an about-to-be-a-huge-movie YA dystopian [romance] trilogy. In Roth’s series, every plot point is punctuated by breathless descriptions of heavy petting. Innocent, if dangerously co-dependent, one-in-a-lifetime “true” love.

If a young adult romance is predicated on an idealized version of what we want love to be or think love is, then I’m not sure exactly how to describe Kosinski’s counterpoint.

Explanations for the 2013-2014 Official USMLE Step 1 Practice Questions

01.06.14 // Medicine

From the official 2013-14 “Step 1 Content Description and General Information” booklet (archived here), I’ve listed the correct answer for each question with a brief explanation ± take home points. I can’t reproduce the questions themselves of course as they’re copyrighted.

The newest set of official questions (2014-2015) has been released. My explanations can be found here.

For those who have done the more recent set, a list of the questions unique to the 2013-14 practice materials are found in this footnote.2

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Don’t Break the Chain, or, the first motivational system I’ve ever used

12.29.13 // Miscellany

Researching ways to get things done (or keep New Year’s resolutions) is like scouring the web for distraction-free writing apps when you’re supposed to be writing. Just because its a related task doesn’t make it anything other than procrastination and self-sabotage. I’ve tried Evernote and Day One and Wunderlist and it seems like every other great app that was supposed to fix me. And they’re all great. But I’ve come to the conclusion–and acknowledged the obvious–that no app or process is going make you do something that you’ve been putting off. You have to make you do that.

That said, isn’t there some simple system that will help me keep these goals front and center, something that will help me actively remember the things I want to do without buying into some time consuming “lifehack”? A short while ago, I rediscovered something I read last year on Lifehacker. It’s called Don’t Break the Chain, and it’s something Jerry Seinfeld is famous for on the internet (in addition to being Jerry Seinfeld). It goes like this:

He told me to get a big wall calendar that has a whole year on one page and hang it on a prominent wall. The next step was to get a big red magic marker.

He said for each day that I do my task of writing, I get to put a big red X over that day. “After a few days you’ll have a chain. Just keep at it and the chain will grow longer every day. You’ll like seeing that chain, especially when you get a few weeks under your belt. Your only job next is to not break the chain.”

“Don’t break the chain,” he said again for emphasis.

It’s so simple. It doesn’t involve anything really. You can get a big calendar, but you don’t really have to. You just need some way to see your chain. After you do it long enough, your habits will be ingrained and you won’t even need that (but you’ll still have the satisfaction of seeing the ever-growing representation).

Then I realized that I’ve been using this method for a long time without realizing it. I’ve been posting a story on Twitter every day for five years. With the exceptions of my wedding, some international travel etc, I’ve never missed a day.2 And it works. The single most motivating force behind every night’s story is that fact that there is an unbroken chain of stories behind it. I’ve recently begun using DBTC formally to test out some resolutions, and again I’m continually surprised by how effective it can be given that it seems geared for an elementary school child.

I’m not a big wall calendar kind of guy. I really like chains.cc, which is the cleanest most pleasant website for this purpose. The website is free, and you can of course use it on your phone. For a more native phone experience, the Chains.cc app is my favorite out of all of the options on iOS:

  • Clean design with different graphics for each chain
  • Easy and pleasant to use and navigate
  • Can handle multiple chains, with unique graphics and colors for each
  • Allow you to mark previous days when you haven’t had a chance to mark them (don’t cheat!). This a must-have feature if you want to use chains to represent bad habits you want to break.

Goals.io is a little more cluttered but actually more powerful (and free) alternative. It allows weekly goals in addition to daily ones, as well as one time and progressive/nebulous goals. Unfortunately, it doesn’t let you backdate anything so you can’t migrate chains you’ve been keeping on paper or in other apps. Part of me also thinks this flexibility may add too many dimensions to what is otherwise a system as simple as it gets. That said, I do like the idea of weekly goals. Some goals can’t or shouldn’t be done on an everyday basis.

Analog is good though, so I’ve created a minimalistic letter-sized 2014 DBTC calendar that begs to be marked and can be put in a binder, in your desk, or on your wall.

Learning Radiology for Medical Students & Non-radiologists

12.05.13 // Medicine, Radiology

Most radiology books make for a terrible and overwhelming introduction to radiology for medical students or non-radiologists. The physics. The detail. The long lists of differentials and rare conditions. A clinician with limited time is best served with having a grasp of the different radiologic modalities, their limitations, and the proper exams to order to answer a particular clinical question. After all, clinicians—unlike radiologists—have the opportunity to correlate clinically.

Next, interpretation of plain films can be an essential skill. This is particularly true of chest x-rays in practice contexts where wait times are too long to guide clinical management. Surgeons of various types will find differing degrees of imaging knowledge to be relevant, particularly for operative planning.

Below is a brief list of high quality free online resources as well as a handful of excellent print books.

General introductory texts for medical students and non-radiologist physicians:

Learning Radiology: Recognizing the Basics is the best book geared for medical students (or non-radiologist physicians). A slightly faster read / good alternative would be Squire’s Fundamentals of Radiology, which was the de facto standard before Learning Radiology came around. Squire’s gives a very readable alternative but has fewer examples and is slightly less helpful in actually learning to interpret images yourself. It also costs more and hasn’t been updated in a while, so it’s a little less fresh (but not out of date). If you don’t want to buy anything, Herring’s companion website LearningRadiology is beloved, widely-utilized, and entirely free.

Learning how to interpret chest films yourself

Look no further than the very readable Felson’s Principles of Chest Roentgenology. The CXR aka chest x-ray is the most common radiologic study obtained by a country mile, and everyone should know how to do this. If you’ve ever worked with someone “who read all of their own films” but then couldn’t see what the radiologist was talking about, read this and you’ll have the context to do better. Actively evaluate the exam, and correlate the films you see in clinical practice with the reads you receive. The combination will help you more than simply opening up the study in the EMR and looking in its general direction for a big white blob somewhere. Pick a search pattern and stick to it. Use it every time. You can’t see what you aren’t searching for.

Free online resources

There are a seemingly limitless number of free online radiology resources, far far too many to even approach. For an example of an extensive list, see Radiology Education.

Here is my significantly briefer list of excellent general radiology resources for medical students, whether you’re interested in the pursuit of knowledge or the pursuit of a career in the field. Everyone has to start somewhere.

  • The Radiology Assistant is probably my favorite, very readable and concise.
  • Radiopaedia is the wikipedia of radiology. Articles are pretty terse, but when you see a finding or diagnosis and want to have an explanation, this is where to look (e.g. what the heck is “ground glass“?)
  • University of Virginia’s Introduction to Radiology online tutorial series is one of the best and even covers some more esoteric modalities (like cardiac MRI).
  • CaseStacks has lots of great paid cases to learn bread and butter for a decent price (and 15% off with code benwhite) but they also have some great free anatomy content.
  • Learning Radiology is a massive resource with lots of cases. The design is somewhat overwhelming and cluttered, but don’t let that discourage you.
  • Lieberman’s eRadiology is another nice, big, well-organized resource, including a lot of lectures, powerpoints, cases, imaging workup algorithms, etc.
  • HeadNeckBrainSpine was easily the best resource for learning neuroanatomy, but it uses Flash, which makes it unusable on most university computers.
  • And my final far-reaching inclusion is Radiology Resources for Medical Students, which is also solid but requires a bit too much clicking to get around the lessons.

Keep your eyes open

For anyone with plans to enter radiology as a career, know that you will almost certainly learn more radiology in your first two weeks of training than you could hope to amass during medical school or internship. Knock yourself out, but don’t forget this is your last chance to be exposed to the unadulterated breadth of clinical medicine.

If you have a book fund and want some good reading geared toward beginning radiologists, then you might find this post helpful.

If you’re a specialist (pulmonologist, urologist, etc) and are looking for more focused resources divided by section or modality, then see this compilation.

How to Succeed in Your Clinical Clerkships

11.14.13 // Medicine

How do you succeed during your third year of medical school? How do you do well in your clinical clerkships? How do you “honor” a rotation (and since when is honor a reverse transitive verb)?

Now, there are entire books dedicated to clerkship success: pages and pages of “pearls,” entire tomes dedicated to helping you earn the gold stars you’ve always wanted. These tend to be painfully repetitive and full of common sense.

Of course, common sense is your most important tool for third year, so don’t discount that out of hand either.

The bare minimum, most essential advice for third year is as follows:

  • Be on time
  • Don’t be a dick
  • Use common sense
  • Be flexible

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Studying for the Texas Jurisprudence Exam

10.20.13 // Medicine

Update April 2024:

My book is up-to-date and has remained the go-to resource for taking the physician JP exam since its release.

Update September 2019:

As of 9/1/2019, the TMB has moved the test to be self-administered online, which is great. The price has also decreased to $34 per attempt with unlimited attempts, which is also great.

They are now also offering their own practice materials, which you can rent limited access to until you pass the test for $99. You do not need to buy those pricey materials. Early feedback is that tested material (like the laws) is unchanged and my book (which is revised periodically and currently up-to-date) remains sufficient for preparation. Given the low cost of the exam and the ability to retake endlessly, I personally would suggest applicants buy my book (or something else inexpensive), read it 1-2 times, and immediately take the exam. The exam is short, and a re-take is cheaper than other materials would be.

Update January 2016:

In the years since I took the JP exam, the other resources have gotten older but otherwise haven’t changed in substance or price. The landscape has changed in only one significant way: In order to fill the missing void for a concise but readable up-to-date resource for busy doctors (and broke residents), I wrote one. I’m super biased, but I think it’s overall the best, most affordable, and most palatable study option out there. Thousands of people agree.

 

You can buy the ebook here:

Buy The Texas Jurisprudence Exam: A Concise Review

 

My original thoughts remain below.

The Texas jurisprudence exam is an irritating last hurrah on your way to getting your license. As a doctor, you’ve taken USMLE Steps 1, 2CS/CK, and 3. The JP exam is not like those tests, in many ways, but particularly because this one is easy. Somewhere between three and five hours of high-yield review should be sufficient. However, don’t take this relative ease further and attempt the test cold. It’s idiosyncratic enough that you need to give the key information a solid once-over in order to pass.

The test costs $58. For this reason (and the fact that it’s extremely approachable difficulty-wise), I find it amusing that both the “recommended” resources and the major online option are so ridiculously expensive. The UTMB book is $100, the TMA Manual is $145, and the accompanying TMA Self-Study Guide is $105. The online course at texasjurisprudenceprep.com is $210. All cost substantially more than the test itself and are probably overkill for anyone who had the skill to pass the boards. You can attempt the exam up to three times if necessary for one fee.

If the residents in your program have passed around a high-yield packet of the more salient bits, studying that exclusively would almost certainly be enough. There is usually someone who has taken some serious notes over the years. As far as I can tell, the test has not changed in any meaningful way recently. By far the most affordable commercially available book is the Texas Jurisprudence Study Guide, which is quite affordable (the Kindle edition is less than $4). It’s very short: roughly 13k words, which is like 25 legitimate single space pages. The book is question and answer format (lots of white space). The form works better in theory than in practice, and the formatting in the ebook version is especially poor. The book is also awkwardly terse, has a decent number of mostly irrelevant typos, and is downright confusing in several spots. It’s essentially a long list of facts without any particular emphasis. No context, no real explanations. That said, it’s totally sufficient. And much much much more affordable. If you’re going to rely on the study guide, this online PDF from TMLT is helpful.

The other books are longer and will take more of your time. The real test is 50 questions and takes approximately 20 minutes to complete (you have 90 min allotted), so there’s lots of extraneous detail to be had here. They just aren’t worth it.

It seems as though the online course is actually pretty popular. It’s a “video” course in the sense that it’s an online audio-backed powerpoint lecture. The audio quality and voice acting approximate the quality of your very first Skype call. The course is also full of painfully awkward juvenile humor, which I imagine is an attempt to make this very dry subject somewhat more palatable. These cringe-inducing bits actually take up a fair bit of talk time. The course itself takes 163 minutes to finish watching. There are also 6 quizzes (#5 and #6 are considered the most relevant), at least some of which are reportedly appropriated from the back of the UTMB book, and some helpful handout downloads, which are honestly the best part. This is not an elegant resource, but it will absolutely get the job done and will do so more quickly than reading one of the full-length resources (The UTMB book is quite dry). They do now have a free practice quiz demo, which takes a few minutes and is worth doing to get a feel for the questions.

So, ask the residents at your program what they’ve been using. Borrow a copy of whatever they used. If you’re on your own, the cheap kindle book gets the job done. As far as I’m concerned, it doesn’t really matter what you use, so long as you don’t waste too much money on it. In this case, more detail is not better.

As for the test itself, it doesn’t necessarily test things you’d think would matter. A large percentage of questions make sense intuitively. Most questions that require reading test facts that are emphasized in all study resources. There are a few randos, but not enough to seriously jeopardize passing. The question writing is pretty poor. There are plenty of “all of the above” questions as well as the negative “which of the following are NOT…” variety–which you’ll remember were stricken from the boards because negatively-framed question stems are a stupid way to get a proportion of people who actually know the answer to select the wrong choice inadvertently.

Anyway.

Good luck.


Buy The Texas Jurisprudence Exam: A Concise Review

Explanations for the 2013-2014 Official Step 2 CK Practice Questions

09.14.13 // Medicine

The NBME graciously provides brief practice materials for its USMLE tests, including pdf and software versions. While answers are included, there haven’t been explanations available online (until now).

If you haven’t taken a moment recently to think about how you approach Step-style questions, I might refer you to my discussion of that particular topic, particularly the section on “dealing with irritating clinical science questions” near the end. For general information on how to study for the USMLE Step 2 CK (as well as some free Step 2 resources), I recommend you read this.

From the 2014 official “Step 2 CK content description and general information” booklet (official link is dead, that’s the Archive.org cache version), I’ve listed each question and its answer with a succinct (grossly simplified) take-home message:

The newest set of official questions (2014-2015) has been released. There are only three new questions, but the question order has been entirely changed. My updated explanations can be found here.
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Applying to Radiology

08.24.13 // Medicine, Radiology

Applying for residency is anxiogenic. That’s true for essentially anyone and everyone but perhaps even more so when applying to competitive fields, advanced specialties requiring a preliminary year, or field/location combinations you are not necessarily competitive for. The bright side is that it’s a temporary problem, and in a few extra months you’ll probably have a job and a very expensive piece of paper that says you’re qualified for it. Like other (sometimes more expensive) alternative sources, I have compiled some sage and mostly common-sense advice for how to approach (and succeed in) the match.

Below are some additional thoughts to aid those who are considering pursuing a career in diagnostic radiology. (more…)