The Littmann Cardiology III.

Oh, you actually want to read a treatise on stethoscopes? Well then don’t let me stop you!

A reasonably good stethoscope is the one (and I mean one) and only piece of medical equipment that every medical student should purchase. You will use it during the preclinical years for training and OSCEs, and starting third year you’ll use it almost every day (possibly for your entire career). Stethoscopes aren’t like ophthalmoscopes; you really need to have your own, and it is absolutely worth it to have one that works well. But there are an overwhelming number of models at a huge variety of price points.

You say the word stethoscope, and the response you’re most likely to hear is Littmann. But even then there are a lot of choices. My recommendation for most health care professionals is to buy the Littmann Cardiology III.

From first hand experience, there really is a difference between cheap and expensive stethoscopes, period (even to some extent within the Littmann line of products). I actually used and continue to use an old Littmann Lightweight that was my mother’s. When it went missing briefly, I used a pink cheapo one that my wife had upgraded from. In both cases, I thought I was hearing the right things. I could hear a heartbeat. I could hear breathing. However, there’s a significant difference between hearing the heart and breath sounds and being able to hear diagnostic sounds. I thought residents were lying about hearing faint murmurs or bibasilar crackles. ((Sometimes they were, but that’s beside the point.)) That’s because even with my old Littman, the amplification and frequency response simply wasn’t that good. Everything was muffled. Moreover, the tubes on cheap ‘scopes are so poorly insulated that any slight movement (even chest movement, patient hair, etc) is enough to obfuscate any actual physiologic noise.

My wife has the Cardiology III (a fun present to get from relatives, as it costs around $150), and if I were in the market for a new stethoscope, it is the model I would buy without question (update: my vintage stethoscope broke during intern year; I replaced it with the Cards III). When I first borrowed it my mind was essentially blown. I had no idea what I’d been missing. The Cardiology III strikes the right balance of features and price for essentially any physician. ((If you don’t want/need a pediatric head or a dedicated bell and do need to look awesome, then perhaps the Master Cardiology is for you (see the comments below.) ))

• Tunable heads mean that you can assess both high and low frequency sounds by altering pressure. Once you practice with a tunable diaphragm, it’s actually a great feature as it allows you to rapidly get a full sonic picture of a location in space without having to futz with the stethoscope
• Double (both adult and pediatric) diaphragms (the peds one can be switched to a standalone bell as well, which can be nice if you want to ignore the tunable feature). Some schools require you to have a double-headed model so that you can “switch” modes when taking standardized exams, and this is the model in the cardiology series that is double-headed. This also means that no matter what you do later, this one will get the job done.
• Excellent (I mean excellent) external noise attenuation. You hear what you want to hear.
• The only con is that is a bit on the heavy side. The up-side of this con is that you can easily use the head to test reflexes.

Someone may come to your school to try to sell you a digital/electronic stethoscope (like this Thinklabs one several of my classmates were conned into buying). Outside of increased amplification for the hearing impaired, most digital stethoscopes (while kinda cool) are stupid for a variety of reasons: bulky, most can’t fold properly for a pocket nor easily wear around your neck, need for batteries, etc. I have yet to see a compelling reason to buy one unless you are an educator, as the second-listener feature is great in a classroom setting.

Some people hate Littmann’s “new” tunable stethoscopes. And while essentially everyone I’ve ever worked with carries a Littman, there are some folks (especially old school docs) who swear by a couple of other models, particularly the Harvey Elite, which is even pricier but is universally acclaimed by its users.

In addition to a good stethoscope itself (and certainly the cheaper/lighter Littmann Classic II gets the job done), many of my classmates and fellow residents also swore/swear by their holster, though I myself just bear with the neck strain.

Do I need to buy an otoscope/ophthalmoscope?
And if I do, which one should I get?

These are two of the first questions I used to hear from every MS0/MS1 during welcome weekend, white coat ceremony, or orientation.

Medically, the answer for most students is “no.” Most hospitals and clinics have Welch Allyn diagnostic sets attached the walls or units hidden away in the supply room on the floors. You will play with them once during first year and probably never again. However, many schools nonetheless “require” you to buy one. My own school did that, and in hindsight, it was a soft requirement, and I probably could have avoided the purchase. That said, there are several reasons to invest in a set:

1. Your school demands you buy a “diagnostic set,” and you feel awkward not playing by the rules
2. The hospital you train at or plan to work at is ill-equipped and does not have access to these tools on a regular basis
3. You are interested in a career in neurology or ophthalmology
4. You want to do family medicine and actually see inside the eye during your fundoscopic exam instead of pretending
5. You are interested in community outreach, rural medicine, or medical mission-work

There are a lot of super cheap sets available online, but if you ever plan on actually using them, then it’s probably worth upgrading slightly. The cheap ones are extremely heavy and optically useless. Either the light is too bright or too dim and non-adjustable. Not infrequently, the optic disc remains blurry no matter how you tweak, because the manufacturing process doesn’t calibrate these devices accurately. Most otoscopes work okay (ears are easy), but you’ll almost always buy it as part of a set anyway.

Neurologists and ophthalmologists are the specialists that most routinely do fundoscopic exams. General practitioners document that they do but frequently don’t, and when they do they typically do not get diagnostic exams. Ophthalmologists actually rarely use a direct ophthalmoscope, as in the office setting they have bigger and better toys, so even for them once again it boils down to your desired clinical context.  Any physician who wants to do community outreach (e.g. glaucoma screenings at a local church) or medical missions outside of a routine clinic or hospital setting can find a use for these tools. Personally, the most use my set got was in a small village in the Dominican Republic.

So which model should I buy?

If you’re looking for a reasonable, affordable, small and light general purpose set, look no further than the Riester Ri-Mini. This is the set I purchased as an MS1, and it strikes a balance of price and quality. They’re well-made, durable, and actually work.  They use AA batteries, so they’re small and can fit in your white coat easily (unlike their full-size C-battery-sipping cousins). For a pocket set, there’s nothing better.

The best  “reasonable” full size optionsis the Welch Allyn Diagnostic Set, which is what you’ll find in just about every hospital setting. It’s big, it’s good, it’ll last forever, and it’s expensive.

If you want the Rolls-Royce of sets, then you’re forced to splurge on the holy Panoptic. To me, everything else in between just doesn’t seem worth it (if you’re really going to shell out $500+ for a Welch Allyn diagnostic set, why not upgrade all the way?). For most people, the Panoptic is a massive waste of money. Its main benefit is that you can do a much more complete fundoscopic exam without dilating the eye. As a consequence, you can accurately assess the optic disc and easily check for papilledema.  Consequently, for neurologists, the Panoptic can be extremely helpful in checking for signs of increased intracranial pressure. For ophthalmologists or family docs, the Panoptic is helpful for community outreach work and school screening, as it allows you to obtain a fast reliable exam without eye drops/dilation.

So for most people, a huge waste of money.

For people who want to do community outreach, medical mission-work, etc—it’s seriously something to consider. If you want to be a GP/PCP and actually do a real fundoscopic exam, then a Panoptic head is probably the most straightforward way to do so in a routine clinical setting. You don’t even have to know how to use one properly; it’s just that much easier.

After taking Step 1, I imagine most students realize how overextended they became trying to get through multiple books during Step studying. In the end, it was the questions that mattered. It’s always the questions.  So, here’s my list of free Step 2 CK questions (updated June 2019):

• The NBME has its free Step 2 CK practice test in Fred (v2) software, as well as some good materials to familiarize yourself with Step 2 CS. You can find my written explanations for the most recent sets here.
• Lecturio has made their 1000 question Step 2 qbank completely free (after registering for a free account). If you’re interested in buying their video lecture/qbank product, you can get a 25% discount with code hpG6C.
• MedBullets has a 1000+ question robust Step 2 qbank with tutor mode, percentage of peers who answer correctly, detailed explanations, etc. They also have another 199 for Step 3.
• Osmosis is a completely free big (>5000 question) qbank and video collection organized by section. No personal profiles, exam creation, metrics or other typical paid-product goodies, but there’s a lot of content.
• ExamGuru has a free trial with 10 questions apiece from each of their 6 shelf exam products and USMLE 2 CK (for a total of 70 questions). Coupon code BW15 gets you 15%  off any package you might want to buy.
• For every Step exam, Kaplan lets you try one 48-question section for free after signing up.
• USMLE Consult has the usual tiny trial for free (30 questions)
• Learntheheart.com has 50 cardiology USMLE 2 CK questions with plans to add more.
• MedMaster (makers of the “made ridiculously simple” series) has a USMLE Step 2 question bank. Like their Step 1 qbank, it’s content review, not Step practice. But it’s short, high-yield, and to the point. It’s not a bad quick companion for the shelf exams as well, especially at the beginning of your rotations. It also includes a section for Step 2 CS full of the cartoons and mnemonics the series is known for.

Not a lot of resources, free or otherwise, are dedicated for Step 2 (especially when compared with its significantly more important sibling). If you take Step 2 CK in the summer after third year, a question bank (USMLEWorld of course) and Crush Step 2 / Step 2 Secrets (same book in different formats, both a very quick and superficial treatment and extremely quick read) are likely enough. For the gunner, the possible addition of a more “comprehensive” text: First Aid for the USMLE Step 2 CK (which is not as good as FA Step 1 but retains the same format you either loved or hated), Step-Up to USMLE Step 2 CK (previously the worst of the big three but recently updated and improved), or Master the Boards USMLE Step 2 CK (more readable but less complete, particularly good for “next best step” questions). Step-Up to Medicine (if you have it from your medicine clerkship) is still an excellent review for medicine (the bulk of the test) if it’s been a while.

Preparing for your shelf exams is 75% of the battle. The longer you wait, the more you forget, and the harder the test is. Contrary to what you might hear, Step 2 isn’t actually much easier than Step 1; it’s just that you’ve done this rodeo before. If you really want to do well, prepare for and take it right after clerkships.

If you’re attempting to cram for Step 2 in a month or less, I recommend forgoing books altogether (except as references PRN) and relying exclusively on USMLEWorld. Go through it once, flag all questions you get wrong or guess on, then do all marked questions again. Only if you can finish that is it worth reading a book cover to cover. More book-reading does not equal more knowledge when it comes to board review, and you’ve already spent a year reading review books for this exam via your shelf studying.

Looking for more info on the third year shelf exams? That would be here.
Worried about Step 2 CS? Then feel free to peruse this post.

Okay, so penlights (pen lights?) are not the sexiest topic within medicine. However, I struggled with them a lot as a medical student. As in, I never seemed to have one when I needed one. And, when I did have one, more than once it had died when I finally tried to save the day on rounds.

I originally used this style: decent light source, reusable, available from my school bookstore. The problem is they’re activated like a pen and are easy to turn on accidentally, so they die constantly. They eat up batteries. And then I lost one. And another.

I then used these cheap disposable penlights. They’re great for several reasons: super cheap (as a cheap $1 each on Amazon) and you can only shine on purpose, so they won’t die accidentally. The problem is that they do die randomly. And the lightsource can be so weak that it won’t work in bright room. The pupil gauge is nice though.

Entering intern year I was in need of a new pen light, as my wife and I had somehow lost all of ours in the move. I looked around and splurged (relatively) on the Streamlight Stylus, which I love. It’s around $10-15 depending on the day, but it’s super bright, lasts forever (like 60 hours on one set of batteries), and is as slim as a narrow pen, so it fits easily in the pen divider of a white coat with room for another pen, so I actually use it all the time. It’s reusable, as it takes 3 AAAA batteries. That’s right. AAAA. Where do you find AAAA batteries you ask (should you rack up 60 hours of pupil gazing)? Inside of the 9V batteries you used to stick your tongue on (and online, of course). Downsides? Extremely bright, so be careful of how you use it. Also, its long length may cause it to stick out of your white coat depending on the size of the pockets.

If you want the Rolls Royce, the Foursevens Preon 2 has multiple light modes (dim for carefree direct pupil, bright for room flooding) and is generally well loved as the most versatile LED penlight around (downsides: bit wider; click button means you can leave it on by accident and waste the battery). In between is the new NexTorch Dr. K3, which costs around 24 but gives you an awesome medical grade light with Goldilocks brightness and excellent build quality.

I’ve spent the majority of my “adult” life as a standardized test taker. As a resident physician, my skills are still developing. But as a student, as an aficionado of the multiple choice question, I’ve already reached (and probably lost) my peak abilities.

I am asked frequently about my thoughts on the Step exams, especially the USMLE Step 1. It is after all the single most important determining factor in what specialty a medical student can reasonably hope to enter and probably the easiest and most-used exclusion criteria used by program directors everywhere (with the likely addition of graduating year and US Allopathic schooling). I can hear your thoughts. They ask, how should I prepare? My answer is simple:

USMLE World.

Theoretically, any good question bank should do. In practice, UW is the best.

More so than First Aid, more so than Goljan, and absolutely more so than Doctors in Training, I believe the USMLE World question bank is far and away the most critical component of Step preparation (with a solid helping of Wikipedia). Here is why:

When you learn a fact in a book, you can congratulate yourself on adding a virtual index card into the Rolodex of your brain. However, you have not indexed this fact in a retrievable way. It isn’t necessary usable in a test-taking context. This is one of two reasons why many people who know things still do poorly on tests. They can talk about it, but they can’t apply it. You may know the right buzzwords but never seen them described in an exam question. When you do questions, you both learn facts and learn them in context. You learn them in a question format, instead of learning them in a paragraph and then struggling to integrate and apply it to a question. Your time is valuable, wouldn’t you rather kill two birds with one stone?

UW questions have extensive explanations and are essentially a textbook page unto themselves. You can learn what you need to know from UW. The only downside to UW is that is not “organized” like a book for those students without sufficient background in need of a stronger foundation (this is what a quick read-through of First Aid as fast as possible at the very beginning of your study process will give you: a reminder of what you’ve learned, a horrifying glimpse of how much you do not know). This can be is a strength for two reasons: 1) it’s [slightly] less boring 2) the USMLE is not divided into sections. You never know on what topic the next question will be. 3) Patchy random exposure to topics isn’t exactly “spaced repetition,” but it does work along those lines.

So read through First Aid in a week or less. Just get through it. Bring up all the hidden junk you memorized long ago, then go straight to questions. Questions, questions, questions. Use books only to memorize tables and diagrams or flesh out your knowledge when you find yourself stumped by concepts or totally out of your element. Many students spread themselves thin trying to get through multiple sources at the expense of not doing enough questions—this is a mistake. Focus and depth trump breadth, end stop. Go through UW and mark/flag all the questions you get wrong and all the questions you guess on. Then do the marked ones a second time. Unless you have a significant problem finishing exams on time, I believe in “tutor” mode: this mode allows you to learn the correct answer and read the explanation immediately after each question. The goal is here is to learn first (and simulate the test second). If you do NBME practice tests closer to test day, those will obviously be done in timed mode. Ultimately, this is a matter of preference.

UW also goes to the trouble of explaining not only why the right answer is right but also why the wrong answers are wrong. This is crucial. This means you learn how to answer similar questions correctly again as well as when the wrong choices would be correct. Several related facts in one caffeine-riddled swoop. These explanations are on the whole excellent. These exams no longer include the classic buzzwords found in review books; they describe those buzzwords and key phrases. UW employs this nuance well.

The second major reason people struggle with MCQ tests is the inability to “get in the head” of the question writer. There are individuals who seem to test better than they should. You could ask them to explain why they choose the correct answer and they typically cannot explain themselves. Or, if they know why, it often is not entirely based on their book-knowledge. They’re able to narrow it down to those same two choices as the next guy, but they pick the right one more regularly. These people are natural test-takers. Step 1 is a MCQ test, but its style is not identical to that of the SAT or MCAT. You need to do Step questions to know how to do Step questions. It’s like any other skill. Hone it.

Because you wouldn’t learn to play guitar by practicing the flute, would you? Sure, the flute is a musical instrument: your dexterity would improve, your knowledge of tempo, rhythm, and music itself would develop. But if you picked up a guitar, you would still suck. Don’t spend 10 hours a day for six weeks learning the flute, then pick up a guitar and hammer on a few chords for a week and call yourself a guitarist. Just play the damn guitar. Skip the middle man.

Here is my compilation of free USMLE questions, which can be helpful before you’re ready to shell out for a definitive resource. Here are some things to keep in mind while studying. And some more thoughts about how I read Step questions.