Working Through the CRIP Interview Process

Three and a half years of medical school education led up to this past week.  The centalized residency interview process, in Frisco, TX ends today. With our board exams being about a week and a half ago, I think we were basically as prepared as we could be. The toughest part, though, is really knowing your stuff. On boards, or any exam, we have the answers in front of us. Multiple choice tests always give us a semi-false sense of security. The pure recall necessary in an interview is just unparalleled and very tough to prepare for.

First, though, we’ll talk about where we’re at. Frisco, TX seemed like a real odd choice to me.

The Embassy Suites at the Frisco Convention Center

The Embassy Suites at the Frisco Convention Center

Here’s the thing. It worked out relatively well. The taxi ride was expensive from DFW airport, right around $60, but once we got here, there was really no need for any more transport. There are restaurants, grocery stores, bars, other hotels, and shops all within walking distance. The Embassy Suites, itself, was well suited, too.

The myriad of suites at the Embassy

The myriad of suites at the Embassy

In any given room, we may be interviewing. On the second floor here, there are some conference rooms for the bigger interviews. Those included both interviews with multiple doctors and one student, which were more common, and those with multiple students and fewer doctors, which were very tough to handle. They also housed some social events and slide presentations in the evenings. Anything on floors three through 14 were fair game for most other interviews. The bar area here, incredibly, provided free beer during happy hour: one of the perks of being in Texas, I presume.

The interviews themselves, for me, went real well. I ended up doing 16 interviews for 10 programs with an additional 5 socials in 6 days. Holy cow. Some interviews were with programs I knew nothing about and did for either experience or to fall back on, though the vast majority were programs I’d gladly attend for three years. They ranged from 10 minutes to 75 minutes, with varying degrees of educational and social questions plus various skill assessments. I had to build towers out of blocks, retrieve foreign bodies with an arthroscope from a mock ankle, and throw various screws and plates on Sawbones fractures.

In looking back at the week, I think Frisco could’ve been significantly worse. No interview really through me off my game, though some were tougher than others. I was notably flustered in two of them, but still did my best to answer what I needed to answer or do what I had to do. I get that the central location offers no school a competitive advantage, while offering a (generally) nice climate. I still think they could find a place closer to an airport, but for what it was, Frisco did just fine.

Hubscher Maneuver vs. Jack’s Test: Battle Royale

According to Podiatry Arena, a site dedicated to international podiatrists battling wits about minutiae, the Hubscher maneuver is primarily performed in the United States while Jack’s test is performed in the rest of the world. According to some of the attending physicians whom I have worked with, one of them is performed weightbearing the other is non-weightbearing. No matter what, however, the test could be described as observing supination of the foot or raising of the medial longitudinal arch with passive dorsiflexion of the hallux. It is a useful clinical tool in assessing a flexible flatfoot versus a rigid flatfoot, among other uses.

The Hubscher Maneuver/Toe Test of Jack, properly performed

The Hubscher Maneuver/Toe Test of Jack, properly performed

Much like the paprika sign, the history of the test has been lost along the way. Obviously, if two people’s names are tied to the same test, something must have gotten lost in the shuffle. Physicians love getting their names on things. From surgical instruments to procedures to durable medical equipment and beyond, if someone described it, the name generally sticks, so it is especially odd when there is a bit of a quandary like this. So, once again, I did some leg work on the issue.

The Hubscher Maneuver is generally what I have heard this thing called. To setle this right away, it appears that the test is always performed weightbearing. With the patient sitting in the treatment chair, supination could be observed as simply calcaneal inversion and could be present whether or not the flatfoot was rigid. Often spelled with the ü, I presumed Hubscher was a German or Dutch word. In fact, the first reference to it that I can find is in a now defunct Dutch journal from 1956 by JE Enklaar, entitled “Hübscher’s maneuver in the prognosis of flatfoot”. I can’t get a copy of the article, as the journal seems to be long gone, but based on the title alone it seems as though Enklaar first describes the test in this article or that it is a recently developed clinical exam and he is describing what it indicates. It’s tough to say anything further, but it may not matter.

The Toe Test of Jack, or Jack’s test, was easier to track down. Ewen A. Jack described his test of dorsiflexion of the hallux in 1953 in the British edition of the Journal of Bone and Joint Surgery. Even more surprising, and empowering, is that he originally presented the paper in 1951 at a scientific meeting, a full five years before Enklaar’s discussion.

A screen cap of the landmark article by the forgotten Ewen

A screen cap of the landmark article by the forgotten Ewen

Jack had real nice drawings and pictures, even solid clinical understanding of what’s occurring in the flatfoot pathology, all in 1951.

I am not one who sticks to my guns in the face of contrary evidence. I have several friends who don’t accept evidence, who won’t allow it to change their mind. After this research, I am willing to accept Dr. Jack as the describer and namesake. I’ll switch and call it Jack’s test, happily. I also propose a new phenomenon: the Bernhard phenomenon. This is what occurs when medical eponymous terms are so far removed from their roots and description that they are forgotten or misattributed. I can only wait for the day when the Bernhard phenomenon is Bernhardized.

Dog Eats Foot! The Dangers of Peripheral Neuropathy

A large percentage of our patient population suffers from diabetes. High blood glucose levels and long standing disease put this population at a vastly increased risk of getting tagged with the diagnosis of peripheral neuropathy. Neuropathy, generally, is characterized initially by a loss of sensation. There are numerous types, from sensory to motor to autonomic neuropathies, but we generally screen for sensory neuropathy which is usually the first manifestation. This doesn’t sound awful at first, to me at least. There was a James Bond villain that has stuck with me forever. In The World Is Not Enough, which came out when I was 13 and quite impressionable, the villain Renard had been shot in the brain, which rendered him immune to pain. He could then fight harder and run faster without the cues of his body telling him to take it easy.

He absolutely looks the part of a Bond villain.

He absolutely looks the part of a Bond villain.

Now, in actuality, peripheral neuropathy is very debilitating. Patients are at increased risk of ulceration, fractures, infection, peripheral vascular disease, arthrtopathies, and, apparently, becoming a meal for a dog.

Last year, Lee Rogers and Nick Bevilacqua published a case report about a Jack Russell terrier eating its owners’ great toe. Whenever an animal bites a person, there is a major potential for complications, most commonly infection. A dog’s mouth  has specific, pathological bacteria like Capnocytophagia canimorsus, Staphylococcus aureus, and Pasteurella multocida among other bacteria in the streptococcus, staphylococcus, bacillus, corynebacteria, and neisseria families. Those are all potentially harmful, especially in a diabetic with a poorly functioning immune system. So, the authors patient, a 48 year old woman, lost her toe and was exposed to dozens of species of bacteria. All without feeling a thing!

So, it's a dramatization. But you could imagine this would probably hurt.

So, it’s a dramatization. But you could imagine this would probably hurt.

Due to her peripheral neuropathy, she slept through the little dog eating her toe off. The toe was “shredded” and not salvageable. The surgeons had to remove the remainder of the stump. As a result, though the authors don’t give a time frame, this patient ended up with a below knee amputation. Her biomechanics were thrown off and she developed ulcerations, which became infected. She lost her entire foot and a little less than half of her leg because of a little 10 pound dog.

This all points back to an important piece from DG Armstrong. Anywhere between 45 and 55 % of patients with neurotrophic or ischemic ulcerations, which may or may not lead to amputation, will die within five years. That mortality rate is higher than breast cancer, prostate cancer, and Hodgkins’ disease and on par with colon cancer. Too many people are too cavalier about their foot health and may take their sensation, and health in general, for granted.

Boards Part II and Interview Studying

Being just a little over a month away, it is time to really kick it into gear and be studying podiatry hard. Every aspect of medicine is fair game for both boards part 2 and interviews and yet I am struggling to find a balance between studying and life. I settle up at the library or the bone room and struggle to keep focused. With the finish line so close, it is hard to be as diligent as I should be. In fact, that’s a big reason for this post! After reading through thirty pages of question based reviews, I had to take a break.

This is a pretty normal set up.

Bones or not, this is pretty much how I study

That skull there is trying to keep me on track.

In reality, I think I am doing just fine though. I started long ago and never let anything get too far from me. I took tough externships and studied while I wasn’t at the hospital. I would work hard and then go home and study. I’m fresh on all of my classification schemes and feel generally good about podiatry. I also use every tool that I can. I will listen to podcasts on topics, rewatch lectures from school, and even change my study location. Many think that studying in the same spot all the time is beneficial, but research shows changing your location helps improve recall. So, I’ll move from the bone room to the school library to any of a group of eight to ten branches of the Cuyahoga Library system. I’ve been around the block.

Medicine, generally speaking, is probably my weak link for boards. It’s probably all of ours. The trouble is that it is a monstrous category. Just medicine. It could be anything. But, I suppose that will be life from now on. We have to be competent, and confident, in our knowledge. We have to be able to treat whatever comes in the door. So, yes I can read First Aid for the USMLE Step 2 or Dr. Kushner’s Pearls for part 2 of APMLE but can I really be ready for anything? I suppose I won’t get a 100% on the test, or interviews, though. I just need to be as prepared as I can and do my best.

My current weaknesses, just to get them out there: anemias, endocrine disorders, antibiotic coverage, specifically cephalosporin names, drug dosages, and reading EKGs. I feel if I get those down, there is very little that could disturb me. Now, I’ll try to keep on the right path. I’ll use all of my resources available, both from KSUCPM and from residents and attendings who have helped along the way.

Maybe I’ll get that done after I finish reading my book…

It’s only 450 pages.

Proper Shoe Gear and Selection – From St. Joseph’s Medical Center, Houston, TX

My most recent presentation, this time from tropical Houston, TX. This was only around 10 minutes, so it is very brief, moreso than usual. That may make it worth checking out more. There is literally nothing in it that can’t be understood on it’s own.

The post about my Houston experience is on the way. Probably after my long overdue Boston and Atlanta ones. Hold tight.

Lower Extremity Anatomy of the Teenage Mutant Ninja Turtles

Two of my childhood favorites: Michaelangelo and Vailla Ice. Word to ya motha.

“[A gang] Known as the foot …  I know it sounds like a funky club for podiatrists”                            – April O’Neil

Though I recently turned 27, I often feel as childish as ever. Last weekend, with my time off, I ended up at an air show. It is always a blast. Now, with some time off and no hotel WiFi, I decided to watch Teenage Mutant Ninja Turtles, but not even the first one. When I was a kid, I saw the first one, but we owned number two, The Secret of the Ooze, on VHS and my brothers and I watched it ceaselessly, so I have a strange affection for it. I can remember being so annoyed that there were two different New Line Cinema animations beforehand, since it slowed down the beginning, and how excited I was when worlds collided; I found out that the Super-Shredder was played by professional wrestler Kevin Nash.

Now, it is a little different, though no less awesome. I just chuckled a little at Donatello’s quote “Give the guy a break. He’s a scientist.” In the opening credits, during their fight in an underground mall, I noticed that their musculature seemed to be way more human than turtle. At first glance, it’s almost exclusively turtle, being that they’re green and have shells, but they also recognizably have biceps, triceps, and sternocleidomastoid muscles. Even the anterior shell, the plastron, looks like pectoral and abdominal muscles. I’m no testudon expert, but I don’t often see the same definition in pet store turtles. Their lower limbs are no different.

Look at those legs

Tom Spina Designs fully restored the original costume. Picture Perfect

I found this fully restored depiction of Leonardo. This is the actual Leonardo from the second movie! I think that’s pretty incredible. Even more so are the number of leg reps he’d have to have done for the definition in those legs. His quadricips femoris muscle group is stunning, with the vastus lateralis, vastus medialis, and rectus femoris all being incredibly defined. You can even see the great saphenous vein proximal to the knee, bilaterally. The iliotibial band can be spotted laterally, as well, with perhaps some biceps femoris poking out posteriorly as well. Without a posterior view, though, it is tough to be conclusive. The knee pads block any shot of seeing a patella, but just proximal to the pad it appears to be muscular. That would be anatomically incorrect, for humans, but maybe it is a normal turtle mutant variant.

Further down the leg we can see the well defined gastrocnemius muscles. On the anterior view, distal to the extent of the gastroc, we can perhaps spy some soleus muscle belly. While his tibial crest looks pretty realistic, the lateral aspect of the leg is suspicious. Either he has tremendously differentiated peroneal muscles or Jim Henson took some artistic license. Or, again, maybe turtles are just different. The most notable difference is the digital anatomy. Not only do the turtles only have two toes per foot (and three fingers per hand), but they also look like two great toes, two halluxes. The intermediate phalanges are not obvious, suggesting perhaps that there is only one interphalangeal joint per digit. The dorsum of the food looks mildly edematous, as no venous structures are apparent, however this would be likely. Leonardo spent three movies devastating the opposition with ninja kicks.

Functionally, the turtles musucloskeletal system is very similar to ours. They can extend and flex at the same joints, are capable of jumping and performing backflips, and can even carry a rhythm. Ninja Rap is perhaps my favorite Vanilla Ice song of all time. They do appear to pretty flatfooted, though they are “teenaged” and are unlikely to have any painful flatfoot deformity at this time. An astute observation of them walking stealthily showed something I thought was pretty stunning. They demonstrated a midtarsal break, which is generally seen as a primitive gait component.

Sasquatch or Turtle?

This picture around the net as evidence for Sasquatch, but I think it demonstrates the turtles’ feet well, too.

Our midtarsal joints lock, allowing us to propel with minimal wasted motion. Other apes, however, have a subluxation of this joint while they walk upright. It’s not much of a problem for them, though, because they spend a large amount of time climbing trees, instead. It is unclear whether or not this would be beneficial to ambulating turtle.

While we have no real way to know how, exactly, the ooze changed the turtles’ genotypes and phenotypes, what we can do is make observations. While, yes, they are significantly different from their pre-mutated form, they have become exceptional examples of (mostly) human animals. Their available motions and anatomical landmarks look grossly human. If it wasn’t for the turtle beaks, the giant carapace, the missing digits, and the green skin, they might just look like really diesel men. We also can’t say whether or not their skeletally mature. If they’re teenage males, they certainly are not. They would have a few more years of growing, which would necessitate some serious molting of their reptilian skin. I, for one, am disappointed that we have yet to see the Middle-Aged Mutant Ninja Turtles, but maybe they end up overweight and diabetic. Odds are at least one would.