greek.doctor

My thesis defence was March 11th. My thesis topic was “Diet in Crohn disease – The effect of diet on the microbiome and its role as a therapeutic modality”. You can read it here. The thesis defence involves defending your thesis against a defence committee consisting of three people, two of which are your designated opponents.

Before the defence

My supervisor was the head of the gastroenterology division of the 1st department of internal medicine, prof. Áron Vincze. Him and dr. Judit Bajor were designated as my two opponents, and as opponents are supposed to do according to the rules, they gave me their separate evaluations of my thesis ahead of the defence.

I was informed of my thesis date by e-mail only 15 days ahead of time, a date they’d chosen without my input. I had already planned a practice in Norway at that date, a practice I had planned 6 months earlier. Plane tickets were already bought. I replied that the date is not appropriate for me, and that we either need to find another date (I had other suggestions which were within the deadline of April 1st) or have it online. The reply was that either of these options would be impossible (even though I know of other students who had it online or were allowed to choose the date themselves). I was also told that the middle of March was the “usual time” during which the 1st department holds its defences, but no one never informed me of this. This means that they were aware of the approximate date of the defence for a long time but decided to inform me only 2 weeks before.

Note that there were no critiques or questions in the opponents’ evaluation. In most cases, students receive questions ahead of time of their defence so they can prepare and answer these questions during the defence. I’d received none.

In most cases, the student is asked to hold a 5 – 10 minute presentation about their thesis during the defence, with or without a PowerPoint presentation. I asked whether I should prepare a pptx, and they replied no, so I assumed I’d have to hold a presentation with no visual help. However, I asked another student who were to have defence with the same department at the same date, and they were told that they shouldn’t have any presentation at all, and that the whole defence should only be reserved for the questions received ahead of time.

So I wasn’t going to hold a presentation, and I hadn’t received any questions. The last days before my defence I was really stressed because I had no idea what I would have to do at the defence. Would I only receive questions for which I couldn’t prepare? Had I received wrong information and would have to hold an impromptu presentation?

Brief summary of my thesis

The gist of it is that there likely exist some possibilities for dietary treatment of Crohn disease, as evidenced mostly by 2 things: Firstly, the well-known efficacy of exclusive enteric nutrition (EEN), the practice of inducing remission in Crohn disease by putting the patient on a nutrition drink-only diet for 6+ weeks, and secondly, the fact that temporarily diverting the faecal stream by using a temporary stoma causes lesions distal to the diversion to heal, and the lesions only recur when the stoma is reversed, which indicates that components in the faeces are important in the development of these lesions. There are a few small studies with special diets for Crohn disease which show some promise, and these diets generally exclude certain food groups (gluten, milk protein, lactose, alcohol) as well as other modifications, but larger studies are needed. As of yet, there is not much evidence to recommend any specific dietary changes in Crohn disease.

The day of the defence

The time of my defence were to be 13:20, so I showed up at approximately 13:00. It turns out that the student who were supposed to start at 13:00 hadn’t started their defence yet, because a member of the defence committee was late, so the whole ordeal was already delayed. While waiting, one member of the defence committee for my defence shows up and waits with us. We have a nice chat, and he tells me that neither of my opponents are present today, so their places on the committee has been replaced by two other doctors. However, according to him, on a defence committee only the opponents have actually read through the thesis, but since both of my opponents were absent that day, none of the members of my defence committee had read through my thesis (although in retrospect I believe one of the members might have read through it on his own initiative, but it’s impossible to know for sure).

He also tells me that I should begin the defence by summarising my thesis in 10 sentences, “of which the first four should be especially good”, and that they’d just ask a few questions and that would be that. I’m glad he told me that, so I at least had a few minutes to mentally prepare some sentences before going in. Eventually, after some delay, it’s my turn.

The defence

They invite me into the library, and ask me to take a seat at the table in front of the three committee members. They are, in no particular order: prof. József Zsimmer, prof. László Czopf, and prof. Imre Szabó. They begin by asking me to briefly summarise the topic of my thesis. I intended to make it 10 sentences but I think it ended up lasting 3 – 4 minutes instead. Some of the questions they followed up with which I remember were:

• What are the main suggestions regarding diet in Crohn disease? (For example exclusion of certain dietary factors like gluten, milk protein, alcohol)
• Do you think that there are any differences between the different stages or extents of the disease regarding these factors in the diet? (Most likely the localisation, severity and type of CD could influence the dietary treatment)
• If there is a patient with fistulising disease and no large bowel affection, what would be your suggestion about the diet? (Here I think I answered that they should avoid dietary fibre, but only because I misheard him so I thought he said stricturing disease, in which case dietary fibre avoidance is correct, but I don’t know what he was going for with this question)
• If you advise dietary restriction to a patient, which by evidence decreases the microbiome diversity, which is potentially harmful, what are the possible correlations with Crohn disease? Are there any evidences or is it too early to talk about? (I think I replied that it’s too early to know, and that during my thesis work I only found evidence of short-term changes in microbiome following dietary modifications in Crohn disease)
• If you analyse a Crohn disease patient for other parallell disorders like food allergies or intolerances, would it change the approach? Do you think these restriction diets work in some cases but not in general because of these comorbidities and not necessarily because of the Crohn disease itself? (I think I answered that yes, that could be a possibility)
• Do you have any data on detailed analysis of the microbiome in Crohn disease patients? (Yes I do, there is a section in my thesis about it. Analysis shows that in general CD patients have less microbiological diversity, lower absolute number of microbes, decreased proportion of “good” gut bacteria and increased proportion of “bad” gut bacteria)
• What is the risk factor if you decrease the microbiome diversity in an autoimmune disease like Crohn disease? Because these restriction diets will decrease the diversity. (I replied that I haven’t seen any studies on whether restriction diets affect the microbiome diversity and whether it has any negative effects on the activity of Crohn disease)
• Do you know of any gastrointestinal diseases which can benefit from modifying the microbiome? (I didn’t know what to answer to this. I only replied small bowel bacterial overgrowth, I think)
• If you would investigate the diet in case of Crohn disease, which approach or direction would seem to be the most feasible for you? (I’m not sure I understood his question correctly, but I think I answered that we could use food questionnaires or asking patients to write down what they eat)
• Do Crohn disease patients have different nutrition than healthy people? (Yes, it’s covered by my thesis that CD patients often avoid foods which they feel make their symptoms worse. They often avoid healthy foods and eat unhealthy foods like soda and snacks)
• Do you consider this to be related to the easier absorption of sugar from these foods? (Yes, that could be an explanation, considering the possibility of malabsorption in CD)

The last line of questioning was the most memorable one:

• Committee member: Based on the results of your thesis, what would be your suggestion to a patient with Crohn disease regarding diet?
• Me: Based on what I’ve read, I’d recommend patients to experiment with their diet, so they could for example exclude one food group from their diet, and—
• C: Based on what? Their relief of symptoms?
• M: Relief of symptoms may be one measure, other could be for example changes in blood tests like CRP level—
• C: Based on CRP you would suggest food diet restriction?
• M: No, just—
• C: This is restriction. If you tell the patient to not eat something, it’s restriction. It can be harmful. You would suggest, without evidence, for the patient to do that?
• M: If they’re interested in trying an approach which is not yet evidence-based, then I would suggest them to restrict certain food groups—
• C: Based on what?
• M: Based on the little evidence that is already present, for example the CD-TREAT diet which I mention in the thesis, which avoids alcohol, lactose-containing milk products and gluten, and these patients have shown good results in inducing remission. So this is—
• C: But that’s not true!
• I’m stunned into silence at this point.
• C: Alcohol okay because it’s harmful, in general we should suggest to avoid it. But you would ask your patient to do a restriction diet, which can be harmful because we know that if you decrease microbiome diversity that’s not a good thing, even without evidence. You should be aware about what you suggest. It can be dangerous. You can not restrict diet if it’s harmful, okay? You can suggest a lot of things, but you’re going to be a medical doctor so you should follow the evidence.

The last line of questioning really took me aback. I don’t know of the evidence that restricting certain food groups can be dangerous like he was talking about, and he obviously wasn’t aware of the studies I was talking about. I suppose vegans, vegetarians, coeliac disease, and lactose intolerance patients worldwide are living dangerously.

Following this, the committee leader thanks me for the presentation and “especially for your work”, which he said he thought was very nice and opens a window into a new area of IBD research. That was very nice of him to say.

Then they started discussing the grade. They check my opponents’ evaluations (both 5), and the leader of the committee suggests 5 as well and asks if the others agree. The member who held the last line of questioning replied that he would give “maximum a 4, maybe even a 3”, but luckily for me the other two members suggested 5 and majority rules. In total, the whole defence took approximately 15 minutes.

And that’s all I have to say about that.

So I had paediatrics final on the 3rd. We got no information on email ahead of the exam, but the time of the exam was 8:30 according to Neptun. I’d heard from other students who had the exam that I should show up at the southernmost part of the main corridor of the main building, close to where the library is. Because I’m an idiot I arrived a bit late, so I wasn’t among the first 3 students to be taken in. After the first student was done with their exam, I entered the room to draw topics and prepare.

The examiner that day was prof. Décsi, and the co-examiner was a young male doctor whose name I don’t know. After each student picked their topics, the professor allowed the co-examiner to choose one of the three topics to examine by himself.

My topics were:

• 15. Disorders of the humoral immune system
• 24. Hepatomegaly. Causes, diagnosis, differential diagnosis
• 15. Most common congenital heart abnormalities not causing cyanosis

The co-examiner chose the hepatomegaly topic to examine me in, and the professor asked me which topic I wanted to start with. I chose the immune system one.

15. Disorders of the humoral immune system

I began by telling him what I’d written down. He then begins asking me questions.

• Examiner: You mentioned the repeated and severe infections as a symptom of these disorders. What other symptoms may draw your intention to a disorder of the immune system?
• Me: So these disorders could also increase the risk of autoimmune diseases
• E: Yes. (But clearly not what he was going for) In a young child what kind of frequently occuring problem may call your attention to a potential immune disorder.
• M: (Not sure) Frequent urinary tract infection?
• E: Yes. (also not what he was going for) And what’s not far from this problem? Which is actually a manifestation of bacterial presence?
• M: Uhm, sepsis?
• E: No, in the end of course but not was I meant.
• M: Pyelonephritis?
• E: Pyelonephritis is also a urinary tract infection. What other tract can be infected and give very specific and easily detected symptoms.
• M: Gastrointestinal infections?
• E: Yes, and what will you see?
• M: Bloody stool. (Was thinking of bacterial gastroenteritis)
• E: Yes but mostly just diarrhoea. Frequent and unexplained diarrhoea. And, if the child has repeated infection and diarrhoea, then what other functions of the child will be disturbed?
• M: Growth?
• E: Oh yes. These are the three major symptoms. Next question: If a child has selective IgA deficiency like you mentioned, the diagnostic of which diseases can be complicated by this?
• M: Oh, well that’s a difficult question.
• E: Oh well yes. Up until now you did well so I increase the complexity of my questions. So where do we use IgA in the diagnosis?
• I was thinking hard on this one. For some reason coeliac disease popped into my mind, but I wasn’t confident enough to say it.
• E: It’s no problem if you can’t answer this.
• I gave it some more thought but couldn’t come up with an answer.
• M: I’m not sure.
• E: It’s coeliac disease. (Damn it! I should trust my gut.) If the patient has IgA deficiency, they will not have high levels of the antibodies we use to diagnose coeliac disease. No problem. Next topic.

15. Most common congenital heart abnormalities not causing cyanosis

Once again I began by telling him what I’d written down about ASD. I start to list symptoms of heart failure as I explain symptomatic ASD, and I mention hepatomegaly, poor growth, dyspnoea, sweating, problems with feeding. He then interrupts me with a question:

• Examiner: What is the first sign of cardiac decompensation, before the symptoms you mentioned.
• Me: Oedema?
• E: Before oedema.
• Thinking
• E: How does the heart try to compensate?
• M: Tachycardia.
• E: Oh yes. Please continue

I continue with VSD and the rest of what I wrote down, and he has no questions after this. I continue with my last topic, at which point I turn to the co-examiner (as this was the topic he chose to examine me on).

24. Hepatomegaly. Causes, diagnosis, differential diagnosis

I begin by listing the possible causes. I then continue like this:

• Me: So in the evaluation of hepatomegaly physical examination is important. In newborns it can be physiological that the liver can be palpated 1 – 2 cm below the costal arch, but in older children you shouldn’t be able to palpate the liver that well. Ultrasound is important in accurate estimation of the size of the liver, but for proper differential diagnosis it’s not enough to only look at the liver, we must look for other features of the disease like jaundice in hepatitis, in mononucleosis you’d have cervical lymphadenopathy, in leukaemia there’d by symptoms of bone marrow failure and splenomegaly. And.. Uhm, yeah, that’s all I had prepared.
• Co-examiner: Okay, so. Hmm. He turns to the professor and says: I think he said everything, I don’t have any questions.
• Examiner: Okay, then let me ask a question. Please give me some special causes of young infant or neonatal hepatomegaly. What is the usual size of the liver at the age of 1 month?
• Oh no, is he expecting a size in centimetres? I don’t know and I’m afraid of guessing because I might be so far off. As I’m thinking about this, he continues:
• E: Is there some difference in the evaluation of liver size below or above one year of age?
• Now this is a common problem of oral exams. I feel like he’s after the fact that the liver can be physiologically palpated in infants, but I already said that in the beginning of the topic. Did he not hear me? Or is he after something else? I’m not sure, but I assume the former.
• M: So, compared to the body size, the liver is larger in infants than in older children.
• E: Yes. Also, the diaphragm is lower. So, during the first year of life, if you palpate the liver 2 cm under the costal arch then it can be physiological.
• I was right, he didn’t catch it when I said it the first time.
• E: Let’s say you have a one month old child with a liver palpateable 4 cm below the costal arch. What might be the cause?
• M: Something like biliary atresia?
• E: Yes, what other features of this biliary atresia can you see or detect during the physical examination?
• M: They would have jaundice.
• E: What type of jaundice?
• I don’t know of multiple types of jaundice, so I assume he means indirect/direct hyperbilirubinaemia?
• M: They would have direct hyperbilirubinaemia.
• E: Yes, and with your eyes, what can you see on the patient? What will be the colour of the skin?
• Now this is kind of a lucky coincidence, because I learned the answer to this exact thing during my paeds practice here in Pécs. Apparently (and allegedly), direct hyperbilirubinaemia causes a more greenish jaundice than the “usual” indirect hyperbilirubinaemia. This isn’t something I’ve heard of anywhere else, and internet search doesn’t reveal more than a few papers about it. However, as he asked this question I was pretty certain that that was the answer he was looking for.
• M: It will be more greenish.
• E: Yes, excellent. It’s a 5.

Conclusion

My exam took about 10 minutes. Neither examiner interrupted me often while I was presenting my topic, and if they did it was usually just to say “yes” or “good” now and then, which was nice. I also think it was nice of the professor to allow the co-examiner to practice examination like this. As they say, it sucks to study for paeds but the exam is quite nice. It was a good experience.

I have my thesis defence on March 11th, and neuro on April 7th. Until then, I’ll be playing Elden ring.

Hei! Så hyggelig at du ville sjekke hva prosjektet mitt innebærer. Artiklene jeg har skrevet er sortert etter fag, som igjen er sortert etter studieår. Hvis du vil se på noen av dem kan du for eksempel ta en titt på artikkelen om antikoagulantia og antitrombotiske midler i farmakologi, artikkelen om O2 og CO2 transport i kroppen i fysiologi, artikkelen om intrauterin veksthemming i fødselsmedisin, artikkelen om akutt appendisitt i kirurgi, eller artikkelen om akutt koronarsykdom i indremedisin. Hvis du har lyst til å se litt statistikk om hvem og hvor mange som besøker nettsiden kan du se på det her.

Med vennlig hilsen Nikolas

PS. For my non-Norwegian-speaking visitors, this post warrants explaination. After finishing medical school as a Norwegian, before applying for residency in a specialisation, one must complete 18 months of medical “internship” in internal medicine, surgery, and general practice, called LIS1. The application period for LIS1 is now, and I mentioned this website on my application, so I figured I’d give all potential employers a proper welcome.

UPDATE: I did not get a spot for LIS1. I’ll have to apply again the next round, which is half a year after the first round.

So I had obgyn final on the 18th and psych final on the 19th.

Obstetrics and gynaecology final

We got an e-mail the day before that the exam would start at 9. The examiner was Péter Gőcze. We drew four topics, two from ob and two from gyn, and sat down to prepare. I drew good topics, in my opinion. These are the questions I was asked.

10. Placenta praevia

I began by telling him everything I’d written down. He then begins asking questions.

• Examiner: When a patient arrives outpatient clinic with a bleeding in the second half of pregnancy, not a heavy bleeding, and you perform ultrasound and diagnose placenta praevia centralis. The patient is around 30 weeks of gestation. What can you do?
• Me: 🤷‍♂️ (What can you do? There isn’t really anything we can do to treat placenta praevia, right?)
• M: I think we would just call the patient back later to see if it resolves spontaneously, but if it doesn’t, we should plan an elective C-section.
• E: But the bleeding is not severe (I feel like I didn’t really understand what I said here). What can we do?
• M: I stop and think for a moment because I have no idea. I go with a far-fetched idea.
• M: Maybe we could give tranexamic acid to decrease the bleeding?
• E: No, no. Something else. Sometimes contractions can cause bleeding. (What?)
• M: Then maybe we can give something to decrease contractions, like atosiban?
• E: That’s right. Let’s say the woman is 29 weeks of gestation, what can you give to prevent the very common problem of premature newborns?
• M: Steroids to induce lung maturation.
• E: That’s right. And also, you have to store blood in the institute which is compatible with the mother, because if the patient has heavy bleeding you have to perform an urgent operation, and may need transfusion. It’s very important to have blood available.
• (It makes sense, I just thought that that was something which was always available, not that you’d have to proactively find and store it)
• E: What do you think, what is the relatively common problem if the patient has a heavy bleeding?
• M: So if the bleeding is severe enough it can compromise the circulation of the foetus as well, causing perinatal asphyxia.
• E: Yeah, and?
• M: It can also cause DIC in the mother.
• E: That’s right. What can you do in case of the DIC?
• M: It’s important to replace the clotting factors which are lost.
• E: How can you do that?
• M: It’s also a transfusion (I forgot exactly which blood product we use)
• E: Yeah but which?
• M: (I say the first that comes to mind) Prothrombin complex?
• E: No.
• M: Fresh frozen plasma?
• E: Yes. Previously a lot of women died because of this. The problem is that we don’t know which phase DIC is in, and this is why the best way is to use fresh frozen plasma because it contains all types of factors. And blood. Fresh frozen plasma and blood, this is the best method to treat DIC.
• E: Okay. What is your next topic?

20. Cervical incompetence; Etiology, diagnosis, therapy

Once again I begin by telling him what I’d written down.

• E: What is very important to do before performing cerclage? What must we always do?
• M: Once again I have no idea
• M: We should supplement progesterone? Said in a tone of absolute doubt
• E: No.
• M: Thinking
• E: If we don’t do it, we can get premature rupture of the membranes
• M: So we have to rule out infection?
• E: That’s right. It’s obligatory to make a culture. Only if the culture is sterile can we do a cervical cerclage.
• E: What kind of other procedure can you do to treat cervical incompetence before pregnancy?
• M: I’m pretty sure I’ve never heard of any such procedure. The only other thing I’ve read about which can treat cervical incompetence is progesterone supplement, so..
• M: You can give progesterone supplement?
• E: No, not that. There’s a surgical procedure which you can do.
• He turns toward the other students in the room and asks them whether they’ve heard about it. No one responds. Eventually he gets up, walks toward a whiteboard in the room, and starts drawing and explaining.
• E: So you cut out a piece of the anterior wall of the cervix, then you suture it. This forms a scar. It’s usually the anterior part of the cervix which is weak, and this strengthens it. It’s very effective but you can only do it before the pregnancy. During the pregnancy, the only option is cerclage, like you mentioned.
• E: Okay. What is your next question?

3. Indications and methods of hysterectomy

Once again I begin by telling him what I’d written down (except the part about trachelectomy).

• E: Do we always have to remove the cervix, or not?
• M: Uhm…
• E: Consider a young woman. You should know that after a total hysterectomy the vaginal prolapse can happen because of damage to the ligaments holding the vagina. And this is why we in young women often use the Chrobak operation. Have you heard about it?
• M: No I have not.
• Once again he asks the other students. No one responds.
• E: Yeah, it’s when the cervix remains in place and we just remove the body of the uterus. It can be useful because the sexual function of the woman remains normal and prolapse of the vagina can be prevented.
• Okay, so it’s just subtotal hysterectomy. Thanks for not just saying that.
• E: Okay. Next question.

13. The criteria and potential complications of IUD

I kept this for last because I didn’t actually know that many criteria and complications. I told him what I’d written down.

• E: Do you know the name of the IUD which contains progestins?
• M: Well I know the name of those used in Norway, but I don’t know if they have the same name in Hungary. Mirena and Kyleena?
• E: That’s right. What’s the indication of the Mirena? Why is it so popular? We can use not just for contraception, after all.
• M: For endometriosis as well.
• E: Yes, very good. And?
• Here I kind of blank out. I knew of other indications for hormonal IUD but I just couldn’t recall any
• E: Endometrial hyperplasia, for example. During menopause, as the progestin component. And dysmenorrhoea.
• M: Yeah, of course.
• E: Okay. I think it was good, but not excellent.

Finishing thoughts

So that was it. I got a 4 in the end. The exam took like 20 minutes.

I don’t think he mentioned the name of the pre-pregnancy operation for cervical incompetence, and I’ve searched for it but found nothing. We never had a lecture or seminar on cervical incompetence, so how would I know about this?

According to a helpful commenter, this is apparently “isthmorrhaphy“, which, from what I can find, is not exactly popular.

Regarding the “Chrobak operation”, from what I can find it looks like this term is almost never used (subtotal hysterectomy instead). Also, we never had a lecture or seminar on this topic either.

Regarding screening patients for infection before cerclage, this appears to be controversial, and UpToDate states that there is insufficient evidence to support that preprocedure culture improves outcomes.

So I’ve spent a lot of time and resources writing notes for this. I’ve used many sources, including lectures, UpToDate, and the Norwegian guidelines for obstetrics and gynaecology. When I spend so much time and effort studying something, and end up not being able to answer questions on the exam because certain things were never taught to us, is basically unfindable in other sources, or not evidence-based, it makes me disappointed and annoyed. But anyway, I’m glad I’m done.

Psychiatry final

We got the email from Tényi the day before the exam that we would start at 7:00. We show up, both 6th year students and 5th year students from all three programmes. Luckily, he deliberately allowed the 6th year students to have the exam first.

There’s not to much to say about the exam. During the practice you write two patient case reports. In the exam he asked me what the two diagnoses were (schizophrenia and anorexia nervosa), and he asked me to explain a bit about the anorexia case, which I did. I realise in hindsight that I spoke mostly about my impressions around the case rather than stuff directly related to psychiatry, but it was fine. He then started asking the usual rapid-fire questions, beginning with questions related to anorexia and eating disorders, before turning to other questions.

I answered all questions correctly, except that I forgot narcissistic personality disorder when listing the cluster B ones, but it was fine. I got a 5 in the end, and the exam took like maybe 5 – 10 minutes? It was a nice experience.

Next up

I begin my paediatrics practice in Pécs on Monday, which will be my only practice in Pécs (except for 1 week of internal medicince, as I could only do 7 weeks in Norway). Paeds is my next exam, but luckily that’s some weeks away still, so I can take it easier for a while.

I just finished the last of the ob/gyn 1 topics. I already wrote ob/gyn 2 notes last semester, so now I’ve covered both semester’s topics. The topics in the ob/gyn final in 6th year are the same.

My ob/gyn exam is on the 18th, up until then I might still revise the notes as I read through them.

So my thesis is (almost?) done, and I’ve decided to share it along with some general information and recommendations regarding thesis work. You can find it in the sidebar.

I had the final exam in surgery-traumatology on the 28th of October (13:00). Me and another student waited outside the room which was written on Neptun (5th floor of 400 bed, to the right when you exit the elevator. Eventually the examiner fetches us into the seminar room (the same where trauma/surgery seminars took place). We draw topics, one from each of three envelopes, and are given time to prepare if we wanted.

There are separate examiners for the surgery part and the traumatology part. There’s no patient examination. While I had my surgery topics, the other student had her traumatology topics. The surgery examiner was Dr. András Papp. I did not catch the name of the trauma examiner.

After a few minutes of preparing, the examiner asked me whether I would like to start without preparation time to get over with it, and I was like “why not”. I believe I remember most of their questions, so here they are.

A12: Abdominal ischemia

• Me: We can distinguish ischaemia of the large bowels and the small bowels
• Examiner: What is the blood supply of the small bowels?
• [damn anatomy]
• M: The coeliac trunk, SMA, and IMA?
• E: And the large bowel?
• M: The IMA, and the superior rectal?
• E: Nononono, the SMA and the IMA. What is the border between the two systems?
• M: The ligament of Treitz?
• E: Yeah. The median colic artery comes from the SMA but the left sided colic arteries come from the IMA. What are the symptoms if the patient has abdominal ischaemia?
• M: Severe abdominal pain, which ..
• E: At all time?
• M: Not always, but if it’s acute, then ..
• E: It’s always acute. Can you tell me the symptoms when it starts and as it’s going on, what starts to happen?
• [I had no idea what he’s going for here]
• M: It kind of depends on the etiology, if there is an embolism there’s a sudden, out-of-nowhere severe abdominal pain, which they say is “out of proportion to the physical findings”.
• E: Okay. And?
• M: They can also have haematochezia
• E: They can, yes. Is the pain constant?
• M: It gets more and more severe
• E: And then?
• M: Uhm..
• E: And then there’s no pain. After a while it starts again, and keeps going until death.
• M: Okay, I didn’t know that
• E: It’s really characteristic. The pain at first is really high, and then it gets better for a few hours, and when it becomes necrotic and reaches the point of no return the pain progresses again. What can you do when there is abdominal ischaemia of the small bowel but it’s only a few cm of the jejunum involved?
• M: You can surgically remove the necrotic part?
• E: Yeah. And then? What is very important in this operation? Can we do the resection and the anastomosis and the patient can go home?
• [no idea]
• M: We should also look for the cause of the ischaemia. We can do some interventional radiological methods like thrombolysis or thrombectomy to remove it.
• E: Thrombectomy is not radiological, it’s surgical. Yeah, we can do that also. We can also do a resection. But what I wanted was that the patient often needs a so-called “second look” operation, where we check again whether there is other necrotic parts.

That was the end of this topic. I got a 4 on it.

B34: Perianal abscesses and fistulae. Surgical management of hemorrhoids.

• M: Okay so perianal abscess is often primary, so there’s some clogging of the perianal glands which causes a subdermic [yes I said subdermic] abscess that’s visible as a bulging out of the skin which is red and very painful, especially during defecation.
• E: And what is the temperature of the patient?
• M: The patient has fever as well.
• E: Yes
• M: And there may be an internal fistula as well, from the anal canal to the abscess
• E: Yeah they almost always go together. We can say that an abscess is an incomplete fistula. In what kind of disease can we frequently find fistulas?
• M: Crohn’s disease
• E: Yes. What is Crohn’s disease?
• [this question is made for me]
• M: It’s one of the two inflammatory bowel diseases where we can have inflammation of the whole GI tract, most commonly the terminal ileum.
• E: Yes. What are the surgical treatments of Crohn’s disease?
• M: It’s mostly used for adhesions and in severe cases you might have to remove bowel which is inflamed and doesn’t respond to medical therapy.
• E: Yes. What is the big difference between the surgical treatment of Crohn’s and ulcerative colitis?
• M: For ulcerative colitis total colectomy is curative, but there’s no curative surgery for Crohn’s. Treatment for Crohn’s is mostly non-surgical.
• E: Yes, and if we need it we resect only the part which is inflamed.
• M: Yeah
• E: Okay. Surgical treatment of haemorrhoids
• M: So we classify internal haemorrhoids as 1, 2, 3, or 4, which …
• E: What does the grade 4 mean?
• M: It means that it’s not possible to retract it.
• E: Yes, so it’s an absolute indication for surgery
• M: Yes. So surgery is indicated for grade 4 and I think grade 3 as well
• E: Yes.
• M: The others are treated mostly conservatively. There are many options for surgical treatment, like sclerotherapy, banding, haemorrhoidectomy …
• E: What is actually a haemorrhoid?
• M: Haemorrhoids are pouches or pillows of dilated veins
• E: Yes, so it’s actually normal, but if they cause symptoms then it’s a problem. Okay, one more question for the 5. What is the Dixon operation?
• M: [after thinking] I don’t remember
• E: Okay, it’s an anterior resection of the rectum with a primary anastomosis.

This was also a 4.

B7: Foot fractures and dislocations. Achilles-tendon injuries.

• I was given some extra time to prepare for the trauma topic. After a few minutes the trauma examiner asks me if I’m ready
• M: I think I’m okay with achilles tendon injuries, but I find foot fractures and dislocations a bit difficult, but we can start.
• E: Actually I think the achilles tendon injuries are the most important anyway. So you can start with this
• M: Okay. So the achilles tendon is the largest tendon and injury of it is common in sports
• E: Which types of sport?
• M: For example sports where you have rapid turning and acceleration, like basketball, football, sprinting, volleyball, etc.
• E: Yes
• M: The patient often feels like someone “kicks” them at the tendon when it snaps. And they lose the plantarflexion, which we can examine with the Thompson test.
• E: What is the Thompson test?
• M: It’s when you have the patient prone, you compress the calf, and you see whether the foot is plantarflexing or not. If it doesn’t, it indicates achilles tendon injury.
• E: Yes
• M: So it’s controversial whether it should be treated surgically or conservatively …
• E: Actually let’s talk about diagnosis. Which modality is good?
• M: Ultrasound, or MRI.
• E: Yes. Usually the ultrasound is enough.
• M: You can also palpate a gap in the tendon itself
• E: Yes. So treatment?
• M: So like I said, it’s kind of controversial whether surgical or conservative is the best.
• E: What do you think, which is better?
• [he’s a surgeon so the answer is obvious]
• M: I think surgery
• E: Yes
• M: Yes, probably because the recovery is quicker. It involves repairing the tendon, sometimes you might need a graft.
• E: If the injury is fresh then you can just suture it. What can we do after the surgery?
• M: Proper rehabilitation is important
• E: Yes, very important. In which position is the rehabilitation?
• M: What do you mean by which position?
• E: Like, which leg position.
• [guessing time]
• M: In plantarflexion
• E: Yes, usually in the first 3 weeks. And after that?
• [no idea]
• M: Probably mobilisation and physiotherapy?
• E: Yes, but in which position?
• [guessing time 2]
• M: Dorsiflexion?
• E: Yes. And after 6 weeks?
• [I’d run out of ankle positions so idk]
• M: I’m not sure
• E: After 6 weeks the patient can take off the brace and start to walk. Okay, please give me some words from the foot fractures.
• M: Okay, so the most common is the talus and calcaneus fracture.
• E: Okay, yeah [hesitating a bit]
• [instant anxiety due to the examiner’s hesitation]
• M: They can be due to high energy trauma like car accident, or falling from a height. So they can sometimes be bilateral. There is local pain, and there can be plantar ecchymosis.
• E: What can you see if somebody has foot fractures?
• M: You could see a deformity of the foot, and the patient cannot walk on it.
• E: Perhaps a haematoma?
• M: Yes, and swelling.
• E: Okay. Diagnosis?
• M: X-ray, maybe sometimes CT as well.
• E: Okay. Could you tell me something about the toe fracture? I think those are more frequent fractures.
• M: There are some named fractures, I’m trying to remember. Is Jones fracture on of them?
• E: No, Jones is a 5th metatarsal fracture. Tell me about the toe fractures.
• [I’d thought that toe fractures include metatarsal fractures but apparently not]
• M: So they can be due to direct trauma. The patient will experience pain, difficulty walking …
• E: And the treatment?
• [idk]
• M: I would say it probably depends on if there’s dislocation or not and how severe the fracture is. If not dislocated and not severe then we can do conservative, if not then maybe we need surgery.
• E: Actually only when the 1st toe is dislocated is when we use the surgery. In other cases it’s conservative, no matter the dislocation.

And that was it. 4 here as well.

Done

So that was it, a 4 in total. It took probably 10 – 15 minutes excluding prep time. They both had calm, non-confrontational voices, and at no point did I feel like I was close to failing, which was nice.

I’m still annoyed, though. Most questions were simple and straightforward, but some were explained as a single sentence in a single presentation in one of the three surgery subjects we’ve had (second-look operation), hidden among a wall of text on lecture (characteristic pattern of mesenteric ischaemia), or never written in lectures at all (the position and timing of casting after achilles tendon rupture, fractures of the toes). I’m annoyed because I put so much time and effort and went through so much stress to prepare for this and write notes, only to have an exam which was relatively non-difficult but still being asked questions I could probably never be prepared for. But that’s not new here, unfortunately.

I’ve added a changelog page, where a list of the 30 most recently added or modified topics are listed. Hopefully this makes it easier to keep up with changes.

You can find the link to the changelog in the sidebar.

I finished the 5th year “what to study” post.

The password module is acting up, causing some problems, in some cases giving an “incorrect password” error message even though the password is correct. To work around this, try to access another password-protected page and enter the password there. It should work, and from then on the password-protected pages should remain unlocked for 30 days.