Dialogue with Dr. Josh

Because this is the Web you can't have a personal conversation with Dr. Josh (until you call!), so here's a substitute, a dialogue with him about how he started tutoring and some of his ideas about the USMLE exam:

Q. Why do we have the U.S.M.L.E. III Examination for Licensure?  

As a colleague of mine once said, “To see if one is a safe doc!” 


Q. When did you begin tutoring for U.S.M.L.E. III? 

 While serving as a Med/Psych Consultant, 


Q. Who exactly needed your tutoring? 

 International medical graduates in their residency 


Q. Was English their first language? 



 Q. What languages did they speak? 

 Arabic and Hindi 


 Q. Did they hail from emerging nations? 



 have you lived in an emerging nation? If so which? 

 Yes, the Republic of Korea 


 Have you learned to be socially polite in various languages? 



 Q. How do your students comment on U.S.M.L.E. III? 

The psychiatry residents say, “Too much Med Surg!” 

 and the Med Surg residents say‚Ķ 

 “Way too much Psychiatry!”  


 Q. Is the USMLE III a general examination? 

 Reasonably so 


 Q. could you give a few sample questions and answers?  

SURE: Here they are!



Q: What is your first diagnosis in a woman of childbearing age with  abrupt onset of abdominal pain?  A: ruptured ectopic pregnancy



Q: What is the most fatal neuropsychiatric condition? A: Anorexia nervosa 



Q: Given A 12-year-old boy, thyroid deficient from birth,  what will happen to the deciduous teeth when he is given thyroid replacement?  A: His deciduous teeth (“baby teeth”) will fall out all at once!  Q: Why? A: Shedding baby teeth is a developmental milestone. All will go reasonably well if the child and his parents are fully informed of what will probably happen!  



Q: Given a 70-year-old woman with headache and vision loss in one eye, your diagnosis is __________ and she needs -------------.  A.  Temporal (Giant Cell) Arteritis. In conjunction with ophthalmology she will probably need pharmacologic “high dose,” steroids “oral prednisone,” as well as a reasonably timely temporal artery biopsy to endeavor to prevent blindness.



Q:  Is acute appendicitis a difficult diagnosis to make in a 90-year-old man?  A:  Yes!



Q: What might well be the “ ClassicLandmark Cases?” A:           Quinlan, Saihewicz, Dinnerstein, Cruzan, Tarasoff.


Q:  Please summarize them: 

A: Quinlan, Karen Ann: The Supreme Court of the State of New Jersey {on or about 1978} ordered discontinuation of her ventilator as, “Extraordinary in her Persistent-Vegetative-State.In this matter the Judge endorsed, “Such matters should be discussed with the Hospital Ethics Committees;” and in so doing, the Quinlan-Matter Judge created our concept of Hospital Ethics Committees.


A. Saihewicz: A 60-year-old man with his Mental Age of 18 months, found to have leukemia. The Supreme Court of the State of Massachusetts (on or about 1980)– on the basis of a guardian ad litem –ordered that, “It was not in Mister Saihewicz’s best interests to receive chemotherapy for leukemia! 


A. Dinnerstein: An elderly woman with, “Alzheimer’s and multiple strokes,” The Supreme Court of the State of Massachusetts (on or about 1980) ordered that her Do Not Resuscitate order is  “Peculiarly the responsibility of her doctors bounded only by the limits of medical malpractice.


A. Cruzan, Nancy Beth: (Perhaps somewhat similar to Cruzan) The Supreme Court of the State of Missouri (on or about 1990) ordered, “Withdrawal of extraordinary means of her life support as she had previously indicated in writing and told her friends that she did not wish to be maintained in a Persistent Vegetative State"  This provided us with our current contemporary living will concept.


A.Tarasoff, Tatiana: She broke-up with her former boyfriend after accepting a sari that he viewed as his betrothal gift; thereafter (as he told his therapist he would) he stalked and killed her. The Court held, “Duty to warn the identified patient would appear to override the Privacy Act;” i.e. planned spousal abuse, planned child endangerment, etcetera is reportable by the therapist to legal authorities. There may well be therapists who insist that their prospective patients sign their acknowledgment of this particular legal obligation of the therapist prior to and before the beginning of their psychotherapy.


Q. Do you work primarily with your students over the telephone? 


Yes, we work a lot on the phone.  In addition, my students are always and uniformly encouraged to come study in my Johnson City office. 

Q. Do you have any additional recommendations that your students have found helpful?

1.  Take Basic Cardiac Life Support (BCLS) and Advanced Cardiac Life Support (ACLS) as these will give the students practice in taking tests. 

2.  As USMLE Step 3 is a general examination, students are encouraged to attend Grand Rounds (physician-didactic teaching) in the fields of Family Medicine, Surgery, Psychiatry, and OB-GYN. 


3.  Obtain as much clinical exposure to patients as they can. For example if the student is working as a radiology resident, the student is encouraged to speak directly to the identified patient for whom the imaging study (X-Ray) has been requested. If the student is working as a cardiac ultrasound (echocardiogram) tech, the student is encouraged to ask the patient why the test has been ordered and further encouraged to listen to the heart of the identified patient.  


4.  Read Images in Clinical Medicine in The New England Journal of Medicine each week, as I do, that will provide some fifty words to read along with an image that might be, for example, a chest x-ray or a Magnetic Resonance Imaging (MRI) of the head, or a standard electrocardiographic rhythm strip.