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Jefferson Medical College Alpha Omega Alpha Guide to the Second Year

FCM: Foundations of Clinical Medicine

This course begins after Thanksgiving break and runs through the end of the year. It integrates clinical medicine, pathology, pharmacology, and physical diagnosis. The material in this course is dense and it is one of the more rigorous classes Jefferson has to offer. A great overall attitude to take when approaching this material is to take the time to understand the material, not just memorize. Each topic, section and system build on each other and the course prepares you very well for the boards. Really try and master the material presented to you in the next 6 months because through this course you will gain the core knowledge that will guide you through Step 1, your clinical clerkships and your entire medical career.

RESOURCES - The Standard Set of Material

  1. Syllabus and Lecture Material
    These are key. Remember that all of the questions on the exams will come directly from the syllabus and lectures (both things the professors have said and what is found in their powerpoint slides). Make sure you use the syllabus and your lecture notes as your PRIMARY resource and learn them well.
  2. Pathology Text - Rubin's Pathology
    This is the textbook from which all of the pathology images, notes and lectures are derived. This text can be cumbersome but ultimately understanding the pathology is key to developing your understanding of a disease process. You are not expected to read this cover-to-cover but it is a great resource. It is a big, bulky textbook and as a Jefferson student you will have free access to it online (via The Point) and in the library (in print).
  3. Lippincott's Review of Pathology by Rubin/Fenderson
    This is a review book written by our own Dr. Bruce Fenderson and is a great resource to test yourself at the end of each section. It is easy to read with many good questions that simulate the FCM exam experience and each question is followed by in depth answer explanations. Check online for free access.
  4. Pharmacology Text - Lange Clinical and Basic Pharmacology
    Generally the syllabus is well thought out and organized and not many students use this. It can be used for topics that you are having trouble working through.
  5. Physical Diagnosis
    You will be given a written syllabus from the Bergs. It is very thorough and all of their exam questions are derived from the given material.

RESOURCES - REVIEW BOOKS (The Extra Help You Might Need)

Disclaimer: The following resources are Step 1 study guides and by no means are they required. Ultimately, you are only responsible for the material presented in class. However, it has been found by previous students that these resources can help to augment and clarify your understanding of complex topics. Most students will pick First Aid and some will also choose a pathology and a physiology review book to have around during FCM. Do NOT get yourself involved in too many review books as they can get overwhelming. Looking through a few and deciding on one per section will serve you well.

  1. BRS Pathology
    This is a great resource and one of the two (along with Rapid Review) most popular pathology review books that students use for Step 1 prep. It is concise but hits on all of the key facts. As it is based off of Rubin's text, it follows the same outline and uses the same images.
  2. Rapid Review Pathology (by Edward Goljan)
    This is a favorite among the Jefferson classes. The book is easy to read, has great pictures and truly takes you through the pathophysiology of disease processes. Most students would highly recommend this as a part of your augmented resources. It is longer and goes into more depth than BRS Pathology (often discussing diagnostic testing and treatment), so look at both books and choose the one that fits you best. In addition, Goljan has an audio lecture set that many students recommend. Feel free to email any 3rd or 4th year student to help you get a copy of the lectures.
  3. BRS Physiology
    This is another favorite among the BRS group of resources and most students find it essential for board prep. It is a very helpful text because each section quickly reminds you of how each system functions. This is key to understanding how things become disordered.
  4. First Aid for the USMLE Step 1
    This is another favorite book to have around during FCM and will be your primary resource to use during board studying. Do not stress about the boards right now and remember that studying hard for FCM is your main goal and that alone will help prepare you for the boards. However, using this book now will help you organize your study material later and give you another way of looking at the material. If desired, a useful approach would be to briefly look through the associated First Aid systems section(s) for each FCM block for helpful learning mnemonics and to better conceptualize topics that are the most high yield. Most students will glance at the sections before and during the block, taking notes in the margins when they begin to understand the topics of the section. However, this is absolutely optional and by no means necessary to succeed in the FCM coursework. That being said, it can help you familiarize yourself with this important resource for later board studying.
  5. First Aid for the USMLE Step 1 CASES
    This is the companion book to First Aid and may help those who enjoy learning via cases and practice questions. It focuses on some of the key disease pathologies and the questions are structured similarly to the exam questions.
  6. BRS Pharmacology
    Similar to the other BRS family of books. Broken down into sections and can be used as an easy reference if needed.
  7. Pharmacology Flash Cards
    Many students like reformatting the material in the pharmacology section to make it easy to understand. Some students like seeing this material in a flash card form to use for easy repetition, others like seeing it in a table format. Use what is best for you.

In general, if students decide to use review books during FCM, they go with First Aid alone or add a pathology and physiology source as well. The later resources listed (Cases, BRS Pharm, and flash cards) are not used nearly as often but you should know that they are out there. Please refer to the AOA Guide to Step 1 for a more complete listing and description of the review books that are out there.


NUTRITIONAL MODULES (MANDATORY)

There will be approximately ten nutrition in medicine online sections that need to be completed during the associated FCM blocks (for example, Hypertension during FCM Cardiovascular and Diabetes during FCM Endocrine) found at www.nutritioninmedicine.net. They basically consist of educational tutorial powerpoints on how to recognize and consult your future patients on their dietary needs and recommendations based on their medical history. After each section there is a graded quiz on the information from the associated powerpoints. They are meant to act as a supplement to the traditional FCM coursework and can be time consuming, so try to space them out over the course of each block because they can be a pain to do the week before an FCM test. Generally, these are fairly straight forward, but you need to pass each block's multiple-choice quiz (i.e. at least 70% and some of the blocks only have 13 questions!), so take them seriously so you don't have to repeat them. If you end up not passing a certain block, you will have to make a new account and repeat the sections/quizzes that you have done up until that point. The moral of the story is do these well the first time around and that way you can avoid the extra work.


THE SECTIONS

Here are some tips for each specific topic. This is where everything comes together and you must take the time to work through the specifics of each system based on the physiology/pathology/pharmacology. Learning to integrate these aspects in your mind will serve you well for the boards and for life.

  1. CARDIOVASCULAR: This is one of the harder blocks. The syllabus is thick, but there is a lot of overlap. Dr. Pavri's lectures are by far some of the best lectures in this whole course. Listening to his lectures and working through his syllabus will ensure you understand the basics of EKG's without any other resources. Some students used "Rapid Interpretation of EKGs" by author Dale Dubin as an additional resource. Valvular diseases are also heavily tested, and Dr. Berko's syllabus is very good for this. This block is not too heavy on pathology but make sure you know the few pathology slides well with special focus on the changes seen post-MI and the timeline of when these changes occur. There is a strong focus on physiology in the section, so you should make sure you understand Starling forces and the pressure volume loops. Make sure you understand the difference between hypertrophic, dilated and restrictive cardiomyopathy. The syllabus is very good for this, but if you need extra assistance, BRS physiology is a great resource. Dr. Tulenko runs the pharmacology portion of the course and is excellent. He does not simply list drugs but rather gives in-depth explanations of the pathophysiology of the diseases and how the drugs work to treat them. Cardiovascular pharmacology in general is high yield both for the FCM exam and for Step 1, with the exception of the antiarrhythmic drugs, so be sure to learn it well. Antiarrhythmic pharmacology is difficult to master but fortunately not a huge focus - just be sure you know the main drugs and their main side affects.

  2. FEMALE REPRODUCTIVE: The female reproductive system lectures are straightforward. Dr. Klein gives very good lectures and you should listen to all of them. Really focus on understanding the hormonal interactions in the menstrual cycle as this will help you in later parts of the block. Dr. Wolf will focus more on obstetrics and pap smears. Dr. Wood's pathology lectures are not particularly helpful to listen to. You can read her slides and they should be enough. Fenderson's pathology questions are a good guide for this section. There is a lot of pathology for ovarian and endometrial tumors. Goljan and BRS will be very helpful supplements for GYN pathology. Dr. Wolf's review session is also very helpful. Learning this material well will also help you on your third year Ob/Gyn clerkship. Remember: A young female with abdominal pain/ vaginal bleeding has an ectopic pregnancy until proven otherwise! There are minimal lectures on male the GU system and its disorders, but don't neglect to study these topics because they have been known to come up on the exam. Understanding the relationship between the components of the hypothalamic-pituitary-gonadal axis is crucial. Also, although often not directly tested, it will be useful to understand the functions and hormones associated with the different cells of the reproductive system and to draw comparisons between the two genders (i.e. FSH stimulates both Sertoli (Male) and Granulosa (Female) cells to secrete estrogen, etc.). Also, strive to develop an understanding of basic steroid sex hormone production and which cells are necessary during this process both in the adrenal gland as well as the gonad.

  3. ENDOCRINE: Dr. Jabbour and Dr. Mills are both excellent lecturers and they will really help you understand the physiology. It is a lot of material, but this really is one of the best-taught blocks. Spend time on the hyper/hypocalcemia lectures as these concepts tend to come up a lot and calcium metabolism is complicated. The same applies for hyper/hypokalemia, and hyper/hyponatremia (although these topics will be taught in more depth during the renal block). Make sure you understand how PTH, calcium and phosphate levels change in the different disease entities. Recognizing the different presentations of the various endocrine disorders will serve you well in the future. Take time now to learn the complications, treatments, and pathophysiology of conditions like Diabetes (HHNK, DKA), Cushing's, and the difference thyroid disorders as you will continue to see these topics come up throughout the year and on Step 1. Make sure you know all of the MEN syndrome associations and the causes of hypo and hyperthryoidism, as well as how to work up a thyroid nodule. For pathology, you need to listen to the lectures because Dr. Kenyon adds extra information which will be tested. Again, use BRS/First Aid/Goljan as you feel necessary, but this was one block where the syllabus and lectures were sufficient. As with the reproductive system (typically these are taught together during one FCM block), be able to recognize the relationships between the hormones/target organs in the hypothalamic-pituitary-adrenal axis and what diseases could result if a defect were to occur during this pathway.

  4. PULMONARY: This section is traditionally very detailed and can seem overwhelming. The syllabus is well done, but it is very helpful to read through the BRS physiology section on the respiratory system and get a good understanding of important concepts: obstructive and restrictive lung diseases, lung volumes, flow volume loops, Ventilation and perfusion (V/Q) ratios, and the A-a gradient. These concepts are very heavily tested on the boards and on the FCM test so it will serve you well to learn them well during this block. High yield conditions include Deep Vein Thrombosis/Pulmonary Embolism, Asthma, COPD, and Acute Respiratory Distress Syndrome (know diffuse alveolar damage is associated with hyaline membrane formation in the lungs). This section is also heavy on pathology. The slides from the path lectures are great, and should be enough to get you through this. Again, BRS pathology and Goljan are great supplements for FCM pathology studying and will make studying for the boards easier later on.

  5. GI: The GI section of the course is very well done and the lectures are very helpful as most of the material is presented very clearly. Go to the clinical medicine GI review; Dr. Herrine will review interpretation of lab values which is very helpful for the exam. Have a good understanding of hepatitis serologies (especially Hep B), understanding liver function tests, GI hormones and their function, and pancreatitis. Colon cancer is an important topic and hereditary colon cancers are common topics on Step 1. This is likely going to be more of a focus in the Oncology block, but anything introduced here is high yield. For pathology, BRS and Goljan organize the material very nicely and will help you recognize buzz words (be careful) that you will see often (for example: birds-beak esophagus = achalasia). Going through Dr. Fenderson's book of questions is a great way to prepare for the test, if you have the time. Also, be sure to spend some time with the presentation of esophageal motility disorders (i.e. which ones which cause progressive vs. acute dysphagia to liquids vs. solids and liquids), the causes of peptic vs. duodenal ulcers, and GERD for the test. Historically, liver conditions seem to be more heavily represented.

  6. HEMATOLOGY/ONCOLOGY: For last year's class, this was commonly this was one of the most difficult blocks and is heavy on memorization. Start early in understanding how to work up anemia, and knowing the most common causes of different types of anemia. Know what to expect on the peripheral blood smear for different types of anemia. First aid is very helpful for this section and organizes information into neat tables. The syllabus has a lot of detail but will ensure that you understand every concept. The coagulation cascade comes up a lot in this section so try to memorize it as best as you can. The coagulopathy and platelet disorders are heavily tested on this test as well as on Step 1 so learn them well now. Know iron deficiency anemia well and that pica (desire to chew on non-edible things, like ice) is a major tip off for this condition. Also, being able to differentiate between the causes of macrocytic, normocytic, and microcytic anemia is invaluable (refer to First Aid as well as the helpful chart provided in the syllabus and try to know it cold). For the malignancies you should try to organize the information in a way that makes sense to you. For the leukemias and lymphomas, focus on important translocations, key pathological findings and buzz words to be able to recognize different leukemias (example: huge spleen and dry bone marrow tap= hairy cell leukemia; starry sky macrophages= Burkitt's lymphoma). Also focus on the cancers that are uniquely treated (like Promyelocytic Leukemia with Retinoic Acid or CML with Gleevec). Also be sure to know how to recognize, prevent and treat the most common oncologic emergencies such as tumor lysis syndrome. Goljan is a great resource for this as he is a heme pathologist himself, so his series of audio hematology lectures are amazing and will really help the information stick.

    In addition to the liquid tumors, you will be introduced to many solid tumors during this block. This includes colon, lung, breast, pancreatic and urinary tract just to name a few. The lecture material is very good, but it is very helpful to supplement it with the BRS pathology and first aid. It is important to be able to recognize key pathological patterns and "buzz words" that help you identify different tumors (example: butterfly appearance of tumor on brain MRI= glioblastoma). Of note, many of the brain tumors will be discussed separately in the Neuro block. However, be careful in becoming too reliant on buzz words (as has been stressed in the Step 1 Advisory talks, the boards do not use buzz words). Epidemiology and risk factors will be stressed in lecture, so try get a good handle on these concepts.

    For the chemotherapy lectures, it is very helpful to start organizing the information into tables or flashcards as early as possible. There will likely be review tables posted on your discussion board for this purpose. There are a ton of drugs to be learned, but the specifics are not a focus on the FCM exam or on the Step exams. An early start on learning the chemo drugs is recommended and make sure you know "ChemoToxMan." (see First Aid) for common adverse reactions .

  7. RENAL: This section is challenging. Acid-base physiology is extremely heavily tested (and clinically relevant). Listen to all acid base lectures and review sessions until you are confident of these concepts (there are good flow charts presented in the syllabus that will also be useful for Step 1 studying). Other heavily tested and important concepts are electrolyte imbalances: hypo/hypernatermia, hypo/hyperkalemia, and hypo/hypercalemia. Work on becoming comfortable with differentiating between concepts like SIADH and DI. First Aid and BRS physiology is a good resource for consolidating the larger number of concepts. The pathology section in this block is also notoriously challenging. Understand the basic differences between nephrotic and nephritic syndrome - both clinical presentation and pathology of these different disease entities are highly tested in not only FCM but also in Step 1 and Step 2. First Aid and the syllabus are useful for learning the epidemiology, clinical presentation and pathology of the different diseases. Goljans pathology organizes these very nicely, so take a look at these resources and decide which one will work better for you. It will also be important to make associations between some glomerular conditions and certain diseases (i.e. the collapsing variant of FSGS and HIV). These can make for some easy questions on the exam.

  8. MUSCULOSKELETAL: The clinical components to this section are fairly straightforward and the lectures are well taught so you really should listen to all of them. The muscular pathology lectures are pretty detailed (BRS Pathology has a good summary). Connective tissue and autoimmune diseases are also taught in this section. Start learning the antibodies and characteristics of these diseases as they are heavily tested all through medical school and your boards. This cannot be emphasized enough! Also, know the reflexes and sensory distributions associated with the different nerve roots (these will help with both this test and physical diagnosis).

  9. SKIN AND CONNECTIVE TISSUE: Dermatology is a little rough because the time devoted to derm is short. Listen to the lectures and focus on the syllabus and you should be fine. There is a lot of pathology in this section so pay close attention to the pictures of rashes and skin biopsies. Know everything about skin cancers! The review sessions are great - you should go to these. Also, the Dermatopathology lecture presents some key terminology that you should strive to know (try to preread this lecture early in the dermatology section and many of the other concepts will be easier to master).

  10. NEUROLOGY: You should attend the neurology lectures or listen online because most lecturers will tell you what is important. Focus on movement disorders, being able to localize a lesion in the brain (strokes and tumors), the different types of demyelinating diseases, upper versus lower motor neuron lesions, and migraines. The neuroanatomy class is good preparation for this section so review your 1st year notes as needed. Dr. Kremens' lecture on the clinical exam is great and very high yield for the test. The neuromuscular junction and demyelinating disorders (i.e. Myasthenia Gravis and Guillen-Barre) will be important to know for the boards, so spend some time with these. General indications for the epilepsy treatments also are important. Once again, the course lecturers will give you a good indication as which concepts are higher-yield than others, as there is a lot in the syllabus. The anesthetics are difficult to master and not often tested in-depth, so just strive for a basic understanding of their general mechanisms of action for the FCM test. These will become increasingly important though during your clinical years.

  11. PSYCHIATRY: The psychiatry portion is interesting and very useful for the boards as well as your third year clerkship. The psych drugs are very heavily stressed. There are a lot of them so an early start is important. Again, sharing review tables or using flashcards is very helpful. Make sure you know not only the common side effects of the psych drugs, but also about Neuroleptic Malignant Syndrome (NMS) and Serotonin Syndrome (SS) - these are high yield Step 1 and Step 2 topics. Know the receptors and nuclei associated with different neurotransmitters and which drugs affect which receptors. It seems like unnecessary detail but it is important, both for your exams and clinical clerkships. Also make sure you know the criteria for common disorders like depression, bipolar, schizophrenia and how long symptoms must be present to make a certain diagnosis. Learn to recognize the different personality disorders and defense mechanisms. First Aid is a great resource for organizing these conditions and presenting some of the Mature and Immature Ego Defense mechanisms that often come up on the Boards.

  12. OPHTHALMOLOGY: The lectures in this block are very good. The material in the slides and the syllabus should be able to carry you through the test. Know the key points of the fundoscopic exam for common ophtho conditions like hypertensive retinopathy, and diabetes. The oculopath lecture is very good so it is unlikely you will need to look to other resources for this part of the block. The ocular trauma lecture is one you will never forget so make sure you make it to class. Strive to learn the anatomy of the eye well (there are many good lateral cross sections available online) as it can really help you understand closed versus open angle glaucoma. Know the differences in how to treat these conditions!

FCM is an intense, challenging course that will teach you what you need to know for Step 1 and gives you an excellent foundation for your clinical years. Your hard work will be rewarding with a great Step 1 score and a strong knowledge base for your clinical years. Good luck and don't hesitate to contact the AOA Tutoring service if you need any further guidance.

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Last updated: 7/12


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