It was hard to look around the lecture hall without seeing at least one person and thinking “That person is the most compassionate human on earth. They are going to be the most incredible doctor.“

Then 3rd year rolled around and after a year of being largely treated like dirt on the wards, those exact same people are – almost without exception – going into radiology, anesthesiology, or leaving medicine altogether for entrepreneurial or non-profit ventures.

And that’s depressing because you KNOW they’re making the right decision. No matter how much you want to fool yourself into selfishly dismissing their decisions as cynical or self-serving, you know the truth: leaving medicine is actually just kind of smart.

These are good people that were beaten down, chewed up, and spat out by the wards and have the self-awareness to leave because they realize there are careers out there that AREN’T fiscally and emotionally abusive.

2. Which leaves you and your career decision… where, exactly?  I mean, if you’re admitting to yourself that those classmates are making a smart decision, isn’t there an obvious link to be made…?  Like, I don’t know, some sort of natural continuation of this train of thought that indicates something about the wisdom of your own career choice?

You are choosing to ignore this. You are ignoring it so hard that simply acknowledging the possibility that you are making a huge mistake doesn’t even seem like an option.

But that’s okay! Because even though NORMALLY the statement “If I ignore the hints that I’m doing the wrong thing, they’ll go away” is stupid – his time it’s totally not! Because of reasons.

… quick, let’s move on.

3. There are a handful of facts you were better off never knowing.

I’m not referring to useless trivia that’s just taking up valuable room in your head without paying rent – that stuff was once worth valuable USMLE points.  I’m talking about tried-and-trued protocols that became out-of-date while you were on a different rotation and useless buzzwords (“spiral fracture” = “child abuse” has some damned important caveats – many of which have nothing to do with blue sclerae).

It feels like a miniature betrayal each and every time you are posed a question, answer “correctly”, and then hear, “Well.. actually – no. Absolutely not at all.”

4. Your career choice will depress the hell out of your classmates. “Pediatrics? Wow, I could never do that. It’s so depressing. Just think about it… sick and dying kids, every day for your entire career. God, that’d be terrible. Don’t you think it’s depressing?”

The counterpoint to point #1: Every few weeks or so, it’s important to find yourself on the awkward “… er, what am I supposed to say to that, exactly?” end of this exact conversation – it reminds you that you’re kind of a jerk for having similar opinions about the career choices of others and should probably continue to keep them to yourself.

5. You and your entire class will drop off the face of the earth. Between audition electives on the opposite coast, research, Sub-Is, and vacation months, you won’t be together again until Match Week. And even then, a bunch will have taken a year off for research or a second degree, so there’s a good chance you’ll just never see them again.

Lately I’ve been listening to how the M1s on campus talk about each other and honestly, sometimes it depresses me – they all seems so close. I remember feeling that way about our class.

But as soon as 3rd year starts, it becomes so easy for people to just slip away. 50% of conversations are about how much your current rotation sucks and the other half are people trying to remind each other who is actually still enrolled, who’s taking a year off, and who just left entirely without a word to anyone.

So, you know, it’s hard for me not to overhear happy conversations about impromptu M1 dorm parties without thinking things like “ENJOY IT WHILE YOU CAN. You’ve got like, 6 months, tops.”

Does that sound too ominous? That probably sounds too ominous.

… must be why no one ever warns us.

But NOT WITH KIDS. With kids, I’ve learned the correct answer to even simple stuff like “is that cardiomegaly?” is No. No, it’s not. It’s probably just a dumb thymus.  (Except for the cases where it totally IS cardiomegaly, in which case it will look exactly the same.)

Goddamn it, thymus, MOVE. You are in a highly inconvenient location.

2.  When In Doubt, The Answer is “Moderate”. Lymphadenopathy in the pelvis? Sure, I see it – it’s ‘moderate’. Quality of the fibrosis in the portal tract? Moderate. Suspiciousness of that periosteal lesion? MODERATE.

(I mean, not really-  if they’re bothering to ask you, that means the most correct answer is either “very subtle” or “OH MY GOD” – but better to err on the side of “lacks experience” than “is not able to discern basic anatomical structures”.)

3.  Radiologists are geniuses. Every time I start feeling confident about my pattern recognition or image-reading skills (“I could totally sit in a cushy chair and read images all day! This is the best!”), I end up in one of their oral boards review sessions watching them all get grilled on isotopes, ochem diagrams, and physics.

I bet I would’ve loved radiology if I were born 50 years ago when everything was just plain films. Or if I had gone to medical school straight out of high school, before taking so many college pre-reqs.  But I didn’t, so now I’m old and cynical and my general attitude about studying “converging collimeters” in radionucleide scans is stuck somewhere between “THOSE WORDS AREN’T REAL” and “YOU CAN’T MAKE ME.”

4.  Sitting in the dark all day is dangerously relaxing.  My Red Bull consumption is nearing an all-time high, which is sort of disconcerting, since this rotation is basically 5 hours a day, 5 days a week. (I’ve lost my edge! I’ve gone soft.)

5.  Reading a radiograph: The “helpfully point out structures” approach that worked so damned well with the attendings last year does not, somehow, impress the radiologists. (“And what do you think of the vasculature?” “Well, that right there is the IVC. And, uh… it is.. not enlarged. So… it is looking good. … or possibly not good? … Hey, look – it’s patent!”)

6-12.  Fact dump: The newborn liver should always be less lucent than the heart – free air would make it brighter. Ovarian torsion is super difficult to rule in or out with imaging alone. Current wisdom is that “shaken” baby syndrome actually involves impact. The bone equivalent of “hazy” (in the lungs) is “broad transitional zone” and it signifies diffuse disease characteristic of malignancy.

Bone ages are fun to determine, but many radiologists believe the “11 year old” and “12 year old” male standards should be switched, the standard deviations are broad and not, in fact, actually standardized, and it’s all based on cohort data from like 50 years ago.

If the neonate’s ossification centers are visible, it was likely a full-term child, because those come in at 42 +/- 2 weeks. Germinal matrix hemorrhage is echogenicity seen anterior to the caudothalamic groove on ultrasound, as opposed to the echogenic choroid plexus posteriorly.

… best rotation ever.

This involved: ~8 hours of driving, 1 rented vehicle, 0 legal parking spaces, 1 missing student ID, 2 irritated security guards, 7 illegal parking jobs, 13 trips to and from a vehicle parked as far as 3 blocks away from actual building, 2 warnings from security, 1 near traffic accident, 1 ruined pair of shoes, and 4 hours of sleep.

Also, tomorrow we have our shelf exam, which while not something I am overly concerned about, is also not.. exactly.. something for which I have spent any time whatsoever studying.

(Oh, and a reflective writing paper on the biopsychosocial model/patient-centered communication? I guess? I mean, I haven’t actually looked at the requirements or anything, it’s totally not due for another two hours.)

(Ladies and gentlemen, we’ve reached a cruising altitude on this rotation. The captain has turned off the “Cool Disinterest” light, so you should now feel free to Mildly Panic about the cabin.)

I suspect my preceptor could tell I was stressed out / delirious / on-the-verge-of-a-nervous-breakdown, as after giving me my end-of-rotation feedback (which was good! Hooray!) he let me go home early.

(Is “let me” the right phrase? Because he did that awesome rare thing preceptors do when they know your “Oh, no, it’s okay – I’m happy to stay!” is just obligatory bullshit you have to say as a med student, so they ignore your half-hearted protestations and basically order you to leave.)

Anyway, I just got home and got this email from him:

[Action Potential],

Unsolicited and probably unnecessary advice:  one beer and a good night’s sleep on the eve of an exam are better preparation than studying.

Nice working with you.

[Preceptor].

PRIMARY CARE FOREVER.

Sure, it depends a lot on your hospital and team – but broadly speaking, having a cup of coffee in one hand during rounds gives off a certain “devil may care” attitude that doesn’t bode well for your med student reputation.

(That said – I did it on surgery rounds because 1) I already knew I wasn’t getting honors, 2) there were no old-school attendings, 3) I deeply suspected the residents were too sleep-deprived to register the sight of me, let alone notice a small coffee mug, and 4) it was freaking surgery; I needed coffee.  I mean, screw it, I’m not a machine.)

But this is SUCH a good example of why medicine is insane: there is nothing intrinsically lazy, unethical, or dangerous about simply holding a cup of coffee outside a patient care area.

But dude, if you’re on the bottom of the totem-pole of medicine, it makes you look like you’ve forgotten your place, and we can’t have that now can we.

So, right: Reddit’s medicine section has been having a discussion about it:

I cannot believe how many non-medical people responded to this topic by raising hell about how inconsiderate it would be to drink coffee in the patient rooms.  YES, WE KNOW.

But honestly – even if the medical team taking care of you does dare to flout JCAHO rules by bringing closed containers of coffee into the room for the whopping 3 minutes they spend with you – unless you are NPO or on chemo, I can’t help but feel detecting a slight whiff of coffee in your room at Crack of Dawn O’Clock is not unreasonable.

But, right, the point here is that we are talking about drinking coffee in the hallway, not a patient care area.

… Yep, pretty much.

It’s such a dead-on example of why students leave med school hating medicine: “don’t drink coffee within sight of your superior” is – for better or worse – the sort of thing we end up internalizing as “professionalism”.

Like, at all. Ever.

Even after mustering up the courage to at least click the damned link, I still spent an embarrassing amount of time avoiding the screen and just generally attempting to evaporate due to Internal Conflict overload.

The internal conflict, to be fair, started about 2 months ago with the seriously depressing disparity between my original “go, fight, win!” optimism and the resulting elaborate series of nervous breakdowns when practice test after practice test revealed a reality that didn’t match up.  

Which, ultimately, I blame on 1) not actually being a secret genius (DAMNIT I was counting on that), and 2) seriously underestimating the workload required to meet the “average” maximal effort concerted by thousands of medical students who have lived their entire lives in the 95th percentile and are not about to release their unholy death grip on it now.

(Honestly, if I learned one thing while studying, it was that a 224 should be greeted with nothing but respect. An “average” score is a freaking achievement.)

Weirdly, after the Abject Despair of taking my dare-to-be-great expectations and pasting them onto a dare-to-be-average reality, I started scoring higher.

In the end, my NBME practice test scores ranged from roughly 21X – 24X, with a baseline of 207 and one UWorld score of 250 thrown in as hyper-emotional outliers.

So, right, that’s why I was sitting in front of my laptop, eyes shut, throwing around the idea of just never, ever checking my score - or at least just closing my eyes and humming loudly whenever it was brought up.

After all, wouldn’t it be nice to live in a world where the 250 was forever a possibility?  A world where it would forever be possible that I definitely did not slide back down Average Mountain to my baseline, thus negating all 6 weeks of blood, sweat, and tears?

But right, my point is: eventually, I looked.

And surprisingly, it did. not. suck

Step 1 score: 23X!  Which is great news! (To me! For my particular goals and study habits! Without making any judgement calls on it as a score in general!)

(For the lucky people reading this who aren’t familiar with USMLE scoring, this score falls right between the National average and the Metropolis Med average. So I can safely justify either “PARTY ON” or “I have brought great shame upon my family” depending on my goals – which luckily, as I said before, are not high.)

Incidentally, I really do respect the Sacred Med Student Moratorium On Score-Talk in real life. It’s an excellent unwritten rule that prevents all manner of med student psychopathy and drama.

But online social codes are different (where would any of us be without pseudonymous score reports?), and I don’t want to post a non-numerical entry that’s just EXCITED YELLING and risk misleading any future orthopods out there into thinking my relative happiness means I actually killed the test and should be listened to.

I mean, tempting as that implication may be (Action Potential, QUEEN OF THE ORTHOPODS) – the fact remains: M2s, if you want to actually kill Step 1, you’re going to want a better role model.

And possibly also – I don’t know, an actual study plan. (More on that later.)

You know how all of Daylight Savings Time’s well-thought-out reasons for existing were ultimately overshadowed by the awkwardness of creating an extra hour?

Well, picture that, but with an extra month.

Personally, I don’t mind. Primary care is fun, and doing an extra few weeks just means I don’t have to study. It’s the perfect post-Step 1 / first 4th year rotation.

Sure is a tough life. Somehow, I’m powering through the burn.

1.  When our med school lecturers joked that “50% of what we teach you today will turn out to be wrong”, I should not have laughed. I always assumed that aphorism was meant more  ”over the course of a career” than “over the course itself” – which makes the joke less “funny” and more “immediately alarming”.

(Seriously, forget about niacin for cardiovascular end-point improvement, statins for primary prevention in women, and beta blockers for isolated hypertension in anyone. Lies, damned lies, and statistics.)

2. Insurance companies DO care – about electrolytes. The health of my patients has truly never been as prioritized and cared about as it is during the 10 minutes immediately after attempting to order a calcium level.

Yes, THANK THE DEAR LORD you insurance companies have risen up to protect us against the abominable scourge of lab-draws for patients with generalized bone pain; thus forcing us to go straight to the much more fiscally-responsible full-body bone scan.

WELL DONE, YOU. Slow claps all around.

(Yes, I did read the Time article. And all the immediately preceding identical articles that, for whatever reason, never blew up the same way despite containing the exact same information. Seriously, healthcare spending has been a mess for far longer than Time Magazine has been in existence, and while the attempts at fixing it have changed, the underlying reasons have 1) not, and 2) never really centered on ionized calcium, to the best of my knowledge.)

3. How to present a healthy patient, with no complaints, with an unremarkable annual physical.

“So… in conclusion, my plan is to shake their hand and wish them a good year.”

4.  Career-wise, I am a cheap date.  My preceptor gave me my own office for the month. It has a phone line! And a desk! And a window!

And that was the moment I knew I was going into primary care.

(I’m kidding. Still, it’s amazing the difference a desk can make: call me power mad, but the last time I had my own office I was 8, and it was a re-purposed Fisher-Price box.)

5. Fine, Geriatrics really DOES deserve to be a specialty. I’ll admit it – I was never convinced the Science of Old People ran much deeper than “\dose adjustment” and “avoid the hell out of anticholinergics”.

“This specialty’s inability to take itself seriously is reflected in its inability to find a title that it’s comfortable with. ‘Geriatrics’ was discarded because many practitioners resented being a ‘geriatric consultant’. ‘Gerontology’ was toyed with, as it made their discipline sound much more scientific. However, this was dismissed as inappropriate for exactly that reason.”

- John Larkin, Cynical Acumen

But I’ll give this to them: pain control in the elderly is a nightmare.  NSAIDs are right off the table, opiates and trazodone are great recipes for broken hips and delirium, gabapentin isn’t exactly the drug of choice for arthritic pain, and it’s hard to muster up the untempered enthusiasm to encourage daily acetaminophen use.

I mean, I knew that already – but I wasn’t 100% sure until I became formally acquainted with the “5-minute warning” pop-up.  (Oh, we spent some quality time together that day, “5-minute warning” and I.)

But the time pressure felt bizarrely reassuring, because I knew – having gathered some solid evidence from taking all 7 NBMEs in the preceding 7 days – the easier I find a test, the more patently obvious it is I’m missing something.

(And by “something”, I mean, “roughly twenty questions more than usual”. Dumb, sleep-deprived, face-palming mistakes on the order of repeatedly trying to swipe your driver’s license at the check-out till).

In fact, the only two practice NBMEs I was just SURE I had nailed were, ultimately, my two lowest scores (by a downright embarrassing margin). And the only two that had me reduced to tears, seconds away from dialing the Office of Student Affairs to sound the Official “Help, I’m A Risk to Our Pass Rate” Alarm? Those two scores were twenty points higher than the rest.

So, right – test was clearly hard, so I felt good. I went back to my hotel room, wikipedia’ed all the questions I was unsure about (common sense be damned, I was curious as hell), marathon-ed half a season of House of Cards, and moved on.

But now its one week later, and while I haven’t thought much about the test, I no longer feel “fantastic” about it: After a week of feeling cheerful, my mental pendulum has slowly swung to the opposite conclusion: “if you felt so good about the test, you definitely bombed it”.

It’s a dumb paradox, but there it is: I wouldn’t be surprised if I got >240, so I wouldn’t be surprised if I got < 220

The truth is, whether I bombed it or not, my score will be 10 points higher than I deserve. I lucked out with my test. It played to my strengths: very, very minimal biochem (4-5 questions total), tons of genetics and neuroanatomy (my two best subjects by far), what appeared to be the entirety of the OB/GYN shelf (?), and even a couple of questions that I could’ve sworn were on Step 2.

So as much as I love complaining about the NBME – if my score sucks, it’s on me. I couldn’t have asked for a better test, and that fact makes the waiting bearable.

(Meanwhile, I started my Family Medicine rotation. So far, Family Medicine seems to be 50% constant awesomeness, 40% riding a bus, and 10% getting up at 4:50am to catch it. The 4:50 am part is pretty inflexible, so I’ll call it quits on this entry for now. Thanks again for all the well wishes!)

Right now I’m sitting at my laptop with two drafts of this post, not liking either one. But since I have to catch an early flight for my try at Prometric #3 it’s getting pretty clear I either need to hit “publish” or call it quits while I still have time to lie wide-awake in bed.

But instead I’m still sitting here, and I suspect it’s because as much as I want to have written a post explaining what the last week of Step 1 has been like, the perfect description has already been written – and I have nothing to add besides a vehement “That. That’s it exactly.” after pointing.

And that’s why I’ve been sitting here kind of wondering to myself how likely you guys are to remember The Rumors Were True – because if you do, there’s no need for me to write anything at all.

But if you aren’t, my instinct – which it looks like I’m going to follow- is to just stick around for one minute longer, dig through my bookmarks, find the paragraph I’m thinking of, and point.

The Unexpected Suck of The Last Week:

… So now, reviewing is an exercise in abuse. Oh yeah, I remember not remembering that fact that I’m not going to remember in a second or two. Hope to God that isn’t on the test. Repeat. Repeat. Repeat.

It’s the feeling of losing. I set out to hold everything in my head, and reviewing is just hammering home that no matter how much I prepared, it was just going to keep falling out, falling out. Every reread line re-remembered is testament.

I feel like I’ve stepped into the ring, seen my opponent, and gone four out of the five rounds. He’s stronger, faster, bigger. Through the blood, I can barely make out that he’s joking with his coach; that he’s not tired. The judges are looking at the girls with the placards, sharing cigars, not worrying about the last round since no effort on my part could change the ruling that is so cemented. I look at my coach.

“Coach, this fight is over. I can’t beat this guy. I’ve already lost.”

“I know, kid. But that doesn’t matter. Rules is rules. You have to fight the last round even if that means he kills you.”

- Topher, The Rumors Were True

That. That’s it exactly.

Yes, I googled it. Not taking any more weather-related chances.

(That said, if you hear about the north-eastern US getting hit with a blizzard / hurricane / surprise Godzilla attack on Friday, you know who to blame.)

Actually, my school’s Dean of Students snagged me this spot.  I guess what I said in the last entry about “making it someone else’s problem” really does work. (Why do I always try to solve my own problems?  I am never the best person to solve my own problems.) The Oscars hadn’t even ended by the time her assistant had gotten Prometric, the NBME, and/or the state government, for all I know, to work something out for me.

(I don’t think I’ve ever said anything negative about my school – but if I had, now would clearly be the time to take it back. The administration has superpowers.  That’s their secret.)

I have so many half-finished blog entries, you guys.  There are an awful lot of things – some of which actually aren’t totally self-centered – that I want to finish writing, and I can only get to the most trivial of them. (Thus, the gifs.)

But on the bright side, since this Thursday will be my THIRD (and please dear USMLE-God let it be the last) Last-Minute-Fact-Cramming Day, I have gotten really, really good at Last-Minute-Fact-Cramming.  I have become intimately aware of the time limits in which this stuff can be committed to short-term memory, so I know right down to the very minute which flashcards, equations, and drawings to crash-memorize.

Ladies and gentlemen, meet my life – in all its morbidly fascinating – perhaps depressing – glory.

(Some people say you shouldn’t cram for the USMLE. They usually compare it to running the day before a marathon.

But if we can just compare the USMLE to whatever we want, I’d rather compare it to community theater. Specifically, the night before the Off-Book deadline – which every theatre slacker in the world knows is more than enough time for anyone to superficially memorize the entirety of Twelfth Night provided they’ve showed up at at least a couple rehearsals beforehand.

And if it’s good enough for Shakespeare In The Park, gosh darn it, it’s good enough for biochem.)