Your Clinical Years of Med School: A Summary

Done With Classroom Lectures – Forever!

Discovering Mandatory Ward Lectures

But Wait – ‘Mandatory’ Is Loosely Defined!

… Though There Are Still Shelf Exams

… And Step 2

Posts I Have Started Writing But Ultimately Abandoned (for One Reason or Another)

Post Idea #1: Advice for New M3s, via Quotes:

This one sort of worked. Easy and topical!  I’d argue that you can learn a lot about how to function on the wards from people like Anton Chekov (“Any idiot can face a crisis – it’s the day-to-day living that gets you down”), Will Rogers (“Never miss a good opportunity to shut up”), and Ron Swanson.

But I didn’t post it because after a 3 month absence, something this trite seemed like a weird re-entrance to blogging (“Okay.. an entry composed of nothing but quotes. So.. you’re not dead?”) – so instead I’ve just been letting it languish in my Drafts folder until I find something better to post first.

Probably should’ve taken Ron Swanson’s advice on that myself.

Post Idea #2: Hey Guys, I’m Back!

I didn’t actually write it, but I thought about it.

And then I remembered that “Hey! I’m back! I’m SO sorry for the hiatus – been super busy!” posts always seem to be 1) boring as hell, 2) the death knell of blogging (once you see one apology post, you can bet good money it’ll be immediately followed by another, even longer absence) and 3) really self-involved. Even by blogging standards.

So I didn’t post this one because it’s a terrible idea. (Though I’m clearly writing a goofy, “self-aware”, meta version of it instead! Which is probably worse! Oh well.)

Post Idea #3: Links to fascinating articles about medical education.

This month I’ve been finishing up a lit review for a research project, and since the next step after “literature review” is “actually just submit the damned IRB protocol already” – I’ve… spent some extra time on that lit review.

Seriously, I’ve become completely obsessed with journals like Academic Medicine (the journal of the AAMC, where you can find out a lot of unexpected things about USMLE grading), Medical Education, and just generally link-diving into the PubMed abyss.

Theatrical data analysis in health policy: IT’S A THING.

In related news, I’m… very easily side-tracked.

I didn’t post this one because all the cool articles I’d want to link are behind equally uncool paywalls. And while I could say some snarky things about a couple of very poorly done studies, at least they actually finished theirs instead of just being stuck on the IRB proposal itself for an entire month. Glass houses, thrown stones, etc.

Post Idea #4: Step 2 CS Is The Dumbest Exam On Earth. So! Besides “research”, the other thing I’ve done this month is the CS exam – which isn’t news. Neither is the fact that the exam is widely considered to be worthless,

Pictured: The medical community’s diverse spectrum of opinion on Step 2 CS.

But the point I kept trying to make while writing this was that it is beyond absurd for a Clinical Skills exam to not actually test Clinical Skills.  It is about whether you can go through the motions while speaking English and not alienating your patients.

… and also that any journalist could easily write an article exposing the US public’s misconception that their physicians are – at any point in their training – ever tested for their ability to actually notice findings during a physical exam.

Think about that for a second. The one thing a doctor is most trusted to do, and it’s never tested. People just assume that an “everything looks/sounds good!” after their yearly physical means something besides “well, you have no chief complaint and I went through the motions, so you’re set!” because, hey, doctors have to pass tests, right? And one of them must be on doctor skills, right?

Wrong. Sure, after all that clinical experience, your doctor can probably be trusted to notice a murmur. But isn’t it interesting that American doctors are tested on their ability to understand the phrase “abdominal bruit” or “cotton-wool spots bilaterally” – but never actually tested on their ability to actually recognize either one?

Personally, I have some mild hearing loss (otosclerosis) and have always been a little self-conscious about the professional implications. So I use an amplified stethoscope and have like to think I’ve actually gotten pretty darned good at discerning soft murmurs – but, still: isn’t it sort of an uncomfortable truth that no one’s ever tested me on it? That no one ever will?

That Step 2 CS wouldn’t let me use my electronic stethoscope – but it was totally okay because there weren’t any murmurs to find anyway?

Since the NBME already went to all the trouble of setting up the national Clinical Skills Centers – and several European countries appear to have already figured out the logistics of netting Standardized Patients with real diseases and physical findings – why not just go the extra step? Actually test clinical skills?

Or at least give me back my $1,500.

I didn’t publish this one because it sounded really defensive, almost angry. Besides, it was both way too long and somehow still over-simplified.  It’s probably a better topic for a book than a blog post.

Post Idea #5: Just posting bits from all the entries I started and why I ultimately decided against them. This one’s been languishing in my ‘drafts’ folder for the last week because it’s incredibly long – too long. I bet you just skimmed the last 5 paragraphs. (A safe bet, since that’s what I did while trying to edit it.)

I actually DID finally post this one because a commenter on the last post (Hi, Barney!) asked whether I had changed careers. Which… is both a reasonable assumption (given how depressing that last entry was), and a good indication I should suck it up and just hit “publish” on something.

So – here I am! Still alive, definitely still in medicine, definitely still over-thinking things as simple as “is this really worth posting?” – but here, all the same.

 

Step 1 Score: Two-hundred-and-majorly-relieved

My score came out! And despite a lot of post-hoc rationalization of just how much i did not allegedly care, as soon as I actually had the option of clicking “View Score Report”, I no longer wanted to.

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.)

USMLE Step 1: The End

It was hard.

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!)

USMLE: Final Thoughts

Does anyone else remember The Rumors Were True?  It’s from a semi-retired generation of med school blogs, so I’m not sure how many current students would remember reading it as pre-meds. It was the origin of the med-school pancakes metaphor, if that rings a bell. 

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.

USMLE: Is it “Bad Things Come In Threes”, or “Third Time’s The Charm”?

My Step 1 exam, due to a second Prometric weather cancellation (I DOOMED THEM), is now rescheduled for Friday!  This time literally over a thousand miles away.  

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.)

They Should Probably Just Name It “Winter Storm We-Don’t-Think-You-Should-Be-A-Doctor”

THE GOOD NEWS:  I’m now re-scheduled to take Step 1 on Tuesday!

I was going to write an actual post about this – I’m not 100% on this, but I think it was going to go something like, “Tuesday!  It worked out!  The new Prometric’s kind of far away, but worth it!”

THE BAD NEWS:

Since I’ll have to drive 200 miles to the new testing center, I figured I’d check the weather in Next State Over.

… Winter Storm.. Rocky?

Okay – granted, it’s a weird coincidence – but hey, what are the odds this one will ALSO hit the night before my USMLE?

Oh.  

… I see.

But we’re still a few days away – still a chance it won’t happen, right?  I mean, come on, weather channel – are you sure?  Are you CONFIDENT?

… Honestly, I’m not actually worried.  It’s weather.  It changes.  And moreover, the article goes on to say they have no idea where the blizzard part of the storm will ultimately hit, so it’ll probably be fine.

(Besides, I’ve used up all my anxiety. It turns out you can do that. If worst comes to worst, all the logistics of how I’m going to get to a Prometric Center next month – in a rural location, with clinic every day, and without a car – are quickly going to become Someone Else’s Problem.)

USMLE Week Number “Just Kidding, 1-3 More”

So Prometric cancelled my test, as they have closed.  Something about “inclement weather”?  “White-out conditions”? “Superstorm Snowpocalypse: The Midwest“?

I just… really?  After my final day of equations-and-oncogenes-I-will-soon-forget cramming?

They did say that someone would contact me by Monday to help me reschedule.  So, hey, that’s good.  I have no plans.  Well, I did, but the storm would’ve cancelled my post-USMLE celebration anyway.  Maybe I will get to take Step 1 next week?

Call me, Prometric. 

“Travel Will Likely Be Difficult To Impossible”

You know, unlike the last time this exact awful thing happened to me the day before a USMLE exam, I don’t even care about driving an icy 60 miles in zero visibility before sunrise.

I really don’t.

I JUST DON’T WANT PROMETRIC TO CLOSE.

There aren’t any open test spots for 3 weeks.

USMLE Week 5: Eh, Good Enough.

So after that mini-mental-breakdown of a practice test, I regrouped.  I montage-ed.  I set out to target my lowest-scoring subjects, grudgingly relearned them from scratch, ultimately spent more time alone in my room listening to morose music than I did during my last major break-up, and then proceeded to score, on two separate tests, just flat-out ridiculously higher.

… which – thanks in part to my newly-acquired Biostats knowledge (see: “lowest-scoring subjects” above) – I now know says more about just how poorly designed this test truly is than it does about how talented I may or may not be at short-term memorization.

(Okay, calling the USMLE “poorly designed” might sound a little harsh and high-minded – but when the NBME is purposefully distancing themselves from the notion that it’s an “achievement” test – in other words, that the exact scores mean anything – preferring instead to categorize it as “minimum competence”, and then still steadfastly reporting 3 significant figures?  At the steep end?  All while knowing that they’re handing out these career-determining judgements to the most self-absorbed, breakdown-prone students in the world?

… if that’s not poorly-designed, it’s at the very least disturbingly cold-hearted.)

And while I’m relieved as hell about scoring better, the relief is transient and the tiredness is a slow burn.  I’m forgetting more and more while caring less and less.

The result of adding this kind of burn-out to the general theme of my Step 1 study plan (which, FYI, would be most appropriately titled “Ways In Which I Helpfully Verified Common Wisdom By Ignoring It Entirely” – subtitle, “Somehow, It Went Poorly”) is a schedule for the last three days that looks something like “do stuff, but not too much or too little”.

I guess I will probably go through my flashcards again.  Or my notes?  Or re-listen to the recording I made of me reading First Aid.  Or learn to juggle.

I DON’T KNOW.  THERE ARE OPTIONS.  It’ll work out – and someday, as a commenter recently reminded me, there will be happiness again.  (Seriously, thanks for reading/tolerating self-absorbed posts like this, you guys.  Thursday can’t come soon enough.)

Meanwhile, Here Are Some Awesome Step 1 Resources Buried Deep In The Depths of The Internet: 

• – Compiled USMLE Step 1 Mnemonics
• – Protein Synthesis Inhibitors: Never Mix Them Up Again!
• – Virology Cheat Sheet – pretty great starting point, and well-designed to boot.
• – The Ultimate Guide to Gastrointestinal Hormones – Dude, seriously, this guy can make a table.
• – Confidence Intervals vs P-Value 
• – Everything I Need To Know I Learned From USMLEWorld – Where has this blog been all my life?
• – Goljan Flashcards (or here, a more selective set strictly from the Goljan High Yield document everyone raves about but never links to.)