A Wholesome Gallop

While straining to keep an interested look on my face while "listening" to a resident physician go through a consent for a procedure, I noticed that the patient was also not listening. Rather, she kept a suspicious eye on the nurse setting up for an IV, and finally put her hand on the nurse's arm and sassily told her that last time she was in the hospital, no one could get the IV and she was not going to allow someone to stick her five or six times again. Anyway, it really set up for a dismal outcome and it made me realize what an impact a patient can make on his or her own outcome.

As a paramedic I heard that 20 times a day- "I'm a hard stick, don't even try." Honestly, that made me really angry. During some of my "darker" days I took that as a challenge (I had a good track record, pun intended).

Now I realize how that sort of comment can be horrific- if you set the stage for failure, both in your head and the other person's, you'll probably fail. I know most of the "I'm a hard stick" patients are the frequent flyers and the purpose of the statement was anything but the denotation, but nonetheless....

So that was going to be the blog. But later that day in a lecture, a physician mentioned a story along the same lines and it really made an impact.

Long story short, a well-renowned cardiologist was treating a patient with bad heart failure, and made a point to have all the students and residents listen to this man's "wholesome gallop" (a heart sound usually only heard in heart failure).

No one thought this guy would last long, but within a few weeks this guy's heart function was completely back to normal! The cardiologist asked the patient what happened, and the patient told him that he was encouraged when the doctor told him he had a "wholesome gallop," because he reasoned that only a strong heart could still gallop.

The doctor clearly hasn't meant "strong" heart; in fact, he meant the opposite, but the patient's positive interpretation resulted in complete recovery!

According to the physician giving my lecture, the moral is that you should always find the good news. If they have a nonresectable cancer: "Good news! Your cancer doesn't need surgery! We can treat you with chemo and radiation!"

I've always held the opinion that words are a physician's most powerful and influential weapon. Unfortunately, on a daily basis, I hear them misused. To many, a doctor's words are the be-all, end-all, and sometimes assumptions are made on both the doctor's and patient's sides. Seemingly minute details in a conversation can change someone's view or even possibly outcome.

I think the toughest part of learning to be a doctor is how to use your words. The easy way out is to be enigmatic and vague- a commonly used tactic. Many healthcare providers, it seems, are comfortable with medicine but are unsure of how to talk ABOUT medicine with patients (somewhat justifiably so given all the litigious people out there). We need to better teach how to feel comfortable talking to patients by giving the whole picture. We need to tell people what we know, and what we don't know. Sometimes we don't like telling patients when we don't know the answer yet, and they interpret our silence as a deliberate omission (and patients therefore make assumptions about why information was withheld).

Deferring- "why don't we wait until the test results come back to discuss this-" can cause weeks of angst and worry. Granted, there are probably situations where this wouldn't be the best decision, but I think that talking to patients is comforting to them. Being in the dark is a thousand times more frightening than knowing (again, in most cases).

That same cardiologist whose "good news" cured his patient's heart failure wrote an amazing book which I started today: The Lost Art of Healing (Dr. Bernard Lown). A parting thought from Dr. Lown:

"As the patient is empowered, the doctor's curing power is enhanced."

Life of a med student..per parodies of popular music

Some of the best med student videos out there:


The Doctor's Out Tonight (Dynamite remix): ALL-TIME FAVORITE!

I wear a coat (I'm on a boat remix):

Somebody that I used to know remix (2nd half is best; pretty much about first aid)

I'm at a code (another I'm on a boat remix)...still pretty funny:

Residency Interview Advice

Interview offers are like new pleural effusions. 

You should never let the sun set on one.

Greatest. Quote. Ever.

Moral of the story: schedule your freakin interview the day you hear back!

How highlighters made me bitter for a second

For a second I wanted to be this girl, who I stood behind on an elevator in one of the clinic buildings near the hospital. I saw this girl in baby blue scrubs, and four perfectly-aligned highlighters.

If you know anything about me, you'd know that writing instruments are one of the few things in life I'm picky about. I am extremely particular about the experience of writing (if it isn't a nice pen, you won't write neatly). I once read that neat handwriting is a courtesy to the reader. (Of course, I am in NO way implying an opinion about physicians...)

Anyway, it had been a long day, and I was on my way out when I became fixated on these highlighters. All I could think was, "what does this girl do, that she only needs four pretty highlighters in her pocket?" And then, "since they're so neatly arranged, does that mean she doesn't actually use them?" (Ie, does she actually do anything.)

Clearly med school has warped my thought processes, seeing pretty highlighters and having such a visceral response. Overwhelmingly I was reminded of my own (short) white coat..a few shades off from the bright white when it was new (ok, a lot), jammed with pens (one of each color, a highlighter, permanent marker and penlight!), lip gloss, a few dollars, a radiation badge, a bunch of old patient lists covered in notes that I eventually want to organize and copy into my "little black book," reference charts, my phone and pager, a small bottle of ibuprofen, and probably a bunch of other random stuff.

I know that that moment was one of my "why am I doing this again" thoughts, which seem more frequent but fleeting, the closer I get to graduation.

I had this instantaneous yearning to have a normal, predictable job where all you need in your pockets are four highlighters. As quickly as that feeling came and went, the next brief thought was, "that seems like a horrible job; how boring and unrewarding would that be?"

Then I just felt guilty for having such a cruel thought, and then I remembered how really, really tired I was, and if I hadn't taken the picture I probably wouldn't have remembered it for this blog anyway.

Dominate Step 2 CK

As promised, I will include a few thoughts in reflection of my Step 2 CK (clinical knowledge) exam prep.  First of all, I scored very low on Step 1 (but passed), and that has cast a shadow over my career since.  Knowing that top tier residency programs were now out of reach, I realized I had to dominate Step 2 in order to have a fighting chance at a decent residency program.  My major concern was that I have always wanted to go into cardiology, and in order to get a cardiology fellowship, you need a great residency position (and therefore, great step scores).  So a low Step 2 score would have pretty much been the kiss of death on my cardiology dreams.

This story has a happy ending: I scored a 251 on Step 2!  (My fiance is so sick of me shouting this number out, even a month after the score came back.)  My dean's office adviser told me it was the biggest jump he'd ever seen between 1 and 2 (I'd rather have the honor of scoring the highest on both, but this will suffice).

I feel like I was not prepared for Step 1, and I'll have to explain that to residency programs.  But I keep telling myself: it's a lot easier explaining one bad test score than TWO bad test scores.  I can truly say that I had a bad day.  While I'm still out of the running for a lot of top tier schools (that I may have had a decent shot at, had I done as well on the first one), I still have high hopes for some fairly good programs.

So what happened?

What I did wrong while preparing for Step 1:

• The WAY I studied: the "test taking prep" center at my school singled me out for "help" before my first exam and did a one-on-one session; they concluded that I just didn't know how to do multiple choice questions and gave me a strategy (this method took about 3x as long).  Assuming that my weakness was rooted in the questions, not content, I essentially just did a massive amount of practice questions.
• WHAT I studied: I figured if I did 2000 practice questions (or all of UWorld) I'd hit every topic, so when I got a question wrong, I'd go through all the wrong answers to make sure I knew that content as well. 
• HOW LONG I studied: I took the test shortly after finishing 2nd year (less than a month) and didn't get many full days of studying in

What I did right while preparing for Step 2:

• Taking it seriously: this unfortunately translates into a financial issue; I researched test prep for about a day before hesitantly deciding to purchase Kaplan's online lecture series (yeah, over $2000 for 3 months).  Best. Decision. Ever.   
• WHAT I studied: I realized that the question banks test you on a microscopic fraction of the material, spot-checking your knowledge for massive gaps, and you have to know how to use your performance to study: don't study with the qbanks.  I'll go ahead and do a free endorsement for Kaplan: they concisely presented a massive amount of material making it a finite amount of material (I felt overwhelmed on Step 1, wondering how you could study everything; well, YOU CAN'T, but no one tells you what to study or what not to study- until Kaplan!).  The lectures were cumbersome but memorable (at times I was falling out of my chair laughing).  Best of all, I remembered it when doing questions.  
• The WAY I studied: after doing lectures, I used UW for its intended purpose: spot checks. I literally only did about 500 questions over the 4 weeks I intensively studied, because I was sure I knew the material.  The best part was seeing the questions in a whole different light: with Step 1 I felt overwhelmed with the question (I often didn't even know exactly what the question was asking), and narrowing down to 2-3 choices and guessing randomly. With Step 2, within the first few sentences of the stem I'd know the topic, what 3 questions they'd predictably ask, and often, the answer (yes, before even finishing the stem).  

Step 2 (and maybe Step 1...can't speak on that obviously) is an extremely predictable test.  The problem is no one tells you that, so you prepare for an unpredictable test (studying a little bit of everything, just in case). They really only ask a few types of questions, so you only need to understand those concepts from each topic (for example: what's the diagnosis/what's the best way to diagnose/what's the best treatment are really the only questions asked).  

But again, Kaplan broke things down to the basics and built up from there. They really focused on looking at things that were similar (ex: lung infections: bronchitis vs abscess vs pneumonia vs TB) and looked at the similarities and then the unique characteristics that the test would focus on:

Pt presents with fever and cough: think lung infection (any of the 4 diagnoses)

Keywords for diagnosis: "normal chest x-ray" (bronchitis); "bad teeth" and aspiration risk like seizure history (lung abscess). If they're going to ask a specific question about a specific diagnosis they have to "tell" you what the diagnosis is!

Diagnostic tests: universally a CXR initially; but based on diagnosis know that there are exceptions for definitive diagnosis, like a lung biopsy is most accurate for abscess 

Treatment: know which antibiotics treat which organisms (ie penicillin family for staph/strep) and then know which organisms are commonly causative (ie abscess=anaerobes so therefore clindamycin)

I didn't touch First Aid, but I hear it's a good resource (wouldn't rely on it solely though, unless you just want to pass).

Crush Step 2 (Brochert): excellent summary of high-yield topics. Not very thorough (you'd definitely pass just reading this, but would use it as a review during the last few days to make sure you got all of the important information down)

Step Up to Medicine: love this as a textbook, to look up pathophysiology you don't completely understand; wouldn't use as the primary study aid though (saw some people do that)

Kaplan's notecards: I got these last minute (Diagnostic tests, physical exam findings and a general one) to have something to carry around. I also do better with short, concise points; plus they have great pictures. I think it's a great supplement (although a bit expensive; I will probably try to sell mine later, but they're good for step 2 and 3).  Like Crush Step 2, makes sure you didn't miss any important high-yield topics.

NBME Practice Tests: again, pricey ($50 each I think). I did 2 of them "officially." Great for estimating your progress and score; I took one about a 2 weeks before the exam, and scored in the 220s, then did one a few days before the exam and scored 241. There are always rumors that some of the questions overlap with the actual exam (I didn't notice that, although some questions just have to be asked on every exam and those may be the ones referenced), but I think more than that it confirms whether you're ready for the exam.  They all seem to correlate fairly well with your actual score (look on message boards on the net for how each correlates- some overestimate/some underestimate, but by a predictable amount).

Anyway, hope this helps someone out there.  I really think that if you approach studying (even for step 1) by seeing it as a predictable test with a finite amount of information you'll dominate it.  You just have to be willing to go find a resource that will teach you what is important.

The EXTERNSHIP

I'd like to start by apologizing to my few dedicated readers, between my board exams in July and 4 hectic weeks of an externship I've barely had time to keep up with my health, much less things like updating blogs. I had planned on more detailed accounts of my recent experiences, but given how busy I've been it'll have to be a brief overview.

As a 4th year, you get the opportunity to practice being an intern for a month-long rotation (sometimes referred to as externship, sub-internship or acting internship). I lucked out in terms of my team. In general I had an amazing group of residents, attendings and 3rd year med students, which resulted in a very fulfilling and rewarding month. I was worried that a bad rotation would lead me to question my career choice. 

But it was pretty awesome. Other than the hours (of course I NEVER broke hour limits, 80 hours/week..), it was a whirlwind of fascinating patients, decision-making freedom and responsibility I didn't expect for another year. 

I was allowed to, for the most part, make my own plans for patient care, with only a few suggestions and reminders here or there.

So, by far, my externship (in internal medicine, the most dreaded of externships!) was the best rotation I had so far. Now that I've moved on to my next rotation, I am filled with nostalgia when I see my old team rounding together on the wards without me, but like in any other career it's best to quit and move on during a "winning streak" (ok I didn't have a choice and I was exhausted, really). But I don't actually miss many rotations- and I really miss that one already. 

So my advice for your externship?
-Pour your heart into it, because if you don't care, you probably shouldn't be going into that specialty. 

-Just do the time. It's long hours but people see you there and know that at the least, you're dedicated. (On multiple occasions residents on other teams said I should go home, because I worked too much.)

-Go out of your comfort zone: I knew going into the rotation that I didn't feel comfortable placing orders or calling consults. I pushed myself (it took 2 weeks though!), but now I feel like those are both old hat. Two fewer things to worry about as an intern.

-Lend a hand: help a resident with an admission, let a 3rd year med student in on a few secrets ("attendings don't care about the chloride level" or "don't give a history in the subjective part of your note"). You feel better AND reap the benefits later (residents and other students often return the favors).

-Be an enthusiastic learner! Just because you aren't getting pimped as much doesn't mean you should shut the books (or close google, to be realistic). 

Anyway, glad it's over. On to bigger and better things!

Dissecting homework

I finally finished with all of my med school board exams (barring failure of course, which I won't know about for weeks or months) yesterday.  I was planning on blogging about that first, because I don't think that many people understand the brutal beasts of becoming a doctor- otherwise known as the Step exams.  More on that later.

While trying to relax after my 9-hour exam last night, I stumbled across an article: Homework overload gets an 'F' from experts.  Ironically, this has recently a point of contention between me and my fiance (mostly because I keep bringing it back up).  We both had very different childhoods: he did his homework between classes and played outside after school; I had 3 hours of ballet or music lessons and then 4 more hours of homework (this is MIDDLE school).  We both agree (I do, at least) that there's probably a middle ground that's healthiest (mentally and physically, highlighted by the article "High school kids don't exercise enough, CDC reports" which was posted near the other article).  Four hours of homework in middle school is excessive.  My high school homework experience was even worse.

The other problem with making kids competitive academically is that the parents become crazy as well.  See article: Police: Mom hacks school's computer system to change kids grades.  She changed her kids grades from like 98 to 99, WTF?

I had a unique experience with schools; while in kindergarten, my parents researched top high schools in the area, and figured out I had to go to a certain elementary and middle school to get into that (yes, public) high school.  So I did the "academically gifted" classes, making rhomboicosidodecahedrons (see picture) out of construction paper in 2nd grade instead of doing connect-the-dots. My first grade science fair project compared the efficacy of using dish soap on dishes rather than just water (I swabbed them and plated them on petri dishes, and found that using dish soap didn't reduce the number of bacteria growths- probably a reason why I slack at cleaning these days).  I was in Key Club, Battle of the Books, National Honor Society, All-State honors bands- you name it.

And as predicted, I'm now in medical school.  No big surprise.  I attribute some of my success to the ridiculous measures I was put through early on, but a lot of it was pure drive.  I wanted to be a doctor, so I did everything possible- and 99% of it was just stupid hoops to get where I needed to be.  Sure, you learn good study habits.  But 4 hours of homework does that just as well as 2 hours.  And busy work just results in burned-out children who lose the energy to follow their dream.  Had school been longer than 13 years I probably wouldn't have made it this long.

I would like to point out that some work is definitely necessary.  No work means no structure, essentially.  The article points out that requiring homework "takes the fun out of it."  That lady was obviously smoking pot.  Homework has never been fun, required or not.  If not required, it wasn't done.  Even if your career doesn't require an ounce of academia, having been forced to sit down and complete a task as a child sure sets you up to be more successful (unless you smoke pot and don't have a job, like the aforementioned woman probably does).  It's all about responsibility.

Just a summary of modified milestones to shoot for if you want the next nobel prize-winning offspring:

My experience preparing for Step 2 CS

Note: this blog was written 2 weeks ago before I took Step 2 CS.  I'll eventually follow up with a brief reflection on the exam and how this worked for me, but things are hectic as my CK exam is next week!

As I'm winding down to the final few study days, I thought I'd share some of my study tactics.  No guarantees, but I guarantee it's better than the usual advice of "just go in, introduce yourself and wash your hands" and "speak English."  I ALMOST fell for those!  I realized about two weeks ago that there's a lot of preparation needed for this exam- not because my skills aren't adequate, but because the exam is overly structured.

A few reasons why you should prepare:
-You lose points for washing your hands at the beginning and not in the middle right before the physical exam
-You will probably have a phone call scenario- this could be as crazy as a mom calling about her sick child which isn't even with her
-You must drape the patient. It seems that doing it in the beginning results in fewer people forgetting.

Important things to go over:

-Physical exams: you need to have them down cold.  Memorize each set (HEENT, cardiovascular, pulmonary, abdominal, extremity, neuro), and be able to pick and choose or prioritize maneuvers because you won't have time to do them all.  My full neuro exam takes over 7 minutes (this includes a fairly thorough set: cranial nerves, motor/sensory, reflexes, cerebellar exam, and mental status exam), but you only have 15 minutes for the entire encounter.  Know what's critical. Also know what maneuvers pretty much need to be done on all patients (listening to heart and lungs).

-Difficult questions: most scenarios will require you to address a difficult question.  "Do I have cancer?" and "I can't afford to come in for an exam, can't you just send in a prescription of pain medication for me?"  There are long lists of examples, but it really boils down to 3 or 4 general questions, meaning just have a few sentences ready (usually something like, "I don't know what is causing your symptoms, but I can't rule out cancer and I'd like to order some tests to make sure").  These aren't something you would be prepared for if you hadn't read the prep books (not that you can't answer them, but it seems CS wants some pretty specific answer types).

-Counseling: you're expected to catch and address "bad" health behaviors, like smoking, alcohol abuse, medication non-compliance, etc.  At the end, in your "closing," you need to make a statement or two about why it's bad and that you're there to help quit (list some resources).  This is an easy one to forget.  In practicing, I try to make big boxes around the topics while taking notes during the interview so I know which one(s) to address later.

-The "closing:" this is pretty insane.  You need to summarize the history and physical exam findings, then give a few differentials.  This is a good time to then ask for questions. Then give a general overview of your planned workup (labs, imaging, etc), in LAYMAN'S terms!  Even "thyroid" isn't a good word to use!  Patients will jump on the medical terms and make you explain them.  For example, instead of chest x-ray, say "take a picture of your lungs or chest."  Then you should make sure they don't have questions (this is usually when the difficult questions happen).  Also arrange for follow-up.

The format of the progress note and grading have changed subtly in the past month; do your research!!

I think a week of intensive studying or two weeks of moderate studying is plenty; I wouldn't start early, as a lot of it is rote memorization and will be quickly forgotten.

Two good books so far:

First Aid for the Step 2 CS
Kaplan's USMLE Step 2 CS: Complex Cases

Good luck!

Update (12/28/12): I forgot to mention that I passed!  I don't know the exact percentiles but I scored at the top of all three categories!