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!

Med school's a bear market, and lucid dreaming masks

So in a recent post I mentioned nightmares.  I was pleasantly surprised while writing that entry that I hadn't had any within the last week or so, and I thought that since my 3rd year was finally wrapping up that maybe I was on the down-slope of the stress and anxiety.

SO WRONG!  After writing that post, that same night, I had another nightmare.  I know this is a totally weird topic to do a blog on, but just having finished my psych rotation, and learning about Freudian and Jungian dream interpretation, I felt the need to share how applicable that is AND how much med school is affecting my subconscious.

If you want to know more about the nitty-gritty of psychological dream interpretation, this site is a good place to start.  It's honestly pretty fascinating.  Anyway, the point is that they both theorized that dreams are/can be manifestations of your subconscious problems, frustrations, etc.

You'll have to research on your own to learn more (highly recommend it!), but back to my nightmare.  Like I mentioned, mine usually involve me in life-threatening situations (makes me wonder if I have nightmare disorder because adults aren't supposed to have nightmares much at all).

So this time I was camping with a bunch of med students (so unlikely on every level: I hate camping/outdoorsy things and I don't really hang out with my fellow med students at all outside of class), and all of a sudden there's a huge, ravenous bear tearing through our campsite trying to kill and/or eat us.  At first we were all working together to find places to hide or escape, but after a while of having to keep moving and hiding, we all get to the point of "ratting out" other students to save ourselves.  It turns into a Hunger Games/Lord of the Flies hybrid but without the gore and without the killing each other part.

I know at one point the bear was kind of also a really evil person and I got caught and somehow escaped (can't remember those details) but I remember running like h*** when I did.  It was also nighttime and it was hard to see where you were going but I remember considering the bear having the advantage because it could still smell.

Anyway, this is a pretty obvious example of my (sub)conscious revealing my true feelings of med school: (in the MOST BASIC SENSE) that they're out to get us and that they are (kind of?) pitting students against each other to "survive" (ie get a good residency).  I think it's been extra tough lately because I've been told that I don't have the best application for residency and may not ever achieve my lifelong dream of becoming a cardiologist.

I know it's not really like that, and that my school is way better than a lot of others (they really do want to help), and the students, on the med student spectrum, are on the compassionate, normal-people side if that's even possible.  Regardless I'm obviously stressed about this whole residency thing!!

Regardless, I'm leaving for a tropical vacation tomorrow for an entire week and hopefully that'll alleviate some of my worries.

On a brighter note, I've been contemplating getting one of these amazing lucid dreaming sleep masks.  That's not exactly the one I was looking at - there's a new one being advertised for about $100 and it's made some of the bigger news outlets.  I'd never spend that much on a sleep mask (I'd have to try that one out before spending that much!), but it's such an amazing idea.  I read about it as a kid and have only been able to lucid dream once or twice (you know, where you're almost awake and can control what you're doing).  The mask somehow detects REM sleep and flashes lights so you eventually are supposed to be able to recognize the flashing lights and know that you're dreaming.  There are a lot of techniques out there to train yourself to be able to recognize that you're dreaming and this happens to be a sort of "cheat."  Anyway, it's pretty neat.  If I could do that I'd fly or sit on a beach or something instead of being chased by a bear.

Lessons from an addiction clinic

One of the really great lessons I learned from my experience in the addiction clinic is that of forgiveness.  I know that one of the 12 steps in Alcoholics Anonymous (wow, I've been to way too many of these groups, as a med student of course!) is about forgiveness.  When the group started discussing it this time, I thought, psh, this isn't something I can apply at all.  I had been able to use a lot of the behavioral techniques in other areas of my life- controlling anxiety, restructuring my assumptions so I have fewer irrational "girl moments," etc.  But forgiveness??  I didn't have anyone to forgive or ask for forgiveness.

Boy was I wrong.  Looking back, I've had a pretty amazing life.  It's been a struggle- I've worked for most things I've gotten (a least the big stuff, and the recent stuff, like med school).  But one thing that I'd pushed from my mind was my last relationship.  I'm so thankful for a wonderful relationship right now, but I realized during this group that I still hadn't really forgiven my ex.  The relationship turned my life upside-down at the beginning of medical school, right when I needed stability the most, and although I've "gotten over it," I don't think I ever had closure.

These days I'm so busy, so I choose to ignore or suppress memories and events that are unsettling.  I am aware that this is an immature defense mechanism, but honestly I guess I think "I'll deal with it when I have more time."  Which by the way, in the life of a med student, is never.  So I think I'm getting out easy.  But then it just builds up, a million of these "I'll just forget it" moments, and I'm full of anxiety again.

The idea of forgiveness isn't easy.  And even more, how do you freaking accomplish this?  You don't usually just wake up one day and think, my conscious and subconscious has forgiven this person!  So I guess part of my problem was not knowing how to start.

The counselor, one of my new heroes, made it really simple.  AA is Christian-based, but it doesn't have to be religious (you pray to your HP, or "higher power" for all of these things).  Anyway, for it to work, he told us, you have to get down on your knees and pray.  (I'm not super-duper religious, for those of you who don't know me.  This was kind of awkward.)  You ask for all the things you want for yourself- happiness, closure, a good relationship, success, money, whatever.  Then you finish at the end by saying that you wish all of those things for whoever you are forgiving.

The thing is, you don't have to really mean it. That's why you say that at the end- that it's for that other person.  You can better reflect on what you want (or what any other reasonable person would want) and then stick that on the end.  And again, you don't really have to mean it.  But it you do it over and over again- 14 days to be exact- the counselor said that you would forgive the person.

I still thought this was crazy.  But I had realized that I needed to forgive my ex.  So I tried it.  I asked for all the things I wanted, then threw in a few that I already had (good relationship specifically, since that was my big issue with him), and asked for it to be given to him.

I didn't feel any different.  And I have to confess I only did it one day.  But the craziest part was that night, I had a dream where we met face to face and I was able to verbalize my forgiveness and I had an overwhelming sense of peace about that part of my life for the first time.  The reason this kind of dream is so weird is that for the past couple of months I've only had nightmares where I'm about to die.  (That's a whole different blog unto itself...obviously my stress has manifested itself in my sleep.)

Anyway, I probably should have finished out the two weeks but I figured at least my subconscious had at least partially forgiven him.  (This is a great example of how my life is full of "I'll do it later" thoughts.)  So the point is, if you have someone you are still angry with, or even someone who doesn't like you for some reason and you can't figure out why (the counselor suggested that scenario), and you're willing to try this, it might help.