At least for the computerized portions (Step 1 and Step 2 CK):

• Practice, practice, practice. I used Kaplan’s Qbank for Step 1 and USMLEWorld.com for Step 2 CK. Half of the difficulty of the exam is being able to sit down at a computer screen and concentrate for 9 hours, and a quarter of it is knowing how to handle questions to which you have no freaking clue what the answer is. This is the big benefit of practice question services (also, it’s easier to make yourself go through another set of questions than to stare at a book again).
• Categorize and conquer! Get used to eliminating answer choices; get used to guessing between two or three possible right answers and moving on.
  I divide questions into three groups:
  a) those I know that I know the answer (answer and move on),
  b) those that I know I’m not sure about (answer and mark to go back to later), and
  c) those I know that I don’t have a clue what the answer is (answer and move on).
  There’s absolutely no point in stressing or wasting your precious minutes on categories a or c. If you know it, great. If it’s some ridiculous question that you’ll never know, and you can barely even eliminate any answer choices, don’t pull your hair and stress. That is letting the exam get the best of you. Take your best guess (usually your first instinct) and move on.
  Once you’ve gone through all the questions for a block, if you have time, go back and confirm/review category b. The key is to keep moving! You can easily freak yourself out by one tough question, when it’s more important to spend your time on questions you could possibly get right!
• Read the last sentence first. Maybe 10% of the time, you’ll get a question with a long, drawn-out paragraph about some patient, but then the question they’re asking is only tangentially related. For example, “Susie takes lithium. She has had bipolar disorder for 3 years now, she has a history of hypertension BLAH BLAH BLAH… What is a common side effect of lithium?” So you’ve just spent a good 30 seconds reading about Susie, when Susie doesn’t matter to the question, only lithium does. By reading the question ahead of time, you’ll also be able to focus in on what they want you to answer while you read the vignette–diagnosis, treatment, pharmacology, pathophysiology, etc.
• Keep track of what block you’re on. You’ll get a dry erase marker and two sheets of laminated paper to scribble on. Write down which block you’re on–it’ll help motivate you toward the end of the test and help you see there’s light at the end of the tunnel.
• Take breaks when you want, there’s plenty of time. You get something like an hour for breaks throughout the day. It’s plenty of time. If you’re thirsty, finish your block and get some water. Need to rest or pee? Go for it. They allot 30 minutes for lunch, but if you bring your own, you’ll eat it fairly quickly due to your nerves–and you’ll want to just get done. There’s plenty of time. (Plus, if you finish a block early, or get through the “Training” session early, those times get added to your break time, too.)
• Breathe. It will all be okay.

Any other tips people have used?

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labnormality, n . lab•nor•MAL•it•ee. A patient’s laboratory testing value that falls outside the normal range. (plural labnormalities) Ex: “Man, this guy has a ton of labnormalities… hyponatremia, hyperkalemia, and he’s hypotensive… crap, adrenal crisis!”

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In medical school, we take “Step 1” of our Nationalized, Standardized Board Exams before we start seeing patients in the hospital. Then, in order to graduate and start residency, we have to pass two parts of “Step 2.” “Step 2 Clinical Knowledge (CK)” is a 9-hour, computerized exam consisting of 8 1-hour blocks of 46 multiple choice questions. “Step 2 Clinical Skills (CS)” is a 9-hour, practical exam where you see 12 standardized patients, perform a history and physical, and write a note about the patient with a basic idea of your workup and diagnosis for the patient.

Now, there is some talk also about combining both Steps 1 and 2 into one exam taken during the final year of medical school. I’ll address this issue and then address the Boards more generally.

I would strongly oppose combining the two exams into one, for one main reason: Step 1 is what a number of residency directors use to help determine who to interview for their residency programs, especially at medical schools which lack grades (Stanford, where I am, lacks grades). I think this would quickly lead to all medical schools adopting grades, which I think is especially detrimental to learning, especially in the pre-clinical years. Medicine is now, for the most part, a team sport. I think it’s incredibly important for medical students to learn how to effectively communicate with their colleagues (classmates) and work together. And I think you don’t learn that when you have grades.

Grades encourage competition, gunner-ness, and cut-throat behavior, when what you really want is the promotion of cooperation. Especially in the pre-clinical years, when all you do is study and take exams. If you eliminate the major way that gradeless medical students are deciphered by residency directors, you give medical school deans all the more reason to put grades back in the curriculum. (I believe grades in the clinical years are a different story, so I won’t comment on them. I do believe, however, if you encourage cooperation in the first two years, you’re more likely to have collegial relations with your classmates when working in the hospital.)

On Step 1
Step 1 seems like a necessary evil in retrospect. It sucks, studying for it sucks, and it’s painful and nerve-wracking. But it forces you to put all your knowledge from the first two years in preparation for seeing patients. It forces you to review everything you’ve seen and forgotten, and integrate and optimize that little brain of yours. This ends up being a really good thing for seeing patients. My main critique is the subject material, but I’ll cover that elsewhere in my discussions of the curriculum.

On Step 2 CS
An utter waste. An utter. Total. Waste.

As I’ve said before , the administrators of this test take in $17 million each year for the exam so that a few hundred students each year don’t pass, take it again, and then most of them pass.

First, there’s only five cities in which one may take the exam. So if you’re not in Atlanta, Chicago, Philadelphia, Los Angeles, or Houston, you get to pay for airfare and hotel for the night, out of pocket (the exam is 7-8 hours long, so it’d be hard to fly in and out without staying the night). Next, most medical schools already require their students to participate and pass an exactly similar exam with standardized patients.

These Step 2 standardized patients are much worse–they have absolutely no personality, only poorly acting their roles. You’re being graded–at least partially–by your ability to show compassion. So you’re constantly pretending to have sympathy, while they’re pretending to actually require your sympathy. You ask, “Do you have any fevers or chills,” and they robotically reply, “No, Doctor, I do not have any fevers or chills.”

You’re also judged on seemingly worthless physical exam criteria like putting your stethoscope in the right place. So to the creators of Step 2 CS, it’s more important to be able to pretend to examine a patient than to actually identify a murmur or hear crackles on exam.

Next is the silliness of the exam itself: once you leave the exam room, you’re not allowed to re-enter. What? Are you kidding? How many times do I think to myself, “Gosh, I guess I need to do a neuro exam too,” and dart back in the room to do one?

Finally is the stupidity of the patient note. You have to come up with a differential diagnosis for the problem in question (this is good), but there’s no description of how wide a net to cast . The “workup” portion of the exam is incredible. It’s apparently more important to be able to come up with a list of lab tests and studies to order than to know what to do if someone is dehydrated and can’t tolerate oral liquids, or to give someone with symptoms of a heart attack oxygen and an aspirin.

Add in the fact that you receive absolutely no feedback on how you did from the standardized patients (it’s fine to just grade us, improvement is beyond the Step 2 CS) just adds icing to the cake.

Look, either make it a real, practical test, and really test to see if people know what to do with patients, or admit that it’s mostly to see if people can speak English. If it’s the former, put some life into it. If it’s the latter, make the International Medical Grads take it and please quit wasting my time and money.

If medical schools are doing their own standardized patient exams, why not allow the schools to proctor their own exams? They can certainly determine English language ability and if the students are competent to become doctors–after all, they are the ones granting the person the MD, aren’t they ?

On Step 2 CK
This actually wouldn’t be all that bad of an exam from the “review everything you’ve learned” point of view if it weren’t such a crappy exam. (No, seriously.)

First, most of us fourth year students take this exam and then spend much of the rest of fourth year vacationing in anticipation of the hell that is internship. So often most of what we learn from studying for the exam is lost to nicer memories like the sights of Europe or the beaches of Thailand.

Second, the exam contains way too much pre-clinical, worthless detail. You know, honestly, I truly do not care what the pathology might reveal on a tissue biopsy of someone with myxedema. It is not important to me nor my patients. It is, however, possibly important to know how to diagnose myxedema or treat it. (Thankfully, the exam is much more clinically-oriented than Step 1, but no way near enough.)

Third, the answer choices are often ridiculous. For a suspected pneumothorax, my options are not “ultrasound,” or “chest CT,” or “X-ray.” They’re things like a) thoracotomy b) needle thoracostomy c) MRI head d) diagnostic peritoneal lavage. I kid you not. If you want me to suspend disbelief for a minute and pretend I’m trying to manage these patients, then give me some realistic answers, people.

The Bottom Line
Keep Step 1.
Drop Step 2 CS.
Fix Step 2 CK.

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It’s not always hunky-dory as a medical student. In no particular order:

1. You don’t have an MD after your name. There’s plenty of times when I’ve wished I was just a resident already. (I know, I know, I’ll be eating my words in July.) It’s frustrating when I can’t just sign off on something harmless and have to get approval for everything.
   It’s also really, really frustrating when patients ask to “see a doctor, not a student.” This happened maybe twice during my whole medical career, so I certainly lucked out. You want to say to the patients, “Wow, maybe you shouldn’t come to an academic teaching hospital then,” but you bite your tongue. It’s hard not to take it personally. Sure, I don’t have as much experience as a resident or attending, and it’s certainly a learning experience to deal with that comment in stride, but you’re going to be seen much faster if a medical student is assigned to see you than if you get put back in the pile, and all the other residents and attendings are seeing patients already. But hey, go ahead and wait.
2. Loans, loans, loans. I haven’t added it all up (mostly because I’m frightened to), but I’ll probably end up with around $110,000 of student loans by the end of medical school. The average debt is somewhere between $100-$135k, so I’m somewhere in the average. (Add in undergrad loans and you’re easily looking at $200,000 for many people.) It can really suck going through your 20s accruing up debt, living the student life while your friends are working, making money, buying homes, cars, and other nice things, building up their investment portfolios and retirement IRAs. Again, wouldn’t trade medicine for anything, but there’s certainly been times where I’m jealous and wish I was doing something different.
3. Pre-clinical curriculum. In medical school, you spend your first two years in the classroom, memorizing literally books of information in preparation for actually seeing patients. These years, from an academic standpoint, suck. Sure, you have time to get to know your classmates, party, etc., (think college but more hardcore), but the rote memorizing sucks. You have no idea what of this information is going to be useful, and what of it is going to be an absolute waist. You don’t have any clue about what real disease is like, and you’re just memorizing random little facts like: Rose gardner = sporothix shenki and reheated rice = B. cereus. (I’m not kidding.) You’re memorizing a ton of facts about drugs that are not used anymore, and that’s just pharmacology. Which brings us to…
4. Med student syndrome sucks. If you’re at all high-strung or anxious or neurotic as I tend to be (if you’ve met me: I hide it well), you have this fantastic ability to diagnose yourself with every possible disease you’ve just read about. Since you have no clinical acumen, you don’t appreciate the fact that if someone has colon cancer, they have more than just blood in their stools. They are also usually old, have other constitutional symptoms, etc. Medical student syndrome tends to go with the unit you’re studying: I was absolutely, totally convinced I had lymphoma during our hematology block. So convinced was I that I made one of our hematology attendings feel my neck to feel one particular lymph node. On the positive side of things, it was then and there that I learned the ability of a physician to provide instant emotional and mental relief, as he told me it was nothing.
5. As we all know from being 9th graders, it stinks be the lowest on the totem pole. You know the least, you get picked on the most, and as we all know, “Shit runs down hill.” Eventually I began to jokingly volunteer for the blame: “It’s usually the med student’s fault, so I guess I did it.” Everyone you’re working with is also evaluating you, so even if the residents have to stick around and do paperwork, and you have little-to-no reason to be present, you end up sticking around more often than not–at least until you’ve proven to the residents that you’re a reasonable, decent guy who will not make more work for them.
6. It’s hard to get time off. This probably applies to all of medicine–residency too–but it always annoyed me, so here we go. Because you’re constantly jumping from rotation to rotation, it’s hard to find time for basic, time-offy things like, oh, going to the dentist, or anything else you have to schedule far in advance? You never know where on a call schedule you’re going to land that month, or how nice your resident is going to be about time off. Sure, you’re given X number of days off per month, but you generally don’t figure that out until the rotation begins.
7. It strains relationships. During my orientation, I remember a senior student saying that many people view medicine as a very selfless profession, but in her opinion, it’s an incredibly self ish one. That we require an enormous amount of patience and understanding from our families and loved ones in order to deal with our schedules and time limitations. The statistic is tossed around that doctors have a higher rate of divorce–unless they’re married to other doctors–and I believe it. Even during our medical school career, the vast majority of couples that started out together no longer are.

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Combing through some old photos, I came across these I took when then-Senate candidate Obama stopped by our offices at PNHP back in early 2003. And for the record, as far as I can remember, he didn’t support single-payer then , either.

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As promised , now that I’ve finished my Boards (cross your fingers that I passed them!), it’s time to take on some big themes of the past almost-five years .

I was one of those people that really enjoyed most of clinical med school. (I would say that pre-clinical med school wasn’t so bad, but I certainly didn’t enjoy it much of the time– my post is still the top Google hit for “i hate med school.”) Clinics were great for the most part. You’ve spent your first two years trying to figure out the basics of health and disease, memorizing countless facts, and you’re not really sure how they’re at all useful. And then you get to clinics, and–wow!–this is the stuff I went into medicine for! So let’s start with that:

1. You get to see patients. You get to take your knowledge, everything that you’ve learned, and try to figure out how to make it useful and practical for a person that comes to you with a complaint. I was simply amazed at the level of trust and openness my new patients provided to me. Asking probing, very personal questions and they answered. Men and women who might otherwise not feel comfortable expressing their emotions–be it through laughter, tears, or anger–would open up, for better or worse. And people get better ! And many were appreciative ! It’s fun to say “you’re welcome” when someone is thank you for helping them. It feels great to shrug, “Hey, that’s what we’re here for,” or “Don’t thank me, I’m just doing my job.” Because it’s genuine. One of the reasons I loved (and continue to love) Geriatrics is that it’s so, so simple to make huge gains in a person’s quality of life. The smallest actions can provide the biggest benefits. Discuss and decide to take a patient off their beta blocker and watch their energy rise! It’s fantastic.
2. You don’t have an MD after your name. I think there’s an assumption (that I hope to dispel) that if you’re a doctor, you have to know everything. That “I don’t know” isn’t an acceptable response to a patient. I think that’s going to change with my generation of physicians, but it certainly still exists today. The best answer you can give a medical student, second to the correct one, is “I don’t know, but I can definitely find out.” ‘Cause see, you’re not expected to know–you’re a student !
   Another semi-benefit: you can’t sign orders. This becomes a pain when you’re ready to sign orders–but nothing annoys a resident more than getting called 20 times a day for stupid little orders to be written. (Brownie points are quickly earned by med students who write the orders for their resident and just ask them to review and co-sign them.)
3. It’s easy to beat expectations. I don’t know if the bar was just set low, but it really seemed like doing well was pretty straightforward:
   • Show up on time.
   • Don’t complain (unless the residents complain first, then you may join in and agree).
   • Try your best.
   • Do what’s expected of you (and know what’s expected of you).
   • Be genuinely interested. (The fake way to do this is to say “Why yes, I’m considering Neurology” when you’re on the Neurology clerkship.) But don’t be so naive to think that what you learn on rotation X will not apply to your chosen specialty Y. Answer: it will!
   • Ask questions if you can’t figure something out by yourself. (I remember my very first day of rotations, we were rounding in the ICU and my intern mentioned “Scids” and had no idea what they were. I finally asked, and found out OOOHHH, those White and Orange things, SCDs, sequential compression devices!)
   • Ahem, ask questions at an appropriate time. I’ve heard of people asking for anatomy tips while a surgery attending and chief are trying to trying to control a big bleeder.
   • All of these rules are actually just this simple gestalt: Do not make more work for your resident and intern.
4. People like to meet medical students. (And it’s fun to have people like to meet you!) After you get past that “Ooooh, a future doctor!” bit, you can easily become the life of the party with stories you’ve stolen from your residents or quirky little anatomy tips.
5. The classmates! I’ve met some of my best friends for life in medical school, and feel incredibly fortunate to have gone through this experience with them. They’re amazing, fun, interesting, creative, compassionate, and brilliant. I’m blessed. And from a larger, life-perspective, I know I have friends in every facet of medicine and in every major city in the country that I can think of if I ever have a question or concern about something going on in a loved one. Truly priceless. (Free lac repairs if you ever need them, guys.)
6. It’s a safe environment to make mistakes and learn. Some of this may be “Why it’s great to be a med student at Stanford,” but I can’t really tell. Thinking through my clerkships, I’d say 80, maybe 90% of my attendings were responsive and interested in teaching and education. Some certainly more than others; some certainly better than others, but it was a rarity to be around a jerk or malignant person. In fact, when briefly swapping stories with friends from other schools, Stanford seems incredibly benign–and incredibly trusting. Once I got the hang of patient care, I was more-often-than-not asked, “Well, what do you want to do with this patient?” forcing me to think through things myself. I wasn’t always right, or someone would teach me something that might be a bit better–the art of medicine–but it made a huge difference that I was even asked. The best rotations were the ones where I was actively involved–that I was treated like a valued member of the team. Just feeling included means a huge deal. Even if the team was going to start lisinopril whether I suggested it or not, just giving me the opportunity to respond instead of writing the order themselves was huge. (And on rotations where I didn’t have this experience, I was asked for–and provided–constructive feedback. They remain nameless, but know who they are!)
7. You can be proud of what you’re doing, if you love it! I’m sure we med students don’t all feel this way, and maybe it’s all just still romanticized in my head, but I feel like I’m truly doing something good. I have friends who hate their jobs; I have others who don’t mind them–that they pay the bills, at least. But I still think I’m incredibly fortunate to be given the opportunity to make this my life’s work. I couldn’t imagine myself doing anything else–and I’ve certainly tried. For some people, optimizing a bottom line is probably as much a thrill as medicine, but this is mine. There’s a lot of crap we have to deal with, and plenty of reasons to complain–but that’s everybody. I’ll take my headaches anyday!
8. It’s amazing to watch your brain learn. It’s a similar feeling to how I felt when my brain just started “understanding” French. I was reading a billboard one day in Paris (lived there for a summer during undergrad), and realized I was reading it in French without the need to translate. Similarly, it’s almost Matrix-esque to be able to spit out the doses of lisinopril without ever sitting down and memorizing them. You wonder, “Where the hell did that come from?” It’s just the osmosis of being around clinical medicine for long enough. (At least for me–I learn best by doing.)

Phew, that’s enough for today. Feel free to add your own. Next up: “Why it stinks to be a medical student.”

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Hey Jon Marshall, DO, thanks for recommending Hydroxycut ! I know you’re just a “Resident Physician” as the commercial says (funny, it didn’t mention you’re a radiologist in training ) but you radiologists interact with patients and advise them on weight loss pretty consistently, right? Look, you’re pretty hot and all, and I’m sure that helps sell the pills, but seriously, dude. You chose medicine for “the science behind it. I also like dealing with people and helping them,” and you’re hawking a product with pretty iffy science behind it (Hydroxycut was sued for making false statements about it being “clinically proven” and paid to settle). And you have to admit, it’s kind of funny that you “like dealing with people,” so you went into radiology.

(Side note: what’s with Midwestern University DO School ? They seem to be churning out the resident DO physician product marketers–it’s where both Dr. Marshall and Dr. Swanson went.)

To be fair, at least the Hydroxycut site gives references for their scientific research (in one study of 30 whole patients, another with 60) plus two studies that seem to be about caffeine and green tea.

But also to be fair, the advertised weight loss of 29 pounds in 8 weeks actually isn’t healthy , Dr. Marshall. And I think people are really looking for long-term weight loss, not just 8 weeks’ worth.

Hydroxycut isn’t limited to DOs, however. They’ve got Nick Evans , a MD and attending orthopedist/sports medicine man hawking the product, too. (At least his specialty is related to exercise and weight loss.) Dr. Evans, dude, you look huge! (My favorite is the Bodybuilding Anatomy book with his head photoshopped on a drawing of a bodybuilder torso.)

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I’m certainly guilty of this one:

http://imgs.xkcd.com/comics/duty_calls.png

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Maria’s got a great post that is funny, true, and speaks volumes. Questions.

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He staged an accident so he could cut off his right hand. A close psychiatrist colleague would’ve gone with a little Geodon action.

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