Liz's Medical School Journey

I feel refreshed from visiting several national parks and family during the past weeks.   I especially want to thank my mother-in-law (also an artist and teacher), who helped me create a set of four encaustic (hot wax) artworks based on memories from human anatomy class.    These images are shared below, although they are much better envisioned in 3-D.

Clockwise from Top Left: Stomach, Muscle, Brain and Heart.  Encaustic with class notes, twigs, wall compound, glitter and oil paint.

Exactly 5 weeks and 5 days after taking my National Boards Step 1 exam, I received the e-mail from SCORES@nbme.org:

“Your USMLE Step 1 SCORE REPORT will be available later this morning on the NBME Licensing Examination Services (NLES) website.  Due to a larger-than-normal score release today (Wednesday, July 14), examinees may experience some delays in accessing their results…”

Since I was flying on Wednesday, I actually got the e-mail on Thursday morning, and didn’t have any problems accessing the score report.  As soon as I opened the PDF, I was relieved to see the bold “PASS.”  To tell the truth, my relief was mixed with a tiny bit of disappointment because I hadn’t achieved my highest dream score.  However, I probably set my imaginary expectations too high, and ultimately I should be pleased by my own efforts and progress.

When I called my dad to tell him I received my passing score, he didn’t even ask about the score.  He simply said, “Congratulations.  Do they give Nobel Prizes for Board Exam Scores?”  In other words, don’t be too disappointed or too proud. His feedback made me grin.  He always seems to have a concise way to offer support while reminding me to keep things in perspective.

So, Step 1 is done.  I passed.  I am officially 1/2 M.D.  Now, I have more important things to think about, like my pediatrics rotation starting in a week!  I am beginning to feel nervous excitement about being a 3rd year student.

Sky while hiking.

It’s official, 3^rd year has started this week. I am taking this first block off to spend time with my family, enjoy nature and attend a far-away wedding.   Despite the fact that I haven’t started my first rotation nor have I received my Board score, I feel like I can say, “I’m a third year!”

Third year is a whole new chapter.  My orientation packet reads:

“Congratulations!  After 19 years in the classroom you are about to begin an entirely different educational experience.  No doubt, you will find it to be the most exhilarating but exhausting year of medical school.  For most, it will be the highlight of your medical education.”

Make that 22 years in the classroom, counting my work as a teacher and my post-bac classes.  Oh yes… this is the highlight I’ve been waiting for!  The advice section includes: “Don’t lose sight of who you are,” “Try to carry snacks/ water,” “Take a deep breath,” and “Be happy/ enthusiastic/ energetic.”

In fact, everything sounds like general advice for a happy life, except a few items, such as “Know how to read a cxr and ekg systematically before starting.”  “Cxr” is chest x-ray, and “ekg” is electrocardiogram (my small group leader last year informed me that “ekg” is actually a German abbreviation and not “proper English,” so now I try to stick to ECG).  Maybe I could handle these tasks somewhat, but my current attempt is rather unsystematic at best.

Fortunately from here onward, my daily experience will guide me to develop my own systematic approach to everything patient-oriented.  I will be an apprentice to doctors and residents, and under their supervision, I will be assigned to my own patients.  I will be on my feet, working hard daily.  No doubt, I will never be the smartest person on the care team and I’m sure to embarrass myself often, but I still feel like third year is a welcome change.

It was strange to see  my schedule for my last two years of medical school listed on paper.  Third year consists of eight 5-week blocks, while fourth year contains thirteen 4-week blocks.  There is no built-in vacation, except 2-weeks at Christmas/ New Years.  The blocks are a short list that fits on a single page, below which is written “Graduation: May 20, 2012.”  Could it really be approaching that fast?

At my university, third year has two mandatory 10-week (2-block) rotations; medicine and surgery.  And 3 mandatory 5-week (1-block) rotations; pediatrics, OBGYN (obstetrics/ gynecology), and psychiatry.  My school encourages everybody to take Family Medicine in the remaining block, although Family Medicine is a 4-week rotation, and can be taken at the beginning of fourth year (which is what I’ll do).

My rotation schedule: I’ll be starting 3^rd year on August 2^nd with pediatrics.  That will be followed by medicine, OBGYN and 2-weeks off for the holidays.  Then, in January I’ll come back to psychiatry and finally, surgery.  Every rotation is at a different hospital, and from now on, my peers and I will have different paths.  Mine begins with this vacation time, and I am determined to enjoy it before I leap into this “most exhilarating but exhausting year of medical school!”

I didn’t do the calculations myself, but one of my classmates added up all the exams we had taken first and second years in medical school, and got 50.  If that’s the case, then this week I brought my grand total up to 52!

I took the Step 1 exam on Saturday, and then I took another little exam that I was trying not to worry about until after my Boards.  Faithful readers may recall that I failed my Hematology-Oncology exam this year (you can read the entry here).  I’m not proud of this fact, and hesitated to make it public knowledge on my blog.  However, I decided that this reality is an important piece of my medical school story.  I am not a perfect medical student (even when I try my hardest) and the first two years have been challenging.

As I was studying for my Board exam during the past months, I spent extra time with Heme-Onc.  The medical school supported me by providing tutoring, and even encouragement.  I’m happy to say that Heme-Onc, including all the chemotherapy drugs that I once dreaded, are now familiar concepts to me.  The make-up exam went well, and now it’s behind me.  Thank goodness!

My Boards are another story.  I still am filled with nagging feelings about my performance, and am slightly disturbed that nobody seems to know for sure when or how we get our score reports.  I was under the impression that I would receive an online score in 4-6 weeks, but the printed sheet I received at the end of my exam said they would mail my results in 8 weeks!  Another friend recently shared that she believes her older brother got his results by e-mail in 3-4 weeks.  I guess I’ll find out soon enough, but right now waiting for the results feels like eternity.

I was full of nerves before my exam.  I tried to stay calm, and treated myself to a full body massage and frozen yogurt the day before.  I asked close friends and family to keep me in their thoughts and prayers.  Nevertheless, I couldn’t get rid of the feeling that somebody had opened a can of jumping beans inside my body.

There was a huge thunderstorm the night before, and between booms and strange dreams, I barely slept.  I had never been awake for so many hours before such an important exam.  My husband comforted me during the night saying, “Don’t worry, I’m sure nobody sleeps well before this exam.”

I awoke feeling mildly ill, and I actually wondered, “Could I be sick?”  I didn’t feel like eating, but forced myself to have breakfast.  I drove myself to the testing center ahead of schedule, all the way feeling like I ought to be in a better mindset before the exam.

Then, I got there.  I found a woman with a large text wandering outside the building.  She looked just as anxious as I felt, so I approached her and helped her find the testing center.  The staff let us get started right away.  I was the only one there all day taking the Step 1 exam, so they checked me in first.  After getting photographed, fingerprinted and documented, I got my seat in a cubicle #2 with laminated paper and a huge set of noise-canceling headphones.

I began the test, and things got better.  I’m not sure if I imagined it, but I felt like the first hour was the easiest, as if they were trying to soothe me into test-taking mode.  How nice of them!  Also, there were only 46 questions per hour.  I was expecting 48.

When I took my lunch break, I saw the same woman I had met in the morning who had just finished.  She had received her results immediately, and confided in me that she had barely passed.  I told her congratulations, and not to worry because nobody would ever know the difference (simultaneously I realized it was important for me to remember these words as well).

8 hours flew by, and before I knew it, I was toasting with my husband and a glass of nice wine. My study calendar is in the recycling bin, and I have cleaned up my piles of books. At this point, I still can hardly believe it’s over!

10… 9… 8 more days until my Step 1 exam!  Do I feel ready?  Um… NO!  Do I feel nervous?  Gulp!

Step 1 is so expansive, I’m not sure I could feel ready.  I can quantify the past 3 weeks with about 125 hours of studying, 3 blue highlighters, 200 note-cards, and one afternoon off.  My husband has taken over all domestic duties.  Thank goodness!  I have gone over everything, and now am going back over everything again… and again.  I’m trying to memorize and learn more details about mechanisms, enzyme names, pathways, drugs, etc.  I am afraid that every piece of new information that goes inside my brain will knock something else out.  And my practice “Q-bank” is down to only a few hundred unused questions.

I’m not sure how I hoped to feel before my test.  Mainly I wanted to feel confident that I know a majority of the material really well.  At this point, at least I feel like I will pass the exam.  I’m not sure if I am satisfied because there is still a part of me that wants to do a lot better than that (215-230 to be exact).   After so much studying, I hope this hard work pays off!

Last Friday night, I had sushi with a classmate who had just taken her exam.  She had a glow of happiness, which gave me something to look forward to.  Completing the Boards is a big accomplishment, and there will be satisfaction just from pushing myself to a new limit.  Hopefully in a few more days I can feel the afterglow too.

After all this hard work, everything comes down to whether or not it will be “a good multiple-choice day.”  I know I’ve put as much effort into studying as I can.  So, my performance will be a mixture of knowledge, specific test questions, anxiety, energy level, and comfort at the testing center.  I’m hoping for a combination that helps me do my best.  As I’m counting down, please send “good multiple-choice” vibes my way.

My updated study schedule.

“Step 1,” “Boards,” “USMLE,” “US Medical Licensing Exam Step 1,” or whatever you want to call it… is dominating my life right now.  If you prefer not to hear about it, then skip this post (and probably the next few as well).

I’ve informally polled my resident and young doctor friends about medical school, and it seems most agree that the Step 1 exam was their lowest point in medical school.  Also, most say they would gladly repeat 3rd-4th year, but  NOT 1st-2nd year.  A high school classmate who is now an OBGYN resident wrote, “Good luck! I have some of the worst memories studying for Step 1, it’s truly the worst Step! Remember, it only gets better after this…”  *sigh* I am at this low point, but have lots to look forward to.

I wish I could tell you more about the history of the USMLE Step exams, but I obviously do not have time for that right now.  I do know at some point, it became mandatory that every 2nd year medical student in the USA pass this exam before beginning third year, including me, of course!  Over the course of this year, I have slowly come to terms with the horrific tests that await me, including my current buddy, “Step 1.”  Now that my test date is less than 3 weeks away, I can tell you all the basics.

The exam is an 8-hour, multiple choice test (seven 1-hour blocks with 48 mixed-topic questions plus 1 hour break).  It is administered by our favorite company, Prometric, who brings us great joys, such as the MCAT, SAT, ACT, LSAT, etc.  The Step 1 exam costs $505, but the real cost is more like $1,000-1,500, once you include the study materials and access to online practice questions.  There is no option to retake this exam, unless one fails it.  In which case, one must retake the exam until a passing grade is achieved.  Each exam is recorded on the medical transcript.

Basically, the score is out of 326 (possible points= # exam questions).  The national average is 215, and the average scores of residents in different areas of medicine vary drastically.  As the deans at my medical school said, “some residency programs are more boards oriented,” meaning they consider board scores to be as important, or more important, than character evaluations or clinical performance.  These areas include Dermatology, Anesthesiology, Radiation Oncology, to name a few.  It is rumored that some of these residency programs do not even look at applicants who score less than 240 or 250 on their Boards.  Fortunately, I don’t believe these professions embody my callings in medicine.

Yet, like all my fellow 2nd year students, I still feel tremendous pressure to do well on the exam.  On my future residency application, this exam score will weigh-in more than my entire performance during 1st and 2nd years.  Given that I don’t know which residency programs I want, or where my husband and I hope to live, I want to keep my options open.  And, most of all, I want to avoid any future disappointments and regrets.  I am humbled by the fact that I have never felt that a standardized test score truly represented my gifts.

At the moment, my mood fluctuates between feeling like “this isn’t so bad, I will  do great,” and feeling like a total impostor to medicine.  Since my last exam ended a week ago, I have been studying around the clock, 7-10 hours of study time daily.  For me, this is the most I’ve ever studied in my life, and it requires mental discipline and stamina.  At first, I thought I was going crazy (feeling anxious, tired, upset, hungry, and restless), but thankfully the human body is quick to adapt.  Today I remembered that it is important for me to avoid total isolation (which is tempting), and hence here is a blog update.

My evolving study schedule I made with sticky-notes, so I can move things around (another student's idea). As you can see, next week is mostly empty.

One of my classmates and faithful readers (thank you Ilana!) reminded me that my description of Physical Diagnosis cannot be complete without telling you about one of my funniest days in medical school.  And I’m positive you would rather read an entertaining story than read about my final exams.  Plus I need a mental break from Boards, so here goes…

That Wednesday it was a dark, rainy morning, especially dark considering it was 5:30am.  I got dressed as usual, trying to turn-on as few lights as possible, so my husband could keep sleeping.  I put on brown slacks, and gathered my white coat and medical tools.  Ready!

It was pouring while I walked to the subway, so I was trying to stay dry.  I commuted by subway 45 minutes to get to my bus.  I picked up my usual Chinese milk-tea and almond bun on the way.  We had the spacious bus that day, so I had a seat to myself, where I could relax and put my feet up.  And as I was doing so, I gasped.  I was wearing two different shoes!

Two very different shoes: different shapes, styles and colors.  One was brown and the other was black.  One was pointed, the other was round.  One was Clarks, the other Ecco.  How could I not notice earlier?!  In fact, they suddenly felt different on my feet too!  Apparently I was more exhausted than I thought.  I’m pretty sure I’ve dreamt a similar scenario, but I always woke up thinking, “Thank god that was only a dream!”  That morning there was nothing I could do.  Home was hours away, and nobody packs extra shoes for the hospital.

So, I was stuck with one brown and one black shoe all day.  The first thing I decided to do was tell my classmates because I knew somebody would notice eventually.  Besides, it was pretty hilarious, and an honest mistake anybody could have made in the early morning hours.

Everybody did find it pretty funny.  After a round of “Let me see!” and giggling, one person suggested I could snag a walking boot at the hospital, take off one shoe, and pretend like I injured that foot.  Fortunately my patient was a 6-month old baby.  He didn’t care about my shoes.  In fact, despite being sick, he was cheerfully cooing and grabbing his feet.  Infants and young children can be so refreshing when they don’t have societal qualms that we do.  His mom noticed at one point- at least I saw her look at my feet, then look up, then scan back down quickly.  I wished I could have tuned in to her thoughts, which probably began, “Wait, are those… YES they are…”

In the afternoon, I was assigned to give my oral presentation to the head of the pediatrics department, a tall fellow who takes things very seriously.  As you can imagine, I felt about 2 inches tall while giving my presentation.  I stayed seated, with my legs crossed (hoping to make my feet less noticeable). But, he didn’t seem to care, and if he did, he never said anything.  Therefore, I made it through a whole day with two different shoes, one of the most embarrassing things I could do to myself, and I survived!

In the future l will be checking my shoes very carefully, especially next year during surgery when I have to get up in darkness daily.  Now, however, I feel more prepared for future embarrassments.   At least I know I can make it through a normal day, even if I look weird.  Most people really don’t notice the things that we feel the most self-conscious about, or if they do, they don’t really care as much as we think they will.  So maybe someday I’ll see a medical student with two different shoes, earrings, socks, or a shirt on inside-out, and I’ll understand.