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Nobody wears a white coat any more...
...a tribute to becoming a doctor.
It is the time of the year when medical students, O Best Beloved, are preparing to take the USMLE step 1.
I finished second year, took a week off, reviewed from four books for six to eight hours a day, five and a half days a week, for two weeks, and did a lot of practice questions. I focussed on pharmacology and got through the entire NMS medicine book. I read First Aid religiously. I pretty much gave embryo a miss.
I did fine. I ticked in just a smidge above the mean on Step 1. If I had done any organizing of my entries at all, I would know where that score was.

I am reading med_school and med_students and trying to comprehend a schedule such as they are proposing. A month or more of studying, hard, every day. Spending hundreds of dollars on review items just in case it'll help.
It's compulsive. We're a society of compulsive students - study this, memorize that, learn the other. Charts and timetables and every little edge you can get you must take. Because it's about becoming the doctor who gets the awards, the one who makes it in Derm. The Orthopaedic Surgeon. The anaesthesiology resident saying that $300,000 a year is a bare minimum salary.
M got an award for the highest score in the entire state on the Pathology final, way back after second year. I caught up with him at graduation and congratulated him. He looked at me with a half-smile. "It's just one test." And I knew what he meant.
We are at a new stage, O Best Beloved, in our education. We are at a point where it is chafing - galling - to be tested and examined like so many laboratory rats; we do not learn from these exams, we do not ever know more than such a percentage in thus an area. For the Clinical Skills step 2, I spent $900, drove to Chicago, stayed in a hotel room and lost $100 in plane ticket change fees. I spent eight hours in white coat and stethoscope moving from rigidly-defined room to rigidly-defined room, filling out forms on a computer that left no room for thought or expansion, mind racing over the questions I must ask and the time limit, barely seeing the patient himself. And I received a white sheet of 8x11 paper, folded in half, with the word "PASS" written in unfriendly block letters.
Tell me, O Best Beloved, tell me what possible contribution my thousand dollars and eight hours, my toil and trouble, tell me what they gave me? When does this painful process where we are subject to review without feedback end? How long are we expected to be both passive listeners - mindless drones who learn and regurgitate - and active learners who question the "accepted way" of things? How many times do we have to subject ourselves to an evaluation instrument that takes away our precious time and gives us nothing back?
O, Best Beloved, I am so tired of being a mouse in a white coat. I am twenty-six years old and I have invested two decades in the art of learning, only to be stonewalled at this final venture. There is a red tube in my bedroom, and in that red tube is a piece of paper conferring on me the degree of Doctor of Medicine and yet the test I had to pass to achieve that degree enriched me not at all.
This is not learning, O Best Beloved. This is not the way of learning, of doctoring, of medicine. There is a National Board who licenses us to become the very thing they have forgotten the definition of. I am a doctor, a physician, and so help me O Best Beloved, I am a teacher.

There must be a better way to get there.

now feeling:: angry angry

12 whispers echo . o O ( ... ) O o . whisper a word
jays_princess From: jays_princess Date: May 24th, 2005 02:53 pm (UTC) (etched in stone)
ah, yes. step 1. how scared am i? i've basically taken to first aid (which i love), and i read the kaplan anatomy book that i borrowed from a friend because i really didn't put any of that into long-term memory. other than that, i'm hitting up QBank pretty hard. i manage about 5-6 hours a day, and i take the exam on the 3rd of june. as far as QBank goes, i'm averaging about a 78 or 80...is that even close to being good enough? i'm asking your advice because i don't know anyone close to me that's been through this before (like, family or close-friends-wise). am i grossly underestimating the difficulty of this test, or am i doing okay?

teach me, oh revered teacher! :) i'm so proud of you!
ayradyss From: ayradyss Date: May 24th, 2005 03:00 pm (UTC) (etched in stone)
You're -fine-. I ran about a 70-75 on Kaplan's free practice tests. The Kaplan ones, IMHO, were harder than the exam itself.

Anatomy's really pretty light, focus on your second-year stuff. If you had a decent pathology/pharmacology program at your institution that'll prepare you better than you think.
Some sections of the exam are easier than others; they come in random order as far as I know - they keep talking about scaling but I don't think it's happened yet.

PLEASE don't forget to take breaks whenever you need them. It's a wicked long exam. Also don't stress over any one question. You never know - the one you're freaking out about might not even count :P
I took my First Aid with me to the exam, did some quick review between sections of the stuff I was shaky on (for me, all the cardioactive drugs) and that helped keep me calm.
jays_princess From: jays_princess Date: May 24th, 2005 03:17 pm (UTC) (etched in stone)
you're amazing...thank you! thankfully, i had dr's emerson and davis for pathology here in indy, and dr. dimicco for pharm...both courses were relatively rigorous so i'm glad for that. i feel pretty strong when it comes to those things. i hear that pathology is a big deal, just because it really involves most everything from embryology disorders to neoplasia.

and i heard that kaplan's QBank was tougher than the actual USMLE, so that makes me smile a little, because maybe i'll do better than i think on this dang test. it is just tough, because i keep hearing that this is the exam that residencies really look at...not that i'm trying to head into something real competitive (i'm looking at ob-gyn, not anesthesia), but still.

sometimes i wish i could learn this stuff matrix-style...they could just plug me into a machine for five minutes and i could learn (and retain!) all of the info i need. i agree, though. it feels a lot like rote memorization and regurgitation right now. i'm guessing maybe it'll get better on the wards.

thank you for your excellent guidance. it's so wonderful! :)
ayradyss From: ayradyss Date: May 24th, 2005 03:20 pm (UTC) (etched in stone)
I completely forgot you were in Indy :P You'll be fine. Path is a huge deal, that and Medicine (which up here in FW was a mess of a course, I don't know about you).

It never gets easier, but it's going to get better. You pick out third-year courses yet?
jays_princess From: jays_princess Date: May 24th, 2005 04:25 pm (UTC) (etched in stone)
i start with family medicine in fort wayne, which i'm hoping is with my old family doctor for a couple of reasons...1)he is excellent and i've worked with him before, in college, and 2)his practice is like 30 seconds from my dad's house. even if i don't get to work with him, i'm thankful they didn't send me to south bend where i don't know anything or anybody. i'm from close to fort wayne (monroeville), so at least i'll know my way around.

then i have vacation for a month. i debated taking an elective, but i think at that point i'll be ready for a break, both for myself as a social butterfly and for my sanity. ;) i have ob during the autumn months, and i have surgery in the winter, which is how i wanted it. i figured, i'm not going to see the light of day anyway, so why take it when the weather is nice? i finish up with internal medicine, psych, and neuro. i'm actually pretty excited about neuro, i think that will be very interesting, even if it is kind of depressing.

my surg sub-speciality is in there somewhere, but i don't have my schedule in front of me so i'm not sure when it is exactly. i'm hoping for either cardio-thoracic or plastics, just because i think it would be interesting and the surgical field would be big enough that maybe i'd get to see something. i had thought about doing neuro-surg or opthalmic, but the surgical field is so small i doubt i'd get much enjoyment out of it.

i've heard that good books for all these rotations are the pre-test books, because they prepare you for the exams you'll have to take. are these all NBME exams? any suggestions?

medicine was actually a pretty good course for us in indy. it was VERY comprehensive, but many times we focused on clinical skills, which isn't something that will show up on this Step exam. however, they really coordinated things so that when we were studying pulm in Medicine, we were covering it in path, too. it was nice the way they did it. did you guys have any coordination like that in FW?
ayradyss From: ayradyss Date: May 24th, 2005 06:16 pm (UTC) (etched in stone)
Coordination only by accident, mostly, it seemed. :P
Path was awesome in FW though.

Rotations are a lot of shelf exams. Don't let the FM one get you down, it's a miserable miserable exam, one of the hardest there is. You've got the same schedule I did almost, block-wise. I found surgery in the winter worked out for me well.
Neuro is super easy, in a lot of cases. So's Psych. Great finisher courses. They just changed the OB exam last year, which is good. Neuro is an easy exam, study the materials they give you.
From: silmaril Date: May 24th, 2005 02:57 pm (UTC) (etched in stone)
Engineers can come up with similarly themed rants, though none with as much justification and intensity---after all, we don't have to be dragged all around the country for our examinations, for one thing.

There has to be a better way. Here's hoping it will be found.
turnberryknkn From: turnberryknkn Date: May 24th, 2005 03:45 pm (UTC) (etched in stone)
(nods nods) It's a real challenge.

I can sympathize for many reasons, ayradyss, as your thoughts have a lot of personal resonance for me not just as someone who has to take the exam, but as someone whose activist career was born fighting it...

A long time ago, I was one of the fools who touched off the five year fight against the Clinical Skills Step 2 exam, which was originally supposed to come into effect in 1999-2000ish. Obviously, we didn't win, but we did manage to throw enough sand in the gears that my younger brother went entirely through med school without having to take the damned thing. A lot of stories of a lot of politics, which I've told in bits and pieces in my diary along the way. Always an interesting situation when the body which makes the money from the exam is linked directly to the body which decides whether said exam is necessary. Said fight was a huge part of the lives of fellow activists like culfinriel, resonance42 and mdrnprometheus. And now, as incoming Chair, mdrnprometheus is gearing up to formally fight the NBME's idea for a *fifth* licensure exam (after the three written USMLE exams Step I, II CK, and III) and the Step II CS you directly cite, what the NBME is calling the "professionalism" exam, an exam whose origin was first mentioned waaaay back when I was still wearing my AAMC hat as official AAMC pain-in-the-NBME's-arse and we hadn't even finished the fighting on Step II...

And to those four licensure exams (maybe five) comes of course your Family Practice Resdiency Board Certification exam, and if you do a fellowship of some kind, the separate Fellowship Board, which will make a grand total of anywhere between five and eight major national exams from start to finish, depending on how they do things. Except now, for you and I and all the rest of us in our generation, we, unlike our predecessors, don't just take those last two exams once in a lifetime, like lawyers take the Bar. We will retake our Residency Boards and our Fellowship Boards every five to ten years for the rest of our profesional lives.

And that's not even counting "continual recertification", which I know Internal Medicine and other specialties are experimenting with, which amounts to mini-licensing exams in between the offical big licensing exams. All of which we get to go places and pay money to do.

And the NBME has often floated the idea of making the Step 2 clinical skills exam also a renewal requirement -- that is, not just once, but every ten years or so, at $900+ a pop. I mean, the NBME gets a lot of money for doing it, and we don't really have a whole lot of say in the matter save whatever sand in the gears we can throw in via activist work like yours and mine...

All what we signed up for, of course, but I understand your feelings. It's a pretty interesting little road we've signed up for, no?
mdrnprometheus From: mdrnprometheus Date: May 24th, 2005 05:55 pm (UTC) (etched in stone)
And mdrnprometheus is really wondering if, on a money and time basis, it might not cost less to just hire someone to go after Dr. Peter Scoles' knees with a tire iron.

At this point, I think our best hope actually lies with something called the Initiative to Transform Medical Education. It's the beginnings of the "Flexner 2.0" process we've all heard about for years. If we can move meded away from being so memorization-based, it'll force a re-examination of the entire USMLE process, and then, then perhaps the tests can once again actually test ability to care for patients.
iliana_sedai From: iliana_sedai Date: May 24th, 2005 05:03 pm (UTC) (etched in stone)
The longer a test is around, the more elaborate the schemes that people devise to either get around them, or to do really well. And after a while, they are no longer testing honest knowledge or ability, but strategic planning. And the strategic planning often has a direct association with money.

Walk into the college counseling office of, say, a long-standing East Coast boarding school, and I can guess they've been telling their kids to take that SAT four, five, six times. I've looked at the score progression and seen them jump ... 900... 1100... 1200... 1400... w00t! 1550! (And now, I suppose the score has 800 more points these days.) Pour enough money into a kid and you can make any average kid look smart. But after that, the test results in no way reflect what they were intended to measure.

Same with the USMLE. The study plans become more elaborate, more time-consuming, and more expensive over the years. The test changes, then eventually the industries -- both the test-taking industry and the medical schools -- slowly adapt themselves and find strategies to overcome the test. So that, at the end of the day, the test has very little real value in describing what you know or in teaching you anything at all. It just shows how good you are at digging up the dirt on how to score well (either by paying Kaplan or doing Internet research), and how much time and money you spent.

There are better ways to do this and many other things.
leon03 From: leon03 Date: May 24th, 2005 10:55 pm (UTC) (etched in stone)
I doubt that a score progression like that over a single year is common. A couple years, perhaps. I took the SAT in 7th grade and got a 1100, again as a sophomore and got a 1250-ish and in the fall of my senior year I achieved a 1450, though I never really focused on SAT-specific preparation. Maybe these schools are encouraging their students to take the SAT once or twice every year in high school, and combining that with specific preparation.

Strategic planning has a connection to honest knowledge, and the strength of this connection depends on the test. This isn't so strong on the SAT, and I don't know about the USMLE. However, when it comes to say, the AIME, the USAMO, or the Putnam Exam, all prestigious math tests, the connection is very strong. In fact, in this context I can barely see a difference between the two in this context, as you need a great deal of honest knowledge as well as a certain amount of "strategic" preparation.
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12 whispers echo . o O ( ... ) O o . whisper a word