End of Second Week

I'm done now with my second week of family med, and the time is really flying. I am still having a great time. You never know what you're going to see when you come into the clinic. Yesterday I got to observe and help a bit with a minor outpatient surgery. I also met a really fascinating patient who survived pancreatic cancer. The coolest part of his story is that the cancer was found incidentally when he participated in a research study that involved imaging his abdomen. He was extremely lucky that it was found so early, because pancreatic cancer is often too advanced to be cured by the time it becomes symptomatic.

Today we had classes. Like I said before, there is never clinic on Fridays unless you are unlucky enough to have call Friday night on one of the inpatient services. Again, we had a surgery patient presentation, then an IM patient presentation. For both cases, we went through the differential and talked about what studies to order to figure out how to narrow the differential. We never did figure out what was wrong with the IM patient, but that's ok. None of the docs who were caring for this patient figured it out either. After that we had a clinical rounds session on abdominal pain led by two surgeons. We didn't get through more than about half of the cases, but I can see now why the surgeon said that he likes abdominal pain so much. There is a huge differential, especially if the patient is female and of childbearing age. The surgeons ran over, but we had to stay afterward for a path presentation on appendicitis. I was having a very hard time concentrating by this point, and the UP students were upset because they had to get back to Case by noon for an orientation and it made them late. Somehow, we got this whole afternoon off, so I had plenty of time to run all of the errands that I needed to do.

Finally Got My Step 1 Score

I didn't sleep very well at all last night. I kept waking up at least once every hour, and I was having these totally bizarre dreams. In one of them, I had gotten a 34 on the MCAT, but it was a 15 VR, 4 PS, and 7 BS. (Note: VR = verbal reasoning, PS = physical science, BS = biological science.) I was worried that I wouldn't get into medical school because of the 4 in PS. (For the record, I know that these subscores only add up to 26, but somehow they added up to 34 in my dream!) In another dream, I was washing my favorite pet cat, now deceased. I had to wash him a little at a time so that he wouldn't struggle while I was bathing him. Because of this, it took me several hours to wash the whole cat. When I was finally done, he was emanating a soft, whitish light. People were crowding around and commenting about how silky and shiny his coat was.

Once my alarm finally went off at 5:20 AM, I got up and went to the computer. I had left it on all night so that I could check for my score as soon as I woke up. My heart was pounding when I logged into the NBME website and saw that the score report was indeed there. I opened it up, and the first thing I saw was the word, "PASS." This caused an immediate resolution of my palpitations (pounding heart) and tachypnea (faster than normal breathing). Then I scrolled down a little farther and saw my actual scores. Total, utter relief. I have been trying so hard for the past three weeks not to think about the USMLE that I hadn't even realized how anxious I was about it subconsciously. I feel like such a huge weight has been lifted off me. I know that this one test score is not the end-all, be-all of residency applications. But I am just relieved to know that if I don't get the residency of my dreams, it won't be because I bombed Step 1.

The score report breaks down your performance by subject area, just like the practice tests I took did. Interestingly, my best subject on Step 1 was micro/immuno, of all things. My worst? Yeah, it was anatomy. No surprise there. :-P

Waiting on my Step 1 Score

Today is Tuesday, and the next batch of Step 1 scores should be coming out tonight at midnight. It has been exactly three weeks since I took the test, so it's possible that mine will come out tonight. I'm hoping it will, but I'm also trying not to get my hopes up too much, if that makes sense. At this point, I really just want to know how I did so that I can make whatever plans I need to retake, or study my butt off for Step 2, or plan the celebration, or whatever.

Yesterday, I had clinic in the morning and then another anatomy session on the extremities and pelvis in the afternoon. I was kind of annoyed about having to come all the way downtown to Main Campus for a 1.5 hour anatomy session. But it was required, so I went. Actually, it was really good. These ortho residents were much nicer about pimping us gently than the thoracic surgery residents were last week. The only bad thing was that the cadaver with the arm dissection was kind of sick looking, mainly because of how the skin was peeling off. It made me feel a little nauseated, and I had to take a quick break.

The preceptor I was supposed to work with this morning isn't here this week, so I wound up spending the whole day working with my afternoon preceptor. I haven't worked with him before, but he's pretty cool too. All the family docs have been cool. I screwed up a Pap smear today, mainly because I still don't have the knack of using these plastic speculums. I always have a hard time finding the cervix with them. Plus, this patient had a lot of discharge, and it was hard for me to see what I was doing. On the bright side, it looks like I'll be getting plenty of practice. There is another Pap on the schedule for my morning preceptor tomorrow. I definitely need to work on the neuro and musculoskeletal exams some more also. The doc today loaned me a physical diagnosis book that goes over these exams and told me to practice at home. It's a good book, actually, because it takes you through the exams step by step. Maybe this weekend I will talk someone into letting me practice on them.

Friday Didactics

The last couple of days have been pretty crazy, but I'm really enjoying my family med rotation. The preceptors are really into teaching, the nurses are encouraging, and the patients have been a varied and interesting bunch. They've also been super about letting me interview and examine them. I think the key is to start by first asking the patient if they mind talking to you for a few minutes. I've never had a patient tell me no. What better thing do they have to do while they wait on the doctor anyway? Asking if you can talk to them first gives you a chance to build up enough rapport with the person to then ask if they'd mind letting you examine them. I've never had a patient refuse the exam afterward either, even after I've been asking them detailed questions about their sex lives or drug use.

Today I had class all day instead of clinic, and this will be the schedule for every Friday throughout the block. We started at 7 AM with a surgery morning report. One of the students in my group who is doing his surgery rotation right now presented a patient, and the group went through a differential, talked about what tests we should order, and evaluated the results. I didn't really know what I was doing a lot of the time, but it was fun to try to come up with a diagnosis and plan anyway. Afterward, one of the students on internal med presented a patient, and we did the same thing for the IM patient. The IM morning report ended at 9 AM, and then we went through two hours of acute renal failure cases. This was a seminar led by one of the internists, and it was a really good review of the material that we had covered back in May.

There is a huge difference in how the surgeons run their morning report versus how the internists run theirs. Surgeons are much more formal and want everything done a certain way. The preceptor went around the table and asked everyone to answer a question. (I had to interpret the blood test results.) The internist, on the other hand, was much more laid back and informal. Unlike the surgery presentations, which have to be done with powerpoint, the internal med presentation was more like a group discussion. People could jump in and make comments or suggestions whenever they wanted instead of having to wait to be called on by the preceptor. I can see pros and cons to both methods. I like how organized and efficient the surgeons are, but at the same time, they don't seem to have as much room for individuality and creativity as the internists do.

This year, CCLCM has a new buddy program to pair up first years with upperclassmen. I went for lunch with my buddy, and we talked for about an hour until I had to go for my FCM class. Yes, FCM does continue on even after second year. The third year FCM class alternates with the third year POD class. (Note: POD is actually called ARM now.) We have all new groups for FCM that I think will stay together for the next two years. The groups are a mixture of third and fourth years. The thought had occurred to me last year that it would be interesting to have mixed-class PBL sessions. This isn't exactly the same thing, but now I'll have a chance to see what mixed groups are like. Most of the session was in a big group. We were asked to write a paragraph about one of our experiences at the end of it, and then several of us read our paragraphs out loud. I wrote mine about the last patient I saw at the end of second year. That was the one where I picked up an MI by going through the review of systems, which is the kind of experience that tends to make a lasting impression on you.

First Day of Family Medicine Rotation

I had my first day of family medicine clinic today, and it was terrific. I'm at Beachwood Family Health Center, which is one of the CCF suburban family health centers. I did two half-days with two different preceptors: one from 8 AM-12 PM, and then again from 1 PM-5:30 PM. Unlike the IM clinic I worked in for the last two years, the family med docs don't cut back their patient schedule to accomodate the medical students. So there were at least a dozen patients on the schedule for each half day, which is twice as many as there are in the IM clinics. Today I saw seven patients on my own, presented them all to my preceptors, wrote SOAP notes on each one, and logged them all. I also went into the rooms with my preceptors for three or four other patients.

I had expected family med to be fairly monotonous after hearing some of my classmates' experiences with their suburban longitudinal clinics last year, but my patients were surprisingly diverse and interesting. The very first patient I saw had been diagnosed by a specialist with an extremely rare disease that the doc had never even heard of before. I knew what the disease was, but only because I just took Step 1 and it was one of those ostensibly pointless things to memorize in First Aid (the Step 1 review book). Now I'm glad that I learned that info! After that, we had to send the second patient for an immediate specialist consult due to concerns that what she thought was a minor problem might be a medical emergency. (This turned out to be a false alarm, fortunately.) The rest of the patients weren't quite as exciting as these two, but they were still a varied lot, from kids with sports injuries to elderly people with twelve different comorbidities and two pages worth of medications. All in all, it was a really good day, and I'm excited about going back tomorrow.

CCF Core I Orientation

Today was technically the first day of my Core I rotation, but it was another orientation day. For some reason, we had to be at the Clinic at 7 AM. First, the faculty who are running Core I told us about each rotation in the block. These include family medicine, outpatient internal medicine (IM), surgery, and inpatient IM. I will be starting my actual rotation (family medicine) in the morning. Then the IT people taught the UP students how to use our portal, and one of the librarians told them about the CCF library resources.

We were finished around 10:30 AM, and then we had to wait until our anatomy session began at 3 PM. I spent the time working on my schedule for the winter block, which will begin in November. It's a good thing that I started planning my schedule this early, because it turns out that the block that runs during Christmas and New Years isn't a four week block for Case. So now I'm going to do my research month in December, after I do my geriatrics rotation in November. Have I mentioned lately how difficult this clinical block system makes scheduling electives and other rotations?

The anatomy session was really good. There were only 14 of us, so we were in really small groups for our prosection stations. This was like a normal anatomy seminar for us, but it was a new experience for the UP students. (They do traditional dissection of embalmed bodies.) The UP students in my group seemed to like the prosections. I had spent some time over the weekend reviewing the anatomy of the neck, thorax, and abdomen, but I still am going to need a lot more review before I'm surgery-ready. We have one more of these anatomy sessions next week to go over the limbs and pelvis.

My schedule for Core I is the following: three weeks of family medicine, then three weeks of outpatient IM, followed by five weeks of surgery, and ending with five weeks of inpatient IM. I will be out at Beachwood for my family medicine rotation. Then I come back to the main campus for my outpatient IM, which consists of general IM clinics in the morning and specialty clinics in the afternoon. My three specialty clinics are a week each of outpatient pulmonary medicine, gastroenterology, and cardiology. My first week of surgery will be outpatient specialty clinics as well, and then I have four weeks of inpatient surgery where I will be assigned to one of the surgery services. For inpatient IM, I will have two or three weeks of general inpatient IM followed by two or three weeks of inpatient cardiology. I'm really looking forward to that last bit, because cardiology at CCF is just awesome.

Bridge Week Day 4

Today was the last day of Bridge Week. We had to come in at 7:30 AM to take a practice Step 2 test for five hours. Taking a practice Step 2 test a week and a half after I took Step 1 (and before I have even done a single rotation!) did not exactly thrill me, but I have to admit that I was curious about what the questions would be like. That's why I stayed the entire five hours and tried to do my best to answer the questions, even though the temptation to mark them all with "As" did cross my mind a few times. I was surprised to find that the test was remarkably doable. I knew the answers to quite a few questions. I'm not saying that I passed necessarily (we'll find out in a couple of months), but I don't think I totally embarrassed myself, either. We have to take three more of these exams: one after Core I, one after Core II, and then one more that we schedule on our own with the administration staff.

In the afternoon, I ordered some books for my rotations, and I registered for two of the electives that I'll be doing at CCF this winter. It turns out that we are allowed to do some of the advanced core rotations with only Core I as a pre-req after all. So I will be doing my geriatrics core rotation this winter. I wasn't expecting to be able to get it done before I take Step 2 for real, so this is a welcome surprise.

Bridge Week Day 3

Today was a long day of hurry up and wait. We had to be at CCLCM by 7 AM, but it was mainly so that the UP students who are rotating at the Clinic could get their IDs, parking assignments, and white coats. I did get two sets of scrubs that I don't really need, and then three of my classmates and I went for breakfast. We spent the rest of the morning learning how to use EpicCare. This is the Clinic's electronic medical record, which we've been using for the past year in our longitudinal clinics. To be fair, I did learn how to do some things that I didn't already know how to do, but all in all, this morning left me feeling kind of grumpy about having to get up so early for not much value in return. At least the power was back on in the Education Building when we got there this morning.

The afternoon session was better. We got to skip the first hour, which was about the grading policy for the UP students. (The CCLCM students don't get graded, although we do get evaluations.) Afterward, we had a session to learn how to use the Clinical Assessment System (CAS) to log our patients during rotation and research blocks. I was playing around with it later, and amazingly, it's extremely easy to use. It will allow me to document all of my clinical experiences so that I can keep track of how many patients I see with various diseases, procedures I perform, and so on. We also use it to submit forms for the faculty and housestaff to evaluate us. The last event was a student panel with half a dozen fourth years from the UP. About the best advice that I heard today was to treat every rotation as if it were the specialty that I was planning to enter. I thought that was very good advice.

Bridge Week Day 2

We had to go back to the Sim Center this morning for another four-hour session. Again, we were divided into four groups and we went to four different stations for an hour each. The first station was to practice presenting a patient to an attending. Of course, we all suck at it, but I got the message that we'll get very good at doing this in short order.

The second station was to start IVs and draw blood. It was run by the same anesthesiologist who taught us acid-base first and second year, the one who is really awesome. It was kind of a weird station because we had these rubber mannequin arms with veins, and we were supposed to put the venipuncture needles into the veins. When you got it in right, you would see a little bit of fake blood come up into the needle. What was funniest is how PC the whole thing was. There were some white (Caucasian) mannequin arms, and also some black arms.

The third station was to practice the female exam and deliver a baby. Again, this was all done with rubber bodies. Delivering the rubber baby from the rubber pelvis (complete with a rubber placenta that could be stuck to the inside of the uterus with velcro) was pretty bizarre! Then we had foam breasts with lumps in them, and we practiced doing the breast exam on those. I did a lot of breast exams in clinic with my preceptor, and these foam breasts aren't anything like real breasts! We also did a practice pelvic exam on, you guessed it, a rubber woman's pelvis. The os was amazingly easy to find, much easier than on a real woman. Each time I have done this exam for real, I have never been able to palpate the ovaries, and today was no different. But at least this time I had a good excuse, because the rubber pelvis didn't have any ovaries, just a uterus. :-P

The last station was for the male exam. We did practice rectals on rubber male rear ends. There were four of them set up, one with a normal prostate, one with benign prostatic hyperplasia, one with an early tumor (which I wouldn't have been able to palpate if I hadn't known it was there), and one with an advanced tumor (which was so obvious by palpation that the only way you could miss it was by not doing the rectal exam at all). Then we practiced catheterizing rubber male and female urethras. When you got the catheter in far enough, it would dribble fake urine. Since men have a long urethra, you really have to push the catheter a long way to get to the bladder. I went to catheterize the female model afterward, and got the catheter into the bladder immediately. This is the difference between having a 20 cm long urethra (men) versus a 4 cm long urethra (women).

This was the end of our session at the Sim Center. We went back to the Clinic, and a bunch of us had lunch with the new first years. The power was out in the Education building (I guess because of the storm last night), so it was really hot, humid, stinky, and dark inside. After the lunch, the first years went off to do whatever they had to do, and we had a class meeting about rotation and research requirements. I have already met with Dean Franco about how I want to schedule my last three years of med school, and she thought my plan was fine. My research PI was also ok with it. I'll mention more about it in another post, but briefly, I will be alternating back and forth between clinics and research over the next three years.

After the class meeting, we were done for the day. I went over to Case to get my PPD test done, then went home. I have to be back at 7 AM tomorrow morning, so this is going to be it for tonight.

Bridge Week Day 1

Today was the first day of the clinical part of my third year. This week is Bridge Week for Case UP and CCLCM students who are doing clinical rotations this year. We only had a half-day of orientation today, although I went over to school early to do some required online modules and run other errands. Tomorrow I absolutely must get over to the Case student health center to get my PPD (tuberculosis skin test) done. I won't be allowed to start my rotation next week if I don't get this done.

Our orientation session today was fun. We went over to the Mt. Sinai Simulation Center on the Case campus. Probably about 50 or 60 students were there, mostly Case and CCLCM third years and some CCLCM fourth years who did research last year. There were four stations: one for reviewing how to read EKGs, one for tying surgical knots, one for reading chest x-rays, and one for stitching cuts. We were divided into four groups, and we spent about an hour at each station. The doc at the EKG station was the same one who taught us about EKGs during our cardio blocks at CCF. I had to be reminded how to tie the surgical knots at the second station, but after I did it once, it came back quickly. I am very glad that I went to that Surgery Interest Group knot-tying session last year. The chest x-ray station was run by an emeritus doctor who was absolutely hysterical. Now I will always remember that alveolar lung infiltrates are patchy, while interstitial lung infiltrates are grainy! The last station was fun too. First, we stitched a quilt, and then we stitched cuts that had been made into mannequin arms. That was pretty weird. The mannequins even had red interiors when the rubber skin on their arms was cut, although they didn't actually bleed!

I had a really good time today, and I am more excited than ever about starting my rotations.

CCLCM Step I Timeline

This timeline will be most useful for CCLCM students, but some of it might be helpful for students from other schools too.

Late October to Early November 2007:
I registered for Step 1 at the NBME website. This is when the UP students register since they take the test in early March, so we have to register at this time too even though we'll be taking it at the end of June. Registrants pick a three month window, which for CCLCM students should be June-July-August. We are then able to register for any day within that three month period, assuming that there is an open slot at that test site. We paid $480 to register for the 2008 test, but they'll probably charge more in future years, so check on the NBME site.

Late November to Early December 2007:
Time to pick a test site and date on the Prometric website after you get permission to register from the NBME. Don't procrastinate on doing this, because the testing sites will fill up and you might not get the date and location that you want. There aren't any Prometric sites closer than a 45-minute drive away from CCLCM. Some of my classmates took the test in Strongsville or Mentor, which are the closest locations. But I am going to study here for five weeks and then go home to take the test. My date is July 1, which is the last Tuesday of our six weeks off. I think most people are taking it a week or two earlier than I am, but I'm waiting longer so that I can have the Memorial Day weekend off.

December 2007:
I took the NBME Comprehensive Basic Science Exam (CBSE) in mid-December. This exam lasts four hours and covers all of the basic medical sciences. It can only be taken through the school, and it is optional for CCLCM students. Some of my classmates took it last month with the Case students, but I couldn't take it that day. So I asked Wilma (the school administrator) about a makeup, and she was generous enough to arrange a second date just for CCLCM students.

Even though most CCLCM students will fail since we are so early in our second year, it's still worth taking the test. Med students at many other schools are required to take the CBSE as part of their normal curriculum in order to assess their preparation level in the basic medical sciences. The test is by the same people who write the real USMLE, and it gives you a valuable preview of what the real test is like, as well as feedback about your individual strengths and weaknesses. I would guess that about 3/4 of the people in my class took it. If you do sign up to take the test, don't back out later if you can help it. The school has to pay for each student who signs up to take it, including anyone who winds up not taking theirs.

March 2008:
I took my first NBME CBSSA (Comprehensive Basic Science Self-Assessment) over spring break just to get an idea of where I was at that point. This was the first time that I passed the test.

May 2008:
I began studying part time for Step 1 for the last few weeks of school, then full time afterward. Many of my classmates started studying much earlier than this. I took all five of the other NBME practice exams. The school gave us vouchers so that we didn't have to pay for Tests 3 and 5.

Late June to Early July 2008:
Usual time for CCLCM c/o 2011 students to take USMLE Step 1.

USMLE Step 1 Resources (Organized by Subject)

General
-First Aid for the USMLE Step 1 (had a love/hate relationship with this book (mostly hate), but it is good as an outline and for tips and mnemonics)

Anatomy
High Yield Gross Anatomy (good for people like me who need extra review, but probably not a very high yield subject for most people)

Behavioral Science
-High Yield Behavioral Science (great, concise book and I highly recommend it)

Biochemistry
-Lippincott's Illustrated Reviews: Biochemistry (strong subject for me, so I only read the 40-page review at the back of this book)
-If I had more time, I would have read Rapid Review Biochemistry

Cell Biology/Molecular Biology
-Didn't study anything specific for this, mainly because I ran out of time and this was one of my stronger areas.
-A lot of people like to use High Yield Cell and Molecular Biology.

Embryology
-High Yield Embryology (cannot say enough about how much I loved this book. Finally felt like I understood embryo, and I wish I had used it during my embryo sessions last year)

Immunology
-Review of Medical Microbiology and Immunology (immuno section only, which I highly recommend)

Microbiology
-Clinical Microbiology Made Ridiculously Simple (good mnemonics and funny drawings to help you remember the bugs and drugs)
-Lippincott's Illustrated Reviews: Microbiology (mainly just read the earlier sections on lab tests for the pictures)

Neuroanatomy and Neurobiology
-Clinical Neuroanatomy Made Ridiculously Simple by Stephen Goldberg (short, easy to read review of neuroanatomy)
-Some of my classmates liked Roadmap Neuroscience, but I found it to be dense and too tough to get through during my study period.

Pathology
-Rapid Review Pathology by Goljan. (Got through this once and most of a second time. Best to use it along with his lectures, but start early if you're going to do this)

Pharmacology
-Lippincott's Illustrated Reviews: Pharmacology (intensive 500 page book with questions; start early if you're going to use this one!)
-High Yield Pharmacology (short, outline format, good later review)

Physiology
-BRS Physiology (looks long and hard, but it's a quick read, especially if you don't do the questions!)

Question Books
-Robbins Review of Pathology (great book for reviewing path, although the questions are easier than the real USMLE)
-Kaplan USMLE Step 1 Qbook (used this to review after I finished studying each subject)

Question Banks and Practice Tests
-Kaplan Step 1 Qbank (used about half of this earlier on in my studying)
-USMLE World Step 1 Qbank (used about half of this toward the end of my studying)
-NBME CBSSA Exams 1-6 (best way to monitor your studying progress. Test 5 was the most predictive for me. CCLCM students get two free tests paid for by the school.)

My General Advice for Step 1

One thing I will warn you about ahead of time is that everyone you ask will tell you to do something different to ace the boards. I found this out for myself very quickly when I started asking some of the CCLCM upperclassmen what they did to study. Get two of them together in a room, ask them one question, and they'll give you three contradictory opinions. At some point, you need to think about what learning style works best for you, and just trust yourself. You didn't get halfway through med school without developing effective study habits. So use that knowledge to help you develop a plan that will be effective for you.

First, you should decide if you are a group studier or a self-studier. There are pros and cons to working with other students, and I think if you get the right partner or group, then studying with others can be extremely effective. That being said, I'm definitely a self-studier. A lot of my classmates worked together in groups, and I'm not inherently averse to doing that. But I have always been more of a self-studier. I studied on my own for the MCAT, and it worked out very well. So I decided early on not to study with other students. For me, the downside of being around other stressed people when I'm stressed myself far outweighs the benefit to be gained by bouncing ideas off other people.

Second, you need to decide what method helps you retain information best. A few people learn well just by reading, or by attending review sessions and having the info presented to them. Some people learn well using audio lectures. I think that many people learn well by doing a lot of practice questions, and that was the approach I took. I find that it is easy for me to kind of skim through stuff without really understanding it thoroughly if I just read it and don't try to apply what I've read to practice problems. I've always done well in math classes, but I have to work problems. I can't read a math book like it's a novel and hope to retain anything. Ditto for the USMLE.

Here's my general philosophical approach to studying for the boards (or any other exam): You start by figuring out what your weaknesses are, and you work on those first. That's how you get better and ultimately score higher. Plus, every school has certain subjects that are covered very well (cardio at CCLCM is, unsurprisingly, very thorough) and others that aren't as good. (I would say that our micro, pharm, and neuro are not as well-done.) You will need to put more time toward filling in the specific knowledge gaps that your school's curriculum has left. In my case, I needed a lot of work in neuro and micro, and I wasn't familiar with a lot of the drugs for pharm. In addition, since physiology and path are two of the highest yield subjects for the boards, I wanted to make sure I had them both down cold.

People often wonder how long to spend studying. Again, this is something that each person has to decide for themselves. Some of my classmates were already doing board review stuff during our first year. Others basically did nothing until spring of second year. I didn't start studying really hard until May of second year. It's hard to review path much earlier than that because you won't have covered the material in school yet. For CCLCM students, two really good subjects to start reviewing early on in second year are micro and immunology, because we cover those during first year but don't come back to them again second year. Neuro is also a good early subject because that's our first block during second year.

The final piece of advice that I have for you is not to go too crazy buying all kinds of resources. You won't have time to use them all. Pick a few good review books, and go with those (and your practice questions). Most importantly, don't give up. It's hell while you're going through it, but make sure that you work hard during your second year and study hard during your study break. If you do those things, everything will work out in the end.

Done with Step 1!

I took Step 1 today, and I honestly have no idea how I did. I feel like I passed, but I'm not sure if I just barely passed or I totally killed it. I know there is at least one question that I definitely missed, and another one that I think I missed except that I can't remember the specifics any more to be sure. There are also a couple of questions I guessed on that I know I got right. I should be getting my scores in 3-6 weeks.

In the meantime, there's not much I can do but relax for the rest of this week and get ready to start my Bridge Week on Tuesday. I'm really looking forward to starting rotations, and also glad that I never have to read First Aid again. (Have I mentioned lately how much I hate that book???)

Feeling Good about Step 1 Next Week

I have one more week to go until I take Step 1. Today I took the last practice NBME exam, and this is the best score that I have gotten yet. It's way higher than I needed or wanted to get. If I do this well on the real test, I am going to be super happy. I'm still not doing as well as I'd like to be in anatomy, embryo, and neuro. So those are going to be the subjects I focus on now, along with cramming all those last-minute stupid details that the NBME likes to ask about. I am too burned out to study any more today though. Also, I hate First Aid more than I can possibly express in words.

Core Rotations at Case

I finally got my rotation schedule for next semester today. I'll be doing three weeks of family medicine, then three weeks of outpatient internal medicine, then five weeks of surgery, and finally five weeks of inpatient medicine. I start on July 14 and finish on October 31. (I also have a Bridge Week that starts on July 8.) I'm really excited about starting my rotations.

I am also starting to get sick of studying for Step 1. It was fun at first to sit around and study all day without having to get dressed or go anywhere if I didn't feel like it. But I am starting to reach a point now where I am getting sick at the very sight of my First Aid review book. I think this means that it's time for me to take the test already. I have a week and a half left to go, so it's getting close now.

Step 1 Study Update

I just wanted to post a quick note to thank the people who are wishing me luck. Things are going well. I'm still studying full-time and taking full-length practice tests. (The NBMEs are not full-length, but I am doing an extra three sets of practice questions after I take them so that I complete the full length of the test.) It's a grueling schedule, but I'm still improving, which helps me feel more motivated. I'll post again soon.

My Next Practice Test

It's finally getting nice in Cleveland. I swear the springs here are the coldest, grayest springs I have ever experienced! I've been studying part time for Step 1 for three weeks now, and my score has improved substantially since I took the last practice test. Today I took another practice test, and I have almost reached my target score. Now I will be studying full time for the next five weeks, so I won't be posting very much for a while.

Last Day of Year 2 and Promoted to Year 3!

We had our last ever PBL session today followed by our last seminar. Then we all went to the office to get our letters. I am now officially an M3. The letter starts out like this:

Dear CCLCMer,

The Medical Student Promotion and and Review Committee met on May 16, 2008 to review your Year 2 Summative Portfolio. Based on its deliberation, the Committee determined that you met the Year 2 standards for all nine competencies and will be promoted to Year 3.

It then goes on to detail some of the specific evidence that the committee felt was particularly convincing. The last part says:

....your portfolio was well written, organized, and an excellent reflection of your performance. It was a pleasure to read. Congratulations on a strong performance and receive our best wishes for continued success in medical school next year.

So that's it. I now have 5.5 weeks to study for Step 1, followed by 1 week of vacation before I begin Bridge Week and my first block of rotations. (I still don't know what my rotation schedule is, which is kind of annoying. Hopefully I will find out soon.)

Lunch with My PBL Group

My group's PBL tutor took us out for lunch today. We went to Cedarland, which is a really good Lebanese restaurant on campus. (For those of you who are visiting the Cleveland Clinic, you should definitely try it. It's on Euclid and 93rd by the Guesthouse, which is unfortunately the area that is under major construction right now.) After we were done eating, the tutor went around the table and predicted which field each of us would enter. I am apparently going to go into heme/onc. I actually wouldn't mind that choice, because I think hematology and oncology are both fascinating. But I'm not sure how I feel about having to do a three year medicine residency followed by a heme/onc fellowship in order to get there!

This Friday will be the end of the best PBL group I have had since I began medical school. Even though I started out as a doubter, this group really demonstrated how awesome of an experience PBL can be. Interestingly, several of my group members were also in my PSS group during our first summer of med school (summer 2006). That was a really great group too. Anyway, I won't miss going to classes next year, but this has been a great way to go out.

CCLCM Goes Tuition Free!

Yesterday afternoon we had the most incredible thing happen. On Tuesday, an email was sent around to all of the students to tell us that an important announcement would be made the next day, and that we should try to be present for it if we could. We all suspected that it was either about changing our school affiliation or free tuition. The dean sent around an email saying that the announcement was NOT about our school affiliation. So then we all figured it would be for free tuition, and sure enough, that is what it was. Next year's first years will never pay a dime. The current students will also get free tuition from now on, as well as a refund on half of the tuition we have paid so far. So the people in my class will be getting back one year's worth of tuition, and the fourth years will be getting back two years' worth. What an incredibly awesome and amazing gift.

Here is the press release from the Cleveland Clinic:

I am pleased to announce that the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University is providing all its students with full tuition scholarships, beginning with this July’s incoming class.

Students currently enrolled in the Cleveland Clinic Lerner College of Medicine will receive additional scholarship funding to offset 50% of the difference between past tuition paid and the financial aid they’ve already received.

Cleveland Clinic will support the full tuition scholarships through existing endowment income and clinical operations. The long-term goal is to fund the scholarships entirely through endowment income.

Training the newest generation of physician scientists is an important aspect of Cleveland Clinic’s mission and enhances our long-term ability to provide patients with state-of-the-art healthcare.

By providing full tuition support, we will ensure that debt does not hinder the ability of bright and talented individuals to pursue a career in academic medicine. It is an investment in our future and the future of medicine.

Everyone was so excited! Dr. Cosgrove, the CEO of the Cleveland Clinic, was there to make the announcement, and I was able to thank him in person for doing this. After the announcement was over, all of the students poured out onto the deck and were calling their families on their cell phones. There were photographers taking pictures, Mrs. Lerner and the Board of Trustees were there, and people were laughing and crying all over the place. It was just incredible. What a feeling. I still can't believe that this has happened. I knew that the school was planning to go tuition-free eventually, but I never thought I'd be around to see it happen! Some of my classmates and I went out for dinner to celebrate.

The only downside to this whole thing is that unfortunately, the UP students are not getting the free tuition. I feel very bad about this, because our tuition for next year is up to $43,000. Hopefully Case will find a way to provide them with free tuition also.

Books for Second Year

For the summer block, I suggest buying Epidemiology by Leon Gordis and reading it cover to cover. That's a really good book, and epi is a subject that is tested on the boards. I didn't like the stats book they assigned us, and I wound up getting a better book from the TA. I did buy the JMP Manual book, and that was useful for learning stats as well as for learning how to perform various statistical tests for the stats projects we had to do. So for the summer block, those are the only two books that I would recommend buying.

There really aren't too many new books that you need for second year beyond Robbins and Cotran Pathologic Basis of Disease, which is why I haven't been writing posts about second year books. Some of my classmates felt that Robbins was too dense, but I thought it was really good. I'm not going to get to a few of the chapters at the end like the eye chapter, but I've almost read the whole book cover to cover now. There is an atlas that goes along with the Robbins book that is really good. A lot of us bought it. You can also get the Robbins Review of Pathology, which is a path question book. I liked that book as well, although I think the questions in there are a lot easier than the practice Step 1 questions I've been doing. All of the other books we've used this year are the same as the ones we used last year: Katzung for pharm, Drake's book and modules for anatomy/embryo, etc. The only other books you will need are whatever you plan to use to study for Step 1. But you really can get away without buying too many Step 1 review books, because there is a whole collection of them in the library that you can use. They pretty much have all of the popular review books on reserve.

Acids, Bases, and ARBs

We only have two more weeks of school left now. The time is really flying by. This week's theme was a whole hodgepodge of things: acute renal failure, renal clearance, electrolyte and acid base disorders. Wednesday was acid-base disorder day, and today we had a hypertension pharmacology seminar. They were both great seminars. I know I went on and on about how awesome the renal block was last year, and I am happy to say that this excellence has continued this year. Most of the renal seminars are in small groups of eight, and most of them are very interactive with good cases. I feel like I'm really getting a lot out of them. The other good thing is that since we have such a light schedule now, I even have time to do all of the reading for class along with spending a few hours each day studying for Step 1. Right now I am studying path and embryology. Embryo is not a very high-yield subject for Step 1, but I suck at it. Embryo and anatomy have been my worst subjects on all of my practice tests so far, so those are the subjects that I'm reviewing first. I'll need to go over them again at the end probably.

Intro to Step 1 of the USMLE

I took my diagnostic practice test today, which is one of the NBME exams. (NBME is the National Board of Medical Examiners, the organization that adminsters the medical boards.) I am happy to report that I am already well above the passing mark at this point. Even if I didn't study at all between now and July 1, I'd almost certainly pass the test. Of course, I want to score higher than I am right now, but it's still a huge relief to know that I am starting from this point!

For those of you who are not familiar with the USMLE (United States Medical Licensing Exam), here's a brief primer on it. There are three parts of the USMLE, which are called Step 1, Step 2 and Step 3. (Step 2 actually has two parts, but we won't get into that right now.) Step 1 is usually taken after the second year of medical school, Step 2 is usually taken in the fourth year of medical school (or possibly the fifth year for CCLCM students), and Step 3 is taken after the first year of residency. I'm going to mainly talk about Step 1 since that's where I am in the process.

Step 1 is a test of basic science knowledge. Some of the most important subjects that are tested include pathology, pharmacology, microbiology, biochemistry, and physiology. Other subjects that can show up include anatomy, embryology, psychology, epidemiology, cell/molecular biology, and histology. The test is eight hours long, including one hour total for break time. It is taken on a computer, but it is not adaptive (every question counts the same as every other). There are seven sections of 48 questions each, and you are given one hour per section. Once you finish a section, you cannot go back to that section. A passing score on Step 1 is currently 185 on the three digit scale. The average score for allopathic medical students (people working toward an MD) is around 220. No one knows what the maximum score is.

Step 1 is important to medical students because many competitive residency programs use it to screen out applicants. The next obvious question you are probably wondering is what constitutes a "good" score on Step 1. The answer to this question is highly subjective, and it also depends on what field you are trying to enter. My personal opinion is that any score above the mean is a good score (220+), and any score above 230 is a highly competitive score for most specialties.

Done with My Summative Portfolio

Our summative portfolios are due next week, but I wanted to get mine turned in early so that I could start studying for Step 1. I'm going to take my diagnostic exam on Tuesday since I don't have to go to clinic any more. (My advice to current and future second years: don't miss any longitudinal clinic days from September to April. That way, you can have no clinic afternoons for the entire month of May when you need that time the most.) The administration took pity on us and didn't require us to print out all the evidence and make those ridiculous binders like we had to do last year. One of my classmates came up with the idea of saving everything on a CD and turning that in. I thought it was a really good suggestion, but so far the powers that be haven't warmed up to the idea too much.

Not too much else exciting going on. The work load is starting to wind down so that we can have extra time to study. FCM ended back in March. We don't have any more Wednesday afternoon communication/physical diagnosis classes or Friday ARM/POD seminars. There was a meeting this afternoon about planning out the research year, but I didn't have to go since I'm only doing a month of research next year. I think this is the first time since I started medical school that I had every single afternoon off for the entire week. I've been using the extra time to work on pharm.

Clinical Reasoning and Communication

Our communication class last week was about ending the doctor-patient relationship. It was insane. I was supposed to be a med student who had just finished my longitudinal clinic from first and second years, and I had to tell the patient that I was leaving to start my third year rotations. My actor was really over the top. He actually started crying with real tears when I told him that I'd be leaving! I wanted to laugh at the absurdity of it all, but I couldn't, because that would not be professional. Don't get me wrong. There are several patients whom I've seen multiple times, and we've built up some kind of relationship. But it's not like any of these people are going to throw a total hissy-fit like this guy did when I move on. Can we talk about dependence issues here? If this guy had been a real patient, I don't think I'd have worked nearly as hard to smooth things over. But when you're in a room with five people evaluating you, of course you have to see the whole thing through.

Friday was the last time we had to do one of those awful small group projects for ARM/POD. I was going out of town for the weekend, so I didn't even go to the presentation part. What a colossal waste these sessions have been. Even worse, what a missed opportunity to have made a series of small group sessions that could have been really interesting and useful. For example, it would have been great if the faculty had us actually go through the process of writing an NIH grant and taught us about different grant awards, how study sections work, etc.

We had another clinical reasoning session today. I had the same group and preceptor as last time, and it went about the same as before. First we each presented a patient and went through the differential as a group. Then we went over to the hospital to interview a real patient. This patient was a character. I'll just say that we heard about her sexual history in exquisite detail. And to think some people claim that you don't learn anything interesting in medical school!

Last week was our last week of GI (liver week), and now this week we have started with renal. Everything is going great. My PBL group still rocks. The renal seminars are as awesome this year as they were last year, interactive with lots of small group sessions. This week, we've been talking about glomeruli, which are the capillary beds that do the filtering in the kidneys. They're really beautiful. Here's a picture of one (the big thing in the middle). The smaller circular things surrounding the glomerulus are parts of the tubules of the nephrons, which are the urine concentrating units of the kidney.

My Last Patient

This week has been much better. We're going over liver pathology. I like the liver because it has so many interesting functions, and it is also capable of regenerating itself. Those are just some of the reasons why it's my favorite GI organ, but I won't bore you by going on and on about how cool the liver is. Suffice it to say that yesterday we went over viral hepatitis, and today we did gall bladder diseases. (The gall bladder is the organ that stores the bile produced by the liver.)

Today was my last day in clinic. Wow, what a way to go out. My very last patient of the afternoon was a guy who came in because a box fell on his hand. His fingers were all black and blue, and he will probably lose some of his nails, but there didn't seem to be any major problems otherwise. I was going through the review of systems (ROS) with him, and when I asked him about chest pain, he said yes. I asked him more about it, and he said that it was a kind of tightness more than a pain. Did it radiate? Yeah, to his left arm. When did it start? About half an hour ago. Had this ever happened before? A few times within the past month. At this point, I excused myself and went to get my preceptor. We personally walked the patient over to the ED so that he could be worked up for an MI (myocardial infarction, popularly known as a heart attack).

I was most struck by the fact that if I had not asked this man about whether he had chest pain, he would not have ever told us about it. He didn’t fit the normal demographic for a patient with coronary artery disease (CAD) that I had learned about in school. He didn’t think his chest pain was important enough to mention to the doctor. I've gone through the ROS so many times over the past two years that it's practically perfunctory and mechanical by now. This experience re-emphasized to me how important it is to not take shortcuts, to ask every patient about life-threatening symptoms like chest pain. You will never have the opportunity to save a person’s life with one simple question unless you ask it.

Shifting Dullness

This week we have been learning about the effects of radiation on the GI tract (not good) and congenital diseases of the GI tract. There are a surprisingly large number of babies who are born with some kind of GI malformation or malrotation. During embryology, the GI tract has to turn twice so that all of the intestines end up where they're supposed to be in the adult. If that doesn't happen correctly, it causes a malrotation. There can also be problems where the intestines don't return to the abdomen after they normally herniate out into the yolk sac during the second month of gestation, or where the neurons of the enteric nervous system don't migrate where they need to go. I hadn't realized that GI embryo was so complex.

Today I had my meeting with Dr. I about the OSCE. He had printed out all of my evals and read through them before I got there, and I got the impression he was kind of surprised that I had requested this meeting. I explained that I didn't feel I had done as well as I should have for the amount of time and effort that I spent preparing. He apparently didn't realize that my classmates and I were studying for the OSCE, because it was supposed to be something where you just kind of walked in and took it. He didn't think I had done badly at all, and he even wrote an email for me to put in my portfolio saying that I wasn't underperforming in clinical skills. Maybe part of the point of the exercise was to see how we'd adapt after we bumbled through the first station. But all I can say is that from a student perspective, it was a very frustrating experience.

My clinical correlation today was on performing abdominal exams. The GI fellow who was helping my group turned out to be one of my classmates from my Clinical Trials course last semester. We saw some interesting patients. One was so jaundiced that she was literally bright neon yellow. We also saw a patient who was positive for shifting dullness, which occurs when the patient has ascites (fluid in the abdomen). To test for shifting dullness, you percuss the patient's abdomen while he is lying on his back, then have him turn on his side and percuss his abdomen again. If the border between the dull and tympanic regions move, the test is positive. On an amusing side note, one of the attendings told us that when he was in med school, he and his classmates had to sit through boring lectures all day, five days per week. They used to call the lecturers "shifting dullness." :-D

Besieged by Reviews

We had a couple of GI path seminars on Wednesday and a really cool pancreatic surgery seminar today. I think I am about the only sucker in my whole class who is still doing the assigned readings for seminars. I brought up something in PBL that I had read in the articles for today's seminar, and I swear the rest of my group was looking at me like I had two heads. It turned out to be good that I had read that article though, because it helped us understand the case. We also had a domestic violence screening communication class on Wednesday. It wasn't bad, but I thought they should have done it about a year ago. I've been doing domestic violence screening on my clinic preceptor's patients since about halfway through last year.

We were supposed to have a Dean's Dinner on Wednesday, but it got cancelled since most of my classmates couldn't go. The first years had their Dean's Dinner last week though, and I got permission to go. As it turns out, my research preceptor was the speaker, so I was glad that I got to be there. I had seen part of his talk before last fall at the conference, but some of it was new.

Today was also the first pathology review session for Step 1. I went to this one, but I don't think I am going to go to any more review sessions. I really didn't get very much out of it, mainly because I have not started studying at all for the boards yet. Being suddenly bombarded by so many review sessions is making me feel a little stressed out and overwhelmed. There are reviews being set up for everything: path, pharm, micro, anatomy, embryo. But right now, I am more worried about getting my summative portfolio done than I am about studying for Step 1. This is the portfolio that will be used by the promotions committee to decide if I am promoted to third year. I feel a little bad about not attending the review sessions, because the faculty are really going out of their way to try to help us prepare for Step 1. I don't want to seem ungrateful. It's just that I am not ready to start studying for Step 1 yet!

Observed H & P

We had a really terrific pharm seminar on Friday about drugs for inflammatory bowel disease. The two pharmacists gave us some cases to work through and then went over them with us. Our POD/ARM seminar, on the other hand, was a disaster. I guess whoever was supposed to give the talk on diarrhea cancelled, because instead we wound up getting a talk by someone from the Innovations Center here at CCF. (They take care of patents for inventions made by people associated with the Cleveland Clinic.) What annoyed me the most about this talk was not that it was awful and had nothing to do with research. No, what really annoyed me is that the only reason I skipped the second look students' lunch and went to this talk at all is that Dean Franco asked me not to skip class when I told her about the schedule conflict. Once again, the faculty for the class didn't show up, and most of my classmates didn't, either. I think skipping it would have been completely justified, but I didn't feel right about leaving after I promised her that I would go. On a happier note, in the evening, one of my friends and I went for dinner at a Thai restaurant I had never been to before, and it was amazing. We are definitely going to go back.

This week seems to be a bit of a hodgepodge of different gastrointestinal (GI) problems. Yesterday we had a seminar on infections, and today we talked about diabetic neuropathy. You may not have known that the GI system has its own nervous system that functions semi-independently. This is one of those facts about the human body that I had no clue about before I began medical school, and that I find just fascinating.

My preceptor was back in clinic today, so I did my observed history and physical (H & P). It went really well. The patient was a very interesting woman who was involved in a variety of charities. I didn't do a Pap smear on her, but I did do a breast exam and instruct her about how to do them herself. I am amazed by how many women do not do breast self-exams. Whenever I ask them why, nearly all of them say that they know they should do self-exams, but that they have never been taught how to do them. This patient was no different. The good news is that patients seem to be getting the message about the importance of monthly breast self-exams. But of course, telling women to do these exams is not terribly helpful unless they also know when and how to do them! Instead of asking patients whether they do monthly self-exams, it is probably better to ask them if they know how to do monthly self-exams. Then if they say no, the provider can show them.

Spring OSCE

On Monday, I participated in the feedback session for our Heme/Onc block. The students are supposedly asked randomly to participate in these feedback sessions, but somehow I sure seem to end up participating in an awful lot of them!

This week is the beginning of our GI block, and the seminars have been on the oh-so-appealing topic of diarrhea. I can't really complain, though. We've had a relatively light schedule so far because we're taking the spring OSCE this week. Yesterday, I had all day to study for the OSCE after the seminar was over at 10 AM, because we don't have clinic this week. Then I took the OSCE today.

It was worth spending the time to review all the exams, but in the end, it wasn't enough. This OSCE was much harder than the one we did last year, and I felt like I was really floundering around for a large portion of it. Like last year, we had to examine standardized patients, and there was a preceptor in the room with a checklist of skills we were supposed to demonstrate. But there were a bunch of new features as well. First, there were more stations (four in all), and they were much more ambiguous. We weren't told anything more than something along the lines that Mrs. Smith was here for a check-up. At the first station, I did a focused history and physical for a patient who had a sore shoulder. Afterward, I was getting feedback from the preceptor, who told me that I was supposed to do a complete history. He said that I did a good job on the parts of the history that I completed. But I still wound up flunking the station because I missed so many of the objectives.

Ok, well, now that I knew I was supposed to do a complete history, I could handle that. I went in to the second station, which involved counseling a patient on smoking cessation. That one went well and I got very good feedback from the preceptor. The next station was for an abdominal exam, and that one went well too. I had to write a SOAP note at the end, and I just barely got it done in time. But I totally missed the point of the last station. That patient had right sided abdominal pain and a cold, so I did the ENT (ear, nose, and throat) and abdominal exams on him. Then I gave an oral presentation to the preceptor. But it turns out that this patient's flank pain was supposed to be chest pain, and the preceptor said that I should have done a complete cardiac exam. I still don't really get how right flank pain was supposed to scream "cardiac problem!" at me. But I guess the lesson to take away from this is that anyone with pain below the neck and above the pubis is going to get a full cardiac exam AND a full abdominal exam from now on.

I am pretty disappointed about how I performed on this OSCE. Considering how much time I spent preparing, it's frustrating that I failed two out of the four stations. I have already emailed Dr. I, who runs our clinical course, to set up a meeting to discuss my performance. Don't get me wrong--I'm glad that I screwed up now and not on the clinical portion of Step 2 that I will be taking at the end of next year. But at the same time, this OSCE is supposed to be a demonstration of our current level of clinical and communication skills, and I know that my performance was not nearly up to the level of which I'm capable.