5 Days Down, 23 to Go

I have a monthly calendar hanging up nearby, with big beautiful blue X's through each of the last 5 days. Underneath those blue sharpie lines are tiny notes of what I attempted to study for that day - renal, pharmacology, GI (gastrointestinal), anatomy, embryology, hematology, and oncology. That's what I've reviewed so far, and it's been a whorl wind mini tour through my brain. I'm happy to say that everything looks familiar - oh ya, the renin-angiotensin-aldosterone system, oh ya, carcinoid syndrome, oh ya, tetralogy of Fallot, oh ya, activated partial prothrombin time, and oh ya, Hairy Cell lymphoma. Familiar, Yes. Memorized, No.

So what am I talking about? Reviewing for the Step 1 Board exams. So OHSU is responsible for giving me my MD (if I pass of course). The NBME (national board of medical examiners) are responsible for allowing me to get a medical license. The two are completely separate. MD does not equal licensed and able to practice medicine. There are three board exams on the way to achieving licensure. Step 1 is taken after the first two years of medical school and its purpose is to see how much of the science you know. Step 2 is taken sometime in your 3rd or 4th year of medical school, and is geared toward clinical skills - not only what disease someone has (step 1 tests this), but more importantly, how do you treat it? Step 3 is taken during your residency and is specific for your chosen line of work.

I talked to an older physician the other day and when he found out it was board study time, he asked, "It's two weeks, two days, and a number 2 pencil right?" I had no idea what he meant, and he explained that when he was taking the board exams (20? years ago) students studied for the step 1 for 2 weeks, step 2 for 2 days, and not at all for step 3 (I guess by the time you get through part of residency you think you know it all). When he learned that not only do we at OHSU only have 4 weeks to study for the step 1, and that we wished we had more time, he smiled as if to say, "boy these med students sure are getting dumber, and they certainly do know how to whine."

I wanted to say that they probably only had a handful of drugs to know, versus hundreds now, and that they didn't have the wonderful genetic and molecular understanding of diseases that we now have...but since I didn't want to add to his perception that we whine too much, I just kept my mouth shut. But I left his office wondering, are we getting stupider? Is OHSU letting in students that don't have what it takes to cram all this information in? (Maybe our heads aren't big enough - ie. we have a little more heart, and maybe a little less ego).

I pulled out the stats on the step 1 board exam to see what the magical numbers have to say. In 2005 and 2006, 94% of allopathic medical students passed the step 1 boards. Not bad! Osteopathic students (who went to DO school, not MD school, but want to match into a MD residency and so take the MD boards) got a 77% pass rate, and foreign medical students who are trying to get licensed here in the US have a 71% pass rate. So how does OHSU fare? They tell us every year that we have an average board score when compared to all students taking the boards (includes DO and foreign students). If you take out the DO and foreign students, we have a below average pass rate for the step 1 boards.

While average, or just below average is nothing to be ashamed about, I can't understand why the Dean's office doesn't want to do everything possible to increase the pass rate, as well as the average score. When I've talked to curriculum leaders about the step 1 boards, they all adamantly shake their heads when it's suggested that we include board prep in our first two years of med school. They don't want to "teach to the boards" since that is not their job. Their job is to 1. teach us the science 2. teach us clinical skills. 3. teach us public health/epidemiology 4. teach us (or at least encourage) altruism.

There's nothing wrong with their goals except for this - When residency directors are overwhelmed with 1000 applications for a mere 40 positions, they need to make fast cuts, and the number one way this is done is with step 1 board scores. It makes no difference that you aced your science classes, that your patients and attendings thought you were stellar on your rotations, that you took a year off to go to Africa and set up an AIDs clinic, or that you published an article in the New England Journal of Medicine. It's a numbers game !!! At least to get you into the door for an interview. Once you get to the interview, you can impress them with your sweet bedside manner, or your altruism, or your research papers.

This is one way that medical school/getting into residency, and undergraduate/getting into medical school is way different. Yes there is a cut off for MCAT scores below which you will not get an interview, but there is way more leniency, and more willingness to look wholistically at the applicant. This is not the case for residency, especially when the competition is high. You learn very early on that if you want to go into a competitive speciality (surgery, dermatology, urology, radiology - all the specialties that make a butt load of money), you have to have stellar board scores, or your application will go right into the recycle bin.

This is fine for me, and for all those at OHSU who are planning on going into primary care specialities. Pass the boards (185 is passing), and it's all uphill from there depending on how competitive a program you want to get into. (Bottom line - you will match somewhere). Compare that to surgery where you need a score of 220 or above, or radiology 240 or above, or dermatology 250 and above! Thank god I don't want to do those specialties.

So why I am carrying on about all this? Partly because it's the inherent nature of medical school to keep climbing uphill. Getting to medical school (doing well in undergraduate, the MCAT, the med school interviews) is like getting up to base camp at 10,000 feet. The first two years are another climb, just to get you to the second camp at 15,000 feet, where you hope to do well on the step one boards so that you can then attack the next hump - fellowship, with the peak of the mountain always in view - that day when it will be just you and your patient, in a small room, and they say "Help me Doctor."

Cheers to all my supporters who won't see me much for the next month. Think of me, and send me good spongy thoughts. (I need all the sponge I can get to soak up these details and get me a 220 on the step 1 boards!)

Valerie's Growth and Development

I choose this title because we are finishing the last class of the school year, Human Growth and Development, and as we go through the stages of fertilization, fetal growth, birth, childhood, adulthood, and the elder years, I realize that med school is so much like growing into a completely new person. I imagine that I am still in the stages of fetal growth, as I struggle to learn this last three weeks of new information, before the eventually birth that will occur with the board exam.

I bumped into an old friend yesterday who asked if I was still blogging, and I have to admit that I've been a bit lax lately, not for lack of things to talk about, but more for fear of saying the same thing over and over, as well as a hesitancy to say what's really going on in such a public forum. As I inevitably say when my family calls and asks how and what I am doing, I reply, no matter the day or time, I'm studying, and I'm OK. It's true, I am neither great nor terrible, and all I do is study. But to say that I am OK greatly understates the storm of emotions and thoughts swirling beneath the surface.

There is very little to look forward for while in medical school, unless you make a very strong commitment of doing something outside of school that "fills" you up. You know what I'm talking about, that thing, or those people, or activities, that make you relax, live in the present moment, and forget all your worries and stresses. What is it for you? Dancing is number one on my list, wine is number two, and the rest are probably all equally number three - watching episodes of ER (or any other series on DVD - no time for commercials), playing cribbage with Erinna, getting a massage, exercise class, and sex. Now, those things still decompress me, and bring a smile to my face, but for most of them, I still can't shut off the train of stressful thoughts in my brain. Which means my list has gotten shorter.

And I have voluntary chosen to take one of my list, at least for a short time. After a very very fun night of dancing with a school friend of mine several weeks ago (haven't been up so late to hear "last call" since I was in college...), followed by a useless day of studying due to a hang over, my friend and I decided to not drink at all for a month. We both struggle with depression and anxiety, and use a glass of wine at the end of the day to de-stress. Every few days I send her a text, with the update of what day we are on (today is day 21), and a question about how she is doing. And it sounds like she is experiencing the same as I am - a much healthier body, and more time to study, but a great increase in anxiety. I have bitten my finger nails down short short short, and I have picked my toe nails until they have bled. What an embarrassing thing to admit, but it could also be that simultaneously, I have tried to wean myself off my depression/anxiety meds. Probably not a great idea, but I want to see how I feel at baseline. Without alcohol, and without mind altering medication, how do I feel?

Well I've stuck to the "no alcohol for 30 days", but the process of getting off my medication has not been fun. My other school friends think I am crazy trying to do this when studying for the board exams (the most stressful experience of the first two years of med school), and I'm beginning to think they are right. (In fact, many med students become so stressed, depressed, and anxious during school that they begin medication). I don't feel depressed as I lower the doses, but the withdrawal effects are terrible (remember this if you ever go on the drug Effexor, or if you ever prescribe it to a patient). The withdrawal effects are so bad that I keep taking the drug, in a very small dose, so that I can continue studying.... I'm not sure when I will have a long enough break to detox, but it's obviously not going to happen anytime soon. So I have relinquished myself to staying on the drug, and as each day comes to a close, and my anxiety rises, I reach for my bottle of Effexor, and stay away from that wonderful bottle of Port that tempts me. Cheers! And thanks for listening.