USMLE Step 2, already?

This morning I made a mistake that cost me 4.5 hours of study time. I was signing up for my first "real" practice test through the National Board of Medical Examiners (NBME) website, which offers half-length (4-hour) self assessments composed of retired questions used on past exams. The Comprehensive Basic Science Self Assessment (CBSSA) is for students studying for Step 1, while the Comprehensive Clinical Self Assessment (CCSSA) is for students studying for Step 2. I accidentally bought a CCSSA instead of a CBSSA.

As I was taking the test, I noticed that the questions were a lot more difficult than those from my USMLE World and USMLE Rx question banks. Friends from the class above me had told me to expect that. It was only after I finished and saw my failing score that I knew something wasn't right.

As aggravated as I was at myself for the mistake - and for the lost time and energy - some good did come out of the situation. I took a short lunch break then finished a second practice test, this time an actual CBSSA. Doing two practice tests back to back allowed me to experience exhaustion similar to the real exam, which is 8 hours long.

I also got a sneak-peek at Step 2. The exam is more clinically-oriented, as its name implies, but the material and knowledge-base is essentially the same. The question stems are all much longer and more involved clinical vignettes that require more careful reading, and they all end with a question like, "Which of the following tests would be most useful in diagnosing this condition?" or "Which of the following is the best course of action in treating this condition?" There's still only one most-correct answer, but these questions have multiple answer choices that are plausible. So that turns Step 2 into a test of clinical judgment.

Customer Service at NBME was forgiving: they kindly gave me credit for another self-assessment, so at least I didn't end up wasting money on the CCSSA.

LAST DAY OF CLASSES!!!

It's hard to believe that today is actually the last day of classes, that my second year of medical school is ending, and that soon I'll be a "real" medical student going through clinical rotations. I've heard from many people that, while third-year may be exhausting, the first two years of medical school are much more difficult in terms of trudging through the curriculum.

To-do list before third-year: one Life Cycles test, one Infectious Diseases test, a month of studying for the boards, then USMLE Step 1 on April 11th.

Scheduling my first clinical rotation

The coordinator for for my first clerkship sent out a scheduling e-mail letting me know that I will be doing Adult Ambulatory Care first (April 25 – May 20, 2011) and Rural Community Care second (May 23 – June 17, 2011). Exciting!

Included in the e-mail was a questionnaire that asked for some basic information and preferences about where I want to do my rural rotation. They also asked some more personal questions getting at my interests in medicine. One in particular caught me off-guard:

"What aspects of medicine do you find MOST interesting or appealing? Why?"

I tried to answer it impulsively, without over-thinking it too much. This is what came out:

Preventative medicine and the obesity epidemic - because it seems to involve everything from society to behavior/psychology to neurobiology to genetics, and it has such a staggering impact on so many different levels.

Geriatrics and the art of medicine

Now that we're approaching the end of the Life Cycles block, we are appropriately covering the end of life. Geriatrics is one of those fields that primarily focuses on symptom management and quality of life.

For example, the other day I saw an 84 year old man whose distal left femur splintered when he tried to stand up. This was after 3 years of not walking on it because of a hip fracture. His options were to correct it with surgery or to put it in a cast. The orthopedic surgeon recommended a full-leg cast for obvious reasons: surgery is not without risk, especially in a frail elderly man, and the patient would not even realize any benefits since he was non-ambulatory before breaking his femur. Watching him and his wife arrive at that decision was sad. It was the lesser of two evils. I thought about my own grandparents and some of the difficult decisions that they have had to make.

One major take-home message of our geriatrics lectures is the danger of drug side effects and drug-drug interactions in older patients who are on many different drugs for many different diseases.

For example, let's say you have high blood pressure. Your doctor puts you on an ACE inhibitor - a perfectly reasonable treatment. But one side effect of ACE inhibitors is nausea. So your doctor prescribes Zofran or Benadryl to help with the nausea. Well, constipation is a common side effect for both of those drugs, so now you're also taking a stool softener such as Milk of Magnesia, which itself can cause folic acid deficiency and anemia. And it goes on and on...

That's already three drugs: one to treat the hypertension and two to address the resulting side effects. You may think that constipation is innocuous enough, something you can live with. But what if that is combined with dry mouth (another common side effect of Benadryl)? Then you're starting to talk about decreased appetite and poor nutrition, which can lead to a downward spiral in an elderly patient who is already frail.

It's easy to see how this can get out of control when you consider that more than one drug is oftentimes required to adequately manage high blood pressure, and that patients typically suffer from multiple medical conditions or diseases. Managing a patient with congestive heart failure, COPD, and urinary incontinence on top of hypertension could be very tricky indeed. And in such a patient, it's not uncommon for one of those drugs or all of them combined to induce a state of delirium or reversible dementia. This not only profoundly impairs their quality of life but could also directly lead to their being placed in a nursing home or assisted living facility.

Our lecturer noted that balancing pharmacological treatment for medical conditions and a patient's quality of life is where the art of medicine comes into play.

(After describing this horror-story polypharmacy scenario, I feel that I should emphasize that prescription drug treatments are usually beneficial and safe when monitored by a physician. I wouldn't want to scare someone out of taking their blood pressure medications. It bears remembering, however, that drugs should not be blindly prescribed or taken. If a particular drug isn't working, try modifying the dose or finding a different drug with a different side effect profile.)

Prolapsed internal hemorrhoids

A patient came into the Emergency Department this morning complaining of severe pain in his anus and lots of blood in his stool that he attributed to hemorrhoids. This patient knew what he was talking about considering he had been struggling with them for 10 years, but they had never been so bad as to compel him to visit the ED.

What exactly are hemorrhoids? It turns out that everyone has hemorrhoids; they are connective tissue that normally serve as a sort of cushion for fecal matter passing through the anal canal. It's only when they become inflamed (think constipation, pregnancy) that you notice they're there. Hemorrhoids are classified according to whether they're internal or external, with the internal ones typically being more bloody and the external ones typically being more painful.

My patient had a few external hemorrhoids, but it turned out that the ones causing most of his pain were prolapsed internal hemorrhoids - that is, internal hemorrhoids that were pushed to the exterior when he had a bowel movement. The immediate treatment is simple: resolve them, which is medical jargon for "push them back inside with a gloved finger." And that's exactly what I did.

Considering that this poor guy has been suffering from hemorrhoids for so long, and that he is no longer able to gain relief from them by standard treatments like Preparation H and ibuprofen, his next step may be to look at a surgical fix. This will be especially true once his prolapsed hemorrhoids can no longer be resolved.

Geriatrics patient interviews: Holocaust survivor

The purpose of this afternoon's interviews with geriatric patients was presumably to teach us how to evaluate activities of daily living (independent or otherwise) and to impress on us how difficult it can be to manage the medications of a geriatric patient. I was unprepared, however, for the real lesson.

One of our geriatric patients was a remarkable 97 year-old man who is essentially still living independently (i.e. he buys his own groceries, makes his own food, pays his own bills). He is sharp as a tack cognitively, and he exercises almost every day. When he pulled out his bag of medications, the whole group laughed because they were all vitamins and supplements (B12, D3, glucosamine, etc...) plus some Tylenol for general aches and pains. He also uses an albuterol nebulizer to help him "feel young again," and he takes a very low dose of Coumadin because of a minor heart attack that he suffered before I was even born. Taking so few medications is exceedingly rare for a man of his age.

But that's not why this man is so special. It turns out that he is the oldest Holocaust survivor living in Colorado. I grew up listening to Holocaust survivors talk of their trials, but it has been such a long time since I've heard one talk because there simply aren't that many of them still with us. This man's story affected me profoundly. Rather than recapitulate it myself, I want to share what a classmate of mine wrote, who was similarly affected by this remarkable man:

Today I heard a story that has compelled me to relate it to the rest of the group. My group, and 3 others I would guess, had an opportunity to listen to the story of a 97 year-old Holocaust survivor. This gentleman was the only member out of 10 in his family to survive the Holocaust. He related that he had spent time in Auschwitz-Birkenau, Dachau, and Theresienstadt. From his story it sounded like he was in the Polish army during the invasion of Poland by the Nazis. After the Polish defeat he was then sent to Auschwitz-Birkenau where he was a janitor for the barracks and a few other places.

The last time he saw his brother was through a barbed wire fence. His brother was a Sonderkommando, one of the prisoners that cleaned out the crematoria and gas chambers. His brother was aware that he was to be executed the next day, which happened roughly every 6 months to the Sonderkommando. His brother told him to "Tell the world what happened here." The next day his brother and a bunch of other Sonderkommando blew up one of the crematoria and unfortunately died during the explosion. ecause of the explosion a great many of the prisoners were sent to Theresienstadt where the crematoria were smaller and the killing was slower.

He [recently] took his family [back] to Theresienstadt, and the tour guide related this story to the group. After the group had moved on, he went up to her and told her that his brother was involved in the destruction of the crematoria, and he rolled up his sleeve to show her his prisoner ID number, and she hugged him and told him "thank you."

As part of his cleaning duties, our patient had to clean up the hospital where Josef Mengele experimented on people. He told us that upon one trip through the hospital he and his work partner, a physician from Romania, came upon a woman on a bunk who had both her hands and feet tied. He told us that she cried out to them to help her but they were too afraid to do anything for her. On subsequent visits, they found out that she was pregnant and gave birth. The woman had her breasts covered so she couldn't feed her baby. The baby died a couple of days later at which time they killed the woman.

This man, who had survived so much, broke down in front of 10 strangers when he described how he and his partner had to take a wheelbarrow and haul the woman and her baby out to be buried. The image of the babies face haunts him to this day. After he was liberated, he was able to find his wife, and they immigrated in 1949 to Denver.

I hope that my relation of this story has not offended anyone, but it struck me today that those who had survived this atrocity are slowly reaching their eternal rest and won't be around to tell us their stories. I fear that in this world of fast-moving media and 24-hour news, the stories of the past - not just this one - will be lost.

When I entered into that room this afternoon, I thought I would hear a story similar to my grandmother's, but instead I was reminded that there is something to be learned from every interaction with another person.

- Ryan F.