That's a whole lotta burritos

I lived on Chipotle burritos during the first two years of medical school. One of those suckers could get me through 4 hours of straight studying, easy. I started to wonder, as my second year was wrapping up, exactly how many Chipotle burritos I had eaten during those first two years. So I looked back at my bank statements and came up with this chart:


That's 104 Chipotle burritos from August 2009 through April 2011, or an average of 5 burritos per month. I was guessing I would average more like 8 per month. At $6.86 per burrito, that's a grand total of $713.44 spent on Chipotle burritos. Money well spent.

Step 1: Bottom line

With this long description and many posts of how I studied for the USMLE Step 1, here's my bottom line advice for students who might have a similar style of studying to my own:

* Use First Aid as an outline for Step 1 studying throughout the first two years, starting as early in the curriculum as makes sense to you.
* Don't rely on First Aid as a stand-alone reference.
* Read as much of Robbins & Cotran's Pathologic Basis of Disease as you can during your course work, then refer back to it frequently to study specific diseases or answer specific questions during the dedicated study period.
* Use BRS Physiology when you start studying organ systems (for the University of Colorado curriculum, at the beginning of CVPR).
* Buy either a USMLE Rx or Kaplan question bank early (for the University of Colorado curriculum, at the beginning of CVPR), and use it to help you study for the current course.
* Also use your USMLE Rx or Kaplan question bank that you bought early to complete 5-10 questions per day. Research those questions that you get wrong, and be sure to read the explanations even for questions that you got right. Try doing these questions timed starting in Year 2 Semester 1 and drawn from all subjects starting in Year 2 Semester 2.
* Use your Summer vacation to review the course material from the previous year, but also be sure to relax and have fun.
* Don't study over Year 1 Winter break.
* Use your Year 2 Winter break to start targeted studying, but also be sure to relax and have some fun.
* For subjects that require rote memorization (Microbiology, Pharmacology), experiment with different ways of learning until you find what's best for you. Try making comprehensive tables or making your own flash cards. When you're in the middle of your dedicated study period, you will be glad for any study tool that you created during the first two years.

Step 1: Practice tests

The National Board of Medical Examiners (NBME) offers seven practice tests, two of which provide "enhanced feedback." At the end of all seven practice tests, you get an estimated score and a list of your performance in various categories as depicted by bars stretching over a range from below average to borderline to above average. These practice tests are all four hours long (four sets of 46 questions) as opposed to 8 hours long for the real McCoy (seven sets of 46 questions, plus 45 minutes of break).

Looking back, I question whether the extended feedback was worth the extra $10 per test. That $10 basically bought me the privilege of accessing all of the questions that I got wrong. However, they don't give you the correct answer or any explanations! This resulted in me spending much more time reviewing the two self-assessments that offer extended feedback than I spent reviewing a comparable number of typical USMLE Rx question sets. I found this annoying and am still not sure what reasons the NBME could have for not providing the correct answer.

I completed 5 out of the 7 NBME self-assessments, which I think is reasonable for a dedicated study period that is 29 days long.

In addition to these NBME self-assessments, USMLE World offers two practice tests that you can buy on top of the question bank. I completed both of those practice tests near the end of my dedicated study period, and they have the distinct advantage of providing both the correct answer and a detailed explanation of why that answer is correct and all the other choices are wrong. These practice exams also spit out a predicted score using what I assume to be a similar algorithm for calculating the score that NBME uses. I found these questions to be very reasonable and highly recommend using them.

If I could do it over again, I think I would complete one of the USMLE World practice exams at the beginning of my dedicated study period and the other practice exam near the end. The truly extended feedback at the beginning would help guide my studies for the rest of the study period while the truly extended feedback at the end would help me identify any gaps in my studying and fill them quickly before the Big Day.

Step 1: Question banks

Every medical student who has taken the USMLE Step 1 exam has most likely signed up for a question bank to practice doing USMLE-style questions. There are many question banks out there, but the main ones are:

1. USMLE World (2000+ questions)
2. USMLE Rx (3000+ questions)
3. Kaplan (2000+ questions)

I think that there's a general consensus that USMLE World is the best question bank of the three because its questions are drawn from a pool of "retired" questions from old USMLE exams and are therefore closest to the real thing. USMLE Rx has the advantage of being linked to First Aid such that the explanations for each question references relevant page numbers and even includes snap shots of relevant pages. Kaplan is generally regarded as being slightly more difficult than the actual exam, with the drawback being you might get frustrated or discouraged with Kaplan, especially early on in your studying.

I used both USMLE World and USMLE Rx but not Kaplan, so I will only discuss those two question banks.

I bought a year subscription to USMLE World near the end of Year 1 Semester 2 during the Renal block. I used USMLE World to study for all of my remaining courses by doing practice questions focused on a given topic. This usually happened during the day or two leading up to an exam. I found that this approach worked very well by helping me to think along the lines of what types of questions could be asked. Plus, I felt like I was being doubly productive by also studying for Step 1.

I worked on the USMLE World question bank over Summer break and Year 1 Winter break, mostly doing questions after studying a particular topic. You have the option of doing questions timed or untimed and setting how many questions are in each practice set. Over the Summer, I did all of my questions untimed with no more than 20 questions in each practice set. I spent a lot of time researching each question that I got wrong and some more time reading through the explanation for each question that I got right.

For most subjects, I also created question sets of all questions in that particular topic that I got wrong (this was only during Summer break and Year 2 Winter break). In that way, I re-did questions over and over again until I got all questions right within that topic. Looking back, I'm not sure exactly how useful that was to me. It certainly helped to drill some information into my head, but the reality is that there are some questions that are simply bad. I think my time could have been better spent doing more research into those questions that I got wrong.

When Year 2 Semester 1 began, I decided to ratchet it up by also doing 5-10 timed questions per day, still limited to the subject matter at hand. I was inconsistent in doing this and wish that I had actually stuck to that plan. When Year 2 Semester 2 began, I ratcheted it up again by doing 5-10 questions per day that were both timed and completely random (i.e. drawn from all subjects). I was more consistent doing those during Semester 2 than I was during Semester 1, and I'm glad for it.

I finished going through all 2000+ questions in USMLE World by the middle of Year 2 Semester 2, having gone through a substantial number of those questions multiple times.

I bought a month-long subscription to USMLE Rx at the beginning of my dedicated study period and used it almost exclusively for completing timed sets of 48 questions drawn from all subject areas. This graph summarizes how many practice questions I did per day during my dedicated study period:


I completed 52 sets at 48 questions each for a total of 2496 questions from USMLE Rx.

During the dedicated study period, I also went back to USMLE World occasionally when I wanted to do some subject-specific questions.

If I could do it over again, I would:
1) Buy a year subscription of USMLE Rx instead of USMLE World, then use USMLE World during the dedicated study period.
2) Buy USMLE Rx at the beginning of Cardiovascular block instead of during the Renal block.
3) Be more consistent about completing 5-10 practice questions per day during Year 2.

Step 1: Studying pharmacology

I was probably most at a loss as to how to study for pharmacology than for any other subject. Even while going through the curriculum during the first two years, I had difficulty with the rote memorization that pharmacology demands. Because of this, I tried a lot of different approaches in order to figure out how to best study pharmacology for the USMLE Step 1.

It wasn't until the middle of Year 2 Semester 1 that I figured out the best way for me to learn pharmacology was a combination of making tables and flashcards. I have a table for antibiotics, antivirals, antifungals, antiarrhythmics, antineoplastics, diabetes medications, etc... The tables were (of course) made in Excel and provided the overall organizational at-a-glance picture of the pharmacology for a given field or disease. I really wish that I had started making these tables during CVPR. The act of making them was a means to learning, but then I also had this great resource for quick reference or for re-learning the material while studying for boards.

I caught on a little earlier to making and using flashcards for learning pharmacology. Like making tables of drugs, the act of making flashcards also helped me learn the material; then, I also had the flashcards as a resource for memorization. I made my flashcards in a program called Anki, which uses an algorithm that purports to maximize learning by spacing out the intervals at which cards repeat based on how difficult you rate it. Cards "mature" as you see them more often. A card that you repeatedly rate as "Easy" or "Very easy" may be presented next in a few months or longer. In that way, "mature" cards don't take away from learning other cards that are more difficult.

I started making Anki decks for pharmacology during CVPR and liked it enough to continue during Neuro and DEMS. By the time my dedicated study period rolled around, I already had a lot of great resources for studying pharmacology - all of which I had created myself. I consolidated all of my pharmacology tables into one Excel document with many tabs. I also consolidated all of my pharmacology-related Anki decks into a single deck with each card categorized with labels. That way I could easily quiz myself on, for example, only anti-epileptic drugs.

With these two consolidated resources in place, I then built upon them during my dedicated study period. I did this mainly through practice questions. Whenever I came across a pharmacology question, there was almost always at least one drug in that question that I didn't know. The obscure drugs were usually one of the answer choices. But I would look up the drug and make a flashcard for it.

I made two types of cards. The first type of card was standardized to look something like this:

Drug X:
1. Mechanism of action
2. Clinical uses
3. Toxicities

The reason for this standardization was to avoid memorizing a particular card and to instead encourage actually learning the material. It would have been too easy for me to start remembering the idiosyncrasies of various cards if they weren't standardized.

The second type of pharmacology card I made was directed questions about very important facts. For example:

What drug has been shown to reduce mortality in patients with congestive heart failure?

The answer, of course, is spironolactone. I made a card like this anytime an important fact like that came up in my studies, most often from practice questions. A lot of these cards were idiosyncratic toxicities of particular drugs.

I bought a set of PharmCards and used them regularly over Summer break, but they didn't really work as well for me because they were too difficult to organize. I ended up giving them away to a friend of mine after they say unused for an entire semester.

I also bought Katzung & Trevor's Pharmacology Examination and Board Review and studied lightly from it over Year 2 Winter break. I became frustrated with it because it seemed that the questions at the end of each chapter did not really draw directly from the material presented in that chapter. I also wasn't a fan of the organization of the text. During the dedicated study period, I did return to this book for helping me to answer some specific pharmacology questions. I also used it to help me study anti-epilepsy and anti-neoplastic drugs, both categories that take a little extra effort to nail down.

Overall, I think that the pharmacology tables and the Anki flashcards together helped to drastically improve my performance on pharmacology questions. I make this claim by comparing my percent-correct performance in pharmacology questions on practice sets early in the dedicated study period compared to late in the dedicated study period.


Click here for the pharmacology Anki deck that I created.

Step 1: First Aid

I bought First Aid for the USMLE Step 1 (2010) toward the end of the first semester of my first year, but I didn't open it and start studying from it until the middle of my second semester of my first year. This is a common story and a common mistake.


There's a lot of hype about First Aid, and for good reason. Back when I first started freaking about Step 1 (the vast majority of medical students do at one point or another), First Aid was to me like an anchor: something tangible and finite. I thought that all I had to do was learn everything in First Aid and I'd be fine. I'm sure many other medical students have felt the same way. In reality, First Aid is only a convenient outline of what must be studied to do well on the Step 1 and to be prepared for clerkships. That's why for me it became so important to study from First Aid as I worked through my classes: I came to view my coursework as one big Step 1 prep course.

I wish I had started using First Aid during my Blood and Lymph (Hematology/Oncology) and Disease and Defense (Immunology) courses at the beginning of second-semester-first-year, but I only began studying seriously from First Aid starting with the cardiovascular block. This consisted of taking notes in it during lecture and constantly using it as a reference as I moved through my courses. I read the relevant sections in First Aid before their corresponding lectures, which definitely helped in terms of repetition.

I did this for the pulmonary and renal blocks, too. During Summer vacation after my first year, I re-read the cardiovascular, pulmonary, and renal chapters and also went through the other chapters that we had already covered: hematology/oncology, immunology, biochemistry, behavioral sciences, psychiatry. I also read through the neurology chapter in preparation for that block in the Fall.

I similarly pre-read the gastrointestinal, endocrine, reproductive, microbiology, etc... chapters before the start of their respective courses. When I say "read," I really mean "read" and not "memorize." I just got a general feel for the nature of the material I would be learning, the general structure of how it would be presented, and when I came across something that looked interesting, I looked it up to learn more about it.

So, by the end of my second year, I had read through First Aid once all the way through, having read some chapters more than once. I think this is a reasonable goal for most medical students preparing for Step 1.

Some people like to un-bind the book, 3-hole-punch it, and stick it in a binder. I was resistant to that idea, mostly because I like to hold a book in my hands and flip easily back and forth from one page to another. The advantage to hole-punching First Aid, though, is that you can mix in useful diagrams or tables from lecture notes or other resources that complement First Aid or better summarize the material. I finally did this in the middle of Year 2 Semester 1 for less than $10 at Kinko's and wish that I had done it earlier.

By the time the dedicated study period rolled around, I was really only using First Aid as a guide for studying a given subject in greater detail. For example, when I first started reviewing embryology, I first flipped through that chapter in First Aid. I had already made a bunch of highlights and underlined what I thought to be important information and made notes in the margin, so this went fairly quickly. Then, as I was reading through a more detailed text or reference (in this case, Langman’s Medical Embryology), I would refer back to First Aid only when necessary.

Bottom line: Overall, First Aid is as necessary for studying for the USMLE Step 1 as everyone says, but its limitations should be recognized, and it should be used for studying while going through the basic science curriculum.

Step 1: Daily routine during the dedicated study period

Last year, as the class above me was slaving away during their dedicated study period for the USMLE Step 1, I wondered about their day-in-day-out routine. Sometimes I saw them in the library or at Chiptole, but these rare sightings only offered proof that they were in fact still alive. So, I thought it might be useful for medical students who have yet to jump the Step 1 hurdle for me to briefly describe my daily routine during the dedicated study period.

I woke up every morning at 6:15 because that is the time I would be waking up to take the real test on April 11th. More often than not, I did some flash cards right after waking up or while making breakfast, just to wake up my mind. After breakfast, I usually did a set or two of 48 practice questions. Each set of practice questions takes 1 hour to complete, and I usually spent about the same amount of time reviewing them. So, if I did two sets of practice questions, that already took me to the afternoon.

I spent the afternoon focusing on a particular topic. That usually involved First Aid together with multiple other texts. For example, I relied heavily on Robbins and Cotran's Pathologic Basis of Disease and on BRS Physiology for pathology and physiology, respectively, while studying each organ system. I would continue studying that particular area until late afternoon or early evening before taking another short break.

Sometimes, particularly more toward the end of my study period, I would then do a third set of practice questions and review them in the evening. Then I would have dinner (which was usually take-out), go home and relax for a bit, then do some more flashcards at night before bed.

My daily routine obviously had a certain degree of variability.

First, my routine evolved as I figured out what worked best for me and what didn't, and as my needs changed. I was doing more subject-specific studying and fewer practice questions toward the beginning of the study period compared to the end, necessarily so.

Second, life does go on even when you're studying for the USMLE Step 1. I signed up for a 5k on March 20th, smack in the middle of my study period, and I also ran a half-marathon a week later. This kept me running almost every day, except during that last week before the exam. As difficult as it was for me to set aside time to run, I can't overstate how necessary running was to maintain my sanity. It helped to have family and friends keep me honest about my running. I usually fit my runs in after my morning practice questions or in the evening before dinner.

Third, I took the weekends a little easier, which for me meant only studying 8 hours or so instead of 12. This was also very helpful in keeping me sane, and I'm very glad that the MD/PhD student who took the exam a few years ago, and gave a talk on studying for the Step 1, impressed upon me the necessity of scheduling time off specifically to relax.

Step 1: Setting my study schedule

Studying for Step 1 was a daunting task when it lay before me. How should I allocate my time? In what order should I study each subject? As the dedicated study period approached, Student Affairs invited an MD/PhD student who took the exam a few years ago to speak to us about setting a Step 1 study schedule. This was just as much about calming over-anxious second-year medical students as it was communicating information that was actually useful. It was a good talk, though. The most salient bit of advice he gave was to enjoy it: to have fun and make the most of the only time in our careers in which a whole month is set aside to just learn as much about medicine as we can - without all the distractions of patients and such (a little bit of tongue-in-cheek). Two other important take-home points: 1) set aside a few days to review and return to subjects covered earlier in the study period, and 2) set aside time to just relax.

My schedule

The semester ended on Friday, March 11. I took that Saturday completely off and started full-steam ahead on Sunday, March 13.

Before starting, I mapped out the days on which I wanted to take practice exams. Because I took my exam on a Monday, I decided that I would take a practice exam every Monday until the real deal on April 11th. I built the rest of my schedule around those practice test dates.

Based on my experiences studying for Step 1 during the school year, I decided to take a fluid approach during the dedicated study period. What that meant was letting go of a rigid schedule in which I mapped out exactly what subject I would be studying on what given day for the next 29 days. Instead, I made a list of all the subjects that I wanted to study. I started out with those subjects in which I felt weakest and that also demanded a more conceptual understanding versus rote memorization.

From there, I almost let whim guide my next subject. For example, while studying cardiovascular, I knew that I needed to understand heart development, so I decided to just tackle the rest of embryology at the same time. It worked out for me because embryology is a more conceptual subject that can be more broadly applied to understanding the organ systems. The point is that everyone has to tailor their study schedule to best fit their own needs.



As the end of the study period approached, it became easier and easier to identify which subject I wanted to study next and to gauge whether I had enough time to do it. As it turned out, I had more time than I needed to cover all of the subjects that I listed. I used that extra time to take more practice tests, the formal practice tests published by USMLE World. I'm very glad that I had enough time to do this.

I spent the bulk of my review days talking through subjects in which I still felt weak and reading through notes that I took from my practice questions. This turned out to be a good use of my time. Importantly, I took those last two review days easy - an attempt to key myself down and control my anxiety.

Step 1: Study statistics

I put in a lot of hours studying over the past month. A lot. Because I was investing so much time into studying for the Step 1, and because I'm just that kind of person, I decided to keep track of my study efforts. Here are some interesting statistics covering my 29 days of the dedicated study period:

* I studied a total of 311 hours. That works out to an average of 10.7 hours per day. Assuming an average of 7 hours of sleep per night, the math works out to studying about 63% of total waking hours.

* I completed a total of 3866 practice questions. Taking each question takes an average of 1 minute 15 seconds, and I spent about the same amount of time on average reviewing each question. The math works out to about 161 hours spent on practice questions, or 51.8% of total study hours.

A picture is worth a thousand words, so here are a few visuals I put together:

Step 1: Studying for USMLE Step 1 during my first two years

Note: This post is mainly intended for medical students looking to hear what others have done in terms of studying for the USMLE Step 1. It will likely not be very interesting to anyone else.

I have purposefully avoided writing about how I study for the USMLE Step 1 until now for two major reasons. First, there tends to be a high level of anxiety among medical students about studying for this test, and I prefer to avoid accidentally stepping on anyone's toes by needlessly broadcasting my approach to studying. More importantly, until now, I hadn't actually gone through the process and had time to look back and assess what worked and what didn't. Now that the whole thing is behind me, I feel that I am in a good position to describe how I studied for the USMLE Step 1 during my first two years of medical school and to comment on what I might have done differently.

Before jumping in, it's important to point out the obvious: everyone is different, with their own personalities and their own study habits and their own preferred ways of learning. What works for me may be ineffective for someone else. I am the kind of person who likes to start early and work steadily on a large project, so my approach to studying for Step 1 may not be as relevant for people who like to procrastinate or to cram as much studying as possible into a short period of time.

It's also important to point out that my perspective and experiences will have the greatest significance for people going through my program at the University of Colorado School of Medicine, which has an organ systems approach. For ease of reference, here is an outline of the basic science curriculum during the first two years:

Year 1, Semester 1:
* Human Body (Anatomy)
* Molecules to Medicine
* Year 1: Winter Break
Year 1, Semester 2:
* Blood and Lymph + Disease and Defense
* Cardiovascular + Pulmonary + Renal
* Year 1: Summer Break
Year 2, Semester 1:
* Neurology
* Digestive + Endocrine + Metabolism
* Winter Break
Year 2, Semester 2:
* Life Cycles + Infectious Diseases
* Dedicated study period
The Bottom Line


Year 1, Semester 1: Anatomy

I didn't do any studying specifically for the boards during Anatomy, and that's the way it should be. However, the one thing I would do differently during Anatomy, with respect to Step 1, is to take the embryology lectures more seriously. I used Langman's Medical Embryology as a reference during Anatomy and ended up finding it extremely useful as a resource when I reviewed embryology during the dedicated study period.

Year 1, Semester 1: Molecules to Medicine

I was so exhausted after finishing Anatomy that I wasn't really thinking in terms of studying for the USMLE Step 1 during Molecules to Medicine. I did buy First Aid for the USMLE Step 1 toward the end of the semester, but I didn't even open it for a couple months. If I could do it over again, I would have had First Aid in my hands before Anatomy ended, and I would read over the relevant sections as we moved through Molecules to Medicine. It's really just scattered parts of the Biochemistry section and some organ system sections, but the point is that it would get me used to doing that for the rest of my courses.

Year 1: Winter Break

I didn't do any studying for the boards over Winter Break of my first year. If I could do it over again, I would flip through First Aid to familiarize myself with its organization and layout. I would get a better sense as to the kind of material I would be expected to learn over the next year-and-a-half. I would also read more carefully through the Immunology, Hematology/Oncology, and Pharmacology sections because those are all covered by Blood and Lymph and Disease and Defense. The same goes for reading relevant sections in First Aid before all of the other blocks.

Year 1, Semester 2: CVPR

CVPR in the second half of Year 1 Semester 2 marks a turning point at which the curriculum becomes much more clinically-oriented. I started using a question bank during the Renal portion of CVPR and found it very useful to prepare for that exam. If I could do it over again, I would have started using the USMLE Rx question bank during the Cardiovascular portion of CVPR (see this post that addresses question banks specifically). I also would have bought BRS Physiology and actively read through the relevant sections as we covered them in class.

Year 1: Summer Break

Whether or not or how much to study for Step 1 during our Last-Summer-Vacation-Ever can be a sensitive issue for medical students. I did study for Step 1 over Summer break, but I felt like I shouldn't talk about it with my classmates. It's not like I hid the fact that I studied, but I didn't want to come across as grandstanding or showing off, and I didn't want to make someone feel bad if they weren't doing any studying themselves.

I didn't keep track of my studying over the Summer like I did during the dedicated study period, but I probably spent an average of 3 hours per day studying. All of this consisted of going through First Aid (see this post) and doing practice questions (see this post). I think that this was a good balance between studying and enjoying my Summer vacation.

Year 2, Semester 1: Neuro and DEMS

Once second-year started, I felt like I needed to be more systematic about my studying. Reality had set in that Step 1 really wasn't all that far off. I tried to map out how many pages of First Aid I would read per day in order to read through it all again before Winter break. The idea was to move through separate topics while also covering the Neurology chapter during the Neuro block and the Gastrointestinal/Biochemistry/Endocrinology chapters during DEMS. This turned out to be too rigid an approach. Also, I found that I was splitting myself in too many directions.

Ultimately, moving through First Aid in course-relevant chapters, along with doing USMLE Step 1 practice questions somewhat regularly, was for me sufficient studying for Step 1. I do wish that I had had BRS Physiology for the Neuro block, too. It would have been useful for parts of DEMS, but it strangely lacks any mention of the liver and pancreas, which are both heavily tested on Step 1.

Year 2: Winter Break

In contrast to Summer vacation, I think it's pretty much understood that the majority of medical students will be studying over the Winter break before the exam. I went home for Winter break and managed to get in some good relaxation time, but I also studied around 6 hours per day. This consisted mostly of reading through BRS Physiology and parts of BRS Pathology.

I think that this was a good balance between studying and enjoying my Winter vacation. However, in the end I was dissatisfied with BRS Pathology. I wish that I had instead used that time listening to the Goljan lectures while at the same time reading through Goljan's Rapid Review Pathology.

Year 2, Semester 2: Life Cycles + Infectious Diseases

This is crunch-time. Two more blocks and four months before the Big Test. The block directors were very aware of this and made significant effort so that the material covered was relevant to Step 1. I think there is some debate as to how effective they were at accomplishing this. In my opinion, the material covered in these two blocks was very relevant for Boards (ID more than LC), but I was frustrated that the questions on the exams were more nit-picky and less clinically-oriented than USMLE-style questions.

It would have been easy for me to spend more time studying for Step 1 instead of focusing on Life Cycles and Infectious Diseases. But I decided that it would be best to consider these blocks as an extension of my dedicated study period. In fact, by the end of my dedicated study period, I realized that all of the basic science curriculum during the first two years is essentially a study period for the USMLE Step 1.

As I progressed through LD/ID, I stepped up the number of practice questions I was doing per day. In addition to doing questions related to those courses, I also started doing one full timed set of practice questions (48 questions in 1 hour). Looking back, I think this was helpful for transitioning into the dedicated study period, and I don't think I would do much more than that.

Step 1: Dry run

I drove this morning to the Prometric testing center where I will be taking my Step 1 exam on Monday. It was a dry run to make sure I know where I'm going on test day, which will be stressful enough without having to worry about getting lost. Getting to the office park where Prometric is located is simple enough, but the office park itself is laid out in a wonderfully confusing symmetric geometry.

Luckily, I spotted my friend's lime-green Prius as I turned into the office park, and she seemed to know where she was going.

Many of my classmates were there this morning. Their nervousness and excitement were palpable - mostly excitement to have this damned test over and done with. Seeing them all about to jump in, I wanted to take my test today, too. But no. I left before I let the atmosphere get to me. One more weekend of studying and it's over.

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.

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.

Jaw pain in a psychiatric patient

A disheveled woman who was talking to herself came into the emergency department yesterday evening complaining that she couldn't eat because her jaw hurt. The resident with whom I was working was more than happy to give me the first go at interviewing and examining her. She said her right jaw hurt and that she was afraid to go to sleep because "the pain is too close to my brain." She also had a strange preoccupation with her ears and told me some story about accidentally inhaling a piece of paper then later pulling that paper out of her ears.

I did a head and neck exam on her but didn't find anything out of the ordinary - her ears were clear, and I didn't feel any creaking in her jaw when she opened it and closed it. After presenting to my resident, she asked me if I had my patient open her jaw all the way. I hadn't. So I went back, and when she opened her jaw wide, I felt a popping on the right side. Classic temporomandibular joint (TMJ) syndrome. We sent her home with ibuprofen.

I learned what TMJ syndrome feels like and how to elicit its sign. I also learned that it can be easy to miss a physical diagnosis in a psychiatric patient. The pain that my patient felt in her jaw and its impact on her life were no less real just because she had fantastical thoughts.

Pediatrics physical exam session

Today I got to play with children. We had a pediatrics physical exam session through Foundations of Doctoring, conveniently coupled with the pediatrics section in the Life Cycles block. This session included an interactive lecture teaching us about developmental milestones. Afterward, we had physical exam sessions with two different families, each led by a pediatrics resident.

This experience differed markedly from some of the exams I gave during my pediatrics elective at Warren Village - it's like playing with puppies when the kids think that the exam is pretend instead of real.

The second family was the highlight of the session: a five-year-old girl and four-year-old boy. We all introduced ourselves (seven students in the group), and when I introduced myself, the little girl said, "There's a boy named Tyson in my class!" She then proceeded to draw a picture of me examining her - and write a narrative of it - while the resident was teaching us about the physical exam.



As far as I can tell, this says: "Tiyson Tyson was taking me a doctur and I said thank you and then Leul [her brother] had a turn and Leul said thank you and it was for are nose." I was looking up her nose with the otoscope. And that's me holding either the otoscope or a reflex hammer.

Fortune

My fortune cookie fortune today: "You will be successful through innovation and determination." In these stressful times, I'll hold onto that.

Phase III orientation "retreat"

The administration recently held a retreat for the class of 2013 to demystify Phase III. "Retreat" is a bit of a misnomer since the conference was held in a lecture hall on campus. Regardless, a lot of thought and energy went into organizing this event, which was primarily for our own benefit and turned out to live up to its purpose.

So many questions...

What are clerkships?
Clerkships are the same thing as "clinical rotations." Their purpose is to expose the third-year medical student to a particular field or specialty. The student experiences that field from the clinical perspective and becomes as clinically proficient in it as he or she can get in the number of weeks allotted to that rotation.

What clerkships are required?
Ten clerkships must be completed during Phase III:

* Hospitalized Adult Care (a.k.a. Internal Medicine) - 8 weeks
* Infant/Adolescent Health (a.k.a. Pediatrics) - 6 weeks
* Musculoskeletal Care (a.k.a. Orthopedics) - 2 weeks
* Women's Care (a.k.a. OB/GYN) - 6 weeks
* Urgent and Emergency Care - 2 weeks
* Psychiatric Care -4 weeks
* Neurologic Care - 4 weeks
* Operative/Perioperative Care (a.k.a. Surgery) - 8 weeks
* Adult Ambulatory Care - 4 weeks
* Rural and Community Care - 4 weeks

These clerkships are then scheduled within six 8-week blocks starting April 25, 2011 and ending April 20, 2012. Mixed in there are three clinical interludes (about which I know very little) and a few federal holidays sprinkled here and there.

So, you get some holidays off?
Maybe. Holidays during Phase III "may not apply at all clinical sites." It's at the discretion of my attending physician. That said, the holidays listed on my schedule are:

* Memorial Day, May 30
* Independence Day, July 4
* Labor Day, September 5
* Thanksgiving, November 24-25
* Martin Luther King Jr. Day, January 16
* Presidents' Day, February 20

I also get a Fall break from August 15-19 and a Winter break from December 17 - January 2. Those breaks are certain, but they may fall in the middle of a clinical rotation, in which case I imagine the break wouldn't be completely worry-free.

In what order will you do your clerkships?
I don't know, yet. I will post my Phase III schedule here when I get it in early February.

Do you get to choose your schedule?
Not really. But, the administration has set up a system in which every student identifies two priority clerkships. Last year, every student but one got their first priority clerkship. On top of that, there is a student-led swapping program that permits two students to switch clerkships if both students agree and if the switch does not cause any other scheduling conflicts. As you might imagine, a lot of anxiety surrounds this whole process.

What were your first and second clerkship priorities?
I chose to have the Adult Ambulatory Care and Rural Community Care rotations (they are scheduled together) first (priority #1) and my Internal Medicine rotation second (priority #2). My reasoning for this was several-fold.

Numerous people - including my preceptor - suggested doing Internal Medicine earlier rather than later because it serves to prepare students to perform better in subsequent clinical rotations. In fact there is an article in the Journal of the American Medical Association (JAMA) that provides evidence supporting this notion:

The positive association between initial internal medicine clerkship experience and subject examination performance throughout the clerkship sequence may reflect general understanding of internal medicine concepts, providing a fundamental basis for medical knowledge in all clinical disciplines.
JAMA. 2010;304(11):1220-1226.

I have other personal reasons for requesting these priorities. I prefer to approach the longer clerkships earlier so I'm less tired and burned out for them. I prefer to do the rural rotation during the Spring/Summer months when the whether is more forgiving. Also, several interns and residents I've talked to said that Adult Ambulatory Care and Rural Care are relatively easy ways to transition into the clinics.

Regardless, the administration was careful to emphasize that there are no guarantees that we'll get even our first priority. So, let's just put this out of our minds and wait until February when I'll have a concrete schedule.

What's this about a rural rotation?
Yes, a rural rotation. Except for Denver, Colorado Springs, and a few other smaller cities, Colorado is a very rural state. As such, the School of Medicine places a strong emphasis on rural medicine. That includes requiring a clinical rotation in rural Colorado. Housing is provided by a program called the Colorado Area Health Education Center (AHEC), either in condos or town homes owned by AHEC, or with a host family. I don't know all of the rural sites, but we select our top preferences from a list in a process similar to prioritizing our clerkships.

It's also worth noting that many of the clerkships have rural sites. Emergency Medicine, for example, has a rotation at St. Mary's community hospital out in Grand Junction. The Women's Care rotation has sites in Colorado Springs, Frico, and Brighton. If I wanted to, I could probably arrange to spend more than half of Phase III outside of Denver.

Will you have a life during Phase III?
No. In fact, this point was specifically emphasized in case there was any ambiguity on the matter. We were told to ask our friends not to get married during this coming year. In fact, it would also be best if none of my family or friends have birthdays or decide to die over this coming year. I'm not to get sick, either.

In all seriousness, though, the administration explained how there are involuntary absences (e.g. sick) and voluntary absences (e.g. wedding, birthday). They then told us that any absences - voluntary or not - may delay our graduation date if we are unable to make up all of the clinical requirements that we miss as a result of our absence. So far, it's certain that I will miss my Nana's 80th birthday celebration. Still up in the air is a close friend's wedding. Luckily, I will most likely be able to attend my sister's graduation, but only because it happens to be local.

This is depressing. But as I told my little sister when we were discussing her graduation and my Phase III schedule, I knew that this was coming when I signed up for medical school.

The rest of the conference

The rest of the conference consisted of presentations by the various clerkship directors. We were also given an opportunity to talk in small groups with the clerkship directors and ask them any questions we had about that particular rotation. I found this extremely helpful.

The co-presidents of the Class of 2011 (current fourth-year students) spoke to us, imparting their hindsight-is-20/20 wisdom. One of them made a list of concrete pieces of advice for incoming third-year medical students, which I will provide in a separate post.

Finally, the 8-hour conference was capped off by a dinner hosted by Student Affairs. A chief-resident sat at each table and chatted with us in that informal setting. The keynote address was given by Dr. Steve Lowenstein, an Emergency Medicine doctor with a degree in public health. His entire speech was excellent, but one quote stood out to me. On how to avoid and deal with burnout, his advice was to fall back on kindness: "Kindness is easy to administer and exceptionally well tolerated." Moreover, kindness speaks to the reasons why I decided to go into medicine in the first place.

There's no doubt about it: Phase III will be physically and emotionally exhausting. But I am looking forward to jumping into that next phase of my medical education.


P.S. Please e-mail me or write a comment if you have any questions about Phase III that I did not address. If I don't know the answer, I'll probably want to figure it out just as much for myself as for you. I may write a follow-up post on Phase III if there's a need for one.