ben white

While Final Exam, a memoir by transplant surgeon Dr. Pauline Chen, deals primarily with doctors’ troubled relationship with death and dying, I was struck most by an essay that deals directly with medical training’s preoccupation with protocol, algorithm, routine, and ritual. For Chen, rituals during her medical training were the foundation on which she built her persona and expertise as a doctor. Medicine is challenging, and ritual is the mechanism by which students—and later, physicians—break down complicated or otherwise difficult tasks in order to approach situations calmly, competently, and treat patients effectively. The harder the situation, the more essential it is to have a ritual to fall back on, as Chen describes how her routines helped steady her during an emotionally challenging pediatric transplant by allowing her to mindlessly do a procedure she had long since mastered.

My favorite ritual example in Final Exam, pre-surgical hand-washing, illustrates both its positive and negative effects. At first, the routine of scrubbing helped Chen ensure that she observed proper sterile technique; by following the ritual, she achieved technical competence and kept her patients safe. Furthermore, the mindless routine of the ritual was a form of calming meditation, a quiet break that helped separated her—emotionally and temporally—from both her clinical and surgical duties.

Years later (and after years of physical discomfort from an aggressive, skin-damaging style), Chen discovered that she was behind the times: she could achieve the same results by scrubbing for five minutes instead of ten and using a soft sponge instead of hard irritating bristles. The danger of ritual is that it leads doctors to routines that may reinforce bad habits, make it challenging to adapt to advances in patient care, or shield us from responding emotionally to our patients. Chen writes:

After nine years of clinical training, I found it hard to conceive of doing these clinical tasks any differently. In, I fact, I believed there was no other way, because these rituals were what assured the quality of my practice. They were what made me a good doctor.

This devotion to ritual is what helps training doctors learn the way of doing things correctly, even when the way is perhaps not the best way. While rituals may be a necessary first step in the learning process, the art of medicine lies not just in following the ritual effectively—but rather in when knowing to deviate. As Chen argues, a good surgeon doesn’t just know how to perform the right maneuvers; she knows how to fix the surprises that invariably pop up in the moment. It is when we fail to leave room for change in our devotion to ritual that our development as physicians stagnates, because while “they protect us from doing the wrong thing, their protective logic can shield us from fully shouldering responsibility.” (94) If we do everything correctly, the logic goes, then the negative consequences must be beyond our control.

Hand-washing is a relatively benign example because Chen was only hurting herself, but ritual pervades every aspect of medical training and practice, from memorizing the steps of the physical exam to sharing difficult news with a terminally-ill patient. The negative consequences of these rituals are only complicated by the role of the “informal curriculum” in medical training, the instruction that indoctrinates young doctors with the habits of their superiors. What happens when the rituals themselves are faulty? What happens when the carefully rehearsed patterns are themselves a source of doctor error?

In our first year training we learned physical exam techniques from both fourth year students and faculty preceptors. Both groups stressed the importance of learning the rituals of different exams, the routines on which to build our future competence, and so we robotically went through the motions, verbalizing our steps and performing the exam with techniques that only appeared analogous to the real thing. The emphasis was on “pretend” competency: the ability to look like a doctor on camera. This is not a shortcoming of any one school but rather an unfortunate result of the nation’s century-old curriculum design, one that places inordinate importance on some topics to the exclusion of others (oblivious of clinical importance). Soon, undoubtedly and embarrassingly, our class will have to relearn how to perform exam techniques in order to actually evaluate our patients. Right now, the sham ritual is all we have.

As Chen says, the clinical aphorism is “see one, do one,” which means that as doctors we train to master the mistakes of our mentors. Our early success will depend directly on how well we copy our teachers (because it is our teachers, with their idiosyncrasies, that evaluate us). And while rituals may be a useful crutch in the short term, it’s not hard to imagine the future consequences. When our patient interactions become ritualized—each sentence just another item on a mental checklist—our patients will be reduced to a given number of steps. The more times we use our algorithms, the easier it will be to categorize our patients as cases, people as diseases, and conversation as a technical skill—instead of an intrinsic part of what makes us human. This reduction is the process of dehumanization that comes with the epidemic of physician burn-out, naked cynicism, and is a chief component of patient dissatisfaction. It is a mainstay of a generation of medicine we should hope to overcome.

No matter how much money you spend on books, every medical student needs to do a ton practice questions for the USMLE Step 1. Questions are an excellent way to learn the useful tip-offs and keywords, and—depending on the source—get a better feel for the board format. They’re also a form of active learning, unlike trying to self-induce a coma with the universally-utilized First Aid for the USMLE Step 1.

For question books, post-Step MS3s and your local Half-Price Books are always good resources to buy study materials on the cheap. But free is better, and the internet is undeniably convenient and portable. I scoured the web to find free question banks online:

• Test Prep Review has a USMLE practice self-assessment section. There are 20 modules of 20 questions for 400 questions. They’re mainly fact-recall and not vignette-based, but it’s easy to use and accessible.
• Wiki Test Prep is a student-written qbank with over 900 questions with explanations. The site is great, and you can browse questions by keyword, flag questions, and create your own tests. It also lets you know what percentage of students answer the question correctly, which is interesting. The questions are in clinical-vignette board format.
• 4tests.com hosts the 60 question Kaplan diagnostic exam. Answers can be exposed during the test if desired and do contain explanations. (Mom MD also has the identical sampler, only organized in six 10-question pages with answers directly below questions)
• Lippincott’s 350-Question Practice Test for USMLE Step 1 is a solid Qbank, but you must register (for free) before using it.
• ValueMD has a large question bank divided up by subject. The site also requires a free registration. The questions are straightforward fact-recall type and the site itself is clunky and hideous, but it’s still good review.
• The NBME offers its own small set of free practice materials for the Steps 1, 2, and 3. You have to download the program here, Windows only.

Enjoy.

It’s no secret that by the time medical students begin residency, many are jaded. It’s also no secret that at the beginning—at least on paper—medical students are good, caring people.

The logical question: what’s behind the change? Is it the never-ending soul-crushing time-wasting torture of basic science education followed by the thankless continued-debt-incurring grind of clinical rotations? Or, or, is it because our medical school ethics classes haven’t done a good enough job teaching us that—contrary to industry wisdom—patients are human beings?

Choice one, obviously.

So, I’ve had a revelation. When medical students are forced to watch Wit (an otherwise good movie so melodramatic that it pretends that the true love of physicians is biochemistry and thinks that repeating 17th century poetry ad nauseum is emotive), don’t tell us to “consider” the issues of death and dying or the patient experience. It’s patronizing. We consider it. Doing that right is probably the single scariest thing about becoming a doctor. Ethics matters. However, implying that first and second-years actively look forward to psychologically abusing their patients is not an effective way of emphasizing the importance of the doctor-patient relationship.

If a factory wants to stop churning out callous robots, then fix the machinery. It’s not time for an amateur film studies class; we’re not in college anymore, and the moments for classroom revelations have long since past.

Some thoughts for intrepid and probably antsy first-years as they stumble upon this page on their search for the truth. Here are some tidbits about the Anatomy, Physiology, Biochemistry, and Microbiology shelves.

Anatomy:

Anatomy, if learned well over the year, is doable. It is crammable if (and only if) you’ve actually paid attention and learned everything once. This is not the time to learn anything for the first time. Even with a good background, it tests a ton of material. Pay special attention to high yield parts—things that are often injured or easily framed in a clinical vignette. While everything is there, it’s not there equally often.

For example, collateral circulation is a big favorite for several systems. You’ll see questions that involve artery transection from stab wounds as well as a occluded arteries from cholesterol plaques. You need to know what other arteries can supply these areas–they’ll be there in spades. Focus not just on knowing body parts but also on 3d relationships between body parts, because they’ll often ask for one part in relation to another (the structure immediately lateral to the X is….).

Lastly, pay attention to common injuries and conditions. If someone falls on an outstretched hand, what bone is probably broken? Scaphoid. What bone is most likely dislocated? Lunate. So on and so forth.

Physiology:

Memorize lab values, especially if you’re the type who doesn’t finish tests quickly (this is also a time-saver on the Step 1). More so than other shelves, Physiology clinical vignettes often include lab values that are actually key to understanding what’s wrong (not the case for Microbiology, for example, where lab values are almost always superfluous). Because the test demands more problem solving/reasoning over rote memorization, the physio test is also one of the more tiring, in my humble opinion.

Almost all physio questions require knowledge of the various trends and formulas; they usually demand that you know why something happened or what happens next. For example, you need to know the body’s compensatory mechanisms to keep fluid volume stable, and how these are used to correct for hemorrhage, dehydration, diabetes insipidus, etc etc etc.

Also, know your renal.

Biochemistry:

Buy a set of notecards and memorize them. Know all of the incredibly rare diseases and what enzyme is deficient in the pathway. Not much to say here: it’s a hard test. The things that are most often covered in detail in your biochemistry class are the things you must know in greater detail. So, you have to know metabolism incredibly well. Intimate knowledge of pathways like glycolysis, glycogenolysis, and gluconeogenesis is very high yield. For less important topics, like microtubules, basic gist-level knowledge is sufficient.

Microbiology:

The most crammable exam. First, know basic virology and bacteriology. How they work, change, evolve etc. You definitely must learn about the multiple ways bacteria become virulent and gain new genetic material. A lot of the test comes directly from the sort of stuff everyone overlooks when they start memorizing pathogens.

Second, for clinical vignettes, a good notecard set is always helpful. For most pathogens, there are a handful of key words that will set you off to the question—they usually ask for either an identification or a secondary fact about it. Everything else in the question is just time-wasting fluff. Memorize the key relationship, and you will be fine on the majority of the vignettes. Will you really understand what’s going on? Probably not, but these questions are often designed to test your knowledge of these stereotypical cases, not whether or not you’ll actually be a competent physician.

For example, H. pylori, which causes gastric ulcers produces urease. If you see a patient with an ulcer, the answer is probably either the ID or the enzyme. Aspergillus makes a “fungus ball.” Coccioides is a spherule in the body. People who get a non-healing lesion after being pricked by a rose thorn have an infection from Sporothrix. If a bacteria is coagulase positive, it’s Staph aureus. It really is that superficial. Key word > answer. The difficulty comes from information overload. The more rare the disease, the more likely the question will be an easy form of memory recall (e.g. fever that goes up and down (undulates) is Brucellosis). For more common bugs like Staph and Strep and the very well known diseases (Malaria, TB, etc)—do a better job nailing down greater details.

And that’s it. You’ll be fine.

The NBME Shelf exams are enjoyable standardized tests that every first year looks forward to with almost unbearable glee. They test a single subject (“Anatomy”) and apparently take the relevant questions from the USMLE Step 1, a test that makes the MCAT look like the GRE and the SAT look like building with Lincoln logs.

Some schools force their students to take a variety of Shelf exams (spending/wasting $30 a pop) to help measure how well their students have mastered the material (AKA how they are doing compared to their national counterparts). What is a bit amusing and misleading about the whole ordeal is that the national norms are probably a big crock.

Different schools use the “shelves” differently. Some use them as a just-for-fun intellectual exercise, others as extra-credit, and still others as a true final exam. Don’t get me wrong, it’s not a bad thing to get some USMLE Step 1 experience, but it’s highly dependent on the environment: if you take five step exams in a single week, you are clearly not going to be prepared or even particularly focused. If it’s your final exam, you are going to do your best to rock it.

So if the national average is computed from all of these groups together, then it’s going to have a huge unseen left tail: if people are taking the exam who don’t care how they perform, they’re going to be dragging the average down from where it would otherwise be. So while the test is technically normalized, it’s not the same normal as a regular standardized test: Unlike the MCAT, not every student has something riding on the exam. I personally knew people who filled out all C’s on an exam that was for extra-credit only.

While your school receives the group’s average and your grade relative to your test group (classmates), the theoretically more interesting numbers a student receives are the grade based on the national average and corresponding percentile. I’m curious as to how far off the scores really are. If all those people who weren’t making a good faith effort actually tried (as they do on the USMLE Steps 1, 2, 3), then I’d wager it’d be a different ball game. It’s essentially an unstandardized standardized test.

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