President and CEO of the NRMP, Mona M. Signer, talking with Medscape:

I certainly understand why applicants and programs engage in post-interview communication, but applicants and program directors shouldn’t create their rank-order list on the basis of post-interview communication from the other party. They ought to create their rank-order list based on their true preferences. Applicants should rank the programs where they want to train in order of preference, not where they think they will match. Program directors should rank applicants in order of preference, not the applicants with whom they think they will match. The matching algorithm works best when Match participants rank each other in order of true preference.

YES. Seriously people. I would also add that people shouldn’t create their ROL based on communication (or assurances) during the interview, either.

After all these years, some students and programs still think there should be other considerations to the ROL. But there aren’t. It shouldn’t really matter what the other side wants in this system. It matters what you want. It’s your list.

From “The Residency Match: Interview Experiences, Postinterview Communication, and Associated Distress” in the Journal of Graduate Medical Education:

In terms of postinterview communication, more than 70% of respondents indicated that they wished such communication were explicitly discouraged, and more than half said they wanted programs to bar candidates from notifying them of a high rank in order to avoid match manipulation.

There are no positives to the ego-stroking, play-acting, and intermittently grossly-misleading game that programs (and applicants) play. Everyone wants to be loved and get their top choices, but the only communication that should really have any impact (or be permissible) is new information:

• My spouse early-matched to a program at your institution.
• My mother has become ill, and I truly hope to end up in your city so that I can help take a greater role in her care.
• I just won the lottery, and there is a significantly increased risk of me not completing your grueling program.

Though the NBME allows everyone to dance, the best advice will always be rank them how you want them.

Do you have any idea how many bullets I pull out of corpses weekly? This isn’t just my lane, it’s my [expletive] highway.

Pathologist Dr. Judy Melinek, responding on Twitter to an NRA tweet admonishing doctors to “stay in their lane” and stop discussing gun control.

A new study published in JAMA last week (summarized by NPR) is another great example of the obvious negative externalities of prioritizing patient satisfaction scores (i.e. the Yelpification of medicine). It analyzed a large number of telemedicine visits for URI:

Seventy-two percent of patients gave 5-star ratings after visits with no resulting prescriptions, 86 percent gave 5 stars when they got a prescription for something other than an antibiotic, and 90 percent gave 5 stars when they received an antibiotic prescription.

In fact, no other factor was as strongly associated with patient satisfaction as whether they received a prescription for an antibiotic.

The outsized and misplaced importance of patient satisfaction scores is a perfect embodiment of Goodhart’s law, well-paraphrased as “when a measure becomes a target, it ceases to be a good measure.”

If you make patient satisfaction scores a critical target—and they are—you will see consequent mismanagement. This is so blatantly apparent when it comes to urgent care and pain management that, if anything, high satisfaction scores are likely a more meaningful signal of poor care (like in this study when patient satisfaction scores positively correlated with patient mortality).

I used to know a bunch of residents who would moonlight at a doc-in-the-box for-profit standalone urgent care. They were, apparently, told to make the patients happy and provide antibiotics for most URI visits.

Even outside of quality metrics, you need patients to make money, and the “customer” is always right.

Here are my explanations for the 2017 version of the official USMLE Step 3 free question pdf. This is a constant reader request, so enjoy my take on these 137 questions.

You can find my thoughts on preparing for Step 3 here. In short, I think the free materials and UWorld should be enough for most folks. If you want books recs, they’re in that post. If you need another question source, I haven’t tried any of them, but you can get 10% off BoardVitals if you’re interested by using code BW10.

As for this free practice exam, Blocks 1 and 2 are “Foundations of Independent Practice” (FIP). These should take up to 1 hour each. Blocks 3 and 4 are “Advanced Clinical Medicine” (ACM). These should take up to 45 minutes each. Total practice time should be no more than 3:30 if taking under test-day conditions.

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Akhilesh Pathipati, writing “Our doctors are too educated” in the Washington Post (emphasis mine):

U.S. physicians average 14 years of higher education (four years of college, four years of medical school and three to eight years to specialize in a residency or fellowship). That’s much longer than in other developed countries, where students typically study for 10 years. It also translates to millions of dollars and hours spent by U.S. medical students listening to lectures on topics they already know, doing clinical electives in fields they will not pursue and publishing papers no one will read.

We’ve done an amazing job in medicine findings way to fill years with reasonable-sounding and potentially useful activities and then pretending they are not only worthwhile but necessary.

Simon G. Talbot and Wendy Dean, arguing in STAT that burnout is actually a misdiagnosed consequence of unchecked moral injury:

We believe that burnout is itself a symptom of something larger: our broken health care system. The increasingly complex web of providers’ highly conflicted allegiances — to patients, to self, and to employers — and its attendant moral injury may be driving the healthcare ecosystem to a tipping point and causing the collapse of resilience.

The term “moral injury” was first used to describe soldiers’ responses to their actions in war. It represents “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.” Journalist Diane Silver describes it as “a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.”

The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.

Which is why the chorus of hollow wellness outreach efforts for trainees and other physicians are so patronizing and eye-rollingly ineffective:

The simple solution of establishing physician wellness programs or hiring corporate wellness officers won’t solve the problem. Nor will pushing the solution onto providers by switching them to team-based care; creating flexible schedules and float pools for provider emergencies; getting physicians to practice mindfulness, meditation, and relaxation techniques or participate in cognitive-behavior therapy and resilience training. We do not need a Code Lavender team that dispenses “information on preventive and ongoing support and hands out things such as aromatherapy inhalers, healthy snacks, and water” in response to emotional distress crises.

The NBME recently released an “updated May 2018” official “USMLE Step 2 CK Sample Test Questions,” but these are actually completely unchanged over the past two years since the June 2016 update, which was itself almost unchanged from the 2015 set.

Since it’s been a couple years, I’ve included the explanations below (which are, again, unchanged). You might see the comments on the old post for possible additional questions you may have. The multimedia question explanations are also at the bottom of this page.

Last year, helpful reader Jarrett made a list converting the question order from the online FRED version to the pdf numbers. I didn’t go through in detail to see if the online version order has changed, but the multimedia questions were in the same spots except that the block 3 question had shifted by one, so they may have done a little something.

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May 2019 update:
This super helpful book was revised for 2019-2020, is still totally free, and even has a new cover. Get it in your inbox by signing up below.

Here’s a new book. It’s called Fourth Year & The Match, and you can get your copy by using this form to (at least temporarily) sign up for my new planned very infrequent/sporadic email newsletter:

If you’d like the book but aren’t interested in hearing from me, just click the instant unsubscribe link at the bottom of the download email. I don’t want to pester you.

And if you want to learn more about this project, keep reading:

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