I had known Dr. Lown as a doctor and a patient; now I got to know him as an activist. We agreed that the health care system needed to change. To do that, Dr. Lown said, “doctors of conscience” have to “resist the industrialization of their profession.”
Focused nonchalance is, I believe, the ideal attitude to cultivate when preparing for and taking a high-stakes exam.
While much much easier said than done, the goal of attitudinal preparation is to strive for a state of flow when answering multiple-choice questions: focused and potentially even joyful as you take an exam, marshaling all of your cognitive resources without falling prey to anxiety and self-doubt.
Flow, the now widely-known phenomenon akin to being in “the zone,” was first described in the 90s by the prominent psychologist Mihaly Csikszentmihalyi in Flow: The Psychology of Optimal Experience:
In normal life, we keep interrupting what we do with doubts and questions. ‘Why am I doing this? Should I perhaps be doing something else?’ Repeatedly we question the necessity of our actions, and evaluate critically the reasons for carrying them out. But in flow there is no need to reflect, because the action carries us forward as if by magic.
While the optimal experience and apparent effortlessness of flow as it is most popularly described is probably out of reach for most students taking a multiple-choice test, my point in this discussion is to state firmly that achieving focused nonchalance or even a flow state is not dependent on your actual test-taking skills and prowess or the fraction of questions you get right easily but is instead a reflection of your attitude and preparation. (Don’t get me wrong, if you always do well on exams and are a natural narcissist, this will likely all come easier). Csikszentmihalyi never argued that flow necessarily meant you were doing awesome; even in the title, he suggests that flow leads to an optimal experience. Nonetheless, that optimal experience goes a long way on a long and stressful examination.
Hitting the Wall
Many people who put in a considerable study effort eventually hit a score wall or plateau where more and more effort seems to yield minimal or even worsening score results.
Your specific goal, whatever it is, is awesome and I hope you achieve it, but you also need to realize that goals are only helpful as a means of motivation, not something to tie your entire self-worth into. Otherwise, the wall is crippling. A friend’s performance, peoples’ forum posts—absolutely none of that matters.
Putting aside the reality that people presumably do have a natural maximum performance range and the fact that the tendency to focus on learning fringe esoterica is unlikely to pay dividends test by test, I think a significant fraction of the mutable wall comes from two places: overthinking and fatigue.
Overthinking
Overthinking a question is a symptom of underconfidence. When you overthink and question yourself it’s because on some level you believe that you are insufficiently prepared to determine which facts are critical within the information provided to derive a correct answer. Therefore you start searching for hidden clues to avoid making a “silly” mistake. This is approaching the question from a position of weakness instead of strength.
The solution is to believe that at any point you are as prepared as you can reasonably be and that you should use the skills you have at that moment to answer to the best of your actual ability. Going hunting or dowsing for tricks isn’t going to help you if you don’t really know what it is you’re looking for.
The components of a question that matter to you only matter because you actually know what to do with them and what they signify. If you change your answer from what you would otherwise pick due to a hunch, you’re guessing. If you want or need to guess that’s fine, everyone does with some frequency, but then guess happily and move on. However, changing what you believe is the best answer just because you wonder if some detail might make a difference but aren’t sure is unlikely to consistently lead to better results.
Overthinking and dumb mistakes are actually two sides of the same coin: one tends to happen when you try to prevent the other. So you oscillate back and forth, even from question to question within a single block. When you check your answers, either in a tutor mode scenario or at the end of a block, the questions you get wrong are a head-slapping frustration-fest instead of learning opportunities.
This frustration is (naturally) compounded by being emotionally invested in your performance. This is why you need to believe that you’re going to do as well as you can. Agony helps no one.
When you’re stumped by a question, the answer isn’t to be sad or angry at yourself. The response should be, “Ah, here’s one of those irritating questions that I’m designed to get wrong. Time to narrow down as much as possible, guess, and move on.” Even if you know that you used to know the answer, you’re still human.
Your job isn’t to get the all the questions right; that’s an outcome you can’t control. Your actual job is to take each question individually, apply your knowledge and reasoning to it, and pick what you feel is the most likely answer.
Guess. Guess again. Guess better.
Sometimes you will need to guess. When you’re down to two choices, try to see if one answer might feel more right. Often, you will like one answer better but won’t be able to “rule out” a second choice. This second choice sometimes seems like it could be correct. Most high stakes exams including the USMLE use a “single best answer” format. This means that other answers don’t all have to be wrong, just that one of them stands out as better (i.e. “the best”). You don’t technically have to know the right answer, you just have to pick it.
Medical school sadly may not contribute very much to your 10,000 hours toward becoming a great doctor as Malcolm Gladwell popularized in Outliers. But it does give you a lot of mileage on the goal of being a great MCQ test taker.
So, the ability to instinctively and comfortably guess the correct choice is another reason to do tons and tons of practice questions from a reputable source. You can develop your innate question sense by practicing and practicing. Using low-budget or alternative questions can be a bit dangerous, as some of these resources over-test minutia or try to trick you in ways that are not typical of the real USMLE.
There’s wrong, and then there’s wrong
I remember that when I’d get questions wrong on UWorld, a lot of the time I would say, “oh wait, that doesn’t count, I knew that one.” But the fact is that there is more than one way to get a question wrong. Most people think of really being “wrong” when they’re totally clueless, but that typically makes up a minority of cases. Many times you will actually know (or tell yourself you “know”) the fact being tested even when you get it wrong in question format. Doing questions means continuing to pair up facts with answers, and it takes time.
One of the difficulties many of my former students had with studying through questions is that getting questions wrong is demoralizing. Again, the bottom line is that when you’re studying over the long term with UW or any qbank, your goal isn’t to get questions right; your goal is to learn. There’s almost as much to learn from the questions you answer correctly as the ones you get wrong.
Building the Routine
As you get closer to game day, however, the need for simulation outshines the learning benefit of savoring each question in a pressure-free study session between looking at Instagram stories. Taking several blocks in succession and not being able to check answers or take large breaks is mentally different than normal studying. The difficult questions wear on you, shake your confidence, and, psychologically, it’s hard to maintain peak performance and concentration. What you want is to achieve Flow but what you are is nervous and miserable (even on a practice NBME).
Athletes train in similar circumstances as their competitions so that they don’t get nervous on game day. Wholehearted simulation is key. I am generally a huge proponent of tutor mode, but this does mean that as you get closer to test day you want to fix your habits and strain your test muscles so that the big day is just another day:
Two weeks out at the minimum is when you want to get your sleep and other habits in line, preferably four. But being mindful of your daily practices should start now. In the final two weeks you’ll need to start doing test mode and doing two or three block chunks in a row so that you get used to working long stretches.
Never forget that the real thing can really feel terrible. It’s long and you never get any positive reinforcement. The questions you had to guess on will weigh heavily in your mind. This is all test psychology. How it feels doesn’t actually need to matter; chances are you are doing exactly as well as you normally do, and that’s what you need to tell yourself as you go through the day to make that true.
Remember, the goal is focused nonchalance. Don’t forget: “this test is a poorly constructed hurdle” is a better mindset than “this test determines my future.”
Amazon is now so dominant as a corporate force that even the announcement of a plan to someday enter a new industry is enough to crush stocks.
This happened to Blue Apron last summer after Amazon bought Whole Foods and filed a trademark for a possible meal-kit service a week after Blue Apron’s IPO, whose new stock proceeded to immediately tank.
Now it’s happening to healthcare, as Amazon, Berkshire, JPMorgan partner to cut U.S. healthcare costs:
Shares of UnitedHealth Group Inc (UNH.N), Cigna Corp and health insurer Anthem Inc (ANTM.N) were 4 percent to 7.2 percent lower at the close. Drugstore operators CVS and Walgreen Boots Alliance (WBA.O), as well as Express Scripts, closed between 3 percent and 5.2 percent lower. Drug distributors Cardinal Health (CAH.N), AmerisourceBergen Corp (ABC.N) and McKesson Corp (MCK.N) were off 1 percent to 3 percent. Amazon closed up 1.4 percent.
To be sure, the $69 billion loss in healthcare stock value should rapidly self-correct (unlike for Blue Apron, which does not enjoy a stranglehold on an entire segment of the economy).
But in the announcement, the new venture has zero stated plans outside of using “technology” to reduce costs for their own employees, but they do plan to “share the strategies and technology they ultimately develop to reduce costs for the economy and the government.” It doesn’t matter what Amazon does, just that they plan on doing something.
The fact that Bezos is joined by the biggest bank (JPMorgan) and the biggest non-healthcare insurer (Berkshire) just nicely rounds out the trifecta.
Who knows, maybe they could deign to start by developing a good EMR that also uses standards to make healthcare data completely portable in order to empower patients and reduce confusion, overuse, and duplication. If it’s just Amazon Prime Rx with cheaper mail order prescriptions, I’ll be a bit underwhelmed.
“The ballooning costs of healthcare act as a hungry tapeworm on the American economy,” said Berkshire Hathaway Chairman and CEO Buffett. “Our group does not come to this problem with answers. But we also do not accept it as inevitable.”
Buffet’s still got it.
From Harper’s January 2018 index:
Amount the US pharmaceutical industry spent in 2016 on ads for prescription drugs: $6,400,000,000
Number of countries in which direct-to-consumer pharmaceutical ads are legal: 2
$6.4 billion? Holy moly, what a depressing figure. Think about how much healthcare that would buy.
In case you’re curious, our partner in crime is New Zealand.
In case you’re still curious, permitting DTC advertising is a terrible idea that can only be satisfactorily explained by the power of lobbying.
Amazon is running a promotion on my book Medical Student Loans: A Comprehensive Guide so that it’s free on Kindle through the end of Friday. If you haven’t already, now would be a great time to check it out and get your finances in order.
Longtime readers know that I don’t do ads, guest posts, or push products. I do however share a coupon or referral code or two for something people might actually want if it results in someone saving money (and not just me making a few bucks).
Which brings us to SmashUSMLE. The bottom line is that if you’re interested, the coupon code BW10 saves you 10%.
I don’t think most people need to be interested at this point.
While SmashUSMLE has Step 1 and Step 2 CK qbanks, it’s essentially billed as a curriculum-replacement tool with hundreds of hours of video lectures. It’s got all the trappings: It has the FRED qbank software. It has accelerated video playback options. It has a phone app.
It’s competing with pricey options like DIT and Kaplan. And while it’s cheaper than both of those, it still costs a fortune ($395 for 1 month, $795 for 3 months). There is a 15-day free trial, however, so if you were planning on doing an expensive course, you wouldn’t lose anything by trying. 15 days is actually a really generous trial; you could get a lot of value for free if you remember to cancel it if you don’t think it’s worth the dough. The solo qbank product option is cheap ($59.99 for a month), but the competition on that front is really stiff.
From my brief review sampling, the qbank lacks polish. Questions use the clinical vignette format but do not ape the USMLE house-style particularly well. A UWorld replacement it’s not.
As for the videos, I would never ever personally be interested in buying a video course, so my intrinsic bias probably precludes a fair assessment. Like DIT, they follow First Aid. The style is pure casual whiteboard—like a friend trying to teach you in a room in the back of the library—which I imagine is nice and approachable for students feeling overwhelmed. But, again, these felt a bit on the unpolished side of the spectrum. I’m not sure I could imagine spending the 100+ hours it would take to watch them all even at 2x speed. The free sample online is representative, so you can make your own decisions.
Medscape’s newest resident compensations survey is out and discussed in “Most Residents Say They Deserve Big Raise, Survey Shows.”
The main thrust is fine, discussing that today’s residents feel more underpaid than generations past, which is no surprise given the proliferation of mid-levels who work alongside them making considerably more (and likely combined with the envy caused by their better-off friends parading happily on social media [when #YOLO, #FOMO can be devastating]).
But then this:
Resident salaries in 2017 vary considerably by specialty. Trainees in hematology lead the pack, at $69,000, while family medicine residents bring up the rear, at $54,000.
The gender gap in resident pay is negligible. Men averaged $57,400 or 1.2% more than women, who received $56,700.
Ugh. Who writes up these Medscape survey articles? I even wrote about the same misleading fake resident gender pay gap back in 2014.
To summarize:
All trainee salaries are based on PGY year and location. There are absolutely no differences between specialties or genders of trainees of the same seniority. Any differences are related to the differing duration of training between specialties as well as the geographic spread of the relatively small sample.
Ultimately, any attempt to differentiate annual salaries by specialty is intrinsically misleading. Any differences that can be created between genders or specialties are simply reflective of different numbers of respondents at different levels of seniority within the PGY scale. The difference between a family practice resident and a “hematology resident” is that almost every family medicine resident finishes in three years while any hematology fellow will be at least a PGY4 or higher. The fact that hematology “led the pack” and not—let’s say—cardiology or gastroenterology just means of the respondents of the survey, slightly more senior hematology fellows answered compared to their other IM-fellowship peers.
There is a real gender wage gap in medicine, but it does not apply to residency. As I discussed almost exactly three years ago, any differences in gender pay during training are related to the known disparities in gender representation among certain fields, particularly surgical specialties (which have longer training lengths and thus get “paid more”). Now, if we want to talk about the “gender surgeon gap,” that would be a different and worthy story. Because there are fields in which women are underrepresented—that’s the story when it comes to residency. Not a misinterpretation of the statistics.
This sort of willfully misleading interpretation has no place on a website that caters to physicians. Medscape should know better. And, reading some of the comments suggests that some readers (primarily the nonphysicians) do latch on to these “differences” despite simply being a distraction from the real issues at play.
The updated 2017-18 official “USMLE Step 2 CK Sample Test Questions” PDF, released in May and available archived here.
The PDF set is completely unchanged from last year. You can read the complete explanations for last year’s set here. A helpful reader Jarrett Lever made a PDF to online version conversion list.
As for the updated multimedia questions found only in the online version:
Block 1
7. A – Classic Moro reflex, entirely expected and normal until it disappears around age 4 months. If you have never seen a newborn before, also note that the mom is concerned about delayed milestones at two weeks of age, which is a red flag for BS: babies aren’t even smiling socially yet by two weeks.
Block 2
3. D – Pill-rolling resting tremor of Parkinson’s disease secondary to loss of dopamine neurons in the substantia nigra.
18. A – I’m going to point out that a normal healthy kid with no cardiac history or symptoms and no family history of sudden cardiac death for a pre-sports physical is probably going to have a benign exam no matter what you think you hear. HOCM is what you want to exclude theoretically, but here we don’t have a real systolic murmur, just a little vibratory flow murmur at LLSB.
33. E – This one is a bit silly. The lung exam is normal outside of the super common basilar crackles. Everything except for PE you would expect to hear a more impressive auscultation abnormality. But for this question: B and C take longer than 3 days. D we would expect fever, productive cough etc. Bronchitis would be possible, but still more often to have at least productive cough if not fever. PE, on the other hand, classically has a nonproductive cough, hypoxemia, and tachycardia. All three are present. And then they mention her med: OCPs, which are an important predisposing factor for PE in young women for whom it is otherwise a rare entity. Young lady on OCPs is a classic set-up for an STD question (who needs condoms?) or a PE question, one of the two.
Block 3
12.1 D – Statistical significance (a low p-value) does not equal clinical significance. A favorite teaching point when it comes to interpreting literature.
12.2 C –A & D are conjectures: the kind of statements people drop inappropriately in the conclusion of a weak paper to make it sound important. E is an exclusion criterion. B is the opposite: including 0 is equivalent to something not being significantly different.
You may not have thought about it, but a lot of people are going to be looking at your glamour shot. The program director and any application reader will see it before you’re chosen for an interview.
- Your interviewers will see it.
- It’ll probably make it into a big interview day composite along everyone else visiting that day.
- The residency selection committee will usually blow it up and put it up on the big screen when they discuss you.
So, for better or worse, people are basically going to see it whenever they think about you. While the people who meet you may form additional images, not everyone who has a role in your selection is going to meet you in person.
Once you land a residency, the photo will almost certainly make more appearances in the “meet our new interns” flyer, get plastered around the department, and may even be accessible online. Rarely, it could even be on your badge.
This is all to say, it might as well not be a terrible photo.
And, like your personal statement, it’s also probably best for you to not stand out.
Not that you can’t be incredibly good looking, of course, but rather that the format of your photo should be the usual bland applicant kind where you’re wearing something you’d wear to the interview while sitting angled slightly in front of a miscellaneous grayish or bluish pseudo-cloud background. Please don’t wear your white coat; you’ll look like a tool.
Stands out in a bad way? How about in front of a random white wall in your apartment under harsh lighting taken by your roommate with your phone where you’re too far away like a B-grade passport photo. The instagram-worthy pic of you in a park with your hair in the breeze and a beautiful bokeh background—while better to look at—also doesn’t scream, “I will answer pages promptly at 3 am and like it.”
Just google something like “residency photo ERAS” and see which examples spark joy for you.
Every interview day we’ll get a big pdf emailed to all the residents and faculty with a composite of everyone who’s visiting. Inevitably, there will be one person who stands out with a blurry poorly lit photo. Does it really matter? I hope not (unless it dovetails with other more serious mistakes/poor judgment calls), but I can’t think of any meaningful benefit to choosing this moment to pinch pennies.
If you have the option of paying an extra 20 or 30 bucks to have the photo professionally retouched, frankly, I encourage you to do so. While this is an irritating expense, again, this photo is used everywhere. Even if you do have it retouched, I still recommend taking steps personally to improve it if you have the skills and desire. Photoshop, its free alternative GIMP, or one of the many free or paid photo retouching apps (including the very nice and very free Adobe Photoshop Fix for iOS) will all do the trick to remove stray hairs, razor burn, leftover blemishes or even whiten teeth. In other words, you want to take reasonable steps to ensure that the photo is a good one.
And, of course, #NoFilter.
The stealth battle between hospitals and insurers over bills for each hospitalization, office visit, test, piece of equipment and procedure is costly for us all. Twenty-five percent of United States hospital spending — the single most expensive sector in our health care system — is related to administrative costs, “including salaries for staff who handle coding and billing,” according to a study by the Commonwealth Fund. That compares with 16 percent in England and 12 percent in Canada.
NYTime’s Those Indecipherable Medical Bills? They’re One Reason Health Care Costs So Much.