Oh Yeah, Step 2 CS

If it's not one thing, it's another ...

Just when I thought I would have nothing to do the next few weeks, I realized I have the next part of my board exams coming up on Monday. It's the USMLE Step 2 CS, which is a day-long clinical exam where there are 12 encounters with standardized patients. You have to take a focused history, do the appropriate physical exams, tell the patient your impression, and then write a progress note on them. (You also have to drape the patients and wash your hands a lot.)

This exam is a recently added component to the Step 2, originally for foreign medical graduates only, but apparently various people complained and now all of us have to take it.

Apparently this is an easy exam for American students, and my medical school has been teaching and reinforcing these clinical skills non-stop over the past 3 years, so I really have nothing to worry about. However, I still don't like walking into any sort of test unprepared, so I am spending an hour or two per day with a review book familiarizing myself with the type of cases commonly encountered ... nothing intense like the Step 1, though.

Anyway, I never have as much free time as I think I do ...

Neurology Notes

Some neuro-related thoughts collected over the past four weeks:

• On the very first day of our neuro unit, I counted down exactly how many days of the 4-week clerkship I would have to work (taking into account weekends, lecture days, and a few school functions). The final count: 12. Only 12 working days out of 4 weeks! Most people in the "real world" would laugh at such a schedule. I, however, barely lasted those 12.
  


• We had a random lecture one day about neuroimmunology ... 2 topics I couldn't despise more. I don't even know what neuroimmunology. I really do not know what puts me to sleep quicker, talking about the cerebral cortex or T-cells. Actually, a topic that does put me to sleep even quicker is anything related to a uterus. There's the triple threat: a lecture on gynecologic neuroimmunology.


• My dog doesn't have reflexes. I tried tapping her knees with my reflex hammer to elicit a response, but I didn't see any movement. Who knows if I was doing it correctly, though, since she kept trying to sniff the hammer. Come to think of it ... I don't know if she even has knees.


• Speaking of reflexes, I need some better ones for myself. I just learned the hard way why one should load silverware into the dishwasher with the sharp sides pointed down. As I was emptying the dishwasher, I was stabbed by a fork ... and I now have 4 holes in my thumb. All in a straight line.


• Neurology rounds are possibly the most boring event ever ... and not just in a hospital, either. One day our attending, while we all stood around and observed, interrogated an obstinate patient for over 30 minutes about a seizure he had had ... it was unbelievably painful since there are only so many ways to ask "what happened during the seizure?". And he ended the whole encounter by pleading with the patient to tell a dirty joke (to evaluate a part of the brain involved with the sense of humor), which the patient refused to do. I wanted to kick both my attending and the patient.


• No more left-sided weakness, right-sided weakness, dysarthria, fasciculations, fibrillations, nerve conduction studies, EMGs, pain and temperature sensation, or two-point discrimination!
  

Neurology is Over!

I just took the neuro exam (aka, the shelf exam. or is it Shelf? SHELF?), which signifies the much-awaited end to my monthlong neurology clerkship. The shelf went as smoothly as all other shelfs (i.e. it didn't), but that is OK as long as I don't have to retake that exam.

I did learn a few things in this rotation:

1. There are rounds more boring than medicine rounds.
2. We still can't do much for stroke patients, despite advances in medicine and technology. Unfortunately if you get a (ischemic) stroke, much of what we can offer is supportive care and rehab.
   
3. There is a good chance I might have MS (multiple sclerosis). But I'd rather not think about that too much.

Anyway, with luck I can retire my tuning fork and reflex hammer for good now.

And actually, now that I think about it, this test was also the last exam I will ever have to take in medical school. Nice.

Neuro Exam

Much as I despite this rotation, I still have to take this Friday's test seriously ... and being forced to work until Thursday doesn't leave me much free time. So posting will resume then. Hopefully.

Nurse Power

I am always on the lookout for tips and tricks to make my intern year -- next year -- easier and less stressful. I am observing others around me, trying to learn how to deal with commonly-encountered problems (e.g. a patient's middle-of-the-night temperature spike) so that when I face these same problems as an intern, I'll be ready.

I am also learning how to treat (and not treat) nurses.

As the ones that maintain true continuity of patient care, nurses have the power to make doctors' lives very easy, but just as easily can make their lives miserable. I got a rare and behind-the-scenes glimpse into the mindset of a nurse who was exercising this power. I was chatting with one of the nurses on our floor -- a nurse who is very feisty but stubborn -- and she began telling me her views on all the interns. The conversation then turned to one specific intern who this nurse hated. I admit, from my limited interactions with this intern, that she was not entirely pleasant to work with, but I learned from the nurse that the intern was particularly rude to her recently.

In fact, the incident she described was one when the intern was on call and began barking out orders in a condescending manner at one point in the night. After that encounter, and for the rest of the entire night, the nurse made a point of paging the intern with every order that was written in order to "double check" them. Needless to say the intern didn't get much sleep, much to the nurse's amusement.

I haven't taken many overnight calls (only ~10) in my brief medical career, but I quickly learned to appreciate sleep the few moments I did get ... and after this conversation, I definitely don't want a vengeful nurse ruining those few minutes of shut-eye.

So, yes, lesson learned. I will not be rude to you nurses.

The Natural History of Blogs

It never fails. I had to stop reading yet another blog because it became lame.

I am not going to get into a deep discussion about blogs and their impact (since I swear, there have more articles written analyzing blogs than there were analyzing 9/11), but in my experience most blogs have the same natural history. It starts with me somehow discovering a blog I find interesting and then reading it conscientiously. This lasts a few weeks or months until some dramatic event occurs in the blogger's life ... something major with either their job, health, social situation, or whatever.

At that point the blog degenerates. The collection of well-written posts revolving around a single theme turns into a bunch of entries describing random events in the blogger's personal life. The focus of the blog is nearly always lost, because that dramatic event usually disrupted the original motivation for the blog. Then the blog starts to suck.

The most prominent example I can think of is Opinionistas, a blog written by a young New York attorney who was highly dissatisfied with her job in a big city law firm. Her blog did an entertaining job of describing the ridiculousness of life inside a large law firm. She eventually "outted" herself, and once her anonymity was lost so was her ability to write posts with any unified topic. Now -- or rather, last time I checked -- she just writes about whatever crosses her mind, and it is not that interesting.

Anyway, the reason I discuss any of this is because I just had to yank two blogs from my "Medical Blogs I Read" (since you know, making it onto my blogroll is so competitive.) I don't read that many blogs in the first place, medical or otherwise, so whenever one fizzles out, my online reading list takes a big hit.

This fate befalls all blogs I encounter, so I hope it doesn't happen to mine. But don't worry ... as long as I don't get kicked out of med school, Axis will be here for you.

West Coast - East Coast

Many months ago I sent in applications to two different medical schools to do a month-long visiting rotation at each (one for his month and next month). While both are prestigious schools, one is in California and one on the east coast ... and what a difference a coast makes.

The California school informed within a week that they scheduled me in to the block I wanted.

Snooty East Coast School didn't get back to me after one month, two months, or even four months. I sent countless emails and made many phone calls to their registrar's office, all of which yielded no response. I even had an old advisor of mine (who is faculty there) send personal emails to the clerkship director, which, again, was fruitless.

After another month I finally got in touch with their registrar ... who not only acted like she had no idea who I was (despite my 5+ voicemails), but who still didn't know if they could accomodate me. It turned out that she had been unable to get in touch with the clerkship director (or his secretary). She certainly didn't feel the same sense of urgency I did, as this month was quickly approaching and I still didn't know if I needed to buy a $500 cross-country plane ticket.

The week before my theoretical start date arrived I gave them one last call, only to get lip from the registrar herself, saying how she had no idea how to get in touch with the clerkship director and that he was probably on summer vacation for all she knew. I was shocked to hear her getting angry with me ... and then she had the f'ing nerve to shrug me off with a "you might have better luck in the spring"!

So I was stuck with an empty month-long block that I need to fill, simply because of a sketchy clerkship director who didn't realize that students' schedules are on the line.

Topping off this story, the California school just recently contacted me, asking if I had a preference as to what attending I would like to be on a team with. What love!

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In other news: I went out with some people last night, including the friend from the previous post. This situation is getting a little torturous for me, since nothing can happen because it would set up a triangle.

To sum up: California is great, and I'm a little conflicted.

Power Walking

It is always amazing what a little confidence can do. A few days ago I dropped by our university hospital -- aka, the fancy, uppity hospital -- to visit a friend who is doing research there. I had never stepped foot inside that hospital before, and so when I walked hoping to find the elevators to the third floor, I realized didn't know exactly where they were.

The front desk people immediately sensed my confusion and asked if they could be of assistance. I mistakenly asked them to direct me to the elevators, because I was immediately directed to several different security guards, each asking what room I was going (no idea), why I was going there (to visit an employee), and how long I would be there (again, no idea). I then was forced to sign in and slap on a tacky "VISITOR" sticker to my white coat ... yes, I was wearing my white coat and was still was put through this unnecessary hassle.

So today I went to visit her again, and this time I headed straight for the elevator as if I had walked it a thousand times. Surprise surprise, no one even bothered questioning me.

And I was wearing neither my white coat nor my ID badge ... there's the humor of it.

And My ERAS is Off!

After two months of working on my personal statement and entering my CV into the system, my residency application has been submitted. Today was the first day applicants are able submit their ERAS (Electronic Residency Application System) so that programs directors can view them.

I am happy -- and slightly surprised -- that I was able to make it on opening day since last night I was a mess. In anticipation of submitting today, I read and re-read my application literally dozens of times despite having reviewed and edited all my documents countless times throughout the past few months. As the night went on, I re-read my application with increasing frequency per hour ... in the afternoon I would look over everything about once an hour, and by the time I went to bed, I would fill up entire hour reading everything back to back ... once I finished reading it, I'd start all over and read it again. I couldn't put my application down, and yet I wasn't changing anything with each additional read. I was definitely driving myself crazy.

I woke up extra early this morning, ready to submit at last, but was prompted by numerous dialog boxes asking questions like "Are you sure you want to submit", followed by "You cannot change your application after you submit", to "Your application will be locked now", to "This is an irrevocable step" ... with each additional click, my anxiety levels rose further and my stomach twisted even more around itself. I'm surprised the final box didn't ask "Did you get your mother's permission to submit?"

I felt sick for about an hours after I submitted, but luckily that subsided. Only then was I happy and relieved. Thinking about it, a few days doesn't matter much, but at least now I do not have to worry about it during this long weekend)

Anyway, nothing to do now but wait for interviews ... I hope.

(How did I write so many words on such a simple event?)