From our anonymous insider…
Exam week: two one-hour clinical standardized patient (SP) encounters, a 4-hour NBME-style 200-question exam, a 2-hour case-based exam, and a 2-hour clinical multiple choice exam over four days.
My first SP is 50-year-old nonobese non-smoking female with a two-month history of radiating back pain. She describes pain beginning in her lower left back, traveling down her buttocks to her feet like a bolt of lightning. She denies urinary incontinence or retention, denies headaches or visual changes. She reports difficulty walking. Physical exam reveals weakness in plantar flexion of the right foot decrease in station over the lateral aspect of the foot. She is unable to walk on heels. She has 2+ pulses in distal extremity. Positive straight leg raise while supine. I diagnosed her with a disc herniation spinal stenosis causing a L5 or S1 radiculopathy. One mistake: I forgot to do sensation testing of the distal lower extremities (feet).
My second SP is a 40-year-old nonobese nonsmoking female presenting for right-side hearing loss and one-hour episodes of dizziness over the past several days. I conduct the Rinne test (tuning fork is placed next to the ear and then on the mastoid bone. If conduction loss, the patient can hear better when fork is placed on the bone) I then do the Weber test (tuning fork is placed on the midline skull, and localizes to the affected ear if conduction loss)
Good news: I have ruled out a problem with mechanical conduction and therefore her hearing issue is due to a sensorineural cause. Bad News: I did not read up on sensorineural hearing loss. Although we are not supposed to discuss the cases (others will see the same patients later in the week), Jane and I overhear the correct answer in the line at Starbucks: Ménière’s disease. Neither Jane nor I had ever heard of this, let alone how to diagnose or treat this disease.
The clinical multiple-choice exam tests ophthalmology, suture technique, lumbar puncture technique, and psychiatric cases. Several questions showed images where we had to identify the correct diagnosis: for example, a cherry red spot in the macula (pigmented area near the center of the retina) suggests a retinal artery occlusion or Tay-Sachs disease. How is it possible to test suture technique with multiple choices? Example: “What suture size and needle type should be used to close a face laceration? What technique is depicted with this diagram?”
Students led by Type-A Anita swarm the clinical director because one of the questions had the wrong units attached to an optic ultrasound measuring the optic sheath diameter. It had calipers measuring the optic nerve diameter at 3 mm distal to the retina. The multiple choice questions all were in cm instead of mm.
The case-based exam covers five patients, each starting with a two-paragraph description of a patient’s presentation. We are then asked open-ended questions about what tests we would order and other symptoms to ask about. The exam for this block covers neurological diagnoses, endocrine diagnostic workups, musculoskeletal fractures, dislocations and malignancies. Neurology questions asked what other symptoms is most likely in a description of a Huntington’s disease patient and localize the lesion for stroke symptoms (e.g,. right anterior cerebral artery for left-sided leg weakness). Endocrine questions dealt with determining if an endocrine pathology is primary (disorder of the endocrine gland itself) or secondary (exogenous or pathologic dysfunction of the pituitary). For example, a patient with low thyroxine hormone and high TSH suggests a primary thyroid disorder; a patient with low thyroxine hormone and low TSH suggests a secondary cause of hypothyroidism. Pinterest Penelope complained about a lifelong smoker with Cushing syndrome (excess cortisol) and high ACTH (adrenal corticotropin hormone, hormone released by the pituitary gland to stimulate the cortisol release from the adrenal cortex). We had to determine if this was a ACTH-secreting pituitary adenoma or paraneoplastic syndrome from an underlying small cell lung carcinoma. “How were we supposed to know what is more likely?”
Jane and I look at the sample question bank on UWorld the night before to prepare for our final NBME block exam. These will be retired Step 1 questions from the National Board of Medical Examiners. I ask Jane about drugs for the treatment of bipolar disorder. She responds, “First Aid says mood stabilizers. lithium and valproic acid.” I look at my own copy of this book: “On page 545, First Aid says you can also use antiepileptics like carbamazepine and lamotrigine.” Jane exclaims, “What!?! Those are sodium channel blockers for seizures.” I add, “I understand why doctors order psych consults and call it a day. We cannot go into psychiatry.”
The Thursday NBME block exam was our toughest so far. Type-A Anita claims to have “blacked out” for the last 15 minutes: “I do not remember anything.” Pinterest Penelope: “Where was the biochem, where was the actual neuro on the test? There was nothing of yield.” Mischievous Mary adds: “I am glad I do not go to lecture because I’ve heard not much was represented on the exam.”
The renal questions required differentiating different types of chronic renal disease. Some questions you could answer using the patient demographics, e.g., African Americans are more likely to get focal segmental glomerulosclerosis (FSGS), whereas whites and hepatitis B/C patients get membranous nephropathy. Others started with black-and-white scanning electron microscopy images and asked about the immune complex deposition pattern. Anita was not happy: “There is nothing to memorize. It’s like learning a new organ system every single question.” Her mood was not lifted by a genetics counseling question concerning the probability that a couple’s potential children will develop an autosomal recessive disorder. The husband has a sibling afflicted with the disease, which has a 1 in 40,000 prevalence in the general population. “I did not go to medical school to do math!” Anita exclaims. Answer: assuming Hardy-Weinberg equilibrium, 1 in 100 individuals are carriers of the disease. The husband’s parents must both be carriers for a sibling to have inherited two affected genes and therefore the spouse has a 2/3rds chance of being a carrier (he doesn’t have the disease so 1/4 of the sample space is removed). Thus the probability of an affected child is wife’s risk of being a carrier times husband’s risk times child’s risk of receiving two carrier genes: 1/100 * 2/3 * 1/4 (1 in 600).
[Editor: In most states, any child born during a marriage will entitle the parent who can obtain custody to child support, regardless of actual paternity. So the wife could have sex with a genetically-clean neighbor and in the event that the husband ever does find out, she can still count on child support profits for 18-23 years (depending on the state).]
After exams, Jane, our class VP, and I help Lanky Luke and Sarcastic Samantha move into their new house. Luke and I rent a U-Haul trailer for his F-150 pickup. While driving, Luke informed us that his uncle has autosomal recessive polycystic kidney disease. “I thought the question Anita was complaining about was a great question. My father is an engineer, but has no idea about medicine. He told us he debated having children out of fear his children would inherit the disease.” He continued, “Just like in that question, the doctor informed my parents it would be very unlikely.” We googled ARPKD — a prevalence of 1 in 20,000 puts the carrier frequency at about 1 in 70. Based on the uncle’s phenotype, there is a 0.24 percent chance of his children getting the disease. Luke continued: “People overestimate certain risks. That’s about the same likelihood as a typical couple having someone with Down syndrome. When you put it in that perspective, you wouldn’t change your whole plans based upon that risk.”
We drink some craft beer on their new porch overlooking a small creek as their dog and cat explore their new home. With exams over, campaigning for the six student admissions committee representatives (from M3 and M4) has begun. Geezer George sets off a firestorm by texting the class GroupMe:
Hey all, I know it’s a little early, but I’d like to throw my hat into the ring for the Medical school admissions committee. If you think I would be good for the job, and if one of your better friends isn’t running, I’d love your support!”
Buff Brad responds:
I would also like to throw my hat into the ring for a spot on the Medical School Admissions Committee. I have been working hard to promote the vision of our school to both incoming applicants and current undergrads. I believe that being elected as a committee member would allow me to really make an impact.
Type-A Anita grills the two men: “What are your strategies for getting more girls at our school?” Our class and M1 are both over 50 percent female, but nobody asks Anita to clarify her question with a target percentage. Instead, Fashionable Fiona announces her candidacy:
… Being a women (@Anita) I will ensure we will have equal representation of genders and as a minority I will ensure we have a diverse class. Let me know if you have any questions! I’d love your support!
Optho Annie, an aspiring opthamologist with a family heritage from the Indian subcontinent::
To piggyback off of Anita’s question, I’m also interested in being on the Admissions Committee and have thought about increasing both female enrollment and enrollment of people of color and minorities, something we severely lack. I think the answer comes down to increasing visibility and outreach through different endeavors to show we host an environment where every student can flourish and feel safe. Happy to talk to anyone in person about my ideas, and would appreciate your support if you think I’d be a fair and just committee member!
Our school was awarded a diversity award by the LCME. What was lacking from Annie’s point of view?
… In general, diversity to me means a community or group of people that are of different races, religions, cultures, which can all help expand their peers’ world views. However, that’s the more obvious form and not all of what diversity means to me. I also think people of different socioeconomic backgrounds, hailing from different geographic areas , and also people on different sides of the political spectrum can contribute to and enhance diversity. …
… our class is pretty diverse when it comes to a lot of things like socioeconomic background, geographic background, and even culture and religion. However, I do think we are lacking in minority enrollment as well as female enrollment. We historically have had very few black, Hispanic, and Native American students. Also, over 50% of medical school students are now women but our class percentages do not always reflect this.
It turns out that one of Annie’s prime motivations was hearing about a class several years ago that was 50/50 female/male rather than adhering to the national trend of majority female. Neither of the two closeted conservatives whom I know in our class offer to sit down with her and share their perspective from their Trump-tainted side of the political spectrum!
Adrenaline Andrew, an aspiring ED physician whose family is from Kurdistan:
I would also like to be considered! I think it’s important we present ourselves as inclusive and well-rounded. I really enjoy talking to future students and believe I can represent our school as such. I am huge advocate of diversity and ensuring minority students feel welcomed in our city (and increasing awareness within our school). This a very exciting position! I would love your support and welcome any advice you have for me.
After an extensive exchange of messages, it turns out that nobody wants to promote diversity of undergraduate majors, age, or any other characteristic other than gender and race ID. No white males come forward (Geezer George and Buff Brad can qualify as persons of color).
Sarcastic Samantha, who currently identifies as “white,” cracks up as we read the texts aloud. “Why don’t they just come out and say what they mean. They want more of everyone except white males.” Our class VP, from a family of Vietnamese immigrants: “I’ve heard being Asian now hurts applying to colleges and medical school. It is not right to group all Asians together on the application box. Chinese and Indians are probably over-represented, whereas South-East Asians are probably underrepresented.” He did not want race to be disregarded in admissions, but was lobbying for Vietnamese applicants to be given a higher priority.
Jane yelps as she gets an email that she was nominated to the position by Hardworking Harold. She does not post her position on diversity and inclusion to the GroupMe: “Best campaign is no campaign.” On Friday we learn that she was right. The Google poll results are in. Jane, Adrenaline Andrew, Buff Brad, and Fashionable Fiona have been selected for the committee.
Facebook is quiet this week due to exams and GroupMe activity. Type-A Anita: “RELEVANT: Happy International Women’s Day… except for the 53% of WHITE women who voted for trump”
Statistics for the week… Study: 18 hours. Sleep: 7 hours/night; Fun: 2 nights. Example fun: Annual “Champagne and Shackles” at Nervous Nancy’s apartment with every class in our school. People are shackled together with zip ties. You are not allowed to cut this until you and your partner finish a bottle of “Champagne” each. Jane and I cheat by consuming only half to two-thirds. Several couples are typically formed at this annual event. Buff Brad, his girlfriend, Jane and myself struggle to play pool while zip tied. Several class pictures are taken. Luke promises to get a pool table for his new house. “It cannot be that difficult to find one on Craigslist. People give away that stuff if you can move it. I become the most popular person for the yearly moving season with my F-150.”