Last week before exams and our first break for the year. Sleek Sylvester, Ditzy Diane, and I are worn out, our motivation waning. We have a new team of residents for the last three days and none of us have the desire to impress them. The senior resident: “Let us know if you have any questions. You guys can just study if you want. We’ll let you know if anything exciting is happening.”
We are actually helpful on Monday during rounds, having previously admitted many of the patients on our service. We provided the only continuity of care for these patients and were tasked with presenting a formal H&P for each of our three patients to the new team.
We also play “Stump the Med Student” on rounds. A 36-year-old gas station clerk, whom I admitted three days ago, has acute renal failure from multifactorial causes — hypertension, uncontrolled diabetes, and three-month long ibuprofen use. He stopped taking his diabetes and blood pressure medications five years ago. The senior resident asks, “Why is his sugar low and his Hemoglobin A1C in the normal range if he is an uncontrolled diabetic?” Sleek Sylvester, Ditzy Diane, and I put our heads together and come up with nothing. “Insulin is cleared by the kidneys,” explains the senior resident. “If you see a patient whose diabetes suddenly becomes remarkably well-controlled after years of noncompliance, it’s likely a result of his kidneys failing, not that he has seen the light and has started to listen to your every piece of advice. It’s ironically the first sign of a serious complication. Our patient likely will be on dialysis for the rest of his life. I don’t think his kidneys will recover.” He concludes: “Well, I’ve done my job for the week; go study.”
After rounds, we do UWorld questions in the lounge, disrupting the residents who are trying to get their notes into Epic. We relocate to the cafeteria for lunch and find Geezer George and Mischievous Mary. Geezer George is doing his elective orthopaedic rotation. “I’m determined to do ortho. I am ready to be miserable through the application process.” Are you concerned about getting into a residency program? “Yes, but my mentality is if the average step score is 245 for ortho, and I know people with 260 are being accepted, that also means they must be letting people in with 220.” Sleek Sylvester questions his symmetric Bell Curve assumption: “Why stop there. People get in with 270, that means they are letting people in who barely passed!”
Jane has had a slow end to her Ob/Gyn rotation with no surgeries scheduled for Monday. She did, however, enjoy M&M (morbidity and mortality) conference. “The attending was pimping the residents. I was like, Bitch, don’t stop! The residents were squirming, it was great.”
I arrive for the three-hour 8:30 am NBME clerkship exam on Thursday at 8:00 am. Type-A Anita and Southern Steve just finished their radiology rotation. They struggled to stay awake in the dark reading room while getting pimped by the radiologists. “The radiologist would put up a study, and select one of us to give an impression on what is wrong. We would utterly fail most of the time.” Steve: “Do you remember that one abdominal CT? We kept focusing on what we were convinced was a hernia. Turned out to be just a normal penis… Apparently there was small bowel thickening from gastroenteritis.” Anita: “Boy, did he get a laugh out of that.”
Internal Medicine exam questions focused on adverse effects to medications (e.g., Stevens-Johnson syndrome in anti-epilepsy medications), management of acute coronary syndrome, and several rare autoimmune disorders.
On Friday starting at 9:00 am, I had two 15-minute encounters with standardized patients, each followed by a 10-minute write-up. One patient was suffering from new-onset chest pain patient while the other had worsening shortness of breath from CHF versus COPD. We are alone with the “patients” while a video recording is made. Our grade is based on a review from the standardized patient (“Did the medical student empathize with my situation?”; “Did the medical student cover me appropriately during the physical exam?”; “Was the medical student’s interview organized?”), a review of the video by a physician or another standardized patient, and the quality of the write-up, again reviewed by a physician or another standardized patient. This prepares us for the pass/fail fourth-year Step 2 Clinical Skills (CS) exam (good news: 98 percent pass rate; bad news: the all-day test costs $1,290 plus travel expenses to a designated testing location, e.g., Los Angeles, Houston, Chicago, Atlanta, or Philadelphia).
Statistics for the week… Study: 8 hours. Sleep: 5 hours/night; Fun for me and Jane: visit her sister and one-month-old nephew. Not fun for Jane’s sister: We practiced testing the baby’s primitive reflexes.
The rest of the book: http://fifthchance.com/MedicalSchool2020