The Muscle-Up

5 years of training –  weighted chin-ups, pull-ups, dips – leading up to:

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The thespian’s exam: USMLE Step 2 CS preparation and thoughts

USMLE Step 2 CS is a fruitless sort of charade, but nevertheless it remains as a necessary component to becoming licensed. My school mandates a practice exam through Kaplan before taking the real exam. While I initially disliked this idea, it was a good primer and once you’ve gone through the thing once, the real one seems much more manageable. Here are some pearls:

  • Use First Aid Step 2 CS: This is a well-organized book that is probably overkill but once you go through it, you have the general gist of the idea. If you don’t have a partner, go through and do the mini-cases by covering the half of the page that shows the diagnoses and orders.
  • Practice with a partner: Either through Skype or in person, interaction is the best way to ease into the weird pseudo-clinical patient scenario. Practicing with another person lets you try your intro and closing in real time, which is probably the hardest part of the exam.
  • Have a script: I used a some sort of acronym to make sure I covered my bases in order to maximize the points I hit.
  • Have a plan: Probably the best change I made with my CS approach was to already have a list of three differentials before going into the room. This way you can ask question to rule thing in and out (pertinent positives and negatives) and include those tidbits in your note.

I took the exam fairly shortly after Step 2 CK and it’s good to know what to order and the sort of classic signs and symptoms because the obvious players show up on the real exam. Overall I’m one step closer to the goal.

Family Medicine: The nucleus

During April I rotated through my mandatory family medicine ‘elective.’ About a year prior, I began my first rotation ever, and, of course, I had formed many opinions of rotations and specialties before I even had them scheduled. Rotating through M3, you hear the stories of other students and their trials and tribulations, misfortunes and misgivings. Everyone’s a pariah. Somewhere along the line, I had formed the opinion that FM was among the more banal rotations, and, naturally, this was supported by mountains of anecdotal evidence.

However, regardless of my preformed inclinations, I always try go into a rotation with an open mind and an eager spirit because there are great teachers everywhere, and prejudgment leads more often to disappointment than substance. I was taken aback by the versatility and welcome of the program I rotated through. It was ideal for a student, and the residents were excited and genuinely caring and kind. The attending physicians were surprisingly well-attuned to listening, and were receptive to our presentations. The structure of the rotation was also well-designed; two weeks of clinic, one week of inpatient nights, and one week of inpatient days.

The population served had abundant pathology and disease, and I was thrown into the thick of it during my first overnight shift when a patient coded and I performed compressions. That memory will stay with me for some time – the code itself was successful, but, I had asked myself that night, at what cost? After the fact, I learned that the patient was on her way to hospice care and her daughter had wavered that day on a Do Not Resuscitate (DNR) order. The code was grisly. Throughout the whole ordeal there was brown seemingly feculent material streaming out of the patient’s mouth. I performed compressions as the resident valiantly attempted intubation, intermittently suctioning. The large laparotomy wound on her abdomen that was leaking serosanguinous fluid was held together tenuously by staples; these began to tease apart during only the second round of compressions – by the fourth or fifth the thing had come undone. The anesthesiologist intubated, and I was rotated out of the compressions, and that pause let me absorb the scene. Somehow we attained return of spontaneous circulation (ROSC), though the patient was unresponsive.

Other memorable events included management of post-surgical hemorrhagic shock overnight, textbook rheumatoid arthritis, and of course, clinic. The abundant clinic time gave me comfort in that setting and I was able to see the wide swathe of patients that FM encompasses; from routine pediatric visits and obstetric patients to idiopathic pulmonary hypertension and sepsis, FM is the first line for many encounters. I remember suturing supervised with a resident’s and attending’s guidance in one clinic encounter – never during surgery had that ever happened.

In short, I had a great time on FM. I learned much, was actually able to get up close and involved with some of the management aspects of ward medicine, and worked with extremely kind and caring physicians in a clinical setting.

13.1 miles in, warmed up and steady

I’ve reached a symbolic midway point in the basic sciences portion of my medical education; three of five blocks in this semester are done, with this being the third of five semesters.

The work of men who died generations ago. From here, it looks like an achievement.

I have developed reservations about the whole process of school, but nevertheless, the fact remains that time has passed and I have learned. Is it an achievement? That’s a very subjective question. In old posts I spoke of what I considered two different types of achievement: personal and existential. In fact, I explicitly said that education was always a personal achievement rather than an existential one, and my opinion on the matter remains so. Over the last ten months, I have understood the machinations and theories of other men, not created my own. This is the key flaw to such an education; however, there is nothing worth doing to change it. Shortly, I will be gone from this place, and the island will be another memory of my past.

That said, the material we’re covering is the most clinically relevant stuff we’ve learned so far. Various pathogens, the complex function of the immune system, and very circuitous (but applicable) neuroscience. The current block for microbiology is a survey of virology, which is a very interesting subject despite the droning lectures we receive.

I am looking forward to starting rotations in a little more over a year, finally seeing things in full color and form. It’s a strange question to ask myself – now that I’m here, halfway, would I start over and do it all again? This question doesn’t really represent the process that will be the other half of my education. In the first half, I developed the capacity to handle large swathes of material and study habits that will assist me for the rest of my life.


Someone wise once asked me:

How do you make a test for someone smarter than yourself?

At the time, I didn’t fully appreciate the answer to the question. I was in high school, and academic achievement tests were a joke. They were timed, difficult, and represented the perfect opportunity to prove my intelligence to others without; the tests were a pure ego-flexing opportunity to have a numerical value to rank me against my peers. The point the question made, nonetheless, was that to make any test harder, you shorten the amount of time allotted to take the test.

Take this notion and supersize it from a test to an entire curriculum, and you have medical school. The material is not hard, the volume is just incredible. It is manageable, though, and begets a transformative experience. While I initially disliked the lack of creativity, the courses I am taking have become more and more detailed, which is to my liking; the purpose is to serve as a survey rather than canvas.

Second semester

Well, I completed my second semester of medical school a few days ago. The last exams, unsurprisingly, were a wild ride. The semester culminated in a 3-day mental marathon. We had two very specific exams on the final Monday of the term, and two comprehensive, board-style exams that were exhaustive in nature on the final Wednesday. During the final hour of the testing, I genuinely wondered to myself how I would be able to complete a grueling 8-hour examination with 100% mental clarity; here I was struggling to stay focused after a mere 4 and a half.

I realized that I still have 50+ examinations left under my belt before anyone even lets me register for the big one, so it’s an inevitability that I will adapt over time to the increasing stresses of medical academia, proving myself ultimately on the USMLE.

My second semester was rough, and overall I am slightly disappointed in the quality of instruction I received. The 2 exhaustive exams I mentioned were ‘Shelf’ exams written by the NBME, and while I was entirely comfortable taking one (Biochemistry), the other left me asking myself if I even knew the material being tested (Physiology).

Nevertheless, I passed, though not as spectacularly as I did in first semester. The takeaway message for me overall for this set of 15 weeks was simple: study hard, but not to death, and you will be fine. For me, it is not feasible to expect perfection every semester. My goal in studying on this island is to learn medicine and perform well on exams. I’d rather not burn out and be a husk of a human consciousness by going overboard in studying.

The name of this blog was chosen deliberately – “a toilsome peace” – because I need to remind myself that consistency and effort are the backbone of any endeavor I will ever undertake if I intend to undertake them properly. I cannot be impatient with things that matter. Originally, this line of thought – this impatience – stemmed from my frustrations with the medical admissions process and my fitness goals. Differentiating complacency and patience has been my large personal struggle, and it will be many years yet before I am entirely at one with my thoughts, goals and motivations fully. I know at certain points I certainly am at this peace I seek, and at others I am furiously displeased. I am happy that I have the wisdom to recognize that, and more often than not I find myself patient rather than complacent.

In other news, I’ve been thinking a bit more seriously about what I’d like to pursue professionally. I’ve been reading more about hematopoietic stem cell transplantation. It is a therapy that is maturing rapidly and, therapeutically, it has amazing potential. Like any therapy, there are risks and routine use, but what fascinates me is the plethora of applications HSC transplants have – I imagine gene therapy in its fullest form.

However, it is now that I exercise great patience, because, as of now, I am on this island, no labs or full-fledged oncologists anywhere. I will wait, but not complacently, and continue to educate myself so that once I have a real opportunity to research and treat, I will make the most of it.

Personality types

What you do is dictated by your personality type. I mean ‘what you do’ as the sum of your actions. For instance, a 35-year-old bright-eyed teacher and a 55-year-old power broker are not going to have the same take on life. The net result of their lives will satisfy each, of course. The teacher, young and happy, will be motivated to and content to instruct and influence young minds. The power broker will be happy with his copious amounts of money and clever business intuition. The teacher will not feel the slightest ounce of regret for not pursing financial glory and monetary acumen, and the power broker will not have any remorse for not spreading knowledge among those seeking it.

A problem arises, however, if that last statement does not come to pass. The thing is, it never will. A person who is truly driven to take up the call of [X] will pursue it. I give age references in the example because I think most all people understand where they are going, and if they do not, they spend time to figure this out and move forward. By 35 and by 55, people should be a far ways down their chose path of action. At age 25, for instance, perhaps the teacher was doing Teach for America; the power broker was possibly interning at valuation firms.

This is a universal principle I am highlighting. People will do what they want with their lives. On top of this, however, is how they pursue what they want. Goals can vary, but the means to achieve them do not. There are two ways to achieve things: (1) slowly and steadily or (2) directly and quickly.

  • The first approach is to grow trees. You plant a seed. Tend it, water it, and observe it to ensure its growth. Overdoing any of these things can be detrimental in the long run. If done properly however, this incremental approach will result in a tremendous or fruitful tree. This is good for a career, a relationship, a physique, strength training, diet, etc.
  • The second approach is to build a house. You know you want a house, it will only be made as quickly as you chop the timber, nail the boards, and lay the floor. This is good for projects, immediate tasks, learning concepts, endurance training, etc.

In order to achieve what you want, each tactic must be applied in the appropriate scenario. Here is where personality types come into play. You can only be successful at what are you are trying to achieve if you understand the difference between the two approaches. People who are always rash and impatient will always try the second approach. People who are largely complacent and passive will try the first. The perfect personality type, like most things, is a balance of the two. Rash and quick with some things, complacent and understanding with others. This balance is needed to properly achieve anything.

There are several things you can change in the world, but personality is not one of them (short of a lobotomy). If you ever find yourself spinning your wheels (as I have) and repeatedly doing a task poorly, personality needs to be taken into consideration. Make your personality work for you. Don’t change something you can’t.

I have noticed that I have bursts of wild motivation and desires of accomplishment and then spans of listless torpor. I’ve been working on finding a healthy balance of the two. Somewhere in the last year I think I became increasingly impatient and frustrated with things outside of my control (read: medical school). This was reflected in my actions. I would have wild bouts where I would try and do everything in my capacity. I was forcing myself to change and be ‘on’ all the time. I would swing from lab to the E.R. all while fasting, and then I would run on top of that.

During this I would be plagued with thoughts of where I ‘should’ be. I was in the wrong mindset. I would come off of this period drained and do deliberately mindless activity to compensate: browse online, watch videos, eat poorly. Not focus. Then, to absolve myself of this, I would repeat this process.

I now recognize that things are better treated as a continuum. I should listen to my body and be satisfied with the work I do. It is not a penance I am paying. Now, I am eager with my work because I am learning about the capacity of research. At some point (not that I have reached this) you know everything there is known about a topic and as a researcher or engineer you realize it is your drive to add to this body of knowledge or use it as you see appropriate.

Currently, I have been resting a mid-back injury, and training has taken a back seat. Every time I do pull-ups, my back is worse for it, so for now, they will take a break. I will not atrophy.

I say this insofar as to not be ‘disappointed’ by my lack of constant activity. To me, progress is the single most important thing in life. Progress is personally defined, but if must occur. As detailed above, progress can be slow or fast. As long as it occurs, I will maintain my sanity.