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.

A guide to M3: The clerkships and SHELF exams

I made this post to help guide study efforts (for NBME Shelf exams) during M3 year. I found that there was a mix of information as to which sources were the best sources to use during core rotations, and given that you have limited time to dedicate to studying, it is imperative to use it well. That being said, everyone, including myself, has their own sets of resources they used that they will claim is the best. It should be stated that the best prep for any rotation is working up patients and looking up their best treatment and management regimen on UpToDate while on the wards. Here’s my additional study plan:

  • Internal medicine
    • UWorld is the staple for prep – about 1400 q’s. This will take a considerable amount of time but is worth it in the end if you can finish it during your rotation.
    • MKSAP for students (aka IM essentials) – another key learning tool. The explanations are better than UW in my opinion. It takes a lot of effort and doesn’t simulate your exam, but it’s great for building a foundation of clinical IM knowledge.
    • Pre-test IM – a few wonky questions and many are too short or easy, but this book gives you some random factoids that might help in tricky stems (e.g. CHF is more likely to cause R-sided pleural effusion). I did about 10-20 q’s every morning to get through the book.
    • MKSAP audio – probably a bit overkill, but I like listening to audio lectures rather than reading, so I went through the sections on cardiology and GI. I love this series, and listened to the bulk of it throughout M3. Great for the gym and commuting. Not great when you’re driving with people though, haha.
  • Obstetrics and Gynecology
    • APGO uWISE – plenty of short quizzes on high yield topics. The problem is that you’re going to miss a lot of questions if you don’t already have a solid foundation of knowledge. This is the best source hands down.
    • Case Files Ob/Gyn – I used this to sort of learn the basics of Ob/Gyn and get a foundation. It’s a good text without too much filler or fluff. Even some of the more esoteric topics in the book came up on the shelf. To note, I never used Blueprints.
    • UWorld – a staple, but not enough. I think it is better to save these q’s for 2-3 weeks before your shelf to use as a gauge.
    • Dr.Chapa’sObGynPearls: Texas A&M College of Medicine – this is the best audio source for this rotation. Go to you podcast app and subscribe. Usually about 7-12 minutes a piece on high yield topics (e.g. endometriosis), covering every salient point (e.g. MCC, presenting symptom). If you learn the material for each topic, you’ll be able to present with some competence and actually have a discussion about stuff.
  • Surgery
    • Pestana – a great ‘cover your bases’ review of many topics. The staple for this rotation. Has some questions in the back.
    • Case Files Surgery – I used this extensively, but be warned that some things might be outdated if you don’t have the latest version (I was burned on thyroid nodules). Overall this was my second staple.
    • UWorld – not many q’s, but you should supplement by re-doing some of IM. Many IM topics are bound to show up. Spleen and GI questions come up a lot.
    • Pestana audio – this was my favorite resource. He reminded me of one of my pathology professors from Basic Science years.
  • Psychiatry
    • UWorld – this covers most bases. There will be a few esoteric topics on the shelf exam that you won’t find anywhere.
    • First Aid Psychiatry – A good thing to review if you have nothing else to do and want to read something.
    • Lange Q and A – I wish I had known about this beforehand – i did some of these and they were good quality questions
  • Pediatrics
    • Honestly, I had little time or patience at this point in my M4 year for this exam – I was more focused on interviews. There are likely better places for advice on this topic
    • UWorld – solid “cover your bases” approach with a decent amount of questions
    • Pretest – more filler questions if you have time
    • UT HSC video review – this was the majority of my studying

Oncos: My month on Heme/Onc

Last month I was on an elective month – hematology and oncology. Part of my inspiration for going into medicine was the book The Emperor of All Maladies, a poetic walkthrough of the history of cancer and medicine from ancient times to present day by SM. The writing in the book is superb, but not the topic of this post.

The month gave me a first-hand look into the face of malignancy. The recurring theme of the month, it seemed, was mortality. Patients and I alike were fascinated by the prognosis of the grim diagnoses and outcomes of disease. There was a definite gravity in the specialty rotation because it seemed (in contrast to my IM rotation) that there was a serious finality or consequence in everything we did. The staging, the cycles of chemotherapy, the radiation treatment. Everything was momentous for me, and moreover, the patients. I, a student with some inkling of education, could barely grasp the totality of the underpinnings of what was partaking in front of me when the oncologist would outline a regimen and discuss the rationale behind it. The historicity of the evidence, the experience of the attending and the fellow, and the confidence of the rest of the team all reassured me that there would be some positive outcome for the patients we treated. However, in my readings, I often encountered scarce data and evidence behind certain therapies.

Part of the reason I was originally drawn to medicine by oncology was the fact that there is something so primal and visceral about cancer that it poses as a problem that must have a primal and visceral solution. Another thing that drew me to it was the fact that it is so prevalent, and can happen to anyone (beyond the obvious associations, many of the patients I saw seemed to have the worst luck if nothing else). And of course, there must have been some macabre fascination I had in my imagination years ago of what being an oncologist would be like, fighting death with science and commiserating with my dying patients if there was no remedy to their fate.

As naïve as those reasons might have been, they now have the weight of some real experience behind them. Now that I have seen the groundwork of oncology in an inpatient setting and in the clinic, I have a more real sense of what that lifestyle and goals might be like, were I to pursue that path. At this time, I still know there is much for me to do and see, including obstetrics, gynecology, surgery, and pediatrics.

Lastly, I will say that the elective did have a few brushes with death. A patient on our service coded and failed to be revived; another passed away after a chronic battle with cancer. These were routine in the hospital setting, but that did not lessen their impact on me. When confronted with such a grim truth, it is hard not to consider my own life and think of other outcomes. One thing my mother told me a not too long ago still resonates with me – she said that if she were diagnosed with cancer and only had a few months to live, she would not waste a single day with chemo or in the hospital. I cannot say I disagree – while there are certainly appropriate times for therapy, I think, there are also times that are not. Seeing the hardship of surgery, the stress of chemo, it is too much for a hypothetical question.

Internal Medicine: Intro to clerkships

I’m deep into my internal medicine rotation – exactly halfway through the 3 month clerkship. The journey from Louisiana to Maryland to Louisiana to Missouri was mechanically necessary, but uneventful. I have transitioned from the ‘being’ portion of my medical career to the ‘doing’ part of it. The hospital through which I am rotating is a hive of activity, and the days I spend toiling as a medical student in the wards are markedly different from those I spent guzzling information and regurgitating it for exams during basic sciences.

As it is with everything in life, the attitude you take with your endeavor determines its outcome. I have been blessed to have great attending physicians and residents thus far so as to nudge me along, and I know that there is always something to be learned from every patient I manage. Even if it is something I have managed just the day prior, even if it is only a comparison of outcomes to a treatment used in another patient with the same condition, the observation is made. With this attitude, I have taken the first few footsteps in the seemingly never-ending career of observation and solution that is medicine.

The hospital setting is ironically the exact opposite of the training environment I underwent to prepare for it. It is a bustle of activity and noise, with teams comprised of attending, resident, and students prowling the floors and corridors. The dynamics of walking as a group and presenting to the team is new to me, and occasionally I feel like a duckling in my short white coat walking behind the rest of the team with their flowing knee-length garb. Gone are the days of pure multiple choice questions, pure lectures, and pure solitude. Interpersonal interaction is constant, so much so as to make me lose myself in the present moment, rounding from one patient to the next, with any momentary lull filled by updates and notes. Being part of the the hospital feels like being part of a living, breathing organism, with a number of functioning systems and hierarchies that crosstalk to a common end. It is engrossing and enveloping, and I have found myself feeling idle on my days off.

I cannot say every experience is gratifying, as with internal medicine many patients are eventually discharged and followed up as outpatients, but when the interventions I suggest are appreciated and contribute to patient care, there is certainly a thrill and rush of easing another human of some suffering. My one dissatisfaction with the particular rotation – internal medicine – is the pace at which diagnoses and care take place. Many conditions are severe and inherently slow to recover from, and despite the fact that recovery is likely and prognosis guarded, the previous instant gratification awarded my multiple choice questions is long gone. My attendings have told me that internal medicine is a field wherein the big picture is important, with the little details falling into place. I look forward to my next few rotations, recognizing that while I have read about many things, I have seen few, so as I broaden my experience, I broaden my insight.

AMK in Saba

After the third block of semester 4, Amanda flew to the rock that is Saba. Our time together is precious, and the days we managed to squeeze in during my semester were packed.

There was much cooking and enjoyment of our favorite foods; hummus, goat cheese, gelato, and crusty bread to name a few. One particularly new treat we made was mango frozen yogurt in a blender; if you freeze yogurt into cubes and blend them with mango and a touch of (soy) milk, you’ll get a thick mango smoothie. To this, we added about 3 tablespoons of vodka; upon re-freezing, there was a light, soft texture that wouldn’t have been there without the ethanol.

We ran together (along with Stephan, Luxmie, and my other friends) in WMSA’s polychromatic race through the Bottom; it was Holi in contest form, with obstacles sprinkled throughout. After much huffing and puffing and jumping and crawling, we emerged caked in colored powder, smiles abound.

Colors!

Post-color run, left to right: Me, Amanda, Vinu, Luxmie, Zelas

Amanda’s visit was timed to coincide with the semester’s Midway dance. Before the dance, we ate at Brigadoon restaurant, as we did about a year before when she came to Saba after my first semester.

Num nums

Brigadoon dinner; left to right: Ankita, Linda, Shauna, Keziah, Vinu, Me, Amanda, Luxmie, Zelas, Malika

The weekend of the visit included some time at the Health Fair hosted by the school, an outing to the market town of Windwardside, and the big hike up Paris Hill, which was only ¾ completed due to injury during the hike.

Jungles!

Somewhere in Windwardside after the Health Fair

The days went by quickly, and it seems like my time on Saba is rapidly approaching an end. I’ll be happy to see the end of this semester and spend time with Amanda in Omaha, where she’ll be starting her MD program soon.

Spring Break 2014

Haggard and realized, I finished my third semester at SUSOM April 17, 2014. Microbiology, immunology, neuroscience, and psychology learned, I enjoyed a travel-heavy break. From Saba to home, home to NY, NY to Toronto, and back.

Getting back home

It was an ordeal getting from Saba to St. Martin. I was obligated to take the ferry due to scheduling conflicts. I had somehow convinced myself that it would be a plain boat ride; this was quickly disproven as the crew, 5 minutes into the ride, handed out vomit bags. The anti-emetics I had taken did their job, however, but the consistent advice I had been given will now be passed on by me: I took the ferry once, and never again. To describe it simply, it’s sort of like riding a roller coaster ride, which can be fun for up to 5 minutes. However, stretch that agony to 2.5 hours, and you can imagine what the ride might entail. There is no reprieve, no emergency stop, no sympathy. The only companion you have is the visceral feeling of your stomach going up and down sporadically.

Upon reaching St. Martin, I, accompanied by a few friends, including Zelas (whose wedding I went to later in the break), took a taxi to the airport, SXM. There, we waited and eventually were told that our flight was cancelled. We stayed in a hotel for a night. I had the particular misfortune of being on a flight that was booked the next day fairly late. Lightning then decided to strike twice and my rebooked flight had some “weight imbalance” issues and was grounded in San Juan for another night. The next day I eventually made it home on even another delayed flight. In essence, 2 days of my life were lost in transit, unplanned. I got back on Easter Sunday, all stores and venues closed.

Home

It was lovely to see my parents after such a long delay. They love me dearly, and they mean the world to me. We drove about town together, seeing some of my relatives and catching up on life.

Seeing Amanda

The only sort of daunting prospect (and it wasn’t THAT daunting) of my break was meeting my girlfriend’s parents. On my last break, she came to meet my family, and it was my opportunity to meet hers. They were gracious and generous hosts, and we enjoyed several meals together.

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Overview at Breakneck Ridge

Amanda and I went hiking at Breakneck Ridge nearby, which was a relaxing and challenging day. The first third of the day was spent scrambling up boulders to an elevation of 1200 ft. I noticed that without safety ropes in place I am much less confident and much more hesitant when bouldering than her. The elevation was nice, and there was a rustic, tawny feel to the whole day, as the new green had not yet returned.

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Near the high point of Breakneck Ridge

Zelas’ wedding

On our itinerary was to attend my close friend Zelas’ wedding ceremony and reception. Amanda and I drove a few fair bit, crossed the US-Canadian border, and made our way into Toronto and its surrounding cities. The bride and groom were stunning and graceful, and the whole day was elegant and pleasurable.

Wedding

Us with friends at the wedding

Zelas’ family were welcoming and invited us to a lunch gathering in between the ceremony and reception; we met his family and spoke with his dad for a long time. All the things we had talked about during the semester, his dad’s struggles, his love for his family, I heard and could see while I was there. The reception was some fun, and there we met some of my classmates and danced.

Niagara

After the wedding we headed to Niagara (the Canadian side) where we enjoyed: wine tasting and learning how to (seemingly) savor wine, a dinner at a Brasa (which, in both my and Amanda’s opinion, proved to be too fancy for our liking), the Bodies Revealed exhibit (which was a bit bland to me as a medical student and raised a lot of questions like what purpose did the exhibit serve), and a stroll around the falls.

Spring blog 4

The rainbow at Niagara

We took pictures, got a souvenir for my niece, and soaked in the ambience of the town.

Reese being cute with her new shirt

Reese being cute with her new shirt

Afterwards

The drive back was fairly long, and we made it back in the evening in time for dinner. The following day we ran a few errands, and I was treated to Mediterranean food by Amanda’s brother (which was my favorite food I had on the trip, I think). That evening, Amanda’s parents took us to a particularly upscale restaurant in NY City, and dinner there was pleasurable.

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Pizza from Little Italy in the city

The following day was my flight back to BR; the day included watching Inside Llewyn Davis, getting stuck in traffic, and having the best pizza I’ve ever had (eggplant, of all things). A final hug and kiss and I took my (heavily delayed) flight to BR; there, I packed and spent time with my parents. One friend was in town, and we met at my house and caught up and later watched the latest superhero movie. And, just before I left, Amar (my close cousin, more my brother than anything) made his way all the way down to my house to see me, though I missed Lauren, his wife, and my niece.

And with that, a flash and a bang, I was back to Saba.