doc w/ Pen

journalist + medical student + artist

Tag: usmle

The white coat

Me in my white coat: a piece of clothing that started as a costume, but over time has become a uniform — just like we were told it would at our white coat ceremony almost three years ago.

At my white coat ceremony almost three years ago, a physician gave a brief speech about this new attire we were about to don. I don’t remember his name, but I do remember, with stunning clarity, his simple premise:

When you start medical school and put on your white coat, he told us, it will seem like a costume. But eventually, as you embrace your new profession, you will come to see it as a uniform.

I’ve thought about this concept throughout medical school, tested its truth as year 1 became year 2, and then year 3. As I approach the start of year 4, I conclude the speaker was right. The first time I put on my white coat, it felt completely foreign. The first time I wore it in the hospital, to spend an afternoon observing in the burn unit, I was shocked at how my white coat and hospital ID acted as an all-access pass. With them, no one questioned my presence, even in “restricted” areas. No one, that is, except for me.

I don’t recall the precise turning point when the white coat finally felt comfortable. What I do recall is that at the start of my psychiatry clerkship, a rotation in which you don’t generally wear your white coat, I initially felt confused, almost naked, as I went about my medical student duties in the hospital. Then I knew with certainty that I had accepted the white coat as a uniform, and not a costume. It had become a part of my identity.

It was with all this in mind that I selected a date for my Step 2 Clinical Skills (CS) board exam recently.

I took my first board exam, Step 1, the February of my second year of medical school. We have to take two more board exams during our fourth year, prior to graduating. Step 2 Clinical Knowledge (CK) is a daylong multiple-choice test. Step 2 CS is a daylong series of 12 encounters with standardized patients (actors). Each encounter lasts 25 minutes. You have 15 minutes to conduct a focused history and physical exam based on the patient’s chief complaint (known as the presenting problem). You then have 10 minutes to write up your findings, top potential diagnoses, and the diagnostic tests you would order next. You are graded on a number of things, including your interviewing skills, physical exam skills, and diagnostic reasoning. The exam is pass-fail. I have to pass to get into residency — but no pressure, right?

Step 2 CS is only offered at a handful of sites throughout the country, the closest to New York City, where I live, being in Philadelphia. So it’s a bit of an ordeal. You have to take the train or bus the night before and stay in a hotel. And you need to plan for a week or two of studying first — this is not a test to go into blind or unprepared. It’s an expensive ordeal, too — $1,285 to be precise. Aside from the terrible effects a “fail” would have on your residency application, you don’t want to shell out that application fee a second time. So, you choose your date carefully.

Based on my fourth-year schedule, I had planned to take the exam in late October or early November. Sitting at my laptop, looking at the dates available, I had to make a choice. But how do you decide between a day earlier and a day later? Was there a strategy to this? There must be. I groaned (audibly, I imagine), with the weight of this decision, and the frustration of indecision.

I looked at the available dates again, more closely this time. As I did so, that speech from my white coat ceremony came back to me.


It was perfect. Poetic.

I would slip into my white coat to take Step 2 CS, an exam that heralds a further transition from costume to uniform, the transition from medical school to medical residency, and from medical student to medical doctor, on the holiday when millions of other people wear costumes too.

I smiled as I clicked on “October 31” as the date to take my exam, and completed my registration. I had no doubt that this was the right day. Suddenly, I had transformed a day that had so far filled me with dread into one filled with meaning.

Changing my attitude in this way won’t erase the anxiety surrounding this exam. But it will ease that anxiety. And I believe approaching the exam with this positive perspective will lift not only my spirits, but my confidence too, because what started as a costume has in fact become a uniform. And I have both been given the privilege, and earned the right, to wear it.


Note: This essay was first published in the online magazine The American. You can read the original version here.

An altered attitude about studying

In the flurry of ob/gyn, I neglected to share this news:

That image comes from my score report for USMLE Step 1. I have never been so happy to pass a test in my life. The six weeks of studying for Step 1 were brutal and often demoralizing. The amount of content tested is more than anyone could ever possibly learn. Much of it is clinically irrelevant, which made it harder for me to motivate. But I slogged through. And thankfully, I never have to think about Step 1 again. Later I will take Step 2 and Step 3, but my understanding is that these exams aren’t so bad.

Medical school, you see, is full of tests. This includes clerkships. At the conclusion of each rotation, we take a comprehensive, multiple choice exam called the “shelf.” My ob/gyn test is tomorrow. It covers everything I’m expected to have learned during these six weeks. Everything from delivering a baby (and all the possible complications that entails) to diagnosing uterine cancer to dispensing appropriate contraception to dealing with sexually transmitted infections — and all manner of women’s health issues in between. Some of this, we learn during our actual time in the clinic or hospital. But there is still book learning to be done.

In the last six weeks, I have spent many weeknight and weekend hours poring over ob/gyn review books and doing practice questions. In doing so, I realized that my attitude about this kind of studying — clinically applicable studying — is markedly different from how I felt while studying for Step 1. I’m finally learning real medicine. I don’t just want to pass. I want to surpass. My future patients are counting on it.

Step 1 study update

FirstAid is the ultimate review book for USMLE Step 1 (USMLE = United States Medical Licensing Examination). I’ve defaced my copy to read “USMILE.” I may not always feel like smiling when I see this book, but this helps with my attitude.

It’s been about three weeks since I’ve written here. During that short time, I feel like I’ve been teetering on the edge of a black hole. I know my fellow classmates are feeling it. Doctors and residents have confirmed it too. Studying for the USMLE Step 1, the first of my board exams, is a soul-crushing process.

There is an inhuman (and therefore impossible) amount of material to memorize. Much of what is to be memorized has little relevance to patient care. And the questions are anything but straightforward. Half the time, the question stem gives you the diagnosis, sometimes the treatment too. That’s not the mystery. The mystery is which interleukin / exotoxin / antibody / enzyme (or other obscure item) is implicated in the disease process at hand.

I’ve been doing this all day, six days a week, for four weeks now. Every day is a struggle. It’s a struggle to maintain focus and motivation, but also to maintain a sense of purpose — why I’m doing this in the first place. Sure, I need to pass this test. But that’s not the end game. The goal here is becoming a physician, and this exam is simply one in a long series of hurdles to get there.

I’ve written positive statements on the dry erase board next to my desk. They’re good reminders when I feel discouraged.

I do what I can to keep myself healthy in mind, body, and spirit. I eat well and exercise regularly. I spend time (on the phone and in person) with people I love. When I’m tired, I take a nap. I take every Sunday off.

In less than two weeks, studying for Step 1 will be a part of my past. I look forward to that day. In the meantime, I know there are things to learn from this excruciating process. Not just about medicine, but about life in general. And those life lessons will last far beyond the memory of anything I’ve memorized for this test.

Recharged and ready to go after winter break

Playing with my dad's cats, Regina and Ismael, was such a treat.

Playing with my dad’s cats, Regina and Ismael, was such a treat.

It’s always hard to get back into the swing of things after vacation. As I got up this morning, inwardly I groaned, thinking about the weeks of intense studying that lie ahead. (I’ve been studying for only five days so far, and already I’m exhausted … only five weeks to go.) But looking back on some of the wonderful memories made over the two weeks I was in Chicago raised my spirits:

  • Spending much-needed time with my parents, sisters, and future brother-in-law. We talked, laughed, ate, drank, played cards, watched movies. I only wish we could do it more often. But since we can’t, our time together is all the more precious.
  • Visiting with some (but not all) of my lovely Chicago-area friends — what a treat!
  • Going to the Garfield Park Conservatory to get a chlorophyll hit as winter raged outside.
  • Watching a Blackhwaks game at the United Center. The Blackhawks lost, but did score so we got to do the goal dance thing. If you’ve been to a Hawks game, you know what I’m talking about.
  • Reading a whole novel — I hadn’t read for fun in months and months.
  • Seeing Rogue One in 3-D IMAX (I hadn’t been in a theater in ages) and then following that up with three more Star Wars movies over the next two weeks in my dad’s man cave.
  • Driving a car.
  • Creating things with my hands.
  • Eating Lou Malnati’s deep dish pizza not once, but twice — giardiniera and sausage, yum.
  • Playing with my dad’s two cats.

These next five weeks, post-vacation, will be intense as I study for my board exam. But this two-week break was exactly what I needed to recharge after such an intense semester. This time off put me in a better frame of mind to start my study period.

I’m ready. Bring it on.

Practice makes better

In about two months, I take the USMLE Step 1, the first of my board examinations. Yesterday, I took an abbreviated practice exam in our main lecture hall with my classmates. This was not by choice — it was a mandated exercise. And I took it begrudgingly.

I plan to study full time for five weeks for the real exam. At this point, I haven’t studied at all. What I have done, though, is plow through three semesters of medical school. While I’m in no way ready to take Step 1 now, the practice exam didn’t have the demoralizing effect I expected. First of all, I remembered more than I thought I would. That suggests that if I do apply myself during my study period, I will be ok. The level of detail required, though, reminded me how much I do have to review. And my difficulty in sitting through even an abbreviated exam reminded me that I need to build test-taking stamina to make it through the real deal.

So as much as I griped about this, I’m glad to have taken it. I know I have my work cut out for me. But I’ll be trying to work through those five weeks of studying with a mindset of calm, not panic.

Repurposing old rules for a new test

Words to live by -- and take a test by.

Words to live by — and take a test by.

Becoming a physician tests you. Your intellect, patience, determination, resolve, and inner strength. Your humanity. This testing happens every day — in the classroom, in the clinic, in the hospital. Part of this process also occurs during actual multiple-choice tests.

More than three years ago, on May 23, 2013, I took the MCAT — the gate-keeper exam for entering medical school. A little over four months from now, on Feb. 10, 2017, I take the next exam in this sequence toward earning my M.D. — the USMLE Step 1 board exam. It’s an 8-hour test, with more than 250 questions probing “whether you understand and can apply important concepts of the sciences basic to the practice of medicine, with special emphasis on principles and mechanisms underlying health, disease, and modes of therapy,” according to the official United States Medical Licensing Examination website.

The stakes are high — I have to pass this exam to move forward. But focusing my thoughts and energy on how high those stakes are is a sure path to test anxiety. After classes end on Dec. 16, I have until my exam date to prepare (minus a trip to Chicago to see my family for Christmas). That’s plenty of time to review and solidify my understanding. It’s a matter of perspective, and directive. Which is why I think it’s time to repurpose the “rules” I developed for the MCAT. They apply here too.

Lorien’s USMLE Step 1 rules:

1. Take a breath.
2. Trust your gut.
3. Take this seriously.
4. Focus.
5. Maintain tempo.
6. Think NOW – not ahead, and not behind.
7. Read every word carefully: passages, questions, and answer choices.
8. Eliminate wrong answers.
9. Estimate.
10. Guess and move on after the allotted time.
11. Keep calm and carry on.
12. Think positive, not negative thoughts.
13. Channel confidence, not fear or doubt.