Medical school blows. If one were to believe one actually likes medical school, one should please reread the first sentence carefully and completely.

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The damn monkey is off my back. I f’ing passed.

Step 2 CS, for those of you who don’t know, is a newly instituted (2004) part of Step 2, the second of three Step exams one must pass in order to become licensed to practice medicine. Personally, I think the damn thing should be its own Step. Have four Step exams to prove how insane the licensing process is, instead of pretending it’s part of Step 2. Before long, the geniuses at the NBME will split off the communications portion of CS and have a “Step 2: Empathy & Social Work” exam.

What does the test entail? It’s a $1000, daylong exam, which is structured as follows: 12 patient encounters, each 15 minutes each. During each encounter, you are supposed to do a history & physical, and after each encounter you get 10 minutes to write out your findings, workup, and diagnosis on a patient note. Ten encounters are graded, and two encounters are non-graded test encounters. (One-sixth of the exam, therefore, is horseshit to begin with.) The grading is pass or fail, and more on that in a bit. There are only five testing sites around the nation: Atlanta, Chicago, Houston, LA, and Philly. The test is insanely hard to schedule unless you do it many months in advance.

It actually took me two tries in order to do it. Yes, I failed the first time I took Step 2 CS. Because of that, some of you might think I’m kind of an idiot. Here’s what I have to say to you:

1. You’re correct: I’m kind of an idiot.
2. Clinical medicine blows and I don’t really care about patients*, and especially not H&Ps and patient notes.
3. I’m going into Path: I’m not gonna be an intern next year or a clinician when I graduate residency, so I don’t give a shit about all this.
4. Actually, forget all that. Blow me, just like Step 2 CS can do.

In all seriousness, this test is crap. I hope that someone sues the NBME over it and wins. Other than it being completely unnecessary, because medical school and residency prepare you to be a practicing clinician, there’s no way to know WHY you passed or (more importantly) WHY you failed. If you pass, which is about 80-90% of US students, all they do is put “pass” on your score report. If you fail, they give little bars in each of the three areas that really give you no good information. The three areas:

A. English Proficiency
B. Communication: You probably can fail because you don’t drape people properly, which obviously reflects your lack of proficiency in medicine. This section is graded by the standardized patient.
C. Data Gathering: A reasonably fair area to test, consisting of the patient encounter and the patient note. The patient encounter is graded by the standardized patient, who ostensibly has no knowledge of disease pathology or presentation (and any sort of degree?) other than the script and checklist he/she is given. The patient note is graded by clinicians.

Supposedly there is a percentage of medical students who are not competent enough to be clinicians, and this test allegedly weeds them out. I’m not a great clinician, I never have been, and I never really aspire to be. But I passed. So the test is about knowing how to pass the test. In fact, someone on the internet somewhere mentioned that someone without ANY medical training could grab First Aid for Step 2 CS, study for a month, and go pass the exam. I agree with that statement.

For those of you that have the exam coming up, do a few things: learn Step 2 CS for First Aid backwards and forwards. Use USMLE World or the Kaplan book as well. Most importantly, practice with a partner or spouse! Have an algorithm for taking a history and physical and do it every time. Know the steps you have to do (state your name, drape, etc.) and the questions you need to ask for each symptomatology complex outlined in First Aid. That is, chest pain = location, quality, intensity, time course, diaphoresis, position, medicines tried, dyspnea, palpitations, etc. That makes it SO much easier to rattle off questions instead of trying to remember exactly what you need to ask. Use First Aid or Kaplan’s mnemonic for history taking. Create lots of mnemonics.

Don’t underestimate the test. Know that it is possible to fail, as I did to begin with, but you can also make a ton of mistakes (as I did the second time) and still pass. 80-90% of US students pass the first time. When I took the test the second time, I changed a few things: I knew the mnemonics better for each symptomatology complex, I did better physical exams, I typed my notes instead of writing them, and I did a better closure. Closure is important! Read First Aid for more about that stuff.

I pity those of you who have yet to pass this evil test. May God have mercy on your souls. As for Step 2 CS: suck it long, and suck it hard.

*I actually care about people, I just don’t like dealing with sick patients. Part of me blogging for Hoover’s badass blog is to help convince some of you NOT to go into medicine. Or, at least, let you know what to expect. That’s pretty damn humanistic!

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One of the things that annoys me most about medical school (aside from the soul-murdering, nasty, vagina-laden OB/Gyn) is the fact that so much of your time is inflexibly dictated to you. I generally mean via lectures, but it can be a whole variety of time-draining nonsense that I’m not going to go into. Lectures, meetings, training sessions, and more.

You’re supposed to be here at exactly 6AM and then there at 7:30AM and don’t forget yonder at 10:00AM, but on Wednesdays you go to hither at noon. On the 30th at 1PM you go to thither, so don’t dare forget and don’t be late or Dr. Pompous Tightass will get his panties all in a bunch and exercise his “love of teaching” by pimping you into oblivion. And don’t forget all of your regular responsibilities! Make sure those colostomy bags are squeaky clean! Oh, by the way, you’re a professional. This means late arrivals are unacceptable and you’ll naturally be held to an unattainably high standard.

All of this horseshit is most apparent during 3rd year, generally because time is already so hard to come by. They just seem to make it harder on you by making you do as much as possible on a daily basis. 1st and 2nd, luckily, have a lot of lecture time that is optional. At least, for many schools. I pity those of you who have attendance policies during the preclinical years. Luckily 4th year is a slacker year, hopefully even for evil schools with attendance policies. But I digress.

Back on point, I fully realize the world is busy, life is busy, and many careers (professional ones especially) are hustle and bustle with very little time to spare. That’s kind of the nature of things. “Overworked people run the world,” is a quote I’ve probably botched. That said, it still seems like during medical school they could make it a little less complicated, less stressful, and more effective. Jumping through hoops doesn’t make you a good physician…it makes you a good medical student. That is, you know how the system of medical education works, and thus you can effectively navigate through the hoops. And when you’re not jumping through hoops you can actually try to become a good physician. (If that’s your bag.)

Since we have Shelf Exams and three Step Exams (I say four, with the addition of Step 2 CS), shouldn’t these exams be enough to make sure one has a basal degree of competence? Why force all of the nonsense down our throats? I mean, do we really need to be forced to attend lectures during our Surgery rotation when we’re half asleep after a 6-hour GI surgery from the call night before? Where’s the sensibility and flexibility?

I suppose it’s the LCME’s fault. In fact, I bet they have a secret ruleset for pimping.

A medical student needs X hours of hardcore pimping during Surgery in order to be demeaned effectively enough to achieve the core competency of self-realization of retractor bitch status.

Screw being a retractor bitch, screw the LCME, and screw all of the nonsense. Give us time to blink!

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In my initial post about pimping I discussed it in a general sense. But, you see, there are many, many types to be encountered during medical school. Some are bad, and on the other hand, some are really bad. This list is by no means exhaustive, but kind of a “pimping sampler” of some of the varieties you can expect while in Hell.

1. Open group question: Not a type of pimping, but here for comparison. An attending/professor asks a group a question like, “Where do you find stratified squamous epithelium in the urethra?” He then opens it up to the entire group. This is fair because you’re not put on the spot, and the gunners who study 12 hours a day and read Harrison’s for pleasure will immediately jump in with the answer so they can “shine.”

2. Rhetorical pimping: Pimpus interruptus. You’re asked a pimp question, and immediately you start to sweat about the answer. A pause…then…voila! The attending answers it. Hopefully if the subject matter REALLY blows then the attending will ask a line of rhetorical questions and then answer them all himself. This is the lightest type of pimping and barely qualifies as such. Consider yourself damn lucky.

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You’re pissed off at an attending surgeon in the OR. Which, frankly, could be all the time. To heck with a potential illustrious career in medicine, time to get even! Some possibilities*:

• Secretly deglove and hand the surgeon a retractor with your bare hand. Mention that your hands were uncomfortable since they don’t stock an 8.375 glove size.
• Walk into the OR while eating a piece of fried chicken. You had no breakfast, and it’s lunchtime, so you have a right to eat. Be firm.
• Remove your facemask and accidently sneeze/cough/spit on the surgeon’s hands right after he gloves.
• Unplug the bovie machine when the surgeon least expects it. Laugh and tell him to lighten up…you’re just foolin’.
• Descrub during an important part of an afternoon surgery, and tell the surgeon you just remembered your dog needs his midday doggie treat.
• While the surgeon is putting on scrubs, remove your gloves and try to touch everything that is sterile.
• During the surgery, push on the instrument table lever so it falls. The louder, the better. Chuckle as the scrub tech tries to reassemble everything that’s still sterile.

*This is satire, for all of you easily offended people. Keeping a patient† sterile and safe during surgery is of the utmost importance.

†Unless it was a patient who was also a surgeon‡.

‡Just kidding.

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