The Step 1 Diaries

I would consider apologizing for my absence the last couple of weeks, but I have been too busy trying to crawl out from under the weight of my course work. First year was sort of nice because they kind of took it easy on students for the first couple of weeks (at least at my school). However as an MS2, the first day consisted of an hour orientation followed by 4 straight info-dense lectures. The information overload hasn't stopped since. Interestingly, one of the few things covered during orientation was an introduction to the first step of the United States Medical Licensing Examination (USMLE), which will now forever be known on this blog as Step 1 or the Boards. The most popular posts I have ever written are about the MCAT, and now with less than 10 months to go before I sit for an even bigger exam, I want to officially start a new feature on this blog: "The Step 1 Diaries."

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The Rod of Asclepius

I am a big fan of Greek mythology and stories. I remember my dad and mom reading me the classic stories before bed when I was a kid, and recently I reread the adult versions of some of these tales. References to Greek mythology are everywhere, especially in medicine. Which reminds me...if your college offers it, take a course on medical terminology (you're the man Dr. Pluta!) - learning prefixes, suffixes, and root words of diseases and body systems is incredibly useful come medical school.

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Thoughts About the First Year of Medical School

After starting way back in August, I finally just finished my first year of medical school. Now it is time to enjoy the very last summer of my life. It is slightly depressing that this is will be my longest "vacation" until retirement, but right now it is just nice to have an abundance of free time (which I will use partly to start writing blog posts again). While everything about my school year is still very fresh, I wanted to write a post about some of the things I learned during my first year of medical school. As a fair warning, some of my musings will be practical and helpful, others will be personal and may not apply to anyone except me.

1. You Can't Learn Everything - Newsflash...there is a ton of material presented to you during medical school. It is hard to explain exactly how much to anyone who hasn't gone through it. One of the hardest parts about first year was learning what exactly to learn/understand/memorize and what to...kind of ignore. At my school a lot of the lectures are given by PhD's. This makes for interesting lectures, but also sometimes leads to a lot more information than is needed. I know I couldn't possibly memorize everything, so I picked my battles carefully.

2. Don't Buy All the Textbooks - The summer before school started we were given a list of "required" textbooks. I didn't buy them all, but I did purchase a few in subjects I thought were going to be especially tough. Looking back, I didn't really use them. There wasn't much enough time, and pretty much everything I needed was in my syllabus and/or review books (speaking of review books, Board Review Series Physiology was a life saver and really cheap). My advice, find someone in the class ahead of you and ask what books you actually need. Otherwise save some of that loan money!

3. Medical School is Hard - It isn't that the material is very hard, because to be honest, it really isn't that bad. Although there is a ton of information (see #1), the hard parts of medical school might surprise you. School can take over your life, especially when exams are close. The studying, and grind of studying then seeps into other aspects of your life: relationships, working out, eating right, having fun, etc. all take a back seat to medical school. Unfortunately, I was definitely guilty of this sometimes during the past year.

3a. Medical School Is Hard Again - Oh yeah, even though living a balanced life is super important, medical school and studying is ever present. Feeling a little sick? Had a huge fight with your significant other? Too bad, you still need to study. Of course life happens and everyone takes days off, but med school is a huge commitment and a lot is expected of you no matter what is happening in your personal life.

4. Learning is Much Easier When It's Interesting - Hopefully if you are going to medical school, learning about the workings and illnesses of the human body is interesting to you. Because that is exactly what med school is! I know that I was bored to death in some of my undergrad courses, especially if they didn't really seem applicable to my interests (I'm looking at you organic chemistry!). However I found at least 90% of what we learned about this year fascinating.

5. I Kind of Hate Anatomy - For me, working on a human cadaver was "cool" for about a week. After that it became a pain and a time sink for me. I just couldn't get excited by the subject. I felt like I was memorizing words and tiny details that I would never remember or use again. Anatomy also never came easy to me. It took me so much longer to learn anatomical structures than it did physiology or biochemical pathways.

6. Living > Working - There are some people in my class who eat, breathe, and sleep medicine. They spend most waking hours in the library...I am not one of those people. I have little interest in matching into dermatology or orthopedics and so I'm not worried about honoring every class. I know I picked the right field. I mostly love medical school and I am so excited for my future in this career. However at the end of the day, I want a fantastic life outside of the hospital. I want to travel the world and work to live, not live to work.

7. Do You - I was used to being one of the smartest people at my undergraduate. School (and A's) came easily to me. Suddenly I was thrust into a situation where I was always surrounded by brilliant people. I am no longer the smartest person in my class, nor even close. I am proud that I never allowed this to bother me. The grades, study habits, and personalities of my classmates didn't change the way I went about getting my work done. Being much closer to the average is a weird feeling at first.

8. Loans Suck - I don't like worrying about how much money to take out each semester. I really hate thinking about how much debt I will have hanging over my head after I graduate. I know I will pay it off, I just don't like it or the 6.8% interest rate.

9. Get Ready for These Questions - What kind of doctor are you going to be? Why does my _______ hurt? How many more years of school/training do you have? I think I got asked at least one of these questions every time someone found out I was in medical school.

I still can't believe how much I learned in a year (or how I still really know nothing about medicine). It was the most difficult year of my life, but also the most rewarding. The year both flew by, and crawled along at a snail's pace sometimes. I am so happy that I have a summer off to rebalance myself before second year and the weight of Step 1 scores. Most of all I am trying to enjoy the journey, not just looking towards the destination.

MCAT Prep Materials

Doing well on the MCAT probably holds back more "pre-meds" from getting into medical school than any other single part of the application. In 2012, the MCAT was taken by 89,452 hopeful future medical school students. The average score...25.2. The average medical school matriculant on the other hand, scored 6 points higher, with an average score of 31.2! Each year this average increases just a bit; I can't even imagine what it will be ten years from now. The truth is, to have a good chance at getting into medical school you are going to have to score a 30 or better on the MCAT. I know there are exceptions but I wouldn't feel comfortable applying without a 30+ (and I took the test exactly 2 years ago today!). But enough with all this "tough-love," because the good thing is that beating the MCAT isn't just possible, it's probable. I should probably step back and clarify that last statement. It is "probable" if you use the right MCAT prep materials, dedicate enough time to studying, take lots of practice tests, and have decent reading comprehension skills. Not too bad, right? Most people don't study enough, or "study" by going to the library with a friend and flipping through a couple of random MCAT prep books. That doesn't count. I am talking hours of intense, dedicated, active reading and studying. It is a lot of work, but there are a ton of resources to aid you in your quest.

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Emergency Medicine

ED Wall I was a patient transporter for awhile, and the Emergency Department (ED) was my favorite place to work in the hospital. This post is all about my future (knock on wood) specialty.  In 1966, the National Academy of Sciences published the "Accidental Death and Disability, the Neglected Disease of Modern Society," more commonly known as The White Paper. This influential report highlighted the poor state of emergency care in the United States. Shortly thereafter the American College of Emergency Physicians (ACEP) was established with Dr. John Wiegenstein as the acting president. The ACEP worked to create a new specialty, along with a dedicated residency program...the idea for Emergency Medicine (EM) was born.

An educational program was developed including training material with the goal of attaining specialty board status and recognition. It seems simple now, but the idea that EM should be practiced by board-certified EM physicians was a foreign concept just 30 years ago. In the late 60's, Dr. Herbert Flessa applied to the AMA to start a new residency program (which interestingly fell under a family medicine residency) at the University of Cincinnati. A little trivia factoid for you: Dr. Bruce Janiak was the very first EM resident at Cincinnati in 1970.

Way back in the 1970s, the Los Angeles County, University of Southern California (LAC/USC) Medical Center was getting over 1,000 emergency visits per day. Something had to change, and the hospital came up with a great answer. They decided to create the very first Department of Emergency Medicine, and Dr. Gail Anderson was appointed chairman.

Since then, EM has come a long way. It is its own recognized medical specialty. EM residencies are 3 or 4 years in length, and there are over 150 different programs in the United States. Now there are even 1-2 year fellowships available for sub-specialization. These include: hospice/palliative medicine, medical toxicology, pediatric EM, sports medicine, hyperbaric medicine, and more.

One of my favorite aspects about EM is that it is shift work. That is, doctors know their exact schedule for the coming months, and they never take their work home with them. Most hospitals have shifts that are 8 to 12 hours long. From talking with EM physicians and reading the SDN forum; it is recommended that EM docs work around 40 hours a week or so (avoiding burnout).

I love the camaraderie of the ER. I really feel like it is one of the places in every hospital where nurses, technicians, doctors, social works, and administrators all like each other. You have to work well with others (think team sports), and have a sense of humor about things.

My favorite thing about EM is that it is a combination of thinking and using your hands. I want to be a "Jack of all trades" (or if you are negative a "master of nothing" haha). EM is all about breadth of knowledge rather than depth in any single specialty. Quickly diagnosing someone is crucial, especially if the problem is life threatening. However, as an ER doc you also get to perform some cool procedures. Airway management is paramount, which can involve intubation and sedation. Lumbar punctures, sutures, ultrasound guided central line placements, NG tube insertion, arthrocentesis, defibrillation, and putting in chest tubes are just some of the examples. For something a bit more intense (and very rare) check out an emergency thoracotomy **warning graphic picture**

Also awesome...the job pays quite well. According to the AAMC, the annual salary ranges from $239,000–$316,296. Take a look at the graph from for even more information.

EM Doctor Salary

I think that an ability to think quickly and care for a wide variety of patients including trauma victims and sick children is required in this profession. Generally EM docs are calm under pressure, and have a variety of interests in and outside of medicine. I have found that I have loved bits and pieces of every specialty and body system we have learned about so far in medical school. Also on a sidenote, I have always wanted to be the guy in the crowd that can answer the call when someone yells "Is anyone a doctor?!" If this sounds like you, EM may be something you want to research further.

However, Emergency Medicine does not come without its disadvantages...

  • The ER is open 24/7, 365 days a year. That means you will be working on Christmas or your birthday some years. 
  • No Follow-Ups - This isn't the specialty for you if you care about continuity of care. There is no getting to know your patients on a deeply personal level, or seeing little Johnny grow up and get married.
  • Pressure - Is that patient you sent home with "heartburn" having a massive coronary? Can you handle multiple crashing patients and their families. Chances are you will see death, child abuse, and other terrible things on a regular basis.
  • Circadian Rhythm Disturbances - Some shifts may be like a traditional work day, however you will work overnight or during other awkward hours. Constantly changing your sleep schedule can leave you tired and grumpy.
  • Drug Seekers - Every ER has "regulars" that come in with vague symptoms to game the system and get high on narcotics.
  • Working in a Fish Bowl - The ER is the entrance gate for the hospital. That means that if you admit a patient, every doctor that comes into contact with the patient afterwards will be evaluating and judging your workup of said patient.

Using Anki in Medical School

In the previous two posts I have introduced you to the science of spaced repetition, and also why it works for memorizing large quantities of information. I highly recommended the free program, Anki, which enables users to create digital flashcards and learn any subject that requires memorization. It makes perfect sense that plenty of people have used Anki to learn foreign languages, and I think it could really help premeds with MCAT preparation. I also have firsthand experience with spaced repetition learning. Since the first day of classes (almost 6 months ago), I have used Anki to learn the vast amounts of material presented in medical school. Using Anki in medical school is easy. It has worked wonders for my studying, and helped me honor over half of my courses. More importantly I am remembering information presented months ago, instead of forgetting everything right after the test.

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