So as I wrote in my previous, and first, entry to my “End of Rotation Review” series, family medicine was super chill (click here to read it). My attending was very empathetic to the med student experience and ensured that I had a good time during my month with him.

During my last week, he said to me, “are you ready to get your ass kicked by surgery next?” Most med students dread surgery as it’s notoriously known as an arduous, soul-crushing experience. Despite being pretty sure I wanted to go into a surgical field, I was a little bit intimidated. It’s natural. I had shadowed a handful of surgeons in the past few years but only scrubbed once before. As a first year med student fumbling my way through the foreign land of the operating room, I was kicked out of the procedure for breaking sterile field twice. Not my finest hour.

After showing up on my first day dark and early, I waited to meet the educational coordinator person (idk what her title is) who didn’t arrive until forty-five minutes after we had planned. After a brief tour of the O.R.’s, pre-op, PACU, endoscopy suites and all that jazz, I eventually arrived at my attending’s office, sat down and discussed the expectations for the rotation. “Do you know what you want to do yet?”, he asked.

As always, I like to keep my answer to this question relatively vague (i.e. if you’re on pediatrics, hate pediatrics, and would rather quit med school than pursue it as a career, you keep that to yourself and say you’re undecided but interested in what every specialty has to offer). However, it was surgery, and I want to do a surgical subspecialty. I am still remotely considering anesthesia as well. So I conveyed this to him.

He outlined the plan:

“So recently we’ve decided to start doing something different. You’re going to do whatever you want. You are not going to be tied to me or any other attending. You have the freedom to make this rotation yours. If you see something on the schedule that interests you, ask if you can scrub in. You pay so much money for every day you’re here and you have so little time to explore and figure out what you want to do for the rest of your life.”

These were his terms. My grade would be determined by comments from surgeons, residents and other staff. As long as I logged enough bread & butter general surgery cases (lap choles, appy, hernias, etc) and worked hard, I was given full freedom to spend my time with whatever specialty, surgeon, and procedures caught my interest.

Again, I struck gold.

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The two months (or whatever) of the autumn season is probably the only time in the calendar year I can say I’m actually not jealous of those who live in more stable climates.   I mean, just look at those colors – pumpkin orange, marigolds and bright red. It’s beautiful, man. Spooky season. Football and chili. Cozying up with a scary movie. Crisp weather and cool fashion. Ghastly decor and candy that we don’t need. Memories and music. Something about the fall is so introspective, nostalgia-inducing, and eerily atmospheric.

This aint your typica fall playlist full yawn-inducing acoustic indie songs tailored to the Pumpkin Spiced Latte crowd.   Certain songs, albums, and even particular sounds are associated with the crisp cool air of the autumn season.

Here’s a collection of my favorite songs that perfectly capture the fall atmosphere. (click the song titles for a link to each song)

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Another day at the office.

Snooze on the alarm clock as many times as you possibly can. Quick shower. Get dressed. Lace up the oxfords. Burn your tongue on cheap coffee. Fix your tie in the car mirror before walking in.

Another day at the office.

Say good morning to the staff. Make small talk with the attending physician. See some patients. Present them. Get asked, “well what do you think? What should we do?” Trepidly reply. Get it wrong. Feel stupid. Get the next one right. Feel smart. Here’s your cookie for the day.

Another day at the office.

Patient after patient. Well check. Med follow up. Ice and ibuprofen. Antibiotics. You’re fine. Refer to ortho. A day in the family med office. A fine-tuned machine with the health care tyrant’s corporate logo plastered on every wall, white coat, and welcome mat. The TVs in the waiting room no longer play the news; rather a 30-second loop of stale advertising from our overlords.

Lunch time is approaching. See patient in room three. Do the little half-hearted “doctor knock” on the door as you’re opening it. Goooood morning, I’m Jsoze and I’m a third year medical student. I’m just going to ask you a few questions and do a quick exam then we’ll get the real expert in here. Chuckle chuckle. What brings you in today?

She was in her late twenties. I think. Maybe thirty. She was dressed in fashionable clothing. Diamond ring on the left fourth digit. Though well put together, she appeared to have malaise. Perhaps she was ill. She said, I am depressed.

Then tears welled up in her eyes.

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Third year began with the familiar anxiety that accompanies each transition in life. In my case, the transition from sitting in my apartment studying constantly to the clinical environment. It’s truly amazing how in the span of a few weeks away from medicine, you can go from feeling like you know so much during dedicated to feeling like a complete idiot when you show up on day one of your first rotation.

While I’m currently on surgery, I started with family medicine and I thought it’d be a good idea to write a little review of each rotation after completion. I’ll include comments about the rotation, my experience/strategy for studying for shelf exams, as well as memorable quotes and interactions (inspired by the “overheard on X rotation” posts on Reddit).

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I have some free time today so I figured it’d be a good time to finally write this post. After spending months alone behind a computer screen, sitting down at my laptop is my least favorite activity. It’s too nice out. Anyways..

Score: > 250

I’ve chosen to omit the exact score for the purpose of anonymity and also because I’ve grown tired of the neuroticism I see on the internet. It’s between 250 and 260. Could be on the high end, could be on the low. Doesn’t matter. As an elder recently reminded me, board scores are the gateway to an interview. The rest, the you, determines where (if) you are ranked, and ultimately where you match.

(Simply glance at the 2018 NRMP Program Director Survey to see what I’m talking about)

Before I dig into my preparation, let’s get a few things straight.

First, what worked for me may not work for you. Like any advice you read on the internet, absorb what you feel is good information and ignore the rest. Nobody is infallible. There are multiple routes to success. I would go as far to say that UWorld is the only resource you absolutely cannot do without.

Second, don’t define your success by an arbitrary number. You don’t need a 250. You don’t need to go into a competitive specialty. Leave your ego at the door, and gravitate toward what you enjoy. Not what will impress whoever it is that you’d like to impress on match day. One person may be disappointed with a 240, while it may be your dream score. And there is nothing wrong with that. Forget about everyone else; you’re competing against yourself. Everyone should strive to do as best as they possible can on this exam, but remember, please remember that the three digit score can vary a decent amount depending on how you perform on actual test day and which 280 questions they generate for you. Learn to love yourself. This test is a game and it should never determine your happiness. Work as hard as you can. Beat the test. And move on.

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Sometimes I feel weird writing this stuff on here. But I pay for the domain so I guess I can write what I feel. I am not some infallible medical school prophet. I am just your medical school classmate. If you’d like to read a post of my morose complaints and reflections, continue. If not, no worries.

While this post is highly personal, I do believe there are lessons that can be extracted by all. This is simply something I’ve needed to get off my chest. My second year of medical school was the most difficult of my life. With deaths, a break-up, and pure social isolation with Step 1 looming around the corner, it was a tough year for me. I can smile now that it’s over, but it’s always important to reflect.

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Yesterday I binged the entire first season of Wet Hot American Summer on my couch. My mother cooked ribs on the grill. My brothers were in town. Last night, I sipped beers, laughed very hard with friends, talked to cute girls, and smiled.

I have smiled more the past two weeks than I had in the past 6 months combined.

I hadn’t smiled much at all since starting my second year. With deaths, self-induced isolation, a break up, and Step 1 looming over my head – it was a tough year for me. I’ll write more on all of this is my next post, but for now I want to send a message to anyone currently entering their second year of medical school. You may read this and scoff, but perhaps someone will read this and learn from my mistakes. This is my message in a bottle. I hope someone who will need it in the future finds it.

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Took Step 1 yesterday nearly a week ago. I meant to write this the day after, but I have developed a strong aversion to the Internet since walking out of the testing center. The immediate post-test hysteria has worn off and I haven’t yet forgotten the test, so I figured it’s a good time to share my thoughts on the actual exam.

But here’s one thing to keep in mind when reading reports of Step 1: Take every single on of these “just took step 1, here are my thoughts” posts with a grain of salt. Yes, this includes mine. I don’t think that any two people have the same exact test. Everyone has strengths and weaknesses. No one feels “good” after the exam.

When I get my scores back, I’ll give a full breakdown of my preparation. For context, most of my practice test scores throughout dedicated were 250+. I never really felt pressure or anxiety during dedicated. I was well-prepared. That said, after some blocks on the real deal, I felt like a failure. During the test, it’s easy to get flustered, but you have to remember that everyone is in the same boat. There are going to be a few questions that are not found in First Aid or UWorld or any prep resource. Don’t sweat it.

I ended up getting pretty sick the weekend before the test, which wasn’t ideal. Took my final practice test shaking, feverish, with a blanket wrapped around me. Didn’t do so hot on that one, which hurt my confidence going into the exam. Like most, I didn’t sleep well the night before the exam, but that’s to be expected.

On exam day, I woke up around 6 am and did some quick review (I couldn’t help myself). Had a big peanut butter banana smoothie for breakfast. I paced around for an hour. Before leaving, my mother reminded that this day would have been my grandmother’s birthday. This Step 1 nonsense makes us all a little crazy, but sometimes you need to step back and remember that many, many people are proud of you and you have come so far since those pre-med days. So, about the exam…

 

Some general stuff

• During the first block, I had razor-sharp focus and submitted with 5-10 minutes left. By the final block, I didn’t even have time to review all of my marked questions.
• I took 5 minute breaks after each section to use the restroom, listen to a song, and take a few bites of a protein bar.
• The only time I did not take a five minute break after a block was the before my last block. I’m certain that it was my worst. I was reading questions three times over again. Fatigue is real.
• After my fourth block, I stepped outside for 20 minutes, sat on the curb, munched on a protein bar and listened to some music. I listened to “Push the Sky Away” by Nick Cave & The Bad Seeds and “Since I Left You” by the Avalanches. Those songs gave me a very strange, calm, confidence. The block afterwards was easily my best.
• I only ate one protein bar and drank one redbull. I wasn’t hungry at all, but in hindsight I probably should’ve forced myself to eat a little more.
• Definitely do the Free 120 within a week of the exam. I had two identical pictures from the Free 120 on my real exam. I also had a couple repeats from NBME exams.
• The test felt like a mix of UWSA2 and the last three NBME exams.

 

Questions

• One thing I did not expect was how easy some questions would be. Seriously. There were quite a few questions that were so incredibly easy that I read them three/four times over to make sure I wasn’t missing something or falling for a trick. Stuff like… “What is E. Coli?”
  • Bacteria
  • Parasite
  • Virus
• Micro wasn’t super difficult, but it was weird and very situational. I didn’t have any algorithmic bacterial identification. No catalase, oxidase, urease positive/negative. Nothing more than gram(+)/(-) rod/cocci.  A good portion of my micro was questions such like…
  • “Patient is septic and had a catheter. What’s the pathogen?”
  • or “patient has surgical wound infection – what’s the pathogen?”
• These weren’t actual questions obviously, but I had many questions of this style. The best word I can use to describe the questions was situational. The last few pages of the FA Micro section is golden.
• My test was extremely heavy on anatomy. I had more anatomy on my exam than biochem and neuro combined. Which was definitely not cool because those were two of my strongest subjects. The anatomy questions weren’t particularly difficult, but spending a solid two days dedicated to re-learning anatomy would’ve been a very good use of time.
• Legit had a picture of a pathogen. No symptoms. Just a picture.
• Biochem, neuro, and Endocrine were the three subjects I felt I had truly mastered (on a Step 1 level) by test day. As in I didn’t even need to open them in First Aid. Of course my test was very light on biochem, neuro, and endo. Classic.
• Like many people have said before me, this test has a weird way of exposing your weaknesses and hitting them over and over again. This happened with me and respiratory. Tons of respiratory stuff. Best way to prepare for this: Don’t have weaknesses. Best of luck.
• Had a couple MCAT/pre-med level questions. USMLE – you wild!

 

Comments on Resources

• Got one question right solely because of a weird Goljan story. The vignette described a vague pathology presentation with one very peculiar symptom. I was like bro, I have no idea. I marked it and moved on, but when I came back to it, a light bulb went off in my head as I remembered a story from Goljan audio describing this one peculiar symptom. I smiled at my prometric cubicle. Thank u Goljan.
• Got several questions right because of Boards and Beyond. I used Boards and Beyond as my primary study resource, so obviously 90% of questions I got right on the test were due to information learned in B&B. But there were specific questions on the test that I wouldn’t have gotten right without B&B.
• Got one question right because one time a doctor told me that I had lymphoma (I didn’t) which prompted a manic week of research into various lymphomas. Something I had read during that week actually showed up on my exam (not in FA, Uworld, or anywhere else). Nice.
• First three chapters of Pathoma are filled with easy points on exam day. Know them cold.
• Sketchy was enough for 80% of my micro. Like I said – situational. I’d make it a point to read through First Aid’s micro section a few times during dedicated.
• LOTS OF PICTURES.
• I had a good amount of pharm, but none of the pharm questions were crazy or hard. Pretty straightforward stuff. Didn’t watch Sketchy pharm so I can’t comment on it.
• I missed one question because as an angsty second year med student with boards on the mind, I decided that class material wasn’t relevant if it didn’t overlap with FA. Jokes on me because I specifically remember thinking, “why would I go through the trouble of learning this, it won’t be on Step 1“. It was on Step 1. Haha!
• I missed one question because I was too lazy to try to remember a particular card in my Anki deck. Every time it popped up, I just said, “nah”. Smh.

 

Above all, if I had to describe Step 1 (at least my exam) in one word it would this: random. It didn’t feel like a selected group of questions meant to be representative of the studying I had done. It was just flat out random. 99% of what you study isn’t on the test. It’s 280 questions. Then it’s over. You could have ten questions on antifungals. You could have eight questions on brachial plexus lesions. I think I had maybe 5 total biochem questions. and at least 30 respiratory. It’s weird and random. Just have to do your best and laugh when appropriate.

As I previously said, I was confident during dedicated and was scoring > 250 on my practice tests. Still, after the exam I felt pretty terrible. It’s easy to focus on those wacky out-of-left-field questions after the test, but the reality is that 90% of the test was manageable and at times, easy.

When you’re done, forget about it. The gold standard treatment for post-step psychosis is a cold drink with some friends. Go out. Have a beer. Or a mojito. Treat yourself to a steak or sushi or whatever you happen to enjoy. Go for a bike ride. Attend a concert. Kiss someone. Make new friends. Laugh with old friends. Smile and remember that you are more than medicine or some stupid three digit score. Be kind to yourself. You are wildly intelligent, you have already made those who love you very proud, and you deserve to enjoy yourself now.

Next up, a very special message to anyone entering their second year of medical school…

Step 1: Post-Exam Thoughts Part 2