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Here we are! It’s a mere 7 months since I took Step 1 and I’m already getting ready for the next Step.

Applying for this exam would be half the hassle of Step 1 if I hadn’t gone and done a silly thing like get married and change my name. So, yah. I have to submit a Form 186 all over again and wait for MUA and ECFMG to verify it so that I can pick my test date and start studying. Because, you know, you can’t start studying without an actual test date.

Most students take Step 1 sometime after Basic Sciences and before Clincial Rotations. The timing to keep in mind for Step 2 is not the date you take the exam but ensuring you have your most excellent passing grade back before applying through ERAS for the match.

You know, The Match.

I’ll include another post on Match stuff later, but suffice it to say for now, it is important enough to deserve capital letters. I have heard varying reports about how long it takes to have your grades reported and available from Step 2, but it is generally accepted that you should have them both complete by June or July. If you don’t feel like you need Step 2 scores to boost your ERAS Match application, then there isn’t any rush to take the exam and you technically have until December or January to complete the exam before rank order lists are submitted.

Rank order lists? Okay, I’m using terminology from The Match again. Will save that for later.

Foreign and international medical graduates are encouraged to have their Step 2 scores available to increase their chances of getting an interview (and thus, residency position) for The Match. As such, I’m hoping to take Step 2 sometime in May.

Lastly, there are 2 parts to Step 2.

Clinical Knowledge (CK) is an all-day exam similar to Step 1. Except it’s an hour longer and is focused on the clinical application of all that Basic Science stuff you’ve forgotten in the last year. Fun! From this exam, you get a 2- and 3-digit score similar to the format used in Step 1.

Clinical Skills (CS) is a hands-on practical exam with people pretending to be patients. You will be expected to do a focused history and physical and write a patient note. All while proving you are a caring human being and can converse easily in English. From this exam, you get a pass/fail score.

Right now, my plan is to study during March and April and be ready to rock the exam in May. I’ll keep you posted on the exam date(s) so you can get those fingers crossed at the right time(s).

previous rotations: Obstetrics & Gynecology, Family Medicine

I was going to wait and write my impressions of my third clinical rotation until after I got my evaluation from the attending. But he is taking his time and I hear he’s (still. again.) browsing this site during the big group 10am meetings.

Embarrassing, yes. But not as bad as if I was actually in the meeting. Hi, everyone! I miss you all!

daily schedule:
7am – meet with fellow students (3 or 4) and interns (3 or 4) to go over patient list (anywhere from 12 to 18).
730am to 10am – pre-round on your patients and write SOAP notes.
10am – meet with the attending, case manager, social worker and entire Silver Team (yes, there is a Bronze and a Gold team).
1130am – start attending rounds in the ICU.
12 or 1230pm – break for lunch.
1 or 130pm – meet back again and finish work rounds.
4 or 5pm – go home.

actual daily schedule:
Pretty close to above, except a few of us students usually added 30 minutes into the pre-round time for breakfast. There were also days where we were done by 2 and others that stretched to 6pm.

what to wear:
As we are encouraged to observe or participate in any procedures being done to or on our patients, wearing scrubs is totally appropriate. But if you like to dress in a similar manner to your attending, then you’ll want to wear dress slacks and a button-down long-sleeved shirt. If it’s cold, toss on a nifty sweater or vest. And don’t forget your white coat and name badge.

what’s in my pockets:
- stethoscope
- small notebook with a list of patients, labs & data
- pen
- phone with Epocrates Drug Reference
- Maxwell’s Reference
- Cecil got bonus points for having q-tips and a tongue depressor on hand one day
- Washington Manual of Medical Therapeutics (okay that wasn’t really in my pocket, but I often carried it around)

patient notes you will be asked to write:
This is your most classic example of a blank-page SOAP (subjective, objective, assessment, plan) note. Our attending didn’t seem to care if the lab values came at the beginning of end of the O and the A/P is mostly a work-in-progress during third year.

If a new patient is admitted to your team, you may also be asked to conduct an H&P. Work on a kickass history and physical. And be able to present it in a logical and coherent fashion, including pertinent positives and negatives. Leave the non-pertinent stuff out.

what to study:
Study your patients. Know their diseases inside and out. If your rotation is anything like mine, you will see the same things over and over (diabetes, pancreatitis, stroke, etc). Diagnosis, assessment and treatment will all sink in a little more each time you see the same thing.

After a few weeks, you’ll look back and take for granted everything you know now and didn’t know before. Most of the time during this rotation I felt like a complete idiot. And yet, this was my favourite rotation so far.

a few unforgettable things learned along the way:
- I can calculate TPN (total parental nutrition) in my sleep! Word!

curious things other students do:
- wear shirts that show cleavage
- include observations in their SOAP note that they didn’t actually observe
- spend a lot of time on their phone

Brandon proved today that he isn’t very good at relaxing. He had the entire day off for the first time in months and I was sadly disappointed to come home and find him starting his next MBA class instead of working on a good butt groove in the couch.

I, on the other hand, did a great job of enjoying some serious downtime in December. But now that the next step of my medical licensing exam is just around the corner, it’s time to get back to the books.

I have found that coming home to study in the evenings after 8 or 10 hours in the hospital is a lot different than 8 or 10 hours in a classroom. My brain is fried. I just want to veg and crochet and absorb everything that happened over the course of the day. I would rather shove toothpicks under my fingernails than roll through just 50 Q&As in a test question bank. Ugh.

So I have to switch it up. I’m going to try getting back to those 4am mornings I was so fond of on Nevis and punch out a couple of hours of studying before hitting the hospital.

I had considered cutting down on my morning caffeine in the new year, but I think that idea might have to wait until after I finish med school.

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*photo: old rendition of the hospital I work at found in a basement hallway of the Capitol Building.

One of the professors at MUA is from Oklahoma City and stopped by the hospital yesterday to say “hello!” It was really awesome to see the super smart, college football-loving, art-appreciating, breast cancer expert, research specialist and clinical skills instructor. Those of you that have spent any time on the Nevis campus should know who I’m talking about by now.

Dr. Plaid Shirt is home for the holidays and spent a lot of time in academia at our hospital. He says he doesn’t even recognize it from the days he worked there. We sat chatting in a conference room in some adminstrative office-y area and there was a painting of the hospital on one wall with the name of the original architect in the corner. It looked like the painting was from the 60’s or 70’s and I sat staring at it for several minutes convinced the painting had the wrong name or wrong city on it. That was NOT our hospital.

When Dr. Plaid Shirt commented on how much the hospital had changed, it clicked. The sprawling 4-story building that encircled a charming courtyard with several small outlying buildings has been transformed over the years into a towering 11-storey model of efficiency complete with a skywalk. I think the first floor bowels of the emergency room and countless unmarked doors (where I once saw a bagged and zippered body being delivered) are probably the only things that remain mostly unchanged.

Everything changes. Even huge brick buildings that take up entire city blocks change.

It’s been 8 months since classes ended for me on the island. There are certainly some things I miss about that time in my life. But I am so proud of how far I’ve come. I can’t wait to rock Step 2 next year, finish out my core rotations, and get excited about narrowing what kind of doctor I want to be when I grow up by participating in some super cool electives.

Today’s photo is obviously of the idyllic and untouched island of Nevis somewhere in the Leeward Islands of the Caribbean. I wonder how much it will change when Brandon and I return someday 20 or 30 years down the road…

I’m still on track to look like an idiot in every single rotation because I get nervous when put on the spot.

Double bonus points this month because I actually *like* internal medicine and the attending I’m working with is just short of genius* and I should probably try to score well if I’m thinking I might want to go into it someday. So, blanking on how lisinopril causes hyperkalemia in the middle of the ICU isn’t necessarily the best way to go. Blurting out completely wrong answers makes me shut-up gun-shy when I actually know the right ones. Lame.

Just in case you were wondering.

And today’s photo is a random picture of Suh sitting on Brandon. Something she likes to do whether he’s on the floor, our tiny couch or at his computer desk.

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*No, he doesn’t read this. No, I’m not sucking up.

We started out with 5 students. Then dropped to 4 as one student rotated out to the ER. After next week, there will be 3 of us left.

Our Internal Medicine team is capped at 15 patients, which can sometimes swell to as many as 18 with special exceptions. With 15 patients and 5 students, we are each assigned 3 patients to pre-round on every morning, present their case and/or updates in our 10am meeting and follow their care during their entire stay. After next week, we will have 5 patients each.

I’m not good at math, but with more patients and the same amount of time, it’s not surprising I find myself going in to the hospital earlier and earlier.

It’s going to be an interesting holiday season with Brandon working and studying for the Step and me voluntarily going in to the hospital on the weekends. I think I noted via Twitter that I went in every day during Thanksgiving weekend. Everyone else on our student team had family close by to visit on the 4-day break. As such, I rather inevitably ended up standing out as (at best) ambitious or (at worst) a “gunner“. Either way, my attending looked at me like I was crazy. I told him I inherited a genetic defect from my dad.

I’m 6 weeks into my 12 week Internal Medicine rotation and something super cool, awesome, weird, frightening or amazing happens every single day. I’ve decided (and I remember this was suggested by some savvy commenter) to start jotting stuff down when I come home and publish it a week or a month down the road.

Please note: this does NOT mean I plan to start sharing real details about real patients.

I’m hoping it does mean I get to share a little more about how much I love learning.

our attendance policy during clinical rotations is rather inflexible: you are not allowed to miss work at any time for any reason.

but when your throat (cobblestone mucosa) and symptoms (fever + cough + nausea + blahs) look identical to the H1N1 you’ve been diagnosing 20 times a day for the past two weeks, you stay home. the CDC recommends that sick kids stay home from school until the fever has been gone 24 hours.

for the record, if the H1N1 vaccine had made it to our clinic, i would have preferred a shot.

also for the record, i’ve tried my best to cough all over Brandon but his immune system has kicked my germs to the curb. he will probably be the last man standing when this form of chemical warfare brings the world to its’ knees. Richard Matheson would be proud.

previous rotations: Obstetrics & Gynecology

daily schedule:
Monday 7am – 1230pm
Tuesday 7am – 6pm
Wednesday 7am – 1230pm
Thursday 7am – 6pm
Friday 8am – 2pm

actual daily schedule:
pretty close to above. be sure to show up early. you never know who rotated through before you and how much of a good impression that might make.

what to wear:
white coat + nametag + whatever “business casual” means to you. the attending i work with doesn’t wear a shirt and tie, but i’m sure you could if you want. ladies, i’d recommend keeping necklines high-ish, skirts long-ish, and shoes non-stiletto-ish. but that’s just me. wash your hair. avoid perfumes & colognes. simple stuff like that.

what’s in my pockets:
- stethoscope
- small notebook with a list of things to look up later
- pen
- phone with Epocrates Drug Reference
- Maxwell’s Reference

patient notes you will be asked to write:
- prescriptions
- that’s about it. your attending may avoid having you write in the chart and you should welcome the challenge. you won’t always have a piece of paper with H&P questions in front of you. start working from scratch and the practice should come in handy later.

what to study:
each night i have a dozen or so things to look up. study whatever you don’t know. which, in my case, feels like a lot.

a few unforgettable things learned along the way:
- kids shouldn’t get the H1N1 vaccine because it’s definitely some sort of conspiracy.
- people only die of lung cancer after they quit smoking.

curious things other students do:
there aren’t any other students on this rotation with me. i’m the one doing all the screwing up for these 6 weeks. it’s fun.

so, in all the hubbub i totally forgot to mention that i got my score back for the USMLE Step 1.

did i pass? yep.

did i do as well as i wanted? nope.

the actual 3-digit score is posted on my password-protected grades page for anyone interested. i know i share a lot of stuff with you guys and i considered just posting it here, but it sort of feels akin to pulling out my underwear drawer, dumping it on the floor and posting a photo of it for you. step scores are pretty personal. whether you fail by 1 point or pass by 45, that silly exam has the potential to make or break a lot of dreams.

suffice it to say, the pre-test estimates were bang on. and i’ll be one of those students that land a great residency “in spite of” not because of my step score.

i’m not complaining though. someone has to fill out the middle of that bell curve.

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images: on top is the Kaplan QBank tally before the test and below is the actual performance map from the National Board of Medical Examiners (NBME). on almost every other NBME practice test i took, i had 3 or 4 of those fancy little asterisk things. i like fancy little asterisk things.

Dr. C from MUA called to apologize for the mix-up with my solo honeymoon here in OKC. i appreciated her forthrightness and have since realized it really wasn’t MUA’s fault. it wasn’t The Hospital’s fault* either.

it’s just the way things seem to work.

would it have been a big deal if it hadn’t occurred in the 36-hour window right after my wedding? of course not.

all that aside, things are sorting themselves out and i’m getting settled into The Hospital and my place as a 3rd year med student. 3rd year is actually a pretty good place to be. almost everything is new and you aren’t expected to know too much yet. sweeet. here are a few details about my Ob/Gyn rotation…

daily schedule:
6am – 5pm

actual daily schedule:
5am – early afternoon

get there an hour before your resident to pre-round and write up all the patient notes in their charts. that way, when the resident shows up, they will round and just have to look over your notes and prescriptions to sign and approve. i found that the days rarely extended until 5pm. most residents will let you go home if there is no one in labo(u)r and nothing going on. you may be expected to wait around until noon-ish though, so be sure to bring something to read.

also, be aware of any planned events in the morning (ie: Book Club at 615am on Thursdays or Grand Rounds at 7am on Fridays) and show up extra early on those days to get all your work done.

if you are watching a c-section, jot down the sex of baby, time of birth, weight and Apgar scores on a little piece of paper. hand this paper to your resident as they are exiting the operating theatre and you will make their life much easier.

what to wear:
- scrubs
- comfy shoes
- short white coat
- hospital name badge & access card (the baby ward tends to be locked up like Fort Knox)

what’s in my pockets:
- stethoscope
- small notebook with patient note & prescription formats
- photocopied list of ward room numbers and patient names/status
- pen
- cafeteria food coupons
- phone
- Maxwell’s Reference
- photocopied chapter from Williams with this week’s reading for Book Club

patient notes you will be asked to write:
- initial H&P** on pregnant women (big long form)
- prenatal follow-up care (# weeks along? gravida/para? blood pressure? weight gain? urine protein/glucose? fundal height? fetal heart tones? fetal movement? vaginal bleeding? etc)
- post-partum or post-op (if c-section) 24/48hr progress (nausea/vomiting? bathroom use? lochia? breast/bottlefeeding? fundus firm below umbilicus? lower extremity edema? etc)
- post-partum or post-op 2/6wk follow-up (complaints? plan for birth control? depression? etc)

what to study:
- Blueprints Obstetrics and Gynecology
- First Aid for the Wards

a few unforgettable things learned along the way:
- post-partum moms are entitled to 48 hours in-hospital. post-op moms get 72 if they want.
- never correct a nurse’s spelling. even if they ask you whether “Benedryl” is right.

curious things other students do:
- fiddle with their hair (ponytail up, down, up, down, back up and down again just looks unprofessional to me.)
- check their phones in front of Attendings*** (we only see them for a few minutes each day. can’t that wait?)
- sit in the nurses’ lounge or library to read (be available and visible. your resident will not take the time to hunt you down if something cool happens.)

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photo: extra large safety pin used by Brandon’s mom for many years to pin her wedding ring to her bra during surgery. she passed it on to me last weekend when we were in Nebraska for the wedding reception. now i never have to worry about tossing any jewelry away with soiled scrubs. i love it!

*although i did receive a gracious apology from the Graduate Medical Education department at The Hospital as well.
**history & physical
***over-seeing and often overly-intimidating physicians.