Pandarandom: Brief Thoughts

Four Percent

Okay, I confess. I didn’t study for Step 3, the last United States Medical Licensing Exam (USMLE) required to obtain an unrestricted medical license in the United States. My strategy to pass it (which I did by a comfortable margin)? Every time I felt the urge to study I just told myself that 96 percent of American medical school graduates pass it on the first attempt and, while I may not be the shiniest nickel in the kitty, I know some of the four percent guys and that’s just not me. Considering that Step 3 tests things you should know, the only way not to pass is to either have no clue or, and this is a definite possibility, overthink the test and look for deeper meaning in the questions. Either that or choke which has happened.

Since the actual score is not important, all you have to do is pass Step 3. Steps 1 and 2 can influence your residency options but Step 3? Nobody cares so I don’t want to overhype it. Odds are you will pass if you are a graduate of an American (or Canadian, also 96 percent) medical school. If you’re worried, remember that primary care is big on the test. Imagine what you need to know in Family Practice (and it wouldn’t surprise me if Family Practice residents do the best on it) and study accordingly. Ultra-specialized knowledge? Not required. I think you might have a little trouble taking it right out of medical school but if you have done a few “acting intern” rotations probably not.

If you must study, this is one of the few times I would recommend a “trivia-based” review book like First Aid, especially if you are taking Step 3 late in your training in some non-primary care specialty. By show of hands, how many of you surgery residents know (or care) what to do with an abnormal pap smear? Maybe you might want to brush up on things like this. I know you neither have the free time to study like you did for Step 1 or would use it for that purpose even if you did.

Foreign medical school graduates only have a 66 percent first-time pass rate but whether this is a result of the language barrier or lack of knowledge is impossible to know. There are a lot of shoddy medical schools around the world which are not up to the standards of countries like the United States, India, the United Kingdom and the rest of the Anglosphere but I imagine if your native language is Chinese you can factor that in. There may also be a different emphasis on subjects in other parts of the world. But since the test qualifies you to practice in the United States this is just a personal problem.

Osteopaths have a lower pass rate but I’ll wager I’d have a hard time on the COMLEX (their licensing exams) even if they took out the manipulative medicine.

Not surprisingly, on the score breakdown I did best on Emergency Management and poorest on office-based medicine. Emergency Medicine seemed fairly well represented on the test so an Emergency Medicine month where you get to at least see some typical Emergency Department bread and butter cases would probably be helpful (and sufficient). I can not emphasize enough however that knowing the practice guidelines for the bread and butter primary care stuff (colon cancer screening, pap smears) would also be high yield.

A reader writes: “Dear Dr. Bear, are some medical schools better than others?”

Not really. There are differences but they are slight and the effect on your education is marginal at best. In fact, prestigious medical schools do not have a monopoly on good teaching and you might find the teaching actually worse at a top-ranked medical school. Research funding is often used as a surrogate for quality when medical schools are ranked but anybody who has ever been taught by graduate students or high-powered academics, individuals who are often focused on research and only teach because it is in their contract, knows that the quality of teaching has very little to do with the size of the school’s research grants. Generally speaking, there are no appreciable differences between any American medical school as far as the education you will get. First and second year are largely self-study everywhere and based on a syllabus that is remarkably uniform from school to school. You can also desultorily pick your way through a cadaver as easily at Harvard as you can at UAMS. It looks like chicken everywhere and I’m sure gross anatomy slackers are equally represented at every school.

As for third and fourth year clinical education, this is dependent on so many factors that the prestige of your school probably has very little to do with quality. If you think about it, it might even be better to get your clinical experience in the sticks as you will probably not only see more normal cases of the kind that make up most of medicine but you will have more responsibility and exposure.  The prestigious centers tend to have a surplus of manpower and the medical students are more useless than they are at run-of-the-mill medical schools (if that’s possible). Not to mention that an extremely strong academic culture tends to detract from the more useful aspects of clinical medicine.

I did a cardiology month at Duke as an intern, for example, and hardly learned a thing except I read a lot on my own. During rounds, the teaching tended to be directed towards research esoterica, for example relative risk reductions in one study versus another and how those ignorant bastards doing the competing study couldn’t find their ass with two hands and a flashlight. Useful stuff if you are gunning for a cardiology fellowship but not very practical for most people. I’m sure our medical students didn’t get that much out of the discussion although they had the usual frightfully interested facies concealing their boredom.

On the other hand Medicine at Duke was a uniformly excellent rotation with highly dedicated residents and attendings who were more concerned with teaching than patient processing if you can believe it. But you see my point about quality being highly variable.

If you have to pick a medical school, prestige should be a minor criterion. Location, price, and teaching style (lecture versus Problem Based Learning) are probably more important in the end as is institutional culture. Institutional culture is hard to define but let’s just say that different schools seem to select for different types or, as is the case for state schools, draw students who mirror the state’s dominant culture. The medical students I met at Duke were very intelligent and strident in their support for Social Justice and other pillars of the academic left (I only met one conservative student and he said he was viewed as something of a curiosity by his classmates). Nothing wrong with this of course and you certainly should go where you feel comfortable. My medical school in Louisiana was fairly conservative and I didn’t notice a lot of activity in the Social Justice way. Where the battle cry at Duke seemed to be, “To the Barricades, Comrades!,” ours was “Laissez Les Bon Temps Rouler.”

Not an Apology

We have discussed waiting times and delays in the emergency Department on numerous occasions and where appropriate I have even issued an apology or two to people who have been forced to wait longer due to my inefficiency. I most certainly am not going to apologize to the lady in the hall bed last night who accused me of “fucking around with the computer” instead of taking care of her. First of all, documentation is an important part of patient care irrespective of legal and billing requirements so, since all of our charting is done electronically, I do have to occasionally type a sentence or two just to keep my hand in the game and your complaint distinct from eight others I may be juggling at any time. Second, our department is somewhat long in the tooth (although we are moving into our new department tomorrow) and was built for a time when hospitals weren’t nearly as busy and only legitimate Emergencies came through the doors, not the constant barrage of barely urgent complaints that we see today. It is crowded and there is no place for me to work without being in full sight of all of the hall patients. I suppose my patient saw me drinking my Cherry Diet Coke too and what she thought about that I can only imagine.

But seriously lady, if you had brought a list of your medications as well as a reasonable knowledge of all of your many medical conditions I wouldn’t have had to spend fifteen minutes surfing three different computer systems for which I have three different user names and passwords to try to glean something about your history. If there is one thing on which I would like to educate the public it would be the importance of knowing your medical history and medications when you come to the Emergency Department non-emergently. That and the importance to us of having an accurate history and medication list. There is unfortunately no omniscient computer in our hospital on which is stored easy to access information about you and, if you don’t know or can’t be bothered to remember your medical history, it’s going to take me some time fucking around on the computer to piece it together.

The casualness with which many patients easily dismiss inquiries about their health, referring us to “The Computer” or worse yet, their primary care doctor who may not be answering the phone at 2AM, displays a touching but entirely misguided faith in our ability to coordinate information. If you can’t be bothered to write a list at least ask your doctor for a copy of your latest complete history and physical, discharge summary, or medication list.

Oh, and “The Pharmacy Knows” is not a good answer either. I’m sure they do but how about those mail-order drugs that the three pharmacies in town where you fill prescription don’t know about? We’re up against the clock, Ma’am. Help us help you by making our job easier.

Man Up

I’ll go ahead and say it: Glenn Beck is a wuss.

No doubt some of you have been following the story of CNN talk-show host Glenn Beck and his recent experiences as a surgical patient. Billed as an indictment of the health care system, his somber teaser on Youtube describing the horrors he experienced piqued my interest and I’ll admit I followed the story closely to see if he had anything legitimate to say.  The way he described it I got the idea that he had undergone major surgery, woke up on the table, and was in incredible pain the whole time, even on presenting later to the Emergency Department with post-operative complications. As dribs and drabs of the story came out, we learned that nobody in the Emergency Department cared and despite being in excruciating pain he was ignored for an hour while the callous triage nurses chatted with each other.

As it turns out, he had a relatively minor outpatient procedure, a hemorrhoidectomy, under nothing more than procedural sedation and had post-procedural pain. I am not one to scoff at pain, rectal or otherwise, and one of the first things I try to do with my patients is control both their pain and anxiety. But apparently Mr. Beck’s pain wasn’t touched by large amounts of narcotics in quantities that would sedate an entire Cuban village. He was sent home on terminal cancer-sized doses of pain meds and returned several hours later with urinary retention and worse pain which again required horse-killing doses of narcotics. I don’t know how long he really waited in triage, we have only his word and pain makes the clock slow down considerably but he sounded like an extremely difficult patient, a guy who required so much narcotic analgesia that you start to wonder if he’s going to stop breathing.

Now, here is a rare caveat for me: I don’t know the real story and, since the Emergency Department can’t comment due to privacy concerns, we will never know. I also will again state that my first goal after airway, breathing, and circulation is to control pain. But Emergency Departments are busy places which is not, in of itself, an indictment of the health care system. People need to be seen and we see them.  We triage them according to the severity of the complaint. Pain and urinary retention might be triaged lower than chest pain or possible stroke and you may have to wait a few minutes or ten or thirty. Without meaning to sound callous, we get patients all the time who complain of excruciating pain of several hours or several days duration. Some are seeking drugs and some are on the level but the extra half-hour wait is often unavoidable. Nurses can’t give narcotics without an order and the doctors are often busy. Maybe the patients who are occupying the doctor’s time are minor complaints but, except for life and death emergencies, it is not always obvious to the doctor who needs to be seen next. Even if it were, it wouldn’t be efficient for him to be so fluid in his response to triage that he is continuously breaking away from less acute patients to deal with the more acute.

Mr. Beck needs to man up and stop whining. I’m sorry he had a bad experience but we’re doing the best that we can.

18 thoughts on “Pandarandom: Brief Thoughts

  1. Nice rant.

    In the interest of fairness, I’m an IMG, my medical schools was 6 years and I scored 94 on Step 3 BEFORE starting residency… Your mileage may vary…


    (I don’t rant.  I just comment on the conventional wisdom.  And I believe I was very fair to IMGs in my article because there can be a language barrier.  Still, 66 percent fail Step 3 on the first attempt so I was just pointing out the obvious and offering some opinions as to why.  -PB)

  2. Great article. Haha, I don’t disagree with anything in this one :p, but I am addicted to this blog so I am forced to comment.

    One thing though, I find it odd that you put India in the ‘Anglosphere’ of medical education. Is it warranted (I genuinely don’t know)?

  3. I’m still amazed that primary care physicians don’t routinely print medication lists for their patients. Sometimes, patients are thoughtful enough to try to keep track of their own medications. Unfortunately, they often produce a 3 x 5 index card with lots of markings, crossings out, and illegible wording about the types and dosages of medications they are receiving.

  4. Medicine, the only place in America systems with a user interface directly attached to the mainframe still exist. Even the airlines have moved on.

  5. My disabled son occasionally must visit the emergency room, generally when he’s had a seizure we cannot control with Diastat (Valium administered rectally in a pre-measured dose). For such occasions we keep a text file on one of our computers listing his diagnosis, past surgeries, and current medications. When paramedics or EM personnel want his medical history, we can just print out the file and hand it to them. That way we don’t have to worry about forgetting anything and no one has to play 20 Questions to find out what they need to know.


    (Bless you.  Trust me, we appreciate this simple thing you do in ways you cannot imagine because all of us want to maximize the time we can spend with our patients but can’t because so much of our job is administrative/clerical (and why a good Unit Coordinator is worth their weight in platinum).  I am very polite, to a fault, and like most doctors I have evolved a good poker face, but the one thing that almost makes me curse is someone with serious medical problems who, while in full command of their mental faculties, has no interest in their own medical history and brushes off every question with a “It’s all on the computer.” 

    It’s not. 

    I think it’s actually a defense mechanism for many patients, pretending to not know I mean. -PB)

  6. Chris,

    You’re the kind of person doctors tend to love, if only because you save about fifty minutes of frustration. Even if your PCP did track that information in a portable form, I suspect your version is more concise and relevant because you have an exceptionally complicated case.

    I did an H&P on a nice lady who was more than a little way down the senility trail. Since it was her first visit to the specialist and figuring out her issue took way too long, I guessed I’d be there another hour deciphering what meds she was on (sample answer: “Yeah, I have the sugar…sometimes.”) I nearly kissed her when she pulled out a clearly handwritten sheet of the twenty plus prescriptions that kept all her fluids in the right compartments. Her daughter makes her carry it.

  7. You’re absolutely right about med school prestige not mattering much in their ability to produce high quality physicians. Rank is really important only if you want to do research or academics (largely because many people currently in those fields went to prestigious schools). And even then it doesn’t matter as much as some would have you believe.

    Ah, yet another thing they make us stress about during the application process that in the end matters very little.

  8. Heh, God love those patients who bother to track their medical history. It’s so much less painful than “well, I take the blue one, and a water pill, and a yellow one…”

  9. My prehospital favorite is when you ask a patient
    “do you have any medical problems”
    and reply with “none”
    then you procede to list “asthma, chf, copd, htn” and they begin to all of a sudden have medical problems.

  10. I agree about the prestige issue. I think some students think medicare will fall all over themselves to pay them more because they went to an Ivy league school.

  11. With regard to Glenn Beck, hemorrhoid surgery is very painful, even the new method, PPH with a circular stapling device, causes some amount of discomfort. Unless a patient is crawling on all fours and has a huge hemorroid sticking out his ass, I would never do a hemorrhoid surgery, because of the postoperative pain and the amount of postop care required.

  12. Glenn Beck is a recovering alcoholic (or so he says), and has ADHD, to say nothing of his often overbearing, overwrought persona on the radio and TV. Is it any surprise that he acted like a total a$$hole over an uncomplicated hemorrhoidectomy?

  13. Credit where credit is due on that sheet. It was my wife’s idea. The main motivation was that it’s so very easy for us to forget something even if we’re available to answer questions.

    I’m pretty sure his PCP doesn’t track his meds anyway. They come from 3 different specialists. We fill them all at the same pharmacy, but it’s stupid to expect them to be open at all times we might have an emergency.

  14. “I’m still amazed that primary care physicians don’t routinely print medication lists for their patients.”

    The doc I shadowed my M1 year always did that, every time he changed any of his patient’s medications. I don’t know why more don’t do the same.

    As for a nice printout of someone’s medical history, there was one time someone had an excellent write-up on herself. Many people have med lists, but this little pamphlet had previous surgery information, details on different procedures, etc. She was only in her 30s or so, and she had a massive PMH, so I’m sure the ED was extremely grateful to see what she had.

  15. TheProwler says: “I’m still amazed that primary care physicians don’t routinely print medication lists for their patients.”

    Don’t talk of best practices when your profession’s ethics come after your wallet is fattened.


    “Heart Group Backs Drug Made by Ally”

    Published: January 24, 2008

    “After a study last week showed Vytorin, an expensive combination of two drugs for cholesterol, worked no better than cheap Zocor alone in reducing artery plaque that can lead to heart attacks, the American Heart Association came to the drug’s defense.

    In a statement issued on Jan. 15, the day after the report’s release, the heart association said the study was too limited to draw conclusions about Vytorin’s ability to reduce heart attacks or deaths compared to Zocor alone. The group advised patients not to abruptly stop taking it without consulting their doctors.

    What the association did not note in its statement, however, was that the group receives nearly $2 million a year from Merck/Schering-Plough Pharmaceuticals, the joint venture that markets Vytorin.”

    Reconstruct this link: http://






    Who can people trust when they can’t trust their doctor, their clergy, their banker, their president, their neighbors, etc.?

    Something ought to change and change fast.

  16. “Don’t stop taking your medication without talking to your doctor” is pretty standard advice and I don’t think there is any conflict of interest in making that statement.

  17. Panda Bear,

    This is a follow up to the above question of who can you trust?

    Seems to me I have lots of company asking that question across our fruited plain.

    This makes for interesting reading and its from experts in Pharma.

    January 24, 2008, 2:00 pm

    What Don’t We Know About the Pharmaceutical Industry? A Freakonomics Quorum

    Stephen J. Dubner, Economist, asks the following of the following:

    “What’s something that most people don’t know, pro or con, about the pharmaceutical business, whether from an R&D, economic, or political perspective?”

    Dr. Harlan Krumholz, professor of medicine, epidemiology, and public health at Yale.

    Zola P. Horovitz, Ph.D, pharmaceutical and biotechnology industry consultant, and member of the board of drug companies including Biocryst Pharmaceuticals, Phyton, Genaera Corporation, and Avigen.

    Dr. Cyril Wolf, practicing physician and prescription sales researcher.

    Dr. Stuart Apfel, founder and president of Parallax Clinical Research and chief medical officer at Elite Pharmaceuticals.

    Ray Moynihan, co-author of Selling Sickness: How the World’s Biggest Pharmaceutical Companies Are Turning Us All Into Patients.

    Reconstruct this link: http:/








  18. Panda Bear,

    More on the question of the day, “Who can you trust?”

    After reading it you should understand why I find it both laughable and outrageous that you criticize me and my profession.

    “Financial Ties Are Cited as Issue in Spine Study”

    Published: January 30, 2008

    skipping…”In the study results submitted to the F.D.A., moreover, an unusually large number of patients were not included, and some of those patients have said they fared poorly. As a result, some patients and doctors critical of the research say the study may have cast the Prodisc in an overly flattering light.

    “The way the Prodisc was tested and approved provides a stark example of conflicts of interest among clinical researchers…”

    Reconstruct link:








    Let me say that even though you and I disagree on much, I don’t believe for a moment the above represents your personal or professional morals or ethics or even that of the majority if M.D.’s.

    To be crystal clear: This is not an ad hominem attack but a generalized observation and criticism of the true and accurate state of medicine today: shabby, seedy and shameful.

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