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.