Today, the ER is not just where the majority of acute care is provided, it is also the portal to the entire hospital. ER physicians pride themselves on being able to care for any patient with any condition at any time—and as such, they are true generalists, with expertise a mile wide and an inch deep. Furthermore, most ERs see a tremendous volume of patients, both the critically ill and those with minor ambulatory complaints. As such, emergency medicine is always busy, varied, and fast-paced.
No matter what field you’re going into, an ER rotation is a great opportunity to hone your general medical and surgical skills. You will get to do a bit of everything during your rotation and be afforded a degree of independence you may not get on other rotations. You will see patients, present their cases to a senior resident or attending, and then formulate a plan for their care. You will do almost all your own wound closures, splinting, and other minor procedures. You will order all the labs and ultimately help decide on the disposition of the patient. You will speak directly with consultants and admitting physicians. You will be an advocate for your patients and their needs. While you probably won’t be directly involved in the critical-care aspects of emergency medicine, time permitting, you’ll be invited into the resuscitation rooms to observe and sometimes help out with cardiac arrests, trauma victims, and other critically ill patients. With luck you might even get the chance to intubate a patient or start a central line.
Emergency medicine is a twenty-four-hour service, organized around shifts. You will work regular shifts just like your resident and attendings, usually eight to ten hours in duration. Your shift mix will likely involved day shifts (roughly 7:00 A.M. to around 4:00 P.M.), evening shifts (3:00 P.M. to 12:00 A.M.), and overnight shifts (11:00 P.M. to 8:00 A.M.). Depending on the size and volume of your ER, you may be assigned to rotate through various sections, like trauma, pediatrics, and ambulatory care. There will be regular didactics for medical students that focus on key areas of basic emergency medicine. In addition you will probably also attend the regular service conferences, as you do on any other rotation.
Career considerations—emergency medicine
Emergency medicine is fast-paced and relatively chaotic. To survive and thrive in this field, you have to like juggling a heavy patient load and you have to be eager to see the widest possible spectrum of pathology. One of the things that attracts people to emergency medicine is that sense of being able to care for any person at any time, with any condition. From day to day you never know what you’ll end up seeing. While you won’t know all the answers because you can’t possibly master every field of medicine, you will be an expert at stabilizing sick patients with life-saving measures, diagnosing most medical and traumatic conditions, and getting the patients the long-term care they require either through inpatient admission with appropriate consultation or by arranging outpatient follow-up.
Another attractive aspect of emergency medicine is the lifestyle. Not only is it a well-paid specialty, it also has the fewest hours of almost any field. Most emergency physicians work anywhere from 120 to 140 hours per month clinically, half what many of their colleagues in other fields work. Furthermore, those hours are distributed over the range of shifts, meaning that ER docs often get to be at home with their families or out enjoying life while their colleagues are working regular daytime hours. The downside is that you will end up working a fair number of evenings and weekends, times when your physician colleagues from other fields and other professional friends will traditionally have off. As with most things, this is a trade-off that you need to evaluate for its fit with your own wants and needs in a career.
The most prevalent critique of emergency medicine is the lack of long-term continuity of care. While most ERs have their “frequent fliers,” you’ll rarely see the same patients on a regular basis. With that said, you have an opportunity to form a profound, albeit brief, relationship with the patients at an often very critical juncture in their lives. Some people prefer not to handle the critical-care aspects of the field or are turned off by the unsavory characters you often end up treating in the ER. You will see a tremendous amount of selfinduced pathology, and the stories and circumstances of your patients’ lives can be tragic and frustrating.
PSYCHIATRY
Psychiatry is another one of those rotations people either love or loathe. It is a definite departure from the majority of your clinical rotations. Your time will be spent observing and interviewing psychiatric inpatients and outpatients. You will learn the basic structure of the Diagnostic Statistical Manual (DSM), which is the psychiatrists’ catalogue of disorders and their specific diagnostic criteria. You will discuss and write fairly extensive H & Ps that detail your impressions of the patient’s condition and its origins. Finally, you will learn how to tailor therapies for different conditions based on both psychoanalytic as well as pharmacologic modalities. In addition to the strictly psychiatric patients, you may have the opportunity to participate in the inpatient consultation service. On this team, you will help evaluate medical and surgical inpatients with potential psychiatric issues like depression, dementia, suicidal ideation, or even psychotic behavior.
Most students are either fascinated by interacting with the bruised or broken psyche or find the experience boring or bizarre. Whatever your feelings, you should take note of the fundamental principles here. Almost any field you go into that deals directly with patients (pathology and radiology as the possible exceptions) will expose you to a diverse array of psychiatric issues, and as such this aspect of patient care will definitely impact your clinical practice no matter what specialty you choose.
Career considerations—psychiatry
The scope of mental-health care has evolved considerably in recent years. There are numerous midlevel providers such as psychologists and licensed clinical social workers who do a huge amount of the one-on-one therapy. Psychiatrists continue to play an important role in direct patient psychotherapy, but because of their highly specialized medical training they also tend to focus on medical management and more complex mental-health care. While the vast majority of psychiatrists are in a private-practice setting, there is a reemerging role for inpatient psychiatrists as psychiatric hospitalizations become shorter and more intense.
The psychiatrist has a range of subspecialization options. Fellowships include child and adolescent, geriatric, addiction, forensic, and research psychiatry. The psychiatry residency is three years long. Most fellowships are one year, with the exception of child and adolescent, which is three years long but can be combined with residency for a total of five years of postgraduate training. With fewer inpatient hospitalizations and almost no procedures, psychiatrists are among the lowest-paid physicians. However, their regular work hours and limited or nonexistent call make for an excellent lifestyle.
FAMILY MEDICINE
Your family-medicine rotation will be another broad-based experience during which you learn and improve a wide variety of fundamental skills. Family physicians, especially rural family physicians, literally see and do it all. Their demographics include newborns to geriatrics, and their skill set often includes obstetrics and basic surgery. In urban centers where there is a higher degree of specialized care available, the family physician may operate more like an internist and pediatrician combined, doing fundamental primary care and making appropriate referrals for subspecialty evaluations. In more rural settings, those resources are either wholly unavailable or at best difficult to access geographically. In these settings the family practitioner functions like the old-time country doctor—handling a broad range of issues independently, and in some cases even making house calls!
Your educational goals during this rotation will be to continue mastering the fundamental skills of patient interviews, exams, and evaluations. You will spend some time both in the clinics and on the wards. If you have the opportunity to do all or part of your rotation in a rural setting, take it. Even if you have no interest in family medicine or in rural medicine, you will experience a
n entirely different form of practice in the rural setting. First, you will probably be the only medical student for miles, so learning opportunities will abound. Furthermore, you will discover how spoiled we are to have every imaginable test and expert available to suit our every whim at the academic medical center we all grow up in clinically. It’s very different when you’re out there alone and the patient before you has something you don’t recognize or something you will have a hard time treating. As the sole provider in an area, you also take on a unique and important role in the community, and you will form lasting relationships that are profoundly gratifying.
Career considerations—family medicine
Most family physicians will tell you they chose their field because they have the opportunity to be longitudinally involved in their patients’ lives, caring for whole families or even generations of families and offering a consistent and trusted voice of advice and counsel on all things medical. Many family physicians now shy away from the obstetrics and surgical side of their practices for a variety of reasons, including liability concerns, the cost of insurance premiums, and because it is difficult to maintain true proficiency at those skills without everyday practice. However, as mentioned, the rural family doctor is still called on to do a little bit of everything.
Family physicians have a relatively rigorous schedule. As in other primary-care fields, their practices are generally orchestrated so that they attend to their regular clinic hours and then complete any admissions for the day and round on their hospital patients. The frequency of call nights will depend on the size of the group. If you’re a rural family doc in solo practice, you’re on every night, like it or not. Reimbursement varies considerably with the practice type and location but tends to be on a par with other primary-care specialties. There is an urgent need for rural primary care, so if you’re drawn in this direction you’ll likely find wide-ranging and attractive opportunities for some time to come.
“Family medicine was an obvious choice for me,” Pete explains. “I knew I wanted service to communities to be a high priority in my professional life, and that I did not want to live in a major metropolitan area. I also saw that prevention is a far more pragmatic approach than treatment for the vast majority of disease affecting the United States today, and further that the emphasis on reactive health care today is doing our patients a disservice.”
CHAPTER 19
Bringing It All Together Again: The USMLE Step 2 Exam
One finger in the throat and one in the rectum makes a good diagnostician.
—SIR WILLIAM OSLER
JUST WHEN YOU thought you were free from the horrors of life in the library, that old beast the USMLE comes stalking you once more. Still wince every time you see a stack of flash cards? Still feel like First Aid for Step 1 is imprinted on your retinas like a solar flash? Well, the time has come to ramp up for the next board series exam.
Most schools require you to take the USMLE Step 2 Exam prior to graduation, and the best time to take it is between your third and fourth years, after you’ve just completed your core required rotations. The bad news is that Step 2 is a more rigorous test of your clinical knowledge and relies much more heavily on your clinical problem-solving skills than Step 1 did; the good news is that by the time they take it, most people find it significantly easier.
The Step 2 Exam is actually two separate tests: the Step 2 Clinical Knowledge (CK) Exam and the Step 2 Clinical Skills (CS) Exam. The CK Exam is a computerized multiple-choice exam in a format similar to the Step 1 Exam. Several years ago the folks who created the USMLE added the Clinical Skills Exam, in which students are observed interacting with simulated patients in a variety of scenarios and evaluated on their personal, professional, and technical skills.
Let’s look at each of these components of the Step 2 Exam in closer detail.
THE USMLE STEP 2 CLINICAL KNOWLEDGE EXAM
The goal of Step 2 is to provide a comprehensive review of basic clinical-medicine and physician skills. According to the USMLE, the test is structured in two conceptual sections; the first covers normal conditions and disease, and the second focuses on the four fundamental tasks of the clinician: promoting preventative medicine and health maintenance, understanding mechanisms of disease, establishing a diagnosis, and applying principles of management. As we’ve discussed, this test is almost 100 percent clinical in focus. The pathology and pathophysiology that is covered reflects the USMLE’s high-impact disease list. This list includes common problems presenting commonly, less common problems where early detection or treatability are important considerations, and “noteworthy exemplars of pathophysiology.”
The majority of your mentors used the First Aid series as a primary review text, supplementing those with other specialty-specific review books as needed. Most dedicated several weeks to studying, but often this was evening and weekend study time, not the 100 percent dedicated day-and-night kind of studying required for Step 1. Most of the information you will need should already be in your head from the rotations you just completed, so your study should be primarily to review and refresh the information.
Clinical information for all the specialty areas is weighted evenly on the test, even though the scope of information may vary significantly. Thus, even though internal medicine is a much broader, more comprehensive field, it will have the same number of questions as psychiatry. As such, time spent perfecting your knowledge of the more limited scope of psychiatric medications and therapies may make for a better overall score.
The written portion of the test is computer-based multiple-choice and lasts a full eight hours. It is administered at the Sylvan Prometric Testing Centers throughout the country. There is a wide range of dates when the test is offered, so you’ll probably be most limited by whether the test center nearest you has an opening on the date you want. Register early if you plan on taking the test in an urban center or near your medical school—these test sites typically fill up well in advance.
THE USMLE STEP 2 CLINICAL SKILLS EXAM
At various points in the book, we’ve alluded to the fact that the USMLE now incorporates an examination of your clinical skills as well as your cognitive skills. In the late 1990s, the Objective Structured Clinical Examination emerged from the simulated-patient interaction efforts of various medical schools across the country. Schools recognized that students were learning their core clinical skills on real patients after they hit the wards, and that this often produced less-than-ideal patient encounters and incomplete skill sets. As a result, schools began using simulated patients (i.e., actors) to provide an opportunity for demonstrating fundamental interview and physical-exam skills. Instruction changed from simply what a physician needs to know to how he or she actually performs on the job.
The next logical step to these simulated encounters and lectures was to turn them around and use them as an evaluation tool to prove fundamental clinical competence in core skill sets. It didn’t take long before the USMLE hopped on this bandwagon and realized that this clinical-examination component should be incorporated into the USMLE test regimen—and hence, the emergence of the USMLE Clinical Skills Exam.
The format of the exam is essentially a series of clinical encounters. It will seem as though you’re seeing a series of patients in an office outpatient clinic. On exam day, you’ll show up at the testing site and go through the registration process. You’ll be given a sequence of patients to see at regular time intervals. At the start of the encounter you will be provided with a basic chart entry not unlike the one’s you’d receive from your office staff. This will usually include the patient’s chief complaint, vital signs, and possibly some background information. You will then be expected to enter the room, introduce yourself to the patient, carefully wash your hands, interview and examine the patient, discuss and formulate a plan for the patient, and then exit the room. On the outside you will have a few minutes to write a brief chart note about the encounter. Then you will move on to the next patient.
; The USMLE has broken down the clinical encounter into three subcomponents for evaluation. The first subcomponent is the Integrated Clinical Encounter, which evaluates your ability to gather data and make a complete patient note. For the Communication and Interpersonal Skills subcomponent, you are expected to demonstrate your questioning skills and information-sharing skills while maintaining a consistent professional manner and establishing rapport. Finally, in the Spoken English Proficiency portion, you must demonstrate clear communication within the context of the doctorpatient relationship. This last portion is primarily intended for the international medical graduates who are attempting to achieve licensure in the United States.
Your Step 2 CS Exam will include eleven or twelve patient encounters. These include a very small number of nonscored patient encounters, which are added to pilot-test new cases and for other research purposes. Such cases are not counted in determining your score. The examination session lasts approximately eight hours, and two breaks are provided.
It’s difficult to study effectively for the CS Exam, since it relies on a range of clinical skills that you will have developed over your first year on the wards. Many schools incorporate simulation training into their clinical rotations, so hopefully you’ll be no stranger to working with simulated patients and playing the game. The USMLE Web site (www.usmle.org) includes tutorials, videos of encounters, and patient notes to practice on.
Med School Confidential Page 23