Most programs will impose one final requirement on their residents—an academic project. This is typically some form of research project and presentation to be completed during their training. The definitions for this project are usually fairly broad and are meant to include everything from original clinical research to case reports to quality assessment studies. You’ll probably be required to prepare a report or presentation on the project. Ideally you’ll be able to present your project at a national meeting. At first the project will seem like a huge undertaking. But take a minute and talk to the more senior residents about what they’ve done. Talk to your faculty members about their research interests and ongoing projects. Chances are that before you know it you will find an idea blossoming in your head. Curiosity is a healthy attribute in a physician, and this is a great opportunity to explore your horizons a little.
Speaking of horizons, it is worth reminding yourself on a daily basis that you are now embarking on a career. You’ve landed in your specialty, and as you progress through your residency you are laying the foundation for years to come. Be diligent, be inquisitive, and strive to hone your skills and knowledge. You are in an incredibly rich academic environment with a group of highly skilled and dedicated faculty whose sole purpose is to teach you, often one-on-one at the bedside. Learn from these people. Get to know them. Ask them about their lives and their careers. Explore the subtleties of your specialty and ask what’s available from the profession. You’ll probably find there are subspecialties, offshoots, and opportunities you never knew existed. Contemplate whether you want to join the academic ranks and continue a career of research and teaching or whether you want to pursue community medicine and its very real rewards.
THE BALANCING POINT
Month will follow month, and before you know it you’ll be halfway through your intern year. What once seemed impossible to contemplate has now become the mundane. No longer a stranger to day-in-day-out patient care and now disturbingly attuned to sleep deprivation and life in a call room, you may ask yourself, “When did I become an inmate in this crazy game?”
The answer, as you know, lies in the murky past, some five or six years ago, when you picked up this book and thought, “Hmram . . . maybe medicine?”
But take heart! Life will get better. Many would say the midpoint of your intern year is an absolute nadir in life. This year, your life has been led way out on a limb of extreme work and fatigue. You’ve found yourself running in the same loop from home to work to home, seemingly without pause. It’s normal to feel trapped. All this rhetoric about maintaining balance is great, but some days just maintaining a modicum of sanity will be the goal. You must weather the storm by whatever means you can. Talk to your peers and you will probably begin to realize you are not alone in these feelings. Recognize the progress you are making and just keep putting one foot in front of the other. Try as best you can to stick to the plan you set out with at the beginning of the year, including the goals for exercise, for time with friends, and for time to yourself.
If you find yourself in a downward spiral or making choices you know in your heart are not wise, seek help immediately. Depression, substance abuse, and other self-destructive behaviors are not uncommon among interns. Just as in medical school, there are people and programs available in your residency, in your hospital, and in your community to help you overcome these hurdles and get back to that track you set yourself on originally. Have the courage to admit you need help and address any issues as soon as you can, before they become unmanageable or derailing.
TTHE USMLE STEP 3 EXAM
The final test is upon you.
In order to qualify for the USMLE Step 3 Exam you must have completed one year of postgraduate training (i.e., an internship). Most people take the Step 3 Exam in the summer after their intern year, when all the basics are still fresh in their heads. At this point, you’re probably not sure whether to cry or leap for joy knowing that the last of these monsters is finally here. The good news is that you’ve already completed 90 percent of your preparation for this test before you even crack a review book. The Step 3 Exam attempts to focus on your ability to actually manage patient care. Just by spending the last three years of your life in the trenches, you’ve developed an impressive arsenal of real-world clinical knowledge that cannot be gleaned from books. You’ll bring this new skill set to bear on the Step 3 Exam.
According to the USMLE, the goal of the Step 3 Exam is to “determine if a physician possesses and can apply the medical knowledge and understanding of clinical science considered essential for the unsupervised practice of medicine, with emphasis on patient management in ambulatory-care settings.” Essentially they’ve already taken great pains to make you prove you’re smart and can memorize a tremendous volume of relatively useless information, so now, after all this time and all the money you’ve paid for these exams, they’re finally going to test what you do as a physician.
It’s about time.
Unfortunately they’re primarily going to test what you do if you’re a primary-care physician, which does cover many fundamentals of clinical medicine but may or may not apply well to your particular specialty. If you have your heart set on being a urologist, you may need to spend some time reviewing and rehearsing the management of things like hypertension, diabetes, and other common illnesses in preparation for the exam.
The exam itself is also a little different from the prior USMLE exams. The test falls over two eight-hour days. The first day will be spent fending off 336 multiple-choice questions broken into seven sections. These will be relatively typical USMLE multiple-choice questions. The second day will start with another 144 multiplechoice questions in four blocks over the first three hours. After these, you will change gears and go through a series of computer case simulations on the USMLE’s Primum simulation software. You will work through about nine cases over four hours.
The Primum software allows you to work through a patient encounter that may span as long as several weeks. Essentially you will be given the chief complaint, vital signs, and pertinent history in a typical appearing triage note. You will then interview and examine the patient by selecting from a list of possible questions and exams. The results of your investigations will be made available in real time. If you order blood work on a patient and you’re working in your “office,” you won’t get the results until the next day. Thankfully the nice folks at USMLE recognized that overnighting at the test center might be awkward, so they included a button that allows you to speed up time. Thus you will see a new patient, order a test, make a provisional diagnosis, and move forward in time as you see fit until you have test results, or you wish to reexamine the patient, or the patient’s condition changes. Some cases will occur in your “office,” some will occur in the “hospital.” You may elect to admit someone from your office to the hospital, in which case you will follow them and be their physician during their inpatient stay.
The software generally uses free-text entry for orders and questions, allowing you considerable freedom in working with the patient. The software is trying to make sure you achieve certain milestones in the case at appropriate times. Once you’ve completed the milestones the case will conclude. If you fail to complete the milestones in the allotted time, the case will still close and you will move on to the next patient.
Studying for the Step 3 Exam is, obviously, very different from studying for the other Step Exams. By and large, the multiple-choice questions cover fundamental clinical knowledge that you’ll probably be familiar with. You should get a good general Step 3 reference book to help you review the essential concepts and make sure you bone up on some of the facts that might be growing a little hazy. Again, this is especially true if your internship has been in a nonprimary-care field where you have not been dealing with these basic problems day in and day out.
The best way to study for the case simulation portion of the test is to spend time getting comfortable with the Primum software. The USMLE allows you to dow
nload the software and a series of example cases. Spend time working through these and getting very used to the controls and quirks of the program. The software is by no means perfect, and in many cases you’ll get frustrated by its lack of realism, but in the end you’ll probably find that it’s a bit like playing a glorified video game.
Pass rates for the Step 3 Exam are the highest of any USMLE exam. More than 95 percent of residents from U.S. and Canadian schools passed on their first attempt. It’s worth some studying so you don’t get surprised by the content or format of the test, but don’t make yourself crazy over this one. All of the hard work you’ve been doing over the last five years will pay dividends here.
THE FUTURE
Take a moment to appreciate what you’ve done.
Internship has drawn to a close. The last USMLE Step Exam is behind you. As a clinician, you’ve grown from a hesitant, halting med student to develop your own relaxed and effective style with patients. As a resident, you’ve watched a cadre of new fourth-year medical students parade through your program, praying for a spot like yours come Match Day. Now you’re preparing to make the jump to second year and your first chance to take on a more pivotal role in the care team.
The fun is about to begin.
Remember when you first got to medical school and you were awestruck by how far the horizon seemed to stretch? You could go in any one of a million directions, and all around you were people dedicated to showing you the way. Since that time, you’ve locked in on some specific niches that appealed to your strengths and interests. You’re well on the path to becoming an expert in your arena. But the amazing thing you’re probably also discovering is that the horizon remains almost as limitless.
Yes, you’ve narrowed your focus and you may now have responsibilities and life choices that constrain your options, but no matter where you stand there is an incredibly broad array of options for someone with your skills. You may decide to stay in clinical medicine or make a foray into research. You may decide to teach and enter an academic career. You may decide to get involved in business and technology, or you may decide to focus on medical relief and international medicine. Whatever your choice, and whatever your interests, there is almost certainly a way to pursue it and a place where your skills are in need.
It has been a long and hard road to travel. You deserve credit and respect for your dedication and perseverance. Your just reward is to be counted among the lucky few who are entrusted with a patient’s care, to make a direct difference in people’s lives and well-being, to deliver a newborn into the world, or to hold the hand of the dying.
Do not take this charge lightly.
No matter how dull the case, no matter how annoying the patient, be humble in your role. Respect the responsibility you carry. And, above all else, respect your patients. Be dedicated to them, and let them continue to teach you for all your years of practice. Strive to achieve that elusive balance in your personal and professional lives so that you can truly serve those you care for and those who care for you.
Finally, as someone who has run the gauntlet and survived the medical training process, consider the opportunity to give back. Look around, and you will find many young faces not unlike yours a number of years ago, eager, confused, and afraid. Take the time to be a mentor, to offer advice and counsel. Above all, offer the encouragement that can lead young students to have confidence in themselves. We stand together as physicians in no small part because of the diligent efforts and unending encouragement of those who came before us.
Long may the tradition continue.
PART SEVEN
Advice for the Spouses, Partners, Significant Others, and Families of Med Students
CHAPTER 29
The Realities of Life with a Doc-in-Training and Strategies for Making It Livable
by Kimberly Bissell
Life is like a diaper . . . short and loaded.
—PROVERB
SURE,” I SAID, “go to medical school.” What was it to me, really? We were dating, and while I liked him a lot there was little chance we’d settle down together, right?
Well, here I am, writing a chapter about what it’s like to be married to a medical student. His training has shaped our lives and our children’s lives for the last ten years. We started dating when he applied and got married in his second year of med school. We had our first child during his third year and our second child in the middle of his residency. We’ve moved once for residency and again for a job. Our story is hardly unique. Now, your significant other or family member is considering medical school. While the focus of this chapter is about what it’s like to marry a med student, much of the information and coping techniques apply to close family and friends as well.
If your significant other is contemplating donning the stethoscope and you’re reading this chapter, you’re probably not married yet or only newly married. If you don’t already have children, you’ll likely want to have them eventually. You’re probably going to school or working full-time yourself. And mostly . . . you’re not sure how to feel about your significant other becoming a doctor.
You’re not alone. This chapter is intended to help educate you about what to expect, both good and bad, from your med student and their schedule. I’ll present some expectations you should have for him or her as well as what they’re going to need from you during this process. And finally, I’ll provide some coping strategies for surviving the tough times and enjoying the good ones.
Most important, know this: your relationship can survive medical school. You may even grow together through the experience. Ultimately your success or failure will depend on the balance you strike with each other in your relationship and the balance you achieve as individuals with separate interests. Together you can meet the challenges medical school presents, but it’s going to take a lot of open communication and patience from both of you.
WHY SHOULD I WORRY?
Two realizations pop up right off the bat when you first learn of your partner’s interest in becoming a doctor: “Cool, we’ll be able to afford a house and nice cars someday,” and, “Come on, is it really that hard to go to medical school?”
It’s no myth that doctors have good salaries. As a whole, they’re not making what they used to make (at least that’s what everyone tells you), but you will be able to support your family comfortably on your spouse’s income. The aging population and ongoing healthcare crisis mean physicians are likely to remain in high demand. In all likelihood, your spouse will have a good chance at finding a job. Depending on the competitiveness of their chosen specialty, you may have to move for residency and/or for the first job, but opportunities are out there.
What you will discover is that it really is that hard to go to medical school. It’s damn near impossible to get into and it completely takes over your life when you do. Your spouse will be breathing, eating, and sleeping medicine for the next seven to ten years. And even after residency is over, chances are they’ll be so attuned to breathing, eating, and sleeping medicine they’ll require a certain amount of retraining. Unfortunately, your life will require a certain amount of breathing and eating medicine as well. The realities of marrying a med student will affect where you live, how you live, and the sacrifices you’ll have to make along the way.
THE TOP FIVE REALITIES ABOUT MARRYING A MED STUDENT
They study and work long hours. Your partner or significant other will work really long hours. Unfortunately, even with new restrictions in residency programs, they will still work insane hours and have little time to think of anything or anyone else. The good part is that hard months are often coupled with easy months, and you will find they do have free time during the year to catch up on being a human.
They will receive little or no salary for a long time. Envision four years of expensive schooling (medical-school tuition is one of the highest in graduate education) followed by three to five years of little pay. You have to be prepared for the long haul of cheap living and loan stress
. In addition, while you’re rebelling against the thought of another box of mac and cheese, many of your friends who are dating or are married to lawyers, investment bankers, entrepreneurs, or other professionals will be living the high life. You will realize the opportunity cost of years of low or no salary from your spouse. Have that box of mac and cheese and carefully consider what you can reasonably afford in your life. The less debt you incur in loans or credit cards, the more freedom you will have down the road, especially when it comes to choosing a specialty.
They have little control over their time. Your partner signed up to become a doctor with the understanding that there would be lifestyle sacrifices. What most soon-to-be med students don’t always think about is the sacrifice that their family, friends, and spouses also have to make, even if they’re not married yet. Once those applications and match lists are sent out, any one of the locations applied to could be your new home. An acceptance letter from a school in a faraway city is a hard thing to turn down after years of premed toil and stress.
They have a hard time finding a balance. It will seem that there is an endless stream of information that your spouse has to know. It’s not possible for them to learn it all and still have huge blocks of free time every day. Most of the time they’ll be studying or working in the hospital. On occasion, it will be hard for them to even break for lunch. There will always be more work to be done.
Your own life and career will be marginalized. It can be difficult to compete when your spouse is late because a grieving family needed attention or a woman went into labor. It can be impossible to still think your needs are important and very hard for your partner to calm down and concentrate on home life.
Med School Confidential Page 28