May 6, 2013 | 2
I’ll start with this: it’s great to be back.
I’ve been on hiatus from blogging for the past few months because of the exam I took last week: the medical boards, or Step 1, an eight hour test that covers all of the first two years of medical school to prepare us for the hospital wards. To give you an idea of what it entails, most second-year medical students use a 550-page review book as a scaffold that at the minimum gets memorized. Subjects include anatomy, physiology, pathology, biochemistry, pharmacology, microbiology, immunology, embryology, and others. One physician writer described the first half of medical school like this: “It was like being asked to enter a grocery store and memorize the names of every product in the store, their number and location, every ingredient in every product in the order in which they appear on the food label, and then to do the same thing in every grocery store in the city.” The test was not so much one of depth, but rather of immense, extreme breadth.
Despite several stressful months of preparing for it, I do not begrudge the exam. The process of going through all the material in a systematic way led to a powerful sense of consolidation, and there were many moments when I made connections I might not have seen otherwise. Absorbing the material set a mental foundation that I hope I can refer back to for the rest of my career. Even if the details fade (as I’ve been assured by nearly everyone they will), there is value to learning them right the first time. Knowing something exists means you know what to look up and how to fit what you learn into a broader context. As I studied, I held in mind a piece of advice from one of our neurology professors: “It is not inherently obvious what subset of information will have clinical relevance.” Second year was the time to commit many, many details to memory, some of which we will use frequently and some of which we may never see again. Having it all stored somewhere means as we enter the hospitals we can sort through what we know, appreciate new information with perspective, figure out what is relevant, and apply it to care for patients.
However, I found the process of studying changed the way I think about medicine. After a while, studying transitioned from learning and understanding to committing to memory. It involved going over things I already knew – but doing it over and over and over. When dealing with a timed, multiple-choice test, much of being successful has to do with making quick associations. This set of symptoms is associated with this one disease; this disease is associated with these risk factors; these risk factors contraindicate these drugs; this drug is associated with these side effects. The months leading up to the exam, I both consciously and unconsciously trained my brain to think in terms of links; of single answers; of being fast. I became skilled at seeing a phrase and having others come immediately to mind. On the boards, you do not make a differential diagnosis. You do not ask: what’s more or less likely? Rather, you ask: what is it?
And on the test, there always was an answer. Our job was simply to select the correct one. The facts in each case added up. Presentations of illnesses were classic and common. There were little to no loose ends – nothing that could not be packaged into a single diagnostic box.
This is quite different from medical reality. On the test, if I did not immediately identify an answer to a clinical case I could reasonably think, “I’ll get to the bottom of this.” I could go over the facts that were given and try to see the pattern that would fit with a known diagnosis. “I’ll get to the bottom of this” is something I would love to be able to tell patients, too. But we know it isn’t always true. Sometimes we will never get to the bottom of a particular person’s case. Sometimes we get halfway there and then have to change course. And sometimes, we only understand snippets of what is happening and why. Pieces do not always fit together neatly. Some facts are tangents and red herrings. Clinical experience cultivates the ability to hone in on the relevant and filter through the rest, yet some information can be mysterious, playing an unclear role in the unfolding narrative.
A few weeks before my exam, I saw a middle-aged patient whose body was mysteriously failing her. She had been seen over the course of years by multiple doctors in multiple specialties. What was known was that various organs were shutting down. The pattern and progression of her symptoms screamed “autoimmune,” but her presentation did not fit into any known category of autoimmune diagnosis. Instead, she was treated symptomatically, without a diagnosis and without an appreciation of the cause. I thought about what she would have looked like had she been on the boards. Details would have been tweaked so that she did fit into a neat disease category. With a click on an answer choice, I would have been able to give her a diagnosis.
I hope what I learned for the boards will help me. Because this week I begin. Classrooms are a remnant of the first half of medical school. Now, I’ll be in the hospitals every day. I will be a part of a medical team. I will be with patients, and I will care for people. This is what all the studying was for. This is what we are here for.
Beyond the incredible privilege of being able to care for other people, I’m looking forward to the creative aspects of thinking about medicine. Of thinking broadly, deeply, and teasing apart mysteries and possibilities. Of spending more than 60 seconds on each case. Of the gray areas, and of the complexity.
I look forward to the cases where A, B, C, D, and E may all have hints of being correct. And I look forward to plugging away to make sense of an illness even when the answer is seemingly none of the above.