There are 3 board exams required for licensing. USMLE Step 1 is the first. This is taken after the second year of medical school and covers all the knowledge acquired during the first two years. Neuroscience, genetics, pathology, pharmacology, physiology, epidemiology, and microbiology are some of the subjects included. It's the hardest of the 3 exams, and the score counts the most. The average score is roughly 220. That's the three digit scores. Then there's the two digit score, a mysterious number that isn't a percentage or a percentile. 75 is passing. I have a 230, which correlates to a 98. I'm not sure how one relates to the other.
Some residency programs have "cut off's" and supposedly won't even consider lower scoring applicants. These tend to be the more competitive programs- the ones on the "ROAD" to happiness (Radiology, Ophthalmology, Anesthesiology, Dermatology) as well as Ear Nose and Throat, and Neurosurgery. I'm really not sure how hard and fast these cut-offs are, but I do know that when our Step 1 scores were released, one of my classmates sadly decided that Neurosurgery wasn't in the cards for him. Another was convinced he would never be an a Radiologist. The former chose another field, the latter is a second year Radiology resident.
Step 2 is taken after third year of medical school, the clinical year. It comes in two parts, CK, or Clinical Knowledge, and CS, or Clinical Skills. It's a little easier, and covers mostly clinical medicine. The score for Clinical Knowledge is also given out as a three digit, and the mysterious two digit, score. It's mostly important for those who feel they didn't do well enough on step 1. My score was again, a 230, and this time, my two digit score was a 95. Step 2 Clinical Skills tests students on their patient interactions. Each student must pay over a thousand dollars to interview, and perform physical exams on, actors.
Step 3 is the final test, usually taken during, or after, intern year. It's supposedly the easiest of the three steps, and supposedly, the score counts the least.
Anyway, I'm studying for CS right now. The patients are actors so in many cases they don't have actual physical findings. So, they act. If a patient is supposed to have a heart murmur, he or she will say "hush hush hush" when you put the stethoscope over the chest. No air going into the left lung? The patient holds his breath while moving his shoulders up and down as you hold your stethoscope over the left lung.
And, if you laugh, this means you lack empathy. Laughing puts you in danger of failing, in which case you will have to pay over a thousand dollars to take the test again.
I hope I don't laugh.
Thursday, December 31, 2009
Sunday, December 13, 2009
Splitting
I was pretty sure my resident didn't like me. On my team at the hospital, the main players were my attending, the resident, and a medical student. The attending has the highest rank- she was the one on the team who'd graduated from medical school and who'd finished residency. Dr. Mia, the resident, was lower on the totem pole. She'd graduated from medical school two years prior to my stay, and was working her way through a Psychiatry residency. The medical student was what I was supposed to be. She was doing her third year clinical rotations.
Mental patients, particularly those with personality disorders, do something called "splitting." This basically means that they either really like someone or really dislike someone. As an example, if I really liked the nurse on the night shift, and really disliked the nurse on the day shift, for no apparent reason, this might qualify as splitting. Those lucky enough to bask in the light on the positive side of a split may be showered with compliments. But, this may be short lived, as the splitter can very easily move someone from one category to another. Someone who is wonderful one day, may be terrible the next from the point of view of the splitter. This usually causes problems, because the splitter often complains about certain people on the team, and when the behavior isn't recognized, the splitter may succeed in manipulating those trying to help her.
I was certain that Dr. Mia didn't like me. But I actually can't say that for sure- I do know that I didn't like her. She told me that I shouldn't worry about not returning to medical school, as many people are successful with college degrees. I didn't really NEED to become a doctor. Leaving medical school wouldn't be such a problem. This caused my eyes to fill with tears, and I answered her questions grudgingly, staring at her shoes during our sessions. Would Dr. Mia be happy if her dreams of becoming a doctor evaporated? I wondered bitterly. Her words swirled around my head and I became angrier and more resentful towards her as the days continued. I liked the attending and the medical student. I worried that my obvious dislike of Dr. Mia would be contrasted with my feelings towards the medical student and attending, and that my team would decide I was "splitting."
Patients who split are considered more difficult so I tried valiantly to hide my feelings.
"Splitting" is most notably associated with Borderline Personality Disorder, a label that is often a euphemism for "I don't like this patient." Personality disorders are also called "axis II" disorders. When evaluating the psychiatric patient, a doctor tries to fill each of 5 categories, called the 5 axes. Axis I disorders include Bipolar Disorder, Schizophrenia, and Major Depression, among others. These are generally considered "not the patient's fault" or sometimes "biologically based." Treatment is generally covered by insurance. Axis II disorders include anti social personality disorder, borderline personality disorder, and dependent personality disorder. Axis II disorders are usually considered to be lifelong, and related to a patient's character. Someone with an "Axis II" problem is often considered to be someone with undesirable character traits. Axis II disorders are usually not covered by insurance. Axis III includes any medical problems, such as pneumonia or diabetes. Axis IV includes any social stressors the patient may have. Being a medical student might go in this category. Axis V is denoted by a number, from 1 to 100, which reflects the patient's over all function. A patient who is a 10 is likely confined to a hospital. Someone who scores 100 is able to function in the world.
When a psychiatrist speaks of someone with "axis II issues" he or she usually means someone with "undesirable character traits." I learned in a subsequent psychiatry rotation that tattoos, sitting cross legged in a chair while speaking to a doctor, and attachment to a stuffed animal past the age of 15, are all indicative of axis II issues.
Mental patients, particularly those with personality disorders, do something called "splitting." This basically means that they either really like someone or really dislike someone. As an example, if I really liked the nurse on the night shift, and really disliked the nurse on the day shift, for no apparent reason, this might qualify as splitting. Those lucky enough to bask in the light on the positive side of a split may be showered with compliments. But, this may be short lived, as the splitter can very easily move someone from one category to another. Someone who is wonderful one day, may be terrible the next from the point of view of the splitter. This usually causes problems, because the splitter often complains about certain people on the team, and when the behavior isn't recognized, the splitter may succeed in manipulating those trying to help her.
I was certain that Dr. Mia didn't like me. But I actually can't say that for sure- I do know that I didn't like her. She told me that I shouldn't worry about not returning to medical school, as many people are successful with college degrees. I didn't really NEED to become a doctor. Leaving medical school wouldn't be such a problem. This caused my eyes to fill with tears, and I answered her questions grudgingly, staring at her shoes during our sessions. Would Dr. Mia be happy if her dreams of becoming a doctor evaporated? I wondered bitterly. Her words swirled around my head and I became angrier and more resentful towards her as the days continued. I liked the attending and the medical student. I worried that my obvious dislike of Dr. Mia would be contrasted with my feelings towards the medical student and attending, and that my team would decide I was "splitting."
Patients who split are considered more difficult so I tried valiantly to hide my feelings.
"Splitting" is most notably associated with Borderline Personality Disorder, a label that is often a euphemism for "I don't like this patient." Personality disorders are also called "axis II" disorders. When evaluating the psychiatric patient, a doctor tries to fill each of 5 categories, called the 5 axes. Axis I disorders include Bipolar Disorder, Schizophrenia, and Major Depression, among others. These are generally considered "not the patient's fault" or sometimes "biologically based." Treatment is generally covered by insurance. Axis II disorders include anti social personality disorder, borderline personality disorder, and dependent personality disorder. Axis II disorders are usually considered to be lifelong, and related to a patient's character. Someone with an "Axis II" problem is often considered to be someone with undesirable character traits. Axis II disorders are usually not covered by insurance. Axis III includes any medical problems, such as pneumonia or diabetes. Axis IV includes any social stressors the patient may have. Being a medical student might go in this category. Axis V is denoted by a number, from 1 to 100, which reflects the patient's over all function. A patient who is a 10 is likely confined to a hospital. Someone who scores 100 is able to function in the world.
When a psychiatrist speaks of someone with "axis II issues" he or she usually means someone with "undesirable character traits." I learned in a subsequent psychiatry rotation that tattoos, sitting cross legged in a chair while speaking to a doctor, and attachment to a stuffed animal past the age of 15, are all indicative of axis II issues.
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