Step II COMLEX and USMLE passed I finally received the score from the COMLEX part II today (well, I didn't receive it - it was finally put online where I could view it). I passed, pretty convincingly. On COMLEX step 1, I scored in the 99th percentile nationally. I repeated that performance on step 2. The same for USMLE steps 1 and 2 - with the exception that I scored in about the 94th percentile on both in the nation. Still, very impressive in my opinion.

I'm still waiting on my PE score - which I think will be in about 3 months, but I may be surprised. They told us 10-12 weeks for scores to be released. I don't know what they are waiting for. They should have the score almost that day, except our progress notes, which they scan and send to various parts of the country to be graded by actual physicians. The rest of the exam is graded by the lay performers who are paid to act like they are sick.

Wonderful system, huh? Physicians being graded by people with no medical knowledge. Sounds like we're asking for trouble...
  ¶ 10:23:00 PM 0 comments

  COMLEX PE As threatened, I took the physical examination portion of my medical board exams today - the COMLEX PE (Comprehensive Osteopathic Medical Licensing EXam) Physical Exam. Ever since I first heard we were going to be required to take this exam nearly 3 years ago, I have been (usually quite vehemently) opposed to it. When the president of the AOA (American Osteopathic Association) came to our school to "answer questions" (read: tell us what he wants us to know and avoid answering any questions we might ask), I was there asking what was the need for this exam when the schools test us on the exact same things that were to be tested on this exam.

The reasons we were given is that there was a "public outcry"to the schools of medicine to prove that their graduates are adequately trained to talk to patients and take medical histories and perform physical exams. This test has been around for years - it was previously administered only to foreign medical graduates who wished to enter residency training in this country, and it was called the Clinical Skills Assessment (CSA). Everyone knew the exam basically tested proficiency in spoken English language and had very little to do with actual clinical skills. This is one reason I opposed the exam - everyone graduating from a US medical school already has demonstrated English proficiency and does not need to be tested on their English language skills.

So, the arms on the clock have turned enough times that I have now taken this exam. Still, I claim it is a waste of time and a very large amount of money. The exam charge is $995.00, which is outrageous enough until one considers the exam is administered in only one place in the US - Conshohocken, Pennsylvania. This means that all 4th year students from all Osteopathic medical schools must travel to this one site and take the exam. Travel and lodging is not included in the exam fee, nor was it included in my loan disbursement. I was told that I would need to "budget carefully" to allow extra money to travel to the site and stay in a hotel (for an average of $150 per night) while there. All this to take a test that has not been proven to be necessary by any study or even common sense.

Needless to say, I'm a bit pissed. I'm even more angry after having taken the exam. It was poorly designed, poorly run, and I assume will be poorly scored. From what I understand, something on the order of 96% of exam-takers pass the test, if not more. This means that basically, I could have gone up there, given the NBOME my $1000 and (statistically) walked back out without having to waste a whole day taking this ridiculous exam.

Why is it poorly designed? Let me explain: The exam uses Standardized Patients (SPs) as their subjects. They are "extensively trained" to perfectly emulate whatever condition they are supposed to "have." They use a series of tricks to try to emulate physical exam findings - none of which are particularly successful or accurate. For instance, if one is trying to elicit reflexes and they want to show them to be decreased, they will contract their muscle as you strike the tendon, thereby diminishing the visible reflex. On the other hand, if they want to show hyperactive reflexes, they will exaggeratedly flex the muscle after the tendon is struck. These two are the most believable methods they use to fake physical exam findings. Others they use is saying "Hush, Hush" while you listen to their heart to fake a murmur, moving their chest wall and not actually breathing to emulate decreased breath sounds, whistling to emulate wheezes, and more.

The problem with these maneuvers is that they are not realistic, and they are frequently inaccurate. For instance, on several patients, I thought they were trying to emulate "crackles" in their lungs, but I could not tell what it was they were trying to do, since I had no idea what their "trick" for making crackles is. Maybe they were trying to emulate "crackles," but maybe they are just coarse breathers. I couldn't tell. All I know is that it didn't sound like any crackles I'd ever heard before.

I suppose we'll see how it all turns out in the end. I'm expecting my Pass/Fail score sometime in January 2006. I expect to have passed, but I really think it's a toss-up. I could have flipped a coin at the front desk and had just as good a feeling about the outcome of the exam as I do now. Funny for someone who always as people remark to him how good his clinical skills are, eh?
  ¶ 9:54:00 PM 0 comments

  Another night on call This is now my third call night - and the second with my current intern.

A few things have changed since my last call - we have a new attending, who everyone said was very hard-nosed and would chew you out for nothing. On the contrary, I have found her to be quite amiable and easy-going. This was a great relief, since our first day with this attending was after my second call. I was having palpitations at the thought of having to present all my patients to her from memory, since she does not like notes being used for presentations.

Anyway, aside from that big change, Ashleigh is now on my team. That means we are on call together - and also that we had Saturday off together. What did we do with our awesome time off? Well, we got rained on... a lot. It dumped about 6 inches of rain on us on Saturday, causing so much flooding it shut down many of the highways and flooded most of the major rivers in southeast Pennsylvania! The good news is that we left early enough in the morning that everything was not completely flooded and we got back just before they shut all the roads down.

We left at about 1130 to go to King of Prussia, Pennsylvania to their HUGE MONSTROUS mall. The mall is so big, it is two buildings!! Something like 400+ shops and restaurants are housed within this monstrous complex. It was freaking HUMONGOUS!! Other than that, I wasn't too impressed. I got to spend some time with Ashleigh, so that was nice, but I'm not a big mall person. Obviously, she is.

So, after my (almost) eventful day on Saturday, now it is Sunday (or by the time I'm done typing this, Monday) and I'm on call. So far, I've had one admission and one consult. The great thing about having Ashleigh on the team is that now we split the admissions :) That's ok - Ashleigh has only seen one consult and no admissions thus far. In fact, as I type this, she is asleep in the call room - hopefully for the rest of the night. I'm hoping we're done (knock on wood) for the evening.

The final BIG change that's happened in the past few days is that with the new attending came new rules. Since Ashleigh and I are 4th year medical students, we're now being treated more like interns - we are seeing our own patients (mostly) independently, writing their notes and their orders and having them co-signed by the intern. Our intern loves it, since he doesn't have to do much, aside from make sure we don't kill anyone :) Just kidding. I think we're doing pretty well for ourselves here.

Ok, I should probably go to bed soon, so I can be fresh and chipper in the morning for rounds bright and early.  ¶ 11:48:00 PM 0 comments

  Just as predicted... Well, just as I predicted, that fellow I spoke about in my last post left AMA after he sobered up in the morning - and of course, after breakfast!!  ¶ 3:47:00 PM 0 comments

  Week 2 I had call saturday, 10/1/05. It was a very long day. I got there at 0700, as is my usual custom. However, I am not used to being in the hospital all day long, all night long until the next morning.

The good thing was that we weren't that busy. We got 2 admissions, a transfer from the unit, and a consult or two. Not too bad. However, things move very slowly here. Maybe it's just me not being used to the system, but all the admissions took about twice as long as they should have - an admission for chest pain took 2 hours because as myself and the intern finished talking to the patient, the upper level came in and wanted to pretty much repeat everything we had already done. It didn't help that the patient was, how do I say, less than cooperative...

Let me share: This was a 48 year old homeless fellow that looked 80. He was picked up at a bar after complaining of chest pain. He had a history of a quadruple bypass surgery about one month ago at the other local hospital here in Bethlehem. He had been admitted here at St. Luke's 2 weeks ago with the same complaint (Chest pain and EtOH intoxication) and left against medical advice (AMA) 2 days into the admission. So, now he's back after being seen at that same other hospital 2 days ago and earlier tonight. The fun part of the story is that when he got to the ED, his blood alcohol level was 198. However, about 3 hours into his visit, he was caught with a mostly-empty bottle of vodka in his room and his blood alcohol level was 218.. pretty impressive, huh? He was also very belligerent, yelling profanities and telling us all to "stop wasting my fucking time!!" as he asked to go out and smoke.

Fortunately, we were able to convince him to stay (mainly by letting him go to sleep) and we admitted him with the full knowledge that after he 'slept it off' he would most likely sign out AMA again. Unfortunately, that is the way of the world - we have to admit them because should we not we would be at fault, but we can't make them take responsibility for their health. So someone like this guy gets to take advantage of the system for a warm bed and a night sleep with a couple of meals any time he feels because he says he has chest pain.

Our system needs an overhaul to prevent stuff like this happening. Ah, well. Such is life. Without people like this, medicine would be boring, right?  ¶ 5:18:00 PM 0 comments