March 20, 2013

Last day of preclinicals… and the general overview of medical school

It’s kind of surreal, but it’s here.  Today was the last day of our pre-clinical years – the last day we will be sitting together in the same classroom, listening to lecturers and seeing the same faces every day.  Technically yesterday was our last day of real lecture – today was just a couple of review sessions before our very last test in this building.  It’s hard to believe that this is it… the culmination of 2 years in medical school.

For those who don’t know, medical school is divided into 2 “sections”, if you will.  The first two years are called “preclinical” years because, as the name implies, it is what you learn before entering the 2nd half, which are your “clinical” years.  Preclinical years are where you spend every day in lectures or small group discussions on medical cases, and you do all your basic science and medical learning.  It includes courses on things like anatomy, physiology, biochemistry, microbiology, etc, as well as organ systems like our school uses, so going through cardio (the heart), respiratory (lungs), GI (bowel stuff and all organs in the abdominal area), renal (kidneys), musculoskeletal (muscles and bones), neurology (brain), hematology/oncology (blood and blood-related cancers/diseases), endocrine (hormones), and the last one we are just finishing up, reproduction (gonads and related diseases).

After this and before entering the clinics, we all have to pass what is called the Step 1 of the USMLE Board Exams (or Step 1 for short).  This is what is going to take up my life for the next two months or so.  The Step 1 is like the MCAT, but probably 100x harder.  It’s made up mainly of clinical vignettes, or short clinical scenarios, that you have to decipher to get at the right answer.  It’s also usually formatted in a “2-step” manner – meaning, they could give you a long story about a patient, but instead of just asking you what the patient has (which would be a 1-step thought process), they would ask something like “what is the genetic mutation most likely associated with this?” or “What other conditions are commonly associated with this?”  So you not only need to be able to recognize what the problem is, but you also need to know all the other random facts associated with it.  On top of just the difficulty of the exam is the fact that for many specialties, especially competitive ones, this is a key determinant to whether or not you will get interviewed, or even if the rest of your application will be looked at.  So in a sense, your Step 1 score will determine what specialties you can feasibly apply for.  Just passing isn’t nearly good enough, especially with the fact that the numbers of medical students are currently increasing, but the residency cap is still in place and thus residency spots are getting relatively more and more limited.  Pretty intimidating huh?

Assuming you pass Step 1, you then move into the clinics for 3rd and 4th year.  The clinical years are basically when medical students really get their feet wet on working in the hospital and being part of the medical team.   3rd and 4th year medical students are the ones who get spend the most time with patients and writing up reports and presenting them to the residents (post-med school trainees) and attendings (who I think of as the “real” doctors).  I think there are core clerkships you need to take, like medicine, surgery, OB/GYN, etc, after which you now need to take national standardized exams called  and then there are electives that you can choose from if you’re interested in them, which include more of the specialized topics, such as anesthesiology, dermatology, orthopaedics, etc.  There’s a lot more specialties than there are rotations for electives, so you need to be thinking about which to choose early.  At the end of 4th year, you take Step 2 of the Boards (which has 2 parts – a knowledge portion (CK) which is like a regular test, and a skills portion (CS) which tests your clinical skills with simulated patients.  You also apply for residencies that year.  After getting into residency, in the first year, you are called an intern, and the following years, you become a resident.  That’s as far as I understand it anyway 😛

As MSTP, it’s a little different for us.  Most schools follow the same schedule we do, which is first two years as preclinical years, then take Step 1, then enter our labs/PhD programs, defend our thesis and earn a PhD, and then go back to medical school to finish our last 2 years in the clinics.  We’ve recently changed it so that 2nd years have the option to do a family medicine elective rotation first before entering the labs, which I think is a good idea because we’ll be coming fresh off of Step 1 and will be able to apply some of our clinical knowledge before going off to a different world for 4 years or so.  The last two years of MSTP’s here have said they it was a good experience as well, so I’m looking forward to it.  Part of the reason for this change was apparently because some residencies, like those in California, require a family medicine rotation before applying, so that’s something to note.  We also only have 1.5 years to finish our 3rd/4th years for some reason, which is another reason why it’s good to get that rotation in early.

Anyway, hopefully that was informative, or at least wasn’t too boring or redundant (I vaguely remember posting something briefly about how the MSTP schedule works out sometime last year or so…)  Sorry if I did end up repeating myself, although I think I understand clinical stuff a bit better now.

Ah, I’m going to miss the people in my class.  As an MSTP, we’re already going to be pretty disconnected with our classmates to begin with, but now also around 1/3 of our class are going off to branch campuses, so it’ll be even harder for me to see them around.  :\  I have heard that the hardest for MSTP’s  is when Match Day comes in 4th year for our respective classes, where everyone finds out where they’re going to go, and everyone we knew in med school will really be gone and scattered around the nation.  I’m slightly depressed already thinking about it, haha.  Ah well, it’s been a good two years.  Best of luck on Step 1 everyone!

March 11, 2013

Random thought of the day: Hospital sanitation/hand-washing

My friend and I somehow got on the topic of Ebola and spread of infection today, and naturally thus fell into talking about  the importance of handwashing.  This has been a big deal in our training so far, in the sense that we’re told to always wash our hands first thing when going in to see a patient (and we are marked off for it in our clinical-based tests in ICM if we don’t).  However, this does not necessarily seem to hold true in practice.  I’ve definitely seen providers in the hospital/clinics being pretty casual about handwashing, and not wiping off their stethoscopes after each patient, and not washing their white coats much.  I myself haven’t either (but I also take much more care than most in not touching anything with my white coat and never sitting on anything in the hospital with it because I’m slightly paranoid with that haha).

Anyway, recently, the clinic we both go to for our personal health has started a new program where they give every patient a paper that asks everyone to mark whether each healthcare giver that saw them washed/sanitized their hands before proceeding with the check-up/procedure.  On my last visit, the technician did.  However, my friend’s story was pretty interesting… and maybe a bit alarming if you think about the implications.

It was pretty impressive how he found it out too – a little bit of sleuth work there haha.  But basically, when the nurse came in to see him, she pumped at the hand sanitizer (antibacterial gel) dispenser and rubbed her hands together when she came in.  He then waved the paper at her cheerily and told her he was checking off that she had washed her hands before talking with him.  She then responded with “Yeah, gotta make sure to get that handwashing in!”  or some such thing.  Then when she put her hand on his arm to put on the blood pressure cuff, he noticed that her hand didn’t feel like it should after being rubbed with the alcohol-based gel.  So when she left, he pumped the dispenser to check.  It was completely empty.

I think the part that bothered me most wasn’t the fact that the dispenser was empty, or even that she hadn’t sanitized her hands (although that in itself is a pretty bad thing – most infections in hospitals are actually spread for that very reason – because nurses, doctors, and other healthcare providers don’t wash their hands).  The worst part of that was her attitude – that it was ok, and that it was so ok she could lie to her patients by faking the handwashing and even lying/acknowledging that she did it verbally when it was pointed out to her attention.

That got me thinking.  It would be a really interesting study to empty out all the hand sanitizer dispensers that are conveniently located at/near patient rooms and see what happens. Maybe have cameras over the sinks and see how many times people actually wash their hands in the sinks.  See how long it takes before someone reports that they are empty.  And see how many people actually report it (and how long it takes for a significant portion, or all, people to report it).  Surely it would become a nuisance if their daily routine was interrupted by having to wash their hands before each patient instead of using the convenient hand sanitizers.  Surely the sinks would become crowded or at least people would frequent them much more often.  Surely, surely, especially since we all “know” that handwashing is so important to prevent infections.

But if the way that nurse acted was any indication, perhaps people would not be that careful after all.  Perhaps people would find washing hands so much to be bothersome, and would skip a few in between without washing.  It would be an interesting psychological experiment.  And then it would certainly be interesting to do an outcomes study out of that as well – to see whether or not the number of nosocomial (a fancy doctor’s way of saying “hospital-transmitted”) infections increase significantly during that time period.

I really wonder what the results would be.  What do you guys think with what you’ve experienced?  Hopefully I’m not being too harsh on the healthcare providers here and elsewhere.  At any rate, I think I may have inadvertently helped given my friend a new idea of what he could do with his degree/life with this discussion (health policy), so for that I’m glad 🙂

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