The Differential: Medscape Med Students Blogs

Enough Whining About Primary Care

Colin Son -- My student loans are forcing me to contribute to the primary care crisis. And with that facetious remark, I initiate a rather controversial discussion.

Let me be clear that I’m a firm believer that primary care is in a crisis in America. There is no doubt that U.S. medical graduates are choosing to go into primary care at rates lower than in previous years.

Many primary care physicians believe that the main factors influencing this trend are primary care’s comparatively poor earning potential plus students' rising educational debt. I’ll be quite frank, I’m profoundly annoyed by this essentially unsubstantiated claim. And it is a persistent claim, even around the medical blogosphere.

It is so pervasive that it has become accepted as fact. What is a little depressing is that these are physicians leaping to this conclusion -- physicians trained to look for evidence of causality. No matter how obvious the association between student debt and specialty selection may seem, the causality simply is not there in the sum of the evidence.

In September, JAMA published a research letter by family physician Mark Ebell. It was a near repeat of a study he had done in 1989 (Ebell M. Choice of specialty: it's money that matters in the USA. 1989;262:1630). In both cases, Dr. Ebell found a statistically significant correlation between a specialty’s median income and its percentage of residency spots filled by U.S. medical grads.

Talk about circumstantial. To draw the conclusion that debt is influencing specialty choice from such removed observations is dangerous. And yet, that is what some have done. One of my favorite medical bloggers over at Medrants was certainly guilty of such in a post on Dr. Ebell’s publication: duh - money matters in specialty selection. MedPageToday, a major online medical news outlet, also gave the study’s conclusions some credence.

My point isn’t to disparage the JAMA study. But the way it was held aloft, despite its obvious leap in conclusion, is a sign of the more systemic problem.

A cursory literature search reveals that few other studies have found student debt to be a statistically significant factor in specialty selection. In the same issue of JAMA that carried Dr. Ebell's study, another study failed to find that connection for general internal medicine. Other evidence to consider: a huge study published in 1999 in the Journal of General Internal Medicine found that, over more than three decades, indebtedness was never a statistically significant factor for female medical students in choosing primary care versus a medical specialty; a 2006 survey published on Medscape General Medicine found that students' debt level did not significantly influence their specialty choice; and, the June 2006 edition of Minnesota Medicine included a study done by a fourth-year medical student that showed the debt burden of students at the University of Minnesota’s main campus did not significantly influence career choice.

I’m not trying to present this as a comprehensive look at the data. But it is representative. I stand by my claim that the sum of the evidence favors the conclusion that medical students are largely not picking their specialty based on their debt load.

In fact, becoming a primary care physician remains a good investment compared with most other career options, even with an average indebtedness of $140,000 for students with debt. Yes, you lose some years during training when you could have been saving and investing. Educational debt means devoting more of your income towards paying off loans and less towards something more meaningful like retirement. Those factors certainly add up, but not to the extent some physicians make it out to be. The choice of specialty has never been simply, largely influenced by debt or future earning potential. It has always been multi-etiological.

That's certainly true for me. I came to medical school thinking I wanted to enter a field where I could work with my hands. But any thought of primary care died when I entered my clinical years in medical school. In my experience, I met only one happy primary care physician. If I were to listen to all the primary care physicians I know, or who I read in journals and online, I would think it was the apocalypse for primary care.

Granted, there are problems with America's lack of focus on improving primary care. But do they warrant the state of fear being spread by the primary care community? Why would any medical student want to enter such a downtrodden, depressing community?

I rarely hear about the rewards of a primary care career these days. Yet despite the widening income gap between primary care and specialists, and the horde of patients each primary care physician is expected to see, there must be some good left in practicing as a primary care physician. I think we need to start talking about that and do less externalizing of the reasons why medical students aren't choosing primary care.

The privilege of practicing medicine should be cheered and cherished. This whining about the state of primary care and medicine in general are just too much for me to take. I’m going to sit back and marvel at the career of caring for patients that stretches out in front of me.

Will a New President Affect Medical Education?

Colin Son -- In case you somehow missed it, a month ago the United States elected a new President. I’ll spare you my personal politics except to say I’m smiling. I will point out the obvious: it appears we are in for a little bit of a change in this country.

What that might mean for health care is a matter of some contention. Major health care reform is undoubtedly expensive, and the current economic climate may make such reform difficult. At least in one jump. Not that Obama's health care plan is comprehensive; it lacks any serious discussion of how his dream reforms would control rising health care costs.

What I’m interested in right now, however, is what an Obama presidency may mean for medical education. Admittedly, a new president is likely to have less of an immediate impact on how physicians are educated than on how health care is delivered to patients. But there are some things that may change, especially concerning how medical students finance their education.

U.S. physicians earn more than their counterparts just about anywhere else in the western world. But many trainees have to take on substantial debt: nearly $140,000 for the average American medical graduate. The burden of repayment over many years with interest can be substantial, especially early after graduation when newly minted physicians are serving as residents. In addition, medical student debt may be affecting health care in the United States, as circumstantial evidence suggests that increasing debt loads are pushing students away from primary care careers.

Last year in the reauthorization of the Higher Education Act, the federal government eliminated the 20/220 economic hardship deferment for residents, which had allowed them to defer a large portion of their federally guaranteed loans for most of their residency, until they were earning substantially more as fully practicing doctors. While Obama hasn’t commented on the 20/220 deferment, and the HEA isn’t up for reauthorization any time soon, I feel safe in declaring that the potential for new advantageous repayment options is substantially better under the incoming administration than under the current one.

Obama may also need to consider longer term changes to how we finance medical education. His health care plan stays away from calling for a single payer system, but it limits the long-term viability of private insurers and potentially brings federally run "insurance" plans in direct competition with them. While a near future without private health insurers is not inevitable, it certainly isn’t unreasonable to imagine either.

In a single payer system, it would be difficult for the physician lobby and their legislator allies to maintain physician reimbursements at their current levels. In other places, global budget systems have done much to lower health care costs, including physician practice costs, so bringing physician earnings more in line with the rest of the world may not be the catastrophe that some physicians make it out to be.

What would have to happen in such an admittedly hypothetical world, however, is that the cost of medical education would have to decline significantly. If physicians are to earn less, it must cost substantially less for them to be trained.

President-elect Obama has many big issues on his plate as he comes into office. The expectations are incredible, and I don’t doubt that health care reform will get its time. Let us just hope that medical education gets its time as well.

Finding Out What You Want to Do

Colin Son -- I’m a fourth year student in the United States trying to get into a residency for next year. The interview trail is going reasonably well. I’ve managed to avoid being "pimped" on clinical questions and have been faced with only a few "difficult" questions -- the latter being those that exist merely to test your reaction under stress and your ability to think on your feet.

For the most part, my interviews have been congenial if not down right fun. And they should be that way as far as I’m concerned. I’m still not quite clear what a program truly gets when a faculty member makes an interview a minefield. This is a two way street, with the residencies evaluating the students and the students doing the same in turn. As one fellow interviewee said on the trail, "Heck, if they make the interview a pain… I won’t rank’em very high."

It is a little wearing answering the same questions over and over. One of the most difficult things is actually asking questions of your interviewers with some sincerity. And yet over and over, you ask the same questions of different faculty just to make it appear as if you have an interest and just to keep the conversation going. I’ll admit though, at times it is good to compare different people’s answers to the same question. I’ve found I’m running into a groove where I ask the same three or four questions at every interview, unless there is something really specific to the faculty or the program that hasn’t been addressed.

I’m sure the faculty get the same faraway glint in their eyes as the interview season drags on. So many applicants must look the same on paper, must give the same answers to the same questions, must have the same suits. But I’ll give myself some credit; my application has some unusual elements. Notable is my considerable political and health care policy experience and, maybe an even bigger conversation jumpstart, my time in film school. If nothing else, it allows me and my interviewers to talk about something different.

I’m also trying to keep my answers to typical questions lively and interesting. For example, I’ve been giving a lot of thought to the question that keeps popping up: "What would you do if you couldn’t be a physician?"

Here is what I have so far:

1. Writer/Filmmaker

I’m a writer at heart. If I had had the stamina to wait tables for five years, trying to break into the industry, I may never have even discovered my love of medicine. The ideal situation would be to make it as a writer, not limiting myself to just film and television, and then be able to pick and choose my own work to get behind the camera and direct. The beautiful thing about writing is you can do it from anywhere. I would love to be a world traveler. I wish I was writing at some Dublin pub right now.

2. Poker Player

A gambler is just what patients want in their surgeon. What can I say though, I love the card table. At least I’m not a craps player. There is some talent with a good game of hold’em. In fact, poker rewards some qualities you would want in a physician -- especially in a surgeon and more especially in a neurosurgeon. Despite what you see on edited televised tournaments, poker is often a game of considerable patience. A fine quality when a brain surgeon is spending eight hours delicately taking out a tumor. Poker also requires considerable nerves, which might not be a bad thing in the operating room. Amongst the best players it also requires an ability to remain calm; to take a “bad beat” as they say without going “on tilt.” I imagine that is what I would want of my surgeon, when something doesn’t go right in surgery.

3. King of England

I’ve got to throw something a little eccentric on the list. But seriously, to be part of one of the most storied families in the world would be an interesting experience. The thing that makes it attractive is to be able to live the lifestyle of the royal family while being able to devote your entire live to civic causes. No one doubts that Prince Charles, whatever you think of him personally, has raised the profile of key world issues. And the Princess, rest her soul, was a great humanitarian.

4. Ski Instructor

I have never met anyone with any skill on the slopes who didn’t dream of being able to fund their life by being a ski instructor. Granted, I imagine that teaching people to ski can get frustrating at times. The ideal situation would be to get paid for simply heading down the slopes yourself. Maybe instead of an instructor I could be a rescue skier or something like that, and help injured skiers down off the mountain. The important thing is to be on the mountain and be skiing. However it works, it is a dream job of mine.

5. Taxi Driver

I like driving. It really is as simple as that. If I could get paid reasonably well, then I would do it. I am, at times, a type A driver. But, I handle traffic very well and even clueless drivers; it’s only when I perceive that others are inconsiderate drivers that I get pretty peeved off and seem to compensate by driving pretty aggressively around them. I’m not sure what I would do if I moved to a cold environment for residency and had to sell my rear-wheel-drive convertible. I’m sure I’d manage; it would be a small sacrifice for training to do what I wanted to do for the rest of my life.

Anyway, any serious or non-sensical comments on how to make oneself endearing and interesting in an interview are welcome. I know that the interview process gets mundane for the interviewers as quickly, if not quicker, than it does for the interviewees.

And now, I’m off to yet another interview. Wish me well.

The Single Greatest Advance in Human History

Colin Son -- I have really neat handwriting. In fact, if I dotted my ‘i’s with little hearts, you’d mistake me for a fourteen-year-old girl. Per the mythos of the profession, my handwriting should probably prohibit me from being a physician.

But not for much longer, hopefully. The days of pharmacists translating the hieroglyphics of some physician’s handwritten prescription or of illegible clinic notes should be over. Indeed, where I come from they already are, but unfortunately, not where I’ve been.

As I’ve written about in previous posts, I’m on back-to-back, month-long away rotations. Before these rotations I had never seen a paper chart in a hospital. And now I have a new found respect for the benefits of computer based medical records.

The time for full fledged electronic medical records has come. Hell, it has been here for a while. It’s just that many places haven’t gotten clued in yet apparently.

Let me be clear, I’m not arguing for some mandate for every private physician to stick an EMR system in their office. But, for large tertiary hospitals to still be using paper charts is absurd, what with the clear benefits of well designed EMR systems. It is shameful, and I don’t use that word lightly, for the health care systems I’ve rotated through recently to still be using paper charts.

I know that paper records have worked well for a long stretch of modern medicine. Ether had a nice run as well in the operating theatre. But the benefits of electronic medical records are undeniable, and I won’t even fancy a discussion with anyone who denies such.

Let me count the problems with paper records.

First, you can’t read them. I don’t know how many times I’ve had to call consulting services because you couldn’t read their notes. And who knows how many times others have had to make that call?

Second, the record is with the patient. For instance, you go to drop a note on a patient or check the patient’s recent vitals and discover that some other service has taken the patient to surgery early and the chart along with him.

Third, there is only one copy of the chart. A physical therapist can hold onto a chart for a long time, let me tell you. Health care has become so specialized, and every consulting provider needs their time with the patient’s chart. It can become a major hassle searching for the patient’s chart you need.

Fourth, you have to chart in geographic proximity to the patient. Imagine being on a floor housing many patients with polytrauma. Imagine all the services involved in those patients' care, with attendings and residents and students plus the hospital staff. Even in relatively modern facilities, there is often not enough physical room for everyone to flip open a big, bulky patient chart on a countertop or desk.

There are plenty more arguments but those outline my complaints against hard charts. And EMR solves them almost in full. In fact, this is more than a matter of convenience and efficiency, it is a matter of patient safety as well.

To be fair, EMR systems have a set of problems of their own. For instance, automation can breed complacency. In many computer based charting systems you can set up templates for notes. Then you have to wonder, is a note accurate or did the physician just forget to edit his standard template?

But EMRs bring so much to the table. Many of them warn physicians about conflicting orders (say, drug-drug interactions) or question unusual orders (say, accidentally prescribing too much of a medication). No longer is there a question about the plan of care for a particular patient. Every service can actually read every note from any computer in the hospital and often even from home.

I don’t buy the pragmatic arguments against EMRs. They tend to revolve around costs or physician opposition to change. I am hard pressed to imagine a lack of funds for an EMR system at any of the hospitals where I recently rotated, and they all are undervaluing the benefits… no matter the cost.

This is an important issue. So much so that it is very high on my checklist of things I’m looking for when I hit the residency interview trail. I’m not kidding. While it is one amongst many considerations, I feel strongly that I want to be at a program whose primary teaching sites have integrated electronic medical records.

Nowadays, it simply is an important part of patient care.

Hot on the Interview Trail

Colin Son -- I have my first interview for residency coming up.

The program where I’m doing an away rotation is going to interview me while I’m here. There are reasons to not want to do an interview while you’re actually on a rotation. For instance, when I make an ass of myself, I won’t be able to hop on a plane and never see those attendings again. Instead I have to stick around and take call with them.

In seriousness though, interviewing while on a sub-I sets you apart from the other interviewees. That has some potential benefits and some potential pitfalls.

The benefits include the fact that this is good place to be starting my interview trail. Pending a few beers, interviews can stir a few nerves for most, including myself. The good thing is I’ll probably be more comfortable starting on interviews here than anywhere else. I have enjoyed myself on this rotation and I am interested in this program, so there is something at stake. I’m also, however, comfortable with the attendings I’ll be interviewing with. It certainly is more than a "practice" interview, but it is nice to have some familiarity and camaraderie with those who will be pitching questions to me.

I might need that for my first residency interview. On my first interview for medical school, I got the following question:

“What is your biggest strength?”

“Well, I think I’m pretty decisive. I’m pretty quick on my feet.”

The next question was obvious:

“What is your biggest weakness?”

An awkward ten second silence followed which prompted the interviewer to comment:

“Let’s just move on.”

Quick on my feet like a fox. I had composed and practiced an answer to that obvious question but in that moment of stress I could not, for the life of me, remember it.

It’s hard to defend myself as a skilled conversationalist and interviewee after revealing that gaffe, but I’ll try. It just takes me some warm-up laps. I promise that I did get better (much better) on the interview trail as my medical school interviews went on.

One thing I always have to work on before I head into the interview are what questions I’m going to ask the interviewer when I get my chance. Often, especially in a situation like this where I’ve gotten to know the program for the past three weeks, I feel like asking nothing. But that is obviously poor form.

If I draw an interview with a female attending, I’m thinking:

“What are you doing this Saturday night?”

I’m also thinking about some questions I may get. Such as,

“Who are your role models?”

The answer is obvious,

“Gregory House…MD”

Personally I can’t wait until I’m actually "pimped" during an interview. Maybe they’ll show me some MRIs and I can pretend I’m taking a Rorschach test.

“I see a monkey drinking a beer,” I’ll say. “Or maybe a sagittal MRI of the brain showing a small posterior fossa and tonsilar herniation below the foramen, indicative of a Chiari malformation. We also see associated agenesis of the corpus callosum.”

Or maybe I’ll be asked to actually tie a suture while answering questions. The end result:

A beautiful bow tie, which I’m pretty sure is how you throw a surgeon’s knot.

When they ask me what my talents are, I’ll tell them MS Paint and offer to email them a portfolio of my work. That should move me up the program's rank list.

Taking a step back and a deep breath, I attribute my goofiness to nerves (and caffeine), and I’m really just using this post to get it out now before I actually hit the interview trail. Wish me luck and that I avoid all of the above as I head off for interviews.

When Does Fourth Year Slow Down?

Colin Son -- The myth is that the fourth year of medical school here in the United States is a time to kick back and take in the future, maybe with a margarita by the pool. You’ve come through a time-consuming third year and your application for residency is set and eventually you reach a point in the year where you can just relax. That is sometime after interviews come and Match Day is approaching.

I’m wondering when that day might be. The horizon does not look all too clear, at least in terms of my schedule. I want to go into a specialty that is relatively competitive and it has clouded the "ideal" of the fourth year.

In my first three months I will have done two away rotations, and sub-Is are typically brutal, at least in terms of the hours put in. I’m in my second sub-I right now and within days of finishing I will go on my first interview for residency. I will be gone almost half of the month of November on interviews. December and January get a little better as my schedule now stands, but interview invites are still coming. Considering I want to give myself the best shot possible to match, I’m considering going on twenty interviews, although I’m continually told that will be difficult and I’ll get exhausted and run out of money before I make it to that many.

Whatever the case, I really didn’t consider how much time so many interviews would take up. I have already rearranged my schedule to take November, December, and half of January off just so I can work in that many interviews without interrupting an actual rotation. In February, when interview season is over, I go abroad to do an international rotation. Granted, that is a personal choice but still is far from a vacation.

My school has mandatory didactics for fourth years during March. Those are supposedly an easy time, but unfortunately, it means I cannot schedule a rotation during that time. With my schedule as it is I will still owe my school a mandatory home outpatient rotation in order to graduate. The only time it works in is during April. That is the last month I will be in school. To be taking a required rotation the last month of medical school is a little unheard of. In fact, I may have to beg to try to get it because they typically don’t let students do those rotations in April. There are a couple of reasons I can think of:

First, what if something went wrong and you got sick and couldn’t complete the required rotation? There would be no time to make it up.

Second, and most importantly, you’ve already matched. You can imagine that the effort put into a rotation post-Match Day may be a little haphazard.

Granted, I get some time from May to June. And I intend to take advantage of it. But my fourth year schedule is a little more hectic that I imagined it would be when I was a first year dreaming of the future.

Let me be clear, I know the next six or seven years of my life will be a whirlwind and I’m not really complaining about my fourth year schedule (okay, maybe a little) except that it is unexpected. Fourth year was supposed to be a little more laid back before you entered the rest of your life.

Oh well.

Discussing Burr Holes Over Pizza

Colin Son -- It is easy to get consumed in the world of medicine while in medical school. Back home, the boys and girls I study with, go out for drinks with, sit and watch the football game with are all fellow medical students. That may be especially true, such as in my case, if your family is composed of healthcare professionals as well. Even a phone conversation with my mother is likely to devolve into talk of patients in her intensive care unit or on my current service.

It becomes second nature.

I am currently, however, out in Los Angeles, hanging out with old college friends who have become investment bankers or construction managers or sports reporters. Old college friends who, for good reason, don’t know a meningioma from someone’s spleen. And I’ve found that I’m lapsing into an age-old healthcare professional sin of talking about bodily functions and diseases and other things I take for granted everyday in the hospital and which, I easily forget apparently, are not so polite out in the real world.

It is interesting how acclimated medical students, nurses, physicians and other healthcare workers get to the human body. Yet even something as non-graphic as describing a Burr hole, drilling into a patient’s head, draws squeamish responses from many outside the healthcare sector. Especially over a deep dish pizza.

It is a tough corner to be put in. Often times my adventures, and I use the term loosely, in the hospital become the center of conversation; especially when I’m with a group of friends who are not involved in healthcare. There is something still mythical and fascinating about the practice of medicine. Especially surgery. Especially neurosurgery. And yet you tip-toe a line of maintaining interest and being polite.

So, I’ve gotten better over the past month at choosing my words, even when what I want to say is the most fascinating and interesting thing I’ve ever seen in the operating room.

Something a little odd has happened as well, though. The observation of the above has, in a small way, renewed my respect for the practice of medicine. It has been my stated goal to never cease to be fascinated by whatever specialty I choose. While I admit that a little acclimatization is inevitable, I hope I never lose at least some wonderment staring at someone’s brain, the seat of their soul -- no matter how many cranis I am a part of performing. And watching the interest, even in the form of a little disgust, from my friends who are not neck deep in the study of medicine has reminded me of what a gift it is to see and be a part of what I am, even if it sometimes from the periphery as a medical student.

Sometimes it is just difficult to capture that for people who are not there to see it in person, without making them think twice about what they’re eating. I’m working on it, though… at least as long as I’m out here in Los Angeles.

Tough Decision

Colin Son -- I’ve been away from blogging for a week. Away rotations will do that. Away rotations will also put you in tough positions at times.

For a recap, I want to do a pretty competitive surgical subspecialty and I’m doing two months of sub-i rotations at away institutions. Right now I’m out in Los Angeles. There are unique and inherent challenges with an away rotation. Moving into a new health care system, with unique ways of doing things, and honing in on some sort of rhythm on a pretty quick timeline is a challenge.

Not all of the challenges are inherent. Some are self created.

I got back today from a wedding. I was in the wedding and it was important that I was there. I love the bride and groom and I wouldn’t have missed the wedding short of an emergency. Taking time off from an away sub-I, however, is nothing short of taboo. The program I’m at right now was very polite and didn’t call me out when I asked for the weekend off, but I know that flying to Georgia this weekend leaves a bad impression. There are many goals of an away rotation but it is arguable that the most important is to demonstrate your work ethic and stamina. Taking time off is a little contradictory to that goal.

I realized that, but after weighing that and my dream of matching this March versus my commitment to some of my closest friends and their wedding, I made my decision.

I was lucky in the way the situation was handled. If I failed to impress my away rotation program, at the least they were polite and understanding about my decision. That might be a bad way to describe it. What I mean is that they weren’t confrontational or upset.

I knew that this wedding was coming for six months, but I don’t buy the argument that if I have a weekend commitment I know about, that it is somehow rude to the away rotation program to schedule a rotation during that period.

Let us not forget, if my goal is to impress, the main goal of the away rotation program should still be to serve as an educational experience for the visiting student. Hard to believe my brief time off hurt my educational experience.

No need to get offended, even for something as taboo as a visiting student asking for time off.

There is another argument I’ve heard around that I’m taking an opportunity away from another visiting student. If I know I’m going to do something unsavory for my chances of impressing and since there are a limited number of visiting student spots, that I should give up a spot to someone else. Maybe. In this case, my away rotation has fewer visiting students than available spots right now. So no one is missing out.

Bad form or not, I have no regrets. And by the way, the wedding was awesome and I have never been happier for the bride and groom.

I’d Like to Do A Little More Than Survive

Colin Son -- I’ve heard some bad stories of students on Sub-Is. These fourth year medical student rotations here in the United States are so named "sub-internships" because they’re designed for the fourth year student, depending on the school and the service, to take on varying responsibilities as would be expected of an actual intern.

If you’re doing the rotation in a specialty you’re interested in pursuing as a career, there can be some pressure associated with the Sub-I rotation, as you might imagine. If you’re doing the rotation at an away school and using it as an “audition” for the residency program at that school, then the stress can be multiplied a few fold.

I’m heading out for just such an away rotation out in Los Angeles to start this week. Although I ran through my Sub-I back at my school, this is my first away rotation.

Talking to residents, the main thing students seem to do to embarrass themselves is just show a complete lack of social skills. I’m pretty reserved and quiet and I am far from stuck up or a kiss up. I work hard, I’m always looking for more ways to help the team, and I have no problem being at the hospital as long as necessary.

But even if you’re not socially inept and you are a hard worker, there are other ways to make yourself look bad. There are stories, always, about students on clinical rotations and especially fourth year students doing Sub-Is having some... embarrassing moments. Stories of students whose scrub pants fell down in the operating room, who had trouble controlling their bodily functions, who prepped or put stitches in or did something else to the wrong patient down in the emergency room.

On away rotations, the situation is not made easier by learning a new hospital and a new system and new ways of doing things. The idea is to pay attention, learn quickly, and ask questions of hospital ancillary staff so you’re less of a burden to the team.

But I’ll be a little stoic about it. Everyone embarrasses themselves sometimes. Going and working hard and letting little screw ups slide off your back is the best philosophy if you can muster it. Besides, I’m well on my way to having a good rotation.

You see, I’ve made the drive out to Los Angeles many times and often not without it being eventful. One year, I blew out a tire in the middle of nowhere between Tucson and Phoenix at about 3:00 in the morning. The tire tread took off the back bumper of the car and the blow-out nearly caused a roll over. Another year I was in an accident in Fort Stockton, TX. It totaled my car. My family was on a camping trip and I couldn’t get a hold of anyone. Now there isn’t much to do in Fort Stockton, as you might imagine, and so I spent three days in my Motel 6 room watching Shark Week on the Discovery Channel until I got in touch with someone who could come pick me up.

This year, however, I am already safely out in Los Angeles. A good sign. Wish me luck and for more good signs as I run through this away rotation.

All I Need to Know for Step 2 I Learned From Television

Colin Son -- I have a friend who likes to pretend he is an attorney* and he hates the television show "Law & Order". The pace and the drama of the show are so much more than what being a criminal attorney is really like. Apparently. Personally I think he’s just being prudish. I get a lot out of shows set amongst my future profession.

For those who may not know, the United States has three licensing exams which all states require future physicians to pass as a prerequisite for getting a license. The first exam, the USMLE Step 1, covers basic science material like biochemistry and physiology and pathology. The second exam, the USMLE Step 2, covers clinical science topics like how to treat hypertension. The third exam, the USMLE Step 3, is usually taken after graduation and covers, more in depth, the clinical practice of medicine.

I take the USMLE Step 2 this week and I’ve been preparing diligently for it; mostly by watching medical dramas and sitcoms on television.

From shows like "House" I’ve learned that the old adage "when you hear hooves think horses not zebras" is baloney. I now know that a dyspneic asthmatic actually has C. psittaci and not an asthma exacerbation, even if the question stem doesn’t mention birds anywhere. I also know that breaking into patients' homes or places of work can be a valuable diagnostic tool.

From shows like "Grey’s Anatomy" I know that all of my fellow residents and the ancillary hospital staff, at wherever I go to residency, will be attractive. Such gives me motivation to pass my Step 2 so that I can get to residency.

From shows like "ER" I know that everyone who comes into the emergency department should get immediate CPR. On a Step 2 practice question I was doing, a mother brought her young son into the ER for bilious vomiting and the question asked for the next step in management. The answer choices didn’t include CPR, so I had to write it in myself. Also, I’ve learned that CPR often works.

From shows like "Scrubs" I know to watch out for the janitorial staff at whatever hospital I’m rotating at as a resident. Also, that I can spend large parts of the day when I take Step 2 daydreaming and fantasizing and still finish the test with ample time.

I feel really well prepared to head into the testing center and conquer my test. I owe it all to Hollywood and its accurate portrayal of medicine on television.

*Okay, he passed the state bar and is an actual practicing lawyer.