Done with Step 3!

I will write about my week on call shortly. But for now, Step 3.

First of all, the basics: This is a two-day test, with seven hours of material each day. Most of it is multiple-choice, but there are some clinical cases toward the end where you are given a patient and you decide how to proceed (what tests to order, what treatment to give, etc.). You get feedback on what's happening after you make a decision (test results, change in patient's condition). It's pretty neat, though the cases had a nasty habit of cutting off right before I felt I finally had a good grip on what to do.

Now, like Step 2 and (kinda sorta) Step 1, this is a test of clinical medicine. Unlike those tests, I did not have a month off to study. I did manage to read First Aid once and do about 400 practice questions. Studying more would have helped a good bit, I'm pretty sure, but regardless, I can say this: The test stunk.

I really had no idea what was going on maybe 20% of the time. Now, I haven't completely forgotten clinical medicine -- I graduated back in May -- but even if I'd taken this test at the end of my third year, I would have balked at some of the questions. No, I don't know what symptoms result from mistletoe ingestion. No, I don't know which of these weirdo tests to order when the patient clearly needs an abdominal CT. No, I don't know which of my four slightly different options for a translator is best. (The psychosocial questions in particular were completely off the wall.)

A lot of the time, I was able to get the choices down to two possible answers, both of which sounded really good. And a few dozen times during the test, I stared at the answers, fully aware that I once knew the correct choice but now just have a hazy recollection of half the details.

I am glad the test is over. From what I've heard, the grading is pretty lenient. Some of the upper-level residents in my program told me they took it years out of medical school and passed just fine. I just want to put the two days and $670 behind me. Past this point, all my standardized tests will be pathology-specific. All I have to do now is learn pathology ...

boards

I am really not looking forward to taking Step 3 tomorrow and Tuesday. It's amazing how much clinical medicine you can forget after just half a year of not using it. I've been studying, but I took a month off for Step 1 and Step 2. Getting an hour or two of reading in after work each night for a few weeks just isn't the same.

I did see a cool thing in the micro lab earlier this week: the "hockey puck sign." Colonies of Moraxella, when pushed, slide across agar like a hockey puck. Very neat.

quick update

CP call hasn't been too bad, aside from a few rough hours last night. I'll post more about it once it and Step 3 are over.

Someone came into the student health clinic here last week not feeling so good. He grew out Salmonella typhi. Yep, typhoid fever. They had to quarantine him, vaccinate his roommate, and interview all the other students who live on his hall. Good times ...

haven't killed anyone yet

I'm on CP call this week. We take CP call for seven days at a time, and then at the end we present all the cases. My call began yesterday, and I only got called once. I just wish it hadn't been at 3 a.m.; I have been dragging all day.

The call concerned a child brought into the hospital who needed a blood transfusion. He had gotten a few units of blood at an outside hospital before being brought here. When they typed him here ... his blood type was not the same as the units he'd received. This is, of course, bad. The blood bank wanted to know whether to give the same blood type as the other hospital, or switch to the patient's actual blood type. He'd received so many units already that he was about half and half.

Not having rotated through the blood bank yet, I got as much information as I could, then called the attending. I think that's how most of the calls this week will go. The case actually ended up being pretty interesting (at least, the parts of it I could understand were), and I may do a presentation about it.

Working with ID teams

I wrote most of this post a few weeks ago (i.e., in August), but never got around to finishing it. I'm back at the "main" hospital for this month, but I wanted to share this anyway.

Aside from the occasional call for a mislabeled specimen or to discuss inappropriate use of lab resources (see below), the only real clinician interaction we have on our microbiology rotation is with the ID (infectious disease) team. As I mentioned in a previous last post, I am at a different hospital this month than I was in July, and man, what a difference a ten-minute shuttle ride makes.

At our "main" hospital, rounds start every day after lunch. The ID attending and fellow are always there to join us. As a result, we discuss cases in depth, with the clinicians knowing everything about the patient's hospital stay and the pathologists discussing the lab findings and their implications. It makes rounds longer but more interesting, as the case becomes more than "this plate grew out some weird bug." The patient becomes a person with a story, not just some lab results. It's easy to get into this mode of thinking when you're tucked away in the hospital lab, and talking with the ID folks about cases really reminds you why you're doing what you're doing.

In contrast, I have yet to see a non-pathologist in the micro lab I'm at this month. The ID team is apparently too busy to make rounds in the lab (I don't mean that sarcastically; with the patient population we have here, they certainly have their work cut out for them). This means that, for the most part, the patients exist as names on specimens, or data in a computer chart. I will occasionally research the clinical presentation of an interesting patient (like last week's Rhodococcus patient) and even go to the floor and look at the chart, but it's not the same as having a knowledgeable clinician discuss the case with you. Fortunately, while I'm on the floor, I can usually find a nurse or resident involved in the patient's care, but I had to go to them, not vice versa.

I've only even heard the term "ID consult" once this month. We wanted to suggest one to a doctor who has been swamping the lab with specimens. He has seemingly cultured his patient's one wound in three separate locations, twice a week, for the past two months. The computer can't even pull up all the lab results without crashing. And the results always show the exact same bacteria with the exact same susceptibility profiles (i.e., they never change in terms of what antibiotics will kill them). This patient has been put on a few different antibiotics, but nothing seems to change. This doctor is apparently upset at the lab, and we're not too happy with him. I feel like I am missing something, but I have gotten as involved in the case as I can, and I'm still confused. Hence recommending an ID consult to sort things out. I just hope that actually happens, and since we never see the ID doctors face to face, it's harder to get everyone working as a team, since we're all just names on a pager to each other.

ah, doctor humor

We had a printout today on a patient that read "Current Diagnosis: CTD" and the culture report listed five assorted organisms. We decided that CTD stood for "Contaminated Tube Disease."

not dead, just busy

The past few weeks have been bumpy, yet uneventful. Micro does not lend itself well to interesting stories and anecdotes, unfortunately. I start surg path next month, so I will definitely have good posts come out of that.

I do have one post I half-wrote a few weeks ago and then never got around to finishing. That will be up in a day or two.

I'm taking Step 3 at the end of the month. This is part of the boards and consists of questions pertaining to clinical medicine. I haven't dealt with clinical medicine for half a year now! Neither have the other pathology interns, which is why I'm glad I am taking this thing so early. Imagine if I waited until fourth year. The test is basically pass/fail, but since some of the pathology fellowships I'm considering are rather competitive, I'd like my score to be as high as possible. Wish me luck ...