the day after STEP

As I clicked what was the last but I hope a long string of correct answers, a divergent thought ran through my head....

the long road

"Ok, just sign here and then if I can get your fingerprint on the scanner," the proctor instructed me as I signed in for my STEP I exam.  "Ok, yup, here you are.  MCAT from 2008, right?"  They had my digital fingerprint on file from when I took the MCAT to get into med school.  And I thought that exam was bad.

2008.  Wow.  Have I really been at this that long???

check list

I mentally ran through my mental check list to make sure I had everything.  Tea. Lots, Lots, Lots of tea.Enough-caffeine-to-keep-me-going-for-322-questions-over-everything-amount-of-tea.Nervousness.Location of closest bathroom for said tea.
Power bar.Anxiety.Sandwich.Fear.Energy drink.Gratitude.Chocolate bars.  Wait what was that last one?  The one before chocolate bars?  Gratitude?  Huh.  Yeah, I guess I really am grateful.  Grateful that this will be over, sure.  But also grateful for this opportunity.  Blood, sweat and tears have been put into this journey which culminates with this chance to take one bohemoth of a test.  Win or lose, I have every right to be proud of where I am and grateful for the opportunity.  I am ready...


If you can make one heap of all your winnings
And risk it all on one turn of pitch-and-toss,
And lose, and start again at your beginnings
And never breathe a word about your loss;
If you can force your heart and nerve and sinew
To serve your turn long after they are gone,
And so hold on when there is nothing in you
Except the Will which says to them: "Hold on!"

...Yours is the Earth and everything that's in it,
And - which is more - you'll be a Man, my son!
-If by rudyard kipling

lots of lube

     "I've discovered the secret to these practice dummies is lube.  Lots of KY.  Actually, that's true in life, too."
- Words of advice from the doc instructing us on how to insert a foley catheter into a practice dummy. 

Absent from the training exercise were the screams and profanities that would be streaming from mouths of a man getting a foley catheter inserted.  (A foley catheter is a catheter that goes up through the urethra to drain the bladder.  There is no numbing involved.  It is not, shall we say, pleasant.)

when you hear hoofbeats...

It's an oft repeated axiom of medicine.  If you hear hoofbeats, think horse, not zebra.  It means the common things happen commonly.  Don't go looking for exotic stuff.  But we're also supposed to keep an open mind as to the possibilities.  How in the world to does one test that?  I don't do as well on standardized tests as I'd like.  I think I'm too used to looking for zebras.  In my prior career, we set out to look for the new, the novel, the (hopefully) revolutionary ways of treating a disease.  I saw parts of physiology that no one else in the world knew.  Fast forward to my brief medical career and my family.  My brother?  Thymic cancer.  That's not even a zebra.  That's beyond zebra.  My dad?  CLL, well that's common.  Except his was highly aggressive.  Everything I've learned from recent lectures has been that CLL is slow and not that big of a deal.  One lecture over the pathology of it had a whopping 122 words over it.  Basically, it's a low-grade disease that's discovered incidentally.  That's it.

A case from a lecture that highlights how slow it is.  This patient has had it for over seven years.  Skip past all this if you're not into all the medical mumbo jumbo.

A 54 yr-old woman presents to your office with fever and persistent bleeding from a dental extraction done 3 weeks ago.  The patient has felt well for the past month with no fevers or weight loss, but she has had some fatigue that she attributes to long hours at work.  Seven years ago she was noted to be pancytopenic and was diagnosed with aplastic anemia.  She was treated with antithymocyte globulin, cyclosporine, and prednisone and had a complete hematologic recovery.

Physical examination shows a pale, middle-aged woman.  There is no lympadenopathy or hepatosplenomegaly.

  Laboratory studies:

  Hemoglobin  8.2 g/dl

  Mean corpuscular volume  117fL

  Leukocyte count  3100μL

–Segmented neutrophils  21%

–Band forms  10%

–Lymphocytes  68%

–Monocytes  1%

  Platelet count  36,000/μL

Peripheral blood morphology shows hypogranular and hyposegmented neutrophils.  The erythrocyte morphology shows both anisocytosis and poikilocytosis with some teardrop cells.

 What is the most likely diagnosis?

a) recurrent aplastic anemia
b) chronic lymphocytic leukemia
c) myelodysplasia
d) B12 deficiency
e) Miliary tuberculosis

     On the one hand, the stress of not measuring up, the threat of a board score so poor, I'll be doing my residency in Gnome, Alaska.  On the other hand, endless monotony, repetition ad nauseum as I try to figure out how to cram a library of information into my head over and over.  I never thought it possible to be stressed and bored at the same time.  But there it is.  Just a few more days.  My board exam is rapidly approaching.