I feel at the moment that I am perched on the top of a hill. The long, slow climb of third year is behind me, and I can see ahead of me in the direction I am already starting to move: forward through fourth year electives and a subinternship or two, two residency application processes (more on that soon), two Step 2 exams, and on to graduation in the not so distant future. Doing all this while planning my wedding just makes me feel all the more future-focused–I even have a countdown timer widget on my iGoogle homepage that ticks down the days, hours, minutes, and seconds (approximately) until I get married, within days of graduation. I just added one for the day I get my MD:
With all of the procedural things that need to happen between now and when I get my degree and my license, it’s easy to forget the actual process that is occurring underneath, the real reason I am here: I am training to be a doctor. I can look back from the top of this hill and see how far I have come since the beginning of medical school, and especially in the last year. I like talking to current third-years, not just because I like to be in a position of giving advice and guidance (which I hope is useful for them, since I certainly appreciated all the help I got from upperclassmen and want to pay it forward) but also because they remind me that I have learned a great deal in the last year and I am on my way to becoming a doctor. I need the reminder sometimes.
Last month all the fourth-years underwent a rite of passage with the somewhat unnervingly simple title of the “HMS Comprehensive Exam.” Everything you have learned in medical school, in five hours. It was our second OSCE (objective structured clinical examination), following the one at the end of second year for Patient-Doctor II. We were told this exam was “designed to evaluate your ability to integrate the knowledge, skills, and attitudes you have acquired over your three years of medical education” and I thought it was fairly well designed to do so, with a series of nine stations each testing us on those three domains of knowledge, skills, and attitudes (communication, more or less) during an encounter with a standardized patient. Those lucky third-years I mentioned will have their own chance to take this test next year, so I will not go into specifics about the stations.
On the day of the exam, it took me a little while to get into the flow of the encounters, which were very tightly scheduled and scripted (e.g. “eight minutes for clarification of history, then five minutes for a focused physical exam” and so on for twenty minutes total). Some of the stations felt relatively straightforward, like the rapid-fire radiology practical; none of them felt easy. I thought I totally flubbed the one on back pain, doing a cursory neurological examination that didn’t evaluate some of the most important reflexes for the patient scenario. I’ve been a dedicated student of neurology for seven years now and had great training in the neurological examination (and the importance of a thorough one) during my clerkships; where did that go in the moment? During the feedback immediately after, the preceptor asked if I wanted her to demonstrate the neurology exam skills she was telling me about. I hung my head and said no, that wasn’t necessary.
The last station for me was in our simulator center, with a lifelike robot patient hooked up to computers with an ICU-style display of his vital signs and his labored breath sounds filling the room. As I took his history and did my exam, pressing my stethoscope against the speakers under his plastic skin, he continued to struggle for breath. I asked for a few diagnostics and tried a few “interventions” but nothing changed. I finally thought of two different things I could try, but I wasn’t sure which one was right to do. I can’t find the right words to describe the deer-in-the-headlights feeling I was having, but I was terrified. How was I supposed to know what to do, when I hadn’t seen this situation before? What if I made the wrong decision? I was in an urgent situation, completely alone, a medical trainee’s worst nightmare–in fact, I have already had nightmares about this, and I have never even experienced it. I just froze up, and the preceptor stopped the encounter early and started the feedback session. It turned out I had missed a large part of the “point” of the station entirely, because my management of the situation never even got us to that part of the story. He was kind and tried to guide me through a reflection on what had happened, but I was so flustered I broke down, and talked through tears. I felt like a failure. I felt sure I had flunked the exam. I felt that I couldn’t be a doctor.
Today, I got an email with my final scores from the exam, with an elaborate spreadsheet comparing my performance to their standards. I passed. In fact, I did a little bit better than the mean. My lowest station score was on the last station, but it wasn’t miles away from the mean. And on the skills score for Management, what I struggled with the most in that station and in so many of the difficult times during third year, I was just about on par.
I am not allowing myself to get complacent after seeing these results; I got the message very powerfully from my experiences during the exam that there is still so much more to do. But at least by this one metric, this test administered by very experienced faculty to many classes of HMS students who have gone on to become good doctors, I am right about where I should be at this time. I am on my way to being a doctor–to knowing enough, and to having the skills and the attitudes, to give my patients good medical care. By this time next year, I will have my MD and I will be responsible for patients as an intern. I know that that is far from the end of the story, as I will learn and grow so much in my ongoing training (and in the months between now and then). I guess these exam results just reassured me that somehow I am on track to have what I need to do that job, and I have the basics to build upon. I can look back from this hilltop, and truly see how far I have come. And I look forward with excitement to the journey ahead.
