"To Everything a Season and a Time for Every Purpose under the Heavens" - Ecclesiastes 3:1

When I was four years old I received a brown, plastic toy doctor's kit. Inside were mysterious and wonderful instruments of the learned: a plastic stethoscope, a toy syringe, a small basin. I cannot recount the many hours I spent gleefully "diagnosing" adults who, in turn, exercised what could be described only as saintly patience.

Later, as a young pre-teen my uncle would refer to me jokingly as "doctor". "Hey doctor!" he would say loudly as I entered a room. I turned my precocious 12 year old self towards him one day and said with mock seriousness, "Not 'doctor', professor!". He thought that was funny.

When in high school I was only one of two students in my class who went to a cadaver lab, an exercise for those who hoped to one day go into medicine. I was 17 when I held my first human heart.

While in the military I served as a combat medic, traveling the world and patching up troops on multiple continents. How many times did I grab my aid bag and run towards the voices yelling, "doc!" - more than I can recall.

These are wonderful and treasured memories. I cannot help feeling, however, that they all have been leading up to this moment. Today, after decades of experience and years of study, I have finished my final medical school requirements. Today, I am finally a physician.

Honestly, it hardly seems possible. My mind has not yet grasped the enormity of what has happened. With the passing of that final exam and the last "click" of the computer keyboard, I have at long last received that for which I have for a lifetime labored: I am a doctor. I am a healer. God has favored me with this profound privilege and staggering responsibility. I know it will be by His Strength alone that I shall live up to this sacred title.

I have much to share with you concerning the details and nuances of medical school. This experience is surely not for the light hearted. Neither is it for those who are not absolutely sure they want to spend their lives in the service of God and humanity. Over the next several weeks I will be casting some illumination on particular experiences and challenges in the hope that this may prove helpful.

Until then, no more books for me. I think I will sleep in tomorrow.

A Very Special Day

Today is a remarkable day, a day for which I have been waiting since I resumed my undergrad studies in 2012. Today, at 1700 hours Central Standard Time in the United States, I officially finished my last day in medical school.

Honestly, I can hardly believe it. This journey has been so much more than I imagined and required so much more than I had to offer. It is God Who has carried my family and myself on eagle's wings (Exodus 19:4) and brought us through tribulation, trial, and triumph on levels heretofore unknown. He has guided us through extraordinary blessing and crippling want, academic success and biting poverty. And, through it all, we have come to know and love Him and appreciate each other as a family more. I will never stop celebrating the reality that I am a physician because of Yeshua (Jesus).

Please note I am not bouncing off the walls in wild exuberance. Though I am terribly thrilled at finally being done with my medical rotations and school work, there remains on final exam (a COMAT shelf exam in surgery) hanging over my head. This is unusual as most students by this time in their academic careers have finished all their academic requirements. When taking this particular exam many months ago, there was a computer glitch that required me to stop and restart, thus robbing me of precious time. I ended up failing by one point. My school has asked that I retake this exam. Until I do, I am not completely done.

I must be honest: this is a frustration. But, I know if God can carry me through undergraduate studies and four years of medical school with a large family and two special needs children, He can get me through this final, petty, exam. It will take about three weeks of study and two additional weeks for the results. God willing, I will pass and then I will be, officially, a doctor. It is at that point, Dear Reader, I will be exuberantly bouncing off the walls!

Despite all, today is a very special day and, though muted, a day of celebration. Shabbat has begun and my family and I will be resting. After shabbat, for me, it will be back to the books.

Thank you for your time. I will keep you posted.

P.S. I'm actually in this picture taken at my med school in 2016. Good times!

The COMLEX Level 2 PE - A Good TIme!

There is, in the saga of the advancing medical student, a particular board exam that tests the student's ability to perform physical exams and offer differential diagnoses. For osteopathic medical students this test is called the "COMLEX Level 2 PE" ("PE" for "Physical Exam"). For allopathic medical students this is called the USMLE Step 2 CE (Clinical Exam). As an osteopathic student I can speak only about the PE but I am guessing the allopathic experience is similar.

My PE was in Conshohocken, Pennsylvania, a distant suburb of Philadelphia. A nondescript, business building squatting near the river houses the testing center. After showing up several minutes early in a plain white coat and dressed with professional slacks and tie, I signed in and took a seat with eleven other medical students similarly attired. The room was filled with hushed voices and the air was thick with tension. A friendly if not slightly bored attendant behind a long counter checked my ID and inspected my stethoscope to make sure I have not surreptitiously snuck in some obscure medical algorithm on microfilm. I signed a non-disclosure agreement and it is because of this that I cannot share anything specific about the test itself. I can, however, share my thoughts about the overall experience.

After waiting what felt like an hour the dozen of us, like white-clad sheep led to the slaughter, were herded into another room where we were given a protracted briefing concerning the structure and length of the exam. It is a very long test, taking over seven hours. During the day we would see twelve "patients" (played deftly by trained actors and actresses) and would be responsible for evaluating them, performing any correct physical exams, and creating a set of differential diagnoses. We then would have a certain amount of time to properly record our efforts on a computer.

These seven hours went incredibly fast. Despite the stress I must admit there was certain sense of adventure for I never knew what was behind the next door. Overall, it was a fantastic experience assisted by a kind and professional staff.

How does one prepare for this? There are a number of professional texts available to cover the vast didactic knowledge needed. For osteopaths, there is also an intense two day course offered for those who want some additional strengthening of skills. The PE medical board exam costs about $1,250 so it behooves the prospective student to make whatever preparations are needed to pass the first time! I've often joked that, if this medical thing does not work out, I should get a job for the company that conducts these tests.

If you are reading this and are preparing to take the PE, might I suggest the following helpful hints:
- Get to the testing center about 15 minutes early
- Bring only what you need. The lockers are small.
- Wear a white coat that has no identifying marks, especially from your school. It's just easier.
- Get a good night's sleep the night before. This cannot be overstated.
- If possible, try to test in the morning. The "patients" tend to be less tired and in a better mood.
- COMBANK has a set of videos covering basic OMM techniques for this exam. I found these very helpful.
- Greet every patient with a smile and be professional at all times regardless of what may happen.
- ALWAYS WASH OR SANITIZE YOUR HANDS BEFORE TOUCHING THE PATIENT! I know you know this but in the heat of the moment it might be forgotten.
- Don't argue with "patients", staff, or admin personnel. They're their to help you.
- Try to enjoy the experience. NBOME has been doing this for a while and they know what they're doing.

There is little more I can share concerning the Level 2 PE. Thanks to God, I have passed this, yet another hurdle. I have one final exam (not nearly as large as the PE) and then I will be done with medical school.

Finally!

Until then, Dear Reader, please take care of yourself. For me it's back to the books.

The Broken Silence

It has been seven months and you, Dear Reader, have heard nothing from me - not a peep, not a tweet, not a sound. At long last, the silence has been broken.

I won't waste your time with eloquent elocutions concerning the rapidity of passing days or the "tempus fugit" nature of our lives. Suffice it to say that the past seven months have been filled with two medical board exams, numerous COMATs (readers familiar with this blog will know the pain associated with that term) and the joys of applying to medical residency programs. As you can imagine, it's been nothing but smiles and sunshine and pink fluffy unicorns riding rainbows for these several months....

Tomorrow I will begin to fill you in on the details of these experiences. For now, please know I have not, during this journey, forgotten you.

https://www.youtube.com/watch?v=qRC4Vk6kisY

COMLEX Level 2 CE

Ah, the bliss! Ah, the joy! Ah, the indulgent luxury of sleeping in! Today I didn’t get out of bed until 11:00 am. Why, you may ask? It was a bit of a reward to myself, a gift for the stress and intensity of yesterday. For you see, Dear Reader, yesterday I sat down and took my Level 2 medical boards exam. Like Level 1 from last year (and the year before and the year before that - see prior blog posts for THAT adventure) this was an eight hour, 400 question exam. Unlike, however, Level 1, yesterday’s exercise in the bounds of human stamina covered clinical medicine. Gone (mostly) were the petty questions covering inane details that I will never use in medical practice (citric acid cycle changes, anyone?) and, instead, yesterday had questions like this:

A 72 year old male nursing home resident comes to the emergency department complaining of abdominal pain, nausea, bloating, and flatulence. His medical history includes diabetes mellitus, hyperchloresteremia, hypertension, hypertriglycedemia, headaches, lower extremity cellulitis, obesity, insomnia, obstructive sleep apnea, schizophrenia, and prostate cancer. His surgical history is significant for an appendectomy, cholocystectomy, partial colectomy, and hang-nailectomy. The patient is taking metformin, amiloride, atorvastatin, zolpidem, sertraline, and acetaminophen. The patient has a 78 pack year history of smoking and drinks about twelve beers a night. He is retired and lives alone and is fond of eating Twinkies, watching reruns of Happy Days, wearing mismatched socks and taking long walks on the beach. Physical exam is significant for generalized lower abdominal tenderness without rebound pain or guarding. Vital signs are: BP 210/130, heart rate 43, respirations 25, and oxygen saturation at 91% on room air. What is the most likely color of the sky outside of the hospital?
A. Blue
B. Cyan
C. Azul
D. Turquoise
E. Green with a skiff of high stratosphere cirrus clouds

From this made-up example you can see the real danger in Level 2 questions: many of them are obnoxiously long and the answer choices, though not difficult, are very, very, very similar to each other. It is our job as senior level medical students to be able to pick the best answer from obscure hints in the question stem (The answer to the above question is “D” because it just is.....)

After the test everyone asks, “How do you feel about it?”  How can I answer this question? I would love to be able to walk out of the testing center, dancing with various spring-time birds alighting on my shoulders whilst whistling in the sunlight. The reality is that sitting for eight hours and clicking on hundreds of purposely complicated questions is the very definition of tedium. How do I feel? Exhausted.

Meanwhile, results will be available in a month. Do I feel I passed? I will be honest: I was pretty discouraged yesterday. This morning, in the light of a new day, I am feeling cautiously optimistic. Beyond my feelings, though, there remains one thing about which I am certain: God Himself placed my family and I on this road. It is God, not I, Who is making me a physician. In order for this plan of His to come to completion I must pass yesterday’s exam. This being the case, faith and logic tell me yes, of course I passed.

Dear Reader, thank you for your time today. I will keep you posted.

"Danger, Will Robinson, Danger!" - Class M-3 Model B-9 GUNTHECR Robot

Oy vey es mir! I promise frequent updates to you, Dear Reader, and find myself losing six months!

Why??

Because of a great danger associated with medical school about which, heretofore, I was blissfully unaware, namely this - medical school is all consuming. First and second year were tough, no doubt about it. Third year, however, has been a monster on time. Put simply, there isn't any. Between rotations, tests, busy-work from the school, and family, this blog has fallen behind. If you are thinking about going to medical school, please know that, as the years progress, you will have less and less time. This fact becomes crucial especailly if you are going to do this with a family. The danger is all too real that you will lose yourself in study and preparation for residency, so much so that the rest of the world begins to fall away. Indeed, there are some students who fail to take care of their own health or hygiene. This is a grave danger, indeed.

In the highs and lows of third year, I found that, with each successive rotation, I would spend less time with my family, less time doing "fun" activities. Danger! I am thankful to God that He brought this to my attention so that I can get my priorities straight. No amount of success in my career will ever make up for being a failure in the home.

So, I'm back! In a few days I will share with you some of the rigors of third year. It was an adventure, one for which I am grateful.

Until then, Dear Reader, God bless you. For me, for now, it's back to the books.

http://cdn1us.denofgeek.com/sites/denofgeekus/files/2018/04/lost-in-space-robot.jpg

"The fire seven times tried..." - The Prince of Aragon in The Merchant of Venice

Remarkably, I am in the beginning of my seventh clinical rotation. I have completed one month each of Internal Medicine (I &II), Pediatrics, OB/GYN, Adult Primary Care, and Family Medicine. This month I am doing an “elective” meaning I get to pick the discipline. I chose anesthesia for a couple of reasons: first, the idea of pain and its control fascinates me, second, this rotation usually offers students plenty of study time for exams.

Oh yes, I forgot to tell you about these exams.

Called “shelf exams” in allopathic schools and “COMATs”  (Comprehensive Osteopathic Medical Achievement Tests - there’s a mouthful for you) in osteopathic schools, these exams are designed to test your knowledge of a particular subject at the conclusion of the rotation. To be honest, these tests are not nearly as hard as the COMLEX step 1. Consisting of only 125 questions, the COMATs deal more with diagnosis and disease management and less with nuanced detail that has very little to do with actual patient care (Kreb's Cycle anyone?).

Though these exams pose little challenge, I still find myself struggling with them. My professors and proctoring physicians tell me I know the material very well and they universally agree I will make an excellent and able physician (thanks to God!). However, when I sit down in front of that computer for the actual exam, my struggles with the COMLEX step 1 flood back. My heart rate doubles and I am reminded of the pain of repeated failures. Perhaps I am naive but I am surprised that this is happening. For whatever reason I thought I would be able to breeze through these simpler tests and prep for the COMLEX step 2 exam next year.

So the challenges of medical school continue though, to be completely honest, I welcome them. I knew this journey would not be easy nor am I looking for a smooth road. After everything that has happened and all my family and I have experienced, I remain solidly confident in God’s goodness and faithfulness to get us through. I love this journey.

Until next time, dear reader, God bless you. For me it’s back to the books.

Me at the start of my 7th clinical rotation. Whoo-hoo!