Step 1: One more point.

Ryan, MD/MA Bioethics Student

May is that time where everyone is furiously studying…except for the seniors…  Of note is the proximity of USMLE Step 1, arguably the single most important test in medical education.  For those unfamiliar with USMLE, Step 1 is one of three all-day written exams necessary for licensure in the US.  Step 1 covers comprehensive basic sciences, and is taken at the end of sophomore year.  So for those who are studying for Step 1 or any other exam in any other school, I’d like to offer a bit of encouragement in the form of a personal story.

First, the moral:  every bit of studying counts.

Some of the more competitive residency programs have a threshold Step 1 score (this is a screening method, because they’re competitive and they can).  This threshold varies between institutions.  In researching orthopedic residencies, I recently found out that I’m one point shy.  Just one point too low to even apply to a few certain residency programs.  Sure, I can apply to many others, but it hurts to feel excluded like that, knowing that it’s only my fault.  But would studying a bit more have even made a difference?  In my case, yes.
Step 1 doesn’t have a one-to-one correlation between points and questions, but it’s very close.  There was one fact that I had memorized wrong during that unit in lecture, and I kept getting it incorrect on my USMLE World question bank.  I just didn’t restudy it with enough focus.  Low and behold, that same question (nearly verbatim) showed up on Step 1.  Go figure, I got it incorrect.  What bad luck.  It was the one question I looked up when I got home (don’t do that, by the way).  In the words of my hockey coach when I messed up, “You just didn’t want it bad enough, huh?”  It’s not that I didn’t want it.  I just didn’t do it.
Many people get the post-test regrets of “I wish I had studied just a bit more.”  Instead of a vague feeling, I have a discrete example of why that’s true.  I hope this little anecdote isn’t discouraging (as it was to me as I experienced it).  It would be easy to say “I’m going to make mistakes no matter how much I study,” or “comprehensive over two years? or “last-minute studying will make a difference.”  And I can’t stop you from drawing that conclusion.  In this case, Dr. Werner was correct:  you’re just as likely to get a question from the last lecture of sophomore year as from the first lecture of freshman year.  However, the point of this story is to give you that extra push, that resolution to keep at it when you’re already exhausted.
So keep studying, because every point matters.  Hopefully you won’t learn that the hard way.

Why Ethics?

Ryan, MD/MA Bioethics Student

I’ve been asked this question by all sorts of people since I joined this program.  It’s always phrased a little differently, but the core question is the same: why ethics?

Few people know you can get a Master’s degree in Bioethics at LLU.  Even fewer know that you can get it tuition-free in one year sandwiched conveniently between 3rd and 4th years of medical school. But medical school is long enough already.  Why would I postpone medical practice yet another year?  Well, six hours of class per week is pretty nice…but it’s about much more than that.

I think doing the right thing is important, but I’m not content just trusting my gut.  The Bible, an incredible collection of spiritual and theological ideas, isn’t exactly a moral guidebook for the health professions. Most of us took some introductory philosophy class in high school or college (I didn’t). From where else can we get our understanding of what is right?  Most important to us right now is clinical ethics.  There are plenty of ethical guidelines published for professionals to use, but where do these guidelines come from? What if those guidelines don’t have it quite right? Can I defend my actions against a legal system whose members have studied ethical theory?

Most medical students dread the Ethics portion of our curriculum. I’m still undecided about whether that’s a problem of content or presentation. I’m leaning towards content. Most students I hear complain that the information is dry and boring. It certainly doesn’t help (from the students’ perspective) that 3rd year ethics sessions are at least 3 hours long. Most students see that as a good, legitimate reason to duck out of surgery, clinic, or rounds on whatever service they happen to be on, but it’s difficult to keep the focus on something that already seems so irrelevant to clinical education. I see it as completely relevant to clinical education. In fact, I see ethics as foundational.

I hope I don’t sound like I’m petty and defensive about my own program. Clearly I chose to spend an entire year focusing on biomedical ethics because of the value I see in it. I don’t advise every medical student to get a Master’s in Bioethics, but I do wish it was seen as more valuable. Perhaps my contributions to this blog will make that case, and perhaps it will help people not need a Master’s in Bioethics.

I grew up hearing that there are three basic motivations for action: fear of punishment, hope of reward, and because it’s the right thing to do. So much of the practice and governance of medicine involves penalties and incentives rather than intrinsic motivation, and I don’t want to live my life weighing a fine against an incentive payment. I think I’ll stick to the third motivation: because it’s right.  I think it’s important to not only know what the right thing to do is, but to know why I know it’s the right thing to do.

That’s why Ethics.

Beginning of the End of the Beginning

I’ll start with the best part: Friday, I presented my thesis proposal––and passed! I’ve spent the rest of the weekend being ecstatic. Typically, the response from others follows a somewhat less enthusiastic motif. “Wow, that’s great…what does it mean? Do you start med school now?”

No, I’m not going to start med school anytime soon, but as far as the PhD goes, making it through the proposal process is significant. Getting a PhD is somewhat of an elaborate hazing ritual, in which pledges must prove to a council of five established researchers that they are worthy of joining their ranks. The thesis proposal is a particularly intense Harrowing, in which I must publicly present my intended doctoral work. I must also let the five scientists on my thesis committee that I know what I’m presenting and that I’m capable of completing the work. Passing means I’ve made it through the first level of graduate school, and am now a PhD Candidate. Now all that stands between me and the PhD is…a whole lot of research and writing.

For anyone that’s interested, my thesis (which I’m sure will come up again) explores the relationship between cholesterol regulation and Alzheimer’s disease. My presentation can even be viewed online. Of course, I’d be happy to answer any questions––what researcher doesn’t love the opportunity to talk about their work?

Since I’m MD/PhD, I have four years of med school after that, and we won’t go into the post-post-graduate years of residency. As my friend described it, I’m at the beginning of the end of the beginning: It’s the beginning of the final push toward my PhD, which is itself the beginning of my path through the combined degree program. Regardless, I’m allowing myself some satisfaction. I might even venture to say I’m around 25% complete, and that’s worth celebrating.

Wild Zones

At one point in my life I spent a lot of time mowing the lawn. We had a decently-sized area with terrain ranging from wide, flat spaces to steep hills and washed-out depressions. The ride-on mower was the closest I got to having a four-wheeler, so the chore wasn’t all bad. Even so, during the height of the summer, the grass had to be cut weekly, essentially pre-booking my Sunday mornings.

One area of the yard was especially treacherous––water runoff had formed a rocky stream bed, sycamore trees hid branches beneath bark pieces and wide leaves, and there were two wells to be avoided. This Wild Zone wasn’t highly visible compared to the rest of the yard, making it possible to leave that area for the next week’s mowing.

Each time I shifted the task to the right on my calendar, it became easier to do it again the following week. Eventually it had been postponed so many times it became part of the landscape. Nature continued to reclaim the Wild Zone, increasing the difficulty of the task and the inertia associated with completing it. And so the grass grew tall and went to seed, rippling with the breeze even as it concealed all manner of organic debris.

Containing the most egregious parts of the Wild Zone was easy enough: I mowed close to the edge and tossed stray branches further inward. Nevertheless, ulterior consequences of such a region are much harder to manage, encroaching into other areas in sinister ways. My dog began returning to house with dozens of ticks, mosquitoes diminished the enjoyment of the rest of the yard, thorns and locust saplings obstructed the wells.

This simply could not continue. I pulled on thick jeans and a hoodie despite the summer heat. I added safety goggles and tucked my earmuffs awkwardly beneath my hood. Thus armored, I adjusted the mower and plowed into the miniature wilderness. Almost immediately, I heard the telltale grind-snapping of a branch being destroyed by the blades, followed closely by stray pieces of wood and chipped rocks smacking into my face. Thorns pulled at my sweatshirt and snared my ankles, digging into skin. Disturbed insects rose to mix with the vast quantities of dust and pollen already filling the air.

This is a rather roundabout way of describing my life of late. It’s easy to carry on with the imperative parts, doing what is absolutely necessary to keep things moving forward. Dealing with the rest of it, however, requires initiative; it doesn’t have to be finished immediately, even if it should. And so life moves onward, visibly well-maintained while the more hidden, personal areas grow wild and unkempt.

Mowing the Wild Zone was every bit as difficult as I had imagined, but it had to be done. Similarly, as exhausting as it may be to continue “hanging in there,” it’s not enough. It isn’t fulfilling to merely keep pace with existence. There is a limit to how much of oneself can be sacrificed before the tangled undergrowth begins to choke even the non-negotiable tasks.

Take the extra time to truly focus on a loved one, to do something creative, to enjoy the outdoors is vital. Not mowing edges or tossing the branches farther in, but applying the same professional focus to whatever represents “the rest of life.” We ignore these things at our peril. For sure, isn’t easy to set aside the urgent to take care of something important. It’s hard to overpower the inertia and plow through the stress in pursuit of fulfillment.

That’s what it takes.

Why Two Degrees?

Looking over the long road ahead of me, one might consider asking, incredulously, why somebody would want to do an MD/PhD program at all. It’s certainly a justified question, to which the short answer is that I think receiving training in both clinical medicine and research science will be especially valuable in my future career.

The MD and PhD degrees differ in more than just the requirements – they represent two perspectives on problem-solving. The way I see it right now, medicine ultimately teaches students how to correctly apply what we have learned to new situations, and how to recognize something you have seen before when it is placed in a new context. Graduate school, however, teaches students how to find the gaps in what we know, and design questions that will yield new information.

I think the two schools of thought are complementary, and that having experience with both will improve my skills as a clinician and as a researcher. Additionally, in the field I’m currently looking at, neurology/neuroscience, I will be able to help bridge the gap between what we’re continually learning in the lab (neuroscience) and the application of that knowledge to patient care (neurology). Not only through translational research (a popular buzzword) I do myself, but also by being cognizant of and having experience with developments on both angles.

I wrote this a while back on mistypedURL, but I think it’s worth sharing again here.