Multiple Gripe Test

These past few weeks I've been studying for USMLE Step II -- the middle installment in the series of board exams needed for licensure. I took Step 1 five years ago and forgot how mind-numbing and trivial it could be. Also, back then, I had a study partner, instead of a blog. This time around, I'm sharing my gripes with you.

The questions on the test are clinical vignettes, where a patient's history, physical, vitals or lab results are presented, and we're asked to guess the diagnosis or appropriate therapy.

It sounds reasonable, except every now and then the vignette has nothing to do with the question, or is utterly superfluous. On these practice tests, you wade through three paragraphs of a case presentation, confusing lab reports, maybe a histology slide, and at the you read: "Which sequelae of strep pharyngitis arises despite antibiotics? Is it rheumatic fever? Glomerulonephritis?"

That's fair, ok, but did I really need to read about the little kid with the sore throat and dark urine? Seriously -- it's bad enough when doctors dehumanize patients, treating them like problems instead of people. But now we're being trained to ignore the clinical vignette, too?

Anyway, this is a big change for me, because it's my first multiple-choice test in which I can draw on real-world experience, along with my book-learnin'. This makes some questions a lot easier, but some actually become harder.

For instance, take a septic knee in a twentysomething with a negative gram stain (please). I think most doctors would empirically give antibiotics for both staph and gonococcus, but apparently for this exam, that would be wrong. You're supposed to go by the demographics and guess it's a gonococcal infection if the patient is under age 40 -- if they're older, you treat it as a staph infection. This shift isn't due to differences in biology, it's just the test-makers' assumptions about philandering. Nice.

I also enjoy these "distracters" that they throw into the practice tests. I guess the theory behind distracters is that they're seductive but wrong, and keep you from recognizing the right answer. For me, though, I actually just get distracted -- some of the fake answers make me wonder, "why haven't I heard of that disease before? What the heck is that?"

My favorite is "Amok", which has appeared as an answer in a few psychiatry questions. Apparently it's an example of a culture-bound syndrome, specifically, Indonesians who abruptly exhibit violent rage, followed by amnesia. I was familiar with the term but never knew it as a clinical entity. Amok may be more common than previously thought, and indeed, with another week cooped up studying, I suppose anything's possible.

After this, it'll be time for the Step II clinical skills exam, which is easy but no less gripeworthy. Izzy is on his way now to take the exam, I'm curious if his opinion will differ from that of any other med student who's taken it...