Exam done. What next?

So..... The big exam is done.

On the bright side, one of the hardest exams in my medical training is over.
On the dark side so to speak, it was probably the easiest thing out of the whole 'let's get the residency in US' malarky.

Onwards and upwards as they say!

One month exactly.

What a week! To summarise the excitement of the past week in few words: phone stolen, new phone bought, project finished, deadline missed, rent paid and new attachment started.

It will never happen to me. A common school of thought of many individuals, myself included, until that something actually happens that is. I never thought that my phone will ever get stolen, not because I am some sort of special munchkin, it is just that kind of things that happens just to other people, right? Well, reality check is not pleasant. My phone was stolen out of my bag at a tube station. A significant chunk of my life just gone in less than few seconds. One does not realise the full impact of dependency on something until that something is withdrawn. I don't remember the time when I felt so at loss, cut out of the modern world in moments feeling rather powerless. Thankfully, the modern world is at ease with Internet, and on the other hand things are not that bad.

Exactly 1 month to go. One month is such a variable quantity! It could drag on forever when you are away from a loved one, or it can zoom by when there is a nasty exam awaits at the end. Why can't we switch the perception? Dragging on during revision and zooming past in separation? A wishful thinking.

Lying here on my comfortable bed, cozily curled up under the duvet listening to a calm sleepy breathing of my loved one. I wish could freeze this moment. Time, stop! Give me a break from this endless race!

'Oops! How did that happen?' Days off revision.

Oh dear.. Somehow I just took 2 days off revision. Realizing such fact evokes surreal feelings, somewhat like 'Oops! How did that happen?'. It was the end of my orthopedic attachment on Friday, a much longed for end of the orthopedic attachment, which warranted an evening off. The evening off has lead to a late night, the late night has lead to a late morning and a caffeine withdrawal headache, which in turn has lead to becoming human by about 4pm in the afternoon and then it was time to cook dinner.

I am afraid to even look at my schedule.

How to stay awake (or at least try to).

It is somewhere in the middle of the night, only the lonely traveller is rushing to the safety of the old travel-lodge that sleepily blinks into the night. There is only a medical student sitting at the table, leant over the thick books revising for exams. Or something like that.

How do you stay awake during the nth hour of revision in that long long night? A search engine presents the standard selection of articles with advice to 'get plenty of sleep', 'exercise' and 'eat a healthy diet'. That is all great, however if I had time to get plenty of sleep as they advise, I wouldn't bring up the question in the first place.

If to steer clear of prescription medication, here are few techniques to support some sort of brain activity during long revision hours that work for me.

Coffee: a staple drink and it does work. A good bold roast of freshly ground coffee is not only a much needed crutch but also a legitimate 15 minutes break in the long stretch of reading, writing and memorizing.

Caffeine tablets: if a standard mug of dark roast no longer works, one can try caffeine tablets. However it is rather easy to take a bigger than optimal dose, and instead of enthusiastic revision to spend the night in cold sweat on the bed feeling queasy. Not exactly the result one aims for.

Water: drinking as much of cold water as possible. It actually works, one feels more awake, either because the well hydrated brain thinks better or the frequent bathroom trips make it impossible to sleep.

Breaks: taking a 15 minute break every 1.5 hours improves the concentration. If to believe memory curves, we memorize material better at the start and at the end of the study session, which is not the case for the material covered in the mid-session. Hence it follows if we minimize the 'middle' bit of the revision  at any one time we will retain more material. I want to think this is true.

Questions, questions, questions.

Right, on the home stretch with Pharmacology. Last 15 chapters of lectures, followed by an overview of notes, and then it is questions-here-I-come. Starting to feel the strain of revision now, especially after tucking into the question bank for the first time. Realizing that all of microbiology has to be read over was not the brightest point in my day, especially when it adds on to an already substantial workload.

Second and third order questions are mind bending. It is not enough to just recognize that something they are talking about in the stem, but also know rather detailed background information on that something. After starting the question bank, one gets this sinking feeling that the optimal knowledge level is a long way ahead and the exam date is approaching terrifyingly fast.

Back to books, spore forming bacteria, oh how I missed you from my microbiology review days..

Doubts

The day is getting closer and closer, and just like a knee with damaged ligaments, the confidence gives way more and more frequently. Is it humanly possible to memorize all this information on a part time revision schedule? More personally, do I have the energy and intelligence to get the top mark? Positive thinking and motivational quotations tell one to think positive, 'you are the best', 'you can do this' and so on, but do they change the reality or do they just make one delusional about own abilities? 

Studying part time for Step 1 is tough. The whole concept of personal life does not exist, revision takes over the world for the 9 weeks in the run up to the exams. Everything becomes about time management and time efficiency. All of a sudden other previously insignificant time wasters become magnified to gigantic parameters. Tutorial running at a slower pace, a patient late for the clinic, people walking slowly and blocking the pavement, train delays... all of these things suddenly become an unacceptable hinderance to one's day. 

Th big question is: are all the very best efforts enough?

Rest and digest, or simply rest.

One mistake I will not be repeating again is having a big dinner before heading off to a warm library. There is nothing quite like the experience of trying to fight off the urge to collapse onto the desk and have a snooze when trying to memorize the side effects and contraindications of diuretics. 


In fact, the closer I get to the exam the more comfortable my bed looks. This is not limited to the morning escapades. All of a sudden hospital beds with their pressure mattress and crispy sheets look oh so tempting during a rheumatology tutorial at 2 o'clock in the afternoon. A liter of coffee and a kilo of sugar emergency resuscitation! Now!


While drinking coffee and feverishly cramming pharmacology, the rest of my medical life is on hold. There is a mountain of work unrelated to Step 1, that needs to be done and I am afraid of going anywhere near it. It sits there in the corner and looks at me. I am pretending not to notice and quickly start another pharmacology video. Unfortunately though it will not sort itself out, and eventually I will have to face doing all the preparatory work for the conference I am presenting at on 15th of March, the elective which I am supposed to be going to in less that 9 months time and the article that needs to be written. Eventually is the key word here. I will do all of this eventually, where will I find time is another matter and right now I don't want to think about it.

Likes and Dislikes

I like:


- Dark roast French press coffee and goat's cheese combination: truly brings one to life!
- Sleeping in: the louder the alarm clock the more comfortable the bed.
- Receptors and signalling pathways: because I am just that cool.
- Detective stories: only with a good plot and unexpected ending.
- Food: anything from winter comfort food to experimental modern cuisine.


I don't like:


- Early mornings: dislike with passion.
- Slow people on the underground.
- Weak coffee: or coffee with milk/sugar, it is just not a proper coffee.
- Being late.

It is 20 minutes past midnight and I am getting up close and personal with anti-arrhythmic drugs while drinking the 6th cup of coffee of the day. What else would I rather do...


What materials does one use to study for USMLE Step 1? Personally I am a big fan of Kaplan course. Lectures are great, they chew everything nicely into digestible bits and support them with a great set of notes. Even though I am a passionate bookaholic, when it comes to revision I'd rather not have a massive pile of thick medical books to plough through. That is where the review notes come in, all 8 of them (no more than 400 pages thick each!). Learn that off by heart and you will be pretty covered for Step 1. Easier said than done of course, however it does cut out a lot of filtering of low yield material.


First Aid is good, I am aiming to use it as a final review book. Personally, memorizing a book full of tables is actually worse than memorizing 8 books of text. First Aid is brilliant though for that last minute cram when one is desperately trying to retain all the information that is humanly possible.


Good anatomy atlas, preferably with pictures rather than drawings. I find it is a great supplement to the anatomy module. Sometimes it is better to see it once rather than having to read the description several times.

The D Day has been announced.

31st of March, 2011 at 8.30am.


Yes, after an endless form filling, clicking, posting and waiting I finally know the date. The whole work ethic has been turned upside down, it is no longer an arbitrary exam that will happen sometime in the next few months, it is  now as inevitable as death and taxes (as they say). The leisurely study is turning into Oh-Dear-How-Will-I-Memorize-All-This process.


Chapter 11, out of 15 set for this week. These are just lectures, that is. I have another 12 hours to finish the remaining 4 chapters and go over the notes for the whole lot to actually memorize the drugs. On that note, I am back to barricading myself in the living room with my pharmacology book for the company.

Social life, here I come!

'Aha!' day

Half the block of cheese, 3 cups of coffee and 4 lectures later... 


I like pharmacology, especially when it  is taught well. It is a similar experience to walking overground between different tube stations, it is the same 'Aha!' moment when connections between familiar but previously disjointed places become apparent.


Did you know that nicotine (found in cigarettes) produces similar effect to a rare tumour pheochromocytoma? In fact this is its mechanism of action for causing damage to cardiovascular system. All of this is due to a small cute nicotine receptor that sits happily in a membrane minding its own business, kicking open ion channels when it is being tickled, without even realizing its power and damage it could potentially cause. If fact, if blocked, it could wipe out the whole of ANS, he is a one powerful chap. It is a pity he is not very clinically relevant.

Progress Report:

Microbiology: tick! Done and sort of dusted. Let's see how much of that I will remember in few weeks time.


Pharmacology: I actually like this subject (something one doesn't encounter very often during revision period). Receptors are cool. Fact.


Curious fact of the day: active components in grapefruit juice (furanocoumarins) can inhibit the metabolism of many drugs such as midazolam, atorvastatin and cyclosporin. These active components may also block drug transporters in GI tract leading to enhanced oral bioavailability of some compounds. 


Moral of the story? If in doubt, don't drink grapefruit juice!

Dear diary,


I need more hours in a day.


Flicking through USMLE preparation forums and journals I have noticed an ongoing theme of self pep talk and constant repetition of motivation mantras, and that's from folks who study full time. I am not sure whether I should be worried about or proud of my laid back attitude. [Something tells me this is not the term my household would use, neurotic would be more like it]


Some folk take out 3 months to study for Step 1. How do they do it? 3 months is a very long time to dissapear off the life radar, never mind a medical life radar. What about attachments? What about ongoing projects? What about publications? Oh, and also there is a matter of a family life. Where does that fit in?


Currently my 'To-Do' list has 4 subsections, and items are being added on faster than I can tick them off. The more items there are on my 'To-Do' list, the more I want to lock myself in the flat and play piano all day.


So, dear diary, how about extra 24 hours per day, please?


PS: At the risk of turning into one of THEM, a personal favourite motivation quatation encountered while clicking through preparation forums:


"Dont quit when the tide is lowest, For it's just about to turn.
Dont quit over doubts and questions, for there's something you may learn.
Dont quit when the night is darkest, For it's just a while til dawn
Dont quit when the hill is steepest, for your goal is almost high.
Dont quit when U have run the farthest for the race is almost won
Dont quit for you are not failure until you fail to try"


by Jill Wolf

USMLE Step 1 prep: Day 1 (Enthusiasm day)

Given:


- 1512 hours
- 5 subjects
- 129 chapters


According to the master schedule, I should be getting through 15 chapters a week. That will leave me with sufficient knowledge to get that desirable 99 plus some time for last minute cram.


The question is, will it really happen like that? I admire people who make schedules and stick to them. Me, I just make schedules. Quite frankly, I cannot remember the last time I actually managed to stick to one from start to finish.


This morning will go down in my own little history as one of the rare tranquil mornings. For starters, I am actually drinking my coffee sitting down, which already in itself is a change. There is no rush, there is no stress, and there are no emails in my inbox.


Just as I like it.