Saturday, August 27, 2016

Plot Twist

I guess my life just had a season finale. No, I’m not dying or anything even moderately close to it… That opening sentence comes across pretty melodramatic, which was not my goal. This is based on something I saw on tumblr the other day. I can’t find it again, but it was something to the effect of “Do you ever feel like your life is a TV show and the writers have started doing some crazy shit just to keep it interesting?” For some reason, likely the eloquent way in which the poetry was written, that line of prose stuck a chord with me. In my life there has been some “crazy shit” lately, or, as they could be called affectionately if I had any affection for them: character building opportunities.

Character building opportunity #1: Failing step 3. Subtitle: Irony is not funny at all.

I failed step 3, or step 3 failed me. Both of these statements have a lot of emotional baggage so allow me to lay out the facts. As of December 11th, 2015, the minimum passing score was increased from 190 to 196. My score, which I received a morning approximately 6 months later was 195.

This score is obviously not a percent… clearly 195% of correct answers would be an adequate score to pass. For those unfamiliar, Step 3 scores are assigned a magical number that is somehow calculated based on the number of multiple choice questions you answer correctly and various interactive cases in which you proceed with patient care correctly. How the cases are weighted in relation to each other and in relation to the questions is unclear. How the cases are graded at all are unclear: obviously if the patient dies, I assume you lose all credit, but is it partially right if you intubate them before they die? Or reorder the right chronic medication?  Or diagnose them properly post mortem?  Clearly, my bedside manner is not the problem.

It is a terrible experience. All of the step exams are. Ask any attending physician if they enjoyed studying for Step 1, 2, or 3. Better yet, tell them that you are – likely they will grimace and express condolences. Even worse, step 3 is a two days of a terrible experience. Day one, you arrive bright eyed and bushy tailed, ready to slay the dragon before you. All 233 multiple-choice questions of dragon. These are divided into 6 blocks of approximately 38-40 questions. Factor in forty five minutes of break time to be divided up between hunger, thirst, nature calling, emotional breakdowns, google searches for how much a plane ticket out of town that same night would cost and a 5 minute tutorial and you have about 7 hours of fun.

When you arrive for day two, you’re already tired. You no longer have the benefit of cautious optimism that has grown as a scab since your last step exam. The raw tissue is now exposed. You know exactly how much pain is involved in staring at a computer screen for an entire day and trying to remember that one day in Immunity and Infection when you went over the mechanism and side effects of Isoniazid and whether or not it interacts with this pretend patient’s lengthy list of medications. You are still haunted by the half dozen questions you knew you didn’t know yesterday – the ones that stuck in your mind and you looked up on break or when you got home, hopeful that you remembered the correct antibiotic, contraindication or physiology. Of course the ones that stuck are the ones you don’t know – at this point, you’ve fully lost sight of every question you got correct. Success is simply what is expected of us – the system has taught us what we need to know, but failure – that is a burden you carry alone: you should have worked harder, studied longer, known more.

You would think that with all this factored in…. For a test for doctors, theoretically designed by doctors – others of our cohort who have faced other exams, medical school, stress, fatigue and anxiety… There are a million reasons to see the logic behind making the second day of testing the shorter of the two. It is like putting the last 100 meters of a 5K on a downhill slope, while it will not drastically change the race outcome, everyone feels a lot better as they cross the finish line.

On day two, the dragon is bigger. As if this post weren’t already nerdy enough, he is the Hungarian horntail of test dragons. There are fewer total multiple choice questions, but because simulated patient cases are involved, the day is longer overall and involves almost 9 hours of sitting in front of a computer screen, pulling out your hair and (in my case) getting yelled at for sitting Indian style in the chair. (Which deserves a separate rant, but seriously? If anyone has figured out a way to cheat simply by sitting Indian style after the invasive full body search performed each time you enter the room, perhaps that person has earned the right to 4 more questions correct.) There are an additional 180 test questions to be answered and 13 individual simulated patient cases to complete. Generously, they once again provide 45 minutes of time to get coffee, buy chocolate and rethink your life choices.

Let’s do the math. I have no idea how these scores are computed and I can’t find much evidence of it online. I’m not sure what threat to medical integrity would be risked by ensuring transparency of these procedures, but apparently it’s not a risk worth taking. However, there are approximations posted on forums: one such equation is 3 digit score = % correct * 2.8

Here goes. Score of 195 – my percentage correct would have been 69.64%. Passing score = 196, which is equivalent to 70% of questions correct. There are 233+180 multiple choice questions for a total of 413. I have no idea how the cases are weighted, especially factoring in that some are longer than others, take place in different locations (ER vs Clinic vs hospital room vs ICU) and have different amount of knowledge involved. For the heck of it, I will assume each case is equivalent in weight to 10 questions. So 13 cases at 10 questions per case = 130 more questions, for a total working count of 543. 69.6% correct of 543 is… drumroll please… 377.9 questions correct. I’ll give the graders the benefit of the doubt and round down… 377 questions that I answered correctly. The passing score, 196, or 70% corresponds to 380.1 questions correct.

Based on an arbitrary number, I have fallen 3 questions short of “what it takes to be a doctor”.

That seems like just the kind of plot twist one would expect in a season finale… actually, didn’t that happen to George in season 1 of Grey’s Anatomy? Sorry… spoiler alert! I understand that the whole point of calling a spoiler alert is to announce it prior to the actual spoiler, but if you’re 12 years behind in that particular show, I just saved you a season’s worth of time.

Character building opportunity #2: Moving away. Subtitle: There is not enough room at the inn.

The Joint Treatment Facility for military medicine of the National Capital Region employs over 12,000 military members and civilians to care for over 545,000 eligible beneficiaries and 282,000 eligible enrollees. (Numbers from the Comprehensive Master Plan for the National Capital Region Medical provided to Congress). Those numbers speak to a pretty impressive staff in the area, so when I was told that after leaving residency, I would be re-employed as a GMO (general medical officer) in the area. Why not? There are literally thousands of jobs around here… it makes sense that the needs of the army would coincide with a job I was qualified for, AKA another faceless GMO in the mass within commuting distance of the National Capital Consortium.

Turns out, these promises that I would stay in the area were misinformed and almost immediately after my resignation was accepted, discussion of new postings were tossed out. Apparently, despite looking for a place for me here, there was simply no room for another GMO. So they considered options – wouldn’t I like to be near family? Where was home for me exactly anyways?

When I informed the person responsible for taking my best interest into account that home was Ohio and sure I would love to be placed near my family, the response was, “Ohio, is there a large army presence there?” which was disheartening for 2 reasons: 1. Shouldn’t the person responsible for assigning jobs in the army know already where there is and isn’t a ‘large army presence’. 2. No, there is not a large army presence in Ohio, so it looked as though being near family would not be an option. I responded that no, the army has not had a major presence in Ohio since our last war with Michigan, which was taken with what has become the company line for my sarcasm here – either the recipient doesn’t understand it or they pretend not to in order to prevent encouraging such behavior.

The back-up options to “move her to Ohio to be with family” were obviously Alaska and Korea. Maybe they understand sarcasm after all.

Someone somewhere in the infinite chains of command where my future was being discussed without my input decided that sending a girl with diagnosed depression to Alaska where the sun apparently just doesn’t shine sometimes might be counter-productive to the needs of the Army. Korea, while certainly sunnier, would leave me similarly isolated.

Long story short, it was decided that if I can’t be close to home I should be somewhere that is going to minimize depression and set me up for success should I decide to return to residency. Lucky for everyone involved, it turns out a GMO spot was available only a short 10 hour plane ride from home.

As much as I love new places, I always hate saying goodbye to the faces. Dr. Seuss should write a book about that. It is going to be sad to leave the home that DC has become and all of the new friends, but I’m excited to say Aloha to new adventures and greener pastures (metaphorically… I guess bluer waters would be a better line) in Oahu - time for me and Lola to learn to surf! Who wants to go on vacation?

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