Reply turned post, COMLEX and USMLE style

A reader and fellow medical student who blogs at the Dark Autumn Hour asked me why I took both versions of the step I board exams. For most of my readers who are not medical students, especially osteopathic medical students, this question and corresponding blog post may sound like wah wah wah, but it is a huge issue in osteopathic medical schools, so I thought I would address it with an entire post.

Here is just a little background for those of you who aren’t osteopathic medical students and are reading anyway. There are two types of medical school and degree designations for physicians in the United States: D.O. (also called osteopathic) and M.D. (also called allopathic). (There are also two for dentistry: D.M.D. and D.D.S.). I am not going to get into the differences in training or controversies regarding the different designations now. Licensed D.O.’s and M.D.’s have the same practice rights in all 50 states and enter all fields of medicine.

Both medical designations have 3 parallel but separate board exams that one has to pass, step I and II in medical school and step III at the end of residency, in order to become a licensed physician. The osteopathic exam is called the COMLEX, and the allopathic exam is called the USMLE. I just took step I. I took both exams, allopathic and osteopathic.

There are many more allopathic medical schools and residency programs than there are osteopathic programs. Osteopathic students can and do apply to allopathic residencies. The opposite is not allowed. Again, not the topic of this post, but a controversy. When an osteopathic medical student is applying for a residency spot in a pool that includes mostly allopathic students at an allopathic institution, their measuring stick will be the USMLE. Some programs say they will consider COMLEX scores, and some osteopathic students have gotten residency spots with only a COMLEX score. But, in general, for many reasons, many allopathic institutions do not have any D.O. residents in their ranks. So, every osteopathic student in their second year has the option of taking the USMLE in addition to their COMLEX.

OK, here is the reply:

Isn’t that the question on everyone’s minds in the first few years of osteopathic medical school?

I took both for a few reasons. I had to take the COMLEX to finish my school’s academic requirements. However, there are no osteopathic obstetrics and gynecology residencies in my state. I find that especially pathetic, since we have no less than two osteopathic medical schools in Florida. When I first went to the ACOOG website to search residencies, I thought I was doing it wrong. But, no, unfortunately, osteopathic ob/gyn residencies are heavily concentrated in a few states, like Pennsylvania, Michigan, and New York. They might want to reconsider their search by state option, since the vast majority come up empty. (OK, I just checked out the site, and they may have removed this option.)

I am geographically limited. Severely. I have joint custody of my older son, and his father lives about one hour south of me in South Miami. There is only one ob/gyn residency within 6 hours of his house. It is allopathic, obviously. I have heard of D.O.s being accepted there in their internal med program with only a COMLEX score, but I wasn’t sure about the ob/gyn residency. I know of a D.O. student who wasn’t accepted there, and spent a year as a rotating intern, then accepted for this year. (He is probably starting this week. I need to get his contact info and pick his brain.) Another student from our school matched there, but I didn’t know her and have no idea if she took both exams.

According to APGO, 600 people applied for 9 slots there. I have also heard they grant a maximum of one D.O. slot per year, although, including the intern, there are two this year, both graduates from the osteopathic school I am attending. So, it’s going to be really competitive. I don’t want the lack of a USMLE score to hold me back. (Let’s hope a lousy USMLE score doesn’t hold me back!) I have shmoozed some of the attendings over there and plan to do some elective rotations there, so I hope I have a shot. I will unfortunately be competing with some be competing with friends from my school for what may be one or two D.O. slots.

There are a few other programs in Florida, and one in Asheville, NC, I may apply to (my husband’s folks have a house near there, but I may have to go to court to take my older son there). No matter what, anywhere I get in other than the Miami program will involve an alteration in our custody arrangement.

There are many arguments both ways about whether D.O. students should take the USMLE. Each exam costs $500 and takes about eight hours. D.O. students are educated slightly differently, and tend to do slightly worse on the USMLE than M.D. students, and a higher percentage will fail. I took both exams, and in my opinion, the USMLE questions were more difficult. The writing style, vocabulary, the question stems, and the amount of higher level thinking rather than rote memorization was dramatically different between the two exams.

Some of my classmates signed up for both exams. Some ended up taking both, and some changed their minds and didn’t take the USMLE even after paying the substantial fee. We got advice from former students emphatically pushing us in both directions.

In the end, I hope I chose best. I hope my score on the USMLE is adequate. I can always withhold my USMLE score and only present my COMLEX score, if I did better on the COMLEX, but the residency programs will see that I am withholding the score, which is pretty much saying I bombed.

Debunking Canadian health care myths

An excellent article debunking Canadian health care myths. I hate arguing with people about health care who know nothing about the realities of how little they are spending elsewhere for much better outcomes and more coverage.

The only answer is single payer.

Yes. This.

Read this excellent post on Science & Sensibility in reaction to this already excellent article in the New Yorker about health care costs and outcomes. I had the same reaction as Amy Romano when I read Atul Gawande’s article:yes yes, but what about obstetrics? If you need an example of costs and procedures run wild at the expense of outcomes, there you go.

Right on, senator

“There is a very small chance any Republicans will vote for this healthcare plan. They were against Medicare and Medicaid [created in the 1960s]. They voted against children’s health insurance. We have a moral choice. This is a classic case of the good guys versus the bad guys. I know it is not political for me to say that. But do you want to be non-partisan and get nothing? Or do you want to be partisan and end up with a good healthcare plan? That is the choice.”—Senator Jay Rockefeller (D-WV), on the necessity of a public healthcare plan and the futility of bipartisanship when it comes to doing the right thing.

(H/t Shakesville)

Pull me out and tent me with foil because

I’m done.

Done done done done.

There is a distinct possibility I may not have to study for anything for an entire year. I may possibly *gasp* read some fiction.

One day until COMLEX

My second step I board exam, this time the COMLEX, is tomorrow. More luck and vibes, please!

I just took a sample exam on the NBOME website. I am pretty happy, having gotten an 86%. A few of my errors were really stupid, and I knew the right answer. One could have easily been remedied by reading more slowly and not being distracted. I won’t being singing Intergalactic by the Beastie Boys and jamming out to my iPod in a crowded coffee shop during the real deal, so I may notice that the scenario about the fainting young woman includes the tidbit that she never injures herself on the way down, indicating malingering.

My pessimistic side is saying I just answered 50 questions on their website that most likely will not be on the exam, since they are on their website. Meh. I hope this indicates that I have a breadth of knowledge likely to be on the exam, but I am not sure.

One comment. We are actually allowed to type and save comments about specific questions on the exam, apparently. I don’t know if I will exercise this option. The instructions did not indicate if these would be read or considered by the powers that be, or a place for me to make notes in case I have time to return to the question.

I used to write comments on my paper exams at school, such as “WTF?” and “You said we didn’t need to memorize specific degrees of angles of components of normal gait!!” next to offending questions. Since it wasn’t on the scantron form, only on my paper copy of the test, I figured it was just garbage. I stopped doing this once I realized my test was always up there first (I am an obnoxiously fast reader and test taker), usually in the hands of a bored department head (or lackey) with not much else to do and no other tests to look over yet.

I never thought of it until one of the professors pointed out, in front of most of the class, that he noticed that I had corrected typos on my exam. I was slightly embarrassed, since my test taking speed is already a much discussed topic among my classmates. I felt a bit of redemption, since people should hear (and stop asking!) that I actually have time to read the questions. Um, yeah, I passed two years of medical school (not to mention the classes and standardized tests leading up to it) by skimming and picking “C”. (That’s my standard sarcastic answer to that.)

But, then I realized if he read my corrections, he most likely read my other editorial comments. I racked my brain trying to remember if I had written anything rude about any of his questions. I doubt it; he tends to be a straightforward test writer, but you never know. I stopped writing out the sarcastic comments at this point.

Anyway, back to the practice test and the ability to write comments. I did type one on the practice test, just to try it out. I doubt I will use it on the actual COMLEX, but I was spurred to try it out today. The stem of the question was the patient’s history. A middle aged male patient came in with various complaints, the chief complaint being headaches. Examination of the patient finds hemiparesis. Um, huh? My comment: “What patient would not complain of being paralyzed on one side?”

Mr. Patient, I know you mainly are concerned with your headaches, but did you notice you can’t move half your body and most likely couldn’t have even walked in on your own volition?

Lazy question writing. Just saying. Poor dude had a chronic subdural bleed.

Feel better Friday

I felt like I just went through a meat grinder. I just swam with a beer (or two) before being prematurely evicted from the pool by thunder. I feel a bit better.

This popped up on the shuffle while I was swimming, and I figured it was appropriate:

Step I USMLE tomorrow

I have the first of my step one board exams tomorrow.

Wish me luck. And, if you see me surfing around anywhere on the interwebs, tell me to get back to studying!

“Natural” birth control pill

Bayer Schering Pharma, the makers of Yaz, has launched a birth control pill in the United Kingdom that is bioidentical to female hormones. It is synthesized from plants.

Fascinating.

Yes, it’s 3 a.m. I had way too much coffee when I was studying. I will be trying to sleep soon, I promise.

ETA: I wonder if they will have to retract any of the advertising for this birth control pill. I don’t think they are allowed to advertise prescriptions directly to the consumer in the UK.

Reply turned post, HIV testing for neonates style

This is one of those three way mirror type reply turned posts. If you want to follow the background, the comment thread appears on this post, but it is actually referring to an older post I wrote about mandatory HIV screening in pregnancy. This reply is in regards to the common practice of testing the newborn when the mother refuses.

I am really conflicted about this. Because, in essence, it is testing the mother. It is not the baby’s antibodies being tested, it is the mother’s that she transferred to the baby. A baby won’t have a valid HIV test until it is 12 months old or more, generally.

So, if it is to decide whether to administer AZT to the baby, which would be what it would be for, I would assume, I would also assume the same woman would probably refuse to have the baby treated. So, where are we then?

I am definitely speaking hypothetically, of course. If I get the local residency I want, I will be in a hospital system where I face the reality of caring for women with HIV and unknown HIV status.

If her child is going to be removed and become a ward of the state, then testing may be ethical once she has relinquished parental rights. Is it ethical to give AZT to a baby against the mother’s wishes? Will the state get a court order to take custody just to administer the medications? How soon until we get to imprisoning women with HIV? Oh, wait we already are.

That being said, I agree it is obviously better for the health of the baby and the mother if they know their HIV status and are medicated. And, both may be lost to the system if not screened and treated at this point. Pregnancy, especially labor and delivery, is a unique time in which women have more access to care due to increased Medicaid coverage and women seek out more care in the peripartum period than when they are not pregnant. But there are lots of ticking time bombs out there that don’t get the government in their lives like women do at the point of delivery. I think she should have a psych consult, possibly, and/or a social worker and a compassionate practitioner who can find out what is going on in her life and why she is refusing. Maybe she will agree at a follow up appointment. Maybe she will sign a release for the baby 12 hours or 18 hours after the delivery. How often does this even come up, and when it does, is it worth it to override her autonomy and remove the child from custody?