Rules for Step 1

I haven’t written in a while because I’ve been in a hole these last couple weeks studying for Step 1, or “the boards” as it is colloquially known. Step 1 is the first of three licensing exams you have to take to become a doctor.

Which, of course, means that Step 1 has almost nothing to do with doctoring. It’s not that bad a test, actually, it’s just incredibly challenging to assess medical knowledge. Step 1, for instance, focuses on the basic science – the science underpinnings to how the body works and what goes wrong in disease. Future exams, like Step 2 and 3, focus on the bigger picture of diagnosis and treatment.

I’m taking four weeks to study, which is slightly less than average because I burn out faster than most people by virtue of my goldfish attention span, and taking the exam in early August. To prepare I’ve sequestered myself in an isolated Maryland river house where the closest Chipotle is exactly 14.6 miles away.

It’s just me, the dog, and a stack of review books. And a GoPro. I periodically strap this on the dog and do things like dump him out of a boat and make him swim for shore.

Anyway. Presumably we learned all this material first year, a belief that is at best a stretch. But even if we had learned it the first time, we promptly forgot it during rotations: the kind of intracellular pathway insulin uses stops mattering pretty fast when you’re being mercilessly pimped on pelvic floor dysfunction. So now it’s time to learn it, and everything else, again.

Generally, my schedule is boring. I wake up, work out, put the dog out, drink coffee, bring the dog in, shower, and spend the next twelve hours studying. I read review books in the morning, and in the afternoons I do sets of practice questions.

With two-plus weeks done, I have developed three simple rules of thumb for doing well on questions.  (Sadly, if you don’t have any medical background this may not make much sense, although you will certainly think I am a much worse person than you already did.)

  1. Be as racist as possible.
  • Black people have sarcoidosis, sickle cell disease, keloids, and high blood pressure. Black women definitely have sarcoidosis.
  • If a black person has yellow eyes, the correct answer is “protection from malaria.” Don’t ask why, it just is.
  • White people have cystic fibrosis, osteoporosis, weird skin things, and congenital diseases.
  • If the person is Jewish, they have a genetic disease and they will probably die from it.
  • Asians have a blood disorder called alpha-thalassemia. Japanese people have stomach cancer.
  • Every immigrant lacks every vaccination, regardless of where they are from.
  • Eastern Europeans have tuberculosis. South Americans have parasites.
    • Vacations to Mexico always end with parasites. Don’t go to Mexico.
  1. Be as misogynistic as possible.
  • Males, and only males, have hypertension and abdominal aortic aneurysms. They also have heart disease and bad cholesterol.
    • The answer is always aspirin.
  • Women with high blood pressure have an exceedingly rare disease called “fibromuscular dysplasia.”
  • Women of childbearing age are pregnant. Women of childbearing age who say they are not pregnant are definitely pregnant.
  • Women get autoimmune diseases, all of the psychiatric disorders except for schizophrenia, and something is definitely wrong with their hormones.
    • The answer is “oral contraceptives,” unless they have right upper quadrant pain, in which case the answer is “stop oral contraceptives,” because they have a liver tumor.
  • Women have iron deficiency anemia.
  • Women with chest pain have an anxiety disorder until they get an ECG that shows otherwise, in which case they have lupus pericarditis.
    • In the unlikely event a woman is having a heart attack, it is always an inferior myocardial infarction. I don’t believe that’s supposed to be social commentary, but I didn’t write the questions.
  • Female children have Turner Syndrome. Still.
  • Male children have Down’s syndrome or bone cancer.
  • Old women have Alzheimer’s. Old men have Parkinson’s.
  1. Be as judgmental as possible.
  • Male teenagers are on steroids.
  • Weightlifters, football players, and angry people are on steroids.
  • If they have acne, they are on steroids.
  • Basketball, soccer, and lacrosse-playing teenagers are about to drop dead from hypertrophic cardiomyopathy.
  • If the person is a “healthcare worker” of any kind, they are surreptitiously dosing themselves or their loved one with a mystery medication, most likely a diabetes medicine.
  • A homeless person has either pancreatitis, alcohol withdrawal, or Wernicke’s encephalopathy. It is always one of these three things.
  • Tall people have Marfan Syndrome.
  • IV drug users have one or more of the following:
    • HIV/AIDS
    • hepatitis B and/or C
    • bacterial endocarditis
  • A teenager diagnosed with a sexually transmitted disease does not want to tell her parents.

I would give tips on the “empathy” questions, but I always get them wrong.

…No, but seriously, I do. They’re hard. Shut up.

Anyway. I wish I could say that just knowing the diagnosis gets you the answer. Unfortunately, Step questions usually make you go a step further, explaining the effect of the gene mutation in cystic fibrosis or knowing exactly how some virus predisposes you to developing cancer. So even though you might know the answer is Turner Syndrome (it’s always Turner Syndrome, remember?), the question will ask for the most common defect.

(I always want to say “coarctation of the aorta,” because I am stupid, but the answer is “bicuspid aortic valve,” which is just as stupid.)

Back to the books to figure that stuff out.

8 thoughts on “Rules for Step 1

  1. This is so true; I have noticed that 19 to 25 year old patients are referred to as either girls if female or men if male. No 19 year old man is called a “boy”. Question writers are sexist, racist and judgmental!

  2. Seems like you’ve covered just about everything. If the exam was based on gross generalizations, you’d earn A++

  3. Sounds like you are keeping up your schedule very well with tillers help! Today I was reading about dr. Oliver sacks and found his TedTalk lecture about Charles bonnet syndrome re hallucinations in visually impaired. I wrote to him to thank him for his writings.he. Taught us the importance of music for a person with dementia. Keep smiling,love,grandma

    Sent from my iPad


  4. Pingback: Taking a (Practice) Step 1 Exam | Laughter is the Best Medicine

  5. Pingback: Rules for Step 2 | Laughter is the Best Medicine

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