Rules for Step 2

In case you haven’t figured it out by now, medical school is actually three different curricula in one.

There’s the Learn To Be A Doctor Curriculum, which is where you haphazardly learn to take care of people mostly by screwing up over and over again. This has almost zero connection to the rest of medical school, as the bulk of the Learn To Be A Doctor Curriculum is taught in residency. Not incidentally this is why medical students are often not allowed to Do Things, which as you’ll recall is practically the only thing I want to do. Things.

The second curriculum is the Shadow Curriculum. I have written often about the Shadow Curriculum. This is how nascent, joyfully optimistic/empathic* med students are shaped, like molten steel in a forge, into the sharp, useful tool that is the modern doctor.

(This sounds great until you realize this includes hours and hours of hitting the cooling steel with a hammer, submerging it in water of various extreme temperatures, and sometimes giving up and just throwing the whole piece of shit back into the fire.)

*Yours truly excluded. As a side note, I recently received feedback on a simulated encounter where I had to fake deliver fake bad news to an actor-patient. The evaluator wrote that I “demonstrated terrific empathy.” AND THE 2016 OSCAR GOES TO…

The Shadow Curriculum includes such exercises as pimping, participating in the Downhill Ritual, learning how to properly address nurse practitioners without getting yelled at (this is impossible),** and realizing that for the vast majority of medical conditions, the combined doctoring profession can truly fix very few things.

**I am not being facetious on this one thing. I legitimately do not know what to formally call a nurse practitioner. In my experience, no one knows. Is it “Nurse?” “Ms?” “Nurse Practitioner Betty?” Just Betty? HELP

I am not alone.

I am not alone.

The third curriculum is the Studying To Take Tests Curriculum. As the dear reader might have gathered by now, medical school consists of one gigantic assembly line of progressively more expensive tests. In the first two years there were block exams and shelves, which only cost the exorbitant medical school tuition. Then there was The-Test-That-Shall-Not-Be-Named, which is hands down the worst of all the “board exams.” TTTSNBN cost approximately $600.

In about ten days I will take Step 2, which understandably comes after TTTSNBN. The key feature of Step 2, besides the fact that it is almost exactly three times as expensive as TTTSNBN (in total, approximately 258 Chipotle burritos), is that it is divided into a multiple choice test and a practical test.

The practical test is scheduled separately and is mostly a check to make sure you can speak English, have thumbs, and can introduce yourself without faceplanting onto the exam floor. No one fails the practical test unless they cannot do one of these things, or lack thumbs.

The multiple choice test, while longer than TTTSNBN, is much more clinically focused. Instead of asking stupid questions about biochemical pathways and genetics defects, the test focuses on diagnosis and management of important and common diseases. It is thus nowhere near as bad as TTTSNBN. For instance:

“A 14-year-old girl is brought to the pediatrician for a routine check-up. She has a webbed neck, a shield chest—“

Wait a minute.

“– swollen hands, and low-set ears. She has never menstruated and is Tanner sta–“


“What is the most common cardiac abnormality present in this patient?

  1. It’s not Turner’s Syndrome
  2. It’s not Turner’s Syndrome
  3. It’s not Turner’s Syndrome

It turns out that Step 2 is really a long amalgam of all of the shelf exams we took last year during clerkships, including pediatrics questions such as the above. When taking practice tests, I now remain calm and have only broken 267 writing utensils when coming across the 370 questions about Turner Syndrome. I am improving.

As I have studied it has dawned on me that there may, in fact, be rules for studying for this test. Rules that might help those who come after me to achieve the same degree of mediocrity that I did when I completed TTTSNBN.

Thus, without further ado, I present:


1. Unhealthy people must stop being unhealthy.

  • In order, the most important things to do no matter what the disease are:
    • Lose weight
    • Stop drinking
    • Stop smoking
  • Often, the question will include all three of these “lifestyle modifications,” in which case follow the order listed above. Fat people are sicker than alcoholics are sicker than smokers.
    • Unless they have COPD. Then stop smoking.

2. How To Evaluate Abdominal Pain

  • If the phrases “free fluid” or “free air” are present, the answer is “CUT THEM OPEN YAAAS” because a surgeon wrote the question.
  • If the phrase “rebound tenderness” is present, the answer is “CUT THEM OPEN YAAAS” because a surgeon wrote the question.
  • If the word “hemidiaphragm” appears anywhere in the question stem, the answer is “CUT THEM OPEN YAAAS” because a surgeon wrote the question.
  • If the patient had recent surgery, look for the answer choice that contains the word “ischemia,” because Step 2.
  • If the word “Mexico” appears anywhere in the question stem, the patient has an amoeba eating his liver and you should treat it with something ending in –zole. Doesn’t matter what.
  • Women are pregnant.

Speaking of which…

3. How To Evaluate Pregnant Women

  • The answer is “magnesium.”
  • The answer is “magnesium.”
  • When the answer is not magnesium (or it has already been given), the answer is lupus, because they will want to know insanely minute details about the side effects of a drug no one uses.
  • If the fetus is the wrong size for how far along the mother is, the answer is always “inaccurate dating.”
  • Once the baby has been delivered, the answer becomes Sheehan Syndrome.

4. How To Evaluate Limping

  • Children limping have a rare disease called “Legg-Calvé-Perthes Disease,” which has something to do with the femur.
  • Preteen boys limping have a rare disease called “Slipped Capital Femoral Epiphysis,” and they are always fat. This also has something to do with the femur, although it is somehow different than the dead French person disease above.
  • Limping adults are trying to get on disability or are pain-seeking, especially if they also have back pain.
  • Black people limping have “avascular necrosis.”
  • Old people limping have a broken hip, they are always women, and the answer is “CUT THEM OPEN YAAAS” because a surgeon wrote the question.

5. Miscellaneous Things

  • For an old person with nausea, constipation, and blurred vision: there will be a list of benign drugs (Tylenol, Prozac, ibuprofen) in the answer choices. There will also be one that you’ve never heard of before, like “trihexyphenidyl,” which is of course the right answer.
  • There is no such thing as a healthy immigrant.
    • Mexico: as mentioned above, plus tuberculosis
    • Asia: hepatitis and tuberculosis
    • Northern Europe: multiple sclerosis in women, hereditary spherocytosis in people who randomly turn yellow.
    • South America: really bizarre parasites.
    • Africa: the world is your oyster, but it’s probably malaria and the answer is “peripheral blood smear.”

Finally: a word of unsolicited advice: I am taking a month off to study for, and take, Step 2. This is one hundred percent unnecessary, unless you also want to have substantial time to watch Netflix and college basketball, go to the gym (hahaha just kidding), and drink kind of whenever the hell you want.

I regret nothing.

3 thoughts on “Rules for Step 2

  1. good morning,nathan, medical school sounds so difficult but you treat it with great humor! you have great coping mechanisms that will aid you all of your life. we all feel better when we laugh-esp. self-depracating humor,right? cant wait to see you. love,grandma

  2. Pingback: I Took Step 2 And It Was Long | Laughter is the Best Medicine

  3. Pingback: Helpful Posts | Laughter is the Best Medicine

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