Wednesday, February 16, 2011

This is only a test.

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"What it all comes down to. . .
Is that everything's gonna be fine fine fine
'cause I've got one hand in my pocket
And the other one is giving a high five
. . "

~Alanis Morrisette's 
"One Hand in my Pocket"* circa 1995
*(constantly played on my mental walkman and real walkman during my med school days!)


When I was a medical student, we were on a standard grading scale--A, B, C, (no 'D', sorry) and F.  You studied hard. You pulled all-nighters. You drank four cups of disgusting coffee in a row, and then you arrived to your lecture hall bright and early to take your lumps, err, I mean exams. And a few days later, there was no mistaking where you stood.  A-B-C-(no 'D', remember?)-F. Period.

A lot of medical schools have gone to a pass/fail system of grading. The drill, for the most part, is similar. You study hard and pull the all-nighters, but now it's a little more fuzzy. Either you pass or you don't.  It's kind of like being pregnant.  You go into the bathroom with the stick, and when you come out, there's either there's two lines or one.  No room for "Mr. In-between."


Somewhere toward the end of the pre-clinical training with all of its pass-fail nebulosity, the anxiety begins. A deafening sound begins pounding in the chests of medical students which they mistake as palpitations when really it's that ginormous drum roll revving up toward the US Medical Licensure Examination (boards). . . .

Thump-thump-thump-thump. . . . .been pass/fail up 'til now. . . .thump-thump-thump-thump. . . . studyin' for boards, 'bout to have a cow. . . .thump-thump-thump-thump. . . . straight P's 'til now, I've had it made. . . .thump-thump-thump-thump. . . .this board exam will feel like my very first grade. . . .thump-thump-thump-thump. . .

Something like that.

And therein lies the problem.  After all this pass/fail business, a whole ton of weight ends up getting placed on this score--this three digit number that suddenly becomes the first publicly objective measure  of where you stand as a medical student. Uggghh.

So like clockwork, it happens. Smart students start freaking out. Pulling out their hair, crying into the crooks of their arms, and having panic attacks over their MacBook pros.  Terrified that, after two years of exceptional test scores that only they and a few powers that be could fully appreciate, everything will come down to one painfully long day in a testing center.  The days of "P = MD" are officially over and by the time it's test day, the drum roll is thundering so loud that the student can barely hear their own thoughts.

Thump-thump-thump-thump. . . . 

If the student is lucky, it's a good day when they take the exam. The birds are chirping, the boyfriend is calling, the hair is behaving, and the knowledge is resurfacing.

If the student isn't so lucky, the day leaves a bit to be desired. A cat is in heat next to the bedroom window all night, the girlfriend accidentally pocket dials while giggling a little to flirtatiously with some dude that you know for sure ain't you--only because you're you, and you're not there. A bad haircut throws your looks into serious question and the knowledge that day? Oh man. You can't even remember your social security number to gain access into the testing center. And if you're lucky, it comes together at some point.

But either way, whether you had a good day or not, a few weeks later, you get a lovely little token via email that includes three digits:  Your board score.

And like I said . . . .for many students, this three digit score has suddenly become the very first outward measurement of their awesomeness as a medical student. And that?  For uber-achieving academic types (aka the type of folks attracted to medical school in the first place) is a hell of a pill to swallow.

And so.

To those whose three digit score is so high that it makes program directors like me stop and scratch their heads and saying, "Damn! I didn't even know you could get a score that high!" and also to the others whose three digit score so narrowly ekes by that they spend six straight weeks wailing over a box of Puffs Plus tissues wondering if they will ever, ever become somebody's doctor. . . . .I have a message for you all:

It's only a test. Seriously.

When I was a medical student, we all took that heinous little USMLE Step 1 on the same day all over the country. This was before the computer centers and before the staggered test dates. And back then, every person in the U.S. and beyond got their scores on the same day.  A treacherous little situation, I tell you.

So picture it:  June 8 and 9, 1994. Two painful days of sweating bullets over scantron sheets after two months of denying ourselves anything remotely close to fun. We took the exam, and on July 1, we hit our clinical clerkships in our short white coats--before the scores came back.

Mid-July we were all working on the wards, doing what spanking new clinical medical students do. And then, that's when the message arrived. Some kind of inter-office telegram (don't I sound old now?) came to all of the hospital rotations and attendings interrupting everything:

"Release all M3 medical students ASAP to the Dean's office to pick up USMLE Step 1 Scores."  Stat.


Back then, the scores hit the Dean's office before they hit your mail box. This was before the whole email thing was available to allow you that privacy of logging on at home.  And sure, a lot of people just waited until they came via snail mail. But at my school? This was the culture: to report to the Dean's office.

But in 1994 there was a problem.  Something really terrible had happened. . .so terrible that the Deans summoned us all out of our classes immediately to get our scores. For the first time ever, for some inexplicable reason, some unconscionable number of people in my class had failed, yes failed, the Step 1 boards. This meant, they didn't get a three digit number that was even high enough to pass go or stay on their clerkships.

Yeah, girl. A scary percentage of your class, the rumor mill gushed. Even the smart ones. Did you hear about so and so?  Even HE didn't pass. And what's-her-face, the student leader? Yup. She didn't make it either.

Lawd have mercy.

I'm telling you. . . .the walk from the parking lot to the Dean's office was like the freakin' green mile, man.  And even worse? All of the pre-clinical students were sitting outside of the building like vultures--staring at peoples' facial expressions in an effort to discern whether or not they were in the number who'd made it or in that dismal group who had pseudo-disgraced the institution.

Lawd have mercy.

A close friend/class mate and I met in the parking lot. We locked arms and charged our way into the building. We pushed past the vultures, refusing to make eye contact with them.  Once inside the building, it was eerie.  I'll never forget it. . . two really smart people were sitting cross legged on the floor near the lecture hall. One was crying, the other was consoling.  "We will get 'em next time," the consoler murmured as the cryer heaved over and over again.

Lawd have mercy.

I tightened my grip on my friend's arm.  We finally make it into the Dean's office where we're each handed an envelope with our score in it.  As a side bar, there was this executive secretary who was known for her vacillating emotions while giving out the results.  Allegedly, she'd show you all kinds of  love if you'd done well, and give you the hairy eyeball if you hadn't.  My experience was somewhere in the middle--a big smile while being given the hairy eyeball. Perplexing. But I digress. . . .

So me and my friend decide we will take a deep breath and open them together.  We studied hard, we told ourselves. We did fine.  I opened mine first:


Okay, I admit---I was so happy to not be one of those who hadn't passed, that I barely realized the relative crappiness of my score.  A little under the national average, which is a nice way to say that it was sho' nuff below average.  Damn.

Next we opened my friend's score:


Tears. Hugs. Consolation.

"I will never be a doctor!"

"Yes, you will. You will."

"This is the end of the world."

"No, it's not. It's not."

But you know what?  At that moment, it really did seem like it.

Well, a lovely little thing happened after that.  Time.  It marched on and gave me something that must marinate before you can really use it: perspective.  And now, I know for sure--it wasn't the end of the world. It so wasn't.

I've met some medical students with amazing board scores who had amazing work ethics and clinical acumen.  But I've also met some test czars who were pompous and unprofessional jerks. And high scores or not, I wouldn't want them anywhere near me or my loved one. One of the best students I'd ever had the pleasure of working with had received a whole lot less than stellar score on the first and second board exam.  He just wasn't a good test taker. But a good doctor?  I tell you without flinching--he remains one of the best I've ever seen.

So with my perspective, I know that folks with three digit scores that don't break records can and do become exceptional physicians. And the other thing is this-- at the end of the day, the patient wants someone who cares enough to listen, to learn, to try, and to know when they need to go find out more.  The patient wants someone who comes through not just in a computer testing center, but when it really, really counts.  A doctor that holds their hand and calls them back. One that remembers what they said.  And that?  That never comes up on those exams.

Let's not get it twisted--I'm not saying that objective measures for medical students and residents should fly out of the window. But I do think that more emphasis should be placed on professionalism, humanistic qualities and how well students care for patients. I just wish there was some universally objective measure that trumped those pesky three digits --especially considering how easily they can be thrown into an upheaval by anything from a feral cat outside your window to an idiotic boyfriend who breaks up with you on Facebook two days before the exam.

The friend who failed the board back in 1994?  A wonderfully successful physician and community leader with legions of loyal patients.  One of those "smart people" who was sitting cross-legged on those cold tiles weeping that fateful day?  Nationally known and recently promoted to one of the most coveted leadership positions at their institution.  And me, the one who made it through just by the hair on my chinny-chin-chin?  I think I turned out alright, too.

And so. . .to every three digit scorer young and old, I say this:  Give it your all, study hard--but then relax. Because at the end of the day, the truth is this: It is only a test. But the patients? Those real, breathing, living patients? That part ain't a test. And as long as we can keep that part straight, the rest of it comes together.

And what it all comes down to. . .
is that no one's got it all figured out just yet
'cause I've got one hand in my pocket
and the other is playing a piano. . .

And what it all comes down to my friends
Is that everything's just fine fine fine
'cause I've got one hand in my pocket
And the other one is hailing a taxi cab. . . 

~ Alanis Morrisette

Somebody needs to hear this song today, too. Aren't we all brave but chicken-sh@%?


  1. THANK YOU for helping me maintain some sanity. April 8 is D-Day!

  2. Love this. I guess you could apply it to most exams too - I know that I definitely work myself up about exams and worrying about marks at times. :)

  3. Wow!!!! Thank you. I think this post was written for me. I recently failed the USMLE step 1 and honestly felt that it was the end of the world for me. I have followed your blog for quite sometime and usually read it in the evenings After studying. This post has given me hope and perspective that if I keep pushing I will make it to the end of the road just as your friend did. Once again thank you so much for sharing this story!!!!!

  4. Marwah, I am happy you read this. Erin, good luck to you! And Lucy, thanks for always reading and commenting! You remain the wisest teenager I've every known! (Much wiser than me at 16!)

  5. Thank you, Kim! :) I just try to be reflective. I really love reading your blog - waiting for the page to load and hoping there's a new gold nugget for me to read. :) I'm still not sure what I want to do when I leave school, but reading some of your posts makes medicine look like a really rewarding career. :) Thank you for being such an inspiration to me. :) You make me want to make a blog too - but I have no idea what I'd write about, I'm only a schoolgirl, not a whizzy internist like you, with patients that I have the pleasure of being able to learn from every day.

  6. Marwah, I think it's really great that you're not allowing this to define who you are, or who you are going to be. I have a bunch of quotes on my bedroom wall, and I'd like to share one of them with you.

    'If you have made mistakes, even serious ones, there is always another chance for you. What we call failure is not the falling down but the staying down.'

    - Mary Pickford

    Keep your chin up! :)

  7. Perfect timing - I think I'll get that pesky email tomorrow. And I was definitely one of those freaking out - although, really, with a newborn, who wouldn't be? Getting about 4 hrs of sleep a night and trying to keep all that darn information in my head was not working. Fortunately my adviser (and your friend, Dr. B) got me straightened out - or at least as straight as was possible.
    Here's to the joy of patients, the joy of family, and the understanding that a number will never define the depth of our caring and the joy we have in serving.


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