Exams in Medical School

Exams, exams, exams. If I could summarize medical school in one word it would be this one: exams. We have written exams, which assess our clinical knowledge, and physical exam exams, that is exams which assess our clinical skills. One after another, it’s just more and more exams.

I have the good fortune of being a good test taker, but the misfortune of having terrible exam anxiety. The kind that strikes deep in the belly, the gastroesophageal dread that refluxes into your throat. Over the years, as I have taken more and more written exams in medical school, my ability to manage the stress that accompanies them has waxed and waned. For several of the past few exams I have had, I have woken the morning of with a migraine. Morning migraines are especially shitty because there really is very little you can do about them.

Is it my fault for choosing a field with so many damn exams? Perhaps, perhaps not. Medicine chose me; I did not choose it. In any case, exams are a relatively short term problem; by the end of this academic year, over my first three years of medical school I will have completed 24 written exams. My final exam in July will be my last written exam of medical school, so in many respects this is the final stretch.

In pre-clinical years, exams are written by professors at the medical school, which means the quality of the questions tends to vary depending upon who wrote what. The subjects which are covered include biochemistry, anatomy, physiology, pathology, pharmacology, microbiology, and immunology.

In the clinical years, really just in third year because there are no exams in fourth year, the exams are standardized; the questions are written by the National Board of Medical Examiners. There are six or seven exams you are required to take —depending upon your medical school— which cover the core specialities. These exams are known colloquially as shelf exams and cover the following specialities: neurology, psychiatry, obstetrics & gynecology, pediatrics, surgery, internal medicine, and family medicine. The exams are taken at the end of your rotation which theoretically gives you anywhere from 4 to 8 weeks  to study.

Shelf exams are good because of the preparation they offer for the final exam of medical school, the United States Medical Licensing Exam Step 2. Step 1 is taken at the end of the pre-clinical years, although in some medical schools, Step 1 is taken after the third year. Shelf exams are fucking terrible simply because they detract from your ability to actually learn medicine. Instead of reading up on patients after a rotation, you spend the evening doing practice questions, watching lectures, and reading exam prep books. It provides few opportunities for an ample, on the job, organic learning experience that medicine demands. Maybe other third year medical students are more capable at managing their time, and are able to read up on real medicine concurrent with studying for their shelves. Fuck those medical students. There are nights after a long day of rotations when I barely have the energy to turn off Netflix after dinner.

Studying for the shelves is not learning real medicine; in studying for the shelves, you learn how to beat clinical vignettes, and pick out the clues that lead you towards the diagnosis, and then you search your brain for a few milliseconds to conjure up the next best step in management.  While learning the next best step in management is arguably quite useful, it’s of little value when we only learn how to recognize obscure, esoteric diseases in the context of a clinical vignette, while retaining little to no idea of how the clinical presentation would actually appear in vivo, in a living human being.

So what gets me through the long days of doing my best impression of a doctor followed by late night study sessions? For one thing, I genuinely love to learn. The fact that my studying is required is what makes it sometimes utterly unpalatable to me, given my authority complex. If there’s one trait that is essential to surviving medical school, it’s a genuine curiosity, an authentic ardency for acquiring completely useless and oftentimes clinically irrelevant knowledge aka trivia. Honestly, that’s what a lot of medical school is; I happen to love trivia so I guess I fit right in.

For another thing, there is a light at the end of the tunnel (or so I tell myself). Doing my best on these exams means I am giving myself the best opportunity to do well on Step 2, which means I am giving myself the best opportunity to get into my best possible residency program, which gives me the best opportunity to obtain the best possible training, and become the best possible physician I can be. Perhaps that is an overly simplistic view, but it’s part of what keeps me motivated to keep going. Speaking of, I should really get back to studying for my pediatrics shelf right about now, to learn about some impossibly rare disease I will likely never encounter as a clinician.


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