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Light warning: While this post does not contain any of the explicit descriptions of dissection featured in the last two entries, it does, to borrow a phrase from This American Life, acknowledge the existence of cadavers and the events of anatomy lab. Also, my perception of acceptable dinnertime conversation remains off center, so please take that into account as you read this entry.

There is a special kind of fear struck into the hearts of medical students at the mention of the anatomical practical exam. Although this frustrating ritual of medical education has decreased in importance in recent years, it is still an important rite of passage for medical students. I call it a rite of passage because I question its direct vital importance to the learning of anatomy, despite feeling that the actual dissection of cadavers has been immensely helpful in my medical education. To be honest, I think the practical exam exists mostly as a means of motivating us to devote the proper time and attention to studying the cadavers, rather than being an accurate means of testing our mastery of anatomy.

At our school, the exams are held on a designated Friday afternoon. The class is divided up into groups, and each group (ranging from 30 to 50 students depending on the number of questions/stations available) is assigned a time. We are to

Seriously though, who even owns a clipboard these days?

bring a clipboard and a writing tool. Those who wish can change into scrubs, but no safety gear is required.

We arrive in the hallway in front of the lab, drop off our backpacks in the locker room, and stand around nervously. Eventually the anatomy professor emerges and hands us all pieces of paper with 60 blank lines. She instructs us to write nothing other than our names on the papers, but as soon as we enter the lab we can scribble whatever notes we wish. Once everyone is ready we file into the lab through the women’s locker room.

One of the lab instructors likes to spice things up. As we enter the lab there are jock jams blaring from an old boom box, and he’s wearing a bright orange baseball cap backwards as he jumps up and down. The man is in his late 50s at least, with a bushy white beard and an awkward, soft-spoken manner, so the first time I saw this I burst into nervous laughter. The other lab instructors and fourth-year TAs are also standing around in their scrubs and white coats, smiling encouragingly at our obvious anxiety.

We each head to a station. There are a number of cadavers, several models, and a number of computer screens with X-rays or CT images. Each cadaver has two stations, one on each side. Each station has a pin, an arrow or a string tied around a structure, and there is an index card nearby with a question or an instruction. There are several orange chairs positioned around the room as rest stations.

One of the professors gives us our instructions. They are the same every time: “Look at the number for your station and circle it. Be sure to write your first answer on that line. Don’t write your first answer on line one unless you are at station one. Check which number you are on frequently. You will have one minute at each station and there are a certain number of rest stations. Stay in order. Do not skip stations. If you get lost ask for help. If you do not know what structure is indicated, ask an instructor. If you ask anything else the answer will be, ‘use your best judgement.’” He says this last part with a sympathetic smile because he knows this is the most frustrating answer in the universe and the only way for the teachers to get through this exam in one piece.

Then he offers the usual advice: “First get oriented: are you on the front or the back? Which way is the head? Then identify the indicated structure. Next, read the card at your station and write the appropriate answer on the blank that corresponds to that station. Answer only the question on the card. Not all of the cards say ‘identify.’”

There are about eight televisions, the big boxy ones on metal shelves hanging from the ceiling like in public school classrooms. The screens are blue with a number in the center. When the instructor says go, the number starts at 59 and counts down silently to zero like you’re on a game show. Whenever the number hits zero, the lab instructor yells some variety of “rotate!” or “move!”

The instruction to “get oriented” seems obvious, but the cadavers are well draped. Mostly this is to protect them from drying out, a major problem, it turns out, once you remove a person’s skin. There is also a fair amount of obscuring done for the sake of difficulty. You cannot see faces, genitalia, hands or feet unless that structure is specifically being pointed out. The cadavers are also largely sans skin, so all the usual orientation clues are missing.

We are not allowed to touch anything either, which is frustrating given than all of our studying has required us to find the structures by digging them out for ourselves. If I’m used to locating the musculocutanous nerve by finding its origin at the brachial plexus, I had better hope they have positioned the cadaver so you can see the brachial plexus when they pin that nerve. It’s also harder to distinguish structures like arteries and nerves when you can’t feel to see if they are hollow or move the drape back just a bit to see if you can see what branches it gives off. I end up twisting and contorting myself trying to peer into body cavities without blocking the light, my nose and hair getting dangerously close to formaldehyde-soaked fabric.

One minute, as it turns out, is precisely enough time to settle on an immediate answer and then second guess yourself. In some ways it reminds me of physics tests from postbac, where it was better not to even try to check your work if you managed to stumble upon an answer. Just keep moving and don’t look back.

Spelling doesn’t count on these exams, which is good because the words ophthalmic and infundibulum will never cease to send my brain and fingers into spams without a spell check. We are strictly forbidden from abbreviations, however, which I find intriguing given how pervasive abbreviated language is in medicine and our school curriculum. (In two labs

Look at that judgmental expression. As if he could spell pterygopalatine fossa off the top if his head.

of brain anatomy alone we’ve already learned about PICA, and AICA, SCA, PCA, MCA and ACA.) They will also, apparently, take off for lack of specificity; it is the styloid process of the ulna, not the styloid of the ulna. There are also no points for being technically correct either; the identity of one x-ray structure was the adductor tubercle, and the fact that the arrow was also pointing to the medial condyle of the femur did not mean that was an acceptable answer.

Once the exam is over, we turn in our tests, file out, and, usually, head off to study for the written exam. By the time our tests are graded and accessible, we are usually well past the point of real concern. As good or as bad as it feels to see where you ultimately fall on the curve, the skills being tested in anatomy practicals don’t seem to correlate to anything particularly useful in medicine. “When am I ever going to have to diagnose someone without asking any questions or touching them?” one of my friends pointed out.

I will say, in defense of the anatomy practical, that studying for something “hands on” is completely different from studying for a written test. I could have pored over dozens of textbooks and memorized every division of every artery and nerve and never have really understood how it all fits together as well as I did studying it within a body. Some of my esteemed colleagues may disagree with me on this point, but I would argue that, although the exam may not have realistically assessed my understanding of anatomy, it was a powerful motivating force. I doubt that I would have ever learned so much or so thoroughly had that impending exam not driven me back to lab so many afternoons.

What do you call the dude who comes in last in his medical school class?

Answer: Doctor!

I was told this joke when I was preparing for postbac. It’s funny, right? Because no one wants their doctor to be that guy. We all hope we’re getting treated by a genius who never misses a needle stick and can diagnose you as soon as you walk in the door. We don’t want to think about our doctors missing questions on exams or struggling to understand the basic concepts of disease.

I think that’s part of the reason I get a funny look when I tell people that medical schools are pass/fail for the most part. (The first two years, anyway.) No one wants to think about their doctor as someone who just barely scraped by with a 70; we’d at least like to think of them striving for that A.

source: Yoga Retreats.

There are good reasons for the pass/fail system, though. By and large we medical students are competitive bunch, and that particular quality is only reinforced though extreme curves and weed-out classes in pre-med. That kind of competition has an ugly side. There is a pretty significant difference between a doctor who made it to the top of her class because she is intelligent and hardworking, versus one who made it by being vicious. (Although, I won’t lie, it makes for great television.)

Beyond that, most of the medical schools I seriously considered attending seemed to take the attitude that, by virtue of being accepted into their program, we had proven ourselves. We all had the capacity to become physicians, and there was no need to put us through the wringer just for the sake of establishing our right to be there. Once you’ve made it to medical school, you’re clearly a smart, driven person. Now it’s just a matter of making sure you’re a smart, driven person who knows how to practice medicine.

Of course. there are degrees of excellence, so in case you’re worried that all doctors are considered equal, keep in mind that the second two years of medical school are graded, and students must pass  two numerically graded board exams before they can be considered for residency. There is another board exam after the first year of residency, and regular board certifications throughout a doctor’s career.

And, if I might just add, having just clawed my way through my first real medical school examination, passing medical school is nothing to sneeze at. It isn’t the same thing as passing high school or a college course. These tests are designed to challenge us, we who fought our way to the top of the undergrad heap.

So to the dude who came in last in his medical school class? I will most certainly call you Doctor. I know very well that you earned it.

I checked my MCAT score with a friend from undergrad holding my hand mentally through the phone. She listened gamely but confused as I started shouting scores into the receiver.

“Is…is that a good thing?” she asked, warily.

I didn’t have the focus to explain what the scores actually meant. The final proclamation that I would never have to take that exam again was easy to interpret though. We cheered for approximately thirty seconds before I begged off to report the scores to my family.

Even in my relief, though, the actual meaning of the score didn’t hit me until I was driving home from work later that evening. The air conditioning and the radio blaring into the sweltering July heat I suddenly started laughing hysterically and banging on the steering wheel. A driver in the car next to me gave me a concerned look, which only made me laugh harder. Done. Finished. This horrible awful test that I had been dreading since I first accepted the idea of going into medicine almost two years ago was complete and I would never have to worry about it again.

Just as quickly as the excitement hit, it’s also starting to wear off. I wasn’t really doing much as I waited for my MCAT score other than worry, so now that it’s over there hasn’t been much change in my daily schedule. The next hurdle, secondary applications, are already piling up and I’ve just lost my absolute last excuse to ignore them….

I’ve been extremely lax about updating this journal. My only excuse for that is my excuse for pretty much everything right now: MCAT. (DUN DUN DUUUUUN)

A year ago the mere thought of taking this test was enough to send a shiver of fear down my spine. I imagined that those five hours would be nonstop torture. Yet as the day draws closer and closer, I find myself far less terrified than I had anticipated.

I think the main reason I’m not trembling at the prospect is because, unlike any other test I’ve ever taken, the MCAT has given me ample opportunity to practice. Oh sure I’ve done preparatory questions for the SAT, and the GRE (which I never actually took) and for every physics, chemistry or biology exam. I even took full practice exams to get ready for a few. But the MCAT is different. By the time I sit down to take the actual test, I will have taken at least eight full practice tests in as close to testing conditions as I can manage. They say practice makes perfect, and even though a million sample MCAT tests won’t grant me a perfect score, there is a measure of confidence to be gained from the repetition. It’s reassuring to know that when I finally sit down at the testing center on Thursday, the screen in front of me will be something familiar.

That’s not to say I’m not still terrified. The exam date is less than a week away and I feel like I’m stuck on a cartoon conveyer belt headed toward clamping metal spikes.

But I also feel like I can do this. I feel like I have some measure of control, and that is something I never expected. I never thought I would feel ready to take the MCAT, but I find myself looking forward to the test date and the enormous weight that will be lifted from my shoulders.

For the most part, I regard standardized tests as a necessary evil. Yes, we need certain measures of learning that put everyone on equal footing regardless of the rigor of their education. But few people would argue that exams like the SATs or GREs tend to favor rote learning over actual intelligence or creativity. I remember taking SAT classes, frustrated that the trick to doing well seemed hidden somewhere in the fee I had paid for the extra tutelage rather than any intelligence or commitment to learning on my part.

So it should carry some weight when I say that I think the MCAT is a pretty good standardized test. It actually measures something beyond one’s ability to spit out memorized answers. You need a strong background understanding of the subjects it tests, but the majority of the exam consists of passages explaining concepts. It is the job of the test taker to combine background knowledge with a critical examination of the material presented to answer the questions. Which, if you ask me, is a pretty good test for future doctors. They need to have strong background knowledge, but they also have to be adaptable and able to incorporate new information. Not only that, but they need to be able to be critical about new information, and the MCAT, at least superficially, tests all of these skills.

Except for the writing portion. Two three-paragraph essays that are assigned apparently to test how completely uncreative the human mind can be. I’m not kidding; the test is graded twice, once by a human being and once by a computer. Usually the two scores agree pretty closely with one another.

I spent a good portion of our review session trying to find a way to wriggle out from under the constraints of the essay structure. Could I include an example from literature? No. How about including some of my concluding paragraph in my opener? Not such a good idea. What differentiated the really high scores from the middle-of-the- road scores? Strength of examples and following the structure. The whole thing felt more like a fill-in-the-blank questionnaire than an actual essay.

What gets me is that this is completely counterintuitive to the goals of the majority of the exam. How backwards is it that the physical sciences portion of the test requires more out-of-the-box thinking than the essay?

The essays are graded on a bizarre scale that ranges from J-T and isn’t factored into the numerical scoring of the test. The average score for everyone taking the test is an O and the average score for students who matriculate is a P. I would dearly love to see their example of a “T” essay; the absolute best writing the MCAT graders could expect. Has anyone ever achieved this mythical score? Would the writer have simply mastered the fill-in-the-blank structure beyond all expectation, or would this perfect essay have thrown out the convention and set the computer grader smoking with its exquisite prose?

In truth the writing portion of the exam is barely a blip on the radar of the whole application. If I want to impress anyone with my writing skills, the personal statement is the place to do it. But it hurts my soul a little to write something so deliberately bad just to prove that I can string words together like beads on a chain.

I’ve feared it, I’ve bemoaned it, I’ve ignored it — but the time has finally come. I’m going to start studying for the MCAT.

MCAT, for anyone who might not have been obsessing about this for the past six months, stands for Medical College Admissions Test. It is required for admission into every reputable medical school in the U.S. In an age where the GREs and the SATs are increasingly disparaged as in inaccurate measure of intelligence and are slowly disappearing from undergraduate and graduate applications, the MCAT exam continues to haunt the dreams of pre-meds nationwide.

There are four parts to the exam; biological sciences, which include biology and organic chemistry, physical sciences, physics and inorganic chemistry, a verbal section similar to the SATs or GREs, and a writing section that is graded separately on a bizarre scale of J-T. Each of the other sections is scored out of 15 points, for a total of 45. As far as I’m aware the maximum score is mythical; most students who get into medical school score in the 30s. One former postbac scored a 42 a few years ago and it’s still spoken of with a reverent tone.

I’ve never been much of a fan of standardized tests. I barely slept the night before I took the national exam for massage therapy, and that was pass/fail. The MCAT is like the mother of all final exams; the anxiety of every chemistry, organic, physics and bio test combined with a splash of fear that my verbal skills will desert me in my time of need. Let me put it to you this way; if I were offered instead to be jabbed with hot pokers for the four hours of the exam and be assured a reasonable score I’d probably do it.

Since the start of the program, the MCAT has existed in the back of my mind as a vague worry, but the full-fledged fear didn’t kick in until we were sent home with our study guides right before winter break. You know those three hundred page paperback SAT/LSAT/GRE study guides? That’s what I was expecting. Instead I was sent home clutching a four-book boxed set; the kind that comes in a cardboard case so you can keep them all together and then wrapped in plastic so none of the volumes can slip out.

The moment I returned to my apartment the study guide went up onto my bookshelf and remained there, untouched, for the duration of break and the start of semester. Other students talked about peeling the plastic wrapping off or starting in on a section or two; my study guide and I just eyed each other distrustingly as we went about our business.

Sadly, though, my days of obliviousness had to come to an end. Spring break arrived and with it the last of obstinacy. Before leaving on break I steeled myself and ripped the plastic from the cardboard case. Figuring my course load would be enough to keep most subjects fresh in my mind, I extracted the chemistry and the verbal reasoning volumes and slipped them into my backpack beside lab manuals and textbooks.

It’s strange; going into the postbac I felt as though I were signing my life away. Even though I knew it was just the first step on a much longer journey, I didn’t really consider the fact that it would someday be over. Now I’m two months away from the end. Terrifying as studying for the MCAT may be, it’s exhilarating to realize how much closer to my goal I’ve become.

This week brought the event I call the “exam double header.” Physics on Thursday, biology on Friday – but wait, there’s more! This time around we have an organic exam the following week. (It was supposed to be on Monday, but our professor took pity on us and is letting us choose a different day of the week to take it.)

As the stress bears down, all of my hidden (or not so) neuroses rise to the surface. My nails are bitten to the quick, my sleeping patterns become erratic, and my humor becomes biting and uncensored.

I also become seriously superstitious.

Most of the time I am an extremely logical person. And as an extremely logical person, I know that my performance on an exam is in no way determined by the clothing I wear or  the desk at which I choose to sit. Yet, like competitors the world over, on the day of a particularly nerve wracking test (read: every physics test I have and ever will take), I find myself locked in to particular pre-test rituals.

If you were to ask me, even in the midst of performing these rituals, if I thought they had any effect on my grades, I could honestly tell you that, no, mostly my performance on exams is a result of a lot of hard work and a few test-taking strategies I’ve picked up along the way. Furthermore, there is no particular custom that I actually attribute any value to; it’s more a need to cover all of my bases than faith any any particular practice.

Psychologically this makes a lot of sense; humans have a habit of relying on ceremony when the outcome is uncertain. “No atheists in a foxhole,” right? Sports figures and fighters are renowned for having good luck charms. My reliance on objects and actions that are supposedly “lucky” are in inverse correlation with how much control I feel over the test I’m facing. Physics tests get the full treatment, but at this point I can face down most biology exams without too much pomp and circumstance.

Lest you think that I’m spending my pre-test mornings praying over an alter to the gods of mathematics, let me assure you that most of my rituals are small things. I listen to certain songs as I’m getting ready, choose a certain spot in the room to take the test. If I did poorly on an exam on a day when I wore a certain article of clothing or jewelry (and remember picking it out) I bypass it the next time around. I discard anything I feel might have jinxed me. A few times I brought along “good luck” charms to chemistry tests over the summer; after a mediocre grade on one final exam I started leaving them at home.

The funny part is that between tests these compulsions lose their power over me. I look back on my successes and failures over the course of the past year and at no point do I think, “Oh well that only happened because I did/didn’t honor my good luck ritual.” Yet the moment that pre-test anxiety hits, I cling to them as the faint assurance that everything will work out somehow.

There are two major tenets to my pre-exam ritual. The first is not to tell anyone the exact make-up of any ritual. (I’m taking a big risk with this blog entry, you should know.) The other is hubris goes before the fall. And thus is my conundrum, for I fear that the moment I leave my superstitions by the wayside I will finally discover their power.

Okay I’m going to say it. God may strike me down and the earth may cease to revolve around the sun, but here it goes:

I like organic chemistry.

Whew! That was easier than I thought. I’ll undoubtedly be made to regret my words before too long—next Tuesday I’ll find out that I have to memorize all 4,347 isomers of pentadecane or my model kit will try to eat me in the night—but for right now I’m honestly enjoying organic chemistry.

I’m not alone either. In the face of the evil, looming monster that is physics, organic chemistry has become a safe haven for most of the postbacs. My suspicion is that this may be due to it being the only class in which we get to play with toys. Okay, technically they’re called “Organic Model Kits,” but really they’re just tinker toys for nerdy people. My inner six year old is having a blast.

Unfortunately, even though I’m enjoying organic chemistry and maintain my deep abiding love for biology, I’m spend an absurdly disproportionate amount of time on the one subject I would gladly avoid altogether. That’s another aspect of this program that seems to be pretty universal: physics is difficult and unrewarding. It can be Newton’s fourth law.

This week we have our first two exams of the semester. The nervousness is palpable; by this time in the summer semester we were gearing up for our final exam. Now we’re facing two unknown quantities and trying to determine the best mode of attack. It’s comforting to be doing this as a group; no matter how confused or terrified I feel after a lecture or a quiz, there always seems to be another postbac who is in exactly the same mindset. Perhaps it’s a case of misery loving company, but when you’re surrounded by twenty-four intelligent, driven individuals who all still find physics utterly impenetrable…well we’re not going to be the first round of postbacs to all fail to get into medical school, now are we.

So keep your fingers and toes crossed for us this week. I’ll be back after the we show the laws the physics who’s boss. (The boss being physics obviously….)