USMLE Step exams are a rite of passage in medical education. They mark the transition from pre-clinical years to clinical years, from medical school to residency and from intern to resident. One of the more difficult aspects of the transition to residency was convincing myself that I really was a doctor. The habits of explaining my role as a student, of hedging every statement with “I’ll need to ask the resident,” proved difficult ones to break. As I studied for my Step 3 exam, the final step, I hoped that this milestone would be the one after which I would believe I was a real doctor. With the exam approaching, I attempted to simultaneously balance my job as a pediatric intern, my responsibilities to my wife and 5-year-old son, and the annoying but persistent need to sleep. I tried to focus on my studies, but I was frequently distracted by these more pressing matters.
On the wards, I could see the progress I’d made as an intern. I was learning more than I ever realized I could, but I answered practice question after practice question incorrectly. I became discouraged and wondered if I would ever be a truly successful doctor. I struggled to balance the pride of my increasing knowledge of medicine and the looming shadow of all the knowledge left out there, waiting to be acquired. I often worried about being the only medical provider in an emergency. The thought was exhilarating but tinged with a distinct fear of failure. Each time I’ve prepared for a USMLE Step exam, studying has exposed this fear and reminded me of the many things I still do not know.
On a cold and dreary day in December, I walked into the testing center for the second day of my 2-day, 17-hour Step 3 exam. I was cautiously optimistic after completing the first day, but the computerized patient vignettes that comprised the second day made me very nervous. These timed, subjective units test a range of management decisions for sample patients. I was hopeful that by getting through this test I could finally get back to the real learning, with real patients.
As I took my lunch break, I walked through the entry room where two proctors sat idly watching the test-takers through a large glass window. I remember thinking the young man looked much less interested than his older female coworker. As I was nearing the end, 5 hours into the 8 hour day, I was clicking button after button to save another 65-year-old with COPD exacerbation when I heard a crash and a scream behind me. I turned around. Where there had been two proctors behind the glass, there was now one, looking terrified. The distracted young man from earlier in the day was nowhere to be seen. As her eyes caught mine through the window, I thought to myself “Don’t say it! This is Step 3. I need to focus. I HAVE to pass this.”
When she motioned for me to come over and mouthed the words “Help! Please!” I felt my heart rip in two. There was a part of me that wanted to put my head down and finish my test. What could I really do anyway? I had been a doctor for only six months, and I hadn’t even had my emergency department rotation yet. There was another part of me, the part that chose to invest my life in pursuit of helping those in need; that pulled me out of my compulsion to continue the test. The woman looked terrified. I could only imagine what had just happened to her coworker.
I felt like I was moving in slow motion. I glanced around, thinking “Surely there is at least one other physician here. I won’t be the only one to respond,” but my hope was in vain. Alone, I stepped out of the testing area and saw the male proctor lying face up on the floor, his entire body shaking rhythmically. Blood mixed with saliva was dripping out of his mouth. His leg was repeatedly smacking into a nearby chair, and his head was inches away from a corner of a wall.
In the next few seconds, I left my test-taking brain at the computer. I didn’t wrack my brain to think through the differential of congenital and acquired seizure disorders. I didn’t consider the risks and benefits of each anticonvulsant. I hardly believe it myself, but my thoughts were “Airway … Breathing … Circulation …”
I knelt down and turned the young man over onto his side, pulling him away from the corner and chair. I watched his chest rise and fall in short rapid breaths and hoped his airway stayed clear. I felt his pulse racing as I tried to stabilize his flailing arms.
“What’s wrong with him?” the other proctor asked from her desk with a phone in her hand.
“He’s having a seizure. Are you calling 911?” I asked, and she broke from her daze to dial the numbers.
I could not tell how long he seized. I imagine it was just a few minutes, but it felt like an eternity. As he regained consciousness, he seemed very disoriented. He asked the same questions repeatedly and attempted to stand up despite my asking him to lie still and rest. I spoke to him calmly, explaining what had happened. I asked about prior seizures, medical problems, and medications. When I finally heard the ambulance siren I couldn’t tell if it had been two minutes or twenty. Two men in dark jumpsuits walked in the front door and opened a box of supplies. As the first turned to me and asked what happened, I reported what I had seen: a crash, a scream, a young man having a generalized tonic-clonic seizure. They took over care of the patient, and I stood up, walked back to my computer, and resumed my test.
My patient with COPD popped back up on the screen as though I had never left. He was still waiting for his bronchodilator orders. Most of my brain fell back into the rhythm of the exam, but part of it stayed behind in the other room with the proctor. As I finished the test, I couldn’t help but think about the irony of the situation. I was taking a formal test to earn the right to practice medicine but the rite of passage I underwent that day had nothing to do with etiologies or treatment modalities. When I found myself the only physician in an emergency situation, the basics kicked in. When I was terrified that I couldn’t help, I sat with my patient and did what I could to help. I do not know what happened to the young man that day after he was rolled out on a stretcher. I will likely never know either what caused the seizure or the patient’s eventual outcome. I don’t know how much, or even if, my intervention changed anything. But as I sat at my computer clicking buttons to finish the test, I felt for the first time like a doctor.
David Pyle is a pediatric resident.
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