USMLE Step 1

So, in order to practice as a licensed physician in the United States, you gotta pass a series of three tests compiled by the National Board of Medical Examiners: the USMLE step 1, step 2, and step 3. Everyone takes Step 1 at the end of their first 2 years of medical school, Step 2 during their last year of medical school, and then Step 3 sometime during their residency; once you pass Step 3 and graduate from residency, you are liscensed to practice medicine as an independant doctor.

These tests are MISERABLE! Argh! I'm scheduled to take Step 1 on march 30th, and I'm kind of losing my mind over it. I mean, this thing is ridiculous. For anyone who has ever taken the MCAT, or the GRE, or even the ACT or SAT, the general concept is the same: here is a standardized test meant to normalize the knowledge obtained from all the different schools and curriculums out there, to put everyone on an even footing so that things like grade inflation or under-the-table bribery are factored out. Except Step 1 is like if you selectively breeded all those other tests for traits such as length, detail, stress level, and horribleness, injected it with steroids, gave it a wooden club studded with brass nails, and then let it loose on an unsuspecting population of medical students.

The freakin' thing lasts for 8 hours, is 336 questions long, and you have about an average of 1 minute and 15 seconds to answer each question. Here's the kind of question they would ask, see how well you would do:

A 45-year old man arrives at your indigent care clinic in El Paso, Texas, complaining of numbness of his fingers and toes. On examination, he is latino, has normal vital signs, has decreased fine touch sensation in his distal digits, with scattered firm, non-painful nodules distributed along both forearms, ranging from 1 cm to 3 cm in diameter. His face is deeply lined and rough looking, which he says (through the clinic's interpreter) is probably from spending all his time outside; he has spent the last 5 years as a migrant worker, and is originally from Guatemala. You identify this man's rare disease, and remember that the causative agent in this case is closely related to another pathogen that causes a much more prevalent disease that affects nearly 1/3 of the world's population. What is the mechanism of action of the drug that would be effective against both of these conditions?

a) blocks the M2 ion pump
b) blocks CCR5 binding sites
c) binds to beta-lactamases
d) inhibits dyhydrofolate reductase
e) inhibits DNA topoisomerase
f) inhibits RNA transcription
g) acts as a DNA chain terminator

Huh? Okay, to start with, the guy in the question has leprosy. Why? Peripheral nerve damage leads to numbness and nodule formation, as well as facial scarring. Also, it is more common in Latin America, and epidemiologically, Texas is one of the only places in the United States it shows up. Bonus question: what animal is the only natural resevoir for leprosy? Armadilloes. Anyway, so the guy has leprosy. But that's not the answer to the question; you also have to know that leprosy is caused by a bacteria, Mycobacterium leprae, which is in the same family as the bug Mycobacterium tuberculosis, which is what causes, well, you know, tuberculosis, which infects about 1/3 of the world's population. Okay, still not done: the question asks which drug would work to treat both leprosy AND tuberculosis. Well, tuberculosis treatment is a regimen of 4 drugs: isoniazid, rifampin, ethambutol, and pyrazinamide. The treatment for leprosy is dapsone, rifampin, and clofazimine. Ahah! Rifampin can be used in both cases. But, that's not one of the answer options.... how does rifampin work?

Okay, option A refers to amantadine and rimantadine, which treat influenza, B refers to anti-HIV drugs like miraviroc, C refers to clavulanic acid, a component of some antibiotics, D refers to trimethoprim, another antibiotic, E refers to fluoroquinolone antibiotics like ciprofloxacin or levofloxacin, F refers to rifampin, and G refers to a class of anti-viral medicines like zidovudine and abacavir. At this point, what we were looking for again? Oh yeah, rifampin....F! The answer is F! So you mark F on your computer screen and go on to the next question.

Okay, how long did that take? Less than 1 minute and 15 seconds? Yeah right. These are the types of questions on this stupid test; they give you, like, five to eight answer options, and the questions require you to answer two or three other questions all in a process to come up with one corrct answer; if you mess up on any one part, then you will get the question wrong. It's not enough to know the microbiology of leprosy and tuberculosis, and it's not even enough to know that rifampin is used to treat both diseases, but you must know how rifampin works. And never mind that there are less than 200 new cases of leprosy per year in the US and you will probably never see one. Bleh. Oh, and I didn't type that question from memory, I had to look things up in my notes as I went along. If I was that good, I wouldn't be so worried about this @#*$ test. Sorry for the rant. We now return you to your regularly scheduled pictures of Layla.