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Issue Date: August 2007 Issue

White Coats

After two years of medical school, one test will determine the future of Case Medical School students Millie Gentry, Mike Norton and Marleny Franco.

Written by Jacqueline Marino, Photography by Tim Harrison
White coats
In the morning Millie Gentry will take the hardest exam of her life, she is kneeling in a cupboard, searching for a plastic container for oatmeal. The instant variety has become a staple of her diet, easily prepared and consumed under the diagram of kidney function in her kitchen or beneath the whiteboard at school where she drew viruses.

Soon she will be able to cook again. Shop again. Live again.

But first, Gentry, a second-year student at the Case Western Reserve School of Medicine, must take Step 1 of the United States Medical Licensing Examination (USMLE), otherwise known as the boards. It is an eight-hour marathon of specimen identification, graph interpretation and clinical problem solving covering anatomy, pathology, microbiology and every other “ology” medical students should have learned by now.

This test has changed Gentry. It has broken her. She started med school determined to have a life. Not because of some romantic ideal fueled by television-doctor fiction but because she was unwilling to accept that she couldn’t. Gentry grew up in Florence, Ariz., a little town with a high teen-pregnancy rate where her parents owned a grocery store and her peers blinked in disbelief at her ambition. A middle child with a defiant streak, Gentry skipped classes during her first year, worked as a model, went out on weeknights and led Medical Students for Choice.
She thought she was choosing balance over perfection, but perfection doesn’t exist in medical school, only pursuit. Pursuing the knowledge you need to practice medicine is an all-consuming endeavor, one that doesn’t stop when you and your boyfriend split up or a clinical experience falls short or one of your evaluators asks you to account for your actions.
White coats
All of these things happened to Gentry. She got in trouble for writing late, brusquely candid reflection papers about an apprenticeship that was so boring she dozed at the nurses’ station. She never thought anyone would read them, but they haunted her. Ultimately, she admitted to concerned faculty and administrators that the tone and content of those papers were immature, and she resolved to voice her opinions more diplomatically in the future.

That was months ago, and the test has become her latest battle. This morning, while attempting to make eggs at 3 a.m., she nearly set the pharmacology flashcard for Clindamycin on fire when she turned on the wrong burner. It was accidental, but she would like to see her study materials go up in flames — after the test. There is still much to do before the purging, much to prove. Her performance today will determine how competitive she’ll be for a residency in dermatology, one of the most sought-after specialties. And it will be the latest indicator of the biggest question of all: Can I be a doctor?

A med-school friend calls. The theme song from “Rocky” booms out of Gentry’s cell phone.

“Take some Tylenol with caffeine,” she says. “You can’t cancel now.”

No, she can’t. She and Gentry will be taking the boards at 8:30 a.m., one week late. They delayed it as long as they could. Monday they start their third-year rotations where they must apply what they’ve learned to the clinical setting.

But first, Gentry must prove she’s mastered the science behind the practice of medicine. Her professors didn’t teach to the boards, so during this six-week break from classes, she has crammed complicated nerve pathways, random side effects and odds ratios in between bouts of distraction, the inevitable result of perusing so many illustrated medical texts (a nose consumed by fungi in blastomycosis; a body infested with pinworm).

She hasn’t studied enough path or pharm, of that she’s sure. She didn’t waste much time on anatomy. She is hoping for questions on genetic diseases, which she studied extensively because they’re interesting and easy (treatment: nothing, prognosis: death).

It’s 7:30 a.m. The oatmeal is packed, the Vitamin B pills are swallowed, and Gentry’s tote bag and worn blue backpack with the broken zipper are straining under the weight of study guides, Coke and Red Bull.

“I’ll be amazed if I don’t puke,” she says, climbing into the car.
Medical school is four years of near-constant evaluation. For Case Med’s Class of 2009, it began in the first year, when the students stood up in front of their colleagues and said their names and undergraduate institutions. They were being sized up then, but it was a superficial evaluation based on academic snobbery.

When the grades started coming — for Biochemistry, Anatomy, Biological Basis for Disease, among others — it got more quantitative. In what percentile did their scores fall? Were they above the mean? By how much? They learn to measure their progress against everyone else’s. The ones who strive for perfection are the gunners. They can pass every subject easily but choose to ace it instead.

If you’re in med school, you’re either a gunner or you secretly want to be. You don’t want to just get by. You want to know for sure that you know enough to be good enough. You need validation because you are going to be the one in the long white coat one day. You will be a healer, a keeper of the public trust, a person who does no harm. You must deserve to wear that garment.

Last year, in an attempt to churn out better, more community-minded doctors, Case underwent a major curriculum shift integrating the studies of medicine and public health, emphasizing civic professionalism and ramping up students’ clinical experiences. It was the second revolutionary curriculum change in Case’s history — the first in 1952 attracted worldwide attention and established what was then Western Reserve University as an innovator in the field.

The brainchild of former dean Ralph Horwitz, the most recent new curriculum fully launched for the class of 2010, around the same time the dean himself announced that he was leaving Case for Stanford’s medical school. Faculty balked and students complained about the changes. The new curriculum added a research component, and to make time for it, two years’ worth of teaching of the basic sciences was compressed into a year and a half.

It will be a long time before anyone can confidently call Case’s second curricular overhaul a success or a failure, but second-year students aren’t talking much about it anymore — except to complain about the pace of instruction. Mentally, they have moved from worrying about classes and labs to obsessing over boards. Their focus has switched from school to the National Board of Medical Examiners, who made the USMLE the standard against which all med students are measured in 1994.

The pass rate for first-time test takers at U.S. and Canadian medical schools was 94 percent in 2005 and 95 percent in 2006, according to the NBME. Case’s pass rate is near 100 percent, says Dr. Daniel B. Ornt, vice dean for education and academic affairs. So most students aren’t worried about failing. They’re worried about doing better than the other test-takers.

The higher their score the greater the likelihood they can land a residency in the most competitive, well-paying specialties, such as neurosurgery, orthopedics, plastic surgery, ENT (ear, nose and throat), ophthalmology and dermatology. Even for less competitive fields, if students are pursuing a well-regarded and highly appealing residency program, the scores count. Case administrators say students aspiring to those fields must score at or even one standard deviation above the national mean of 220 to get an interview. Applications of students who received lower scores may not be reviewed at all.

Even though researchers have shown there’s little evidence taking commercial preparatory courses will improve Step 1 scores, students spend hundreds or thousands on them anyway. They pore over guidebooks, such as “First Aid,” and pay Kaplan hundreds of dollars for access to its QBank, an online database of USMLE-type questions and explanations of answers.

They ignore friends and relatives, hole up in libraries and coffee shops and mostly get annoyed at anyone or anything that takes them away from their studying. They can’t absorb all the knowledge that will be on the test, but they know they must try. This test is the gateway to the wards, where the real test awaits.

In her second year, Marleny Franco made three patients cry before she touched them. It happened once as she was getting a family history of a 60-year-old, 330-pound former Air Force cook who came to the Louis Stokes Cleveland VA Medical Center for shortness of breath. He said his mother had undergone several bypass surgeries, but he didn’t know about his father. He hadn’t seen his father since he was 7.
“So your mom raised you all alone?” Franco asked.

It wasn’t a question that would lead to any pertinent medical or social information, but it was a human thing to ask, a gesture of empathy. Traditionally, medical students have been taught to distance themselves from their patients. But recent research shows that empathetic doctors are better doctors, and Case is among the institutions infusing its curriculum with greater humanity. It has brought into the light the “hidden curriculum” of compassion that student doctors have long absorbed from being immersed in the doctor culture. Franco’s class has been talking about empathy since the first day, and they will still be talking about it on a regular basis in their third year.

Although Franco is not a gunner when it comes to tests — in fact, she failed two in her first year and had to remediate them — she is a natural when it comes to empathy. A Dominican immigrant who grew up poor in Boston, Franco became interested in medicine in the hospital where her mother used to work as a nurse before coming to the United States and finding blue-collar work in cleaning and retail. Franco’s aptitude for math and science got her into a well-regarded public school and then Brown University, where she majored in community health before winning the national Jack Kent Cooke scholarship, which has awarded her $50,000 a year toward her medical school costs.
She had trouble with biochemistry, but she knows people. They open up to her. They cry to her.

Until that question about his mother, Franco’s patient had been smiling, somehow, despite all his medical conditions, including chronic obstructive pulmonary disease, congestive heart failure, type 2 diabetes, glaucoma, cataracts and erectile dysfunction. But her question leads to his telling her about the daughters he left when they were 5 and 3. Through tears behind thick bifocals, he says he has written to them, and he’s trying to get better, so he can see them this year.

Franco spends two hours with the man, asking him questions and examining his entire body, from the skin folds of his neck to the small joints of his feet. This is far more time than she will get to spend with patients on her third-year rotation, where students see most patients for no longer than 15 or 20 minutes.

Having the luxury of time is both a tease and a thought-provoker. She knows she can’t get used to it. But what if she could? How much better care could be delivered if doctors had time to get to know their patients? How much better would patients feel about them?
In medical school, there’s never enough time for studying. In medicine, there’s never enough time for patients.

What you know, what you decide, what you do — someone’s always watching, listening and recording mental notes or written ones. By year two, Gentry’s knowledge and skills have been tested in labs and computer-based exams. She has been videotaped taking patient histories and performing physical exams. The process is meant to give the students practice, but Gentry can’t get over how fake it feels to examine actors pretending to be patients.

It’s hard to think of what to do next when you are trying so hard to sound smart on camera. It slows her down thinking about what they’re going to say next to throw her off. One time she had a practice patient who was acting like a depressed, 55-year-old man. She got so nervous during the interview that she forgot just about everything about this person except for the chief complaint, then tried to make up for it by asking lots of questions, including whether he’d had a colonoscopy and a prostate exam. She was thrilled when the preceptor praised her for asking health-maintenance questions.

Unlike the brief, uneventful clinical apprenticeships of her first year, Millie Gentry’s clinical experiences at the Douglas J. Moore Health Center at University Hospitals Case Medical Center have pushed and amazed her. She has become confident at taking personal histories. Naturally curious, she gets patients to tell her exactly the kind of information she needs most of the time. But the physical exams have been nerve-wracking. She often has to work through bouts of paralysis when she’s told to auscultate (listen), percuss (strike) or palpate (touch).

“After spending countless hours chained to [my] desk, endeavoring to learn how to spell words like ‘pancreaticoduodenal’ and ‘uvulopalatopharyngoplasty’ (words I don’t actually know how to spell, but do know how to copy from a medical dictionary), it is difficult for me to explain why I chose to become a doctor,” she wrote in a reflection paper. “Yet, after time spent at places like Douglas Moore [Health Center], I am reminded why I continue to study, and just how much I have to learn.”

One Sunday morning a few weeks before the boards, Marleny Franco woke up to a spinning room and a reeling stomach.

She leaned over the side of the bed and threw up. When she turned her head, she threw up again. Afraid to move her head again, she remembered the neurology she’d been studying. Something was wrong with her inner ear.

Without moving her head, she reached for her cell phone and called her mentor, a doctor in Rhode Island, who assured her it wasn’t an “acoustic neuroma” (tumor). He thought it was a virus. She called Case society dean Robert Haynie, who also thought it was a virus. She called the student health services, and a nurse there told her it was probably a virus.

Franco lay face down in her bed for hours. Finally, she got up to go to the health clinic. On her way down the stairs, she threw up twice, both times on her boyfriend, Steve. The worry welled up in her. How long will this last? How will I study? What if I get sick during the boards?
For the next several weeks, she endured more throwing up and a shot of a potent antivomiting medication followed by the same drug in pill form. Sometimes the nausea went away, but not the worry. She went through the symptoms as if she were a question on the boards: dizziness, nausea, nastagmis (a condition that causes the eyes to twitch in their sockets). But unlike with the board questions, she couldn’t check a text or ask doctor friend for the answer. No one knew how to fix her.

In between bites of a turkey wrap, Mike Norton studies a question from the Kaplan QBank, which he bought along with Kaplan WebPrep for $1,100, money he had saved by opting out of the Case student medical plan:

A 62-year-old man with severe shortness of breath undergoes a lung biopsy that reveals diffuse disposition of calcium into the pulmonary interstitium. Which of the following diseases is most likely to produce this type of severe metastatic calcification?

A) Amyloidosis
B) Goodpasture’s Syndrome
C) Hypoparathyroidism
D) Medullary carcinoma
E) Multiple myeloma

Norton chooses “E,” the correct answer. He gets many of the QBank questions right, but he’s still worried about the test.

I ask him why.

“It’s the uncertainty of how it’s going to turn out,” he says, picking the peppers out of his sandwich.

Science’s goal is to eliminate as much uncertainty as possible, and Norton is a man of science. Uncertainty bothers him — he can’t even read the clincher in a book without skipping to the end to make sure the hero lives. Perhaps that’s one reason he has filled his life with as many fixed variables as possible: Kate, the always patient and supportive wife who holds his same values; the Mormon religion he was born into and believes deeply in; 18-month-old Megan and (quite possibly) a new baby on the way, the first two children of the big family he has always wanted.

There is comfort for Norton in knowing what he’s good at, who loves him and why he’s here on Earth. It baffles him that lesser issues, such as this test, can fill him with so much anxiety. He sees a biochemistry question he doesn’t know and he’ll think, I don’t know anything! Then he’ll look up the answer and remember it forever, hoping he’ll see it on the test but knowing, of course, that even if it is, the test will remain an ordeal of uncertainty.

He takes comfort in a quote from his favorite show, the TV sitcom “Scrubs”: “OK, you’re scared. That’s good. That’s what makes you not a crappy doctor.” Or a crappy med student.

Norton treated studying for the boards like a job. He got up at 7 a.m., got to school by 8 and studied there until 6:30 p.m., which gave him an hour to play with Megan before she went to bed. Sometimes Kate brought Megan to see him at school and she cried when it was time to leave.

Norton didn’t worry about earning a 185, the passing score on the boards. (The average is between 200 and 220.) He wanted to score in the 230s, or even better, the 240s, which would make him competitive for everything, including cardiology or pulmonology, the specialties he’s considering now.

He studied by reading review books, watching Kaplan online audio lectures and taking practice tests, as many as four a day. He talked about the test all the time. When he mentioned it, Kate rolled her eyes.

“You’re worried about by how big a margin you’re going to pass, not whether you’re going to pass,” she reminded him.

The night before the test, he focused on studying antibiotics and anticancer drugs in between watching episodes of “Scrubs.” At night, he, Kate and Megan went to Dairy Queen and splurged on Blizzards. Being $110,000 in debt for med school already, they don’t go out much. But after four weeks of dealing with this test, he figured they all deserved a treat.

Really, not being able to afford treats is the least of it. The three of them depend on the state for food stamps and medical care, including Norton’s medication for attention deficit hyperactivity disorder, which he manages with Wellbutrin. When Norton needed a root canal, his parents had to help him pay for it. Kate never complains about having to dress Megan in second-hand clothes, but Norton wants them to have more.

When he saw an Army recruiter posting fliers in the medical school, Norton stopped and asked him for more information. He learned that if he joined the Army as an officer, the government would pay for his education. It would give him training at an Army hospital after medical school or, if no military residency was available in the specialty he chose, allow him to compete for a civilian one. Army residents make $70,000 a year, much more than what most residents earn at civilian hospitals. He would owe the Army one year for every year of residency. For instance, if he did a two-year family practice residency, he’d have to serve for two years. If he chose to stay in longer, the Army would take over the loans he incurred during his first two years.

Norton feels he owes his country a great debt. One grandfather won a Bronze Star in the Battle of the Bulge and the other earned a Purple Heart after being burned by a phosphorus grenade in World War II. Joining the Army would be a great thing on every front, he reasoned, except one.

The war.

He talked to the recruiter more, who assured him that after spending so much money to train him, the Army would do everything possible to keep him out of danger, even if he were sent to Iraq. He talked to other medical students in the armed forces, as well as Army doctors. He talked to Kate about it, for months, and she never rolled her eyes. They weighed the benefits of becoming an Army family over the drawbacks. Kate wanted him to do it. He wanted to do it. He thought about the uncertainties, studied them, and decided they would be there whether he joined or not. 
The building where Millie Gentry will take the test that will decide her future is a tan storefront next to a Wal-Mart and a Lowe’s and across the street from a Dollar Tree. She walks into the mauve waiting room with its mauve chairs and mauve doors and mauve rugs and gives a man at the window her ID, then she pops some Tylenol and plops down on the mauvish carpet underneath a picture that says “The tougher the challenge, the greater the triumph.”

She panics. If only she had more money, she could have taken the Kaplan course. If only she had been more organized, she could have taken the test earlier. If only. If only. If only. She feels resigned. She feels like she’s going to die. She feels resigned again. What she knows, she knows. That’s all.

She takes a few sips of Red Bull, checking the Vitamin B content. She flips through a study guide on which she has taped the sentence “Med school can be a real killer.”

“Millicent,” the man at the window says. “Let’s get you up.”

She stalls a moment more, flipping through the guide. Reluctantly, she rises, throws her backpack over one shoulder and her tote filled with food over the other. She opens the door with great difficulty and passes through.
All three students scored at or higher than the average.

(They didn’t want their actual scores published.) Norton says his score makes him competitive in all specialties, while Gentry wished she’d done better, given the competitive nature of the specialty she is considering. Franco said she did fine but doesn’t think her score reflects the amount of studying she did.

Both Gentry and Franco plan to take Step 2 earlier in their fourth year, and if they do well on Step 2, which tests their clinical knowledge, those scores will offset their Step 1 standing. Combined with good clinical experiences and research, their applications for residency could still be quite strong. Norton can take Step 2 anytime before he graduates.

After the exam, Gentry threw her notes in a “to burn” pile. (As it turned out, she should have studied more anatomy. And she only got questions about one genetic disease.) The following Monday, she started her outpatient clinical rotation at the Cleveland Clinic.
Marleny Franco did not throw up during the exam and her vertigo lessened. In March, she began her inpatient rotation in surgery at MetroHealth Medical Center.

Mike Norton began his research block at the VA, where he worked in a microbiology lab, trying to determine what makes one class of bacteria resistant to penicillin. He began his clinical rotation in July. He’s looking forward to meeting his son, who is due this November. In June, he was sworn into the U.S. Army as a second lieutenant.

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