Test, Test, and Test

I'm sorry not to write any article in my blog recently.
I took 1 Japanese medical board exam, 2 US borad exam (clinical knowledge), and 3 another US board exam (clinical skills).

The end of last week, I got official result of 1 JP med exam from Health ministry. I passed it. It means I can start to work as a doctor from next April.

After I've finished JP med borad exam, I immediately started to prepare US borad exam (clinical knowledge). I took this test in the beginning of this month. The content of this test is partly same as JP med board exam. But there are two different factor between both exam, time limitation and score requirement. First, this test is one day, 8 hours test. On the other hand, JP med exam is 3 day test. Therefore, we need different type of concentration. It is really tough.
Second, score requirement means we need high score. This is different from just pass or fail test.
All things considered, it is difficult of compare these tests.
Anyway my result is still pending.

After I've finished US borad exam of knowledge part, I quickly left my apartment and went to U.S.
During my flight to NY, terrible earthquake attacked to Japan. From U.S. we can know the disaster only through Internet TV, some mail from my family and friends.
This week's cover of the Economist is really shocking. There is the Sun shaped red circle in slope. Japanese people who wear protective clothing try to stop going down the Sun.
I don't know well about nuclear science, but I hope Japan can recover as soon as possible.

In New York, I attended one of prepare course for clinical skill part of US board exam. This course is presented by Dr Mark Schwarz who is author of "physical diagnostic exam." My mentor recommended me to this textbook, so I was really looking forward to meeting him. I brought my textbook from Japan to get sign from him.
This course emphasis on how to communicate well. Some part of this course is beyond mock med interview exam, but it is useful for real clinical situation.
This course is at home, So after finishing this course, I practiced for other participants.

I just spend my time when I don't need to be hurry.
I will go back to my home country

Now I'm in Los Angels international airport to go back to New York. After going back to NY, I'll transit to Narita airport. Unfortunately I cannot find any free Wifi. There is some time lag to post this article.

CS mock interview parctice

Today, I practiced a case of step2 CS in skype.
Today's case was a mock patient who came to clinic because of abnormal result in health fair.

I missed check his physical exams to suspect heart problems. In this case, he has high blood pressure, hyperlipidemia, family history of heart diseases. Based on these, I should check his JVP and pulse.

I've not had enough time to ask CAGE questionnaire.
These questions are useful to screening alcohol dependence.

Time limitation is severe. I should pick up what I ask, and control 15 minutes. Of course, it is ideal to ask all questions. From patients' information, we should change our differential diagnoses, and change our questions to detect diseases. While do that, we also pay attention to patient's concern and personal problems.
Medical interview is difficult to do well.

Failure is good experience. Through failure, I can learn. Before taking real exams, I fail a lot, and learn a lot.

Mock exam

Today, I didn't go out, just stayed home. I tried to do mock exam. The real exam is 8 blocks an hour each, and total an hour rest time. It was so tough for me to do that.

Previous exam was 7 blocks. I was used to long time test than first time. But the end of mock test, final block was difficult for me to concentrate.

We don't have enough time to think deeply to answer each question. We need to answer average 1 minute for each question. I should adjust this test style, and become "dog of Pavlov."

I hope these overwork experience will be available for me to be more mentally tough.

Tomorrow, suddenly I'll go to Mito to attend On the job training. I hope to become busy, and get a lot of clinical experience.

case10 -persistent cough-

I have to improve the following points.

• Asking more detail about suptum
• Asking more detail about sick contact
• When I suspect tuberculosis, I should ask last PPD
• Don't ask the detail of sexual activity which is not directly related to the situation in this time-limited situation
• advice her to do a standard protection to prevent around her

One expert of infectious diseases taught us that his big mistake was related to tuberculosis.
It is easy to say "suspect of Tb" retrospectively. But it is difficult to do that prospectively.

case7 -the patient's mother come to clinic-

Today, I practiced CS case. Today's case was little irregular one.
The setting was the child's mother came to the clinic. It means we can gather information from mother without physical exam.

I have to correct the following points.

• Asking the medication's effect (I'm satisfied to ask only medication)
• Asking last check-up (it is really important especially for child)
• Asking more detail about the brother who also had sick (we need to know more about sick contact)
• Suspecting of otitis media and UTI when you see a fever of child

Making a mistake is going shortest way to learn. However, I made same mistakes in different case.
It is difficult for us to select and concentrate on what we ask in time limitation.

What "Sakano ueno kumo" teaches us

Recently, a drama "Sakano ueno kumo" is broadcasting.
The novel was written by Shiba Ryotaro, one of Japanese famous writers.
It was historical novel about Japanese-Russo War 1904.

Some people confuse that this novel admire Japanese win of the war.
He tried to find the cause why Japan won the war and lose next World-war 2.
Fundamentally Japanese had persisted the success until our critical failure in WW2. It is difficult for human to throw away their successful experiences and to face with miserable reality.

Nowadays, we are in a same situation.
After WW2, Japan was in remarkable high-growth period. Once Japanese high-growth system was made a lion of. However, now Japan cannot recover from economical shrink, while other countries tried to find new growth way.

Maybe it is a time to throw away our successful experiences in 1950's and to accept miserable reality that our country become shrink gradually.
We should learn our history more.

I like this novel, so I read twice. In my policy, I don't read a same book twice until I value the book more.

Concentration of my attention and time

February 2011, I will take Japanese medical board exam. When I will pass all exams, which are included graduation exams and Japanese medical board exam, I start to work as a doctor from April 2011.

Now I and my friends have to study hard to pass the board exam.
One of doctors who take charge of medical students advised us to concentrate our attention and time to study before the board exam. When we have two tasks other than studying board exams, it is high risk to fail.

Therefore I tried to manage my schedule not to do so many things. However I tired to get ECFMG certification in same time. It means I'm high risk student to fail.
I read a twit that US medical students do multitask. It means they run in treadmill, while they study flashcards. I follow them to do multitask. Actually I don't have enough time to do all things slowly.

My goal until April 2011 is the following.
1. Graduation from University school of medicine
2. Pass the board exam
3. get ECFMG certification (it means pass CK and CS)

USMLErx

先週の金曜日からネットの問題集を始めた。

STEP１の時に３つやったので、それをSTEP2でもやろうと計画している。
まずはネット問題３つのうちに最もとっつきやすいこれから始めることにした。
月単位で購入するので、まとまった時間がなるべく取れる時期を見計らって、この時期にした。まだ本媒体の問題集を解き終わっていないが。

１ブロック４４問にまで減っているので、だいぶ気持ちが楽だ。最近の傾向として１ブロックあたりの問題数がどんどん減ってきている。

ただ、STEP1と比べてSTEP2では長い問題文の数が多いし、それらの問題文の長くなっている印象を受ける。

最近やっと英語を読みとばしに抵抗がなくなってきた。今までは、英語というと受験英語の悪しき慣習が身についていて、精読を目指す傾向にあったが。そんなことをしていたら、埒があかない情報量を処理しなくてはならないと、自然と多読できるようになる気がする。そして、文脈から大凡を推測して拾い読みもできるようになる。

ここからは、眼と頭に対して酷使と回復のサイクルを如何に効率良く回すかと勝負になる。

Pretest ClinicVignettes for STEP2

Pretest ClinicVignettes for STEP2 2nd Edition

こちらは、システム毎ではなく、ランダムに50問1セットで8セットの問題集。
全体的に50％ちょいと取り組み始めてから日が浅い割には、そこまで（Step1の時ほど解いていてやめたくなるほどひどくない）ではないので、あまり凹まずに解いていられる。

これで、およそ計2500問程度。
ペーパーベースでは、
pretest Pediatric
Kaplan Step2 CK
First Aid Q&A 後半
が残っているが、時期をみてウェブ版第1関門、USMLErxを始めようと考えている。

PreTest Medicine

Medicine PreTest Self-Assessment & Review, 11th Edition

Internal medicineの分野を、各システム毎に載せてある。Step1の知識内で対処できる問題も多いが、いかんせん忘却してしまった項目も多いことを実感させられた。

各システム毎に分かれていて、類似問題も近接しているので、大枠が頭に入っていない自分にとっては役に立った。

First Aid 上ではpretestシリーズの評価は高くない。確かに一部細かすぎると思われるものもあるし、全体的に画像が出てくる問題も多くはない。
それでもやる価値はあるとおもう。
現在では12版が出ている。

PreTest Psychiatry

Psychiatry PreTest Self-Assessment & Review

終わった。半分（500問中250問）まではだらだらやってしまったが、残り半分は12/31-1/3の間に集中してこなした。

OB&GYNに比べて、Step1との重複が多く、時々そこから足を出した問題があった程度なので、苦にはならなかった。・・・というかOB&GYNが予備知識がない状態でのチャレンジだったので、予想通り時間がかかったというべきか。
リチウムの血中濃度や投薬開始後からどれくらいで血中濃度がプラトーになるのかといったマニアックな問題には手も足も出なかったが。

Pretest Medicine
Pretest Pediatrics
Pretest ClinicVignettes(STEP2)
(Pretest Physical Dignosis(STEP1&2)はやるか微妙)をやった後で、
Q&A for the USMLE Step2 CK
の残り半分（前半の分野別のは既にPretestに手をつける前にやってあるので）そして
Kaplan USMLE Step2 CK
を紙媒体の問題集としてやる予定。
ネットの問題集としては、USMLErx, Kaplan, USMLE world
の３つができればベスト。

全てこなせれば単純計算では12000問くらいになる。このうち間違えた問題を反復するので、延べ20000問くらいになるのでは？
step1の時も計算していないが、これくらいかこれ以上はこなしたはず。
後は、残りの使える勉強時間とその間に入ってくる予定達との兼ね合いだ。時間がいくらあっても足りない・・・

PreTest OB GYN

Obstetrics & Gynecology PreTest Self-Assessment & Review

やっと終わった。Step 2ではOB GYN（産婦人科）Psychyo（精神科）が海外の受験者には１つの試験の山になると言われている。米国特有の知識が要求され、かつ国試ではそこまで深くは要求されないからだ。

婦人科検診の頻度（リスクファクターや以前の検診結果によって微妙に変わる）や、垂直感染（母親から子への感染）防止のための妊娠後のワクチンについてなど、国試の産婦人科すらまともに勉強していない自分にとっては、難しく、時間がかかってしまった。

First Aid step2などでは、あまりこの問題集の評価は良くないが、不得意分野の補強という意味では項目ごとにまとまっていて勉強しやすい。確かに部分部分ではここまで細かい知識は必要ないのでは、と思える個所もある。いただきものなので、一版前のものだが。

次はpretest psychologyに取りかかろう。