Step one: Burnout

The board exam that did (most) of us in.

I heard the cue of the The Office theme song from the other room. I knew exactly what that meant: It was the middle of the day (about noon or so) and my roommates at the time were taking their usual mid-day study break to eat lunch and attempt to dump any remnant of dopamine into their synaptic clefts after a long and difficult 2 years of medical school seemingly depleted it all.

Usually when I heard that theme song, I let out an exasperated “sigh”. I didn’t do that only because I disliked The Office (hot take: Not that funny of a show, overrated - fight me), but because it meant that half my study day was over and the familiar feelings of “I didn’t learn enough this morning and I am going to completely fail this board exam and the rest of my life is ruined and I am going to have to move to a desolate part of Nicaragua and to live amongst the natives who hopefully will accept me for the failure that I am” would set in.

Enough said.

Perhaps that’s a bit dramatic, but the point is this: Studying for the Step 1 exam at the end of your second year of medical school was no friggin joke.

For those of you reading who have not had the distinct pleasure of studying for medical school board exams, allow me to give a brief overview of what this Step 1 exam is and why it made me want to apply for Nicaraguan citizenship.

Essentially, there are 3 “Step” exams that us medical students / residents are required to take to in order to graduate from medical school and hold that esteemed title of physician - Step 1, 2 and 3. These are administered by a governing body known as the USMLE (United States Medical Licensing Examination). These exams are taken at various points in your medical career. In my time, Step 1 was taken near the end of your second year. Step 2 would be completed in your third year of training. And the last one, Step 3, is completed during your intern year of residency, when you have so much free time to study while working 80-ish hours a week and trying to juggle the new demands and responsibilities that come with making life or death decisions for patients.

And these exams are not like a 10 question quiz you answer to figure out “what kind of bread you would be” or “guess which country these McDonalds menu items are from”. These are the real deal. Step 1 is an 8 hour exam, about 280 questions, taken at a centralized testing center of your choosing. If that wasn’t enough, Step 2 doubles down with 2 days of fun - one day is another 8 hour exam, followed by another day with the “Clinical Skills or “CS” portion”. See, with this part you get to generously pay your own money to travel to a city (usually Chicago! Or, if you’re extremely lucky, the Las Vegas of the Northeast - Conshohocken, Pennsylvania) to run through a series of standardized patients demonstrating your interviewing and clinical skills. *** Now here’s the best part - the almighty “they” collectively thought, “hey!, you know what would be an excellent idea? Let’s make Step 3 two days as well!” And just like that we found ourselves brimming with joy as we conquered two more 8 hour days of multiple choice questions.

***The above explanation of the board exams is somewhat simplified, depending on if you were an M.D. candidate or a D.O. candidate, like myself. I chose to not get into the nitty gritty details here, but there certainly were some differences.

I’m sure you can tell from my tone that there have been few more enjoyable experiences in my life to this date.

Alright, so to the point, finally - why am I boring you all with details of these exams and false narratives about satellite Las Vegas locations?

The one exam we are going to focus on here is Step 1. Step 1, in my time, was a BIG. FRIGGIN. DEAL. Things, however, have since changed. Step 1 is now a “pass / fail” exam, a 2022 revision that was met with both joyous “hoorahs!” and several dissenting hisses. And sounding true to the old man who says “back in my day, I had to walk to medical school, up hill both ways through tornadoes, blizzards and while fighting ninjas” - back in my day, Step 1 was most certainly not pass or fail. It was a numerical score you were given. And this score held some serious weight.

My first 2 years were a build up to the Step 1 exam. It is a cumulative test of all the basic science knowledge that a physician needs in order to diagnose and treat patients. Let me state the obvious: this was a TON of information to try and learn, retain and understand. I pushed myself to the limit daily throughout my first 2 years in order to succeed; and now I was being asked to take it a step (ha!) further for one final, cumulative exam.

So what are the stakes? I am glad you asked.

When I was in high school, I used to play poker (Texas Hold ‘Em, and will still dabble in the ol’ cards a bit here and there). Step 1 is the huge pot at the center of the table. This exam, as we were taught, will essentially determine the rest of your career as a physician. Whatever score you get, that’s it. And if you want to do a certain specialty thats very competitive (plastic surgery, ENT, neurosurgery), then you better score high, or you can kiss that specialty goodbye. Don’t score high? Say adios to the prospect of 500k per year as a vibrant-skinned dermatologist who seems to always be on vacation. Instead, your reward would be choosing a specialty amongst the bottom dwellers, like Family Medicine, where we say “hooray for FMLA!” and try and hold our ground as the last line of defense in healthcare.

High stakes right? And heres the thing. It didn’t matter what hand you had. Maybe you feel like you’re a 7-2 offsuit because you barely made it by in your first 2 years of medical school. Or maybe you have a royal flush - maybe you have absolutely owned the basic sciences and you know you’re ready to go all in. It didn’t matter. You better have brought your “A game” come exam time. You better have a good poker face. You better be ready to endure a round of poker with all the best players. Because no matter what hand you have when it comes time to take the exam, you better be all in, and confident you’re going to win.

Im getting the heeby-jeebies just thinking back to these days. I mean those are some serious anxiety provoking thoughts right there. And for us type-A people who want to control every aspect of our lives, the idea that our hopes and dreams could be crushed by one number may start you on a path you never intended to go down.

And that is what happened to me.

I did well my first 2 years of medical school. I was mostly near the top of my class the whole time. And I did that through sheer perseverance, dedication and hours on-end of studying. There were kids in my medical school class that were inherently brilliant human beings, and I had to work 6x as hard as them to meet them at their level - and they hardly ever studied.

I took that same mindset into Step 1. But I will be the first to tell you - 2 years of isolation, constant studying, extreme stress and expectations, does start to wear on you. At some point you’re hoping for a little reprieve and restoration. At the end of my second year, I probably had an 1/8th of a tank left, but somehow had to make the trip to - and through - Step 1 city.

So I floored it. I pushed my engine to the max. I studied 10-14 hours a day. And each day my exam drew nearer, the fear grew in me. I started sleeping less. I started drinking a lot more caffeine. I started exercising less. Now, I was coasting on fumes.

The night before my exam, I stayed at a friends parents house that was near the testing center I was taking my exam at. They were lovely, of course, and extremely accommodating. I got there early evening, planning to go to bed shortly after arriving. As soon as I walked in the room where I was going to sleep, I knew I was in for a battle.

I think total that night I slept about 1.5 hours. Despite trying to go to bed at 9pm, I tossed, I turned. I tried sleeping sideways, upside down. I tried sleeping on the floor. It was no use. I would have had more luck selling ice to an eskimo. I was so anxious. So worried about this exam. My breaths were short. My shoulders were tense. My mind was racing. Tomorrow was the day that essentially determined my whole future. How am I supposed to rest knowing that?

I “woke” up the next day essentially feeling hungover. My friends parents, who had made me coffee, asked how I slept. Being polite, I said “great!”, but you could tell from the looks on their faces they knew I was not well rested. I undoubtedly looked like disheveled squidward. I chugged as much coffee as I could and left for the testing center.

“Lets get this bread”

On the way, I stopped at a gas station and purchased enough caffeinated beverages to be just under the lethal limit that my heart could take for that day. I walked into the testing center, anxious, jittery, exhausted. I was spent. I was done. I felt like I couldn’t take this any more. I felt so horrible. It was then, when I sat down at the computer to start the exam, hand quivering over the mouse, barely able to control it, that I first slammed into that proverbial wall.

I AM SO FU***** OVER THIS.

-Bryce Bowers, 2017.

I took the exam. I finished the whole thing. Fueled by pure adrenaline, ungodly amounts of caffeine, rage and exasperation, I clicked an answer to each question, each time feeling my soul slip away, knowing that I had reached a point of almost no return.

And that was it. I didn’t care anymore. I got done with my exam. I called up my friend who was close by. I said “I just took the hardest exam of my life. Let’s go celebrate. I want to forget anything and everything about these past 2 years”. And off we went to do just that.

Looking back, this was the first thing that really sent me down the path of burnout, though I didn’t realize it at the time. The cumulation of the first 2 years of medical school and that exam absolutely broke me. I was so far gone by the time the exam was over, it made “Finding Nemo” look like child’s play. And the problem was, there was no break. There was no time for me to restore. I was moving on to my third year, my clinical rotations, a whole new set of demands, exams and expectations. Did I push on? Yes I did. Thats was what was being asked of me and what I felt like I had to do. But now I was continuing my medical career through a lens of resentment, exhaustion, anger and burnout.

So why do I share all this? So you can reach out to me on here or your favorite social media platform and pat my back and say “wow that was really hard for you?” No! I am vehemently against victim mentality. During that time I was in my late 20’s, and basically thought I had life mostly figured out. I realize now how naïve I was. How short-sighted I was. I honestly almost laugh now at myself thinking of how much of a tizzy I got myself in over that exam.

This is for anyone - medical students, residents, anyone, in any field, who is chasing dreams and trying to achieve anything at all.

There is no score, no exam, nothing external in this world, including nobody’s opinion of you, that defines who you are.

I was so caught up in the score that I received on this exam. I felt like it would define me the rest of my life, like I would have to walk around with some stamp on my forehead and it would stratify me into some part of a utopian society based on “intelligence”. And now, honestly, I could care less about any of that. Scores do not define you. Your career does not define you. If you need to take that exam, whatever exam it is, and get a score, because thats what you want to do to chase your dream, then do it. But don’t make it your whole life. Don’t waste precious time in the best years of your life agonizing over something so superficial. There is so much more to you as a human and individual then your subjective performance on some standardized exam or the alike. I know brilliant people who did poorly on that exam. I know people who were average joes like me who did great on that exam. What does that tell you?

The only regret I have about that time was how poorly I took care of myself, both mentally and physically. How I Isolated myself from friends and family. How I missed out on life experiences because I chose instead to obsess over 280 questions. Please do not make this same mistake. Because here is the thing - when you do all the above (exercise, eat right, socialize, live life), I can guarantee you that will you be more effective in how you study, and how you perceive yourself, so that come exam day, or whatever day it is for you, you wont just say “FU** IT” like I did. That is not a good or healthy place to be. As you will see as I continue my journey with this blog, it is extremely difficult to come back from that, and some people never do. I do not think what I am saying here is profound. I think it is actually common sense. But sometimes we lose track of what is important in life and what common sense is. (I am the most guilty of all this). And when that happens, you lose sight of yourself. You lose sight of your values. Of your other priorities. Of your human being! And let me hit you with this insightful dagger that has never been said before: Life is extremely short. It is so short! I see it everyday in the work I do. People who wish they did this. Or that. Spent time with this person. Did this experience. But instead they were so wrapped up in something, it consumed them, and they lost sight of everything. And now, unfortunately for many, it is too late.

I am fortunate that it is not too late for me. That is why going forward, I do my best do do what is asked of me, and what I need to do, but not to agonize over it. Not to let it become who I am or define me. I do my best to take care of myself. To do the things I enjoy. To see the people I want to see. This is not an easy task, I know. It takes deliberate practice and effort. But I promise that this lifestyle, this mindset, is unequivocally worth it. Whereas the dark, unforgiving road of burnout, is unequivocally not.

I appreciate you reading, friends. I appreciate your time. If this resonated with you in any way, please share. If you know anyone who this might help, please share. I want to grow a following to bring awareness to burnout. Please help me do that. Comment below as well and share your thoughts!

P.S.

I did just fine on my Step 1. The human body is an amazing thing, being able to pass an exam of that caliber after trashing myself for so long. So that begs the question - imagine what can be done if you actually take care of yourself?