Thursday, April 24, 2014

The Gateway Exam - MSU CHM

Image modified by me from the original at

I have (un)officially completed the Gateway Examination, which is basically a 4-hour experience wherein we, as second-year med students, show that we've learned enough of the physical examination and patient interviewing skills to be trusted with real patients on the wards in the coming clinical years. I haven't gotten my score back yet, but I think I passed. More importantly:

What IS the gateway exam?
I'll tell you, but first - 
Imagine this:

You're a medical student, and you're almost done with your second year of med school. You've completed at least 4 years of undergraduate work, studied for and did well on the MCAT exam, and spent a year applying to medical schools and going on interviews. You most likely took out loans to be here, and at this point (if you're a financially average student) are probably more than $100,000 in debt. You've completed so many classes in med school, it's hard to remember all of their names, let alone their content. Biochemistry, Physiology, Gross Anatomy, Neuroscience, Pathology and more from M1, and now almost all of the Systems/Domains of M2. Last week one of your classmates messaged your class group on Facebook that you've completed your 1,000th hour of med school lecture. That seems like a lot, but you know it pales terribly in comparison to the number of hours that you've spent studying outside of lecture. 

Anyway, you are riding the elevator up to the fifth floor (unless you're in East Lansing, in which case I have no clue where you are) to complete the Gateway Exam. You've practiced all five sections: Cardio Exam, Neurological Exam, Acute Abdominal Exam, Newborn Exam, and you've gone over in your head what you need to do when meeting with a patient with an undiagnosed condition. 

You meet up with several other students, all of you nervously exchanging halfhearted jokes designed to lower the tension, while everyone knows that the tension can't really be lowered. You know you shouldn't feel nervous, but you can't help it. Nobody wants to fail. Nobody wants to do less than perfectly, and so everyone's nervous.

Each student is assigned a room number, and after a 15-minute spiel on what to expect, we file out of the room to walk across the hall to the simulation suite. The sim suite is basically a big grid of fake doctor office exam rooms, each one complete with examination table, physical exam equipment on the walls, and video cameras mounted to the walls with microphones dangling from the ceiling - all the better for the silent evaluators and recording devices to see/hear you with. 

You stop at the room to which you've been assigned. Mounted to the door is a white plastic box with a sliding panel on the front with bold black letters that state, "Do not move this panel until instructed to do so" or something along those lines. Behind the door you know there is a simulated patient and possibly (depending on which experience lies behind that door) a silent physician preceptor with a clipboard, ready and waiting to grade your performance.

You wait. And wait. And wait - until one of the preceptors standing guard in the hallway raises her walkie-talkie to her mouth and says, "Students in North Hallway ready." You hear a crackly voice echo down the hallway from her receiver, "Students in West Hallway ready." Apparently they're only running two hallways at once today, as the next sound is a "Bing BING bing BING" from the speaker in the ceiling above your head, followed by a calm-sounding male voice that says, "Students, you may now access the patient information on the door. When you are ready, you may knock and enter."

Stomach flipping a bit, you slide that white plastic door aside and quickly scan the printed information:

"Mrs. Eleanor Falloway. 55 years old. Chief complaint (from nurse): Abdominal pain."

Until this moment, you didn't know which experience you would be completing after walking through this door. In a couple seconds, you mentally reorder your expectations for what lies on the other side of the door. You're going to be doing an interview with a patient, trying to lightly tease out the underlying etiology of their disease while also addressing their concerns in a caring, supportive manner. Then, you're going to switch to doctor mode, getting all the pertinent positives and negatives, making sure to note all of the important symptom dimensions and risk factors for diseases X, Y, and Z. Throughout the interview, you're doing your best to take detailed notes because you know you're going to need it all when you write your SOAP Note later on. Within a few questions, you're formulating your differential diagnosis, and it never even crosses your mind that even one year ago, what you're doing would have seemed impossible. You've learned a lot.

After the patient-centered and doctor-centered interviews, you transition to the physical exam, specifically tailored to assess the acute abdomen:

1. Inspect the abdomen.
2. Auscultate for bowel sounds. (Patient hands you a card telling you what abnormal bowel sounds their pathologic belly emitted into your stethoscope.)
3. You ask the patient to cough, and she makes a big deal about how much it hurt her right lower abdomen.
4. You make a point to be sensitive of that as you palpate, lightly then deeply, each of the four quadrants of her abdomen.
5. You go on to assess for Rovsing's Sign (+), Rebound Tenderness (+), Obturator Sign (+), Psoas Sign (+), Murphy Sign (-), and you're done. Classic appendicitis. Ain't no thang.

You wrap things up and leave, already formulating the SOAP Note that you'll need to write once you finish up with all of the other examinations. You take the extra time before your next station (you got out FAST! Did you forget something? Did you mess something up?? No, no, you just did a good job. You keep telling yourself that...) to jot down a few more notes before Ding DING Ding DING - on to the next station.

Again, preceptors exchange flat-toned commentary on hallway-specific student readiness, and Calm-Man-Voice tells you that you can access the information behind the secret sliding plastic panel. It's the Neuro exam. Okay - get that vision card ready, you're going to need it. There'll be a preceptor and standardized patient behind this door...


And on and on you go. It would take far longer to type everything out than it takes to actually do it, so I'll just leave you with the steps for each part of the Gateway Exam, in case you're interested. Hats off to all of the upperclassmen who read my blog out of some sort of deranged nostalgia for their preclinical years when "all we had to do was learn!"

A much bigger hats off to all my fellow classmates who completed this milestone with me this week. We're one sizeable step closer to Step 1 this summer, and to the hospital rotations after that. 

Well done.

And now, without further ado, 
click to embiggen any of the below images:

The Cardiac Exam:

The Neurological Exam:

The Newborn Exam:

The Unknown Problem Visit:
For this one, we were evaluated by:
1. The patient we interviewed based on how they felt we did.
2. A miniature 10-15 question quiz we took immediately after the interview, asking us about various features of their presentation to determine to what degree we elicited the most important details.

The Acute Abdominal Interview & Exam:
For this one, the simulated patient evaluated our interview (not shown) separately, then evaluated the physical exam:

The SOAP Note:

So yup. Today was a blur. Four hours of lecture, lunch, the Gateway Experience, a run with Hobbes, then two hours of Therapy Dog Training during which he had his first patient visits in the hospital! Today was just a day full of clinical skills for us budding healthcare workers, hahaha. After several hours, a hefty plate of Wife's Taco Casserole, and a blog post of epic proportions, I'm ready for bed. Today was a complete wash in terms of Step 1 Studying, but I'll remedy that tomorrow afternoon - and this weekend, and every day of the domain afterward...


1 comment:

Susan said...

Whew! THAT'S a workout! Nice work and congratulations. On to the next hurdle. Go get 'em!

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