Month: April 2012

Most of my postal mail consists of the following:

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• letters from various organizations and charities soliciting donations
• letters from schools I have attended soliciting donations
• recruitment postcards from random medical practices throughout the nation
• letters from the AMA, requesting that I become a member (they send out at least one letter a month; I wish they’d stop already)
• letters from the AMA, urging me to sign up for their life insurance and disability policy
• various advertisements for restaurants, furniture, services, etc.

I continue to daydream about regular exchanges of handwritten letters with people. And it remains a daydream. (Three years later: The best way to get letters is to send letters.)

Correspondence from the American Board of Psychiatry and Neurology is uniform. The envelopes are always 8.5 by 5.5 inches. The logo for the board appears through the plastic window and the address is perfectly centered.

One evening about three weeks after I took the exam, I opened my mailbox and found a solitary letter waiting for me. The white envelope was 8.5 by 5.5 inches. It had heft; there were clearly several sheets of paper in there.

I flipped the letter over to view the sender: The American Board of Psychiatry and Neurology.

My hands immediately began to tremble and I felt a layer of sweat instantaneously form in my armpits.

I wanted to laugh at myself: This is not my usual reaction to mail. I, however, was unprepared to receive this letter. I wasn’t expecting it for another week! I wasn’t ready right now to deal with the prospect of having to take the exam over again, to go through the onerous task of setting up a future date, to resume studying again…

… but you don’t even know if you need to do all that yet.

I hurried into my apartment, silently willing my hands to stop shaking. The points of contact between my fingertips and the envelope were becoming soft; the moisture from my hands were warping the fibers of the paper.

After I turned the deadbolt on the door, I didn’t proceed the usual ritual of “coming home”:

• toss mail onto table
• take bag off of shoulder
• take coat or jacket off, if wearing one, and hang it up
• take shoes off
• peel socks off and deposit into laundry basket
• take lunch sack out of bag and put on kitchen counter
• take water bottle out of bag and pour any remaining water into a tall tumbler
• open mail

Instead, I stood in front of my desk, bag, coat, shoes, socks, and anxiety still on. The letter opener swiftly sliced the envelope open and my shaking fingers fished the papers out.

“Please say I passed, please say I passed,” I murmured to myself.

Call me weird, but I wanted to remember that moment: Just then, anything was still possible: I didn’t yet know if I passed. I didn’t yet know if I had failed. It was a branch in the decision tree: This bit of knowledge would significantly affect my future behaviors.

(This is called the illusion of control.)

I unfolded the paper and my eyes jumped straight to the word “congratulations”.

A smile spread across my face.

The rest of the letter announced my status as a diplomate of the American Board of Psychiatry and Neurology, that I would be receiving a document attesting this in a few months, blah blah blah.

“Thank God!” I exclaimed.

Relief. A lot of it.

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So what advice do I have for other people taking major exams, whether in medicine or not?

• Learn the content of the exam. You’ve got to know the information that the exam will present. Usually, you already have a sense as to what study strategies work best for you. If you know that you do better with a study schedule, make one up and stick to it. If you know that you study better with other people, set up a study group. If you know that you need a lot of pressure before you’ll get to work, make sure that you have sufficient time nonetheless to get all the information into your head.
• Learn the format of the exam. If you know how the exam will be administered, that will reduce your anxiety. Should your exam involve interactions with other human beings, this knowledge will also help you appear more calm and confident.
• Practice. Do practice questions. Do practice exams. When you study, go about it in a way that mimics the actual exam (e.g. talk out loud if it is an oral exam; use a computer if it is a computerized exam; etc.).
• Spend time on anxiety management. No one wants their emotions to sabotage their efforts. Figure out what works for you to remain (relatively) calm. You will feel anxious and it is up to you to figure out how to keep all of that at bay during the actual event. Whether this means breathing exercises or reciting affirmations or wearing an amulet that you can rub or whatever, have a plan as to how you will manage stress. It’s important.
• Reward yourself for your efforts. Treat yourself to something you enjoy both before and after the exam. There is more to life than the exam (though it may not seem like it) and engaging in those little pleasantries in life will help remind you that you are more than just a Test Taker.
• Let go after the exam is done. Easier to say than it is to do. Obsessing over the exam when you can’t do anything about it is draining. Figure out methods to sufficiently distract yourself so you don’t fall victim to your anxieties. (This could easily fall under “anxiety management”).

Before I left Boston a few hours later, I changed out of my suit and into jeans and tee shirts. Some friends, The Beau, and I met up at a mall that was clearly designed in the 1970s. The Beau had thoughtfully purchased a Vietnamese sandwich (banh mi) for me; I purchased a cookies and cream milkshake.

We didn’t talk about the exam too much. My friends are sensible people.

By the time I got into the Bolt Bus to go back to Manhattan, my body was tired and I could not keep my eyes open. The sun was beginning to set and the golden orange light flickered through the bus windows. I nodded off, but was thinking, thinking, thinking…

… and, perhaps an hour later, I awoke and noticed that the bus was crawling along with the rest of traffic. Red taillights glowed in front of us in the purple-blue night sky.

The Beau noticed that I had stirred and looked at me.

“There’s a good chance I didn’t pass the exam,” I murmured.

He might have said something in response; I don’t remember. I fell back asleep.

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I knew what I had said, though. And while I hoped otherwise, I knew that my statement had validity: There really was a chance—maybe even a “good” chance—that I didn’t pass. Everything that I had done “wrong” returned to my mind as soon as my anxiety had dissipated:

• I hadn’t asked the patient about homicidality.
• I didn’t assess her for eating disorders.
• I could have asked more about her past history.
• Why did the examiners keep asking me about her employment history? Why didn’t I ask her more about that?
• I probably shouldn’t have stuck so firmly to my answers with the vignette.
• He was probably asking more for pharmacological recommendations; why did I address those?
• I didn’t read the vignette as closely as I could. I probably looked like an idiot.

And on. And on. And on.

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They had told us that results would be sent in about a month. That gave me one month to distract myself. There was nothing I could do now.

We tend to learn processes as linear patterns, though, in reality, things are interconnected. Some postulate that emotions always follow thoughts (beware of aphorisms that include the word “always”), though we can all cite personal examples of how bad moods can lead to negative thoughts, even about things completely unrelated to whatever precipitated the bad mood.

During particularly hectic or otherwise mentally taxing days at work, I found myself utterly convinced that I had failed the exam and had internal dialogues that went something like this:

“You probably didn’t pass the exam.”

“You don’t know that.”

“This is true, but I missed a few key things.”

“Right, but you didn’t miss every key thing.”

“Fine, but I don’t want to take the exam again.”

“And if you have to take the exam again, so be it! You’ll at least know what to expect.”

“It’s the principle of the thing. I don’t want to spend that chunk of change again.”

“You may not have to.”

“You’re right.”

“I know.”

“But I still feel anxious.”

“I know.”

And then I’d try to think about something else. I used a lot of the distress tolerance skills I had ever learned or taught.

While running early in the morning (only after the exam did I revert back to 5:30am runs), my mind would wander all over this again. The running, though, was therapeutic in its own right in helping to dispel some of the anxious energy.

Ultimately, all I could do was wait. And take comfort that the exam was over. And that I could spend more time doing other things—like write here.

Really, the most prominent emotion I felt as I walked out of the building was relief. I didn’t care during those moments if I had passed or failed; I only cared that I was done.

As I had mentioned earlier, there are arguably many flaws with this oral exam (live patients are not standardized, the examiners are not necessarily standardized, etc.). Was the exam as bad as I had imagined? Well, no. Did I have any horror stories to tell? Not really.

Would I have to do this all over again—pay the $1350, book a hotel room, make travel arrangements to go to another city, restudy, etc.?

As I exited the building and felt the breeze sneak into my suit, I thought, I don’t think so… right?

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People began talking on the bus. It was the kind of conversation that I never enjoyed overhearing and have always tried to avoid.

“How do you think you did?”

“I didn’t understand what they were trying to ask with that vignette—what did you end up saying?”

“Oh, is that what you said? You think that’s what they were trying to get at?”

The air in the bus was warm and still; it had that tour bus smell that again reminded me of those early mornings at UCLA when the marching band piled into a series of commuter buses to go to the Rose Bowl for football games.

A few people were still comparing notes and, restless, I fished my cell phone out of my bag and exited the bus. Hearing these conversations was not helping me: We had no way of confirming or correcting our responses now. I craved distraction.

I had brief conversations with a few people as I ambled back and forth along the length of the bus. The Spring breeze was cool against my neck. People congratulated me for completion of the exam. They wished me safe travels back to New York. They hoped I would treat myself to a cookie. Or two. Or several.

(Okay, only I wanted “several”.)

Only when the bus driver appeared did I saunter back into the bus. The engine was soon rumbling throughout the metal rectangle on wheels.

A few people continued to talk with each other on the way back to the hotel. Most people fell silent, though, ostensibly napping or staring out the windows. Trapezoids of sunlight stretched into the bus from the windows and slowly travelled up and down the center aisle.

I tried to read a book, but couldn’t concentrate sufficiently on the story line. I leaned against my travel bag and pushed the sleeves of my suit up my arms. Fields rushed past; then small suburb communities; then the river; then the buildings of Boston.

It looked a little bit like those sporting events where the two teams meet in the middle and shake hands with each other prior to the start of the game.

The eight examiners stood on one side of the wall; the seven examinees stood on the other side of the wall. Four examiners and four examinees peeled away to the other end of the hallway; the three of us remained with the leftover four examiners. We all shook hands with each other. I forgot their names the moment they finished the last syllables.

The rules of the exam were explained to us. We were to sit in the chair outside of the room until instructed to go inside. We would spend 12 minutes in the room and complete the task. Then we would have three minutes to move over to the next room. This would occur four times, for a total of one hour.

“Good luck!” the nasally man said to us. “Remember, your examiners want you to pass.”

All right, all right, so we’ve heard.

The three of us sat in the chairs and idly looked around as the examiners filed into their individual rooms. A petite woman wearing a charcoal grey skirt suit clicked down the hallway in her petite heels and peeked into all of the rooms.

“Okay. You may go inside.”

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“I am going to read this vignette to you,” she said. Her English had a distinct Asian accent. “This is a treatment vignette, so all the questions will be related to treatment.”

She read the scenario with the excitement of someone reciting a grocery list. She then asked me for treatment recommendations.

After I supplied my succinct suggestions, she chuckled quietly. “No, no. Tell me about pharmacological treatment recommendations.”

I paused, my eyebrows reflexively furrowing. I wouldn’t recommend any pharmacological treatments in this scenario. I stuck to my guns: “One might consider using this or this, but I still would recommend What I Originally Said.”

She laughed quietly again, nervously looking at the timer on the table. “Okay, okay, we’ll come back to that question. Let me move on.”

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The second examiner wore glasses and sported a warm smile on his face. He spoke evenly and seemed genuinely interested in me. Under different circumstances, I imagined that he was a well-liked teacher. However, these were not different circumstances and I had to stop imagining so I could get on with the test.

“I will play a clip from this DVD,” he said, “and this vignette will test your diagnostic skills.”

The video showed a faceless, male psychiatrist in a light brown tweed suit with those leather-like patches over the elbows interviewing a woman with a remarkable appearance (that I won’t repeat here for fear of receiving a “cease and desist and stop helping people cheat” letter from the board). I scribbled down some notes about the interaction.

“Question number one. Tell me about….”

BAM!

“Number two. What would you consider….”

BANG!

“Number three….”

POW!

(You didn’t think an oral board exam would sound like a Batman cartoon, didya?)

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“Sit down, take your time, we’ve got plenty of time,” the third examiner said to me. He spoke with a Southern drawl. His hands were large. One hand could have easily crushed my face. (What? What do you mean I sound intimidated?)

As he read the vignette to me, I silently willed him to read faster. He was taking a leisurely jaunt along a lazy river, pausing frequently to smell the flowers, look up and pick out animal shapes in the clouds, and take in deep breaths of fresh mountain air.

I squashed the urge to begin bobbing my leg up and down.

“Any questions about that?” he finally concluded. I was sure six minutes had already passed.

“Nope,” I answered.

“Okay. So this is a treatment vignette. Tell me what risk factors this patient has for….”

I reviewed the sheet of paper and provided my answer, albeit interspersed with a few “um”s.

“What about this modality?”

“Oh, right,” I said, feeling my face flush. “This and That are also options.”

“Very good,” he said, turning the page. He would redirect me two more times.

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After we easily got through the rest of the questions, the first examiner did eventually return to the first question. I repeated the same answer for the third time. I was that confident (foolish?) in my response. I don’t know if she finally agreed with me or resigned to my stubbornness, but she ultimately said, “Okay. Time is up.”

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The last examiner also wore glasses, though his face was all serious and no smiles. His posture and style of dress was consistent with his facial expression.

“The questions for this vignette are focused on diagnosis,” he began. “I will read this to you.”

I don’t remember much more about this interaction, save that he spent at least three minutes asking about infectious diseases.

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The petite woman in the charcoal grey suit saw us treading out into the hallway.

“You guys are all done! You can go back to the buses now!” she said brightly.

I lingered in the hallway while the other two examinees walked away. I pulled out a bottle of water and took a few gulps. After a stop at the restroom, I swung my bag over my shoulder again and began my exodus from the building.

No one else was around. The sunlight gleamed on the tiled floor and I caught a few specks of dust floating in the warm air. I felt the cloth of my suit sticking to the back of my neck. I began to walk faster, eager to feel fresh air on my face.

We were directed to another room for the second portion of the exam, though it would not begin for nearly an hour. We were one of the few groups whose exam was interrupted by lunch.

One side of the room was constructed almost entirely of windows and the view revealed empty fields, a few uniform buildings constructed of steel and glass, and distant houses stacked alongside each other. On the other side of the room was the door and more windows that looked out into the hallway, though these were partially covered with blinds. A white board was on the third, narrow wall, and the fourth wall was empty. A large conference table was in the center of the room, surrounded by conference chairs, and on the table were several bottles of fluids: sodas, waters, and juices.

Our small group of seven filed into the room and sat down. More familiarity was present.

“I wish we could just get this over with,” someone commented. “I don’t want to sit here for an hour.”

“Yeah, I know,” someone else replied.

“But! we’re halfway done,” I said. One must help maintain morale in these situations. Context matters and I didn’t want to spend my lunch hour listening to people grouse.

“Yes,” people said, sighing. “Halfway done.”

A few of us brought lunches and we began to take them out of our crinkling plastic bags. The others wandered out of the room to forage for food in the cafeteria. Some returned with small boxes filled with sandwiches and chips; others returned empty-handed, having devoured their meals elsewhere.

Because eating is a social activity, and because we obviously had several things in common, conversation began to flow amongst this group of strangers. This is what I remember:

• a community psychiatrist from Washington, DC, whose spouse is in the military
• two addiction psychiatry fellows, one from New York, the other from Connecticut
• an inpatient psychiatrist from South Carolina
• an inpatient psychiatrist from New Jersey
• one person who didn’t participate in any conversation, so I don’t remember where he hailed from
• one person who had flight problems getting into Boston
• one person who was originally from Russia, and this spawned an enthusiastic conversation about cold weather and life in Russia
• comparisons between programs and occupations
• one person who went to medical school with someone who was one of my fellow residents; I provided updates
• discussions about pregnancy and raising kids in medical training
• plans following the exam
• dialogues about things to do in Boston

I was also struck by the age range in the room. It was a small sample, indeed, but I was undoubtedly one of the youngest people in the group. The oldest person’s age was probably somewhere in the middle to late 40s.

The hour passed. Food disappeared, we shared some laughter, the beverages on the table lost a few of their comrades, and we brushed the crumbs off of our suits. The sunlight continued to stream in through the large windows and the streets and parking lots remained empty.

An older man with a nasal twang appeared in the doorway.

“Are you all here for the vignette portion of the exam?” he asked. He was wearing a bright red vest underneath his dark blue blazer. We nodded.

“Good. We’ll get started in about five minutes.”

He disappeared and the conversation dwindled away. The second half of the exam would start very soon.