Education Lessons Nonfiction Observations

The Oral Exam (V).

I am grateful that my patient was kind to me.

She was fully aware of this testing situation. In my patter, I nonetheless reminded her:

As you may already know, these two individuals are examining my skills as a psychiatrist today. They will not be evaluating you; they are evaluating me. Thank you for agreeing to participate in this exam. We have thirty minutes together today and you may find me interrupting you—let me apologize in advance for that. I just want to make sure I get as much information as possible. So, can you tell me about why you are currently receiving psychiatric care?

I was supposed to say something like that, anyway. Despite all of my rehearsing, I ended up saying something less eloquent.

(As an aside: Several psychiatrists reported to me that they took propranolol, a medication often used to treat high blood pressure, prior to their own oral board exam. They advised that, if I was going to use this medication, I try it at least once before the actual exam, as some people get light-headed or dizzy as a result. They reported that the medication helped to minimize their anxiety and feel more comfortable during the test. Should propranolol be considered a “performance-enhancing drug”? Discuss.)

(And, no, I did not take any propranolol prior to my exam.)

But, again, my patient was kind to me and, bless her, she made a point of turning to the examiners halfway through the interview to note, “I’ve never told anyone about that before. She’s good.”

I felt my heart beating in my ears and my speech unfolding quickly during the first initial minutes of the interview; I coaxed myself to slow down and take a deep breath. As the interview progressed, I soon forgot about my audience and attended to the patient.

(I’m fortunate: my current training involves multiple diagnostic and therapeutic interviews of this sort—though not limited to 30 minutes—per day.)

In my peripheral vision, I did spy Dr. Grey Hair nodding enthusiastically at some point in the interview. I think that’s against The Rules, but I appreciated that inadvertent warm fuzzy.

The 30-minute interview was the easy part. After the close of the interview, the patient and I thanked each other (“good luck! you did good!” she remarked as she walked out the door) and I settled back into my chair, preparing myself for The Pimping.

“Please present the patient,” Dr. Eyeliner said to me. Her arms were crossed in front of her chest. Dr. Grey Hair’s hands were in her lap. They looked at me expectantly.

Now, when I feel anxious, I talk fast (or, more properly, the rate of my speech is significantly increased). In medical school, people exclaimed, “Slow down!!!” because the words fall out of my mouth like coins out of a winning slot machine. In this setting, talking fast does not work in the examinee’s favor, as this gives the examiners more time to ask questions!

I launched into the presentation: “Ms. Betty Crocker is a 74 year old woman with a reported past history of…” and rattled through the template of a presentation. I heard the words spill out of my mouth in a surprisingly organized deluge… and then I heard myself tripping over a series of consonants… and then I heard myself make that pop! sound with my lips because I was “rebooting” myself.

I made that pop! sound twice in my presentation and sheepishly smiled immediately afterwards. That’s not the mark of professionalism or coolness; it’s the mark of anxiety and self-consciousness. I hoped that the examiners would find it endearing. Their faces suggested that they didn’t care one way or another.

I completed my presentation in less than ten minutes. I waited for the first question.

Dr. Eyeliner looked at me and asked, “So… what is her global assessment of functioning?”

I looked back at her and said nothing.

I just told you her global assessment of functioning… were you listening? do I not know what a global assessment of functioning is? did I actually just think it, and not say it?

The pause lengthened and before I could say something, Dr. Grey Hair, in an effort to save us all, turned to Dr. Eyeliner and began to say, “She said—”

“—oh yeah, right, right, never mind,” Dr. Eyeliner quickly said. For a brief moment, her expressionless face flashed with annoyance.

The questions then came quickly:

  • What is her prognosis?
  • What pharmacological recommendations do you have?
  • What psychotherapeutic options would you suggest?
  • Are you sure about that?
  • How do you think she would do with that modality?
  • Is there anything else you’d like to add?
  • What concerns do you have about her safety?
  • Anything else?
  • Why do you have those concerns?
  • Would you like to add anything more?
  • What about the safety of the other people living with her?
  • Do you think she is qualified to do that kind of work?

… and on, and on, and on. As the questions progressed, I felt myself floundering: They were asking me questions that I frankly couldn’t answer without doing a whole lot of speculation. I don’t like to speculate on exams.

I also realized that I hadn’t asked the patient if she had any thoughts about wanting to harm or kill anyone else. That’s part of The Golden Triad:

“DO NOT FORGET to ask about suicidality, homicidality, and substance use during the exam!” People said this over and over and over again… and what did I do? I forgot to ask about the second item, even though I ask everyone else about it nearly every day when I at work. Rackin’ frackin’….

I sheepishly conceded this during The Pimping session: “I neglected to ask her about homicidality, which is something I should have done….”

This omission would haunt me.

During the last few minutes of The Pimping, I said, “I don’t know; I’d want more information before answering that,” at least three times. The questioning session was grinding to a halt with my reluctance to give any opinions without more data.

Thankfully, Dr. Grey Hair chimed in, “Okay, our time is up.” Both women smiled at me—the first time they revealed any facial expression whatsoever.

“Thank you and good luck,” they both said. We all stood up and they shook my hand. They then dismissed me from the room.

I threw the bag over my shoulder and walked out of the room. As soon as I was out of earshot, I heaved a great sigh.

Halfway over, I thought. You’re almost done.