Category: Education

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Education Homelessness Medicine Nonfiction NYC Observations PPOH

Daily Schedule: Homeless Outreach Team.

A sample agenda as the consulting psychiatrist with a homeless outreach team:

8:17am. Arrive at the office, which is in a tall building that is a short walk from the New York Stock Exchange. Speak with the case managers and social workers about who should be seen that day.

8:55am. Walk with a case manager to the ferry terminal meet Paul[1. All patients described here are composites of people I have seen across time.], who is a young man the outreach team has seen over the past two weeks, particularly in the early morning. Paul has said that he lives with his father in Washington Heights. When asked why people see him at the ferry terminal at night, he only repeats that he sleeps in his father’s apartment at night and walks the 10 miles to and from the ferry terminal every day. He doesn’t say much to people, but he’s often mumbling to himself. The security guards have shooed him out. He returns everyday.

He’s sitting in a chair with a ripped jacket draped over his head. Dirty sweatpants that are three sizes too big hang off of his slender frame. When he hears “good morning, outreach team” for the third time, he slowly pulls the jacket off of his head. His eyes are closed. When he hears “are you okay?” for the second time, he opens only one eye. With some prodding, he says his name, but says little else.

“I gotta go to work,” he says as he gets up. The sweatpants begin to slide down his hips. He’s not wearing any underwear. He starts to walk away and the legs of the sweatpants begin to bunch around his ankles.

“If you want, we can get you a pair of pants that will fit you better—”

He starts to walk faster and does not listen to entreaties to stop. With his left hand he grasps the waistband of his pants and walks down the escalators. He blends into the crowd of people exiting the terminal and is soon on the road outside, walking north.

“That’s Paul,” the case manager says.

“We’ll try again tomorrow.” Provide teaching on different strategies to build rapport—maybe present him with a pair of pants? a package of underwear?

9:20am. Say good-bye to the case manager and hop on a subway and head uptown, but don’t exit the station. On a bench near the rear of the station is Eleanor. She’s been homeless for over twenty years. She’s wearing two jackets and her fingernails are painted pink. No one has ever seen her nails unpainted. They always look manicured.

She’s darning socks with her wrinkled hands. Nearby is her large rolling suitcase, which is open today; inside are more jackets, several pairs of shoes, and two large bags of potato chips.

“Hello,” she says quietly. She smiles. She reports that she is fine, but her back hurts this morning. She wasn’t able to lie down last night to sleep. The security guards frequently asked her to move.

“You could move into a small apartment where security guards wouldn’t bother you. It would be your own space.”

“Oh, but I can’t,” Eleanor says. “They will exterminate me if I do that.”

She’s said this consistently over the past seven months.

“The alien transmissions—they use the satellites—tell me that I’m not allowed to move inside. They’ll exterminate me if I do. They’ll use electrocution. I don’t want to be exterminated. I can’t.”

With much coaxing, she’s actually been able to visit a housing project to see a studio apartment, but she refused to actually step into the room.

“I’ll get exterminated.”

She also declines to take any medication.

“The only medicines that work are potato chips and chocolate. Dark chocolate works better than milk chocolate. I feel better when I eat chips and chocolate.”

It’s hard to argue with that. She declines housing again today, but she’s open to another visit later on in the week.

10:00am. Get back on the subway and get off at the stop two stations away. Climb the stairs out of the station. Barry is sitting cross-legged in front of the bodega. He’s rocking back and forth while smoking a cigarette. Barry says he’s been homeless for the past eight years and the bodega owner says that Barry has been sitting out there for the past five years.

“I’m sorry,” Barry greets. A stranger leans over and leaves a deli sandwich and coffee for him. Barry mumbles, “Thanks.”

The dirt on his arms and hands indicate that he hasn’t showered in several weeks, maybe a month. Dirt is packed underneath his fingernails and bits of food are stuck in his beard. His fingertips are yellow and knobby with callouses.

“I gotta get back to work, I gotta get back to work,” he says, pointing at the building across the street. “I think my boss would give me a job again, I did good work while I was there, I did good, I did good.”

Barry also declines housing again today. “I gotta get a job first before I get an apartment. A man’s gotta work first, he’s gotta work, I gotta get back to work.”

The office receives his monthly cheques for disability (schizophrenia), but he won’t withdraw any money. His bank account has tens of thousands of dollars in it. He could afford to rent a small room, but he won’t do it. He can’t say why.

“It’s starting to get cold. If you don’t want to move inside, can I at least bring you a jacket or two?”

Barry stubs out the finished cigarette. He stops rocking.

“Yeah, sure,” he finally says.

11:00am. Team meeting. Discuss progress on different clients the team is following. Two people moved into transitional housing in the past week! One moved into permanent housing. People are excited about the individual who moved into permanent housing because he was homeless for over ten years. He often shouted at and hit himself for sins he said he committed. Despite that, everyone liked him, including the police, because he also had a sharp sense of humor. He also fed the pigeons every day.

He refused to move inside for over a year. After multiple visits to the housing project, he finally said he would give it a try. It’s been three days and he hasn’t left. Sounds like he was adjusting fairly well to his new digs, but he still sleeps on the floor.

12:00pm. Lunch. Chart the encounters in the morning.

12:45pm. A case manager brings a man to the office who is willing to sit for a psychiatric evaluation. A plastic bag hangs from the man’s hand. Inside is a brown paper bag that holds two 24-ounce cans of beer. One of them is open. He looks down at the bag.

“I won’t drink this now. Please don’t throw them away.”

He’s been homeless for four years. He was sleeping on the floor of the pizza parlor where he worked as a sweeper, but the owner was closing the business because of financial problems. He now sleeps on trains, in subway stations, sometimes in parks. He tries to avoid the shelters because people have stolen things from him.

“I know I have an alcohol problem,” he says, his eyes sad. “It wasn’t always this bad. I don’t know how to stop. Sometimes I think I will never stop, even though I hate waking up in the hospital. Life is too hard. Beer helps me feel better. ”

1:45pm. Charting that encounter. Diagnosis determines what housing he is eligible for.[2. “Diagnosis determines what housing he is eligible for.” This is an example of psychiatrist as an agent of social control.] It’s not clear if he has a “severe and persistent mental illness”. Suggest that he return in a week; the meeting can happen outside if that’s easier. No recommendations for medications right now, but harm reduction in his alcohol use would probably be helpful. He demonstrated insight, but that may not result in behavior change.

1:55pm. Case manager asks for help with a person who lives in a park. Hop into the team vehicle and drive north.

2:20pm. Arrive at the park. The client was there earlier in the day and said that he would be there, but a walk through the park shows that the client isn’t.

Three people by the picnic tables wave hello. The outreach team sees them regularly, though they are not eligible for this program. They have been drinking, but they are not grossly inebriated. They laugh as they tease us for following them around; everyone is now enveloped in the strong fragrance of fruity, sugary alcohol.

They each hold a bottle of beer that sits inside a wrinkled brown paper bag. They offer some. They aren’t offended when their offer is declined.

2:30pm. Walk around the park one more time to find the original client. He’s still not there. Children play with a ball on the lawn, multiple games of chess are in play, students read thin books on park benches, couples hold hands as they walk along the park paths, elderly women sit and watch people walk by. The three people who are drinking alcohol laugh loudly.

2:55pm. Arrive back at the office. A client is sitting in a chair by the door. He says nothing, but he looks upset.

A case manager requests consultation.

“This guy never agrees to come in,” she whispers. “Maybe you could talk with him? He’s been homeless for a long time, but finally agreed to move into an apartment about eight months ago. He was doing fine, even saw the psychiatrist there once or twice… but apparently he’s been sleeping outside for the past two days and won’t say why.”

There are introductions. The man doesn’t want to get up from his seat. He frequently looks at the door during the stilted conversation.

“How are you, Charlie?”

“Fine.”

He learns what the case manger shared. He says nothing.

“How long have you lived there?”

“A few months.”

“What’s it like?

“Noisy.”

“Anything you like about it?”

“It’s warm.”

He suddenly starts talking about the freedom of living outdoors, except the cops harass him sometimes. He also doesn’t like the kids who try to set him on fire. The zombies send them to do that. He’s tired of the zombies.

“Who are the zombies?”

“I don’t know! Stop asking me questions!”

He abruptly gets up. Everyone pauses.

Charlie wipes his mouth on his sleeve. He drops back down into his seat.

“The zombies want me to be homeless. Every day, same thing: ‘You’re a homeless motherf-cker’. Damn!”

He talks more about the zombies and his apartment.

“You wanna try going back this afternoon? We can take you there. It’s starting to get cold out. You mentioned that your apartment is warm.”

Charlie chews on his lip and snarls.

“Let’s get into the car so I can drive you back,” the case manager gently says. He says nothing, but he gets up and walks out of the office. Everyone looks at him.

“You gonna drive me back there now or what?” Charlie mumbles.

3:45pm. Go visit a local church to try again to speak to a young man. No one is certain of his name. He believes the church is his home: The pews are his beds, the altar is his kitchen. He has washed his clothes in the font of holy water. He occasionally yells “in tongues” at parishioners. When security guards have consequently escorted him out of the church, he has tried to “cast the devils out” of them. He notably avoids the church during formal services.

Inside the church, tourists and visitors speak in hushed voices as they walk through the aisles. The security guards nod hello.

The young man is seated quietly in a pew in the chapel. His eyes are closed. He doesn’t respond to whispered entreaties to go outside and talk. He keeps his eyes closed, his hands clasped, and he breathes quietly. Another security guard watches him.

4:05pm. Back at the office. Charting.

5:05pm. Depart the office and get swept into the current of people walking towards the subway stations. Automatically look for people who are homeless along the way. It’s too crowded right now; the homeless can’t find any places in there that offer peace.

Step onto a train and notice a sleeping man holding a tattered backpack to his chest. His clothes are soiled, including his three oversized coats and flimsy cap. The soles of his shoes are ripping off, showing the dingy yellow socks inside.

A lot of people get up so they don’t have to stand or sit near him. Most people don’t look at him.

I do.

Categories
Education Lessons Nonfiction Observations

Daily Schedule: Geriatric Adult Home.

A sample agenda as the consulting psychiatrist at a geriatric adult home:

8:20am. Arrive at the concrete building. Wave through the locked glass door at the woman sitting behind the desk. She pushes a button and the door buzzes. Pull the door open. Say good morning. She never sounds cheerful when she replies, “Good morning.”

Because there is no open stair access, take the elevator up one floor. It travels slowly. The doors slide open on the second floor with the speed of a clam.

8:25am. Walk past the dining room. Many of the residents are eating breakfast. Silverware clinks against plates. Few people speak to each other. Some people make eye contact and nod hello. Some stare.

8:30am. Walk into the main office and into the recreational supply room. Sit down at the old desk and log into the computer. Stand up and arrange two chairs so that they are facing each other at about a 45-degree angle. During the summer, turn on the window air conditioner. In the winter, keep a sweater on.

Review the daily schedule and skim notes from the previous patient visits. Look over any notes from the consulting primary care physician. He’s an infectious disease doctor. He’s kind and intelligent. Make notes about what to discuss with each patient.

9:00am. First patient[1. All patients described here are composites of people I have seen across time.] arrives. He doesn’t like to take psychiatric medication, but, for unclear reasons, continues to do so. As usual, he plans to walk about sixty blocks for exercise, but only along the major streets and avenues so that the government agents won’t try to kill him. He decides to wear a red necktie today to communicate to the agents that he knows they are monitoring him.

Scribble notes for the documentation later and schedule a follow-up appointment as needed. This happens after each meeting with a patient.

9:30am. Second patient arrives. Staff called for an ambulance two nights ago because he was disoriented and wearing pants on his head. He had bought three bottles of cough syrup from the bodega and drank them in one sitting. The emergency room released him and told him to stop drinking cough syrup. He bought three 24-ounce cans of beer this morning. He has only drank one so far. He doesn’t think there is a problem.

10:00am. Third patient hasn’t arrived.

10:05am. Third patient still hasn’t arrived.

10:06am. Call the front desk. The Woman Who Never Sounds Cheerful confirms that the third patient is in the building.

10:07am. Climb up two flights of stairs. Pass an elderly man who is slowly walking down the stairs, one arm holding the railing, the other an aluminum cane.

10:08am. Knock on the door of the Third Patient’s apartment. No response after 10 seconds. Knock again.

10:09am. Third patient answers the door. She forgot the appointment. Her memory is failing her. She points at a chair. She sits on her bed, the linens neatly folded. She plans to go to the adult day program today. Her dentures bother her, but she’s due for a size adjustment next week. She shows you the magazine pages she has taped to the wall: Whitney Houston, Michelle Obama, and Ella Fitzgerald.

10:27am. Return to the recreational supply room. Passed the fourth patient on the way back in.

10:29am. Fourth patient wants a tranquilizer, the kind that can induce mild intoxication. He talks about dirty liberals withholding medications from him. He hasn’t showered in about two weeks and wishes people would stop asking him about this. He doesn’t think he needs to clean his room, but rats have been nibbling at the leftovers he leaves by the bed. He doesn’t like that.

11:00am. Fifth patient just got back from a computer class. She is attending a talk this afternoon at the community center and plans to enroll in swim classes. On lower doses of medication, she smashes all of the mirrors in her apartment because Satan tries to kill her through the mirrors. She never talks about medication.

11:30am. Meet with the social work staff. Discuss possible new referrals. Also discuss patients who may benefit from visits in their apartments, as they may not be able to come to the office directly. Provide consultation on difficult interactions between staff and patients, and amongst the residents themselves. Talk about the weather, cookies, and news.

12:15pm. Lunch.

12:35pm. Begin writing clinical notes. Call a hospital to ask for an update about a patient. Review client list for the afternoon.

1:00pm. Sixth patient says he hates doctors. The primary care doctor won’t give him more pain medications, the psychiatrist probably thinks he’s crazy when he’s not, and the dermatologist doesn’t listen to him. For someone who hates doctors, he is always early to his appointments, has never missed a visit, and has to be assertively walked out of the room.

1:30pm. Seventh patient hasn’t arrived.

1:35pm. Seventh patient still hasn’t arrived.

1:36pm. Social worker thinks that the seventh patient is in his apartment.

1:37pm. Climb up three flights of stairs. Knock on patient’s door. He says, “Come in.”

1:38pm. Seventh patient is sitting in a chair. An open box of cereal and a nearly empty two-liter bottle of soda is on his nightstand. He hasn’t left his apartment in three days, even for meals. He hasn’t taken a shower in five days.

“The food is my body,” he says. Efforts to challenge this belief are unsuccessful.

“I don’t want to eat my body.”

He has been accepting antipsychotic medication over the past week. He doesn’t object to a higher dose of the medication. He learns that the dose will increase tonight and that staff will knock on his door before each meal to encourage him to come downstairs to eat.

1:55pm. Tell the social worker about plans about the last patient. If his condition worsens or he stops eating completely, he should go to the hospital for possible admission.

2:00pm. Eighth patient arrives. She hasn’t smoked any cigarettes in 12 days! She also, as ordered, stopped taking the antipsychotic medication about three weeks ago. The medication was tapered off over four months. She occasionally talks to herself, but this does not distress her. She reports feeling more energy. She also has a medical appointment in three days; she appreciates the friendly reminder.

2:30pm. Ninth patient arrives. He and his girlfriend are going through difficulties. He doesn’t know how to handle the situation; he’s not sure if he still wants to date her. He realizes that he is only getting older and thinks that he probably won’t ever date anyone ever again. He wonders if this is all he will ever experience.

3:00pm. Tenth patient arrives. He just moved into the building; he was just in the hospital a few weeks ago. He’s taking a high dose of an antipsychotic medication; if he stops taking medication, he soon believes that he will develop STDs from the people around him. This causes him to scream at people and throw things at them. He used to play the trombone and says that he makes a tasty lasagna. He hasn’t drank alcohol in twenty years. He’s glad to be out of the hospital and wonders if the building serves good food.

4:00pm. The eleventh patient won’t remember her appointment, so the meeting occurs at her apartment. The only furniture in her room is her bed, though there are no linens on it. The unfolded cardboard box is on the floor. That is where she has slept for the past five years. She is losing her sight, but she still applies lipstick every morning. She thinks the bricks in the building contain body parts of aliens, so she doesn’t want anything to touch the walls. She doesn’t want to take any medications, but she’s willing to attend appointments in the future.

4:30pm. Close the door to the supply room. Return phone call and speak to the hospital psychiatrist about a shared patient. Call grandson of the man who isn’t eating to provide an update and to help coordinate care. Leave a message for the primary care doctor about the woman who has stopped smoking.

4:50pm. Type up notes from the day.

5:30pm. Log out of the computer and walk out of the office. People are eating dinner, but the man who thought he was eating his body is not present. Take the elevator downstairs, and walk past the front desk, now manned by a person who regularly smiles. No one on the busy avenue outside knows what happened in the building earlier in the day.

Categories
Education Lessons Medicine Nonfiction Observations

An Open Letter to All the Patients I Have Ever Cared For.

Originally written during my second year of residency. Now that I am an attending, I believe more than ever that patients “are our best and most effective teachers”.

Dear Patient(s),

Thank you for educating me.

Thank you for letting me shine bright lights into your eyes and place Q-tips up your nose. Thank you for not shooting me a dirty look when I ask you to lift up your pendulous breast so I can listen to your heart. Thank you for letting me ogle at your protuberant belly—whether it contains a baby, a liver tumor, or liters of fluid inside. Thank you for not experiencing an erection and for refraining from snide remarks when I examine your penis. Thank you for telling me that my speculum use is suboptimal and has caused you pain during your pelvic exam. Thank you for nearly kicking me in the face when I tap on your knees to test your reflexes. Thank you for peeing all over me after I remove your diaper.

Thank you for answering questions that, in any other context, are completely obnoxious and rude. Thank you for being honest with me when I ask if you are a prostitute, an IV drug user, or an alcoholic. Thank you for not assaulting me when I ask if you have sex with “men, women, or both”. Thank you for answering questions about hearing loss when you’re actually concerned about your chest pain. Thank you for not yelling at me in impatience when your back pain is “a ten out of ten”.

Thank you for telling me that it doesn’t seem like I am taking that symptom seriously. Thank you for not masking your facial expressions and allowing your face to contort in offense when I phrase a question or statement poorly. Thank you for saying “OW” when I do something that causes you pain. Thank you for screaming in my face for the duration of our time together after I look into your ears.

Thank you for letting me wake you up at 4:30am for the sole purpose of allowing me to examine your belly wound. Thank you for letting me wake you up at 8:30am, a mere ten minutes after you fell asleep after being up all night and writhing in agony in the ER. Thank you for asking me if I could get your a cup of water or ice chips. Thank you for reminding me that your thirst matters more to you right now than the fact that your potassium level is uncomfortably low.

Thank you for apologizing when you throw up all over yourself—not that you should, but your mindfulness in that moment illuminates a strength that you have that I don’t know that I would have in that moment. Thank you for crying in front of me. Thank you for sharing your deepest fears with me. Thank you for asking me to leave so you can spend time with your family, all of whom are devastated with your prognosis. Thank you for asking me to sit with you. Thank you for asking me to listen. Thank you for reminding me that sometimes, being present with patients is more important than writing for another antibiotic.

Thank you for answering questions that you have already answered for five other people. Thank you for not yelling at me when I ask the same question twice in the same interview. Thank you for refraining from comments like “You’re totally imcompetent” when attending physicians have brought up a diagnostic or therapeutic possibility that I had completely overlooked (or just did not know). Thank you for not spitting in my face when all I seem to say is “I don’t know”. Thank you for not throwing things at me while I nod off when the attending physician is speaking to you.

Thank you for telling me that you have thought about killing another person. Thank you for your attempts at pushing my buttons, whether it be through questioning my technical knowledge, academic status, or medical specialty. Thank you for sneering at me.

Thank you for calling me “doctor” when I don’t feel like one at all. Thank you for saying “thank you” when you’re getting better—in spite of me, not because of me. Thank you for poking fun at me for the express purpose of making me laugh. Thank you for giving me a hug before you leave the hospital. Thank you for smiling at me.

Medical school and residency training involves a lot of reading, tests, and studying. But the truth is, you are our best and most effective teachers. And for that, I thank you.

Sincerely,
Maria

Categories
Consult-Liaison Education Informal-curriculum Lessons Medicine Observations

Informal Curriculum: Lesson 5.

Another recommendation in the informal curriculum is to regularly acknowledge patient strengths.

Physicians are specifically trained to look for problems. The purpose of diagnosis is to identify what is wrong with a patient’s health. As a consequence, we spend a lot of time thinking and talking about what is ill, incorrect, out of order, defective. Our worldview can shift so that we overlook what is healthy, robust, flourishing, hopeful.

Patients, like all people, like to hear what they are doing well. None of us like the experience of receiving only negative feedback, particularly when we are doing the best that we can. Acknowledging patient strengths explicitly recognizes the contributions patients make towards improving their health. We want them to continue to do those beneficial things.

Physicians are in positions of authority and power. Taking the time to comment on what a patient is doing well can strengthen the relationship between patient and physician. Furthermore, this positive feedback can encourage patients to continue their efforts in improving or maintaining their health status. (Positive reinforcement[1. Positive reinforcement is an active intervention that increases the likelihood that a specific event will happen. Example: A woman wears an orange blouse to work. People tell her that the orange blouse looks great on her (intervention). As a result, she wears the blouse more often.] is often more effective than negative reinforcement[2. Negative reinforcement is the removal of something unpleasant that increases the likelihood that a specific event will happen. Example: A woman wears a green blouse to work. People incessantly whine that she looks better in an orange blouse. She wants the whining to stop (i.e. removal of something unpleasant). As a result, she might wear an orange blouse more often.] or punishment[3. Punishment is an active intervention that is meant to increase the likelihood that a behavior will stop. Example: A woman wears a green blouse to work. People spit at her because she is wearing that blouse. She learns not to wear the green blouse… but note that she does not know what the desired behavior is. Compare this with negative reinforcement.] in changing behavior.)

Acknowledging patient strengths need not be saccharine. Simple observations can serve as encouragement:

  • You’re checking your blood sugars regularly.
  • I see you’ve gotten out of bed three times already today.
  • You’re keeping a record of how much alcohol you’re drinking.

These observations may ostensibly appear neutral. However, patients know that doctors pay attention to those things that we find important. This attention is often highly valued currency. Patients may find themselves attending to and doing these desired behaviors more often as a result.

How often do you explicitly point out what people are doing well? Do you find yourself commenting more on problems?

  1. ”Tell me what you think helped keep your blood sugars within this healthy range on this day.” or “A lot of your blood sugars are too high.”
  2. ”You’ve helped your body recover by getting out of bed.” or “You should get out of bed more often.”
  3. ”What’s helped you limit your alcohol use to a bottle of wine on that night?” or “On most nights you’re still drinking two bottles of wine. This is a problem.”

Of course, there are occasions when we must discuss problems and focus on what is wrong. This is not a call to willfully disregard what is out of order. This is a reminder to balance what we say.

And lest these suggestions seem foolish, consider your own experiences with your supervisors. We like it when people recognize and praise the work that we do. It’s a drag when we only hear about our lack of productivity, patient complaints, or the urgency to discharge patients from the hospital. Most people want recognition and encouragement for their efforts.

Patients are no different.

Categories
Education Lessons Nonfiction Observations

The Oral Exam (X).

Most of my postal mail consists of the following:

  • 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.

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”).