Category: Lessons

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Education Lessons Nonfiction Observations

The Oral Exam (VII).

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.”

“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.”

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?)

“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.

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.”

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.

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.

Categories
Education Lessons Nonfiction Observations

The Oral Exam (VI).

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.

Categories
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.

Categories
Education Lessons Nonfiction Observations

The Oral Exam (IV).

I couldn’t find Bus Number Six.

Buses Eleven and Fifteen were parked around the corner. The driver for Bus Three was smoking a cigarette outside of his vehicle. A Peter Pan bus—unnumbered and unassociated with the exam—was parked across the street.

Bus Number Six eventually pulled up to the curb. I threw my travel bag over my shoulder—I wouldn’t return in time before check out from the hotel—and watched a line of people approach the bus.

“You’re going to Worcester, right?” one of the men asked. The bus driver nodded. The line advanced and I soon stepped into the vehicle. The morning sun had warmed the upholstered seats and that travel bus smell brought back memories from my days in marching band.

There were only twelve or fourteen of us on the bus. And none of us said a word during the hour long ride to the University of Massachusetts Medical School in Worcester.

Really, what could any of us say? None of us wanted to be there. All of us were anxious.

After the bus left Boston, I pulled out the book I had purposely brought for leisure reading: Haddon’s The Curious Incident of the Dog in the Night-Time. (Excellent and engaging book, I should add—funny, heartbreaking, and the narration is elegantly simple. I purchased it from the book sale at the local branch of the New York Public Library, along with Kostova’s The Historian, which is not funny, is heartbreaking, and the various narrations are numbingly uniform and not simple. Go support your library today.)

I heard the rustling of papers behind and in front of me. Against my better judgment, I glanced around the seat and saw the beams of sunlight fall upon the open book on the lap of the woman sitting in front of me. One of her hands held that textbook open while the other clutched a stack of index cards.

“It’s too late!” I wanted to exclaim. “You already know all of this! Stop studying!” This was, of course, merely a reflection of my own anxiety: Why should I care if someone else wants to look over her notes prior to an exam?

The bus rumbled past a river—The Beau was running a leisurely eleven miles along that river; never before had I felt such envy over running eleven miles—and empty fields overgrown with weeds. We passed through suburbia and soon pulled into the medical school campus. Its wide open spaces and glassy buildings reminded me of the medical school I had attended, which also rises out of agricultural fields.

Everyone in the bus stirred.

“This is it,” the bus driver announced as he pulled up to the curb. Only a few cars dotted the expanse of the parking lot and there was no one to be seen. We began to file out of the bus—still silent, still anxious—and wandered towards a non-descript building.

“It’s over there,” the bus driver called out from the bus. He was pointing in the opposite direction. “Do you guys know where you’re going?”

Clearly, we didn’t.

“No,” someone offered. “Thanks for telling us.”

On the building was a sheet of bright orange paper that directed us to go inside, up the elevators, and down the hallway. We piled into an elevator. Only one of us in the elevator was not wearing a suit.

“So you guys are here for the test, huh?” she asked, looking around at us. “You guys look nervous.”

She was a patient who had agreed to participate in the exam. A few people laughed nervously.

“Good luck,” she said as she exited the elevator.

“Yeah,” someone replied. “Thanks.”

While walking through a maze of hallways, we passed a room with a large table in the center. On the table were platters of sandwiches, chips, and other lunch foods. Rows of beverages stood at attention nearby. A sign on the open door announced in no uncertain terms, “LUNCH FOR EXAMINERS ONLY”.

“Food!” someone exclaimed.

“But it’s not for us,” I dryly remarked. “It’s for the examiners.”

“Man! You would think that they’d give us lunch after we’ve paid over a thousand dollars for this stupid test!” he replied.

“Heh,” I said.

The signs eventually directed us to what appeared to be the psychiatry library. Stacks of books lined the walls and a projector that was probably close to my age sat on the center table. Bottles of water and juices were also on the table. As we all began to sit down, someone poked her head through the doorway and said, “Hello. We’re going to meet in about ten minutes. Now is your chance to use the facilities before we begin.”

The small gaggle of women weaved back through the hallways and small talk began to percolate amongst us. That’s a nice suit. Lovely necklace. You’re from where? That was a patient in the elevator, huh. Yes, it will be nice to get this over with.

Soon, we all returned to the library and glanced at the clock located high up on the wall. The Time was approaching. As the second hand swept past the blemish of 12 on the blanched forehead of the time piece, that same someone who had advised us to empty our bladders reappeared.

“Welcome to the second part of your board exam,” she greeted. She smiled—warmly, genuinely, it seemed. “Let me go over the rules with you. If you have questions, please ask.”

It wasn’t anything none of us hadn’t heard before. After she checked our government-issued IDs to prevent fraudulent behavior, she launched into her patter that lasted less than five minutes.

“Now we will go outside and I will introduce you to your examiners,” she continued. “Come with me.”

We trailed out and saw a group of older psychiatrists, also all in suits, standing at opposite end of the hallway.

She called my name first.

“This is Dr. Grey Hair. This is Dr. Eyeliner. You will be going to the room at the end of the hall. Drs. Grey Hair and Eyeliner will take you there.”

“Thank you,” I said, giving myself a last-minute pep talk. You’ve done these before, patients generally take to you easily, you just need to pass, you don’t need to shine, forget about the examiners, just attend to the patient and make him or her comfortable….

“Hi,” Dr. Grey Hair said as we walked down the hallway. “Your patient is already in the room. You can get started after you get settled in.”

I took a deep breath and pushed the door open.

Categories
Education Lessons Nonfiction Observations

The Oral Exam (III).

We then went to a bar, drank too much, and awoke late for our exams the next morning with uncomfortable hangovers.

No.

We had done our research and intended to have a leisurely dinner at a sandwich shop, but found that it was boisterous and noisy when we entered. Someone in our cavalcade serendipitously ran into an in-law on the streets of Boston and this in-law recommended a seafood joint not too far from where we stood in the chilly rain.

This meal was the highlight of the trip. We spent over two hours at a large table, munching on tasty food in the quiet room on the second floor, trading stories and sharing experiences. We all tacitly understood that we didn’t know when we would have the opportunity to do this again; we had to enjoy these shared moments as they unfolded before us.

After wishing each other good luck, we all retired to our hotel rooms and hoped for a restful night.

I woke up a few times that night, sometimes for unclear reasons, sometimes due to strange dreams that hinted at anxiety, though the content flew from my memory when I awoke.

One of the attendings who had graciously offered to administer a “mock” oral exam to me told me that he himself had taken an official board review course prior to his oral exam. He interlaced his fingers and leaned forward.

“I love your style,” he said, “and you look fine. But I would recommend that you tone your hair down. You want to look as conservative as possible. You just want to pass; now is not the time to draw any more attention to yourself than necessary.”

“No big jewelry,” he continued. “You’re not wearing any necklaces now; don’t wear them on the day of your exam, either. Just wear one pair of earrings; take out that second pair. And nothing dangly. Your makeup is fine. You want to look professional; nothing too colorful. Don’t look like a prostitute.”

He didn’t see my socks, which were as they have been and usually are: Kind of loud and, some would argue, not entirely appropriate for work (not in the “NSFW” sort of way—just lots of stripes and patterns in bright, occasionally clashing hues).

That morning, I heeded his advice: Black suit (the one that had faithfully served me for residency and fellowship interviews) with a splash of light pink underneath. A single pair of faux pearl stud earrings. No necklace. And, sadly, I even wore conservative trouser socks. (If I could do it over again, I would have worn my usual, loud socks.)

I trotted out to the local 7-11 to purchase lunch: a ham sandwich and a bag of chips. I thought about buying a small bag of cookies, but demurred. I could always buy cookies later to celebrate.

My heels clacked against the uneven sidewalk as I made my way to the hotel to catch the bus that would take me to Worcester. My day was about to begin.