Category: Nonfiction

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Education Lessons Nonfiction Observations

The Oral Exam (II).

The hotel that was designated the “home base” for the exam is located very close to the Boston Public Garden. People of all ages were wandering along the perimeter and through the Garden, shielding their eyes from the sun with either their hands or with sunglasses.

Several bellhops glanced at us as we passed through the entrance. Inside, clumps of people were standing in the lobby. Some were in suits and clearly examinees—the test was divided so that some people were taking the exam that day—and others were in more casual attire. Others were seated in the leather chairs in the lobby, looking over brightly colored papers—registration documents, no doubt. Overhead hung several large chandeliers that glinted and sparkled from the light bulbs hidden within them.

Signs marked the way to the ballroom where we could pick up our materials. The woman behind the desk—friendly, calm, smiling—looked at my ID and then handed me a packet.

“Good luck!” she brightly said.

The packet included a bright yellow sheet of paper with my schedule on it, a name tag, and a few loose sheets related to who was administering the exam.

“Worcester?” I asked out loud. (And I am pleased to say that I pronounced it correctly: “Wooster”.) “I’m taking my exam in Worcester?”

Where is Worcester?

Apparently, it’s about an hour away from Boston by bus. And as much as I had hoped that I would be able to take the exam first thing in the morning to get it over with, no such luck: The first hour of the exam preceded lunch; the second hour of the exam followed lunch. Though we all paid $1350 to take this exam, lunch was not included. Neither were accommodations or travel fees.

The mandatory orientation was scheduled for later on in the afternoon to prepare us for the events of the following day. In the interim, I reunited with a close friend from residency, who had elected to stay at the hotel.

“There was a gruff guy on the elevator,” he told me, stretching his legs out on his bed. “When the elevator kept stopping on the floors before his, he was rolling his eyes and sighing loudly. Finally, when the elevator got to his floor, he walked off in a hurry and said some stuff under his breath. I saw him later and it turns out he’s one of the examiners.”

Fantastic.

The Beau and I also strolled through the Public Garden and the Common, taking in the beginning of Spring, the clouds that were rolling in overhead, and the cool breeze that had kicked up. What was left of the sun glinted off of the gold-leaf roof of the State House and illuminated the now blue-green awnings of the copper-topped buildings. Soon, it started to rain.

I returned promptly for the mandatory orientation and quickly spotted another close friend from residency. His face lit up with recognition and he stood up to hug me. I was so delighted to see him. To our surprise, we saw another peer from our residency program, who now works in Boston. We waved enthusiastically at him before sitting down again, as the orientation had begun.

Imagine this: Between 300 and 400 psychiatrists sitting in one ballroom in a hotel. One man stood at the lectern on the stage and, summoning up as much enthusiasm as he could, intoned that this exam was meant to test your skills as psychiatrists and that, really, the examiners want you to pass. They’ve taken the exam before and they know how anxiety-provoking it is. Just make sure you take the buses assigned to you on your schedule; if you miss the bus, that’ll cause problems and you might have to take the exam again in a different city. And always have your ID on, because if you don’t have your ID, you might have to take the exam again in a different city. Don’t go out and drink tonight, you want to be rested for the exam. Remember, take the bus assigned to you and always have your ID because, if you don’t, you might have to take the exam again in a different city. If you have any personal questions relating to the exam, you can ask me afterwards. Any questions?

Someone asked a personal question.

“Talk to me afterwards,” he said. A few more people asked questions about timing, paper, receipt of results. He called on a guy seated near the front.

“So, uh, I plan on passing this exam,” he said loudly. “So when do I become board certified? Tomorrow [when I take the exam], or when I get the letter of congratulations?”

Quiet titters filled the room. The man behind the lectern chuckled and shifted his weight.

“Well, IF you pass”—some people laughed at his emphasis on the “if”; I turned to my friend and we simultaneously rolled our eyes—was that dig really necessary?—”your board certification will be backdated to the day of the exam. The document will be dated in April.”

When the room was exhausted of questions, the man behind the lectern wished us a final congratulations before dismissing us. Most of the people quickly filed out of the room.

A few of us lingered to speak with old friends and colleagues that we had not seen in close to a year. We remained in the ballroom for about 20 to 30 minutes, catching up on the professional and personal details of life that we had missed as a result. The ballroom didn’t seem so impersonal and stodgy anymore.

“You hungry?” someone asked. “We should go eat.”

Part one of this story is here.

Categories
Education Lessons Nonfiction Observations

The Oral Exam (I).

A psychiatrist on Twitter recently asked me if I could share a series of posts I had written in the past about the psychiatry oral board exam.

Here’s my answer.

The series was originally written in May 2009. May it be helpful to psychiatrists who are finishing their training. May it be amusing and perhaps illuminating to the general public who wonder what “board certified” means.

(P.S. Original content will come soon. In the past few months, I have experienced notable shifts in life change units according to the Holmes and Rahe stress scale. Thank you for your patience.)

As medical students, we had all heard about “board exams”. By the time we graduated from medical school, we had already taken two medical licensing exams (the USMLE). As interns, we began to hear about the specific board exams for our chosen specialty. However, most of us didn’t expend too much mental energy about the specialty board exam, as we still had to take the third medical licensing exam.

The board exam in psychiatry involves two parts: a written exam (multiple choice questions on a computer) and an oral exam. Residents take the written exam in the last year of their residency—literally days before the end of their training—and, upon passing, are then eligible to sit for the oral exam the following year.

Most people feel some anxiety about the written exam, as with most standardized exams that represent hurdles one must hop over (doesn’t have to be a graceful leap with a silent finish; you just have to get over the dang thing) before advancing to The Next Stage. By the time the written exam comes around, though, people know how these events go: we had all taken numerous exams and filled in thousands upon thousands of bubbles, whether by pencil, pen, or the click of a mouse.

The oral exam, though, is something else completely. There’s a lot of lore about the oral exam in psychiatry and it just freaks everyone out.

To be clear, not every single specialty has an oral exam. My understanding is that family practice, internal medicine, and pathology do not have oral exams. Those physicians fill in a lot of bubbles and BAM—they’re board certified.

Radiology, surgery, anesthesiology, psychiatry, and neurology have oral exams. (These are not comprehensive lists. These lists tell you more about the physicians I know and talk with.)

You can imagine that some people feel some mild bitterness about this.

This is the current (NB: “current” means “as of 2009”) structure of the oral board exam in psychiatry. It occurs in two parts:

(1) The trainee interviews an actual patient for 30 minutes. Two examiners (who know nothing more about the patient than the trainee) observe this interview. In the following 30 minutes, the two examiners ask the trainee questions about diagnosis, treatment, prognosis, and any other issues they deem pertinent.

(2) The trainee rotates through four “stations”, with 12 minutes at each station. At three of the stations, there is a written patient vignette that one examiner gives to the trainee. The examiner then asks questions about diagnosis or treatment related to the vignette. The fourth station features a video clip of a patient interview. As with the written vignettes, the examiner asks the trainee questions related to diagnosis and treatment.

The ultimate goal is to eliminate the live patient interview and use vignettes only. I believe the live patient interview will be phased out in three or four years. This shift is due to the highly variable nature of the live patient interview. No two patients are the same and this lack of reliability across trainees is problematic. Though the live patient interview allows the trainee to showcase her interviewing/empathic/”I come across as a nice person” skills, it does not necessarily offer opportunities to demonstrate sufficient knowledge of the field. Does that make sense?

Please also note that DSM-V is scheduled to come out in 2012 (NB: this has been pushed back to May 2013). You can imagine that some of the current trainees feel some mild bitterness about the changes in this examination system. (Really, I’m not one of them.)

The reason why people get totally freaked out about the oral exam is because we hear so many horror stories about the experience. And if they’re not horror stories, they’re tales of discomfort.

  • “My patient was partially deaf and blind and I had to shout at him the whole time.”
  • “My patient kept telling me that I wasn’t making sense and telling the examiners to fail me.”
  • “My patient wouldn’t talk.”
  • “My patient just got up in the middle of the interview and left.”
  • “My examiners kept interrupting me and they sounded really sarcastic.”
  • “My examiners kept frowning at me and asking me if I was sure about my answers.”
  • “One of my examiners looked like he was going to laugh at me during my entire presentation.”
  • “One of my examiners asked totally obscure questions about which chromosomes are involved in this disorder.”
  • “One of my examiners wanted me to discuss the history and evolution of understanding of schizophrenia in Portugal during the Industrial Revolution.”

You get my point.

We’re told, of course, that examiners are instructed to keep completely straight faces. They’re not supposed to smile, nod, or offer any signs of any encouragement. They’re supposed to be bland. We’re not supposed to gauge our performances on their facial expressions, style of questioning, or anything else.

(Never mind that SO MUCH of human interaction lies in these non-verbal cues. This is exactly why some people don’t like speaking with psychoanalysts—if there’s nothing there, some people find it unsettling and not therapeutic.)

I had the good fortune of training in a residency program that went through “mock oral board exams” annually (which apparently isn’t the norm, as I have learned this year in my fellowship). And, as a resident, it was unnerving to go through that practice, particularly if your mock examiner was, say, the chair of the department or the training director. No one wants to look like an untherapeutic idiot in front of the boss.

There is some comfort in knowing, though, that the actual oral exam won’t happen for a while. “I have time to prepare for that,” we muse. “I have to get through the written part first.”

Well, time passes.

I took my oral board exam in early April (2009). To prepare for it, I did the following:

  • made flashcards (yes, I’m analog like that) of most of the diagnoses in DSM-IV-TR, but not the adolescent stuff, and went through them a lot
  • read through all of the APA practice guidelines
  • read through a study guide dedicated for the oral board exam
  • underwent five mock interviews with attendings and patients who were obliging enough to help me study and improve

I embarked on all of this about five months prior to my exam date.

My other preparations included:

  • making arrangements to NOT stay at the hotel that the American Board of Psychiatry and Neurology claimed as “home base” (because I didn’t want to spend time with a whole bunch of anxious neurologists and psychiatrists)
  • making plans to meet up with friends from residency and go out for a leisurely, quiet dinner the night prior to the exam (this was undoubtedly the highlight of the weekend)
  • bringing along The Beau for company and laughter
  • utilizing all of my healthy, effective coping strategies to reduce my anxiety (as opposed to eating a whole lot of cookies)

After checking my luggage three times to make sure I had everything (“Registration slip? Check. Suit? Check. Pad of paper and pen? Check. Water bottle? Check. Novel to read while waiting? Check. Sense of humor? Check.”), I hopped onto a Bolt Bus early Saturday morning outside of Penn Station. Four hours later, The Beau and I walked through the streets of Chinatown in the bright sunlight and cool air. We were in Boston.

“It’s really clean here… and where are all the people?” I mused.

Categories
Nonfiction

Stairwell.

Originally posted in 2005:

I lingered in the stairwell for a few moments—just a few—today.

The entire stairwell is composed of concrete. The walls are off-white and the floor is now that dingy copper-grey-brown color from years of feet tromping up and down and up and down again on those tired steps. The ceilings are probably close to fourteen feet high and a slim, scratched, rectangular window starts about six feet from the floor. One has to be standing on step two or three from the ground to actually look out the window.

The liquid orange light of the dying sun—and it dies so early these days!—poured through the small gaps between the thick wall of charcoal clouds surrounding the city. A shiny white ribbon of car headlights rippled far below; to its right was a parallel ribbon of shimmering red tail-lights.

It’s cool in that stairwell; the vents that allow the chilly air flow in aren’t visible. Very few people use that stairwell, partially due to its distant location from the rest of the hospital, partially due to the low temperature of the ambient air. It has been completely empty every single time I have set foot in there.

And those few moments of respite are necessary. The ambient noise of the hospital—the malfunctioning IVs, the flushing toilets, the retching or crying or moaning or snoring or yelling patients, the ringing telephones, the beeping pagers, the tapping of keyboards, the thuds of dropped charts, the clatter of dropped silverware, the weird syncopated tonal rhythms of the ventilators, the sobbing of family members, the murmuring of the teams rounding, the sighs of the housestaff and medical students, the uneven rumbling of the cafeteria carts rolling past, the quiet Christmas music floating from the guitar in the performer’s arms—can be too much.

Sometimes it seems like the suffering that surrounds us all never ends. Even though miracles may be happening in every single room—the birth of a baby, the healing of a wound, the deaths of millions of bacteria in the blood, the sealing of fractured bones, the clotting of a wound in the esophagus…

… and for those few moments in the stairwell, everything is quiet and still.

And when my right hand turns the handle and I fling the door open back into the hospital, I am ready to jump right back into the fray.

Categories
Nonfiction NYC

Visiting Rikers Island (IV).

The people operating the sally port were not vigilant. They opened the first door and permitted us to walk in. Before the first door, now behind us, completely closed, the second door, in front of us, opened. We could not see the officers who were monitoring the doors. They were located above us and hidden behind a darkened window. We only heard them knock on the glass and saw one shady hand point at the black light on the wall. They wanted us to put our hands there so they could see the stamp that was placed on them earlier.

Two officers greeted us on the other side.

“Who are you here to see?”

“The Person,” we said.

“Go to Table 14, over there in the corner,” an officer instructed, pointing over a group of inmates seated near them. They were in grey jumpsuits, wearing flip-flops on their bare feet, and examining us.

The top of each table was about knee-height. Three grey chairs were on one side of the table. One red chair was on the other side of the table. All the red chairs faced the single point of entry to the room.

The Person strolled in and sat in a chair, looking around.

“The Person?” the officers called. “The Person? Go to Table 14! Over there!”

Fellow inmates laughed as The Person jumped up and looked at Table 14. The Person had no idea who we were. I hadn’t seen The Person in over six months and didn’t recognize The Person, either.

Our conversation was short. The Person didn’t have much to say to us and it was noisy room. Many of the tables in the room were occupied, some by couples who were holding hands (above the table), others by family and friends, everyone leaning in over the table. People laughed, chatted, and murmured.

No one in the room was white.

My companion and I got up to leave. We had only spent about fifteen minutes in the room.

“SIT DOWN!” the officers shouted at us. “The Person needs to leave first.”

We immediately sat back down. The Person nonchalantly got up and walked back into the jail block. Rooted in our chairs, we looked at the officers, waiting our turn to go.

“Okay, now you can leave,” they said. They handed us back the notecards that documented our times of entry at the various checkpoints in our trip.

Back out the sally port we went—they were more vigilant about our exit—and we rejoined the crowd of over 20 people in the waiting area. The officer who opened my locker said out loud to no one in particular, “Why did people spend so little time in there?”

Buses reportedly only came around once an hour. This meant that the officers had to monitor us until a bus arrived to take us back to the main gate.

Everyone had put their earrings back into their earlobes, rings back onto their fingers, necklaces around their necks, and belts through the loops. Overall, everyone seemed more relaxed; people talked to each other and were leaning casually against the wall. One woman, though, appeared sad and on the verge of tears. She stared blankly out the far window.

Buses rumbled past and people expectedly crowded near the exit, hoping to get out of the jail first. They sighed audibly with disappointment and irritation when the buses didn’t stop.

Ah, New York, I thought.

A bus finally pulled up about fifteen minutes later and the driver honked the horn. The police officer was still big and burly, but no longer bilious: He smiled broadly at us as he collected our notecards. His teeth were straight and white.

The bus was completely full. People stood in the middle aisle and gripped the vinyl seats for stability. I was the last person to get on the bus and balanced myself on the steps leading into the vehicle.

“Lean back,” he barked at me when he began to turn a tight corner. “I can’t see the mirror.”

I bit my tongue and leaned back. Don’t complain, don’t explain.

After stopping at another cell block to let people off and other people on, we finally arrived at the main gate. People pushed their way off of the bus and walked quickly through the gated chain fence. A city bus, the Q100, was at the stop and people were boarding.

“Wait wait wait,” people breathlessly said as they raced up to the Q100.

“Hey, there’s the bus,” I said to my companion, bracing my bag as I picked up my legs to run.

“Wait—we still have to get our stuff from the locker,” he called out to me. I immediately halted, starting to smile at myself.

“Right,” I said. “Right. I am so ready to get out of here that I completely forgot about all of my stuff.”

“Yeah,” he said. “I almost did, too.”

I think he was just being nice. We hastily walked back to the lockers as a steady stream of people walked in the opposite direction, many of them picking up speed as they noticed the city bus.

There wasn’t a single white person in the crowd.

(Part 1 is here. Part 2 is here. Part 3 is here.)

Categories
Nonfiction NYC

Visiting Rikers Island (III).

We were seated over a rear wheel. The bus was probably older than me and any shock absorption it may have had in the past was now completely gone.

The bus pulled away from the building and lurched onto the main road on the expansive grounds of the jail. We passed open fields surrounded by tall chain-linked fences that were wrapped in concertina wire. Canadian geese sat on the grass, their necks tucked into their bodies. There were structures that looked like mobile homes on the outer perimeter; some of them had signs that suggested that they were legal centers. Most of the cars in the parking lots were neither fancy nor wrecks: trucks, vans, sedans, and coupes. An identical bus, half filled with people, roared past us in the opposite direction.

There was the view of Laguardia again, and then a view of the island of Manhattan. The skyscrapers looked like dollhouse structures from that distance.

The bus halted in front of a cement building and some people began to get up. We glanced at the stamped initials on our notecards, then at the name of the building. They matched.

A police officer, big, burly, and bilious, opened the door of the structure as we walked up. An automated voice—that of a young woman—filled the small foyer. She repeated instructions about what items were permitted in the jail and what were not. The police officer then began to talk over the automated voice, barking instructions to remove your shoes, no jewelry is allowed, take our your ID, put everything in a bin, put your items in a locker, the other officer will write the number on the back….

In the window were Polaroid photographs. Several were of men whose hands were handcuffed together, dark rectangular bars over their eyes. “THIS IS WHAT HAPPENS IF YOU TRY TO BRING ILLEGAL ITEMS INTO THE JAIL.” In other photographs were men seated on examining tables, their torsos, arms, and legs severed open and oozing blood. “THIS IS WHAT HAPPENS IF YOU GIVE RAZOR BLADES TO INMATES.”

Most of us quietly took a plastic bin and began to remove our jewelry. A man—tall, older, with dark skin—began to vent his frustration: “We pay taxes, you know. They can’t treat us like this. We’re citizens. We’re not under arrest. We have rights.”

“Put your stuff in a bin,” the police officer sternly said to him.

The man sighed irritably, pulled off his belt, and tried to shove it quickly into the bin. He began to walk through the metal detector with shoes still on his feet.

“TAKE YOUR SHOES OFF,” the police officer shouted. “I said that before. You need to listen.”

The man walked backwards, pulled off his sneakers, put them on the conveyor belt, and walked through the metal detector. Another officer, a woman with her hair tightly pulled back away from her face, looked at the screen attached to the conveyor belt. She nodded once.

The man retrieved his shoes and began to put them on.

“Take the bin off of the machine,” the police officer ordered. The man stifled a comment and grabbed the bin.

The metal detector beeped when I walked through. The disgruntled police officer took a wand. We stood, arms at our sides, facing each other.

“Move your—” he said, clearly annoyed, moving his arms apart. Realizing what I was supposed to do, I lifted my arms. He floated the wand over my chest and abdomen.

“Turn around,” he muttered. After finishing the task, he mumbled, “You’re fine. Take your bin.”

I slid my feet back into my shoes and then put my bag inside a locker. My companion and I had our IDs in our hands. The female officer saw us clutching our IDs and sighed impatiently. “You gotta put your IDs in the lockers. None of y’all are listening today.”

My companion blurted, “I thought that’s what he said—” I shook my head. Don’t complain, don’t explain.

We had only our clothes and shoes on after we stowed our IDs. The female officer scanned the group and then began pointing at several women.

“You, you, you, and you,” she said, pointing at me last. “Come with me, ladies.”

We were directed behind a curtain. I was probably the oldest person there. The youngest looked like she was in her late teens. She was flicking the rod in her tongue piercing over her teeth.

The cops allow that…?

“Sit down,” the officer ordered. We immediately settled down into the hard plastic chairs.

“Take off your shoes and socks.”

Standing with her arms crossed in front of her chest, she scanned our bare feet. She and I were about the same height, though I had no doubt that she could throw me into a wall. Maybe I could run faster than her. Maybe.

“Put them back on.”

“Stand up.”

“Put your hands in your pockets and then turn them inside out.”

Her eyes looked at our pockets. One woman had something glistening in her fingers.

“What is that?”

“Candy wrapper.”

“Throw that away.”

The officer nodded, tacitly instructing us to put our pockets back into our pants.

“Put your thumbs inside the waist of your pants and run them around your entire waist.”

A woman in the group clearly had gone through this routine before. Unsure of what the officer wanted, I sneaked a glance at this woman before following the instructions. She pulled the waistband away from her skin. If anything was lodged there, it would have fallen to the floor.

We all pulled our pants away from our waists.

“Turn around.”

The officer walked to the other side of the spontaneous circle we had formed.

“Lift up your shirts, lean forward, and shake.”

What?

I again sneaked a glance at the returning visitor. Through her shirt, she had hooked her fingers underneath her bra, leaned forward, and shimmied. This was meant to dislodge anything we might have hidden in our bras.

“Mouth.”

We all opened our mouths. The officer looked.

“Why do you have that in there?” the officer asked the young woman with the tongue piercing. “You can’t have that here. You either go out and remove it or give it up.”

The young woman frowned, indecision on her face.

“You either go out or give it up. Ladies, the rest of you can go.”

We were directed to a second waiting room outside of the sally port. I waited for my companion to undergo his inspection. He and I exchanged wordless glances of relief when he joined me.

Over two hours had passed since we had first arrived at the jail. We now looked at the sally port, wondering when it would open.

(Part 1 is here. Part 2 is here.)