Category: Observations

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

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

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

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

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

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

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

---

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

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

And on. And on. And on.

---

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

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

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

“You probably didn’t pass the exam.”

“You don’t know that.”

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

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

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

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

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

“You may not have to.”

“You’re right.”

“I know.”

“But I still feel anxious.”

“I know.”

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

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

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

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

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

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

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

---

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

“How do you think you did?”

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

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

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

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

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

(Okay, only I wanted “several”.)

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

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

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

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

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

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

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

All right, all right, so we’ve heard.

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

“Okay. You may go inside.”

---

“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.

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.

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.