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.

Categories
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
Consult-Liaison Education Informal-curriculum Lessons Medicine Observations

Informal Curriculum: Lesson 4.

Another lesson in the informal curriculum is how to interrupt patients.[1. The skill of interrupting is also useful for unfocused patient presentations, preoccupied nurses, and rambling doctors.]

Due to financial challenges in the healthcare system, patients and physicians have decreasing amounts of time with each other. Doctors need specific information for an accurate diagnosis, which guides appropriate treatment. Sometimes patients want to share information that they believe to be important, but it may not be clinically relevant.[2. Physicians should take care: Sometimes the information that patients find important is, in fact, relevant, though we may not initially recognize this.] Confusion and frustration result when patients view their information as both important and relevant, while doctor finds the information to be neither important nor relevant.

When medical students learn to interview patients, they often nod, smile, and exhibit body language that tacitly encourages patients to continue, even if patients are sharing anecdotes about a recent vacation. Afterwards, when I ask students for their opinions about their interviews, they often express disappointment.

“I didn’t get the information I needed. But I didn’t want to interrupt because I didn’t want to be rude. It seemed like that the patient really wanted to talk about her vacation.”

Two points to consider:

Firstly, though the dialogue between patient and doctor may seem to follow the rules of a usual conversation, the clinical interview is not a normal social interaction.

Do you routinely ask your friends or family if they are are experiencing side effects from medications? if they are having regular menstrual cycles? if they’re thinking about killing themselves? if they’re passing gas?

Such questions rarely come up in usual social interactions. Imagine how other people might react if you asked these questions during a dinner date, while waiting in line at the grocery store, or in an elevator.

Context matters.

Secondly, consider short-term versus long-term goals. Physicians don’t want to be rude to patients. Building and maintaining rapport is important in clinical care. However, patients (often reluctantly!) see physicians to receive guidance and treatment for their health. These are not friendships. If you require history to arrive at a diagnosis and treatment and you are unable to get that information, then you are not actually helping the patient. It may feel better in the short-term to let patients share irrelevant information, but, in the long-term, the health of patients will not change.

So, what are some ways to interrupt people while minimizing rudeness?

The vast majority of patients understand that time with their physicians is limited. Patients who talk a lot often know that they talk a lot. Orienting patients to the possibility of interruptions before starting can be extraordinarily helpful if the need arises.

All human beings want acknowledgment that you heard and understood what they said. I often counsel medical students to jump in when they can (when the patient takes a breath, when the patient is trailing off, etc.) and briefly summarize the last few things the patient said, and then append a question. Example:

“… she always says it’s my fault and I never do anything right and she only says that when things don’t go the way she wants them to and she never sees all the things I do right and when I point them out she thinks I’m being arrogant but I’m just trying to point out that I do some things right most of the time—”

“You get upset when your girlfriend doesn’t see how hard you try—how have your blood sugars been?”

Bonus points if you can tie the summary sentence to your question (e.g. “With all of that frustration you’ve felt with your girlfriend, have you noticed if it has affected your blood sugars?”).

This strategy requires your full attention. If your summary statement is completely inaccurate, your patient will feel vexed.

Other strategies, with increasing urgency (always done with respect):

  1. Say the person’s name (most people will stop talking).
  2. Lean forward and express urgency on your face.
  3. Make some other sound (e.g. firmly putting your hand on a table) in addition to saying the person’s name and leaning forward.

Never raise your voice or shout.

I advise students to try different methods of interruption with friends, family, and classmates, and ask them to gauge what seems to work, what doesn’t seem to work, and how people respond. These experiments serve both as practice for interrupting people in general, but also shapes behavior to interrupt with grace and tact.