Category: Observations

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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.

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.