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Wednesday, February 3, 2010

A Piece of My Mind - editorial in JAMA

Vol. 303 No. 4, January 27, 2010
JAMA. 2010;303(4):309-310.

by Julie Wu, MD

Belmont, Massachusetts


I cannot bring my own tissues. The test administrator confiscates these in the glass-walled fingerprinting vestibule and replaces them with special, nonprogrammable American Board of Internal Medicine Recertification facial tissues. A well-coiffed physician I recognize from the hospital where I used to practice widens her eyes when confronted with the lipstick tube found in her pocket.

"I can't bring this in?"
The administrator jokes, "Who are you trying to impress?"
We laugh and are shushed; on the other side of the glass, some people are already taking their examination. We remove our watches, our bracelets, our jackets. We place our index fingers on the fingerprint scanner and then are ushered into little cubicles in a windowless room with video cameras in the corners.

I wonder, if you did want to cheat, how you would possibly do so. The amount of material covered by the examination is staggeringly, impossibly huge. This is why internal medicine has subspecialties. I have spent months and thousands of babysitting dollars memorizing the criteria for Bartter syndrome, the chemotherapeutic regimens for Hodgkin lymphoma, the prognosis for the different stages of small cell and non–small cell lung cancer—none of which I would, in practice, ever manage without consultation.

It's all I can do just to stay awake at my work station. Six hours of long cases, one after the other, and I read the chief complaints over twice, three times, to keep them in mind. A 63-year-old man with nausea, fever, and joint pain. A 48-year-old woman with fever, cough, and pruritus. I blink my eyes at the flat screen, struggling to envision a face for each vignette. There are fewer pictures than I’d hoped. I am not a chief resident type, the type who rattles off lists of differential diagnoses and acronyms and a bibliography of recent articles to support them. Though I dutifully memorized the Krebs cycle and the structure of the cytoplasmic membrane along with the best of them, once the tests were over I forgot them immediately.

I am inherently artsy fartsy. I have the ability to be linear, to cram lists into my head, and to pay my bills on time, but my mind is largely that of a writer, a dreamer whose memories are a sea of personal experiences linked together across time by feeling and perception. I remember personality, body language, tone of voice. I remember that my college roommate liked coffee ice cream, that my sister-in-law loves lebkuchen. That ten years ago one patient grew New Dawn roses and another, Chinese eggplant. How an early Alzheimer patient recalled watching his first wife swim from pier to pier in the Hawaiian surf—how the waves obscured her, now rising, now falling, and how he had worried. But I will never, ever, be able to remember the coagulation cascade for longer than 60 seconds, and I pray it will not appear on this examination.
At break time, a pulmonologist who works in the pharmaceutical industry reveals that she has already completed two sessions in the time I have struggled to complete one. The rest of us exclaim in amazement. I wonder that she can even read through the cases so quickly without getting distracted, without worrying about how her kids are doing and whether the babysitter has bipolar disorder or simply hypomania and dysphoria, or whether her son actually has attention-deficit disorder and got it from her.

In the second session, I make use of the dry-erase board to take notes, trying to stay focused. I have not practiced medicine for five years. I perceive this as a disadvantage, but most of the material I studied I would never have seen in any case, and the bulk of what I used to see every day is most likely tested on the American Board of Psychiatry and Neurology exam, not here: There's one last thing, Doctor: I just feel so down.

The time pressure is the same. You cannot rush a sobbing patient. In my community practice, at times two or three people broke down in my examining room in one day, and I would run an hour late. My university practice went faster because people there, while just as depressed, did not cry; they were too busy.

At my second break I unwrap my bologna sandwich in an echoing atrium that smells of plastic wrap and disinfectant. A primary care physician at a prestigious Boston practice sits down at my table. She has finished her lunch and could go back to complete her exam, but she takes the time to sit with me and complain about how irrelevant a closed-book examination is to clinical practice. I can't argue. Of course, it's useful to do a comprehensive review of medicine. But a good primary care physician doesn't guess the diagnosis or treatment. She knows what she doesn't know, and goes to find out the answer, either by reading or by asking someone who does know. She can tell who really knows, and who is bluffing.

Years ago, I saw a patient who was flying to Bolivia the following morning. He had excruciating pain in the floor of his mouth when he ate. My boss, a chief resident type extraordinaire, tried to talk me out of an emergency ENT consult. Tell the patient to soak it. Salt water gargle. Call with problems.

I truly admired my boss, and still do, but I called ENT anyway, and my patient had a salivary duct stone extraction that night. I didn't save his life, but at least I saved him from wandering the streets of La Paz looking for Percocet and an English-speaking otolaryngologist.
I start the final exam session refreshed from lunch. The super-speedy pulmonologist has gone home. The well-coiffed physician looks just fine, from the back, without her lipstick.
The first few questions are a breeze, then I start having to use the dry erase board. Nausea. Vomiting. High LFTs. Rash. After a half hour I catch myself writing no murmurs, rubs, or gallops.

Until there is a way to measure common sense and integrity, perhaps this is the only way to test our worthiness as internists. I accept this—it is just another standardized examination, one more hoop to jump through. I accept that the medical system rewards and promotes physicians who can memorize all the tables from Harrison's Principles of Internal Medicine and retrieve each one sequentially on demand. While I, with Sanford's Guide to Antimicrobial Therapy stuffed in one pocket, a miniaturized pharmacopoeia in the other, with UpToDate constantly open on my desktop, and the telephone ringing off the hook with curbsided specialists, will be nothing more than a regular doc. I find recompense in referrals from patients, colleagues, and specialists who know me by first name. I am lauded with chocolate mice, with gilded Egyptian perfume bottles, porcelain bouquets of lavender, and heartbreakingly grateful, tearful embraces. I consider myself blessed.

I finish the examination with seconds to spare. I wonder whether I will take it again if I fail, because trying to learn and retain that much information has taken its toll on my family. The primary care physician I ate lunch with echoes my sentiments.
It's not worth it. I missed all my daughter's soccer games.

I walk out and hope that whatever answers I clicked on will show that I am a good doctor.

Editor’s Note: Dr Wu reports that she passed the examination and is thrilled not to have to take it again until 2019.

A Piece of My Mind Section Editor: Roxanne K. Young, Associate Senior Editor.

[I like her style. It is an abomination of our modern medical community that this type of recertification and certification is allowed to exist. It is an encumbrance to medical practitioners everywhere and wholly unnecessary and only stresses an already stressed system. Furthermore it pads the pockets of the test givers and their "colleges and institutions." -JP]

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