Thursday, November 20, 2014

Passing the Test at the Quarter Mark

Nothing figurative in the title. Last week, I had to take my American Board of Family Medicine Recertification exam--an eight hour death march. Almost four hundred questions. One terrible headache. Other than the actual marathon, this was the biggest single thing that I had to accomplish over these twelve months, a focal point of time, energy and concern. Three months in, it's been the real world coming to call, to see if I'm competent to hang my shingle, treat patients, earn a living, support my family, and have enough spare time to ponder the deeper things and blog about it, which is what I've hoped to be the main thrust of my 40th year. As long as this test has been looming, it's been tough to claim any emotional (or physical) space or time to really sink myself into a spiritual routine. But that's part of the whole trick, trying to strike a pragmatic balance in the real world while reaching out into both the infinite Cosmos and the messy chambers of my heart.

I think board certification is a good idea. Society and patients need a way to evaluate and certify a doctor's competency. Cool. I just wish there was a better way to do it, because this way stinks, in no way measuring my clinical competence. It's more about regurgitating information and outguessing the question writers. Which is a shame, because at this point, eight years into my clinical practice, I feel like I've really hit my stride as a physician, with a seasoned clinical intuition and style to match a solid knowledge base. Plus, as far as I'm concerned, the key to being a successful doctor today is not about regurgitation or being an encyclopedia. It's about knowing how to expertly diagnose and treat 80% of the problems that people present to you with, and then for the other 20%? It's about knowing what you don't know, when to be concerned, when to get help, how to access and filter accurate information, and then how to compassionately apply your clinical judgment sharpened through real-world experience to the highly specific, intimate context of that distressed patient sitting in front of you. I'm not Dr. House, but I'm a good doctor, and I wish that these tests could both certify and celebrate that.

I counted them up, and between three COMLEX exams, two USMLEs, three residency inservice exams, my initial family medicine board certification, ABIHM certification earlier this year, and now my family medicine board recertification, that this was my eleventh time taking a standardized certification test. COMLEX was the worst, as we had to answer eight hundred questions over two days, with paper and the old No. 2 pencil. Now at least we have computerized testing, which has lots of advantages, but the one major disadvantage of having to stare at a computer screen for eight straight hours. Thus the headache. With each of these exams, I've left the test wondering if I passed, only to find out a few weeks later that I actually did pretty well.

Which is probably why my overarching feeling after leaving the testing center last week was anger. I just get mad at these tests, and the sadists who write them. Their motivation appears to be to write the longest case scenarios with the most irrelevant red herrings, and then to ask the most confusingly worded question possible.

My favorite representative question on this test went something like this:
A pregnant couple comes to your office and asks you a question about what type of dog they should get. You reply that the BEST evidence indicates that which of the following is NOT true: 
A) Large dogs bite more often than small dogs
B) Between the ages of 2 and 5, most bites occur on the lower extremities.
C) A dog bite ALWAYS requires antibiotics as part of a treatment plan
D) None of the above.

What???? Seriously??? So this terrible exam question--that is evaluating nothing about my clinical acumen by asking about a scenario I have never encountered for which no amount of studying could prepare me--includes confounding specifiers and vague qualifiers that impossibly muddy the waters, and then it phrases the actual question in a way that today I still can't figure out what the hell they actually want to know. You want the BEST evidence that one of these is NOT true--come again?

Answering such a question correctly has nothing to do with whether or not I'm a good doctor, and yet it is weighted equally with the other 399 questions I had to answer that day. You hit that question seven hours into a test of similarly terrible questions, and that means clumps of hair are about to be pulled, screens punched, keyboards tossed. Or at least inner screams of rage are being unleashed.

But I kept it together, and based solely on my experiences with the other ten similar exams, I'm pretty sure I did just fine, even though it feels like I failed.

My point in including this post in my "40th Year Quest": mostly to vent, and to celebrate. Now that I'm done with the test (and the marathon), I have no major looming deadlines or events, and I can enjoy the upcoming holiday season with my fambly, and start to focus on the other more rewarding aspects of this journey: meditation, reading, service, nutrition, yoga, exercise, strengthening relationships, exploring other religions, finalizing my unified field theory equation.

It starts tomorrow with a three day meditation retreat at the Shambhala Mountain Center outside of Boulder. Time to get my zen on.

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