Friday, September 26, 2008

The Thing In The Chest That Pumps Blood

You stand outside the door of a hotel room in the Four Seasons in downtown Philadelphia. Your dark suit is too warm, your hands a bit clammy, and your mouth is dry, as you swallow hard trying to calm yourself. You look down the hall and see several other tense young men and women waiting as well. You are about to take your final exam in general surgery.

You have worked 5+ years learning surgery.

You have spent more than 500 nights in the hospital
You have performed over 1000 operations.

You have done thousands of physical examinations.

You have written tens of thousands of doctor’s orders.

You have read hundreds of articles, chapters, and books.

You have attended hundreds of conferences, lectures, and meetings.

You have come to work before sunrise almost every day for 5 years.

You have worked well past the point of exhaustion.

You have gone home at 10 o’clock at night only to curl up with a textbook to prepare for the next day’s cases.

You have lived and breathed surgery for five years…

And here you stand outside a hotel room where all of your work will be measured in three 30 minute oral examinations.

You would probably expect to be pretty anxious for you board exams, but the one thing surgical residency taught you was how to handle pressure.
You’d rather face a couple of examiners than a torn portal vein any day. So you gird yourself with the same resolve you have used to face the countless challenges over the last 5 years. Shoulders back, chin up, let’s go!

The door swings open, and the board examiners invite you in, introduce themselves, sit you down, and then start reading the cases.
The examiners seem cold as they walk you through the various clinical scenarios. They never confirm a satisfactory answer with even as much as a smile. Although when you forget something or make a poor choice, the examiners make it abundantly clear that you are off the mark. “Is there anything else you need to do before going to the operating room?” Your mind races, but you are not sure what they mean…you hesitate too long, and they demand a decision. You try your best to be systematic, to give conservative safe answers, to remember physiology, operative technique, and everything else you have learned. On some of the cases, you feel confident that you handled them well, but on many cases you are uncertain, and on some, you are certain that you totally screwed up. The next 90 minutes go by blindingly fast and after the last case is complete, you are relieved, but a bit bewildered… not to mention dissatisfied with yourself for your performance on the questions you feel you did not answer well…the other thing residency has taught you is to demand excellence from yourself.

Some of your co-examinees are eager to talk after the exam to compare experiences, confirm correct answers, and comfort one another.
Some however are the opposite, and quietly gather their belongings, eager to escape the venue all together. None of the examinees, talkative or quiet, appear confident that they have performed well on the exam, which is some consolation that you all share in the trauma you have just endured.

You make your way to the airport in a fog, and head back home replaying the exam in your head.
You lick your psychological wounds over the next couple of days as you await the examination results to be posted online.

You log into the ABS (American Board of Surgery) website at 12 noon EST, when the results are to be posted.
Your heart rate accelerates as you navigate the site to check your results. You scroll down the page as you recall the years of school and exams from the SAT to the MCAT to anatomy quizzes and clinical skills practicums in medical school to USMLEs to ABSITEs to the qualifying written board exam you passed a few weeks ago…all leading to this last final exam to become a surgeon. You reach the bottom of the page, and read the following sentence: The ABS wishes to inform you…


I have never had a fearful attitude about tests and exams.
I see them as necessary to discern who has the knowledge needed to hold a position or have certain credentials. In fact, I have always celebrated difficult exams. Why? Because passing a difficult exam means much more than passing an easy one. If the exam is easy it has not measured anything in any depth, but if the exam is difficult, then the score of the examinee is much more useful in measuring that examinee’s abilities. I am not saying that exams (especially standardized exams and college admissions tests) do not have flaws. Clearly, these exams can be biased in the sense that they might not measure what we say they do. (The SAT is not a perfect measure of how well someone will perform in college, even though it is interpreted that way.) While I understand that exams have limitations, I recognize how important they are in our society. Exams help to maintain certain social standards. For instance, the exams to become a commercial pilot are arduous, but that allows for a high standard of safety in commercial aviation and is part of the reason flying is so statistically safe compared to driving. The relatively easy exam one must pass to obtain a drivers license sets a relatively low standard for the quality of drivers on the road. Society demands high standards not just among professionals, but of many manufactured goods and services (food and drug industry, restaurants, children’s toys, etc). We all support these high standards, especially if they are applied uniformly and fairly without bias. When I get on a plane I am very glad the pilot had to pass many difficult exams to demonstrate his/her competence.

I say all of this to explain why unlike many people who hate having to take exams, I have always liked exams.
I don’t like failing them. (I was very upset when I failed my driver’s exam the first time by hitting a cone while trying to parallel park…maybe I should not have taken the exam in a 1989 Lincoln Continental.) While I don’t want to fail, I do like the thought that the exam is going to actually measure something important. I had to pass difficult exams to get through medical school and to obtain a medical license, but those difficult exams set a high standard for the medical profession, and that is more important to me than me feeling good about my score. I have never viewed exams as personal obstacles (or assaults) for me to overcome. I have always been able to step back, and say I am glad the exams are hard, because I want my credentials to be an authentic confirmation of my abilities to be a good doctor.

So for the last 20 years in high school, college, medical school, and even residency…while many of my classmates have been uptight about exams, I have always had a healthy appreciative attitude toward them.
Even when I have been less well prepared and performed poorly, I appreciated the process. I have been able to face these many exams with very little anxiety, and often found it pleasurable to be able to measure my knowledge, and make sure that my education was coming along appropriately.
But this past Tuesday in Philadelphia, when I prepared to enter that hotel room, I experienced a different perspective.

I did not care about maintaining high standards in the surgical profession.

I did not appreciate that the reason we have to take this oral exam in surgery is to prevent unsafe surgeons from practicing.

I did not want the exam to be difficult.

I experienced a fear of failing that I had never known.
I’m not sure if it was just the thought of having to pay another $1500 to take the exam over (exam fee is $900, plus airfare/ hotel, etc.). Maybe it was the face to face nature of the exam, and the fear of being judged by such accomplished surgeons. Maybe it was the horror stories I had heard of examiners trying to throw off the examinee by asking impossible questions, yelling, or other antics. I’m not sure why, but I felt very different about this exam. I was anxious, and very myopic. All I could see was myself, and how awful it would be for ME to fail. What if I misunderstand the question? What if my mind goes blank? What if I have to go to the bathroom? What if…what if…what if? Usually, I would be hoping for some challenging questions that would really test my knowledge, and maybe show me areas I needed to work on. But today, I wanted the exam to be easy. I wanted the questions to be no harder than, “what’s the name of that thing in the chest that pumps blood?”

This was a new experience for me.
I guess after all the work, and everything I have done to get here, my desire to complete the process made me temporarily selfish. For a moment, patient care, and professional standards meant nothing, and passing was all I could think about. I feared the shame of failing more than I was concerned about the integrity of the board certification process. Fortunately, this was a very temporary feeling, and by the time the test started, I had regained my usual composure, and I actually felt quite calm during the test. When I checked the ABS website for my result two days later, the sentence read: We are pleased to inform you that you successfully passed this examination.

The test seemed quite challenging, but in hindsight, I am glad it was so.
It’s very difficult to assess how you are doing on the exam, because the examiners are instructed to give you absolutely no positive feedback. Most everyone leaves the exam room with some doubts even when they have done very well, because of the way the exam is structured. Those two days of waiting for my score were uncomfortable, but it was worth the brief psychological discomfort to know that I have passed a very stringent process to get here and be able to practice surgery. I would hate to think that there are doctors with scalpels in their hands, who had not been thoroughly examined and approved to be safe surgeons. The ABS is actually developing stricter standards to maintain certification in the future, and I applaud these efforts. Even though it may mean a little more work for me, it will maintain and possibly raise standards in the surgical profession, and society will benefit from higher standards overall.

That said, I have to admit that for a moment, I was not on society’s side.
I was only on Chad’s side. I wanted the easiest questions possible. I wanted the lowest standards imaginable. I wanted to pass. Fortunately, I did…even though the questions were much harder than naming the organ in the chest that pumps blood.

Yours in passing,


To have striven, to have made the effort, to have been true to certain ideals - this alone is worth the struggle.

William Osler


At Fri Sep 26, 01:15:00 PM, Blogger Theo said...

Congrat Chad! Even though that little blog left the suspense up in the air for a while I had no doubts you passed. If I am ever standing in front of you some day you better ask me about that thing in the chest that moves the air in and out.

Best of luck in Kenya.


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