While you're deciding

I took my board exam this week, and I think I liked it.

Which is not to say it was easy, or even altogether fair. And though I felt a little bit better upon finishing than these folks, I could be grossly deluded in my estimation of the number and trickiness of truly tough questions.

But there was a point in the exam, three or four hours into it, when I was overcome by the sheer variety of extraordinary patient presentations -- the environmental catastrophes, bizarre overdoses and bites from creatures great and small. Overcome, not because I've never seen patients like this (for the most part, I haven't) or because I didn't know how to diagnose and manage them (I think I did), but really because these questions underscored what an amazing specialty I've chosen.

I like that my specialty board expects a mastery of emergency topics on which there's no consultant to turn to, and that they expect me to be able to work in any part of the US -- places where snake bites or diving complications or altitude sickness is more common than my neck of the woods. Too often in emergency departments, we get caught up in managing patients with existing, complex diagnoses -- transplants, hereditary disorders, and the like -- who present with a list of specialists to notify. It's nice that our board has crafted a curriculum and though their exam, reminds us that at least occasionally, our medical input is indispensable. 

Favorite parts of the exam (that I can mention in an open forum):
  • Taking the exam at 500 Fifth Avenue, an overlooked gem of a New York City skyscraper. In any other city, this 60-story art deco tower would be celebrated, iconic. In midtown, however, people's attention is drawn to the nearby New York Public Library and Grand Central Terminal, just a block or two away, as well as the other towers along 42nd Street -- Chrysler, Grace, and the new Bank of America building. But 500 Fifth is worth a closer look, if only to draw a comparison to the tower its developers built immediately after, a little farther down the street.
  • I recently co-authored a short "chapter" in a review book about a rarely-encountered (by me, at least) ophthalmological emergency. It was on the board exam!
  • When you walk into this Pearson testing center, you take a number -- and that's the testing station you're to which you're assigned. I took Number 14. The lady behind the desk called Number 12 to snap his picture and get him registered. Then, she called on me. When I jokingly asked what happened to Number 13, she replied something to the effect of: "You doctors may not be superstitious but we know better than give someone that number."
Of course, I do have a few gripes:
  • For an electronic exam that's criterion-referenced (not curved), it seems odd that it'll take so long (usually 40-50 days, I think they reserve the right to take 90 days) to score it. 
  • A huge fraction of the exam -- by some estimates, a third of all questions -- are experimental. I recognize the examiners' need to know how challenging or fair new questions are before making them "count" -- but when so much of a test is, well, untested, the examination process becomes an exercise in confusion and frustration, and it becomes impossible to gauge one's performance. By the time the scores come, months later, an opportunity for constructive feedback has been lost. Maybe this is ABEM's way of simulating the actual practice of emergency medicine? As a recent grad, let me suggest: why not experiment more on the residents? There's a lot of them, and their inservice exam is free (yes, I spent nearly $1000 for the privilege of taking a largely experimental test -- shouldn't it be the other way around? Maybe ABEM could offset some of the cost by letting us choose how much of the exam day will be spent giving them data on future questions).
  • For a specialty that prides itself on recognizing zebras and considering the life-threats for even the most benign presentations, the exam has an unseemly predilection for "most common" questions -- the most common bug responsible for a given infection, the most common age group affected by a given disorder, etc. I know some demographic information and context is important, but these questions arise so often, it's almost as though the board doesn't want us to use broad-spectrum antibiotics, for instance, or work up younger adults with chest pain.

All in all, though, the exam experience was ok -- and not as bad as I was dreading. I just hope I don't have to repeat it.