Test panic

At the testing site in Conshohocken, PA

 Two weeks ago,  I took what should be the 5th and final board exam of my medical school career.

To brief those who are unfamiliar, there are 2 governing medical boards in this country: ACGME (which oversees M.D.'s and D.O.'s) and AOA (which oversees D.O.'s only). My school requires that we take the AOA boards in order to graduate and to obtain a license to practice. I have chosen to take the ACGME boards also, because I want to match to an ACGME residency.

Translation: double the cost, double the work, double the stress and all for an equivalent outcome of any M.D. student. What can you do.

Anyway, the AOA boards includes a simulated clinical experience, with trained actors standing in as our "patients". The rub is that there is only 1 testing center for the whole country, near Philadelphia. So we all pack up and fly to Philly and spend 8 hours seeing 12 patients and documenting the "appointment." We are allowed 14 minutes to take a history, do a physical, treat and provide appropriate patient counseling/education. Immediately afterward, we have 9 minutes during which we compose a 1-page handwritten documentation for the history, physical, vitals, labs, imaging, assessment of the problem and an overall strategy to work up a diagnosis. During this exam, we are recorded on videotape and these videos, along with our notes, are graded and cross-referenced independently by multiple physicians. It's a pass/fail exam. It costs $1,200 + expenses. So if you *don't* pass, you will be re-spending $1,200, re-flying to Philadelphia and re-taking the exam so you can graduate.

Ergo, we are all appropriately motivated to pass on the first go-round.

For perspective, I'll add that 9 minutes is a stretch for me to be able to handwrite a one page note, whereas, if we were permitted to type, it would be no sweat to produce up to 80 words/minute.

My school expends a tremendous amount of energy during the first 3 years of our training in order to prepare us for this Philadelphia trip. So the nice thing was that when I arrived and began my testing, I was not in any way shocked or stressed out. It was almost exactly like the school had taught us. However, as one encounter led into another, they began to blur in my mind. When writing the note, it became difficult to remember which patient had which findings. The burden of second-guessing myself began to accumulate, and I would fret circularly "Did I do that part of the physical exam?" "What was my finding?" "Did I ask the patient this?" or God forbid, "Did I just document something that I *didn't* do this time?" Egad.

Arguably the most important part of any patient assessment is the HPI, or History of Present Illness. This includes all of the qualifiers and quantifiers of a patient's complaint:

• what is it
• where is it
• when did it start
• has it ever happened before
• did anything precipitate this
• does anything make it better/worse
• what does it feel like
• how severe is it
• is there a timing pattern to it
• does the pain radiate to other parts of the body
• any recent sick contacts
• any recent travel history

Really, it's the meat of any workup, and only after you know these things do you pursue medical/surgical/family/social histories, medications, allergies, vaccinations and review of associated symptomology. Then you proceed to a physical exam. By the time you're done with a good HPI, you should be 90% or more clear about the diagnosis and its differentials.

Well, during one encounter, I was feeling pretty good about my timing. I had collected all my data, done my physical and written a portion of the note even before I left the patient's room. I then finished my note in about 4-5 minutes and sat at my station, waiting for time to be called. After a bit I decided I'd check over the note for completeness' sake. When I did this, right about the time they gave a 2 minute warning, I discovered that I HAD NOT WRITTEN THE ENTIRE HPI. Breathless and panic-struck, I immediately began scribbling in the relevant data. The problem was that the rest of the page was symmetrically filled with the other components of a good note, so I was scrambling to smash this HPI data into the upper right corner, where it appeared to blend into all the other data around it. I was able to get all the relevant data on paper and was debating internally whether I should draw a box around it so it would actually be discernible, when they called time and I dropped by pen like it was a murder weapon.

Unquestionably the most stressful 2 minutes of my entire life.