How it all went down. (IV)

Exam day.

I wake up before the alarm goes off. The exam is not until noon, and there is time to spare. I eat a leisurely waffles-and-yogurt breakfast in the hotel lobby, returning to my room only when it’s time to get ready. In a token gesture of rebellion, I’ve decided not to wear a full suit. Instead, I dress in black pants and a semi formal jacket. I check my ID, throw a granola bar and a water bottle in my bag and leave for the exam hotel.

The hotel lobby is full of examinees, reviewing notes, talking to each other, watching their watches. I notice a woman from the course- her mother is with her, handing out snacks, socks, papers. I get a coffee and call the husband for a last minute pep talk. Soon, it’s time to board the bus.

The bus is taking us to the local university medical center. The man next to me engages the bus driver in small talk- I am thankful for that. The bus driver points out local landmarks, including Warren Buffet’s high school. Soon they start talking about football and I drift off.

The exam center is in a modern looking medical building, all glass and curves. New-ish, bright artwork adorns the walls. We walk in, holding doors for each other, making small talk, laughing nervously. The first floor seems curiously empty. Then I remember- it’s Sunday.

Up on the second floor, our team leader greets us. I recognize her as the program director of a residency program where I was offered a position and had to decline. She seems to recognize me as well, but does not say anything, launching into a well rehearsed speech about the exam process. Since she is not one of the examiners, it does not really matter if she knows me. I try not to think about it too much. After she is done, we are led to a hallway where the examiners are waiting. Our names are called and we are introduced to our examiners. We shake hands and follow them to the exam rooms.

It’s on.

The vignettes are played much like musical chairs. All of us walk into our respective rooms. My first vignette is about a dementia/pseudodementia case. I give a happy inwards sigh- this is my subspecialty. The examiner lifts his eyebrows when I list rarely used dementia meds with their doses, titration schedules, current evidence- I risk a smile. He smiles back. The rest of it flies by.

Time to step out, switch doors, step into room 2. The second examiner is an older Indian/Pakistani psychiatrist. The vignette is about metabolic syndrome- the weight gain/hypertension/hypercholesterolemia/increased risk of diabetes that seem to come with a lot of antipsychotics. I feel comfortable with this, starting with how I would educate the patient, monitor weight, blood pressure, etc, refer to primary care, consider other, less risky medications. He presses me until I give him the word ‘psychoeducation’. Somehow, we end up talking about the few first generation antipsychotics that are weight neutral but rarely used. I’m hoping he gives me bonus points for knowing which ones are not available in the US anymore. Soon, time’s up.

My third vignette is trickier- a young woman with sudden onset anxiety symptoms, referred by her PCP. They clearly sound like anxiety due to a medical condition. I talk about hyperthyroidism, pheochromocytoma, even plunging into other endocrine tumors, a hazy territory for me. She keeps asking for more. I veer back to psychiatry, listing possible psychiatric disorders lower on my list. She keeps digging until we run out of time. What did I miss?

Out in the hallway, I try to focus on what the team leader said about using these minutes to ‘take a deep breath and just clear your mental screen, like an iPad’. Time for vignette 4.

This is a video vignette, a classic borderline patient admitted after an overdose. We discuss defense mechanisms. I refrain from saying the word ‘borderline’ with it’s negative connotations, and stick to describing the actual behaviors obvious from the video. My examiner seems satisfied, though she maintains a poker face.

Half time. We walk outside into the sunshine and take the bus to the local community mental health center for the live patient interview.