Friday, December 26, 2008

My first NBME board exam

It's Christmas break.

Thank God.

I just wrote my Surgery exams and they were well-timed to occur just before the break. I'm not sure I would have lasted if I had to go back to work the day after my first NBME (National Board of Medical Examiners) written & oral exam of the year.

Now only 4 more to go. We write 5 NBMEs in our third year - Psychiatry, Obs/Gyn, and the "Big Three" - Surgery, Internal Medicine, and Pediatrics.

Before I wrote my first NBME, I was given a heads up about what they're like. The way these exams were explained to me by those who had written it?

"You study your butt off for 8 weeks for one of the subjects, you live and breathe it, you learn everything there is to know, all the basics, all the obscure rare diseases you'll never see, and then you show up to the exam and feel like you get 0 of the 100 questions correct. Everyone thinks they failed. Everyone does just fine."

Another piece of advice, which I'm not sure how it was supposed to help me prepare for the test (other than psychologically):

"People walked out of the exam room crying. I heard someone sobbing during the exam."

On the test day, we had to sign and be read a few dozen disclaimers about the exam and not sharing questions, so the following isn't word-for word, but it suffices as a sample question:

A 42-year-old man presents with bilateral ear pain. Choose the correct diagnosis from the following list of options (a through f):

Or, to compliment the questions with too little information, there are also long, detailed clinical scenarios of patients who present with a plethora of symptoms, have every known comorbidity, and their family history, social history, physical examination results, and lab data are all spelled out for you. So, you read through and underline the pertinent information, convert the lab data from American to International units, and then realize the question at the end of the scenario has nothing to do with the scenario and simply asks something like,

What is the most common cause of small bowel obstruction?

I'm not sure the point of writing an exam that gets curved so vehemently that it doesn't really help you learn what you know and what you don't, or why we aren't given the opportunity to see where we went wrong and use the questions as a learning experience.

Just another hoop to jump through, I suppose. Just like the oral exam.

I'll rant about that one another time.

For now, you'll find me on the couch by the TV, sipping egg nog.

One more thing - thanks to Medblog Addict for including me in the unique Christmas feature interviewing a different blogger for the 12 days of Christmas. You might enjoy the picture of myself that I submitted :)

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Thursday, December 04, 2008

I don't think your arm is "bruised"

He was coming into the family doctor's office I was placed for an entirely different reason, this pleasant, absent-minded, blissfully unaware old chap. "Hello, young fellow!" he said, when I came into the room.

I returned his happy greeting, and asked what brought him in. "Oh, nothing much, just here to get my prescriptions renewed, then I'm on my way! Sorry to trouble you!" He was such a cheery guy.

"Why are you wearing that long hankerchief around your neck?" I asked him, making small talk as I started copying out his drug list.

"Oh, just for a bruise on my arm, it's a little sore. I tripped over my shoelaces while I was getting my morning paper a couple weeks ago." He held up his arm.

My eyes bugged out when I saw it.

His bruise had gone away, but he had much more than that left over - about six inches up his arm from his wrist, he had what is called a "step deformity" - his arm bone was simply no longer straight. An obvious sign, visible from across the room, that his arm was broken, not bruised.

Not surprisingly, the doctor I was working with sent him to the emergency department to get his arm casted.

On my way back home from the office at the end of the day, I stopped at the hospital and called up his x-ray on the computer. Sure enough, he had a definite Smith's fracture of his distal radius, typical of a fall onto a closed fist.

By chance, the emerg doc was walking by, saw I had dropped in to look at the x-ray, and said, "We're about to reduce that patient's fracture - do you want to do it?" Nice!

So, we put the jolly old fellow into an even more blissful state with some propofol ("milk of amnesia," as this white liquid is sometimes called), and yanked and pulled and tugged on his arm to get it back in the right place, then wrapped a cast around it. I love working in small hospitals - a pretty neat chance for followup on the patients, and no other resident or student there at the time so I could just jump in and do the procedure.

Epilogue: I didn't stick around to look at the post-reduction x-ray, but a few days later, I came back to the emergency department and called it up to see if the bones were set in the right place. Randomly enough, there was an orthopedic surgeon charting at the desk next to me, so I told him the story and asked him what he thought of the post-reduction x-ray. He was not impressed - turns out that if someone's arm has been broken for two weeks, it shouldn't be reduced in the ER because it's too far into the healing stages - surgery would have been more appropriate. Well, now I know.

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