Thursday, December 9, 2010

Oral Board Exam

Back in the United States, I am about to take the Obstetrics & Gynecology Oral Board Examination. It is an exam that all Ob/Gyns fear and dread. We discuss it endlessly in training: “When you take the boards, make sure you say xxxxx.” Everyone who has taken it has their story about what questions they asked, or how scary and poker-faced the examiners were. Even older physicians who are decades out from their oral exam betray a very visceral retelling of their experience. And here I am, about to complete this monumental event. It’s like an Ob/Gyn bat mitzvah.

Part of the exam requires that you collect cases that you then submit the list to ABOG (the American Board of Obstetrics and Gynecology) for approval. These cases are in three different categories – obstetrics, gynecology and office practice. The obstetrics cases are either cesarean deliveries or complicated obstetrical inpatients. The gynecology cases are either gynecologic surgeries or inpatient gynecologic cases (such as pelvic inflammatory disease). The office practice cases are patients seen and managed as outpatients. Within the three different categories, there are many subcategories of which you need to fulfill a certain number, to demonstrate the diversity of your practice.

I collected all of my cases in Uganda. This was a daunting task. I didn’t know anyone who had previously taken their boards by collecting cases from a developing country. Would ABOG let me do this? Would I be penalized because my diagnostics and management resources would be limited? Was it crazy?

But then again, what is obstetrics and gynecology if not applicable to the entire world? What kind of message is that sending if ABOG only allows cases from developed countries? Does it mean we can’t provide adequate obstetric and gynecologic care without abundant resources? In truth, obstetrics and gynecology are very bare-bones specialties. They require a history, a physical exam, a pelvic exam, a scalpel, and a suture. Pregnancy testing, ultrasound, and some basic medicines (oral contraceptives, oxytocin, antibiotics) help a lot, too. We have added very valuable resources into our practice, such as epidural anesthesia, electronic fetal monitoring, CT scans and serology, but you can do a lot without those things.

Nothing in ABOG’s regulations precludes entering cases from other countries. I wrote to ABOG, and they were remarkably supportive. They made some modifications to their procedures to make it easier for me to submit the required documentation from Uganda, which I very much appreciated. I took this as a good sign.

As I collected my cases, I tried to fit them into the predetermined subcategories. This was difficult. For example, “Hyperlipidemia” – I can’t check cholesterol in Uganda, nor does it really matter. Life expectancy isn’t long enough for most people in Tororo to worry too much about cholesterol levels. (Besides, what would someone do if they had high cholesterol? Take a statin? Change their diet? Most people are lucky to get the food they can.) There were other subcategories that required laboratory testing or pathology diagnosis to meet the criteria, and I had to ignore those. That left me fewer categories to work with, but I made it fit.

When I got back to San Francisco, I started showing people my list for editing advice. Everyone said the same thing “Your list is crazy.” It is? I couldn’t see it myself. I knew that it was a little different from the others, but this was my life for a year, and I suppose it had come to seem normal. I guess most lists don’t have seven ruptured ectopic pregnancies, but really, was it that different? People on my list had abnormal bleeding, infertility, preeclampsia, fetal distress, cervical cancer, pelvic organ prolapse, pelvic inflammatory disease, HIV. Was this really so different from everyone else? Maybe because I trained in the Bronx, I’m used to seeing a high level of abnormal (and “rare”) pathology. But even my Ob/Gyn friends in the Bronx thought my list was crazy.

I started to get nervous. Once I had submitted my list, ABOG could still reject it. I had paid about $1300 to take this exam already. If they rejected the list, I would lose all that money, and have to spend another year collecting cases. As it got closer and closer to the date on which I was supposed to hear from them, I got increasingly anxious. Had I missed the letter? Had they rejected my list? I started paranoiacally checking their website (which is stuck in 1997, apparently) and calling them – to which I got no response.

Finally, exactly one month to the day before I was supposed to take my exam, the letter came. My list had been accepted, and my date was set for December 8, 2010.

Relief hit me. Then paranoia again. Wasn’t that Pearl Harbor Day? Crash and burn! Kamikaze! Is that a bad omen? Noooooo! Then my superego stepped in and calmed me down. I was being superstitious, and besides, Pearl Harbor Day is December 7. Sheesh.

I spent the next month studying assiduously. I practiced answering questions, and solicited advice from anyone I could find.

And now, here I am, on the plane on the way to the boards. The captain asks us to turn off our electronic devices, so I pull out some good old-fashioned paper reading. I decide to review my case lists, which I have printed out in preparation for tomorrow.

As I look through my cases, I remember these patients. The woman with ovarian torsion who was basically saved by the nurse, who was so concerned about the patient’s severe pain that she called me in urgently. (Sadly, this is not to be taken for granted.) The patient tried to give me a chicken after the surgery to show her gratitude. The woman with pelvic inflammatory disease two months after a delivery who stayed for much longer than she needed to because her IV antibiotic doses kept getting missed by the nurses for days at a time. I finally gave her oral medication and figured she could be more adherent taking that at home. The woman with a tubo-ovarian abscess whose pelvis was so scarred that I couldn’t do anything at all in the surgery – I washed with some sterile saline and closed her back up, feeling guilty. Somehow, that resolved her symptoms, and she came to visit me in the clinic, convinced I had saved her life and forever grateful.

As I think about these patients, my anxiety level reduces. I have such affection for them, and as I read their cases on my list, I wish I could show the examiners a photo of each woman, to describe the three-dimensional person behind the case. I also remember the feeling of being in Uganda, and how much I loved it. I remember the frustration of trying to track down an anesthetist, or schlepping the ultrasound back and forth to the ward, or sweating as I try to evaluate the patients who need me as the afternoon rainclouds close in and threaten with a dense humidity. That frustration was very real, but never once did it compare to the enormous satisfaction I got from doing the work. Shaking hands with a patient who was grateful to be cured, or just grateful that I was giving her any medical attention at all. Seeing a healthy mother and healthy baby after a cesarean in which I wasn’t sure that either was going to survive. Laughing as I speak in English and a patient speaks in Japadhola or Ateso, but we both wave our arms frantically and somehow manage to communicate something. Seeing a patient whom I had treated for an ectopic, proudly exposing to me her lovely pfannenstiel (“bikini cut”) scar and thrilled with how it has healed painlessly and almost invisibly. Whipping out my practiced Ugandan English accent, and seeing the patients’ sheepish, shocked and relieved smiles that they can actually understand me, despite all that glaring white skin. Walking with the midwives to the police station to support the arrested midwives, singing “We Shall Overcome” and a Ugandan civil rights song to entertain ourselves, and feeling indescribable pride to hear the midwives say “Dr. Veronica, you are really with us.”

No, I couldn’t have had a better year if I had planned it.

I love this job so much that sometimes I am surprised - that it all worked out in the end. Surprised that I had no clue what I was getting into when I chose premed, but that apparently I chose right. Surprised that the lazy memorizer and multiple-choice-overthinker turned out to be a mild workaholic with a pretty good memory for the stuff that counts.

When I go into the exam tomorrow, I am going to carry these memories with me, because they are the ones that motivate me to work my hardest, and to know that I know what I am doing, and I can practice obstetrics and gynecology competently. I want to walk into that exam room not as if I am going to walk into a barrage of esoteric questions, but a room full of Tororo patients, whom I have to evaluate and treat in a logical and safe way to the best of my ability. I can do that.