Board Exams

Don’t you just hate it when some old codger says, “You guys have it easy. In my day…”? Well, in one area things were tougher in my day: specialty board exams in psychiatry. In addition to examining two psychiatry patients, we had to examine a neurology patient and answer questions in basic science neurology, i.e., neuroanatomy and neuropathology. It was this neurology half that most concerned me. I had just been discharged from 2 years in the army and had acquired skill in psychiatric examination greater than that of most of my colleagues. At the same time, I had been away from an academic center for 2 years, and the little neuroanatomy and neuropathology I had once known had largely evaporated.

There was a semiannual course called “Neurology for Psychiatrists,” and I decided to enroll in it as soon as I had been given a date and place for my exam. The course met on Sunday mornings, from 9:00 a.m. to 12:00 noon, at Manhattan State Hospital on Wards Island just off Manhattan. The first trial class was to be free. Wards Island was the last place I wanted to be on a Sunday morning, and the hospital was old, dingy, and cheerless. My heart sank as I saw my fellow applicants in crumpled suits, all quite middle-aged, looking as though they were gearing up for a seventh or eighth try at the boards. (State-employed psychiatrists receive a considerable pay advantage for board certification.) The anxiety in the room was palpable and, unfortunately, contagious.

At 9:15 the young instructor entered. He began with a few jokes to relax the crowd, such as, “A funny thing happened to me on the way...,” etc. I looked at my fellow applicants and saw that they were furiously, mindlessly, writing down the jokes! I told the instructor I could study better on my own and fled the room.

My assigned station for the exam was at the University of Florida in Gainesville on a Saturday. I was to take all five subsections, one hour each, in the one day. My head bursting with facts, I took a Friday flight to Jacksonville. I decided to then fly to Gainesville rather than rent a car; the airplane trip would be only half an hour.

It took a while to find the small one-engine plane that shuttled between Jacksonville and Gainesville. It was out on the runway already. The man who took my ticket also stowed my valise and then, when he had done this, hopped into the pilot seat and put on his earphones. There were but three passenger seats, one to the pilot’s right and two behind him.

The noisy little plane flew just above the trees, lurching like a roller coaster. The interior was, of course, not pressurized. When we landed in Gainesville, I remember saying to the medical student seated at my left, “Some ride.” He moved his lips, but no words came out. Poor fellow must be mute, I thought. It took me a few minutes to realize he was fine. It was me—I had become stone-deaf. And tomorrow morning was the Big Test. My heart sank; if I could not take the test tomorrow, there was no way I could ever relearn all the minutiae of psychiatry and neurology for the next test date 6 months hence. The medical student understood what had happened to me, having seen the “blocked ear syndrome” many times before on this particular flight. He took me to a Gainesville hospital emergency room. A kindly ENT resident dilated my eustachian tubes, and my hearing was immediately restored. He said my ears would hurt like hell for a time, but at least I could hear my examiners’ questions. I took to bed at once and slept fitfully.

That Saturday was the longest day of my life.

My first test was in clinical psychiatry. Two young examiners, one from Ann Arbor, Mich., and the other from Cambridge, Mass., both academic types, sat with me waiting for the patient. The patient was brought in. He spent the entire interview staring at his feet, clasping and unclasping his hands. He looked and sounded like Billy Bob Thornton in Sling Blade, slow of speech and with dampened affect. I asked him the stock opening question: “Why are you in the hospital?” but I received an unusual answer:

“Ah cut off my penis.”

I heard the sound of two pencils dropping to the floor. The hierarchy in the room dissolved as our joint curiosity took over.

“Tell me about it,” I asked. And the three of us pulled our chairs closer to him as he began his story.

He told us he had been hearing voices accusing him of wanton lusts and wickedness for at least 2 years. Recently his voices had told him to cut off the offending member, how and where to bury it, and what Scripture to invoke at its interment. He was digging a small grave and bleeding badly when his brother Cletus discovered him. Cletus rushed him to their family doctor, who patched him up and arranged for admission to the psychiatric unit at Gainesville. Slowly, ploddingly, he depicted his primitive, solitary youth: skinning rabbits and squirrels and helping Cletus “nut pigs” on the farm where they worked just outside of Gainesville.

Although I had seen young men of a similar stripe in the army (but not with such an extreme outcome), my two shaken examiners clearly had not. When the patient had been taken away, they asked me a few perfunctory questions and passed me on. They were still talking to each other when I was dismissed.

“Have you ever seen anything...?” one was saying.

“Could you imagine working in a place where...?” said the other.

By the time my last exam took place, at 5:00 p.m., I was running on empty. Two young neurology examiners were quizzing me on a plastic model of the brainstem when Dr. Francesco Dura-Mater walked into the room. Bad, bad luck. Dr. Dura-Mater was the chief neurology examiner and the world’s expert on infections of the nervous system. He hated this even limited association between neurology and psychiatry, that is, sharing specialty boards. It was reputed that he ate the psychiatry applicants for breakfast. “How many strains of polio virus are there, Druss?” he asked me abruptly.

“Three, sir.” He glowered at me through rimless glasses.

“Would you by any chance know the names of the three strains?” His red pen was poised in the air, waiting to place an X after my name, but Dr. Dura-Mater did not know that he was talking to a charter member of Polio-Phobics Anonymous, that if asked I could tell him the number of new cases of infantile paralysis that had appeared in August 1939, and that I had sighed audibly in relief when the trivalent Salk vaccine first appeared.

“Lansing, Leon, and Brunhilde,” I declared. He stopped in surprise and put his pen down.

“And,” I continued, “Lansing was a city in Michigan where the virus had been rampant, Leon was the boy who had contracted the disease, and Brunhilde was the rhesus monkey on whose kidneys the polio virus was propagated.” He sputtered angrily and told his two associates to pass me through.

An hour later at the hotel dining room, the head psychiatry examiner walked by and gave me a broad wink. I took this to be an indication that I had passed. Six weeks later I got written notice that I had.