It was well past 11:00 pm, and once again my head began to nod, and the words on the page began to blur. Struggling, I tried to refocus on the long paragraph about measuring methylmalonic acid levels in the diagnosis of B12 deficiency, but it was just no good. Then, inspiration struck.
"Fight through the fatigue," I mumbled to myself. Those were the words that 7-foot tall sports announcer Bill Walton, of basketball fame, had said the other night on national television. To win the championship, I had to focus and fight through the fatigue. I tried again. "FIGHT THROUGH THE FATIGUE!" I bellowed at my wife, an internist, who had long since given up on her studying; but in response to my mad machismo, she simply turned over and went to sleep. I, on the other hand, grandly pumped my fist in the air, and read like a fiend for another hour on the niceties of hematology.
The year was 2003. As I had first taken the internal medicine boards in 1993, I was part of the third group of internists who were required to recertify 10 years later. The initial step required the usual tedious paperwork, followed by 5 to 6 books of 60 multiple-choice questions to be answered at home. I decided to recertify in both internal medicine and infectious diseases at the same time, therefore swallowing the bitter pill in 1 try. I therefore did 3 modules of internal medicine and 3 modules of infectious diseases, over a 1-year period.
I knew quite a few physicians who had either just finished recertifying or were starting the process. My colleagues took a variety of approaches to the modules: some took a laissez-faire attitude, spending minimal time on the questions; others, hearkening back to their days as neurotic, perfectionist medical students spending huge blocks of time in the library, scrupulously studied each question and compulsively looked up answers in textbooks and even in the literature.
One nice experience with all this was that my colleagues of a certain age would consult each other on test questions. It was a common sight for one of us to hail down another physician in the hallway and pull out a set of questions for an impromptu discussion on the treatment of superior vena cava syndrome in small cell lung cancer. In fact, the more questions a colleague asked your input on, the more honored you felt. In addition, being attending physicians of a number of years of experience, we had no compunctions about criticizing the questions. Although many of the questions were quite fair, there were a few that did not seem to bear much resemblance to real-life situations.
It was difficult to find time to study. As was the case with many of my colleagues, I was in an extremely busy practice, with 2 small children at home. My responsibilities were far greater and more diverse now than when I was a resident. Between seeing patients and some minor administrative duties, I easily put in 60 to 70 hours per week. And of course, family life could not be suspended. Children had to be fed, clothed, dandled on 1 knee, and educated. Birthday parties had to be planned. And after doing taxes, paying the bills, and replacing lightbulbs as needed, there was not a whole lot of time left in the day to review the appearance of the delta wave in Wolff-Parkinson-White syndrome. The only time left for study was at 10:00 or 11:00 pm at night. In addition, as a young father, I did not want to attend any board review courses away from home. That would have just taken me away from the family even more.
Still, it did not take that much to motivate me. One day while in the hospital, a gastroenterologist I knew and respected was rounding with a medical student and discussing a case. The gastroenterologist smiled in greeting and said to me with a world-weary, knowing glance, "This student doesn't know it all goes downhill from here. After you become an attending physician, you know less and less." I had heard this type of comment many times before, starting when I was a student. Only now, this truly irked me. I thought any physician with a modicum of professional pride could not possibly say this. I would just have to crack the books open late every night to prove this statement wrong.
I did discover the wonderful world of audiotapes. For years, I had resisted the notion of using my drive time to listen to medical tapes, but now, efficiency came into play. My daily commute was 30 minutes each way. I spent the better part of a year listening to tapes in the car. This worked much better in the mornings. On the evening drives home, I usually had to resort to Mozart or Bach to shake the cobwebs out.
In November, at long last, came the test itself. Those who were just recertifying for internal medicine needed to sit for three 2-hour sessions. Those recertifying for internal medicine and their subspecialty needed to sit for four 2-hour sessions. We sat nervously in the big auditorium clutching our number 2 pencils, waiting for the test to begin, and smiling wanly at friends across the way.
Having gone through the process, I will say that there are definite pros and cons to recertification. On the plus side, I believe I am a much stronger infectious disease physician because I was obligated to review such diseases as sarcoidosis, Wegener granulomatosis, Churg-Strauss disease, and Goodpasture syndrome, all of which come up occasionally in the course of our practice. In addition, at this point in my career, I have a more realistic sense of my strengths and weaknesses than earlier on, and I could therefore concentrate on those weaknesses. And contrary to the gastroenterologist's comment, I feel that I understand disease processes far better than I did 10 years ago, after years of seeing actual cases, buttressed with a reinforced foundation of basic knowledge. In addition, the experience showed me that with some efficiency and motivation, there is just enough time in the day to squeeze in a little extra work. This year, knowing that, I volunteered to do grand rounds at our community hospital, despite an extremely heavy practice.
On the negative side, the process does require significant expenditures of time, energy, and money, along with causing an inordinate amount of stress. The necessary time commitment is impressive. The year or so you intensely review for the boards, will undoubtedly prevent you from keeping up with the current literature. It is also not advisable to embark on other ambitious projects during this time: grand rounds? Let someone else do it! New drug trials? Forget it! Implementing a new electronic health system in the office? Fat chance! Family time? That is one luxury you would not be able to afford!
The biggest negative in my mind is the enormous amount of significance given to 1 or 2 testing sessions. It is always conceivable that around the time of the examination, a candidate may have to deal with family illness, death, or some other unusual situation, such as being involved in a malpractice case, which does not allow one time to prepare adequately. I have known a physician who took the recertification examination a week after her mother passed away, and another physician who took the examination only several months after his wife died. Others have had to contend with recertification around the time of divorce. Thus, too much credence is put into the result of a single day's testing, during which time there are always some uncontrolled factors at work. That single test may or may not reflect accurately a physician's knowledge and experience. And it is conceivable that a hospital or insurance company could take away a physician's accreditation for failing the recertification examination, thereby putting that physician's entire career and livelihood in jeopardy.
In fact, my preference, as I expressed in a letter to the American Board of Internal Medicine (ABIM), is to take mandatory, strictly quality-controlled continuing medical education courses without the pressure of a secure examination. Alternatively, the ABIM could make the modules mandatory and the secure examination optional for those who wish to have an added qualification, such as "master of the ABIM." In addition, as there is a major effort required to fulfill the requirements of recertification, I would submit that one should receive extra compensation for this, although realistically, this is unlikely to happen.
For a few weeks after the results of the boards came back, I recall passing by peers who had taken the examination at the same time, giving a little questioning look, and being rewarded with a pumping fist and a satisfied smile of relief. High fives all around! Another survivor!
I look back with a wry smile on Bill Walton's admonitions on the television that spring. And what do you know, we did just what the old Celtic said: we fought through the fatigue. And we wound up bringing home the championship.