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EMERGENTOLOGY: On My Emergency Medicine Boards

Walker, Graham MD

doi: 10.1097/01.EEM.0000410877.18820.14


The topics in this piece were not on my board exam. The following is best read aloud in one of those war-era propaganda film announcer voices.

Ladies and Gentlemen of the Jury of my Board Certified Peers, I write to you not in a flurry of joy or despair but one of frustration, eyes rolled. Not in celebratory glee, but in the nausea of a thousand high-grade small bowel obstructions. My annoyance today can only be described as “worse than the migraneur trying to bargain for narcotics because ‘they always work, and then I'll leave.’”

You see, mesdames and messieurs, only hours ago I sat for my qualifying exam in emergency medicine.

Now I will admit, I was convinced about the usefulness of preparing for said exam once my studying commenced. While I had studied diligently for the residency inservice test, now that I'm a residency graduate, my increased clinical experience has helped me to solidify a few concepts I had still not wrapped my cranium around. A few lightbulbs glowed where previously only sparks had flickered; the vertigoes peripheral now are easier for me to differentiate; the illnesses tickborne have come into focus as well.

ACEP's PEER VIII, published just in time for this year's exam, provided a great deal of high-yield review when the Carol Rivers (may she rest in peace) series became too bullet-pointed. This board's preparation was, for the most part, clinically useful to help me rearrange my differentials when appropriate; it cleared up topics that previously were difficult to comprehend (except for EMS/administration; I'll never get those right).

But the examination itself? Be forewarned, children — and those of you with weak constitutions — you may wish to leave the room before, dare I say, shenanigans! horsefeathers! poppycock!

I am assuredly no gynecologist, and I admittedly know few rare, nonemergent gynecologic syndromes. Likewise, I am no hepatologist, and do not care to comment on the physiology associated with partially treated hepatobiliary disease. Why were similar topics on my emergency medicine boards?

I am, quite proudly, an Emergency Physician. Capital E, capital P. I evaluate for disease, I resuscitate, I prescribe, I determine disposition. I work with constraints, I practice despite the limiteds: histories, resources, consultations, and patience (but, ho, never patients!). I am happy — delighted, even! — to be tested on my clinical prowess. But please, at least provide me with a full set of vital signs or a full lab test. All I ask is that you do not tie one hand behind my back, blindfold me, tie my tongue, and then expect me to guess whether the fictional patient has a viral pharyngitis or a viral URI. In no way does a difference matter to me or the fictional (or even real) patient. Why were such jagged-edge question-stems and answer choices so frequent on my emergency medicine boards?

Similarly, I don't do lists very well. I haven't focused on memorizing Rosen tables professing risk factors for diseases. Which is most important? Fat? Female? Fertile? Forty? Do any of these rule in or rule out biliary calculi? Sure, risk factors may be useful in predicting which patients will end up with which diseases, but why should comparative risk factors be such a focus on my emergency medicine boards?

Some suggest that if one knows the minutiae, one must certainly know the foundation, but I find this can't be further from the truth. So wide is the breadth of the emergency physician's knowledge base, surely there must be better things to test than multiple questions on fractures of the distal radius? In fact, only recently did I learn of the bucket-handle meniscus tear or the newest pharmaceutical wonder for tumor lysis hyperuricemia. Instead, I'm challenged again and again about otitis media? Why would questions be so frequently repeated on my emergency medicine boards?

In some areas of medicine, the seemingly clinically irrelevant can actually be quite useful. Remembering that lithium sits just above sodium in the periodic table may help the otherwise esteemed clinician recall its propensity for causing insipid diabetes; recalling the course of the internal carotid artery may prevent a peritonsillar abscess aspiration from going awry. But to recall parts of the coagulation cascade without even a nod to its clinical relevance to medications, coagulation studies, or (heaven forbid) the patient seems, simply … barbaric. Why would there be such a focus on pathophysiology without any clear relationship to its effect on the patient on my emergency medicine boards?

Must the definition of the best, next, or first step be subject to interpretation and constant scrutiny? I believe my colleagues will agree; we are able to do multiple things at once. I typically place acute pulmonary edema patients on a monitor while gently tossing nitroglycerin under their parched tongues, having the nurses secure IV access, starting an intravenous nitroglycerin drip, and calling for BiPAP and chest x-ray. All at once! Apparently ABEM only works sequentially. Should I give fluids to the hypotensive patient? Or choose the correct antidote? Is this question trying to test my knowledge as a toxicologist or my knowledge of prioritizing initial resuscitation? Why were so many questions so nebulous on my emergency medicine boards?

The boards were not all they were cracked up to be, and left me quite underwhelmed and disappointed. (I wanted to show off my newfound knowledge of all the erythemae rashes!) While the preparation for the boards was actually a quite useful activity and may help me take better care of those patients in need, the actual exam made me question what testmakers realistically expect me to know, demanded that I guess what they were thinking, made me dive back to medical school esoterica majora, and forced me to choose between two actions done clinically in parallel. Now that it's over, I look forward to seeing a patient, not a computer screen, where my decisions matter and my careful consideration of the patient is as complex and three-dimensional as they are. I don't at all mean to suggest that test-writing is easy, but why test so imperfectly when there are so many perfectly good topics to consider … on my emergency medicine boards?

Dr. Walker

Dr. Walker

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