Board Review and the Middle-Aged Doctor

Article · June 19, 2017

Last fall, along with thousands of other internists all over the country, I hunched in front of a computer screen and endured 8 hours and 240 multiple-choice questions on the American Board of Internal Medicine (ABIM) decennial recertification exam. The day was grueling. By midmorning, deep in nephrology and hepatology, my lower back spasmed and ached. The noise-canceling headphones felt like a vise around my head, and the spongy foam earplugs tickled my ear canals. Late in the afternoon, I was answering questions on rheumatology, gastroenterology, and neurology with one eye squinted shut to keep the large floater in my right eye from blurring the screen.

And yet taking the test was nothing compared with the hundreds of hours I had logged over the previous 2 years (and especially the previous 2 months) reasoning through a thousand or so review questions, scrawling diagnostic criteria in pocket-sized notebooks, and listening to a 12-chapter board-review course while driving.

But the most challenging aspect was neither the lengthy exam nor the endless studying. It was the intimacy.

Twenty years ago, studying for the boards was a journey into a strange and fascinating world of disease that felt reassuringly distant. Things happened to patients — to others — but generally not to members of my immediate family, not to my cousins and uncles and aunts, not to my friends.

Over time, the strangeness faded. I could link diseases with actual patients whom I’d treated. When I prepared for the exam 10 years ago, a decade into my primary care career, I was immersed in clinical work with a panel of nearly 700 patients. The hypothetical patients in the written study cases often morphed into real ones I knew, and I’d find myself alternately relieved that my diagnosis had been correct and alarmed that I’d neglected to consider a different one.

As I reached middle age, something else started to happen. Like many academic physicians who have been around for a while, I have seen my clinical work shrink with the expansion of my teaching and administrative responsibilities. I haven’t taken care of hospitalized patients since before my last board exam, and my primary care hours are far fewer than they were 10 years ago.

This time around, studying for the test was not just an intellectual exercise or one that conjured up images of patients I’d encountered. The familiar faces of the diseases in board-review questions were now the faces of those closest to me: friends, friends of friends, family members.

First, there were just a few: tuberous sclerosis, obstructive sleep apnea, breast cancer, ulcerative colitis, glioblastoma multiforme, lymphoma, and rheumatoid arthritis. Then more, with diseases from Crohn’s and Alzheimer’s to colon cancer and coronary artery disease — the history of my family and friends catalogued by illness.

As doctors, we want to understand how diseases affect the everyday lives of our patients and their family members. We fleetingly imagine what it might feel like for an elderly patient with a portable oxygen tank strapped over one shoulder to labor the 20 feet to the mailbox on a hot summer day. We picture his daughter, living several hours away, worrying about him. But then the patient leaves the office, and we’re on to the next.

When the person in the role of patient happens to be a close friend or family member, it’s a different story. When hypothetical cases bring to mind aunts and uncles, grandparents, old friends, newer friends, even children of friends, board review gets real. Very real.

A question about diagnosis in a patient with headaches and a ring-enhancing lesion on brain MRI sparked memories of my sister’s glioblastoma: the aching pit of anxiety and uncertainty that took residence in my heart and gut, especially when we were waiting for test results; the fear that etched her face (and tightened my throat) when chemo was delayed because her white-cell count was too low; the shallow breathing that I tried desperately to suppress when a new symptom occurred so I could reassure her, and myself, that everything was going to be okay. A question about a patient with ulcerative colitis and 2 weeks of bloody diarrhea brought to mind my lively cousin from California burdened by an obstinate trio of pain, diarrhea, and anxiety. For her, spontaneity wasn’t an option; every outing, every walk around town required forethought — was there or wasn’t there a public bathroom nearby?

Ten and 20 years ago, I barreled through the review books, minimally distracted by emotion. Now my heart is softer, marbled with lived experience. Middle age is the best age to be in this difficult profession, because we are old enough to have suffered ourselves or to have witnessed the suffering of people we love and yet young enough to have the opportunity to pay forward this heightened sensitivity.

Middle age can awaken something like compassion, but it’s more than that. The German word mitgefühl, “with feeling,” marries compassion with condolences, commiseration, and sympathy; the prefix “mit,” or “with,” avows the togetherness, the accompaniment, what the psychiatrist Christine Montross calls abiding with patients. In middle age, that feeling can augment our ability to be there for, to be with our patients, because we may have been there ourselves, or somewhere close enough that we can relate. Imagining the doctor I’d want to have when facing a serious illness, I’d prefer one with a few wrinkles and a greater reserve of lived experience.

It slowed my pace, of course, imagining what wasn’t included in the straightforward presentations of the review cases: the indignities of disease, the suffering, small and large, transient and perpetual. Evenings at the kitchen table, puzzling through case descriptions, I’d sometimes feel a wave of sadness course through my chest, and occasionally I’d sigh loudly enough that my teenaged kids would look up from their homework with concern. When they realized the source of that sigh was a hypothetical review case, they would shrug and get back to their own work.

Little did they know about the unexpected perks of studying for the board exam 20 years post-residency: mitgefühl aplenty, a validation of witnessing (and abiding with) the pain of those close to me and, from my middle-aged perspective, a certain comfort.



From the Department of Internal Medicine and the Program for Humanities in Medicine, Yale School of Medicine, New Haven, CT.

This Perspective article originally appeared in The New England Journal of Medicine.

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