The most important outcome

In the months preceding my board exam, the advice came almost daily. How to study, who to study with, which textbooks to study from. Tips for keeping composure during the oral exam while projecting both self-assurance and humility. Pop quizzes while scrubbed and many iterations of “you will be fine” that were paradoxically irking and reassuring. I listened attentively. When the time came to sit the test, I felt as though I had heeded the advice and channelled it into something meaningful — the makings of a surgeon. I was ready for the exam.

I was not, however, ready for the crippling anxiety that followed.

Many of us anticipate our licensing exam for the entirety of our residency, if not longer. I went to medical school in a small city and often sat next to residents in coffee shops or libraries; me preparing for a block exam and them for their boards. The expanse of knowledge they were responsible for dwarfed the limited focus I was committing to memory, and I wondered whether my fear of failure would swell in proportion as I neared my own licensing exam.

Once in residency, I regarded the chiefs; mere months from adding “general surgeon” to their signature line, their answers to questions were as quick as their ties. A fascinating reversal of roles was observed, where, as they approached their exam, staff would ask questions not to test their knowledge, but because they themselves wanted to know an up-to-date answer. Or, better yet, in a demonstration of true Socratic method, a question would be asked that had no answer. Discussion between peers would ensue. As a junior, I was filled with envy. Those discussions required conviction in one’s knowledge, and I aspired to speak with comparable certainty.

By the time I reached my chief year, I felt no such self-assurance. Returning after a six-month maternity leave, I was trying to memorize Fukuoka guidelines while negotiating the competing demands of mother and doctor.

From watching those esteemed chiefs, I knew that our final year was surrendered to the profession — if you’re a runner, don’t train for a personal best; if cooking’s your hobby, it’s not the time to attempt beef Wellington — but the lived experience was even more erosive than it appeared. Between being at the hospital and studying, stretches of days would pass when I wouldn’t see my son. If a person was to tabulate the total number of waking minutes that he and I were apart in his first six months of his life, I suspect they would find that it exceeded the total number of minutes that we were together in the subsequent six. It was sacrifice.

The burden to bear was not just my own; I shared it with my husband, who had supported my career ambitions since long before I received an acceptance letter to medical school. During this final year, he said nothing to suggest wavering support, but I could sense his frustration. His body language would manifest small betrayals; an audible sigh or a fleeting frown when I would have to study or go to the hospital unexpectedly. In essence, he had become the sole care provider for an infant in the middle of a pandemic while navigating his own work-from-home order. His tank was running low, as was mine, and the only reassurance I could offer was, “As soon as the exam is over, I will be myself again.”

But I lied. In the days and weeks after the exam, I was not myself. Suddenly idle, with reduced clinical responsibilities and study requirements, my plan to spend quality time with my family was swallowed into a tornado of insecurity. During the day, I was distracted as I tried to both remember and forget questions. At one point, while watching a movie, the main character made a reference to the groin, and we had to pause as I quelled the rising anxiety that I had incorrectly answered the question on femoral hernias. Nights were sleepless in a whole new way; no real patients with real problems, just fictitious ones with problems I couldn’t solve. Sometimes, I would retrieve knowledge deeply buried in my memory and materialize an answer that I had missed on the exam, which was simultaneously validating and devastating. I was utterly distraught.

The thoughts that orbited my mind during this time ranged from what a revised study plan would look like to whether my career could survive a private insult displayed on such a public stage. Because of the enormity of sacrifice we make for our professions — particularly in this endlessly demanding year — where “my career” ended and “I” began was no longer discernable, especially not to me. The exam — designed to be objective, assessing every person’s readiness for practice in a standardized way — was contradictorily deeply personal. In the balance of its judgment was my belonging, and my fear was not just that of failure, but exclusion.

The fear and shame were dark feelings, and they created a positive feedback loop with imposter syndrome. It didn’t matter how many days of residency I had survived, how many diagnoses I had made or how many operations I’d done skin to skin. Irrationally, the more I identified my anxiety, the less I identified as a surgeon. I knew that concealing these sentiments would only drive me further into isolation, but I hesitated to admit them. Surgical culture rarely rewards admissions of self-doubt.

As luck would have it, I was retrieved from the abyss by a phone call from a friend and newly hired trauma surgeon who wanted to discuss an unrelated issue. After our obligatory conversation, she asked, “How are you?” Her tone was one of insight, and the sincerity cut through the unspoken expectation of bravado. As soon as I admitted the extent of my worry, she assured me that the feeling was quite common. She likened the exam-taking experience to being told to drive home alone after a motor vehicle collision where her car was totalled.

Unburdened by common experience, I confessed my anxieties to other colleagues and staff and was relieved to learn that most of them had experienced a similar consuming distress. One staff member told me that he had been tachycardic from the moment he took the exam until he received his results. Another, who had already been hired and placed on the staff call schedule, gave away all her call shifts, convinced that she had failed. One colleague told me that the night after his oral exam was the worst night of his life, bar none.

It’s easy to convince ourselves that fates are sealed the minute that the exam is done. Responses can’t be changed and the exam result will either reflect enough correct answers or too few. But, fate is more than just a grade, and even though our identities are deeply tied to our professions, we are more than just our credentials. With reason, our profession overtly values what we are, but how we are matters far more. The number of letters that trail a name may reflect achievement, but capacity is determined by wellness. In essence, shared experience can affect the ability to practise as much as the exam outcome itself.

The morning our exam results were posted I logged in with my husband sitting next to me. My eyes barely focused on the emboldened word “successful” before the visceral relief set in, and I realized the whole dehumanizing experience was over. As I spread the news, other surgeons would share their own experiences as: “one of the best days of my life,” or “a close second to the birth of my child.” I could hardly believe that I had finally passed the crossroad and was walking the long-desired path.

A lingering feeling gnawed at my insides though and I couldn’t help but glance over my figurative shoulder at those whose news had them walking the other way. It could have been as little as a single question that marked our divergent paths. Were we so different? I could not convince myself that a test result would suddenly supersede all that we had in common. Quietly, I wondered if anyone was asking them, “How are you?”