Primitive Defences
LEARNING TO LOVE YOUR PRIMITIVE DEFENCES
Tuesday, 29 January 2008
A.K.A. HOW TO SURVIVE FAILING THE CLINICALS
by Carol Silberberg
As I write this, I have just finished my 2nd attempt at the clinicals in NZ. I don’t know how I did, but I’m hopeful, which is more than I can say for how I felt the last time around. I started thinking about writing this guide while procrastinating between the OCI and OSCE, after a colleague commented admiringly on my ability to effectively suppress all memories of the OCI in order to proceed with the OSCE, instead of hopping on a plane back to Melbourne (or off the hotel balcony).
Reflecting on the past nine months since I started my clinical exam preparation, I read all sorts of guides on how to pass the exams. But nothing really prepared me for failing the exam, or how to cope with it afterwards.
Going into my first attempt at the exams, I had been told that I was a good chance. Friends and family believed unfailingly in my ability to pass purely based on the fact that I’d never failed anything before. No one seemed to understand that by the time we get to this stage in specialist training, you’re not being measured up against some of the spanners you may have gone to school with, but an elite and obsessional group who have spent as much time as you – probably more – preparing for exams. And given that around 50% of people fail each time, someone has to be the one to fail. Nonetheless, I was reasonably confident, although rather anxious.
I was one of those who failed in May. I had never failed anything before (unless you count my inglorious repetition of high school chemistry in summer school, which technically I didn’t actually fail, but that’s a long and irrelevant story) and had to face the prospect of doing it all over again in October. The thought of going through it again was a task which seemed insurmountable at the time. And I couldn’t find anyone who could tell me how to go through it, and get though it. None of my preparations actually dealt with how to cope with failing.
So if you (or I) are one of the unlucky people to have failed, what do you do now? How do you go on?
Let me take you through my experiences.
May 14, 2007.
Arrive home from Sydney, certain in the knowledge that I had failed.I then had to endure two weeks’ worth of people trying to reassure me ‘Of course you’ll pass’; this was not very helpful and I think served more to reassure them rather than me. Because of course they don’t know: I felt that them saying it meant nothing.
May 25, 2007
‘A day that will live on in infamy.’When the results came up on the website, I can’t say I was surprised to see the word ‘Unsuccessful’ next to my number. That doesn’t mean it was pleasant.
The next few hours were filled with the grim task of informing anxious friends and family, and having to hear endless refrains of ‘I’m sure you’ll get through the next time’, as well as vilification of the exam process and all that it entails. At one stage, my mother even offered to organise a hit on one of my examiners.
Feelings, thoughts and actions in this period:Secret guilt and shame over my relief that other people I know have failed (sorry, guys).Wait for the world to fall in. Secret disappointment that it hasn’t, and this is really happening.Drink, cry, solace from partner.
Emotional experiences over the next few days:
Shock
This seemed to mainly happen to my family – I could actually fail something! I wasn’t that shocked. In fact, I had to suppress the near-irresistible desire to say ‘I told you so’.
Denial
Very useful for the first few days, until the letter arrived in the mail confirming my results.
Anger
This started when I read the letter which revealed that I’d missed out by 0.3 of a mark, which seemed ludicrous in such a subjective field as psychiatry (see, I’m still partially stuck in anger). To be honest, I wish I’d failed by more than that as it would have been easier to have something to work on, rather than attributing it to ‘bad luck’ or ‘evil examiner’ (see below under externalisation). Anger also at people like my supervisor (hi, there) who told me that by failing, I would value my fellowship even more when I finally got there. Bullshit!
Despair
When I realised I had to do it all over again, I couldn’t face the thought of doing any more OCIs, or any aspect of the experience. I started to re-evaluate my career options.
Acceptance
Still waiting…
The first few days back at work after failing were the hardest. Emails went around congratulating all the successful candidates at our hospital, and no mention was made of those who hadn’t made it. I felt invisible. This was made worse by many people coming up to me asking how I did, as they didn’t see my name in the email.
Suggestion to deal with this stage:
If your service has sent around a similar email, bite the bullet and send out one of your own telling everyone you failed. Although having to directly face your humiliation and narcissistic injury, it does avoid the excruciating interactions over the next few days as everyone eagerly asks how you did, and then flounder for things to say, forcing you to help them out: ‘Yeah, I know, it sucks’ ‘It’s ok, I was pretty close, hopefully next time…’. Even worse were those who pretended to forget that I had been through the exam experience, or just ignored me until they judged that it had been long enough that I probably had forgotten about the whole sordid affair. Yeah, right. To give credit, all the registrars and the teams I work with were all great. Management and senior psychiatrists were the worst.
Other coping strategies
Information-seeking
Talk to other people who failed with you to confirm that you are not alone in your misery and anger. Talk to other people who failed and then got through to reassure yourself that it is possible, and that many of them have no idea what went wrong/right to make the difference the next time around.It also helped to talk to my supervisor about all the fantastic consultants I knew who had failed their own exams. To a certain extent, it also helped to highlight the futility of the situation by looking at some of the less capable registrars and consultants who seemed inexplicably to have passed.
Fantasies (don’t try these at home, kids)
Organising a break-in at the college headquarters to destroy all records of my results.
Hiring a hacker to get into RANZCP’s system to change my result – given their budget website, I’m sure their firewalls are pretty sub-standard.
Externalisation
Blame bad luck. Blame the examiner. Blame the patient. Blame the system. Blame anyone other than yourself and mistakes you may have made, otherwise you may not be able to go through the process again.Yell at or ignore anyone who spouts the line ‘Well, you want to do psychiatry, so at some level you agree with and accept that this is the process you need to go through’. Wanting to do psychiatry and wanting to do these exams are about as related to each other as the exams are to the practice of psychiatry.
Suppression
Very, very helpful if you can manage this trick. This is probably one of the most valuable things you can learn. I actually visualise pushing the thoughts down out of consciousness, which seems to work.If you are still experiencing any of the re-experiencing criteria of PTSD, try using a combination of distraction, alcohol, and sheer bloody-mindedness to block out any intrusive memories of the examination.
Rationalisation
When I sat my writtens, I had to sacrifice many things in my life in order to get through. This included seeing friends, having fun, and by extension, my happiness. When I was preparing for the clinicals – both times – I told myself I didn’t want to go back to that sort of life, and vowed that I would maintain a semblance of a normal life, as that was more important than getting through exams. Which is what I did (although my friends and family may disagree). This was not much comfort when I did fail, though.
Intellectualisation
If you can’t feel it hurting, maybe things are ok. Pick apart the system, examine all the unfair aspects.Write articles on how to get through failing the exams before you know how you’ve done (maybe I should have filed this under ‘Denial’).Plan on getting onto the committee for examinations at some point in your future so you can work to change it into a fairer system and not make future trainees have to experience this hell.Start plotting your revolution.
Altruism
Throw yourself into your work, forget about the fact that you’ll have to do exams again, and focus on what psychiatry is actually about. Remember that exams do not test your skill as a psychiatrist, they test your skill at exam technique.
Desensitisation
Alas, the time finally comes when you do have to face up to the fact that you are going to be sitting the exams again, and actually, it’s rather soon (see denial and suppression – they may have been working a bit too well). I don’t really think I came to terms with the fact that I had to do it again until I was sitting with the timer ticking in my first practice OCI, which was probably the hardest thing on the road back to preparing for exams the 2nd time around. Luckily, something clicked and I just fell back into the OCI routine like I’d never stopped doing them.
In retrospect, I don’t think I learned any new techniques during my time re-preparing for the exams, but going through the motions certainly helped to desensitise me to the process.
The Second Time
When I finally got to New Zealand, I still felt anger over the futility of a process that seems unfair, inequitable, and stupid. I felt less confident than the previous time around, mostly because I knew that no matter how much preparation I did and how ready I may be, I cannot control for bad luck, bad examiners, etc. I also felt less anxious than the previous time, probably because of my familiarity with the process. I think that my residual anger and acceptance of an arbitrary system were probably the most helpful things in getting over the whole failing episode.
What happened? In my OCI, I didn’t get the worst-case scenario patient that I had imagined – a forensic demented Maori patient with an eating disorder and an undecipherable accent – and instead got a woman from a farm with stable BPAD and maybe Parkinson’s. She was nice and seemed possibly more nervous than me; thankfully, I could connect with and talk to her as a person rather than as an ‘exam patient’. This doesn’t mean that I didn’t feel afterwards that I couldn’t have capitalised more on what seemed in retrospect an easy case. I had a road trip from Hamilton to Auckland where I could debrief with some other candidates about their horror stories to feel better. The OSCE was also fraught with unimagined perils, not the least an actor that fell asleep mid-station. Not in the sleep station, either.
What happens next? I wait for the results, and hope.
Post script – I passed. Yay! It is possible to get through the system. Now, the revolution!