The American Board of Internal Medicine compels us internists to take a 6-hour multiple-choice Maintenance of Certification exam every 10 years. I, by an accident of birth year (being old), am one of the few doctors who have had to take “the Boards” three times—in 1994, 2004 & 2014. The exam tests our knowledge of 500 diseases that we haven’t seen in the 10 years since we last had to take the exam. It’s kind of like a college reunion: a chance to catch up with old friends.
I was given a test date of May 5, 2014. My New Year’s resolution to read 10.41 pages per day for 125 days for a total of 1301 pages never really got off the ground, and so with two weeks to go before the test, I opened the first of my eleven Medical Knowledge Self-Effacement Program XVIII books. I thought I’d start off with one of my weaker organ systems, and so I opened “Pulmonary & Critical Care Medicine” and began to read:
Cryptogenic Organizing Pneumonia
Cryptogenic organizing pneumonia (formerly called idiopathic bronchiolitis obliterans organizing pneumonia) is a rare, idiopathic lung disease with the relatively nonspecific histopathologic correlate of organizing pneumonia.
Nonspecific Interstitial Pneumonia
Nonspecific interstitial pneumonia is a rare idiopathic disorder that shares many clinical features with idiopathic pulmonary fibrosis.
Idiopathic Pulmonary Fibrosis
The lung biopsy in idiopathic pulmonary fibrosis shows usual interstitial pneumonia. However, the pattern of usual interstitial pneumonia is not specific for idiopathic pulmonary fibrosis.
Although I could hardly wait to use this knowledge for the benefit of my patients at my next Primary Care Clinic session, I fell into a deep, nonspecific sleep.
I find myself in a darkened gymnasium. There are tables, a mirror ball, a keg of beer, and a band playing cover tunes. One wall is covered with photographs of microscope slides and unfortunate people with hideous, grotesque rashes. A big banner reads…
WELCOME BACK, CLASS OF 1994!
AMERICAN COLLEGE OF ESOTERIC & ABSTRUSE MEDICAL KNOWLEDGE
An ACEAMK worker at the registration desk tells me, “Place your right hand in the Advanced Integrated Cogent Automated Palm Identification System scanner.”
A crowd of 500 is milling around the gym. Everyone is wearing a nametag, but the tags have all flipped over on their clips so that only the blank side is showing. As I wander over to the keg I overhear snippets of conversation.
“Diastolic Dysfunction was my maiden name. Now I go by Heart Failure With Preserved Ejection Fraction.”
“I’ve changed my name, too. I used to be Reiter’s Syndrome, now I’m Reactive Arthritis. I think it has a nicer ring, actually.”
“So what have you been up to?”
“Oh, not too much. Some minor infestations, a little consulting work. Last summer I infected 19 Cub Scouts in a hot tub at a jamboree—that was great! But there’s just not all that much of it. To tell you the truth, I’m pretty much retired.”
A man walks up to me, looks me in the eye, and says, “Well if it isn’t Michael Tanner! How have you been?”
“I’m sorry. I’m terrible at names. You’re a triad, right?”
“Actually, I’m a pentad.”
“Give me a hint.”
“I’m also known as Crow-Fukase syndrome, Takatsuki disease, or PEP syndrome.”
“Sorry, I’m still drawing a blank.”
“Okay, let me spell it out for you: Polyneuropathy, Organomegaly, Endocrinopathy, M-protein, and Skin abnormalities.”
“No, my good man. HELLP would be Hemolysis, Elevated Liver enzymes, and Low Platelet count. She’s over there by the keg. I’m POEMS.”
“Wow, I haven’t seen you since…since I studied for the test 10 years ago.”
“I’m incredibly rare.”
And a bit stuck up, I think to myself, but don’t say it.
I realize that I’m striking out here. I’m a terrible mingler. I recognize no one. After 10 minutes of standing by myself pretending that it’s perfectly fine to be standing by myself, I manage to strike up a conversation with an attractive, slightly familiar young woman. After the requisite pleasantries, however, I am totally at a loss for what to say next.
“So! Are you sexually transmitted?”
“Droplet spread!” she snaps, striding away. Story of my life: open mouth, insert foot.
Suddenly everything goes black. Someone is covering my eyes from behind me.
“Guess who!” says a female voice.
I love “Guess who!” It’s such an aggressive, sexy maneuver. I gently remove the palms from my eyes and turn around to see a slightly crazed young woman wearing a nurse’s uniform, heavy makeup, and a retro hairstyle. She is sweating profusely.
“I know you!” I say for the first time that evening. “You’re the mentally unhinged nurse with severe hypoglycemia who abuses diabetes pills! You never miss a reunion, do you?”
“Nope. But I always do try to switch it up. In ’92 I was into abusing synthetic thyroid hormone—Synthroid® 400 mikes a day.”
“My question is designed to test the examinee’s ability to detect factitious disorder, Münchausen syndrome, intentional overdose, all that kooky stuff.”
“It’s so nice to finally see a familiar face. O crazed, glyburide-abusing nurse, will you be my Sybil, my guide through this Underworld of Abstruse Maladies?”
“If you’ll be my Aeneas.”
Before you know it, we’re slow dancing to “My Girl.”
I whisper into her ear, “Honey, you’re clammy, confused, and tachycardic. We need to get some calories into you–stat.”
En route to the punch bowl we pass a table of snarky people who smirk as we go by. “Don’t look now,” Sybil says, “but there they are: the Diagnoses of Exclusion.”
I’ve always hated the Diagnoses of Exclusion: Fever of Unknown Origin, Hysterical Syncope, Chronic Fatigue Syndrome, and the worst of the lot, Fibromyalgia. Too cool to have a diagnostic gold standard. At the 2004 reunion they all disappeared into the bathroom together and came out giggling.
We come upon an unfortunate fellow who is coughing his lungs out. Sybil offers him some punch.
“So what do you do for a living?” I ask.
“I print Bibles,” he replies between paroxysms.
“Hey, that’s a clinical entity! Let me just check your nametag.”
As soon as I flip his name tag (which indeed reads “BIBLE PRINTER’S LUNG”), I feel powerful hands gripping my upper arms.
“Doctor Tanner, you need to come with us. The American College of Esoteric & Abstruse Medical Knowledge has a zero tolerance policy for academic dishonesty.”
When they snap my number 2 pencils in half, I lose it. “The ACEAMK is nothing but a bunch of unarmed bandits! How about giving paying members a vote instead of piling on more of those stupid Practice Improvement Modules? This nightmare cost me $1650!
TO WHOM ARE YOU ACCOUNTABLE?!”
I feel a big needle jab my left buttock. That was the Ativan 2. Then another needle on the right. That was the Haldol 5.
As they pull me from Sybil’s arms and drag me away I cry out to her, “Any study tips for the big test?”
“Forget about reading the text! Just do the questions!”
I awakened. The MKSEP XVIII was lying on my chest. I opened it and read the first sentence on page 894.
Lymphangioleiomyomatosis is a rare progressive cystic lung disease occurring in women in their 20s & 30s as a sporadic disorder or in conjunction with tuberous sclerosis.
Resolving to remain on the lookout in clinic for the lymphangioleiomyomatosis-tuberous sclerosis combo, I got it together, studied really hard for the last two weeks, and passed.
I’ll even reveal my score, esoterically: 10 to the 2.72 power.
To sign the “ABIM Should Recall the Recent Changes to Maintenance of Certification” petition online (now over 16,000 signatures), visit: www.petitionbuzz.com/petitions/recallmoc
Dr. Michael Tanner is the Executive Editor, Clinical Correlations