In adherence with the anesthesia board re-certification process and maintenance of my medical license, I've been taking an online, self-study continuing medical education (CME) exam. In all honesty, I've been avoiding it for the last six months. Since the 30 hours of credit expire on December 31, 2012, and I've already paid $300 for the exam, I figured I may as well suck it up and get 'er done over the holidays. The questions range from absurdly easy ones like this (the answer is "Duh!"):
Which of the following is most likely to occur in rhabdomyolysis?
- Metabolic alkalosis
to redonkulously obscure ones like this (eliciting a head-scratching, hair-twisting "Huh?!"):
In which of the following situations would a paired t-test be the MOST appropriate statistical test?
- Determining the neurologic outcome (graded as "intact," "neurologic compromise," or "dead") in patients with subarachnoid hemorrhage due to intracranial aneurysm
- The presence of headache following donation of autologous blood in 50 subjects, each of whom donates 2 units of blood--once with a fluid bolus and once without
- Heart rate change from baseline measured in the same individual given neostigmine with glycopyrrolate
- Blood pressure changes with propofol versus thiopental for induction of anesthesia in 1000 patients
To obtain CME credit, I had to answer all 100 questions correctly. As much as I'd like to say I got them all right on my first attempt, I had to go back and reset the responses on more than just a few, after taking time to read through the scholarly discussion provided with each question. The discussions are actually pretty awesome. For me, doing lots of practice tests is the smartest way to study for a written exam. It's no secret that exams don't exclusively test knowledge: they measure how well you take a test. By studying a multitude of questions and answers, you gain an understanding of how they're structured, and even if you don't know the answer off the top of your head, you can usually eliminate at least two choices based on wording alone. "Always, " "only," and "never" are pretty reliable red flags. When you've got it narrowed down to two choices, but you're still unsure, an educated guess will typically produce the correct response. Wrong answers are usually A) the result of not reading the question or answers thoroughly OR reading too much into them, B) a knowledge deficit, C) failure to apply existing knowledge logically, or D) ignoring gut feelings and changing your original answer. Never change an answer unless you're absolutely sure you got it wrong! If you happen to guess wrong, the discussions provide a brief review of the basic science or clinical pathways involved, walking you through a dissection of each scenario so you can determine for yourself why there is only one BEST response. Before I'm even halfway through a discussion, it's already evident why the correct answer is cut and dried.
After finally getting through the exam, I re-read the questions, and the answers seemed so simple and straightforward. None of the material was new to me: I've seen it all before. In fact, I knew it all like the back of my hand when I took my initial written and oral boards in 2006, so it's more like assimilated information that's on hiatus...gone, but not forgotten, absorbed and committed to what I consider an even loftier level of knowledge: intuition. Much of my decision-making in anesthesia practice has its basis in what feels right, which is also how I live my life. I've never been one of those who can recite studies or regurgitate factoids when I'm being pimped onstage, which is probably why I despise the Socratic method of teaching. Real life patients and scenarios aren't textbook. Rarely (if ever) cut and dried, an evolving situation is nuanced, complex, and dynamic in nature, and it won't stand still while you're busy crunching data. Relying solely on logic and reason is myopic at best, eliminating the very real possibility that sometimes, shit just happens. That's when you just have to trust your gut and act accordingly.
What is it that we think we know and how do we know we know it? Where exactly do we get all of our facts? Aren't there things we know just because--instinctual, intuitive knowledge that defies explanation or justification? Is something spontaneous and fundamental lost in translation when we know that we know, when we start thinking about thinking? In continuity with the universe, we beat our own hearts and breathe our own breaths. We don't have to think about these processes, we just automatically do them: they are central to our existence. It's only when we start thinking about these things that we feel anxious. Self-awareness leaves us wondering if there's something we've missed, ignoring the obvious because we're driven to complicate what's basic and simple, effectively permitting minutiae to supersede experience itself. Does how and why we breathe really matter as long as we're spontaneously breathing? Can all questions be answered at a molecular level, and do our answers always warrant a defense? Although the mechanics and physiology of automaticity have been fully elucidated, they still fail to explain the basic question: what is it that makes our hearts beat in the first place? Why isn't "because we're alive" enough of an answer? It's when "just because" becomes unacceptable that we separate ourselves from nature, and become dispassionate observers, victimized by existence, instead of engaged participants who are too busy enjoying now to worry about what's going to happen next. Here's the thing. I am my body and my body is me. I'm marvelously self-contained, a symptom of nature, a unique expression of the cosmos. I am my existence, not a victim of it. I am just because.