As of 1 September 2008
[Recall questions are available at the bottom at this introduction.]
In studying for the Boards, this site offers some general recommendations and provides some recall questions to help candidates. While Part I and the recertification examination require recognition, the oral Boards have the higher cognitive hurdle of requiring recall, not just recognition. Furthermore, it seems less like a waste of time to be studying recall, as clinical work requires recall in our clinical decisions and in explaining the disorders to patients and their families. So, we have provided some PowerPoints to practice recalling clinical psychiatric material at this site infra. Written examinations
For the written Part I examination, reviewing recent PRITE questions, American College’s PIPE, and APA’s Focus questions will be quite helpful. You should know Kaufman’s book on neurology for psychiatrists thoroughly.
For the recertification exams, you will find that the questions are clinical. The American College’s PIPE and APA’s Focus questions are about the same level of difficulty as the recertification questions. At this time, passing the recertification exam requires that you answer two-thirds of the 200 questions correctly, a cut off point that is attained by almost all candidates.
While the Part I and Recertification exams only require recognition, you still may want to do the recall questions at this site infra, since recall questions will be more useful to you in your practice. Oral examination:
For the oral exams, in addition to the live-patient-interview hour, you will be presented with four vignettes for 15 minutes each. Two examiners will grade you independently from 1 to 8 points. For the vignettes, there will be set questions established in advance. This increases the standardization of the oral exams and this change has apparently increased the percentage of candidates who are passing the examinations.
[You many have heard that the ABP&N is going to abolish the live-pt hour. That is in the future, probably beginning in 2010, so pt interview will be part of the exam of those completing their residency in this decade.]
Two books are valuable in preparing for the oral Boards:
1. Morrison and Munoz’s BOARDING TIME. All your peers will have read it. So should you. It contains many useful suggestions. Reading this book will decrease your chances of developing performance anxiety at the oral Boards.
2. Michael G. Rayel’s PASSING STRATEGIES. Overlaps with the Morrison and Munoz’s book, and its way of presenting material may be of use to you.
Some key points to remember in preparing for Part 2, the oral Boards. I. Keep in mind that you are preparing yourself emotionally and cognitvely. Performance anxiety is a frequent reason people fail. Thus, it is essential for most of us to have had some Board-like examinations in advance. Be sure that those examining you stay close to the Board’s format, and that they not be too tender. You want to feel you are ready, and feeling you are ready will be markedly enhanced if you’ve already had challenging Board-like experiences.
“Disorganized” is a common word on the documents of those who failed, a result of performance anxiety. Some of us become disorganized when the examiners are silent, e.g., “Tell us your case summary, your differential, your diagnosis, and your treatment plan,” and then wait and wait as you talk and talk. You want to be able to give the findings, dx, differential, and psychiatric management without prompts. On the other hand, you may have examiners who are very active, even interrupting your effort to describe your findings many times with, “What did you think of her tremor?,” – and so forth. With either type of examiners, you do not want to become disorganized. Obtain experiences with both styles.
In these practice sessions, If the pt agrees, audio tape the sessions. Listening to tapes of your mock Board examinations is an excellent way to address your denial of problems.
You will get feed-back from your Mock Board examiners as to how you could improve your performance. While all of the suggestions are likely to have merit, you should go with what you are comfortable. Many different styles have passed the Boards. The closer the mock Board examination is to zero day, the less it makes sense to try to change your style. II. It helps some to have one anchor point during the orals. A useful anchor is to keep thinking, “I am a safe psychiatrist.” To pass the orals, brilliance is not required. To pass the orals, being charismatic is not required. What is required is that you are safe. Being a safe psychiatrist includes:
A. Being a safe psychiatrist, you make the pt comfortable so that you can obtain the maximum amount of information during the 30 minutes.
B. Being a safe psychiatrist, your evaluation and your psychiatric management fully addresses pt’s risks to self and pt’s risk to others.
C. Being a safe psychiatrist, you know a lot of clinical psychiatry, you know what you don’t know, and you know what to do to obtain the information you do not know. D. Being a safe psychiatrist, during the oral examinations interview of the pt, you avoid any reflections to the pt as to the pt’s dx or treatment. You do NOT intrude even faintly into the pt’s relationship with her/his treatment team. You do NOT make comments to the pt like, “Your psychiatrist’s choice of lithium seem wise.”
E. Being a safe psychiatrist, you approach your evaluation and psychiatric management comprehensively, i.e., both are approach with a biopsychosocial breadth. A common phrase written on the evaluation sheets on failed examinations is something like “premature closure.” While you do not want to dodge the examiner’s questions, you might preface your answer with, “first I would obtain a liver profile and then probably select . . “ or “first, I would like to have the family’s prospective before diagnosing the pt Bipolar II, but that would likely be my dx because . . . [as you know, confirmation from another person is expected to make the dx of Bipolar II]. F. Being a safe psychiatrist, in your psychiatric management, you include the treatment choices you are familiar with. If you frequently prescribe sertraline and rarely prescribe paroxetine in your practice, then, if possible, select sertraline for your psychiatric management, as you will be much better prepared to handle follow-up questions. II.In preparing for the written or orals, the two books that have the officially correct information are DSM-IV-TR and the APA Practice Guidelines. While Sadock and Kaplan, Tasman and First, Hales and Yudofsky, and so forth are excellent, you want to begin with DSM-IV-TR and the Practice Guidelines. While DSM-IV and DSM-IV-TR have the same criteria for diagnosing, you will want to study the TR as the text in some chapters was far more considered in the TR version [some of DSM-IV was rushed] -- and more current. The Practice Guideline Compendium’s thousand-plus page book is impractical for most of us, so study the 300 page Practice Guideline QUICK REFERENCE. III. What Disorders to focus on? Go with the common, not the zebras. The Disorders addressed in the Practice Guideline QUICK REFERENCE cover the pts you are likely to have to address on orals. Some Disorders are especially likely, e.g., many a pt is likely to have alcohol abuse or dependence as a secondary dx, if not the primary. [Substance abuse and dependent pts commonly volunteer to be examined.] If you can’t talk for at least ten minutes about the psychiatric management [management includes evaluations and monitoring] of alcohol-related disorders, you are not trying hard to pass the orals. IV. Style issues. How to conduct the examination raises several common questions:
A.Attitude. Assume you are taking this exam to assure the examiners that you are a safe psychiatrist. You are not there to play games. Assume that the examiners want to pass you, and you will help them understand that you are competent and caring psychiatrist. Repeat: Assume that the examiners want to pass you – they do. Playing games with the examiners is a mistake. B. Writing notes during the exam? Go with what you are used to. Heavy note takers have passed. Those who take no notes have passed. Most candidates are light note takers. What is important is that the note taking not slow up the examination. Whatever you decide, practice and practice, including, if possible, using the same style in your clinical work so that your clinical work overlaps with your preparing for the orals. C.Presentation of material. Practice providing findings, diagnosis, differential, and psychiatric management that are well organized and lack editorial side comments. OK to say periodically on important material a comment like, “if there were more time, I would have asked about family history of mental illness,” and such. But don’t throw “if I had more time …” into every other sentence. The term “psychiatric management” may help you keep in mind that you want to include evaluations and use of other disciplines in the treatment plan.
D.Advice from others. As you talk to others and as you do mock boards, you will get advice. Keep in mind that many different styles have passed the boards. Agreeing to some advice may pull you from your usual style and increase your anxiety. Best to agree to recommendations that increase your being a safe psychiatrist, but accepting all suggestions may pull you in too many directions. V. Intense Approach. The following approach is suggested for anyone wanting to make an intense approach to preparing for the oral Boards. You should prepare yourself for an oral exam by practicing presenting material orally. Reading books and articles are helpful, but Part II is not a reading test. It is an oral test. Taking multiple choice exams is helpful, but Part II is not a multiple choice test. It is an oral test. So, what to do?
The following ten step approach should help prepare you for both the content and the anxiety of the oral exams. First, write on a card each common psychiatric disorder that is included in the APA Practice Guidelines, a separate card for each Disorder that you are prepared to be tested on. Eventually you will want a card for every APA Practice Guideline Disorder, but beginning with just a few should be very helpful. Second, obtain a tape recorder.
Third, shuffle the cards with the blank sides facing you. Fourth, turn on the tape recorder, select a card, turn it over and decide which pt with that dx that you know will be this oral practice exam pt. Don’t worry if there are facts that you don’t recall. For example, say you turn over “OCD.” Describe the last pt you saw with OCD as best you can recall not worrying about missing details, but keep the presentation well organized regardless of the lacunae. Fifth, present the pt just as you hope to do on the oral exam. Keep the information close to the level of what you would write or dictate into a medical record. When you come to that part of your outline that you don’t recall the facts, simply say, for example, “I don’t recall her education level,” or “I don’t recall the results of my memory testing of him. Sixth, still talking to the tape recorder, give the differential dx and your bottom line choices, explaining your choice/s [most pts have more than one Disorder]. Can give this in Multiaxial format if you want. State a formulation that includes bio [family hx of mental disorder, medical issues, etc.], psycho [dynamic, interpersonal or cognitive issues, etc] and social [setting, family, cultural, spiritual, etc.] Seventh, still talking to the recorder, state the psychiatric management. Because you are a safe psychiatrist, psychiatric management includes evaluations as well as treatment. Because you are a safe psychiatrist, you often include other disciplines or family in the care and treatment. Because you are a safe psychiatrist, the psychiatric management addresses risks to self or others as a high priority in the management. Discuss what factors lead to the choice of this or that psychotherapy, and describe the psychotherapy. Describe the group psychotherapy’s focus for this pt if that is to be used. Discuss what factors lead to this or that medication choice. If the pt has a second disorder, weave the management of the second with the first [integrated approach is usually recommended for pts with more than one dx.]. Explicate what you will do if your first approach is only partially successfully, what you will do if your initial management is totally unsuccessful. Eight, thank yourself for taking this exam – and reward yourself with a dessert or drink. Ninth, in listening to the tape, time the psychiatric management part. If less than ten minutes, you are probably not being as thorough as you will want to be for the oral exam. I say “ten minutes” because Board examiners try to give the last ten minutes to the psychiatric management.
In listening to the tape, are your responses well organized and clear to a person who has never met the pt? Do you think the recording strongly suggest that you are a safe psychiatrist, one able to present material well and have a thorough knowledge of clinical psychiatry?.
Obviously the more often you do this and the broader your number of cards of common Disorders, the better. When a card is turned over with a dx that you’ve done before, select a different pt you know with that dx. Again, it is not essential you remember a great deal about the pt. Each pt with the same dx will have some differences that will force you to alter the psychiatric management some – fine pre-Board experiences.
VI. The exam day. Several points, most obvious:
A. Professional appearance and dress. B. Have an opened package of tissues in your pocket/pocketbook. The pt may need them. You may need them. An examiner may need them. C. Keep the caffeine and medication levels at those levels you have already experienced. This is not a day to experiment. D. Use the Board’s transportation to the test site. You need no additional worries. E. If you find out the day before the location of the exam, and if you want to do some last minute reviews, focus on the obvious, such as VA setting is likely to have PTSD issues [but watch out that this doesn’t lead you to make premature closure]. F. When they call your name and the name of the examiners, if you personally know one of the examiners, let them know of the conflict. This happens all the time and they can quickly make the change in examiners, so you are not being a trouble-maker in pointing out the conflict. G. Don’t expect the examiners to be very social as you walk with the examiners to the examining room. They are not suppose to get to know anything about you, to preserve their neutrality, So you will not have an opportunity to tell them that you worked at NIMH, climbed Mount Everest, and so forth. It is OK to clarify if the examiners are going to tell you when there are five minutes left in the examination of the pt. H. When you get to the room, arrange the seating the way you think will work best. Keep in mind that some others will be coming in briefly besides the two examiners [the others don’t grade you – they are checking on the examiners]. These others don’t want to be noticed, so arrange the room to where they will not trip over the pt on interring the room. When they do inter, don’t notice them. I. Once your interview begins, avoid looking at the examiners. First, they don’t want to be noticed. Second, the less you look at the examiners, the less likely the pt will focus on them rather than you. J. Begin by clarifying if the pt understands the purpose of this examination. While the pt has been told the purpose, don’t assume they know. Besides, even if they have been told, you may need to prepare them as to the purpose and any additional points you want to make. Some candidates point out in advance that since there is only 30 minutes, there may be interruptions. Be sure to thank. While some candidates rush this part of the exam, take your time as these early minutes will be the most important as to establishing rapport. Use “Mr. Sanchez,” “Miss. Stein,” Mrs. Patel,” etc., not first names. Work on rapport throughout the interview. At the end of the exam, thank again. K. While the biopsychosocial approach means everything is important, for you there are two priorities: 1] Clarifying the present illnesses [most often, more than one Disorder] and 2] clarifying the risks. L. Don’t be shy about asking the pt about his/her diagnoses and treatment. M. Use the full thirty minutes. Letting the pt go early opens you to “premature closure.” N. At the end of the 30 minutes, all you have to do is thank the pt again. The examiners will escort the pt out of the room. O. If the pt insists on leaving early, try persuading him/her to stay. If that fails, you can still pass the exam. Just be prepared for questions as to your thinking as to why the pt left. Part of his/her illness? A topic came up about which the pt couldn’t bear to talk? You offended the pt? Transference issues? A thorough critique that is not defensive can impress the examiners. A safe psychiatrist still can stay relevant under stressful circumstances. Many a candidate has passed the orals even though the pt walked out. P. Examiners sometimes try for a ten minutes of reviewing the findings, ten minutes for dx and differential, and ten minutes of psychiatric management, but often more than ten minutes is spent on treatment, less on the others. Q. If you are on a roll and get interrupted by the examiners, don’t be upset. Being interrupted usually means that they have included you know that topic and want to explore another aspect of your knowledge. Repeat: Being interrupted is probably a good sign. R. If the examiners are digging into a topic and getting beyond your knowledge about a topic, a few “I don’t know” will probably move them to switch to a topic about which you are more informed. For example, if you don’t do ECT and know little beyond its indications and cautions, after they have exhausted what you know about ECT, an “I don’t know” or two should achieve a change of topic. Many a candidate has passed with a number of “I don’t knows.” OK to add where you would obtain that information: “I don’t know and would have to check the PDR.” S. Be sure the “I don’t know” doesn’t sound like you think the question is not important. Agree or not, your attitude is that all of the examiner’s questions are very important. T. At the end of the examination, give the examiners your written notes if you have written anything. That will emphasize that even under this high-stress circumstance, you remembered this detail.
