Every year,
about 50% of ABPN II oral exam candidates fail.
Why?
Excessive
anxiety, ineffective preparation, and disorganized interview and
presentation are some causes. But is this exam really
insurmountable?
While some
candidates don’t make the grade, others have successfully used
effective strategies to pass this tough exam. What are the ways to
overcome this exhausting challenge?
Conduct an
empathic interview
Establish an
alliance immediately — during the first few seconds of contact. A
warm handshake and simple respectful gestures such as guiding the
patient to a seat should help establish a good impression. Building
rapport, however, should be maintained during the course of
interview.
Avoid a
symptom-focused interview. A real understanding of the patient
requires knowledge of psychosocial issues and ongoing concerns.
Searching for a DSM diagnosis through a rigid question checklist
signifies poor interview skills. Moreover, pursue patient’s cues. If
a patient mentions a life event or crisis, explore this area and
temporarily defer the pursuit of symptoms.
Maintain a
‘conversational’ tone during interview. Use open-ended and
close-ended questions liberally and interchangeably. Stay away from
excessive close-ended questions during the first 20
minutes.
Show empathy
generously. Offer a tissue to a tearful patient. Use empathic
statements (e.g. you’ve been
through a lot, you sound upset ) to recognize patient’s situations and
difficulties.
Organize
your history-taking and presentation
Establish a
structure during interview and presentation. Use an outline,
mnemonics, checklist, templates, and memory aids to create a coherent
performance.
Symptomatology
that can support DSM-IV criteria should be pursued. Know the
chronology of events. However, you also need to obtain adequate
information from other areas of the history, not just HPI and
PPH.
Blend the
mental status examination (MSE) into the interview. From the very
beginning, observe the patient’s affect and check for behavioral
impairment, psychomotor abnormality, and involuntary movements. Doing
so, a rigid MSE at the last phase of the interview may be
avoided.
When performing
MSE, just focus on what is important and clinically relevant. For
example, a patient complaining of memory loss may require detailed
questions on recent memory, aphasia, apraxia, agnosia, and executive
functioning. Not all patients however require cognitive
assessment.
To create a
graceful interview, use history-taking techniques such as transitions
especially when moving from one section to another. When presenting,
employ organizing tools such as pronouncements (e.g.
regarding PPH) and transitions (e.g.
subsequently ). Make your presentation short and
crisp.
Elicit
safety issues and provide appropriate
intervention
In the oral
exam, clarifying safety issue is a must. Be alert for destructive
signs such as superficial marks on the wrist. Ask for suicidal and
homicidal ideas, plan, and intention. Know history of attempts and
gestures and the circumstances behind those
behaviors.
Pursue clues
that signify potential harm. For instance, a patient may talk about
joining a dead spouse or having thoughts that life is not worth
living. Ask for more information.
Explore risk
factors such as significant psychopathology, prior attempts, family
history, substance dependence, and feelings of hopelessness, among
others.
Appropriate
intervention needs to be discussed during presentation. The level of
observation and the need for hospitalization should be determined.
For outpatient intervention, keeping away potential weapons and
mobilizing support networks are essential.
Demonstrate
diagnostic and clinical skills
During
interview and presentation, it is crucial to explore and discuss
symptomatology and relevant history that will support a diagnosis. In
other words, your diagnosis and differential diagnosis should have
supporting evidence.
Mention only
differential diagnoses that are feasible based on the clinical data.
A shotgun approach will not be perceived favorably by the
examiners.
Interventions
should utilize a biopsychosocial approach and should be specific to a
particular patient. An all-encompassing treatment approach — covering
all interventions including unrealistic ones — is a surefire way to
failure.
Manage your
time wisely
Create a
balance in obtaining adequate information. Aside from HPI and PPH,
give importance to other sections of the history. Personal, social,
family, and medical histories are just as vital. Persistently
pursuing symptoms at the expense of other critical information is not
beneficial.
Divide your
time appropriately. The first 12 to 15 minutes may be devoted to
introduction, HPI, and PPH. The remaining time should cover other
sections and MSE.
Facilitate
an adequate psychiatric assessment
Adequate
psychiatric assessment is the goal in this oral exam. “Comprehensive”
or “complete” assessment, although ideal, can’t be realistically
achieved during a 30-minute interview because this type of assessment
requires time and follow-up.
Despite the
30-minute time limit, it is still central to have a good grasp and
understanding of the patient. Relevant symptomatology, familial and
psychosocial issues, and prior illnesses and treatment should be
explored.
Through
adequate assessment you, as an oral exam candidate, should be able to
suggest individualized treatment
interventions.
In summary, the
board certification exam is an essential test of your clinical
competence. Through the above techniques, show to the examiners that
you have the necessary skills to assess, treat, and keep patients
safe.
References/Suggested Reading
Materials:
Rayel MG.
Passing Strategies: A Helpful Guide for the Psychiatry
Oral Exam. Newfoundland: Soar Dime;
2000.
Rayel MG.
Successful Preparation for the Psychiatry Oral
Exam :
How to Effectively Organize Your Interview, Oral Presentation, and
Video Exam. Newfoundland: Soar Dime; 2001.
Shea SC.
Psychiatric Interviewing: The Art of Understanding.
2nd
ed. Philadelphia, PA: WB
Saunders; 1998.
About the
Author:
Copyright©2004
Dr. Michael G. Rayel, author of Successful Preparation for the
Psychiatry Oral Exam and Passing Strategies, conducts Psychiatry Board Review for ABPN II
. He is a Diplomate of the American
Board of Psychiatry and Neurology with subspecialty certifications in
forensic and geriatric psychiatry and psychosomatic medicine. Also,
he's certified in Clinical Psychopharmacology by the American
Society of Clinical Psychopharmacology.
