Education Lessons Nonfiction Observations

The Oral Exam (I).

A psychiatrist on Twitter recently asked me if I could share a series of posts I had written in the past about the psychiatry oral board exam.

Here’s my answer.

The series was originally written in May 2009. May it be helpful to psychiatrists who are finishing their training. May it be amusing and perhaps illuminating to the general public who wonder what “board certified” means.

(P.S. Original content will come soon. In the past few months, I have experienced notable shifts in life change units according to the Holmes and Rahe stress scale. Thank you for your patience.)

As medical students, we had all heard about “board exams”. By the time we graduated from medical school, we had already taken two medical licensing exams (the USMLE). As interns, we began to hear about the specific board exams for our chosen specialty. However, most of us didn’t expend too much mental energy about the specialty board exam, as we still had to take the third medical licensing exam.

The board exam in psychiatry involves two parts: a written exam (multiple choice questions on a computer) and an oral exam. Residents take the written exam in the last year of their residency—literally days before the end of their training—and, upon passing, are then eligible to sit for the oral exam the following year.

Most people feel some anxiety about the written exam, as with most standardized exams that represent hurdles one must hop over (doesn’t have to be a graceful leap with a silent finish; you just have to get over the dang thing) before advancing to The Next Stage. By the time the written exam comes around, though, people know how these events go: we had all taken numerous exams and filled in thousands upon thousands of bubbles, whether by pencil, pen, or the click of a mouse.

The oral exam, though, is something else completely. There’s a lot of lore about the oral exam in psychiatry and it just freaks everyone out.

To be clear, not every single specialty has an oral exam. My understanding is that family practice, internal medicine, and pathology do not have oral exams. Those physicians fill in a lot of bubbles and BAM—they’re board certified.

Radiology, surgery, anesthesiology, psychiatry, and neurology have oral exams. (These are not comprehensive lists. These lists tell you more about the physicians I know and talk with.)

You can imagine that some people feel some mild bitterness about this.

This is the current (NB: “current” means “as of 2009”) structure of the oral board exam in psychiatry. It occurs in two parts:

(1) The trainee interviews an actual patient for 30 minutes. Two examiners (who know nothing more about the patient than the trainee) observe this interview. In the following 30 minutes, the two examiners ask the trainee questions about diagnosis, treatment, prognosis, and any other issues they deem pertinent.

(2) The trainee rotates through four “stations”, with 12 minutes at each station. At three of the stations, there is a written patient vignette that one examiner gives to the trainee. The examiner then asks questions about diagnosis or treatment related to the vignette. The fourth station features a video clip of a patient interview. As with the written vignettes, the examiner asks the trainee questions related to diagnosis and treatment.

The ultimate goal is to eliminate the live patient interview and use vignettes only. I believe the live patient interview will be phased out in three or four years. This shift is due to the highly variable nature of the live patient interview. No two patients are the same and this lack of reliability across trainees is problematic. Though the live patient interview allows the trainee to showcase her interviewing/empathic/”I come across as a nice person” skills, it does not necessarily offer opportunities to demonstrate sufficient knowledge of the field. Does that make sense?

Please also note that DSM-V is scheduled to come out in 2012 (NB: this has been pushed back to May 2013). You can imagine that some of the current trainees feel some mild bitterness about the changes in this examination system. (Really, I’m not one of them.)

The reason why people get totally freaked out about the oral exam is because we hear so many horror stories about the experience. And if they’re not horror stories, they’re tales of discomfort.

  • “My patient was partially deaf and blind and I had to shout at him the whole time.”
  • “My patient kept telling me that I wasn’t making sense and telling the examiners to fail me.”
  • “My patient wouldn’t talk.”
  • “My patient just got up in the middle of the interview and left.”
  • “My examiners kept interrupting me and they sounded really sarcastic.”
  • “My examiners kept frowning at me and asking me if I was sure about my answers.”
  • “One of my examiners looked like he was going to laugh at me during my entire presentation.”
  • “One of my examiners asked totally obscure questions about which chromosomes are involved in this disorder.”
  • “One of my examiners wanted me to discuss the history and evolution of understanding of schizophrenia in Portugal during the Industrial Revolution.”

You get my point.

We’re told, of course, that examiners are instructed to keep completely straight faces. They’re not supposed to smile, nod, or offer any signs of any encouragement. They’re supposed to be bland. We’re not supposed to gauge our performances on their facial expressions, style of questioning, or anything else.

(Never mind that SO MUCH of human interaction lies in these non-verbal cues. This is exactly why some people don’t like speaking with psychoanalysts—if there’s nothing there, some people find it unsettling and not therapeutic.)

I had the good fortune of training in a residency program that went through “mock oral board exams” annually (which apparently isn’t the norm, as I have learned this year in my fellowship). And, as a resident, it was unnerving to go through that practice, particularly if your mock examiner was, say, the chair of the department or the training director. No one wants to look like an untherapeutic idiot in front of the boss.

There is some comfort in knowing, though, that the actual oral exam won’t happen for a while. “I have time to prepare for that,” we muse. “I have to get through the written part first.”

Well, time passes.

I took my oral board exam in early April (2009). To prepare for it, I did the following:

  • made flashcards (yes, I’m analog like that) of most of the diagnoses in DSM-IV-TR, but not the adolescent stuff, and went through them a lot
  • read through all of the APA practice guidelines
  • read through a study guide dedicated for the oral board exam
  • underwent five mock interviews with attendings and patients who were obliging enough to help me study and improve

I embarked on all of this about five months prior to my exam date.

My other preparations included:

  • making arrangements to NOT stay at the hotel that the American Board of Psychiatry and Neurology claimed as “home base” (because I didn’t want to spend time with a whole bunch of anxious neurologists and psychiatrists)
  • making plans to meet up with friends from residency and go out for a leisurely, quiet dinner the night prior to the exam (this was undoubtedly the highlight of the weekend)
  • bringing along The Beau for company and laughter
  • utilizing all of my healthy, effective coping strategies to reduce my anxiety (as opposed to eating a whole lot of cookies)

After checking my luggage three times to make sure I had everything (“Registration slip? Check. Suit? Check. Pad of paper and pen? Check. Water bottle? Check. Novel to read while waiting? Check. Sense of humor? Check.”), I hopped onto a Bolt Bus early Saturday morning outside of Penn Station. Four hours later, The Beau and I walked through the streets of Chinatown in the bright sunlight and cool air. We were in Boston.

“It’s really clean here… and where are all the people?” I mused.