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.regardingPPH) 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.