Today’s post is based on a fine case summary sent in by one of our readers who shares his story for the benefit of psychiatry oral board candidates. Good news – he passed! See what lesson there are here for you.
I was sent to the VA and interviewed a married man in his early 30s who stated that he was on an inpatient PTSD unit. He was a Gulf War veteran. The pt was initially nondisclosing and almost confrontational. It took me about 15 minutes to build rapport. He would make statements like “Easy doc, I’m just getting to know you.” I backed off and let him talk initially, but I sacrificed a great deal of time to do this. He eventually opened up after I made an empathic statement when he spoke of his war-time trauma. I then began screening him for PTSD and he stated, “Are you sure that you’re not a doctor? No one has ever asked me these questions before.”
During the interview, he also may have had a flashback. (I was not peppering him with questions and stated that he need not retell traumatic details.) He asked for “a minute,” to recompose hiself which I gave him. When he was quiet, I leaned over and told him, “you’ve been through a lot.” From the remaining time, I was able to get a 4-month history of PTSD symptoms, a firearm at home, a history of 3 head traumas, a history of aggression, a history of alcohol abuse, estrangement from his father because his father does not like his wife, and a possible history of depression.
Because of limited time, I only did a cursory review of psychotic symptoms, which seemed only to reveal flashbacks and not first-rank symptoms. I did not have time to screen for mania or other anxiety spectrum disorders. I did a quick cognitive screen, which revealed nothing significant, though he did mention memory loss.
I remembered to ask about HIV, Hep B/C, and his military history. With one minute remaining, I went back and asked him if he would tell his doctor about his aggressive thoughts towards others. He agreed he’d do so and then said that if the examiners failed me, he’d come after them. He was joking and conveying that he thought I was doing a good job.
During the presentation, I focused on safety (especially aggression towrads others), PTSD, alcohol use, depression, and head trauma. During my presentation of the past psychiatric history, one of the examiners cut me off and asked me to estimate his IQ. I stated that he possibly had borderline intellectual functioning vs mild mental retardation. (I regret saying mild MR). My examiner then asked me to estimate his IQ, which I said 84, but that further neuropsychological testing is necessary. My examiner then asked me what the IQ range is for mild MR and I told him that I would have to look it up. He asked me why I though his IQ was low and I answered that the patient had a limited vocabulary and did not use complex clauses in his sentences. The examiner then moved on and asked me to present the usual things (biopsychosocial formulation, etc.) I made my differential diagnosis broad: PTSD, Mood disorders (carefully mentioning that I could not rule out a bipolar disorder-this actually elicited a nod from my stone-faced examiner!), alcohol dependence/abuse, personality changes due to head trauma, dementia/amnestic disorder due to head trauma. On Axis II, I stated a tentative diagnosis of Borderline Personality traits and Borderline Intellectual Functioning vs. Mild MR.
During the treatment questioning, I stated that I would need to gather more history from other providers, especially because he did not recall his medical history, medications, and details of the one psychiatric hospitalization. Also, that I’d order a medical workup (CBC, head CT, neuropsych teating etc.), and focus on safety. I stated that I would have him remove the firearm from his home and interview him further regarding his aggressive thoughts. I stated that he belonged on an inpatient unit until these safety concerns could be evaluated and addressed.
Then they asked me about medications with my working diagnosis of PTSD, chronic. I chose sertraline and quetiapine, stating that I would stay away from benzos and hypnotics because of his history of alcohol use. The same examiner who asked me about IQ, then asked me, “Does he have any strengths?” I stated that he had a sense of humor (the pt sassed me a few times during the interview) and seemed to have a strong relationship with his wife which could be a protective factor. They went on to ask me about countertransference issues. I presented the idealization during the interview that could make me feel overly positively towards him and the eventual possible devaluation with treatment that could leave me feeling frustrated and angry. I stated that my job would be to maintain a consistent, patient stance. I was then cut off. The other examiner then asked me “He said something about his family, what would you do about it.” I said that he was estranged from his father because of his choice to marry his wife and I stated that family therapy would be indicated so that he and his father could communicate in an assertive, nondisparaging manner. The senior examiner then stated, “I think that time is up.” There were 2 minutes remaining on my clock.
I felt bad about this whole exam because I felt flustered during the interview with the patient’s initial guardedness and then idealizing transference. I did not do an adequate review of systems, though I did state numerous times during my presentation that “I did not ask about [insert syndrome].” I’m kicking myself for the IQ response and have realized that I forgot to inquire about his education, or present it during the Q&A. I also felt as though the examiners never gave me time to do an adequate problem-intervention list for this complicated patient. I should also add that one examiner sat perpendicularly to me the whole time and picked at her nails during my entire interview and my Q&A session.
Jack’s Response
Thank you anonymous for your careful and detailed case presentation. Let me add that since you wrote me, you’ve learned that you passed your exam. Congratulations!
These are the lessons I learned from this case that I’d like to share with you.
1. Almost everyone who takes the exam feels frustrated and uncertain during and after the exam (See previous post.) I mention this to inoculate you against allowing these feelings to derail you. Just accept that when you take the exam, you’re going to be kicking yourself for messing something up. Why do I predict this? Because no one does a perfect interview and presentation. But you don’t have to! Just like this candidate, even when your performance is less than perfect (this candidate missed screening for mania, for example), you can pass – and most candidates do. I’ve even had a candidate who forgot to ask about suicide who ended up passing her exam. I don’t recommend this. Rather, I’m highlighting this fact so that you never give up even if some aspect of the exam is not going your way.
2. One very positive factor in this candidate’s interview was that he was empathic with the patient. Sure, he felt frustrated that the patient took half the interview to warm up and open up to the candidate. But he kept that frustration in check and continued to cautiously and sensitively interview the patient. He paused when necessary and communicated empathic concern at the appropriate times. One of my mottos applies here – Sometimes the best way to go fast in the interview (that is, gather a good amount of data) is to go slow. And conversely, sometimes if you try to go fast, you end up going slow. Imagine how this patient would have reacted if this candidate tried to bulldoze his way past the patient’s initial resistance or tried to pepper him with questions as he was undergoing a flashback. The patient probably would have shut down and rejected the psychiatrist, who would have been left with less information, with a defiant patient, and with examiners unhappy with the candidate’s unempathic performance.
3. The other questions that I’m sure left a positive impact on the examiners were the questions on medical history. Yes, remember to ask every patient about HIV and HEp B and C, especially veterans. If you have an examiner who practices in the VA system, they expect these questions to be asked routinely and assess a candidate negatively who doesn’t assess these areas. Also, the questions on miitary history were a crucial area of questioning with this patient.
4. My last point is that the examiners did not seem very encouraging or positive towards the candidate. The question and answer period was cut off before time was up. The one examiner was stone-faced. The other examiner kept pushing questions regarding the patient’s intellectual functioning that could have felt like they were pushing the candidate to make a mistake. Also, the candidate didn’t feel he got his footing presenting the treatment plan due to the frequent interruptions. My point is that all this happened and still the examiners passed this candidates. You should never allow yourself to get discouraged due to a negative or challenging demeanor of the examiners. Their behavior reflects their beliefs of what an examiner should act like. Very often it is not an accurate reflection of their judgment of you. Many candidates pass with stern or even mean examiners while others fail even with supportive and acknowledging examiners. So do your best to ignore ther examiners stance, facial expression, tone of voice, etc.
Today’s Quote
“Where your talents and the needs of the world cross, there lies your vocation.” – Aristotle
Jack Krasuski, MD
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