Treatment Algorithms on Board Exams

Last updated on August 9th, 2023

Medical board exams primarily test clinical knowledge. As such, questions that assess your knowledge of treatment interventions are common. There are three aspects of treatment that can be tested:

• Details of specific treatment interventions
• Treatments in specific populations and by disease variants
• Treatment algorithms

Treatment algorithms on board exams are the focus of this post. Treatment algorithms are a rank ordering of treatment interventions beginning with first-line treatments proceeding to second-, third-, and fourth-line treatments, and ending at last-line treatments at whatever level they happen to fall.

Some exam questions present a case vignette in which the patient should receive what’s considered first-line treatment and a first-line treatment intervention is available in the question’s response options.

This is an easier type of question since it only tests your knowledge of first-line treatments. This type of question would be appropriate for rare disorders where you would not be expected to show more than basic knowledge of clinical management. Alternatively, the condition could be common but usually treated by a physician from a different specialty but with an expectation that in your specialty you are expected to know the basics of that condition’s presentation, diagnostic assessment, and management. An example would be a psychiatric condition being tested on the internal medicine or family medicine boards. Or a neurologic condition being tested on psychiatry boards.

A different type of board question presents a clinical case that tests your knowledge of treatments found at lower levels of the treatment algorithms, that is, at the second, third, fourth or even lower stages. These types of questions can be structured in one of two ways.

The first approach is to have the question vignette include information that makes it clear the patient is NOT a candidate for first-line treatment. For instance, the vignette may state that the patient has an allergy to certain first-line treatment medications, has previously responded poorly to first-line treatment or has had a serious adverse reaction to a previous trial of a first-line treatment. Therefore, in the vignette, you have been provided a reason to look for treatments other than first-line treatments in the response options.

The second way an exam question can force you to choose a second-line (or lower) treatment option is by simply not providing you a first-line treatment in your list of response options. The question stem presents a straight-forward case for which you would choose a first-line treatment if you could. However, the answer options do not include a first-line treatment option. Thus, you are forced to choose the most appropriate response option from the ones included.

Example Exam Question from Psychiatry Boards

Question: A 21-year-old male college student presents with depression and intense fear and avoidance of nearly all social situations. He has failed trials of several SSRIs, venlafaxine, mirtazapine clonazepam, and propranolol. In addition to cognitive behavioral therapy, which medication would you most likely recommend to the patient?

1. Phenelzine
2. Quetiapine
3. Levothyroxine
4. Valproic acid
5. Lithium

Question Explanation

The patient in this case vignette suffers from depression and social anxiety disorder. He has had failed trials with several classes of first-line and FDA-indicated medications: several SSRIs, an SNRI, mirtazapine (an antidepressant with a more complex mechanism of action), a benzodiazepine, and a centrally-acting beta-blocker. The only FDA indicated medications for social anxiety disorder are paroxetine, sertraline, and venlafaxine XR. Out of the response options available, the medication with the most evidence of efficacy is phenelzine, a monoamine oxidase inhibitor (MAOI). Prior to the availability of SSRIs in 1985, the MAOIs were the most commonly prescribed medications for social anxiety disorder. Studies show comparable or better efficacy of MAOIs compared to SSRIs for social anxiety disorder. However, MAOIs now have been relegated to lower levels in the treatment algorithm for social anxiety and major depression due to the danger they pose in precipitating a hypertensive crisis when a diet high in tyramine, an amino acid with noradrenergic effects, is ingested.

If you need help preparing to take your board exams you can access our board review courses for psychiatry and neurology at Beat the Boards, and all other medical specialities at The Pass Machine.