Treatment Interventions on Board Exams

It’s not a secret that board exams test your knowledge of the details of the myriad treatment interventions used in treating patients. In addition to knowing the circumstances of when to choose a particular intervention over another (discussed in other posts), you are expected to know the details of each specific treatment intervention. Thus, the question that arises for the exam taker is “just how much detail about treatment interventions do I need to know?”

Each field of medicine has treatment interventions that are administered by only a subset of practitioners in that field or, alternatively, patients are referred to other specialists to administer these procedures. For the purposes of the board exam, you are assumed to be an average and general practitioner in your specialty. Given this, what are you expected to know about treatment interventions you may not yourself administer?

One touchstone to help you gauge the level of knowledge needed is to base it on what you would need to know in order to obtain informed consent from a patient. If you are the physician who is recommending a procedure, either as part of the work-up or treatment, and yet are not the physician administering that procedure, you nevertheless need to know enough about it to obtain the initial informed consent for that procedure from your patient. These are examples of facts you should know:

• The main concept behind the procedure. How the procedure is known or theorized to help establish a diagnosis or treat the condition. What the effects of the procedure are on the body.
• What the risks and benefits are of the procedure.
• What alternative procedures or treatment interventions are available and what their risks and benefits are.
• What the risks and benefits are of no treatment (which is always an alternative).

Here are some examples:

• Neurologist needs to know the indications for, and general procedures and interpretation of, findings of electromyographic studies.
• General surgeon who is not a breast cancer specialist needs to know the risks, benefits, and general procedures of lumpectomies versus mastectomies for various forms of breast cancer.
• Psychiatrist who refers a patient for electroconvulsive therapy (ECT) needs to know indications, general procedures, and the risks (including death) and benefits of ECT.

Example from Psychiatry: What Do You Need to Know about ECT

On the psychiatry boards, a general psychiatrist is expected to know the following about ECT and can be expected to see between 1-3 multiple choice questions on the topic of ECT.

• Disorders with an indication for ECT:
  • Common indications: depression, mania, psychosis
  • Rare indications: neuroleptic malignant syndrome, unresponsive severe Parkinsonism (akinetic-mutism), uncontrolled epileptic seizures

• Indications for ECT:
  • Failed medication trials
  • Patient preference
  • Previous good response to ECT
  • Severe depression placing patient at acute risk of suicide, dehydration or malnutrition
  • Catatonic features
  • Mania in the context of pregnancy (since several anti-manic agents confer high risk for congenital malformations)
• Main concepts of ECT treatment
  • Patient needs extensive informed consent
  • Patient needs to be NPO midnight prior to procedure (to minimize risk of aspiration)
  • Patient is placed under general anesthesia for procedure (with an induction agent)
  • Patient receives “muscle relaxant” such as succinylcholine
  • Patient receives assisted ventilation during time of muscle paralysis
  • An electrical current is passed through the brain to induce a seizure
  • Seizure activity should last between about 25-120 seconds
  • If seizure lasts longer than 120 seconds, it should be aborted with IV anticonvulsant
  • Seizure activity is monitored with EEG and by cutting off circulation to one leg prior to injection with succinylcholine, thus, preventing paralysis in one limb to give a visual cue of tonic-clonic seizure activity
  • A bilateral generalized seizure is required for effectiveness
  • Usually 12-20 individual treatments are required, that are given 2-3 times a week
  • As soon as ECT stops, patient will begin to relapse and continuation treatment is required, either with medications or with maintenance ECT
  • ECT is presumed to provide benefit because of massive releases of neurotransmitters from neurons during seizures, including of serotonin, norepinephrine, and dopamine
• Contraindications
  • Note there are no absolute contraindications, only relative ones
  • Cardiovascular system
    • Recent MI (risk of re-infarction during ECT due to blood pressure fluctuations)
    • Uncompensated congestive heart failure
    • Severe cardiac valve disease
    • Aneurysms and vascular malformations
  • Central nervous system
    • Increased intracranial pressure
    • Recent cerebral infarction
  • Pulmonary
    • Severe COPD or pneumonia
  • Potential Adverse Effects
    • Death at a rate of between 1 in 10,000 and 1 in 50,000 ECT applications
    • Myocardial infarction and stroke precipitated with fluctuations in vital signs. ECT often causes tachycardia and hypertension followed by bradycardia and hypotension. (These fluctuations are related to discharges predominantly of the sympathetic nervous system initially quickly followed by the parasympathetic nervous system)
    • Prolonged apnea, usually as a result of pseudocholinesterase deficiency. Examinee needs to know that this adverse effect, if it were to occur, should be managed through assisted ventilation until normal breathing returns. And if the patient has a known deficiency, then alternative paralyzing agents are available.
    • Post-ictal agitation that can be monitored and controlled behaviorally if mild or with a benzodiazepine or antipsychotic if moderate to severe
    • Cognitive impairment is common. Patient usually recovers from post-ictal confusion in a matter of minutes to hours. Long term memory deficits and deficits in other cognitive spheres can last for months as they slowly resolve. There is no evidence that ECT causes brain damage or permanent cognitive deficits.

This may seem like an exhaustive list. However, if you are a psychiatrist who administers ECT, you would know much more as exemplified by the following list. Knowledge about the items below would not be required for a general psychiatry board exam, however.

• The different induction agents used and which ones increase or decrease seizure thresholds
• The electrical parameters of the stimulus: energy settings and wave forms
• Placement of leads and differences in seizure parameters that need to be observed between bilateral and unilateral lead placement
• Medications and their doses for aborting a seizure
• Detailed understanding of managing adverse effects, including which medications can be used, at what dose and with which timing

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