I. Strategies for Part II of the American Board of Psychiatry and Neurology (ABPN) examination "The Oral Boards"

A.   The task of the clinical interview

  1. First, prove that you can listen to the patient
  2. Next, prove that you can direct the interview.
  3. Finally, never sacrifice rapport.

B. About the clinical interview

  1. Expect a degree of randomness.
  2. The examiner team shouldn't be the major random variable.
  3. The patient is a very random variable.

1.  Don't be "Dr. Robot."

  1. The patient is not a "checklist."
  2. You must make an appropriate attempt to establish rapport.
  3. Let the patient talk freely for at least 5-10 minutes.

2. Don't be "Dr. Free Association."

  1. At some point, you must start directing the interview.
  2. Use smooth transitions.
  3. In the last 15 minutes, gently try to get the patient into "short answer mode."

C. HPI: conditions to screen for

  1. Major Depressive/dysthymic disorders
  2. Bipolar disorder
  3. Psychosis
  4. Anxiety (possibly)

1. Past psychiatric history

  1. Ask about previous diagnoses.
  2. Ask about first TX and approximate number of hospitalizations.
  3. Ask about prior meds and what's worked in the past.
  4. Ask about prior suicide attempts.

2. History taking, continued

  1. "Tell me about past medical problems."
  2. Ask about allergies.
  3. Very brief review of systems.

3. Review of systems

  1. Head injury?
  2. Seizure disorder?
  3. Thyroid disorder?
  4. Risk factors for HIV? (preface this)

4. Substance abuse history

  1. ETOH (if yes, ask about DTs and AA)
  2. Illicit drugs
  3. Prescription drugs
  4. Psychiatry Review Course
  5. Tobacco
  6. Excessive caffeine
  7. Substance abuse treatment?

5. Social/developmental history

  1. Demonstrate interest in the patient as a person.
  2. Birthplace, and how was childhood.
  3. Trauma and abuse? (use caution.)
  4. Who do they live with and how do they support themselves

6. Mental Status Exam: Include the cognitive screen

  1. Has become standard practice, whether indicated or not
  2. Avoid serial 7s.
  3. Test abstraction with an easy proverb, (e.g., "the early bird").
  4. Don't forget to ask for the 3 objects again.

7. "SHSH": ask every patient about

  1. Suicide
  2. Homicide
  3. Substance abuse
  4. HIV

8.  Difficult patients

  1. Mute
  2. Acutely paranoid
  3. Floridly manic
  4. Dementia

D. Presenting your ideas

  1. Be organized
  2. Keep the HPI concise
  3. Mention things you forgot to ask
  4. Work in red flags early
  5. Never blame the patient
  6. Don't say "there wasn't enough time"
  7. Avoid unnecessary risks

1. The formulation: biopsychosocial

  1. Announcement
  2. Recap the identifying data
  3. Biological formulation & genetic factors
  4. Psychological formulation
  5. Social/axis IV factors

2. On every differential diagnosis

  1. Consider substance induced disorder
  2. Due to GMC
  3. Hint at Axis II early on, if necessary

3. The workup

  1. Establish a context of treatment
  2. Old records
  3. Current treating clinicians
  4. Physical exam
  5. Labs (must justify anything you say)
  6. CT/MRI/EEG?
  7. Psychological testing?

4.The treatment plan

  1. Again, establish a context
  2. Use a biopsychosocial approach
  3. Remember informed consent

5. The examiners

  1. Lack of nonverbal feedback
  2. Expect them to "grill" you
  3. Expect some distraction

6. Be able to discuss

  1. 12 DSM-IV diagnoses by memory
  2. The labs you would order and why
  3. At least one drug in each class in extensive detail
  4. Handling the suicidal patient
  5. Setting limits
  6. Refractory symptoms
  7. Tardive dyskinesia

Conclusion

Organizing the 30-Minute Interview

I. Purpose of the Exam

II. First 5 Minutes

III. 10 Minutes

IV. 10 Minutes

V. Last 5 Minutes = Mental Status Exam and & Cognitive Testing