One way I’ve found categorizing board exam questions helpful is to view them in a hierarchy of three levels, each one building on the previous one and requiring a more use of one’s clinical judgment. My three levels are:
Know It → Recognize It → Decide It
Now let me explain and I promise this will be practically helpful and, I believe, comforting even.
This lowest level of question relies almost exclusively on recalling some specific piece of information (some fact) that you’ve learned. It requires virtually zero judgment. With this type of question, you either know the information or you don’t.
Example Question: What is the most common heritable cause of intellectual disability?
- Fetal Alcohol Syndrome
- Fragile X Syndrome
- Prader-Willi Syndrome
- Trisomy 18
- Trisomy 21
The right answer is B Fragile X Syndrome. Trisomy 21 or Down syndrome is the most common etiology of ID but the majority (about 95%) is due to abnormal gamete formation during meiosis, leading to a gamete with a diploid chromosome 21. The zygote then ends up with three chromosomes 21. So, Trisomy 21 is a genetic (and chromosomal) disorder but in the majority of cases not due to an inherited mutation or other abnormality.
Our second level of board exam question is based on the ability to recognize one disorder or scenario over another one. It is based on knowledge of pertinent facts but requires some judgment. A common example of this type of question is a case vignette style question that asks you to choose the right diagnosis. In this style of question, you must be able to extract the pertinent information from the vignette in the context of incomplete and sometimes conflicting data.
Example Question: 33-year-old man presents to outpatient psychiatry with chief complaint of, “I believe I have stomach cancer but my doctor says, ‘it’s all in my head’ because the gastroscopy was negative. But that scope can’t see through my stomach wall, just the inside surface.” Patient denies any change in eating and appetite, and identifies no problems with digestion, elimination, or pain. He says he’s stressed at work but says, “Isn’t everybody these days?” He says he started worrying about stomach cancer after vacationing in Thailand last year and eating “a lot of super spicy food.” He says he’s convinced that “could be the reason” for developing this disease. Medical records disclose normal physical exam and lab results after extensive work-ups. What is his most likely diagnosis?
- Body dismorphic disorder
- Conversion disorder
- Somatization disorder
- Illness anxiety disorder
- Somatic symptom disorder
This is the same question I used in a previous blog post to highlight how you must be able to pick out the one or two specific pieces of information that will differentiate one disorder from another. In the case of this question, the most likely diagnoses are the somatic symptom disorders: somatic symptom disorder, conversion disorder, and illness anxiety disorder. The vignette above describes a patient with worry rumination and health care seeking but in the absence of somatic symptoms. It is this absence of somatic symptoms that is the key feature that separates illness anxiety disorder (D, the correct answer) from the other two somatic disorders, both of which are characterized by presence of somatic symptoms.
This third level of board exam question builds on 1) factual knowledge, 2) recognition of most pertinent information, but now also requires 3) deploying a high level of professional judgment. After providing a case vignette, this type of question will ask you what you are most likely to do (or to do next) in terms of evaluation or management of the patient from the options provided. Let me provide the following example.
Example Question: 39-year-old woman presents for an additional evaluation with chief complaints of continued depressive symptoms and intolerance of her current antidepressant. She reports she’s been sad, lonely, and feeling “like a loser who’s bad at relationships” after the breakup with her significant other whom she dated for three years. She found herself doing poorly at work, not keeping up with chores at home, and starting to lose weight and sleeping poorly. When she realized she was thinking a lot about killing herself, she became afraid and went to her primary care provider for help. She was started on sertraline 25mg four weeks ago but has continued to feel nauseous and “headachy” on it with no change in depressive symptoms. On follow up visit two weeks ago, her provider asked her to “give it a couple more weeks to really see if it works or not.” She has been only partially adherent and decided to get a second opinion. Based on what you’ve learned so far, what is your most likely recommendation?
- Continue sertraline 25mg qd with addition of ibuprofen and antacids as needed
- Increase sertraline to 50 mg qd with addition of ibuprofen and antacids as needed
- Decrease sertraline to 12.5 mg qd for two weeks
- Stop sertraline and start mirtazapine 15mg qhs
- Stop sertraline and start trazodone 50mg qhs
Hmmm. See what I mean? Factual knowledge is needed but not enough. Recognition of the competing problems that must be resolved is needed but not enough. To answer this question requires making a judgment call. In this type of question there is not a single right answer as in the first two levels of questions, but options that fall on a continuum of being more or less likely to lead to a positive outcome.
I believe that the best approach is D Stop sertraline and start mirtazapine. My justifications are:
- The patient is frustrated with her medication (sertraline) and has probably already decided in her mind that it is not a good medication. She is equally frustrated by her primary care provider who told her to hang in there for another couple of weeks on the same med at the same dose. So, in a perfect world, decreasing sertraline to 12.5mg qd is eminently sensible – she may be a slow metabolizer after all. But in the real world, the patient is likely to be unsatisfied with this approach. She has likely given up on the sertraline and ready to move on. (She is likely to experience continued intolerance and lack of effectiveness related to the nocebo effect.) Starting her on a new medication, whatever it is, is likely to be a positive reset in her experience with treatment and with her new provider.
- Mirtazapine has the benefit of being sedating at this lower dose and may improve her sleep. Improved sleep makes many other symptoms more manageable. Mirtazapine is also low in GI adverse effects, a category of adverse effects she’ll probably be especially attentive to and, if present, she is likely to reject the new medication as she did the previous one.
- The other three options are not very strong. To highlight the trazodone option: it is indeed sedating, but it is nearly impossible to get a patient on a therapeutic dose of 300mg-400mg qd of trazodone due to its extreme sedative effect at those dose levels.
Given that every board exam includes these “Decide It” questions, what do you do? My answer includes the following:
- Avoid driving yourself crazy by wishing the question was other than the way it is. You may be engaging in a Valsalva maneuver hoping to push out a clear fact-based answer to a judgment-based question. Ain’t gonna happen! Remember that the type of person who is drawn to becoming a physician is often a conscientious, hard-studying person who is more comfortable with problems that have clear solutions. However, treating patients in the real world is really, really messy and this is sometimes emotionally difficult to accept and deal with. And this type of board exam question injects that real-world messiness into the exam, and it is frustrating. Does this at all ring true for you? I know I have always struggled with this messiness, sometimes more successfully than at other times.
- Trust your clinical acumen. Remind yourself over and over that there is not one right response option in a sea of wrong ones. Rather the responses lie on a continuum of ones that are more or less likely to lead to effective evaluations and/or treatments. All you have within yourself to rely on is your professional judgment gained through all the knowledge you have learned and all the experiences you have had that honed that knowledge into the ability to make decisions on your patients’ behalf day in and day out. If it’s not immediately clear what the question-writer was getting at, avoid trying to figure that out. You do not want to give up deciding the right answer based on your clinical judgment by taking on guessing what the writer may have had in mind.
- Stop thinking about what else you think should be done or that you would like to do that’s not included in the response options. After reading the vignette above you may think that if you had a patient like the one described you would do something else entirely. Well, there is no “write in your own treatment plan” option on the exam. Haha. So let it go. You also may be diverted by the fact that this patient has raised the issue of “a lot” of suicidal ideation. Sure, this is important but not a focus of the present question. If this question is part of an extended vignette style question series, then perhaps evaluating or managing the suicidal ideation may come up in a later question. But again, for every question choose the best response based on your judgment from the ones you’ve been given. You can write the to the boards later to give voice to your frustration with their response options. Or let it go and take a walk instead.
Take care. All the best on your exam.
Jack Krasuski, MD