Study shows women are still better at everything

Yesterday in JAMA:

We found that elderly patients receiving inpatient care from female internists had 30-day lower mortality and readmission rates compared with patients cared for by male internists. This association was consistent across a variety of conditions and across patients’ severity of illness. Taken together with previous evidence suggesting that male and female physicians may practice differently, our findings indicate that potential differences in practice patterns between male and female physicians may have important clinical implications for patient outcomes.

and

Furthermore, given that there are more than 10 million Medicare hospitalizations due to medical conditions in the United States annually and assuming that the association between sex and mortality is causal, we estimate that approximately 32 000 fewer patients would die if male physicians could achieve the same outcomes as female physicians every year.

Confirmation bias aside, this general finding does ring true to me.

Reading a bit deeper, though, one physician characteristic that was underplayed was that female physicians saw fewer patients overall (i.e. more were part-time). This might function as a proxy for burnout and its associated poor patient care outcomes. Something to consider for the men who are already in medicine and dragging it down.

When breath becomes air

I actually posted this excerpt once before, but I just finished Paul Kalanithi’s When Breath Becomes Air and was moved anew by his missive to his infant daughter:

When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.

Earlier in the book, in conversations with his oncologist about coming to terms with how to spend his life with cancer, this entreaty comes up multiple times:

Find your values.

In his moving memoir (which doesn’t at all belittle fields like radiology), Kalanithi softly and compellingly argues that this is the key to how you live like you were dying.

How to Study for the ABPN Psychiatry Boards

About the Exam

The ABPN psychiatry exam is a marathon day-long computerized multiple choice exam offered once a year with two dates in September. You can apply as early as November but deadline is February (current dates here) through the “folio” website. You won’t schedule the actual exam until scheduling is opened, usually around 2 months before the exam dates. Results take around 8-10 weeks. In 2016, scores were released on November 30 (so 10 weeks).

Eligibility (see the info document):

  • Graduate from a legit medical school
  • Have a full medical license
  • Finish residency (or be a senior on track to finish it before taking the test)
  • Complete 3 Clinical Skills Evaluations (CSE)

Costs:

  • $700 application fee when you register to tell them you’re ready
  • $1685 examination fee when you schedule the exam with Pearson VUE.

You have 7 years after finishing your ACGME residency to pass the ABPN to become board certified. So you have plenty of tries if things go south (subsequent tries “only” cost the $1685 exam fee).

Exam & Content

You get 50 minutes of break time that you can take between sections. Any breaks you take past the 50 minutes are permitted, but they then eat into your actual test time, which is 8.5 hours.

8 sections are split between Part A+B or Part C questions:

  • 110 questions in Part A (Basic Concepts in Psychiatry)
  • 110 questions in Part B (Neurology and Neurosciences)
  • 230 questions in Part C (Clinical Psychiatry).

screen-shot-2016-11-05-at-1-43-50-pm

So 8 sections of 50-65 questions each for a total of 450 questions over 510 minutes. About 20% is neurology/neuroscience. Tack on a 5-minute intro and 5-minute post-test survey and 50 minutes break time, and the whole day can take up to 9.5 hours. 4 sections are vignette based and 4 sections are pure stand-alone questions (from the format and scoring document):

Stand-alone questions are one-best-answer multiple-choice questions that are not associated with any other questions. Part A and Part B questions are all stand-alone questions. For vignette questions, there are typically two to ten multiple-choice questions linked to a common case that may be presented in a video clip, which may vary in length from one to four minutes, an audio clip, or in a text vignette.

The ABPN does provide one sample video vignette to whet your appetite.

Historically, each Part was graded separately and needed to be passed. Now the test is graded in aggregate; it’s no longer possible to fail a single section and thus fail the exam. In 2016, a 71% correct overall was the passing threshold.

And everything is now DSM-V (from the policy document):

Starting in 2017, all specifications and content of all ABPN computer-delivered examinations will be based solely on DSM-5. No DSM-IV-TM classifications and diagnostic criteria will be applicable.

Board Books

Question Banks

Board Vitals

The most popular question bank for the ABPN is Board Vitals (which also has question banks for other specialties as well). This resource is definitely not error-free, and some users feel that it contains too much esoterica, but it’s still widely used. It’s $139 for a month. Using the code BW10 at checkout also gets you 10% off (buying after clicking that link gives me a referral; if you don’t want me to get anything, then just use the coupon code without clicking the link).

Overall, questions represent the board style pretty well, and the product is a good size (1639 questions). As of 2016, BV still contains DSM-IV questions, though one imagines these will be pruned shortly. A lot of the “neuro” questions are actually psychiatry, so the neuro coverage is less than you’d guess from when you first log in. As an exclusively web-based product, there is no off-line access. You also need to hit the “show explanation” button to see the explanation for a question, which gets tiring after a while.

There is also a new optional 250 question package (actually 257) based on video vignettes available as an add-on (another $139/month), which is pricey but basically the only a la carte source for this question format currently.

TrueLearn

A new player TrueLearn, which has products for both the PRITE and the ABPN (code “benwhite” saves 10%). Questions overall feel harder and have a more basic science/med school type feel than those found in the other resources. The interface is a little more cluttered, but the software is overall solid: you can cross out answer choices and there’s also a “bottom line” summary statement, which is helpful.

Ultimately, TrueLearn is a reasonable second online question source after Board Vitals but overall probably not quite as high-yield yet. Overall, a couple of question sources are likely to be sufficient, so after Kenny & Spiegel and Board Vitals +/- more neuro review depending on your background, most test takers are probably done question-wise.

Beat the Boards

Is a $1,097 online lecture course with a ~1000 questions and ~50 vignettes. We reached out to them to provide access for this review and were totally ignored. This is really expensive and ultimately unnecessary to pass.

Book round-out:

  • Kaufman’s Clinical Neurology for Psychiatrists may be too long to read cover to cover during a limited post-work board review, but it also contains 2000 questions (extras are online) to help round out your neurology review.
  • Psychiatry Board Review: Pearls of Wisdom is a change of pace written in a concise Q&A format which was useful as an adjunct, but it’s now a bit out of date and was neither as consistent nor as thorough as the other review books. It does contain a lot of high yield facts organized in a quick-read manner but is crying out for a DSM-V update.
  • Unlike for Step 1, First Aid for the Psychiatry Boards isn’t the strongest source for psychiatry review and can be ignored. It purportedly does a passable job for neurology but remains a safe pass unless you just need to have another book.

Thanks to my awesome wife (the esteemed psychiatrist) for help in writing this post.

Best Books for Elective Rotations and Sub-internships

First, my book recommendations for the core third-year clerkships can be found here. What follows are “best” book recommendations geared for MS3/MS4 elective rotations and sub-internships (“sub-i’s”), including most of the surgical and medical subspecialties. Some of these books are geared for medical students; others more for residents. I’ve done my best to include both when appropriate, including a first buy single resource when possible and alternates and options for further reading when necessary. For more info about methodology, feel free to peruse this.

Let me preface this list by saying that a typical student on a normal rotation in a field outside their main interest does not need to buy anything. Even in a field of interest, many (most?) students will simply wait to buy books until they have a book fund during residency and will nonetheless succeed. No one has a monopoly on medicine and medical knowledge; in 2016, you don’t need to buy anything simply for your education if there isn’t an important test at the end of it.

As a general rule, you will rarely go wrong reading UpToDate for your typical brownie point efforts (particularly in non-surgical fields). As a matter of gamesmanship, you of course never say, “UpToDate says,” you merely state the information as a fact, occasionally referencing “reading” you did or “studies have shown.” It works well to click on the link to the footnote on anything you feel might net you a gold star, click on the reference, then browse the abstract. Then you could say, “a big RCT in Sweden demonstrated…” and if anyone pushes you on details you didn’t glean from the abstract, you simply say good question – I don’t recall – I’ll need to go back and look further.

It should also be said: your success on your rotations has much more to do with how you function as a human being than how many facts you know.

 

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