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 the 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).

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

• Psychiatry Test Preparation and Review Manual (“Kenny and Spiegel”) is the favorite overall. It was updated to DSM-V in 2016 and includes 1100 questions (6 tests of 150 questions + 160 case vignette questions). The book does come with online qbank-style access, which is cool and can give you topic-performance feedback as well as access to 8 video vignettes.
• Massachusetts General Hospital Psychiatry Update & Board Preparation, which is a review book coupled with ~400 questions. Succinct material coverage but not updated to DSV-V yet.
• Kaplan & Sadock’s Study Guide and Self-Examination Review in Psychiatry, also not updated to DSM-V yet.

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.

Overall, questions represent the board style pretty well, and the product is a good size (1639 questions). BV was completely updated to DSM-V in 2017. 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 is TrueLearn, which has products for both the PRITE and the ABPN ($25 off with that link). 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.

Rosh Review

Rosh Review is the third of the big three online qbanks, and they offer a Pass Guarantee. 10% off their certification, child and adolescent, and PRITE products with code RoshPsych10.

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.

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 this new era of medicine, 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.

Read More →

After a few years of seeing medical students on their interviews from the other side, here are a few of my favorite new considerations for dos/don’ts during your interviews (note, many of these also apply to your personal statement):

Don’t: Say negative things about other fields.

The fact that you think other fields suck is not the reason people want to hear when they ask you, “Why X?” The biggest problem with field-specific negativity is it often reveals your naivete. An applicant applying to radiology who says they didn’t go into medicine because they don’t like writing long notes and spending the day on the phone calling specialists may sound silly, because of course a radiologist spends all day dictating reports instead of notes and talking to referring clinicians on the phone. Every field has its pros and cons, and in many cases, the overlap between fields can be as substantial as it is surprising. There’s no free lunch in medicine. So stay positive.

Don’t: Spout overly familiar things with your field

You may be familiar with concept of “fourth year swagger”: the horrible disease that strikes when a student finishes their third year and, after being exposed to a few weeks of multiple different specialties, thinks they understand everything about medicine, knows all the ins and outs of various fields, and certainly isn’t just parroting the shit that other people who also don’t know what they’re talking about say to them. If you casually repeat things you read on internet forums, this goes doubly for you.

If you had the chance to interview college students applying for medical school, you may have been surprised at how clueless they are about medicine. But of course they are! And almost certainly you were as well. If you think a med school applicant who wants to do a “cardiology residency” sounds naive, then keep in mind your imperfect grasp of your chosen field. You’ve at most done a few months rotating as a student, potentially as little as none before you made your choice. You have no idea what it would actually be like to do that field day in and day out for decades. The things that excite you now will likely be routine. Other aspects that you hadn’t considered may be your passion. So while you need to articulate why you’ve chosen your field, you don’t want to come across as a know it all. Overconfidence is a vice (unless you’re a general surgeon [ba-dum-dum]).

Do: Be normal if you have an MD/PhD…

People with PhDs need to play the game of both implying future academic productivity with a seemingly earnest desire to master clinical skills and do patient care. You don’t want to fall into the trap of seeming like a scientist who views residency and patient care like an obstacle to doing their true work. Or an awkward serial killer. Or, even worse, someone who is tired of doing research.

Do: Own your problems

You just can’t be embarrassed and don’t need to be nervous. Consider the interview as your chance to see if the program is right for you and less about you auditioning for them. It doesn’t matter if you have (in no particular order) a failure, a leave of absence, a heinous evaluation, a stutter, a disfiguring condition, or a weird laugh. You need to be comfortable and happy with yourself if you want people to be comfortable with hiring you. So own it. When appropriate: offer explanations, not excuses; acknowledge everything, apologize for nothing. If you needed to get better, explain how you have and that you’re still working on it (whatever it is).

I recently came across this guide from UW that I liked that addresses this nicely.

Do: Have “questions” ready

The hardest question you’ll get on the trail very well might be “what questions do you have for me?” It’s the hardest because the real answer is none, and you’ll stop listening the moment you ask anything. Here a few of my favored BS ones to put in your arsenal, particularly helpful for later in the season when you’re tired of pretending you care what a random person thinks about anything.

• What is one thing that surprised you when you came to work here?
• Was there anything you didn’t expect between when you applied and when you started working here? (for a resident interviewer or newish faculty)
• How has this place changed over the past few years?
• Do you foresee any changes coming to the program or department in the near future?

Specific questions about the curriculum, rotations, electives, dedicated research time, etc are all great—IF they haven’t been discussed already in a presentation, aren’t in a printout in your interview folder, and aren’t readily available on the website. Asking about things people think you should know is awkward. If you do or aren’t sure, try to frame them as opinion questions (e.g. “How do you feel about the research track offering? Is there support for this dedicated time among the faculty?”).

Also consider: my thoughts on not screwing the interview process in general.

Let’s start with this premise: In the 21st century, the medical school basic science curriculum is probably best learned through guided self-study and likely not whatever your school is trying to teach you (especially if that involves the blind leading the blind via TBL). How much you can fulfill this ideal will unfortunately depend on how cooperative your school is with reality.

Read More →

Among young adults with a BMI between 25 and less than 40, the addition of a wearable technology device to a standard behavioral intervention resulted in less weight loss over 24 months. Devices that monitor and provide feedback on physical activity may not offer an advantage over standard behavioral weight loss approaches.

That’s the conclusion of a 2-year 471-participant randomized controlled trial in JAMA of how wearable tracking technology affects weight loss.

Wrinkles: Only 75% completed the study. And both groups did lose weight: 3.5 kg in the “enhanced intervention group” and 5.9 kg in the control.

One wonders if meeting your goals with a wearable might cause some people to skip working out or quit an exercise session earlier than they might otherwise do (at least on occasion). The study also didn’t use one with any of the gamification principles that some people have promoted as making exercise more “fun.”

The public apparently likes the 16-hour shift cap:

After people hear arguments both in favor and against eliminating the 16-hour shift limit, voters’ opposition holds firm at 86%, 79% strongly opposed,” she said. “Eight in 10 would support decreasing the shift limits for second-year residents from 28 hours to 16 hours as well.

These are results from a probably biased Public Citizen survey, a group that vocally opposes the FIRST and iCompare trials that are testing loosening the shift restrictions in surgery and medicine programs across the country.

What I find confusing is that the contemporary discussion always centers on whether or not shift limits are good for residents and/or for patient care. But this focus is always on the impact of shift length on acute fatigue and sleep-deprivation. Nothing about total shift burden, especially when you know that the residents in these studies aren’t magically conforming to the 80-hour rules that are frequently ignored.

I don’t know about most residents, but one imagines a physician to be a lot more likely to do okay on a long shift if (s)he weren’t chronically fatigued working 80+ hours a week. The focus on shift length I think misses the larger and probably more important issue about general overwork, burnout, and chronic fatigue. It’s like being worried about how fresh the oil is in a car without a transmission.

For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.

That is the conclusion of a paper just published in Annals of Internal Medicine.

Outpatient doctors spend at least twice as long proving they provide medical care for billing and compliance purposes as they do actually providing it. “To Err is Human” is more apt than the IOM ever realized.

MEDSKL is a new free medical education site with a much greater than average pedigree. It’s a group of 180+ physicians/professors/faculty from medical schools in the US and Canada who are promoting FOAMed (free and open access education) for medical students.

Its clinical (not basic science) focus is well-suited to third and fourth (and industrious second)-year medical students with brief animated videos, written lectures formatted in a SOAP note format for specific problems (clever), and video lectures. The handful I sampled were polished, high quality, and at a basic unintimidating level.

The educational content is all free. There are a lot of fields represented, but this is clearly a work in progress, and lots of topics have only token coverage. In the future, a paid account will net you self-assessment quizzes, which I imagine is the business model to sustain the project. There are also plans to add official CME this fall.

It’s probably a lot easier to recruit educators for clinical medicine presentations that they’re passionate about than it is to find good basic science educators, who are rare. We now have MEDSKL joining OnlineMedEd in the free clinical medicine lecture series, but no one wants to touch the boring parts of medical school (for free). Still, it’s only a matter of time until these sorts of platforms grow and mature.

I’ve long said that the non-clinical parts of the medical school could be a correspondence course. With the increasingly professional and multimodality online resources available, often for free, this is becoming more and more true. There will be a time not long in the future when the vast majority of schools will have basically nothing to offer students during the basic science years that they can’t get better somewhere else other than friends to commiserate with, a rigid schedule, and an external source of accountability. The current trend of supplanting lectures with TBL/PBL curricula isn’t going to change that one bit.

People often ask me about Step 1 corrections, particularly with regards to the Free 150 120 (for which I’ve posted explanations for several years). The data I’d come across over the years was super old.

Last month, Reddit user Waygzh posted the results of a 208 person survey (with an above average mean score of 245), which includes correlations for UWorld, the Free 150, multiple NBMEs etc.

The spreads are huge and the correlations not particularly good, but it’s the best you’re likely to get. Just don’t get discouraged if the number you see isn’t the number you want. Inspiration is better than deflation.

UPDATE: There’s now a 2017 Reddit survey available here as well.