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1
General Information
THECANDIDATE 3
PRESENTINGYOURSELF 3 THEDAYYOUARRIVE 4 THEEXAMINERS 4
STRUCTURE OF THEEXAMININGTEAM 4 TRAINING OFEXAMINERS 4
HOWEXAMINERSPLAN FOR THESESSION 4 GRADING 5
YOURINTERACTION WITH THEEXAMINERS 5 THEANXIETYFACTOR 6
HINTS FORDEALING WITHANXIETY 6 INFORMATION ON THEBOARD 6
Passing part 2 of the Neurology Board Exam depends on a variety of factors, circumstances and players. While it is true that one cannot control all the variables of this complex equation, it is possible to maximize the chances of success by becoming conversant with these variables and by acquiring the skills and attitudes appropriate to the task. The best preparation on books and clinical prac- tice remains a necessary condition for passing, yet it may be a sadly insufficient one if it is not matched by a savvy understanding of the process. Candidates who come to the exam with a meticulous preparation on the players, the flow, and the overall choreography of the test are more likely to be able to deal with any unexpected circum- stances and, at times, even turn obstacles or surprises to their advantage. Similarly to any tests, there are dos and don’ts, shoulds and musts. There is also the impondera- ble, the unexpected, the variable, for which there is no control. In spite of this inevitable uncertainty, the process has rules, some written, others unwritten, that give the exam an internal consistency and an overall fairness. We begin by looking at this process and its rules, illustrating along the way major pitfalls, misconceptions, errors to avoid, and suggestions that may help you make a favor- able impression on the examiners.
The Candidate
Presenting Yourself
Presenting yourself appropriately is important for the out- come of the exam. First impressions may not “make you or break you” but, if they are favorable, they will certainly help you. Since you do not have much time to prove your competence, projecting a professional image is an oppor- tunity, however slight, likely to help your cause. In some ways this process is very much like a job interview. As in most job interviews, you will not have much time to make a good impression and errors will cost you dearly.
Ask yourself: “Would your hire someone whose image does not meet professional standards?” The examiners are people who have never seen you before and will probably never see you again. Therefore, you have only one chance to affect the way they think about you. Here are some hints:
1. Dress appropriately, with business attire: Business suit with tie for men; business suit or appropriate dress for women.
2. Follow acceptable standards of grooming and hygiene;
be neat in your appearance.
3. Be professional without being too formal, and cordial without being overly friendly. This may be hard at a time when anxiety may affect your every expression, but the rule of thumb should be: Do not overdo it and do not try too hard. Discretion and moderation should be your guide.
4. Be aware of your signs of nonverbal communication, such as posture or involuntary movements. Poise will go a long way toward projecting a confident image.
Overall you should try to present yourself as you would at your office with your patients and their families—
professional, balanced, in control and able to tolerate the uncertainty and stress, without letting them affect your clinical judgment.
Good planning will maximize your chances of arriving for the exam sharp and focused instead of emotionally and physically drained. By the time you get to the Board, you have taken so many exams you may well be an ex- pert. But this test is different and unique in so many ways.
Therefore, you need to be extra careful on how you pre- pare for it from beginning to end. For example, if you are flying across time zones, make sure that you allow plenty of time to counteract any potential jet leg. There are no reasons to get anxious about having to fly across the country for your exam if you take the necessary precau- tions. Get abundant rest for several nights leading up to the exam, especially the night before. Do not overeat or drink alcohol in the days before the test. Do not “cram”
4 1. General Information
the night before. What little information you will retain will not offset the effects that the loss of sleep will have on your performance. It is better to go to sleep at your regular time, making sure that you have taken the appro- priate steps to wake up on time the next morning. In ad- dition to setting an alarm, arrange to have a wake-up call, or for someone to wake you up. All the knowledge and preparation will not help you if you get to the exam burned out, overwhelmed and out of focus.
The Day You Arrive
You will get to your hotel the day before the test. After checking in, your next step is to proceed to the registra- tion area, where you will receive a packet containing all the instructions on part 2, including a booklet, timetable, location of the exam, bus schedule, and name of the team leader who will administer your exam. It is absolutely essential that you familiarize yourself with the hotel’s lay- out, and the place and time of departure of the buses.
Although private transportation is certainly an option, it is less advisable than the official transportation, which is very efficient and certain to get to the destination on time.
A general orientation will go over the details and logis- tics. Once you have taken care of registration and orien- tation you will have some time before you have dinner and retire. Spending the evening in the hotel lobby may not be the best idea. Examiners and examinees are ac- commodated in the same hotel. Therefore, it is likely to see examiners in the hotel lobby. They are easily recog- nizable for their red and white badges. It is best to avoid socialization between examiners and examinees, to avoid uncomfortable situations and any possible appearance of impropriety.
If you hook up with some colleagues for dinner, it is better to avoid the topic of the exam as much as possible.
Beware of the anxiety-inducing doomsayers and obses- sional types who may significantly reduce your chances of getting a good night’s sleep.
The Examiners
Structure of the Examining Team
Since you will be evaluated by a team comprised of sev- eral people, it may be helpful to understand how this team is formed and which function each team person has. The American Board of Psychiatry and Neurology (ABPN) has a highly structured higherarchy consisting of eight teams headed by a Board Director.
The team leader works with four senior examiners who have considerable experience, sit in several exams at a time, and help settle scoring controversies between the two examiners, should they arise. The director himself may join the seniors during the evaluation to give the
examiners his attendance card and to assess the examin- ers. The exams themselves are administered by two ex- aminers. Primary examiners are volunteers who have requested to be examiners and submitted their qualifica- tions. In addition to their qualifications, examiners are selected for geographic criteria, which allows the Board to save on expenses. Examiners are paid a per diem and their expenses are reimbursed.
Training of Examiners
New examiners and old ones who have not examined for two years or more are trained the day before for half a day by experienced examiners and sometimes directors.
During such training, examiners are instructed in detail about specific elements of the exams, minimum require- ments for a passing grade, examples of conditional scores, and attitude to keep during the exam. Tapes and mock exams can also be part of the training. Fairness to the applicant in the examining process and its evaluation is stressed and examiners are taught to keep a neutral attitude throughout the experience to avoid giving can- didates a false impression about their performance. Pit- falls are discussed: lecturing or teaching is discouraged, as is giving feedback to the candidate.
The examiners are also taught not to be hostile, sar- castic, or condescending, and not to dwell on what the candidate does not know. They are directed not to ask only questions pertaining to their area of expertise. Fi- nally, they are reminded to be mindful of the anxiety fac- tor during the examination, both on their approach to the candidate and to the grading.
How Examiners Plan for the Session
The two examiners agree in advance on who should take the lead in asking questions. Though often only a silent observer, the second examiner may ask questions as well.
The Board takes great care to assure the highest standard of fairness during the exam. To that end, new examiners are coupled with more seasoned ones the during their first experience as examiners. Examiners are also given the opportunity of experiencing different partners as they are systematically rotated in their pairings during the two days of the exam. To further ensure unbiased and fair test conditions, examiners must report to the team leader the names of candidates they personally know. Similarly, in- formation about the candidate’s background and educa- tional institution are purposely kept out of the process, again to avoid any undue influence on the course of the exam and evaluation.
In preparation for the exam, examiners spend a few hours going over the vignettes and discussing signs, symptoms, localization, and differential diagnosis, ensur-
ing consensus on what the candidate will be expected to know.
Grading
The grading system is based on a form that contains grades on subcategories and a preliminary overall grade.
Depending upon the importance the Board gives to each subcategory, the grading varies from pass/fail to pass/
conditional/fail. The preliminary overall grade is pass- conditional or fail except when a candidate returns for one part only, when the choice is pass or fail. At the end of the grading conducted individually by each examiner, the two exchange their preliminary grading and after a brief discussion they attempt to come to a consensus grad- ing. The condition grading can be upgraded to pass de- pending upon the discussion between the examiners about strengths and deficiencies of the candidate. The process is repeated for each of the three neurology tests, after which a final grade is given.
The criteria upon which the grading is based for the live patient test are the subcategories of
• Eliciting data and technique of the examination.
• Organization and presentation of data.
• Phenomenology, diagnosis, differential diagnosis and prognosis.
• Etiologic, pathogenic, and therapeutic issues.
For the vignette test and the child neurology case the first two categories above are replaced by the subcategory of observation of data. Otherewise, the subcategories are similar.
For each of the three tests, at the end of subcategory grading, the examiners give a grade of pass, conditional, or fail.
Examiners are instructed to give an overall evaluation of “pass” when, in their judgment, the candidate has shown to possess the minimum standards of neurological competence. “Conditional” is the grade by which the ex- aminers express doubts or reservations about the candi- date’s performance/competence, precluding a pass grade.
“High conditional” is closer to pass, while “low condi- tional” is closer to fail. A grade of “fail” in any of the three tests means that the candidate needs to repeat the failed part or parts.
The preliminary grading should reflect the subcatego- ries. When there is wide difference on the grading by the two examiners, the senior examiner tries to have them arrive at a consensus grade. If consensus is not reached, the case is taken up by the director. The combination of one pass and one conditional is usually upgraded to a pass. Two conditionals are considered on the candidate’s individual merits/deficiencies. A conditional/fail combi- nation rarely gets converted to a pass.
By and large, however, strong disagreement among the examiners is rare. The senior examiners and directors base their final determination on clearly written evalua- tions with specific examples of deficiencies and assets.
Because of this laborious process as well as the possibility that the candidate may appeal the final decision, exam- iners are told to be very careful and specific in their notes supporting their grades.
Your Interaction with the Examiners
During the first 30 minutes of the live patient examination your interaction with the examiners will be minimal.
There may be examiners in and out of the room. Even though you may find that distracting, you need to make a conscious effort to ignore that process, as it is a normal occurrence in all the exams. In rare circumstances, the examiner will intervene to redirect a stalling process be- cause the patient might not cooperate or the candidate might have crippling difficulties leading him to a dead end. Your interaction with the examiner will start when you present the case and your findings, and will peak during the 15-minute section with questions.
There are no hard and fast rules on how to interact with examiners, mostly because examiners themselves, like candidates, are different, have different styles and different views. However, there are some general rules which may maximize your chances of making a good impression:
• Be respectful.
• Be formal and professional. Excessive informality may sway your examiners in a negative fashion.
• Avoid sarcasm and arrogance.
• Listen carefully to their interventions/questions.
• Never interrupt the examiner in the middle of a sentence.
• Never argue with the examiners. Even if you disagree with some of the questions or the way an examiner redirects you, you should never lose your cool, get testy, or challenge the examiner. This is a cardinal rule to which there is virtually no exception.
• Do not split between the examiners. If you feel that one examiner is fairer than the other, act equally with both of them.
• Do not patronize/teach or correct an examiner (Ex- ample: “What you are saying is only partially true.”).
• Excessive confidence is not advisable (Example: “I know that, of course.”).
• If there is something you do not know, it is better to acknowledge it than to make it up: “I am sorry, but I don’t remember. I will go back to the books and review it.”
• If a question is not clear it is better to ask for clarifi- cation or repetition of the question than to give the wrong answer.
6 1. General Information
• Do not volunteer information that is not of conse- quence in the case, it may open a Pandora’s box and you may end up grilled with all kinds of questions.
• If there is something you missed in your interview/
clinical examination because of lack of time or because you simply missed it, admit it or acknowledge it. Your examiners do not have any way of telling whether you did not think about it, did not know it, or did not have a chance to elicit it.
• If you think your examiners are too tough, do not lose your composure; stay the course, it will benefit you in the long run.
• If you feel you are not doing too well, do not fall apart;
pull yourself together and do the best you can.
• Do not try to guess what the examiners are thinking; it will distract you and it will never help you.
• If you are looking for signs of approval, forget it. The examiners are trained to control them as much as they can.
The Anxiety Factor
The Board is the culmination of your training, what you have been working on for the past three years, perhaps longer. It provides the indication of what you know and how you present yourself professionally. Passing it con- fers affirmation of your work, study, and sacrifice; the prospect of a rewarding career; and recognition by your colleagues and mentors. In essence, it represents the clo- sure of an important chapter of your career and the be- ginning of a new exciting one.
Conversely, failing the Board could be a blow to your self-esteem and a harsh judgment of the way you trained and studied. Failing the Board means more studying and financial sacrifices, forgetting about job offers for Board- certified neurologists only and the embarrassing feeling of telling your colleagues and supervisors about it. No wonder this is one of the most anxiety-provoking expe- riences of your life. Mishandled or excessive anxiety is also one of the main reasons why people fail the Board.
Since anxiety does so many things to your cognition, in- cluding hampering your concentration and memory, it is important to recognize its effects on your performance and to take the appropriate steps to minimize its conse- quences. On the other hand, anxiety my be useful in chan- neling productive energy in the right direction and gear- ing up for what is coming. In other words, lack of anxiety and overconfidence may hurt you as much as being overanxious.
How anxious are you? You should have a good under- standing about anxiety symptoms and how they affect your performance. Some people have good insight into how anxious they are and how anxiety affects their per- formance while others lack this awareness. A history of
somatic symptoms, such as palpitation, excessive sweat- ing, breathing irregularities, and restlessness, during pre- vious exams or public performances should alert you to the possibility that excessive anxiety may affect your performance.
Hints for Dealing with Anxiety
As stated before, do not expect signs of approval or feed- back from the examiners because they are instructed not to provide any. As much as it is not in human nature to ignore nonverbal signs in significant and emotionally charged interactions, remembering this simple fact throughout the exam should automatically decrease your anxiety.
Practice, practice, practice. Oral vignettes and exami- nations of live patients are invaluable reducers of anxiety as they build self-confidence and reduce the chances of error during the real exam. Seek out anxiety-provoking vignettes and discuss with examiners you do not know and ask them to zero in on your weaknesses.
Behavioral modification, biofeedback, and relaxation/
visualization techniques teach you ways to keep your anxiety in check.
Do not use alcohol, or benzodiazepines as they may considerably impair your cognition as well as your performance.
If you are unable to control your anxiety, propanolol is the most effective and safest choice. Taken appropri- ately (20–40 mg 45–90 minutes prior to the the anxiety- provoking situation), this drug acts on the physiological part of anxiety while keeping the psychological compo- nent intact. It is also wise to try its effects on yourself before the test. Propanolol may make a huge difference in your performance but it should be taken wisely, with- out exaggerating. High doses of Inderal may hamper your ability to adequately perform.
It also important to mention here that the Board dis- courages the use of any anxiety-controlling drug or substance.
Information on the Board
Any neurologist in training who has gotten this far will have plenty of information and more or less accurate news about part 2 of the Board. Although the ABPN also offers certification in child neurology and a double cer- tification in psychiatry and neurology, we will deal only with the adult neurology certification. The ABPN itself is the best source of information. Its staff is professional and courteous and they will be more than happy to pro- vide you with all the details you need, including the in- formation booklet that contains all the essential infor- mation about the exam.
The Board itself is undergoing a massive process of
transformation dictated by a need to keep up with chang- ing times. Therefore, one of the advantages of contacting the Board directly would be to have up-to-date informa- tion on recent changes.
The Board website www.abpn.org is well designed and exhaustive in dealing with the major questions and an- swers a prospective candidate might have. What follows is a summary of some of the most basic information a candidate needs.
Board eligibility—Although the Board does not use the term eligible, most applicants and prospective employers still do. The Board determines whether a candidate is ad- missible to take the examination based on requirements for certification. The four most important requirements are:
1. Graduation from an accredited medical school in the United States or Canada. For International Medical Graduates the requirement is graduation from a medi- cal school listed by the World Health Organization.
Accredited Doctor of Osteopathy schools leading to a D.O. degree are included.
2. Possession of a current license to practice medicine in a state, commonwealth, or territory of the United States or Canada.
3. Completion of neurology training in a program ac- credited by the Accreditation Council for Graduate Medical Education(ACGME), or by the Royal College of Physicians and Surgeons of Canada. The candidate may have the option of four years in neurology resi- dency or a combination of a postgraduate year followed by three years in neurology. In the latter case, an in- ternship year in medicine is acceptable. Alternatively,
an internship year with at least six months of medicine and less than two months in neurology also meets the Board’s qualifications
4. Pass Parts 1 (written) and 2 (oral) of the certification examination.
Transferring residents should have completed a mini- mum of two years of neurology in the same program to qualify. Exceptions are considered on an individual basis depending upon the type of rotations and appropriate documentation by the Training Director
While there is no limit to the number of times a can- didate can apply for part 1 (written) of the exam, some limitations apply to part 2 (oral). A candidate who has passed part 1 has six years or three attempts (whichever comes first) to pass part 2. If six years pass or three at- tempts have been unsuccessful, the candidate is required to retake part 1. Since April 2000, unexcused absences count as one of the three chances to take the exam.
Depending upon space availability, the Board tries to schedule part 2 of the examination within one year of the passing of part 1.
Certificates issued after October 1, 1994, are valid for 10 years. Another exam is required prior to the expiration date to renew certification for 10 more years.
A detailed compendium of information about require- ments and procedures, including applications forms, can be found in the Information for Applicants booklet which can be obtained from the Board or from its website.
Further info may be requested from
American Board of Psychiatry and Neurology, Inc.
500 Lake Cook Road, Suite 335 Deerfield, Ill 60015-5249
