25
5
Reasons for Failing
A CANDIDATE’SSTORY 25 THESAFETYFACTOR 26 THEINFORMATIONFACTOR 26
THEDIFFERENTIALDIAGNOSISFACTOR 26
LOCALIZATION OF THELESION 26 DETERMINING THETEMPORALFACTOR 26 POORPLANNING ANDTREATMENT 26 THEVARIABILITYFACTOR 27
Understanding the reasons why candidates fail is an ex- cellent way of recognizing and avoiding the most com- mon pitfalls and traps. In interviews over the years, we gathered considerable insight into this important area.
Some of the reasons are more obvious, while others are based on a global judgment by the examiners. By the same token, some candidates know they have failed as they walk out of the door, recognizing some fundamental flaw of their interview/test, while others are blissfully un- aware of where they went wrong only to be dumbfounded when the notice comes in. In the event of a failing grade, the ABPN allows the candidate to request an explanation of reason for the failure determination, for a fee of $100, but not many who made such requests feel they received a satisfactory answer.
A Candidate’s Story
Dr. CM volunteered to recount her failure to pass part 2.
I had had a good training and I felt I had kept up to date on the literature throughout the residency. I had spoken to some people who had passed them but did not find their sugges- tions very helpful. I felt I was as ready as I could ever be.
Still I was very apprehensive about it. So, in spite of all my attempts the night before the test I had little if any sleep at all. My exam started at 8:30 AM with the pediatric session.
Perhaps because of some Inderal I took before, I felt confi- dent and relaxed, in control. I calmly went through the pe- diatric vignettes and I was able to discuss each case point- edly and comprehensively. Although I was told not to rely on the examiners’ responses to my discussions, I couldn’t help but notice what I interpreted as signs of approval. I walked out of the room thinking I had passed that part.
The next test, the live patient was scheduled for 1 PM in another hospital. I spent the four hours waiting for the time pacing around nervously. The patient was an easy case of radiculopathy. I did not feel pressured by the examiner and felt I had covered all the basics. I did not know the answers
to all the questions, but I felt that I had a good shot at passing.
The adult vignette was scheduled at 4 PM at yet another hospital. After four more hours of pacing, I was feeling tired and somewhat emotionally drained. I couldn’t wait for the day to be over. From the outset, I felt the test was not going well. I felt intimidated by the examiners and thought my answers were not hitting the mark. I had the distinct percep- tion from their nonverbal communication that they did not like my performance. I think I reached the bottom when the examiners were not satisfied with my answer on the locali- zation of the lesion and although I had tried several answers they kept on asking me “Where, where?” After that I was very demoralized. I saw one of them leaving the room. I thought he did so because I had failed. The end of the exam came as a liberation. But for weeks after I obsessed about that third test, alternately blaming myself and my examiners for my dismal performance.
The candidate in this example failed the adult vignette and waited one year to repeat that single part.
This personal account can teach a few points:
1. Be prepared for a long day, although you may be luck- ier than the above candidate. During waits, do some- thing to relax and take your mind off the exam, or else you will be physically and emotionally spent before the end of the exam.
2. Avoid scanning the examiners for signs. If you feel that the examiners are tough, continue doing what you know without losing it, getting anxious, or depressed.
It will not help you.
3. Every exam has a story and a course of its own. You may be prepared, but you need to be flexible and ready to respond to unforeseen challenges.
Reasons for failing are a very important issue. In gen- eral, the examiners tend to be fair and impartial and to have solid and justified reasons for failing a candidate.
Some of the reasons for failing are described below.
26 5. Reasons for Failing
The Safety Factor
Perhaps a fundamental criterion used by the examiners in making a final decision is the determination of potential dangerousness to the patient. This domain can be divided into two categories:
1. Making dangerous decisions.
2. Not recognizing neurological emergencies.
A dangerous decision is a decision that can be life threatening for the patient. It can involve a dangerous diagnostic or therapeutic decision.
Here are some examples of dangerous diagnostic decisions:
• Performing a lumbar puncture in a patient with papil- ledema and focal signs because it may cause the risk of herniation (example, brain abscess).
• Not recognizing signs of impending spinal cord compression.
• Not recognizing impending myasthenic crisis or the difference between myasthenic and cholinergic crises.
• Not recognizing an acute cerebellar hemorrhage.
• Performing a Tensilon test without being in a special setting (Emergency Room) or without the necessary precaution (atropine sulfate has to be available due to the rare possibility of bradycardia).
Examples of dangerous therapeutic decisions include
• Giving the incorrect dose of medications to a child in status epilepticus.
• Lack of knowledge on how to treat status epilepticus.
• Giving the wrong dose of edrophonium chloride.
Obviously, not recognizing neurological life-threat- ening emergencies or being unable to intervene with the right treatment is as important as making unsafe decisions for the treatment of the patient.
The Information Factor
Another major factor in determination of failure is the information factor. An adequate fund of knowledge in clinical neurology is an essential prerequisite for taking and passing this exam.
The Board examination requires a deep and careful preparation which may require several months. This prep- aration is based on books and practice. All the major cate- gories of neurological disorders need to be refreshed in- cluding diagnostic approach and treatment. Lack of information is a very essential reason for failing. This is particularly true for certain areas such as the pediatric part when the adult neurologist is involved. Pediatric neurol- ogy must not be underestimated, particularly because many disorders are different from the ones found in the adult population and have a different treatment.
The Differential Diagnosis Factor
During the live patient examination as well as the vi- gnette, it is imperative to arrive at a sound differential diagnosis.
The perfect diagnosis is less important than a a com- prehensive, pertinent, and well-thought-out differential diagnosis that takes into consideration all the symptoms and signs elicited in the test. You should be able to sup- port every possible diagnosis with the appropriate find- ings as well as enumerate some of the diagnoses that are less likely and reasons why.
Localization of the Lesion
It is helpful to first place the signs and symptoms you have elicited though your interview into broad anatomical areas such as supratentorial, posterior fossa, spinal canal or vertebral column, peripheral neuromuscular system, or at several levels. Once the broad anatomical area is iden- tified, a more narrow, focal and side localization may be hypothesized. Examples include focal on the right or left side of the nervous system, or focal in the midline area involving both areas of the nervous system. Obviously, the level of the lesion may also be characterized as non- focal and diffuse. A question that needs to be answered is also the likely etiology of the lesion, i.e., inflammatory, vascular, neoplastic, traumatic, congenital, degenerative, or metabolic.
Determining the Temporal Factor
An essential element in the assessment of neurological signs and symptoms, as well as in the formulation of a differential diagnosis, is the temporal factor. Was the on- set of the signs/symptoms acute, subacute, or chronic?
Was the course/progression of the symptoms progressive or stepwise or chronic?
Poor Planning and Treatment
In dealing with treatment issues, there are therapies with which you need to be very familiar. This part can be a reason for failing, particularly if you do not know how to treat major illnessess such as status epilepticus or my- asthenia gravis.
There is a difference between not remembering the lat- est medication for migraine headache treatment vs. the right management of acute cord compressions. It is also better to be honest than to give the wrong numbers.
The candidate is expected to know the best diagnostic procedures for the case as well as treatment options.
The Variability Factor 27
The Variability Factor
If you are well prepared and ready to appropriately react to unforeseen situations, you are likely to pass. Candi- dates who fail once or more than once often talk about a wide range of examiners, going from the toughest to the easiest.
Dr. MC failed the test the first time and passed the second. Here is an account of his experience.
There was a huge difference between the examiners on my first exam and the second one. The first exam, the examiners seemed to react negatively to everything I said. I know they
are trained not to react but I could tell. They asked me a lot of details which may or may not have been of consequence.
I also felt I was interrupted too many times.
The second time it was like night and day. They seemed to nod, never stopped me, and shook my hand like they meant it as I left. I knew I had passed.
While there could be a degree of variability in human nature, there is limited value in fixating yourself on how supposedly supportive the examiners are. The best idea is not to let your perception of the examiners influence your performance as it could cost you the exam. Just stay the course and do what you have trained for three years to do.
