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Some Observations on Psychiatry Subspecialty Board Examination: Up from Complacency in Improving Psychiatric Education

Winston W. Shen,

On April 10-11, 2010, I participated as an examiner
in this year’s psychiatry subspecialty board
examination of the Taiwanese Society of
Psychiatry. Among 73 candidates taking the oral
exam, 41 passed the exam while 32 failed. The
passing rate this year is 56%, which is roughly the
same as previous years. Some candidates at some
residency training programs are happy while others
are sad. But the result is nothing new under the
sun, which will continue to rise from the east and
to set from the west.
Coming from a different clinical training
background, I have noticed the candidates’ performances
in the board exam and have expressed and
exchanged opinions with fellow examiners over
the years. Through my observations and those of
other examiners, I hope that this commentary article
can stimulate some thoughts for the psychiatrist
educators to abandon their complacency and
to do something in improving psychiatric residency
trainings in Taiwan.
Some Observations
Comparable passing criteria among the
examiners
The current oral exam format takes two examiners
to sit in and watch a 40-minute patient’s
interview by a candidate. After a 10-minute break
to let the candidate organize the case material, the
two examiners will then spend the same length of
time to listen to his/her case presentation.
Afterwards, the examiners would ask pertinent
questions concerning the case including the understanding
of diagnoses and treatments. Often,
the candidate is also quizzed with some questions
to assess his/her clinical competency. A third examiner,
so-called fl oater, would also drop in the
interview room to observe part of the oral exam.
The whole process of the oral exam is labor-intensive
for the Taiwanese Society of Psychiatry and
nerve-racking for the candidates.
The examiners basically all focus on trying
to fi nd out what the candidates know rather what
they do not know. One simple yardstick for an examiner
to pass candidates is that they need to win
the professional trust from the examiner. In other
words, the examiner would feel comfortable to refer
to the candidates a friend or a family member
who is in need of psychiatric care.
Usually the fi nal score of each examiner is
ranged between 57 to 63. My team examiners’
scores are usually comparable to mine. The scores
are rarely more than two points apart between us.
Candidates work hard for the interview
skill training
In 2008, I organized a seven-hour mini-workshop
for patients’ interview training at Taipei
Medical University-Wan Fang Medical Center. I
arranged a mock fl oater for rotating three simultaneous
mock patient’s interview, and also invited
two mock examiners to help watch chief resident’s
interview. Of 52 chief resident candidates who
participated in this workshop, several came from
Taichung and two from Kaohsiung.
Since the passing rate for psychiatry subspecialty
exam is about 50% to 60% over the years,
all candidates-to-be are anxious and would like to
take every possible opportunity to brush up their
interview skills. If an interview training takes
place at a hospital, the chief residents of the neighboring
hospitals will come to join the training.
Inter-hospital training among chief residents
has become popular in the recent years. This popularity
has evolved from endemic to pandemic
phenomenon in Taiwan. I have learned that this
year one chief resident had received about 40 patient’s
interview skill training outside his own
hospital before February 2010.
Styles of the patient interview
Over the years, I have witnessed the different
interview styles of “regional” or “institutional”
characteristics of various training programs. But
this year, this phenomenon has become less prominent,
if not strikingly similar, regardless where
the candidates have been trained. For example, in
the patient’s interview during the oral exam candidates
asked almost exactly same three things to
check for recent memory, used the same proverbs
for interpretation, recommended for hypnotics
and sleep hygiene for treating chronic sleep disturbances,
and recited “bio-psycho-social” jargons
for treatment plan. All candidates used the complicated
test of the serial substractions of seven
fi ve times to evaluate the calculation ability although
simple tests like 11+7, 5+2, 7–4, and so
forth, could have been used for the same purpose.
A typical interview in the oral exam usually
starts with gathering patient’s identifying data,
and ends with data collection in the mental status
exam in the last fi ve minutes. All interviews presented
in the exam looked as if they were based on
a semi-structured interview protocol. Although
every candidate are supposed to use the diagnostic
concept of The Diagnostic and Statistical Manual
of Mental Disorder-IV [1], I still detected the use
of non-DSM terms, such as neurotic depression,
organicity, JOMAC, “manic-depression,” etc.
Comment
The oral exam, or part two exam given by the
American Board of Psychiatry and Neurology,
Inc. in the United States, is scheduled to be abolished
by 2013 (www.ABPN.org). But this is not
what I want to address in this editorial commentary.
Instead, I am going here to focus on the issues
what our chief residents have been taught in
their residency training.
It is good to see that chief residents received
adequate interview skill trainings before taking
the exam. It is professionally benefi cial that they
received trainings from different supervisors of
various institutions. Thanks to their time and efforts,
our residents are exposed to a more comprehensive
training.
Although ICD-9 is in use at all hospital in
Taiwan for reimbursement claim from the Bureau
of National Health Insurance, DSM system [1] is
also well-accepted and practiced in most psychiatric
residency training programs. I urge my colleagues
to stick to using the DSM concept in ruling
out the diagnosis of dementia [1]. Abandoning
the concept of “JOMAC” (the source being unclear
to me), we need to teach and stress to our
trainees to practice with DSM-IV 294.1x diagnostic
criteria: A1 memory impairment, and A2 one
(or more) of the following cognitive disturbances
(aphasia, apraxia, agnosia, and executive functioning
[1, page 157].
Based on the BNHI data, Chien et al. [2] reported
that depressive/anxiety patients who received
diagnoses of DSM terms are more likely to
receive antidepressants. In their report, the antidepressant
prescription rate in Taiwan for patients
with “neurotic disease” (300) is 47.5%, for those
with “anxiety state” (300.0) 32.5%, “anxiety disorder”
(300.0 except 300.1) 30.4%, “other neurotic
disorder” (300.8) 31.2%, and “other neurotic
disease” (300.89) 27.7%. Furthermore, the antidepressant
prescription rate for patients who have
received the valid DSM diagnoses of “major depressive
disorder” (296.2 or 296.3) is 90.9%, “obsessive-
compulsive disorder” (300.3) 80.0%, and
“panic disorder” (300.01) 68.5%. To note, US
Food and Drug Administration approves the indications
of antidepressants or other psychotropic
drugs only based on DSM diagnoses. Since most
current psychiatric medications have been developed
in the US, the patients with DSM diagnoses
tend to receive more accurate medications. The
above-listed fi ndings here may also explain some
of reasons that antidepressants are under-used in
Taiwan [3].
“Manic-depression” was an idea introduced
around the 1900’s whereas the concept of “bipolar
disorder” was fi rst introduced into psychiatry in a
citation-classic article [4]. Again, the FDA only
approved psychotropic drugs for the indication of
bipolar disorder not for “manic-depression.”
Many Taiwanese psychiatrists have been unable
to adopt this new nomenclature. I also noticed that
the Taiwanese Society of Biological Psychiatry
used “manic depression” instead of “bipolar disorder”
in its offi cial spring 2010 program announcement.
This may seem like a joke to some
members. Our psychiatric trainees deserve the
most updated knowledge that the educators can
offer. To have better chance to prescribe right
medications, I am urging my colleagues to teach
correct information to our psychiatric trainees.
After all, they are the future of our Taiwanese
Society of Psychiatry.
Psychiatric diseases which carry more psychosocial
symptoms and disabilities, are still like
other medical illnesses and should be treated. as
such. Treating psychiatric illnesses are just like
treating diabetes mellitus, hypertension, osteoarthritis,
peptic ulcer, etc. and should not be compromised
under the cliché of “biopsychosocial”
intervention [5]. This message needs to clearly
pass on to our future Taiwanese psychiatrists.
Key Word
Editorial Committe, Taiwanese Journal of Psychiatry
9F-3, 22, Song-Jiang Rd., Taipei 104, Taiwan
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