Board Certification in a medical specialty is in essence the 'stamp of approval' of a doctor's competence to practice medicine. In most states a doctor can practice medicine without completing a full residency, but such work is limited to urgent care centers or other clinics where there is no need to declare a specialty. In order to call one's self a psychiatrist, a medical school graduate must satisfactorily complete an accredited residency in psychiatry. A psychiatrist who has completed residency is assumed to be competent to practice, but most physicians and some patients recognize that the person who graduated last in his residency is still called a psychiatrist. If a psychiatrist wishes to be considered a true expert in the field, Board Certification is required.

The Psychiatry Board examination process is quite thorough. Candidates for Board Certification must first complete a residency in psychiatry, a process that usually takes a total of four years. The candidate is then eligible for Part I of the exam which consists of a day-long test that covers topics in psychiatry, psychology, neuroscience, and neurology. The test is difficult, and requires a great deal of study for most candidates. The reward for successful passing of the Part I exam is the ability to sit for Part II, the Oral Boards in Psychiatry.

The psychiatry oral boards consist of two parts. The first part consists of an interview of a real patient under the scrutiny of two examiners followed by the candidate presenting the case, coming to a multi-axial diagnosis and treatment plan, and answering questions about the patient and related psychiatric issues. The second part of the oral exam consists of four patient vignettes that are either written or on video; the candidate reads or watches the vignettes in the company of an examiner, and then answers a series of questions about the patients portrayed in the vignettes. During both halves of the oral exam the successful candidate must make an impression on the examiners in several spheres: he/she must appear professional, must be organized, must know the material, and finally must be able to think and formulate while at the same time being observed and feeling anxious.

Passing the oral portion of the psychiatry board exam is as much about performance as it is about knowledge. This is not a criticism of the exam, as being a good psychiatrist involves more than knowing facts. If Board Certification is to mean something, psychiatrists who obtain that distinction should be able to interact with other physicians using effective organizational and communicative skills, present themselves to the public in a professional manner, and have the ability to educate patients clearly and succinctly.

That said, I recognize the challenge facing physicians who are taking the boards in their second language or struggling with performance anxiety. The exam goes by very quickly on the day of the exam; if a person has any problems there is little if any chance to recover and make it up on the rest of the exam. In fact if a person has problems with one part of the exam, I recommend that he/she do all in their power to forget about it and move on as the next part of the exam will be with a different examiner who will judge the candidate anew.

How to prepare for the performance factor? Like everything else—Practice! I think the most effective technique is rarely used— a person should consider videotaping himself presenting a case, and then watch the tape to identify all of the little nervous tics that take away from the performance. A person can learn a great deal using this technique—not just for the boards. I learned for example that I am a bit 'hyperbody' when I am nervous, and my hand and arm movements likely reduce my ability to put psychotherapy patients at ease. Behaviors identified in this manner CAN be changed... with PRACTICE.

The knowledge aspect of the part II exam can be approached in similar fashion-- confidence is enhanced when the candidate has a sense of truly knowing the material. But how can the candidate hope to cover all of the material from a residency in preparation for the exam? For Part II, the primary task at hand is to diagnose the psychiatric condition of patients in multiple settings, and to provide a differential diagnosis for the patients as well. There are other details of course related to treatment issues, but the foundation of the exam is diagnosis. If the candidate has a thorough understanding of the system for classifying mental illness, i.e. the DSM criteria for diagnosis, he/she will be miles ahead. For example, during the patient interview portion of the exam, the candidate with a solid understanding of the diagnostic criteria will be able to assign a diagnosis to the patient with relative ease; and when the examiners ask, 'why do you think that is the diagnosis', the candidate will answer with confidence.

For my own exams, as I pondered the best way to study I realized that during both halves of the exam I would be called on to talk about how different symptoms are assimilated into psychiatric diagnoses. I knew that I would become confused; for different diagnoses there are different lengths of time, different numbers of individual criteria, different exclusionary criteria, etc, and if I got nervous all of the criteria would start to jumble together. I realized that if I really knew the criteria themselves-- the building blocks of psychiatric diagnosis-- the other parts of the exam would fall into place.

I turned out to be right; I found that during the day-long exam I had ample opportunity to demonstrate my knowledge, and being able to recall the criteria in an automatic fashion made me appear professional and knowledgeable. Moreover having the criteria in mind and at the ready—knowing that I would be able to come up with the diagnostic criteria even when I was 'on stage'—eliminated that internal voice that otherwise would have made my voice shake and my mouth go dry. I was able to portray a sense of confidence throughout the exam.

I am now Board Certified in Psychiatry, thanks to a large part to practicing my performance, and to a greater part from knowing the criteria for diagnosis down cold. I find the knowledge of the criteria helpful even now, as I assign diagnoses to patients I see in my solo practice. I wish you the best as you prepare for your own Part II Exam in Psychiatry.