Psychiatry Miniboard

Each rotation culminates in an NBME (National Board of Medical Examiners) miniboard exam, so that we can be somewhat standardized (you know, so people can't open up their own Billy Bob's School of Medicine and start churning out inadequate doctors.)

This is a useful outline that the NBME provides to help you figure out how much weight each subject carries on the exam for each discipline, and includes a few sample questions. Here's the psych miniboard outline:

• General Principles - 5-10%
• Promoting Health and Health Maintenance - 1-5%
• Understanding Mechanisms of Disease - 10-15%
• Mental disorders usually first diagnosed in infancy, childhood, or adolescence - 5-10%
• Substance-related disorders - 5-10%
• Schizophrenia and other psychotic disorders - 5-10%
• Mood disorders - 5-10%
• Anxiety disorders - 5-10%
• Somatoform disorders - 1-5%
• Other disorders/conditions - 5-10% (this probably includes personality disorders, because there was some of that)
• Applying Principles of Management - 20-25%
• Diseases of the Nervous System and Special Senses - 10-15%

The NBME also exists to be the bane of medical students' existence (I picture them all to look like Mr. Burns from the Simpsons - sitting around being animated, rubbing their palms together and going, "Yesssssss ...") The psychiatry miniboard, incidentally, wasn't bad at all. Other than reading a little throughout the rotation for our every-other-week quizzes, and doing further reading about a few major patients that I wrote up, I only studied hard(ish) for a day or two. I am a compulsive book-buyer, and I used Lange Psychiatry Q&A 9th edition, Blueprints Psychiatry, and First Aid for the Psychiatry Clerkship. I don't think there was anything that I couldn't answer by using these books, had I studied a little more (I looked up items that I didn't know later. As Christy says, I may be the only person on earth who studies more AFTER the exam that I do before it. Heh.)

Most rotations require a score at the 11th percentile to pass the exam (except OBGYN, which I think is 22nd percentile, and Family Medicine, which is somewhere around the 5th percentile because it includes surgery and OB questions, which are separate rotations that the student may or may not have had yet. The Family Medicine department gives its own exam in addition to the NBME one.)

So, I really liked psychiatry. Not just because the hours were really good or because the material wasn't beat-your-head-against-the-wall hard, but because it was interesting. I had a great group of fellow students to work with, too. I'm going to miss them when I start Internal Medicine tomorrow! I'm thinking of doing some time in psych as an elective next year, because no matter what your specialty is, you're going to deal with psychiatric patients and psychopharmacology. I would like to actually have a little extra training (seeing how I'm planning on a primary care residency) instead of just giving my patients whatever antidepressant that is written on my ink pen! (Not that primary care providers do that - I'm not insinuating that.)

A hairy situation

One of the most interesting cases that I saw during my psych rotation (which, by the way, ended on Friday with the NBME miniboard*) was a pediatric patient who presented with abdominal pain and an episode of vomiting. Some sort of scan (not sure if it was a CT or MRI) revealed a mass that was about the size of two footballs, which could be easily felt when palpating the abdomen. The size could be estimated by percussing and by using the scratch test, too.

When they figured out what it was, they consulted us in our psychiatry dungeon (psych & behavioral health is in the basement of the hospital.) It was HAIR. The patient's scalp had a few bald spots, and questioning revealed that she was pulling out her hair and chewing on it. Rapunzel syndrome at its finest. They told us about bezoars (glorified human hairballs) in GI pathology last year, and then followed up by telling us that we'd never ever see one. The surgeon that removed this patient's bezoar hadn't seen one. And the images that were taken after surgery were amazing - the patient's stomach was so full of hair that the bezoar looked like a cast of a stomach made of hair after it was removed. Her intestines had to be scoped 70 feet to remove all of the strands.

I went on a consult with the child psychiatrist, when the patient was a few days post-op, and we couldn't find any other OCD-type behaviors, so I don't know what was going on. And I expected her to look malnourished, because she had been doing this for at least two years and, judging by the size of the resected hairball, should have definitely had obstruction problems (she didn't until the week she came to the hospital.) She said that she drank 1 gallon of chocolate milk every day, which provided her with enough calories, I guess - but milk also curdles and adds to the mass. Nice, huh?

There's some pictures and other interesting information on trichotillomania (hair pulling) here - I don't want to post the pictures, lest I make someone spew on their monitor!

*Each rotation culminates in an NBME (National Board of Medical Examiners) miniboard exam - which I'll talk about in a separate post, because the hairball? Deserves to stand on its own.