Preparing for Your Boards

As you prepare for your neurology board examination, you will be faced with the dilemma of what books to read. Neurology covers a broad spectrum of disease processes. Moreover, your certification examination will also include psychiatry and other neurologic subspecialties such as neuro-ophthalmology, neuro-otology, and neuroendocrinology, to name a few. Unfortunately, there is not one convenient book that you can read that will contain everything you need to know to pass your boards. Although this book is entitled Ultimate Review for the Neurology Boards, it is not intended to be your single source of study material in preparing for your examination. Rather, it presumes that throughout your residency training, or at the very least, several months before your board examination date, you will have already read primary references and textbooks (and, therefore, carry a considerable fund of knowledge) on the specific broad categories of neurology. However, because you cannot possibly retain all the information you have assimilated, we offer this book and web review tool as a convenient way of tying it all together. It is best used 1-3 months before your examination date.

Ultimate Review for the Neurology Boards contains 24 detailed chapters on all subjects included on the neurology board examination, as well as a web-based self-assessment and review tool (Http://www. ultimateneurology. com) with hundreds of interactive flash cards and cases keyed to specific chapters in the text.

For maximal retention with the shortest amount of time, we have used an expanded outline format in the text portion of this manual. The topics are arranged from the most familiar (i. e., clinical topics) to the least familiar (i. e., basic neuroscience topics) so that you will read the easiest-to-remember first and the most-likely-to-be-forgotten just before you take your boards.

The main headings and subtopics are in bold. A few phrases or a short paragraph is spent on subtopics that we think are of particular importance. Crucial or essential data within the outline are italicized. Thus, we present three levels of learning in each chapter. We suggest that you first read the entire chapter, including the brief sentences on each subtopic. After which, you should go back a second time, focusing only on the headings and subtopics in bold and the italicized words within the outline. If you need to go back a third time to test yourself, or, alternatively, if you feel you already have a solid fund of knowledge on a certain topic, you can just concentrate on the backbone outline in bold to make sure you have, indeed, retained everything.

Whenever appropriate, illustrations are liberally sprinkled throughout the text to tap into your "visual memory." Quick pearls (such as mnemonics to remember long lists and confusing terminology, tables to organize a complex body of information) and high-yield topics are preceded with this symbol "NB:" (for nota bene, Latin for "note well"), to make sure you do not miss them.


Some chapters overlap. For example, some diseases discussed in the Pediatric Neurology chapter and the Neurogenetics chapter can also be found in the individual chapters of the Clinical Neurology section. This is intended to maximize memory retention through repetition.

The interactive web component of this manual presents a case-based "mini-atlas" on gross and microscopic neuropathology and, whenever possible, their corresponding neuroradiologic picture. For this edition, we have also developed a totally new case module for neurophysiology review. All of the cases are designed to help you think through histories, imaging, and pathology and to prepare you for the "pictures" that will appear on the boards. We believe that pictures are most remembered when cases are tagged along with them. After all, your residency training was predominantly a case-based learning program, and recognizing these pictures correctly is only useful if you can apply or relate them to the daily cases you confront in your practice. The web component also contains several hundred terms in flash card format. The flash cards are a tool designed to help you master difficult-to-remember minutiae. Based on excellent comments from users of the first edition, we have improved the flashcards to be more intuitive. In addition, we added a dedicated section for reviewing medications.

The flash cards are divided into nine categories (based on the chapters in the textbook) of difficult-to-remember facts that often appear on board exams. Each flash card is paired as a term with a second flash card that contains its definition. The design of the flash cards is such that you will be able to quickly drill yourself on the computer until you have memorized all of the rare facts that may appear on the examination. Additionally, each flash card contains a reference to the chapter(s) in which you may review the details of the subject.

After reviewing the categories of questions, you may choose to look at either each category of flash cards in random order or all of the flash cards in random order. The randomized feature allows you to solidify your knowledge of difficult-to-remember facts.

As a suggested approach for using this book and web-based review, you might first review the relevant chapters in the book and then review the related category of flash cards so as to test your knowledge and understanding of the print material. Later, you can review the flash cards in a given category in random order to help maintain your currency and understanding of the material. Finally, after reading the entire book and reviewing the flash cards by section, both in order and randomly, you may wish to review all of the flash cards in random order to determine how well you have learned and retained the material in the review book.

The cases are divided into seven categories (tumor, vascular/stroke, pediatrics/congenital, eye, neurodegenerative, other imaging sequences, and miscellaneous). Cases include combinations of common and uncommon histories, imaging, and pathology. The cases are designed to allow you to think through the answer based on the information provided before proceeding to the next screen within the case. For example, many cases offer a history, then an image, then the imaging diagnosis, then the pathology, and then the pathologic diagnosis. It is in this way that we hope you will learn to think through cases and recognize common pictures. You may review the cases in order in each topic module, or you may select a random presentation of cases within any given module. We have also created a new section for neurophysiology review containing case examples of EEG, EMG, and sleep studies.

For the oral board preparation, this Introduction includes tips on how to prepare for your oral boards, how to lessen your anxiety, and how to improve your presentation skills.

Good luck and we hope you pass your boards in one attempt!

II. Preparing for Your Board Examination

Although most residents initially feel that after a busy residency training, it is better to "take a break" and postpone their certification examination, we believe that, in general, it is best to take your examination right after residency, when "active" and "passive" learning are at their peaks. There will never be "a perfect time" (or "enough time") to review for your boards. The board examination is a present-day reality that you will need to prepare for whether you are exhausted, in private practice, expecting your first child, renovating your newly purchased 80-year-old house, or burning candles in your research laboratory. You just need to squeeze in the time to study.

Here are a few pointers to help you prepare for the Board Examination. All or some of them may be applicable to you:

A. Board preparation starts from day 1 of your residency training. Although most residency programs are clinically oriented and have a case-based structure of learning, here are some suggestions as to how you can create an "active" learning process out of your clinical training, rather than just passively learning from your patients and being content with acquiring clinical skills.

1. Imagine you are on your sixth month of a boring ward rotation carrying eight patients on your service. Below is a table containing the diagnoses of your patients in the neurology ward and the reading initiative we recommend.



Reading initiative


Thalamic lacunar stroke

Master the anatomy of the thalamus.


Embolic stroke

Become familiar with the literature on the use of heparin vs. aspirin.


Guillain-Barre syndrome

Master the differential diagnosis of axonal vs. demyelinating polyneuropathy.


Amyotrophic lateral sclerosis

Master the differential diagnosis of motor neuron diseases.


25-year-old with stroke, unclear etiology

Master the data on stroke risk factors.


Seizure breakthrough for overnight observation

Know all the mechanisms of action of antiepileptic agents.


Hemorrhagic stroke

Know and be able to differentiate the magnetic resonance imaging picture of a hyperacute, acute, subacute, chronic bleed.


Glioblastoma multiforme (a "dump" from neurosurgery)

Know the pathology of all glial tumors

2.  Always carry a small notebook that fits in your coat pocket so you can write down all the questions and observations that may arise in the course of your day. If possible, do not sleep without answering those questions. Likewise, jot down all the new information you have learned. Read through these notes one more time before you call it a night.

3.  Follow your grand rounds schedule. Read the topic(s) beforehand. This will help you in two ways: (1) the talk itself will serve as reinforcement because you already read about it; and (2) you can ask more intelligent questions that will, at the very least, impress your colleagues and mentors, if not make you learn and appreciate neurology even more.

4. For the driven resident: have a monthly schedule of books or book chapters to read. Maximize your reading on your light or elective rotations. On the average, a "good" resident reads 25-50 pages per day (from journals, notes, books, etc.). If you read more than 50 pages per day, you are driven and will be rewarded with an almost effortless board review period. If you read less than 10 pages per day, or, even worse, are an occasional reader, you are relying on passive learning and will need to make up a lot of lost time (and knowledge) during your board review.

B.  Take your RITE/in-service examination seriously. If possible, prepare for it weeks in advance. People who do well every year are the ones who pass their written board examination on the first attempt.

C.  Know all board examination requirements several months before you finish your residency training. Know all the deadlines. Check the name on your identification and the name on your admission slip to make sure they are identical. Contact the American Board of Psychiatry and Neurology (ABPN) if they are not. Ideally, you should be distracted as little as possible when your examination date approaches.

D.  Start your formal board review midway (that is January 2) of your senior year. Make a general, realistic schedule. Do not make it too ambitious or too detailed. Otherwise, you will find yourself frustrated and always catching up to your schedule. As we mentioned, there will never be a perfect time to study for your boards—you need to create your own time.

E.  In general, start with topics you know the most about (and, therefore, are least likely to forget), such as clinical neurology, and end with topics you know the least about (and, thus, are more likely to forget in a short amount of time), such as neurogenetics, metabolic disorders, neuroanatomy, neurochemistry, etc. The flow of this book is arranged such that the clinical topics are first and the technical topics are last.

F.  Use your book allowance wisely. Read and underline books during residency that fit your taste and that you are likely to use for your board review. Underlined books are less overwhelming, provide a sense of security that you have already been through the material (even if you have forgotten its contents), make review time more efficient, and significantly reinforce learning and retention.

G.  End your formal review at least two weeks before the date of your written boards. Earmark one week for the psychiatry portion (do not forget to read on child psychiatry) and one week for recapping high-yield topics; questions and answers; looking at radiology and pathology pictures; and reading the answers to past RITE/in-service examinations (they do repeat!).

H.  Arrive at your examination site city at least 24 hours before. You do not want to realize on the day of your examination that your hotel reservation was inadvertently misplaced or that your flight was canceled because of a snow storm. Print directions to your testing site on both Yahoo (Http://www. yahoo. com) and MapQuest (http://www. mapquest. com). Make sure your cell phone is fully charged and you have your driver's license with you.

I.  You might consider bringing ear plugs, an extra sweater, and a reliable watch. When one of us took our boards in the basement of a hospital, there was a general announcement through the public-address system every 30 minutes. We have heard different stories: the heater was not working, a dog convention was going on in the next room, etc. It is best to be prepared.

J.  If this is the second or third time you are taking the Boards, consider the benefits of a small study group or having a study partner. You will be amazed that two or three people Assigned the same topic to read will emphasize different items. It could very well be that you are underlining the wrong words and need someone to give you a different perspective. At the very least, a study group will keep you on pace with your schedule.

III. Preparing for the Oral Portion (for those who graduated residency on or before June 30, 2007)

Adult neurology candidates will take three examinations:

•  One 1-hour examination in clinical adult neurology (with a live patient)

•  One 1-hour examination in clinical adult neurology (case vignettes)

•  One 1-hour examination in clinical child neurology (case vignettes)

Child neurology candidates will take three examinations:

•  One 1-hour examination in clinical child neurology (with a live patient)

•  One 1-hour examination in clinical child neurology (case vignettes)

•  One 1-hour examination in clinical adult neurology (case vignettes)

NB: Distribution and number of adult and pediatric case vignettes may vary from year to year.

Here are some tips to help you prepare for your oral boards:

1.  Right after you pass the written portion, start preparing the materials to read for your oral boards. You will need a good book for (1) differential diagnosis of adult neurologic disorders, (2) differential diagnosis for pediatric neurologic disorders, and (3) neurologic emergencies (pediatric and adult) and critical care neurology (pediatric and adult).

2.  As you read and prepare, create a list of all the medications per disease and memorize the exact dose and frequency of each. Pay particular attention to the doses of all antiepileptic agents (especially in status epilepticus of both the adult and the child), drugs that lower intracranial pressure, plasmapheresis, intravenous immunoglobulin, interferons, etc.

3.  Practice! Practice! Practice! This is the only way you can gain confidence in your delivery. Practice case vignettes with someone you are least comfortable with, someone in your department who has been an examiner several times, or someone who recently took (and preferably passed) the oral boards.

4.  If your funds permit, consider taking oral board review courses given before the examination. Participating in it gives you more practice and makes you more confident, and watching others mess up their presentation allows you to learn from their mistakes. Remember, the oral portion is only a "fair" examination and a true test of your knowledge and competence as a clinician if your nervousness is not in the way.

5.  Prepare your medical bag. Have all your instruments ready.

On the day itself. . .

1.  Do not forget to wear a reliable watch. You may be going from one hospital to another for the three parts of your oral boards.

2.  Go to the bathroom before you leave your hotel room.

3.  Wear formal, conventional, neat yet comfortable attire. Make sure there are no holes or stains. Blue, black, and dark green are the best colors. Have a neat/conventional haircut. No earrings for men. Cut your nails. In other words, do not do or wear anything that will attract undue attention. Give the impression that you are a mature, balanced, intelligent, humble, and affable neurologist.

4.  The first thing your examiners would like to make sure of is that you are a safe neurologist. Therefore try to stick with conventional treatment options (especially in the neurologic emergencies and critical care portions). If you are making a last ditch effort, and you have an unconventional plan for your patient, then say "at this point, I shall consider what some neurologists may classify as nonstandard. . ."

5.  Do not place used safety pins back in your medical bag. Do not hurt the patient. Be nice to your patient and treat him/her with respect and dignity. Never show you are frustrated or getting impatient.

6.  The next thing your examiners would like to make sure of is that you are an organized and practical thinker. When you begin your discussion, do not paraphrase the entire case. Choose a major problem (e. g., I am essentially faced with a 3-year-old boy with monoplegia. . .), then state and discuss your differential diagnosis pertinent to your case only, and end with your impression. You do not need to show off and give them a laundry list of differential diagnoses, especially if it is not pertinent to your case. It will only irritate your examiners.

7.  The final thing they want to know is that you are competent. Make sure you know the basic diagnostic test and treatment for each of your differentials. They can interrupt you anytime to elaborate on a particular diagnosis. Do not forget to state the need to obtain vital signs, electrocardiogram, complete blood count, routine chemistry, urinalysis, blood culture, chest X-ray, etc., to rule out a general medical condition.

8.  When given the choice, we recommend that you ask your examiners to read each case of the vignettes for you. This allows you to organize your thoughts while the case is being read.

9.  Pretend that you have a panel of medical students and that you are teaching them. Answer your examiner's questions as if you are lecturing to students. They may not know the answers to their own questions and they are not necessarily more knowledgeable than you in a particular subject. The only clear difference is that they already passed the boards.

10.  For the most part, your examiners are there to pass you, not to fail you. Be receptive to the clues they might be giving you to arrive at the correct diagnosis or answer.

11.  For live pediatric cases, do not forget to check the head circumference (and if abnormal, check the parents' as well). Always do a funduscopy. Check for neurocutaneous lesions.

12.  For live adult cases, do not forget to check for bruits, pulses, and blood pressure of both arms for stroke patients; check for tongue fasciculations for motor neuron disease patients; make patients with tremors write a sentence, perform a task, and draw concentric circles.

13.  Always maximize the 30 minutes given to you to examine your live patient. Never finish early.

14.  Take out all the instruments you will need to examine the patient and lay them out neatly on the table. Put them back in your medical bag one at a time after each use (except for the safety pin, which goes to the trash can). That way, at the end of your neurologic examination, you will be reminded if you missed a test because the instrument for that test would still be on the table. When your table is clean, you are confident that you performed a thorough neurologic examination.

15.  Keep on talking. If you do not know the answer to a question, first tell them what you know about the topic or question before telling them that you do not know the answer to the particular question. But be honest. Do not bluff.

16. Be aware of the body language you send. Put your hands together or place them on your lap. Do not swivel your chair. Do not slouch. Do not cross your legs. Do not appear too relaxed or too tense. Show some calmness and sincerity.

Despite the horror stories on the oral portion that are passed on from generation to generation, it is actually, in some respects, a more balanced and fair assessment of your competence in your chosen field than the written portion of the boards. Just try to relax and show them that you are a safe, respectful, organized, practical, and competent clinician.

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