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 BOOK REVIEWS

Stahl’s Self-Assessment Examination in Psychiatry: Multiple Choice Questions for Clinicians

Richard Balon, MD

Wayne State University, Detroit, MI, USA

By Stephen M. Stahl. Cambridge University Press; New York, NY; 2012; ISBN 978-1-107-681590; pp 338; $45.44 (paperback).

Continuing medical education (CME) has been part of our life for a long time. Many of us go to conferences focused just on CME and crammed with expert lectures. Some attend local CME lectures. Others get CME hours by completing tests on the internet or in journals they subscribe to. We have been accruing CME hours to fulfill our state license requirements and, hopefully, also trying to learn new things and maintain our level of expertise. It seems that the ever-expanding field of CME will be expanding even more as CME requirements have become part of Maintenance of Certification, and thus an element of future recertification.

There are different ways to learn new things; some are passive, some are active and self-directed. Answering questions about the material studied is a way of testing whether one retains anything from the presented material. However, it also means active learning. Answering questions before studying materials (CME or others) also may help direct one’s learning as it may point to one’s weaker areas of knowledge. One can and should use questions before and after studying certain material. This is what Stephen Stahl, author of this self-assessment volume, calls a “knowledge sandwich”: “meaty information lying between two slices of questions” (p viii). Stahl and his collaborators at his Neuroscience Education Institute (NEI) put together the “bread” part of the sandwich—a book of 150 self-assessment questions in psychiatry. He suggests that the reader obtain the meat part by consuming the subject material in any textbook, preferably by consuming his book, Stahls’sEssential Psychopharmacology, as most questions in this self-assessment volume are geared toward his book as a main reference (he also uses Alan Schatzberg and Charles Nemeroff’s Textbook of Psychopharmacology as a frequent reference).

This volume of questions consists of an Introduction explaining active learning through self-assessment; CME introduction with the mandatory statement of need and learning objectives and all other proscribed CME text; 150 questions; and CME posttest and certificate (one can obtain a CME certificate from NEI online; it has to be submitted by March 21, 2015).

The questions “cover” 10 areas—basic neuroscience; psychosis and antipsychotics; unipolar depression and antidepressants; bipolar disorder and mood stabilizers; anxiety and anxiolytics; pain and the treatment of fibromyalgia and functional somatic syndromes; disorders of sleep, wakefulness, and their treatment; attention-deficit/hyperactivity disorder and its treatment; dementia and its treatment; and substance use disorders and their treatment. Each question is printed on the right hand page with a multiple-choice answer. After answering the question “either in your head, on the page, or on another piece of paper,” (p x) the reader can turn the page and “on the left hand will appear not only the correct answer, but also an explanation of why the correct answer is correct, why the incorrect answers are incorrect, and references that document the correct answers, both in the companion textbook Stahl’s Essential Psychopharmacology and elsewhere. The reader will also see at this time what several hundred peers who have already taken this test thought was the correct answer” (p x). The fact that questions are immediately followed by answers is a positive feature compared with many question and answer books where there are question and answer sections, forcing the reader to flip back and forth. Most questions are in the form of a case vignette and most are good and quite thought provoking (eg, a question on antipsychotic formulation that may be a good option for long-term treatment of a patient with absorption problems after bowel resection—these options do not include just injectable depot antipsychotics, but also those with sublingual formulation). As I mentioned, the most frequently used references are Stahl’s and Schatzberg and Nemeroff’s textbooks and some of Stahl’s other texts; this is, in my opinion, a major weakness of this otherwise laudable volume. We have to rely on the author’s opinion and interpretation, without knowing the original source—eg, “Although not rigorously studied, there are some controlled studies of high-dose olanzapine use. These studies suggest that higher doses may lead to increased efficacy and are not generally associated with an increase in side effects” (p 52). I am not questioning the author’s knowledge and interpretation; I am just suggesting that the availability of the original source of information is always best. It is also an important part of self-learning, encouraging one to look for the original source of information. I also felt that answer discussion could be more sophisticated—eg, the question on mood stabilizer use in pregnancy emphasizes lithium teratogenicity, specifically Ebstein’s anomaly, but does not mention that this applies to the first trimester because the fetal heart development is completed during this time. I was surprised by a question on agomelatine, because this antidepressant is not approved in the United States and its development for the US market was discontinued. Nevertheless, these are fairly minor issues correctable in further editions (which would, hopefully, also include other disorders not covered in this edition).

I am not questioning the author’s enormous knowledge, expertise, hard work, and innovative approach to CME. This useful book of self-assessment questions demonstrates all these qualities. I think that an enterprise such as question writing is, at times, better served by a group of experts. Dr. Stahl definitely is at the forefront of a new industry (this is, again, not criticism, just a word of caution). He is correct in his assertion that “Research has shown that when the re-exposure is done not as a review of the same material in the same manner, but as a test, retention is much enhanced. This results in the most efficient way of learning because the initial encoding (reading the material or hearing the lecture for the first time) is consolidated for long-term retention much more effectively and completely if the re-exposure is in the form of questions. Thus questions help you remember…” (p x).

Those in love with Dr. Stahl’s other texts will appreciate and like this little book. Others who are just interested in psychopharmacology will probably enjoy testing their knowledge. Those interested in acquiring CME certification will find it useful (the price of the book is reasonable and the American Board of Psychiatry and Neurology [ABPN] accepted the questions in this book for ABPN CME requirements). This is a useful and relevant CME tool for busy clinicians. However, older lifelong learners may not like the book’s small print.