Treatment Algorithms on the Family Medicine Board Exams

Family medicine board exams mainly test the clinical knowledge of the test-taker. Therefore, a number of questions in the American Board of Family Medicine exams are based on assessing your knowledge regarding various treatment interventions. Three significant aspects of treatment interventions may be tested:

• Treatment algorithms
• Treatment interventions in specific patient populations and in different variants of the disease
• Details of particular treatment interventions

Treatment algorithms are the primary focus of this blog post. A rank ordering of treatment options, starting off with first-line treatment and then progressing to second-, third-, or fourth-line treatment options, coming to an end at last-line treatment, is referred to as a treatment algorithm.

Some of the board exam questions present a clinical scenario in which a patient requires a first-line treatment intervention for a particular condition, and the correct first-line treatment is present in the response options of the question.

This is a relatively easy type of question, as it only tests knowledge regarding first-line treatment interventions. Such questions may be suitable for rare diseases, for which you are not expected to demonstrate more than a basic level of knowledge of treatment. Alternatively, the condition may be common, but it is usually treated by a specialist from a different field of medicine, and in your specialty, only a basic knowledge regarding clinical presentation, assessment, and clinical management of that condition may be required. An example would be of an ophthalmologic condition being tested on the family medicine board exams.

Another type of board exam question includes a clinical case that assesses your knowledge of the lower steps of the treatment algorithms such as the second, third, or even lower stages. There are two ways of structuring these questions.

One way is to have the question vignette clearly specify that the patient is NOT a suitable candidate for receiving the first-line treatment. For example, it may be stated that the patient has a history of allergy to a particular first-line treatment medication, has had a poor response to the first-line treatment in the past, or has previously had a serious adverse reaction to the treatment. Therefore, the vignette has guided you to look for treatments beyond the first-line treatment in the question’s response options.

Another approach is to simply not provide you with a first-line treatment intervention in the list of response options, thus forcing you to select a second-line or lower treatment option. The vignette describes a straight-forward clinical case for which a first-line treatment option would normally be selected, however, the correct first-line treatment option has not been included in the response options. Therefore, you are now forced to select the next most suitable response option from the ones that are listed.

Example Exam Question from Family Medicine

Question: A 19-year-old man presents to his primary care physician with complaints of fever and sore throat for “the last couple of days”. On examination, enlarged cervical lymph nodes and tonsillar exudates are noted. No cough or hoarseness is present. A rapid strep test is performed and is found to be positive. The patient has a history of developing skin rash whenever he uses penicillin. Which of the following may be the best treatment option for this patient?

1. Amoxicillin-clavulanate
2. Clindamycin
3. Azithromycin
4. Prednisone
5. Cephalexin

Question Explanation

Acute pharyngitis refers to the rapid onset of pharyngeal inflammation and sore throat, with or without the presence of pharyngeal exudate. It may be caused by a number of viral and bacterial pathogens, including group A beta-hemolytic streptococcus (GABHS). GABHS pharyngitis may be seen in both children and adults and is found to be more common during the late winter and the early spring season. The first-line treatment intervention for GABHS pharyngitis is a course of penicillin or amoxicillin for a period of 10 days. However, in penicillin-allergic patients with type IV hypersensitivity reactions towards penicillin, such as a rash, a first-generation cephalosporin (e.g., cephalexin) should be used. For patients who have type I hypersensitivity reactions to penicillin (i.e., anaphylaxis), it is recommended that clindamycin or a macrolide (such as azithromycin or clarithromycin) be used. Corticosteroids lead only to a small decrease in the duration of symptoms of GABHS pharyngitis, and should not routinely be used for the treatment of this condition.

Source:

Kalra MG, Higgins KE, Perez ED. Common questions about streptococcal pharyngitis. Am Fam Physician 2016;94(1):24-31.

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