Preparing for Oral Boards

1
Preparing for Oral Boards

• E. Steele, M.D.
• May 2006

2
Overview

• Pass Written
• Application for Orals automatically mailed to you
• Given in April October
• You dont get to choose
• But you can call and ask for a particular day

3
The Big Day

• You are assigned and day and time to report to an
  orientation room
• Orientation last about 20 minutes
• You get Question No. 1 here
• Approx. 10 minutes to work on your outline
• March to your assigned examination room

4
Examination Room

• Suite-type hotel room
• Two examiners one senior, one junior and
  possibly an observer who sits behind you
• Small desk with pad of paper and pen and a glass
  of water

5
Format of examination

• Main stem intra-op and post-op OR intra-op and
  pre-op
• Senior examiner begins
• Junior examiner jumps in later
• All the time they are filling out a scantron
  sheet (what does it mean?!)
• After they finish grilling you, they begin
  grab-bag questions

6
Grab bag questions

• You dont see it before they ask it
• Brief clinical scenario and what would you do?
• Child comes for PE tubes and mom says he has a
  hole in his heart. Do you proceed?

7
A busy week

• Each day there are about 5 sessions, each session
  has several orientation rooms, each orientation
  rooms has about 20 applicants for five days in a
  row. This means 900 to 1000 people are taking
  oral examinations the same week as you!
• Lots of nervous people in the lobby
• Lots of anxious people leaving the lobby

8
Scoring the exam

• Two rooms are separate
• Not all questions or examiners are created
  equally
• Statistical analysis and conversion factor for
  difficulty of question and examiner
• It takes awhile to do all this

9
What are the trying to assess?

• Written exam knowledge of general medicine and
  anesthesia
• Oral exam
• Soundness of judgment and rationality of thought
  in making and applying decisions
• Ability to assimilate and analyze data so as to
  arrive at a rational treatment plan
• Ability to define the priorities in the care of a
  patient
• Ability to recognize complications and to respond
  appropriately to them adaptability as evidenced
  by the ability to respond to changing clinical
  conditions
• Ability to communicate effectively about those
  issues of specific relevance to anesthesia care
  and also those topics of general medicine which
  are crucial to the care of patients with diverse
  diseases.

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In summary

• Judgment
• Application of knowledge
• Clarity of expression
• Adaptability to changing, sometimes unexpected,
  circumstances
• Your job to convey verbally an organized,
  rational approach to safely anesthetizing
  patients and managing complications and
  developments

11
Pitfalls

• PPPPPP
• prior planning
• You must practice OUT LOUD!!!

12
Problems as listed by the ABA

• Superficial knowledge
• If you dont know it, you cant discuss it
• Inability to apply knowledge to a clinical
  situation
• How abnormal PFTs might change your management
• Inability to adapt to changing clinical
  conditions
• Routine case I got it! Managing hypoxemia
  during thoracotomy how do I do that? Hmmm.

13
More problems

• Inability to express ideas or defend a point of
  view in a convincing manner
• Well I could do this, or this, or whatever
• Faulty judgment
• Dont choose the risky option
• Transmittal of insufficient information because
  of excessively slow and deliberate knowledge
• Not enough time to convince them that you know
  something

14
Problems from Board Stiff Too, UW Dept of
Anesthesia

• Failure to prepare
• Getting rattled early on and never getting back
  on track
• Trying to cater to the examiner
• Getting mad
• Not doing first things first (HP/airway)
• Not showing proper urgency
• Not stating pros and cons, not indicating if a
  choice is controversial

15

• Pigeon-holing the question too early
• Not getting consultations for specific problems
• Asking questions of examiners
• Slow pace with excessive lists
• Tangential answer (answer the question- repeat if
  necessary to remind yourself)
• Airway
• Unfamiliar with common technique
• Not asking surgeon for alternatives to planned
  surgery

16

• Cookbook approach
• Using unfamiliar techniques
• Not calling neonatalogist at beginning of
  difficult OB case
• Forgetting Abx for heart lesions

17
How do I actually take the exam

• How to dissect the question or what to do with
  your ten minute allotment
• Brainstorm!
• Write down as much as you can about the case.
  Youll want to refer to your notes later.

18
Timing

• Emergency just go with it and manage!
• Urgent time for a few studies? Labs? But prob.
  Needs to go today
• Elective Do all you want

19
What are they getting at?

• Why is this an oral boards question?
• Multi-organ systems involved
• Conflicting interests
• A case everyone should be able to manage?
• Difficult airway!

20
Anesthetic planning

• Preoperative assessment
• Pre-op preparation organ systems
• Premeds
• Monitors
• Choice of technique
• Induction
• Maintenance
• Emergence/Extubation
• Post-op

21
Pre-op assessment

• History and physical
• Labs
• Consults
• Studies invasive and non-invasive

22
Organ systems

• Patients comorbidities
• Expected and anticipated problems
• Management

23
Monitoring

• Standard monitors
• Cardiovascular
• A line
• CVP
• PA
• Echo
• Neurologic
• Twitch
• ICP
• SSEP

24
Anesthetic technique

• Many choices but each patient gets one (in
  general)
• Pick one and defend it
• Lay out your reasoning

25
Induction

• Agents
• Options
• Problems
• Propofol may drop CO too much in this frail
  patient with AS

26
Maintenance

• Not much on how youre going to maintain
  air/iso/remi etc.
• But critical incidents happen here
• Hypoxia
• Hypotension
• Tachycardia

27
Emergence and extubation

• Not waking up?
• Life-threatening hypoxia, hypotension,
  hypoglycemia, brain bleed
• Big hitters drug, metabolic, neurologic
• Not ready to extubate?
• Transport issues

28
Post-op

• Pain
• Oxygenation/Ventilation
• Fluids
• Cardiovascular management

29
Critical Incidents

• List from Wrights handout
• Mechanics Manual from Board Stiff Too
• Know your algorithms!
• Expect to see difficult airway and hypoxia

30
Lets try it!

• 61 year old man scheduled for lumbar lami at
  1130am
• PMhx HTN, DM, MI 4 years ago
• Meds Oral hypoglycemic agent, metoprolol,
  thiazide diuretic
• VS 80kg, 130/90, P 72, T 37, Hbg 16.5, glucose
  130

31
Case 2

• 62 yo woman s/f thyroidectomy and r.radical neck
  dissection for thyroid CA
• Smoker with long standing chronic, productive
  cough
• Anxious, thin (51kg), cough a lot
• 132/80, P 92, coarse rhonci throughout
• Hct 52, room air ABG 7.38/34/68
• EKG r. axis deviation