You’re an anesthesiologist nearing completion of your residency and fellowship. You’ve passed the written exam from the American Board of Anesthesiology, and are preparing for the oral exam. You’ve heard that 20% of examinees fail the oral exam, and you’re worried. What should you do?
I’m not an American Board of Anesthesiology (ABA) Examiner, but I’ve been lucky enough to know a dozen or more ABA Examiners over many years. Twice a year at Stanford we provide mock-oral exams to the anesthesia residents to prepare them for when they officially take the real exam at the conclusion of their training.
The mock exams follow the exact format of the real oral exam, and I’ve co-examined with experienced ABA examiners on multiple occasions. Here’s what I’ve learned from them, and what Stanford’s ABA examiners teach their residents about passing the Oral Board Exam in Anesthesiology.
- Read Miller’s Anesthesia cover to cover. Read it during your entire residency, and consider re-reading it in its entirety prior to taking the Exam.
- Be well-trained. Work hard during residency. Do challenging cases and read about those cases before and after the anesthetic. Attend the department lectures, and mortality and morbidity conferences.
- Download and memorize the algorithms in the Stanford Emergency Manual/Cognitive Aid for Perioperative Critical Events.
- Find board-certified anesthesiologists who are willing to give you mock-oral practice exams. It helps.
Taking the actual oral board exam test:
- Format: You will be tested in two 35-minute sessions, Part A and Part B. For each session, you will have two examiners, a Senior Examiner and a Junior Examiner. For each session, you will be given a stem question of a specific anesthetic case 10 minutes prior to the session. An example question might be something like: “A 50-year-old man, 120 kg, 6 feet tall, is scheduled for a cholecystectomy. He has ankylosing spondylitis, and uses an insulin pump to manage his diabetes. He has dyspnea on climbing one flight of stairs.”
- The format for Part A: The Senior Examiner will question you for 10 minutes on intraoperative management, then the Junior Examiner will question you for 15 minutes on postoperative management and critical care, and then the Senior Examiner will question you for 10 minutes on 3 or more additional topics.
- The format for Part B: The Senior Examiner will question you for 10 minutes on preoperative management, then the Junior Examiner will question you for 15 minutes on intraoperative management, and then the Senior Examiner will question you for 10 minutes on 3 or more additional cases. Your examiners for Part B will not be the same individuals who examined you in Part A.
- The stem questions and additional questions will be scripted to cover all aspects of anesthesiology, i.e. obstetrics, pediatric, neurosurgical, cardiac, pain, regional blocks, trauma, etc.
- You’ll get the stem question 10 minutes prior to entering the exam room. Use these 10 minutes of time to organize your thoughts. Take notes and formulate your anesthetic plan. Try to discern the biggest medical risks/pitfalls of this particular case, and make a plan to anticipate these risks.
- Examiners score each candidate in four qualities: A. Application of Knowledge (Did you demonstrate that you not only knew facts, but that you applied them in a clinical scenario?), B. Judgment (Did you make sound decisions?), C. Adaptability (Were you able to change your plan in response to a changes in the situation or the patient’s condition?), and D. Organization and Presentation (How well did you communicate? Are you an anesthesia consultant?)
- Remember Airway-Breathing-Circulation, in that order. Don’t harm a patient by losing the airway. Know the ASA Difficult Airway Algorithm by heart.
- If the question relates to one of the 25 algorithms in the Stanford Emergency Manual/Cognitive Aid for Perioperative Critical Events, then explain exactly how you’d follow the steps in the Manual.
- Imagine yourself in the OR actually doing the case, and explain exactly what you would normally do and why. Don’t follow a plan you would never take in actual practice.
- Try not to ask questions. Use your time to answer questions.
- There is no one right answer for most clinical scenario questions. Just be prepared to justify why you chose the plan you chose.
- Expect bad things (complications) to happen to your patients. Don’t be alarmed, the complications are written into the script. Tell the examiner what you would do.
- If you don’t know an answer, it’s better to say “I don’t know” than to blunder and guess.
- Make eye contact with the examiners throughout. Speak confidently and talk to them like a colleague.
- “Ringing the bell.” During your oral answers, your job is to “ring the bell” as often as possible with pertinent facts of pharmacology, physiology, and medical knowledge pertinent to the case. Demonstrate what you know. Demonstrate that you can apply your knowledge, adapt to changes in clinical situations, use reasonable clinical judgment based on the information available, and present your ideas in a clear and organized manner.
- EXAMPLE STEM QUESTION:
“A 50-year-old man, 120 kg, 6 feet tall, is scheduled for a cholecystectomy. He has ankylosing spondylitis, and uses an insulin pump to manage his diabetes. He has dyspnea on climbing one flight of stairs.”
For this stem question, a Part B oral exam may proceed as follows:
I. First 10 minutes (preoperative management)
Expect questions such as:
- How would you work up the shortness of breath? Would you cancel the surgery? Why? Would you order pulmonary function tests? What do you know about pulmonary function tests? What is an FEV1?
- What is ankylosing spondylitis? What are the anesthetic risks?
- What would you do with the insulin therapy preoperatively? What types of insulin are there? How does insulin work in glycemic control? Would you stop the insulin pump? Continue it? Why? How tightly will you control the glucose level preoperatively?
- Define morbid obesity. Is this patient morbidly obese? How does obesity affect pulmonary physiology? Discuss the anesthetic risks associated with morbid obesity.
- Do you need a cardiology consult preoperatively? Why? Why not?
- The surgeon tells you the surgery is urgent, and he can’t wait for a cardiology consult or a treadmill test before surgery. What do you tell the surgeon?
II. The next 15 minutes (Intraoperative management)
Expect questions such as:
- What monitors will you use for the surgery? Why? You are unable to insert an art line. What will you do?
- How would you induce anesthesia? (If you chose to induce general anesthesia without an awake intubation, and you paralyze this patient, expect the examiner to give you an impossible intubation in this patient with ankylosing spondylitis. If mask ventilation is impossible, you will have a difficult rescue problem). Bottom line: this patient needs an awake intubation via a fiberoptic technique. Discuss how you’d do this.
- What maintenance anesthetic would you use? Why would you choose sevoflurane over isoflurane? What is MAC? How does the MAC vary with patient age?
- How often would you check blood glucose levels? The glucose concentration is 495 mg/dL, what would you do? The glucose concentration drops to 33 mg/dL, what would you do?
- The oxygen saturation drops to 85% intraoperatively. What would you do, both diagnostically and therapeutically?
- The intraoperative blood pressure drops to 65/35. What would you do? What diagnostic interventions, if any? What therapies? How does ephedrine work? How does phenylephrine work?
- The heart rate increases to 150 beats per minute. What would you do? What diagnostic interventions, if any? What therapies? The heart rate drops to 30 beats per minute. What would you do? What diagnostic measures, if any? What therapies?
III. The final 10 minutes (examples of 3 additional cases):
- A preeclamptic woman presents for an urgent Cesarean section. She has a blood pressure of 160/100 and platelet count of 30,000. How would you do the anesthetic? Would you do a spinal? An epidural? Why or why not? If you do a general anesthetic, how will you manage her blood pressure?
- A 2-year-old boy presents for surgery. He has an open eye injury and a full stomach. How will you induce anesthesia? Will you start an awake IV? Will you do a mask induction? What are the risks of each?
- An 89-year-old woman with end-stage-renal-disease presents at 1 a.m. for emergency bowel obstruction surgery. Her last hemodialysis was four days ago. How will you manage her renal disease? Will you delay surgery to dialyze her? The surgeon tells you that delaying surgery will result in her dying of sepsis. How will you proceed?
In addition to reading Miller’s Anesthesia twice, read through the Clinical Cases for Anesthesia Professionals in theanesthesiaconsultant.com, and follow the guidelines I’ve outlined in these cases.
Introducing …, THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a legal mystery. Publication date September 9, 2014 by Pegasus Books.
The first four chapters are available for free at Amazon. Read them and you’ll be hooked! To reach the Amazon webpage, click on the book image below:
Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.
Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.
Bang-Up Debut Novel, November 16, 2014
By Norm Goldman “Publisher & Editor of Bookpleasures”
This part legal and medical thriller is structured with a mixed bag of situations involving relationships, jealousy, evil, lies, courtroom drama, operating room mishaps as well as moments that engender conflicting and unexpected outcomes. Noteworthy is that as the suspense builds readers will become eager to uncover the truth involving a mishap concerning Nico and a surgical procedure that has unanticipated ramifications.
This is a bang-up debut from a writer who understands timing and is able to deliver hairpin turns, particularly involving the courtroom drama,that you would expect from a book of this genre.
TwinCities.com PIONEER PRESS Entertainment
by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press email@example.com, January 4, 2015
“The Doctor & Mr. Dylan” by Rick Novak (Pegasus Books, $17.50)
Dr. Nico Antone doesn’t hide the fact he hates his wife, but he says he didn’t kill her during an operation. The authorities think otherwise and his trial is the riveting suspense in this novel that is part medical thriller, part legal thriller, part exploration of family relationships.
Nico is an anesthesiologist (as is the author) who leaves his wife, their plush life in California and his job at Stanford to move to his hometown of Hibbing so their son, Johnny, has a better chance of getting into a prestigious college. Johnny hates the idea of moving to a small, cold town, but he’s popular from the first day in school. Nico doesn’t do so well. He’s envied by Bobby, an anesthetist who’s jealous of the better-educated Nico. But it’s hard to take Bobby seriously, since he thinks he’s the young Bob Dylan and lives in the house where Bobby Zimmerman grew up. To complicate matters, Nico is attracted to the mother of the young woman his son is dating. When the two teens get in trouble, Nico’s furious, rich wife comes to Minnesota and needs an emergency operation that puts her on Nico’s operating table.
Novak grew up in Hibbing, where he worked in the iron ore mines and played on the U.S. Junior Men’s Curling championship teams of 1974 and ’75. After graduating from Carleton College, he earned a medical degree at the University of Chicago and spent 30-plus years at Stanford Hospital, where he was an associate professor of anesthesia and Deputy Chief of the Anesthesia Department. His courtroom scenes are based on his experiences as an expert witness.
The Physician’s Late-Night Reading List
Two Pritzker alums pen captivating tales
By Brooke E. O’Neill, University of Chicago Pritzker School of Medicine, editir, Medicine on the Midway Magazine
For most physicians, writing — patient notes, case histories, perhaps journal articles — is part of the job. But for anesthesiologist-novelist Rick Novak, MD’80, and neurosurgeon-memoirist Moris Senegor, MD’82, it’s a second career that consumes early morning hours long before they step into the OR.
Fans of John Grisham will find a kindred spirit in Novak, whose fast-paced medical thriller, The Doctor & Mr. Dylan (Pegasus Books, 2014), transports readers to rural Northern Minnesota, where an accomplished physician and a deranged anesthetist who thinks he’s rock legend Bob Dylan see their worlds collide in the most unexpected ways.
Delivering real-life twists and turns — and a love letter to the Bay Area — is Senegor’s Dogmeat: A Memoir of Love and Neurosurgery in San Francisco (Xlibris, 2014), a coming-of-age tale chronicling the author’s away rotation with renowned neurosurgeon Charles Wilson, MD, at the University of California, San Francisco. Brutally honest, it spares no details of a time Senegor, who also served as a resident under the University of Chicago’s famed neurosurgery chair Sean Mullan, MD, describes as “one of the biggest failures of my life.”
One a vividly imagined nail-biter, the other an intimate peek into the surgical suite, both books deliver an ample dose of intensity and drama.
The Doctor and Mr. Dylan (Pegasus Books, 2014) by Rick Novak, MD’80
“I thought it was a novel way of killing someone,” said Rick Novak, deputy chief of anesthesiology at Stanford University, describing the imagined hospital death that was the genesis of his dark thriller The Doctor & Mr. Dylan. A huge Bob Dylan fan — the rock icon was born in Novak’s hometown of Hibbing, Minnesota, where the story takes place — he then dreamed up a possible culprit: a psychotic anesthetist who thinks he’s Dylan.
From there, the words flowed. “I would write whenever I was with my laptop and had a free moment: in mornings, in evenings, in gaps between cases,” said Novak, who also blogs about anesthesia topics. “I don’t sleep much.”
After finishing the manuscript — one year to write, another to edit — came the challenge of finding a publisher. “In anesthesia, I’m an expert,” Novak said. “In the literary world, I’m an unknown.” After 207 responses of “no, thanks” or no answer at all, he landed an agent. Two months later, she informed him that Pegasus Books had bought his debut novel.
“I started crying,” Novak admits. “I have a third grader and at the time the big word the class was learning was ‘perseverance.’ That was it exactly.”
Dr. Joseph Andresen, Editor, Santa Clara County Medical Association Medical Bulletin, from the January/February 2015 issue:
BOOK REVIEW “THE DOCTOR AND MR. DYLAN”
This past month, Dr. Rick Novak handed me a hardbound copy of his debut novel The Doctor and Mr. Dylan. Rick and I go way back. It was my first week of residency at Stanford when we first met. A newcomer to the operating room, all the smells and sounds were foreign to me despite my previous three years in the hospital as an internal medicine resident. Rick, a soft spoken Minnesotan at heart, in his second year of residency, took me under his wing and guided me through those first few bewildering months, sharing his experience and wisdom freely.
Fast-forward 30 years later. Dr. Rick Novak, a novel and mystery author? This was new to me as I sat down and opened the first page of The Doctor and Mr. Dylan. I have to admit that I didn’t know what to expect. Few books highlight a physician/anesthesiologist as a protagonist, and few books feature a SCCMA member as a physician/author. However, a medical-mystery theme novel wasn’t at the top of my must read list. With my 50-hour workweek, living and breathing medicine, imagining more emotional stress and drama was the furthest thing from my mind. However, three days later, as I turned the last page, and read the last few words. “life is a series of choices. I stuck my forefinger into the crook of the steering wheel, spun it hard to the left and …” This completed my 72-hour journey of and free moments I had, completely immersed in this story of life’s disappointments, human imperfections, and simple joys.
Rick, I can’t wait for your next book. Bravo!
Hibbingite writes twisted medical tale
HIBBING — Readers who are looking for a whodunit that will keep them up all night are in for a treat.
Hibbing native Rick Novak recently released his first book “The Doctor and Mr. Dylan,” a fiction set in Hibbing that merges anesthesia complications, a tumultuous marriage and the legend of Bob Dylan.
“The dialogue is sometimes funny, and there are lots of plot twists,” he said.
Novak said the book will not only entertain readers, but teach them about anesthesiology, Dylanology, the stressful race for elite college admission, and life on the Iron Range.
“The book is very conversational and streamlined,” he said. “I try to write as one would tell a story out loud.”
Novak said “The Doctor and Mr. Dylan” took him three years to perfect. He is currently working on his second book.
This review is from: The Doctor and Mr. Dylan (Kindle Edition)
Just finished Dr. Novak’s delightful novel. I sincerely enjoyed his honest take about the pressures and values that exist within California’s Silicon Valley. He also brought the North Country of Minnesota to life with memorable characters and a twisting, addictive plot. Buried beneath the fun and funny story is a deeper message about how to best care for your kids, your relationships and yourself. Very well written and highly recommended.
Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below: