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.
Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW: