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THE ANESTHESIA CONSULTANT

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group

Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

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The Department of Anesthesiology, Perioperative and Pain Medicine at Stanford has administered Mock Oral Board Exams to its residents twice yearly since the 1980s. The Mock Oral is designed to mimic the conditions of the American Board of Anesthesiology (ABA) Standardized Oral Exam (SOE), which candidates must pass to become board-certified. The reference article The American Board of Anesthesiology’s Standardized Oral Examination for Initial Board Certification provides an extensive summary of the oral board examination process. 

In a previous column I advised examinees how to best prepare for the Standardized Oral Exam, and how to best perform on the exam. In this column I’ll outline how to set up a Mock Oral Exam program.

The pass rate for the Standardized Oral Exam is approximately 88%.  By subtraction, about 12% of candidates fail the SOE. 

I believe all candidates can benefit from taking Mock Oral Exams before they take the ABA test. I took my initial Mock Oral as a first-year resident in 1984 and I failed, botching the management of a difficult airway by performing a tracheostomy too soon. I took two Mock Orals each year after that and passed the ABA Oral Exam on my first attempt. I can attest that Mock Orals are an effective simulation to prepare for the ABA exam. One can search online and find books and prep classes to prepare for the Standardized Oral Board Exam, but the only way to rehearse verbal skills for an oral exam is take practice oral exams. It’s within the resources of every anesthesia residency program to provide Mock Oral Exams for their trainees. As an examiner I’ve administered Mock Oral Exams to over 100 residents since 1989. The recipe on how to set up such a program follows below:

SCHEDULING MOCK ORAL EXAMS

Assume a residency program has 10 residents in each year, for a total number of 30 residents. On three separate evenings in November, set up Mock Oral Exams for the first year, second year, and third year residents. Provide an equal number of examiners as you have examinees. Group the examiners in pairs and send each pair to a separate office room in your hospital headquarters. For example:

November 28^th. First year resident exams from 1700 hours – 1735 hours, and from 1745 hours – 1820 hours. At 1700 hours the team of Faculty Member A and Faculty Member B will examine Resident Alpha. At the same time, in four adjoining rooms four other pairs of faculty members will examine four additional residents. At 1745 hours Faculty Member A and Faculty Member B will examine Resident Beta with the same exam question. The same format is followed in the four adjoining rooms, testing a total of ten first year residents. 

November 29^th. Second Year Resident exams from 1700 hours – 1735 hours, and from 1745 hours – 1820 hours. The same staffing as November 28^th is repeated. The examiners may be different. The exam questions are more difficult, given that the residents are one year further in their training.

November 30^th. Third Year Resident exams from 1700 hours – 1735 hours, and from 1745 hours – 1820 hours. The same staffing as November 28^th is repeated. The examiners may be different. The exam questions are more difficult than on November 28^th or 29^th, given that the residents are in the last year of their residency training.

In May of the same academic year the exam sequence as above is repeated, giving each resident their second Mock Oral in the same training year. Each Mock Oral Exam lasts 35 minutes. The first 25 minutes will be questions about a hypothetical patient. The first examiner (e.g. Faculty Member A) begins by asking 10 minutes of questions dealing with preoperative anesthesia issues, followed by 15 minutes of questions about intraoperative issues by the second examiner (e.g. Faculty Member B), and in the final 10 minutes Faculty Member A asks questions about three completely different patients with assorted anesthesia dilemmas. 

SAMPLE MOCK ORAL TEST STEM:

An example of a Second Year Resident Mock Oral Board stem follows:

A 50-year-old man with hypertension, diabetes, obesity, and obstructive sleep apnea presents for an emergency surgery for a small bowel obstruction. He has been vomiting and unable to eat or pass gas for 12 hours. He has 8/10 pain in the abdomen. His medications are hydrochlorothiazide for hypertension, last taken 24 hours prior to admission, and a continuous insulin pump which he stopped 10 hours ago. He is 5 feet 6 inches tall and weighs 100 kg for a BMI=35. His pulse=120 beats per minute, blood pressure=170/105, oxygen saturation on room air=96%, respiratory rate=24 breaths per minute, and temperature=98.6. 

Physical exam: He is doubled over in abdominal pain and looks exhausted. His airway shows a thick neck circumference of 18 inches and a full beard. Except for tachycardia he has normal cardiac and lung exams. His abdomen is distended, and he has rebound abdominal tenderness and hyperactive bowel sounds. His labs are normal except for a glucose = 455 mg/dL and a potassium = 3.0 mEq/L. His ECG shows normal sinus rhythm. His chest X-ray is normal.

The script given to Faculty Member A reads as follows:

10 MINUTES – INTRAOPERATIVE MANAGEMENT 

1. Blood glucose. How would you manage his blood glucose level? What would be your target glucose concentration? How would you administer insulin? How do you administer U-100 insulin? How would hypoglycemia present during general anesthesia? 
2. Monitoring. Does this patient require invasive monitoring? Would you place an arterial line prior to induction? Why?  Is a CVP necessary? Why or why not? Would you use a pulmonary artery catheter? What about TE echo?
3. Airway management. How would you manage the airway? Would you do an awake intubation? How would you do this? Would you do a rapid sequence induction? Which muscle relaxant would you use? Why? Assume you do a rapid sequence induction and you cannot see the vocal cords. What do you do? What if  you cannot intubate the patient and you cannot ventilate the patient with a mask?
4. Potassium management. Will you administer potassium? Why? How fast would you give potassium? What are the risks of a low potassium during anesthesia? What are the risks of a high potassium concentration during replacement?
5. Choice of anesthetic. What will be your plan for anesthetic maintenance? What are the advantages of inhaled anesthesia? Of total intravenous anesthesia? Which would you choose and why? Is there a role for regional anesthesia for this case? Why or why not?

The script given to Faculty Member B reads as follows:

15 MINUTES – POSTOPERATIVE MANAGEMENT 

1. Extubation. Would you extubate the patient following the surgery? What would be your criteria for extubation? You decide to extubate the patient in the operating room. Immediately following extubation, his oxygen saturation falls to 80%. What is your differential diagnosis? How would you manage the situation?
2. Arrythmia. On arrival to the ICU the patient’s heart rate increases to 150. How would you evaluate? Assume the blood pressure is 110/70. What therapeutic measures would you take? Assume blood pressure is 70/40. What therapeutic measures would you take?
3. Oliguria. Assume the cardiac status is stabilized. The patient makes 80 ml of urine over the first two hours postoperatively. What is your differential diagnosis? What tests could you order? Why? Would you give a fluid bolus? Would you give a diuretic? Why? 
4. Chest pain. Assume the patient is extubated on arrival to the ICU. He complains of upper abdominal/mid chest pain. How would you evaluate? What is your differential diagnosis? What tests would you order? How would you manage the situation?
5. Postoperative pain. Assume no heart abnormalities are found. The patient is complaining of abdominal pain after surgery. How would you manage pain control? 

The final script for Faculty Member A reads as follows:

10 MINUTES – ADDITIONAL TOPICS 

1. Pediatric open eye, full stomach. A 5-year-old child presents with an open eye injury due to a fall against a sharp table corner. She needs emergency surgery to save her eyesight. She ate a McDonalds Happy Meal two hours ago, but the ophthalmologist says the surgical repair cannot wait. The child will not let you start an IV while she is awake. How would you induce anesthesia? Would you consider a mask induction? Would you consider an intramuscular induction? How would you deal with the full stomach? How would you proceed? The child vomits during induction. How would you manage this?
2. Morbidly obese patient for C-section. A 30-year-old woman presents in labor at 39 weeks. She is morbidly obese with a BMI=42. Her obstetrician decides the patient needs an urgent Cesarean section because of late decelerations on the fetal heart monitor. Would you choose regional anesthesia or general? Why? You attempt to place an epidural but get a wet tap. What would you do? If you had to administer a general anesthetic, how would you proceed?
3. Family history of malignant hyperthermia. A 17-year-old boy with a tonsillar abscess presents for tonsillectomy. His uncle had a history of dying from malignant hyperthermia after tonsillectomy. Is this case appropriate for a freestanding outpatient surgery center? Would you delay the case? Would you order any preoperative tests? The surgeon says the case is urgent. What is your anesthetic plan?

At the conclusion of the 35-minute Mock Oral exam, the two examiners will stop. At this time the examiners discuss the performance with the resident examinee. This conversation includes:

1. Asking the resident how they felt they did. 
2. Discussing whether the resident made any anesthetic decisions that were unsafe, i.e. made the patient’s condition worse, or that led to a poor outcome.
3. Discussing whether the resident answered the questions by describing what he or she would do. (This is the key to succeeding in oral examinations.)
4. Discussing the resident’s communication and presentation skills, i.e. did they have effective eye contact, a confident speaking tone, and acceptable body language?
5. Discussing whether the resident projected a fund of knowledge acceptable for their level of training.

Advice to Faculty Examiners on how to best perform a Mock Oral Exam:

1. If you know the examinee personally, conduct the exam as if this was the first time you’d met them, i.e. they are “Dr. Examinee,” not “Justin,” or “Jennifer.”
2. Read each question within the stem to the examinee, and listen to how they answer. Your job is to assess the examinee’s expertise in managing challenging anesthesia circumstances. If their answer is correct, quickly move on to the next question so you can test them on a new aspect of the patient care.
3. Anytime an examinee introduces a new drug or a new test or a new fact into their answer, consider digging deeper by asking, “What is _____? What do you know about ____?”
4. Don’t give immediate feedback after an answer by saying “OK.” Don’t reveal correct answers to the examinee during the exam.
5. The examinee should not be asking you questions. If you are asked a question, deflect it by re-asking your previous question.
6. Interject unexpected complications into each patient management, e.g. the blood pressure rises markedly or falls markedly, the pulse rate rises markedly or falls markedly, the oxygen saturation falls markedly. Find out what the examinee’s answer is in terms of differential diagnosis of the cause, and what their action(s) would be to correct the complication.
7. Evaluate whether the examinee manages anesthesia and complications safely.
8. Include a management of a difficult airway situation. The quickest way for an examinee to fail an oral exam is to lose an airway. 
9. The purpose of the three extra cases in the last 10 minutes of the exam is to assess the examinee’s performance in areas that weren’t covered by the stem question, i.e. to round out the examination of pediatric, neuro, obstetric, cardiothoracic, pain, or regional anesthesia knowledge.
10. Pay attention to the examinee’s body language, their eye contact, the confidence of their verbal answers, and their fund of medical knowledge. Does the candidate speak and answer like a consultant in anesthesiology would?

The University of North Carolina Department of Anesthesiology also administers twice yearly Mock Oral Board Exams. They videotape each exam so that each resident’s performance can be reviewed at a later date. 

Writing Mock Oral Questions is not difficult. Performing the role of an examiner is not difficult. Prior to the exam, faculty examiners can look up the answers after reading through the questions, if they don’t know that specific area of anesthesia knowledge. 

Beyond the role of faculty members providing a Mock Oral Exam program, it’s also possible for examinees to prepare and give Mock Oral Exams to each other on their own time, as an opportunity for practicing and honing their verbal answering skills.

I recommend a Mock Oral Exam program as a key step toward passing the ABA Standardized Oral Exam, and toward becoming a board-certified consultant.

 in our field. As stated above, the only way to rehearse the verbal skills necessary for an oral exam is take practice oral exams. Good luck! 

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The most popular posts for laypeople on The Anesthesia Consultant include:
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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM