Tag Stanford Anesthesia

ADVICE FOR PASSING THE ORAL BOARD EXAMS IN ANESTHESIOLOGY

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THE ANESTHESIA CONSULTANT
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
THE ANESTHESIA CONSULTANT
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As a faculty member on the Stanford Department of Anesthesiology, Perioperative and Pain Medicine, I enjoy the opportunity to give mock oral exams to the Stanford residents. First-year residents struggle mightily, while third-year residents are experienced and savvy. Taking six mock oral exams during a three-year anesthesia residency is valuable preparation for the real American Board of Anesthesiology exam. Based on decades of experience, here is my advice for passing the oral board exams in anesthesiology.

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.

You’ve heard that 20% of examinees fail the oral exam, and you’re worried. What should you do? 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.

Preparation:

  1. 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.
  2. 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.
  3. Download and memorize the algorithms in the Stanford Emergency Manual/Cognitive Aid for Perioperative Critical Events.
  4. Find board-certified anesthesiologists who are willing to give you mock-oral practice exams. It helps.

Taking the actual oral board exam test:

  1. 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.”
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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?)
  7. Remember Airway-Breathing-Circulation, in that order. Don’t harm a patient by losing the airway. Know the ASA Difficult Airway Algorithm by heart.
  8. 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.
  9. 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.
  10. Try not to ask questions. Use your time to answer questions.
  11. There is no one right answer for most clinical scenario questions. Just be prepared to justify why you chose the plan you chose.
  12. 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.
  13. If you don’t know an answer, it’s better to say “I don’t know” than to blunder and guess.
  14. Make eye contact with the examiners throughout. Speak confidently and talk to them like a colleague.
  15. “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.
  16. 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:

  1. 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?
  2. What is ankylosing spondylitis? What are the anesthetic risks?
  3. 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?
  4. Define morbid obesity. Is this patient morbidly obese? How does obesity affect pulmonary physiology? Discuss the anesthetic risks associated with morbid obesity.
  5. Do you need a cardiology consult preoperatively? Why? Why not?
  6. 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:

  1. What monitors will you use for the surgery? Why? You are unable to insert an art line. What will you do?
  2. 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.
  3. What maintenance anesthetic would you use? Why would you choose sevoflurane over isoflurane? What is MAC? How does the MAC vary with patient age?
  4. 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?
  5. The oxygen saturation drops to 85% intraoperatively. What would you do, both diagnostically and therapeutically?
  6. 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?
  7. 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):

  1. 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?
  2. 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?
  3. 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?

Additional advice:

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.

Good luck!

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below:

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KEEPING ANESTHESIA SIMPLE: THE KISS PRINCIPLE

THE ANESTHESIA CONSULTANT 4 Comments
THE ANESTHESIA CONSULTANT
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
THE ANESTHESIA CONSULTANT
Latest posts by THE ANESTHESIA CONSULTANT (see all)

Clinical Cases:  You’re scheduled to anesthetize a 70-year-old man for a carotid endarterectomy, a 50-year-old man for an arthroscopic rotator cuff repair, and a 30-year-old woman for an Achilles tendon repair.  What anesthetics would you plan? “Keep It Simple, Stupid…” The KISS principle applies in anesthesiology, too.

 

Discussion:  In 1960, U.S. Navy aircraft engineer Kelly Johnson coined the KISS Principle, an acronym for “Keep It Simple, Stupid.” The KISS principle supports that most systems work best if they are kept simple rather than made complex. Simplicity should be a key goal in design, and unnecessary complexity should be avoided. The KISS Principle likely found its origins in similar concepts such as Occam’s razor, Leonardo da Vinci‘s “Simplicity is the ultimate sophistication,” and architect Mies Van Der Rohe‘s “Less is more.”

Let’s look at the three cases listed above.  For the carotid surgery, you choose an anesthetic regimen based on dual infusions of propofol and remifentanil, aiming for a rapid wake-up at the conclusion of surgery.  For the arthroscopic rotator cuff repair, you fire up the ultrasound machine and insert an interscalene catheter preoperatively.  After you’ve inserted the catheter, you induce general anesthesia with propofol and maintain general anesthesia with sevoflurane.  For the Achilles repair, you perform a popliteal block preoperatively.  After you’ve performed the block, you induce general anesthesia with propofol, insert an endotracheal tube, turn the patient prone, and maintain general anesthesia with sevoflurane and nitrous oxide.

All three cases proceed without complication.

Ten miles away, an anesthesiologist in private practice is scheduled to do the same three cases.  For each of the three cases she chooses the same anesthetic regimen:  Induction with propofol, insertion of an airway tube (an endotracheal tube for the carotid patient, and a laryngeal mask airway for the shoulder patient and the ACL patient, and an endotracheal tube for the prone Achilles repair), followed by sevoflurane and nitrous oxide for maintenance anesthesia and a narcotic such as fentanyl titrated in as needed for postoperative analgesia.  The carotid patient is monitored with an arterial line, and vasoactive drugs are used as necessary to control hemodynamics.

“Wait a minute!” you say. “Elegant anesthesia requires advanced techniques for different surgeries. Why would a private practitioner do all three cases with nearly identical choices of drug regimen?  Why would a private practitioner fail to tailor their anesthetic plan to the surgical specialty? Total intravenous anesthesia and ultrasound-guided regional anesthesia are important arrows in the quiver of a 21st-century anesthesiologist, aren’t they?”

In my first week in private practice, just months after graduating from the Stanford anesthesia residency program, the anesthesia chairman at my new hospital emphasized relying on the KISS Principle in anesthesia practice.  He stressed that the objective of clinical anesthesia wasn’t to make cases interesting and challenging, but to have predictable and complication-free outcomes. Exposing a patient to extra equipment (two syringe pumps), or two anesthetics (regional plus general) instead of general anesthesia alone, adds layers of complexity, and defies the KISS principle.

There are no data indicating that using two syringe pumps and total intravenous anesthesia will produce a better outcome than turning on a sevoflurane vaporizer.  There are no data demonstrating that combining a regional anesthetic with a general anesthetic for shoulder arthroscopy or Achilles tendon surgery will improve long-term outcome.

The KISS principle opines that most systems work best if they are kept simple rather than made complex, and doing two anesthetics instead of one adds complexity.  I’ve learned that an anesthesiologist should choose the simplest technique that works for all three parties:  the surgeon, the patient, and the anesthesiologist. The hierarchy from most simple to complex might look something like this:  (1) local anesthesia alone, (2) local plus conscious sedation, (3) a regional block plus conscious sedation, (4) general anesthesia by mask, (5) general anesthesia with a laryngeal mask airway, (6) general anesthesia with an endotracheal tube, or (7) general anesthesia plus regional anesthesia combined.  The combination of drugs used should be as minimal and simple as possible.

If all three parties (the surgeon, the patient, and the anesthesiologist) are okay with the patient being awake for a particular surgery, then the simplest of the first three options can be selected.  If any one or all of the three parties wants the patient unconscious, then the simplest option of (4) – (7) can be selected.

I’m not an opponent of regional anesthesia.  Ultrasound-guided regional anesthesia is a significant advance in our specialty for appropriate cases, and substituting regional anesthesia for a general anesthetic is a reasonable alternative. Compared with general anesthesia, peripheral nerve blocks for rotator cuff surgery have been associated with shorter discharge times, reduced need for narcotics, enhanced patient satisfaction, and fewer side effects (Hadzic A, Williams BA, Karaca PE, et al.: For outpatient rotator cuff surgery, nerve block anesthesia provides superior same-day recovery after general anesthesia.  Anesthesiology  2005; 102:1001-1007). On the other hand, meta-analysis has demonstrated no long-term difference in outcome between regional and general anesthesia for ambulatory surgery.  (Liu SS, Strodtbeck WM, Richman JM, Wu CL: A comparison of regional versus general anesthesia for ambulatory anesthesia: A meta-analysis of randomized controlled trials.  Anesth Analg  2005; 101:1634-1642). Why perform combined regional anesthesia plus general anesthesia for minor surgeries?  Are we doing regional blocks just to showcase our new ultrasound skills? If there is an ultrasound machine in the hallway and an ambulatory orthopedic patient on the schedule, these two facts alone are not an indication for a regional block. Patients receive an extra bill for the placement of an ultrasound-guided block, and economics alone should never be a motivation to place a nerve block.

In a painful major orthopedic surgery such as a total knee replacement or a total hip replacement, a regional block can improve patient comfort and outcome. This month’s issue of Anesthesiology a retrospective review of nearly 400,000 patients who had total knee or total hip replacement.  Compared with general anesthesia, neuroaxial anesthesia is associated with an 80% lower 30-day mortality and a 30 – 80% lower risk of major complications (Memtsoudis et al., Perioperative Comparative Effectiveness of Anesthetic Technique in Orthopedic Patients, Anesthesiology. 118(5):1046-1058, May 2013).

Many outpatient orthopedic surgeries performed under straight general anesthesia require only modest oral analgesics afterward.  I had general anesthesia for a shoulder arthroscopy and subacromial decompression last month, and required no narcotic analgesics post-op.  If I’d had an interscalene block, the anesthesiologist could have attributed my comfort level to the placement of the block.  No block was necessary.

Achilles repairs don’t require a combined regional–general anesthetic. Achilles repairs simply don’t hurt very much. One surgeon in our practice does his Achilles repairs under local anesthesia with the patient awake, and the cases go very smoothly.  Other surgeons in our practice insist that a popliteal block be placed prior to general anesthesia for Achilles repairs, a dubious decision because (a) it defies the KISS Principle, and (b) the surgeon has no expertise in dictating anesthetic practice.

Every peripheral nerve block carries a small risk. Although serious complications are unusual, risks include falling; bleeding; local tissue injury, pneumothorax; nerve injury resulting in persistent pain, numbness, weakness or paralysis of the affected limb; or local anesthetic toxicity.  Systemic local anesthetic toxicity occurs in 7.5–20 per 10,000 peripheral nerve blocks (Corman SL et al., Use of Lipid Emulsion to Reverse Local Anesthetic-Induced Toxicity, Ann Pharmacother 2007; 41(11):1873-1877).

Use the simplest anesthetic that works.  Assess whether combined regional–general anesthetics are necessary or wise.  I realize that complex anesthetic regimens are routine aspects of a solid training program, because residents need to leave their training program with a mastery of multiple skills.  But once you’re in private practice, my advice is to take heed of the KISS Principle.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

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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.

KIRKUS REVIEW

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:

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Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

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