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Preparing for Oral Boards
E. Steele, M.D.May 2006
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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
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The Big Day
You are assigned and day and time toreport 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
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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 anda glass of water
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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 begingrab-bag questions
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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 youproceed?
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A busy week
Each day there are about 5 sessions,each session has several orientationrooms, each orientation rooms has about20 applicants for five days in a row. Thismeans 900 to 1000 people are taking oralexaminations the same week as you!
Lots of nervous people in the lobby Lots of anxious people leaving the lobby
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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
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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 andapplying decisions
Ability to assimilate and analyze data so as to arrive at a rationaltreatment 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 tochanging clinical conditions
Ability to communicate effectively about those issues of specificrelevance to anesthesia care and also those topics of generalmedicine which are crucial to the care of patients with diversediseases.
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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 anesthetizingpatients and managing complications anddevelopments
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Pitfalls
PPPPPP prior planning You must practice OUT LOUD!!!
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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 duringthoracotomy: how do I do that? Hmmm.
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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
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Problems from Board Stiff Too, UWDept 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 (H&P/airway)
Not showing proper urgency Not stating pros and cons, not indicating if a
choice is controversial
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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
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Cookbook approach Using unfamiliar techniques Not calling neonatalogist at beginning of
difficult OB case Forgetting Abx for heart lesions
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How do I actually take the exam
How to dissect the question or what to dowith your ten minute allotment
Brainstorm!
Write down as much as you can about thecase. Youll want to refer to your noteslater.
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Timing
Emergency just go with it and manage!
Urgent time for a few studies? Labs? Butprob. Needs to go today
Elective Do all you want
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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!
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Anesthetic planning
Preoperative assessment Pre-op preparation: organ systems Premeds
Monitors Choice of technique Induction
Maintenance Emergence/Extubation Post-op
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Pre-op assessment
History and physical Labs
Consults Studies: invasive and non-invasive
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Organ systems
Patients comorbidities Expected and anticipated problems
Management
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Monitoring Standard monitors Cardiovascular
A line CVP PA Echo
Neurologic Twitch ICP SSEP
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Anesthetic technique
Many choices but each patient gets one(in general)
Pick one and defend it Lay out your reasoning
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Induction
Agents Options
Problems Propofol may drop CO too much in this frailpatient with AS
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Maintenance
Not much on how youre going tomaintain: air/iso/remi etc.
But critical incidents happen here Hypoxia Hypotension Tachycardia
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Emergence and extubation
Not waking up? Life-threatening: hypoxia, hypotension,
hypoglycemia, brain bleed Big hitters: drug, metabolic, neurologic
Not ready to extubate? Transport issues
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Post-op
Pain Oxygenation/Ventilation
Fluids Cardiovascular management
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Critical Incidents
List from Wrights handout Mechanics Manual from Board Stiff Too
Know your algorithms! Expect to see difficult airway and hypoxia
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Lets try it!
61 year old man scheduled for lumbar lamiat 11:30am
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
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Case #2
62 yo woman s/f thyroidectomy andr.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