Preparing for Oral Boards

E. Steele, M.D.
May 2006
 Overview
• Pass Written
• Application for Orals automatically mailed
to you
• Given in April & October
• You don’t get to choose
– But you can call and ask for a particular day
 The Big Day
• You are assigned and day and time to
report 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
 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 and
a glass of water
 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 begin
grab-bag questions
 Grab bag questions
• You don’t 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 you
proceed?
 A busy week
• Each day there are about 5 sessions,
each session has several orientation
rooms, each orientation rooms has about
20 applicants for five days in a row. This
means 900 to 1000 people are taking oral
examinations the same week as you!
• Lots of nervous people in the lobby
• Lots of anxious people leaving the lobby
 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
 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 and
applying decisions
– Ability to assimilate and analyze data so as to arrive at a rational
treatment 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 to
changing clinical conditions
– Ability to communicate effectively about those issues of specific
relevance to anesthesia care and also those topics of general
medicine which are crucial to the care of patients with diverse
diseases.
 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 anesthetizing
patients and managing complications and
developments
 Pitfalls
• PPPPPP
– prior planning…
– You must practice OUT LOUD!!!
 Problems as listed by the ABA
• Superficial knowledge
– If you don’t know it, you can’t 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 during
thoracotomy: how do I do that? Hmmm….
 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
– Don’t 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
Problems from Board Stiff Too, UW
Dept 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
• 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
• Cookbook approach
• Using unfamiliar techniques
• Not calling neonatalogist at beginning of
difficult OB case
• Forgetting Abx for heart lesions
How do I actually take the exam
• How to dissect the question or what to do
with your ten minute allotment

• Brainstorm!

• Write down as much as you can about the

case. You’ll want to refer to your notes
later.
 Timing
• Emergency – just go with it and manage!

• Urgent – time for a few studies? Labs? But

prob. Needs to go today

• Elective – Do all you want

 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!
 Anesthetic planning
• Preoperative assessment
• Pre-op preparation: organ systems
• Premeds
• Monitors
• Choice of technique
• Induction
• Maintenance
• Emergence/Extubation
• Post-op
 Pre-op assessment
• History and physical
• Labs
• Consults
• Studies: invasive and non-invasive
 Organ systems
• Patient’s comorbidities
• Expected and anticipated problems
• Management
 Monitoring
• Standard monitors
• Cardiovascular
– A line
– CVP
– PA
– Echo
• Neurologic
– Twitch
– ICP
– SSEP
 Anesthetic technique
• Many choices but each patient gets one
(in general)
• Pick one and defend it
• Lay out your reasoning
 Induction
• Agents
• Options
• Problems
– Propofol may drop CO too much in this frail
patient with AS
 Maintenance
• Not much on how you’re going to
maintain: air/iso/remi etc….

• But critical incidents happen here

– Hypoxia
– Hypotension
– Tachycardia
 Emergence and extubation
• Not waking up?
– Life-threatening: hypoxia, hypotension,
hypoglycemia, brain bleed
– Big hitters: drug, metabolic, neurologic
• Not ready to extubate?
• Transport issues
 Post-op
• Pain
• Oxygenation/Ventilation
• Fluids
• Cardiovascular management
 Critical Incidents
• List from Wright’s handout
• Mechanic’s Manual from Board Stiff Too
• Know your algorithms!
• Expect to see difficult airway and hypoxia
 Let’s try it!
• 61 year old man scheduled for lumbar lami
at 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
 Case #2
• 62 yo woman s/f thyroidectomy and
r.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