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Preparing for the ABR oral exam: a residents guide

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Dr. Stephen Humes

Copyright 2004 AuntMinnie.com

Preparing for the ABR oral exam: a residents guide

This document is meant to provide residents with a guide to prepare for the final phase of their training: the American Board of Radiology (ABR) oral exam. At the most basic level, the main thing that kept me settled during the whole process was my deep-seated belief that the examiners want you to pass. They are there to help you pass. They really are. You will hear this from those who have gone before, yet it always seemed the hindsight perspective was all too easily shared. Its hard to see this as the days wind down to the exam. But it's true. No examiner gave the impression that he or she was "out to get me." One examiner had even set up a nice little wet bar and candy because he thought it might help. Another kept asking me if I wanted to rest between cases. So when its hard to breathe and the anxiety sets in, remember the above. It helps. This guide contains the following items: A section on how the exam is graded A list of the key books and resources you should know An overview of some review courses Scheduling review sessions An approach to individual cases Pearls on boardsmanship Some advice on taking the exam

So thats it in a nutshell. Nows your chance to actually learn more than youll ever know again, so dig in and go for it. Dr. Stephen Humes

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How the exam is graded

Each section is held in a different hotel room at the exotic Executive West Hotel in Louisville, KY. You will know which section you are being examined in, and there are no normal cases. You will have approximately 22 minutes per section. Scoring is based on a scale of 68-72. Your case score is based on observation, synthesis/impression, and management. The overall score is rounded down, which is not the most comforting thought. Heres how it works: Scoring 72 -- outstanding (You know more than the examiner; its a score thats not given that often). 71 -- good (You know as much as the examiner). 70 -- satisfactory (Youre not deemed dangerous). 69 -- unsatisfactory (Youre not quite killing patients). 68 -- thoroughly unsatisfactory (You're killing patients). Observation 72 -- comments on all pertinent positive and negative findings. 71 -- sees all major and most secondary findings. 70 -- sees the major findings but needs aid in identifying secondaries. 69 -- detects major findings, but only with assistance. 68 -- misses major findings, or worse, thinks a major finding isnt important. Synthesis/impression 72 -- Confident limited differential with most likely diagnosis mentioned first. 71 -- Good differential, but in the wrong order. 70 -- Some inappropriate but not dangerous differentials. 69 -- Rote differential unrelated to the case at hand. 68 -- Fails to mention critical diagnosis. Management 72 -- correct management offered without asking. 71 -- management handled well, but not accurately. 70 -- adequate management with prompting. 69 -- unaware of important management issues. Inappropriate follow-up study recommendations. 68 -- dangerous management. Inappropriate invasive tests.

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The key books

There are 10 sections that make up the exam: Musculoskeletal Cardiopulmonary Gastrointestinal tract Genitourinary tract Neuroradiology Vascular and interventional Nuclear radiology Ultrasound Pediatric radiology Breast radiology

The following is a list of suggested books that you should get familiar with as you prepare for the exam. Please note that these are only suggestions. Keep current with the new books as they come out and listen to others for what they recommend. Note that you wont be able to read all these. Note also that you should take advantage of the window between taking the written boards and the start of the oral exam reviews to read aggressively if you havent read throughout residency. Once the reviews start, you dont want to be reading through things for the first time. You want the reviews to be just that -- reviews. Musculoskeletal Fundamentals of Skeletal Radiology by Helms, C., 2nd ed., Elsevier Science, St. Louis, 1994. Note that the entire book is a part of Fundamentals of Diagnostic Radiology by Brandt, W., Helms, C., 2nd ed., Lippincott, Williams & Wilkins, Philadelphia, 1998. Case Review: Musculoskeletal Imaging by Yu, J., Elsevier Science, St. Louis, 2001. Contains all the key cases you need to know. Musculoskeletal Imaging: A Teaching File by Chew, F., Maldjian, C., Leffler, S., Lippincott, Williams & Wilkins, Philadelphia, 1999. Great first chapter on hand radiographs.

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Musculoskeletal MRI by Kaplan, P., Helms, C., et. al., Elsevier Science, St. Louis, 2001. Just buy it. Youll need it the rest of your career. Arthritis in Black and White by Brower, A., 2nd ed., Elsevier Science, St. Louis, 1996. A great book on heavily tested boards material. Orthopedic Radiology by Weissman, B., Sledge, C., Elsevier Science, St. Louis, 1986. Great for fractures.

Cardiopulmonary Radiology of Thoracic Diseases: A Teaching File by Swenson, S., Elsevier Science, St. Louis, 1992. Another classic that is out of print. It has all the key cases. High-Resolution CT of the Chest: Comprehensive Atlas by Swensen, S., Stern, E., Lippincott, Williams & Wilkins, Philadelphia, 1995. All the key cases. Good book to have on an important topic. Case Review: Thoracic Imaging by Boiselle, P., McLoud, T., Elsevier Science, St. Louis, 2001. On par with the other titles in the Case Review series. Imaging of the Chest: A Teaching File by Mergo, P., Lippincott, Williams & Wilkins, Philadelphia, 2002. Perhaps the new classic. Written by an examiner. Cardiovascular MRI & MRA by Higgins, C., de Roos, A., Lippincott, Williams & Wilkins, Philadelphia, 2003. Great book for all the cases you will need to know.

Gastrointestinal Alimentary Tract Imaging: A Teaching File by Johnson, C., Elsevier Science, St. Louis, 1993. Yet another out-of-print classic for all the barium you will need. Four of my ten cases in GI were barium. Case Review: Gastrointestinal Imaging by Feczko, P., Halpert, R., Elsevier Science, St. Louis, 2002. Gastrointestinal Radiology: A Pattern Approach by Eisenberg, R., Lippincott, Williams & Wilkins, Philadelphia, 2002. The standard resident text on the subject. Filled with barium. A smaller paperback version is available and sufficient. Textbook of Gastrointestinal Radiology by Gore, R., Levine, M., 2nd ed., Elsevier Science, St. Louis, 2000. A really big set of two books, but easy to read and contains a great chapter on the key descriptors for barium studies (Chapter 5, Pictorial Glossary of Double Contrast Radiology).

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CT and MRI of the Abdomen and Pelvis: A Teaching File by Ros, P., Lee, S., Lippincott, Williams & Wilkins, Philadelphia, 1997. A great text to have -- all the standard cases, good differentials. A must read. The Abdominal Plain Film with Correlative Imaging by Baker, S., Cho, K., 2nd ed., McGraw-Hill Professional, New York, 1999. A classic radiology text filled with plain films. You will be shown a plain film, and asking for a CT will only irritate the examiner.

Genitourinary Textbook of Uroradiology by Dunnick, N., Sandler, C., Newhouse, J., Amis, Jr., E., 3rd ed., Lippincott, Williams & Wilkins, Philadelphia, 2001. This is probably one of the best radiology texts. Its current, succinct, and has everything you need for boards and for practice. Dr. Dunnick was at the oral exams in 2003. CT and MRI of the Abdomen and Pelvis: A Teaching File by Ros, P., Lee, S., Lippincott, Williams & Wilkins, Philadelphia, 1997. The chapters on the kidneys and retroperitoneum are good. Case Review: Genitourinary Imaging by Tung, G., Mayo-Smith, W., Zagoria, R., Elsevier Science, St. Louis, 2000. Another in the Mosby series. Clinical Imaging: An Atlas of Differential Diagnosis by Eisenberg, R., 4th ed. , Lippincott, Williams & Wilkins, Philadelphia, 2003. A classic text, with tons of IVUs for your viewing pleasure. Good for other subjects as well. Genitourinary Radiology: The Requisites by Zagoria, R., Tung, G., Elsevier Science, St. Louis, 1997. An alternative to the Dunnick text mentioned above. Many people swear by it.

Neuroradiology Neuroradiology Companion: Methods, Guidelines and Imaging Fundamentals by Castillo, M., 2nd ed., Lippincott, Williams & Wilkins, Philadelphia, 1999. Just buy this one -- it will do nothing but help you through life. Great for a quick prep before review sessions. Fairly comprehensive. Diagnostic Neuroradiology by Osborn, A., Elsevier Science, St. Louis, 1994. The queen of the Armed Forces Institute of Pathology. Buy this one if you want to understand neuro. No longer being published, so get it while you can. Neuroradiology: The Requisites by Grossman, R., Youssem, D., 3rd ed., Elsevier Science, St. Louis, 2003. A favorite among residents and book thieves. Fun to read.

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Spine Imaging: Case Review by Bowen, B., Elsevier Science, St. Louis, 2001. Buy one of your very own. A high-end text with all the most important cases. Head and Neck Imaging: Case Review by Youssem, D., Elsevier Science, St. Louis, 2001. Another in the Mosby series, with some good jokes along the way. All the key cases and then some. Brain Imaging: Case Review by Loevner, L., Elsevier Science, St. Louis, 2001. Yet another in the Mosby series. Magnetic Resonance Imaging of CNS Disease: A Teaching File by Yock, D., Elsevier Science, St. Louis, 2002. This book has a neat index that allows you to see lots of cases quickly. Nice for when youre wrapping up your review. Neuroradiology, Continuous Professional Improvement Program, American College of Radiology, Reston, VA. Quick hits for important cases. Two of my neuro cases came straight from this text. There are modules for all 10 areas included on the ABR exam.

Vascular and interventional Recognition and treatment of reactions to contrast media: a model for resident and faculty education employing lectures and case scenario workshops, by Echenique, A.M., Joseph, R., Casillas, V.J., Academic Radiology, March 1997, Vol. 4:3, pp. 230-234. Interventional Radiology Essentials by Laberge, J., et. al., Lippincott, Williams & Wilkins, Philadelphia, 2000. A short comprehensive text on the subject. Shows you all the key pictures. Atlas of Normal and Variant Angiographic Anatomy by Kadir, S., Elsevier Science, St. Louis, 1991. Shows you just what the title says. Some residents have said they get straight anatomy questions on angio. Syllabus Series by Society of Interventional Radiology. These have nice cases with appropriate management at the end of each book in the series. Cardiovascular Radiology by Gedgaudas, E., Elsevier Science, St. Louis, 1985. An oldie, but a goodie. Great diagrams of congenital heart disease and the radiographic manifestations. Dated in terms of modalities, but the disease and the anatomy are unchanged. For those who want to understand.

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Nuclear radiology Nuclear Medicine on the Internet by Williams, S., AuntMinnie.com, 2004. This is free to you and hands-down the best text on nukes. Gets you through all the written board questions. Download it and read during those long slow mornings. Will also help you later in practice. Use one of the teaching file books below in conjunction with this text. Essentials of Nuclear Medicine Imaging by Mettler, F., et. al., 4th ed., Elsevier Science, St. Louis, 1998. This is the one book on nukes you should buy. Short, comprehensive. All the most important cases with images. All the protocols are neatly tucked away in the back. The chapter on cardiac is among the best, and you need to know the protocols and the artifacts and the significant findings -- all of which Mettler shows you. Dated in terms of PET. Nuclear Medicine Imaging by Habibian, M., Lippincott, Williams & Wilkins, Philadelphia. A big book with lots of pictures and thorough discussions. A bit overwhelming, however, unless youre a nucleon. Just look at the pictures in conjunction with the Williams text. Nuclear Medicine: A Teaching File by Datz, F., et. al., Elsevier Science, St. Louis, 1992. An abbreviated Habibian, but out-of-print. Short but sweet.

Ultrasound Diagnostic Ultrasound by Rumack, C., Charboneau, J., Wilson, S., 2nd ed., Elsevier Science, St. Louis, 1998. One of two texts to have. You need both volumes because the ABR wants you to know obstetrics ultrasound. You will be shown several cases, so Volume II is important, too. An easy read, even though the size is intimidating. General and Vascular Ultrasound: Case Review by Middleton, W., Elsevier Science, St. Louis, 2002. The only other text you need to prepare for the ultrasound portion of the exam. Imaging in Obstetrics and Gynecology by Abbitt, P., Lippincott, Williams & Wilkins, Philadelphia, 1997. This great text takes you through the blighted ovum to the trisomies to the hydrops to SIN and the hysterosalpingograms. Ah, the uterus in its many manifestations. Its a lot of information to tag on at the end of your training as a senior. A word of advice: Go to your ob/gyn rotation, not the library. You will learn more from the technologists there in one week than a month of study in the library. Just follow them around, interact, and you will learn everything you need to know.

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Ultrasound: The Core Curriculum by Brant, W., Lippincott, Williams & Wilkins, Philadelphia, 2001. A nice new book thats a quick read/review. Good for firstyears through seniors. Ultrasound: Radiology Requisites Series by Middleton, W., Kurtz, A., Hertzberg, B., Elsevier Science, St. Louis, 2003. A standard favorite among residents. The anatomy chapters in RUQ are the first images you will be shown in the oral exam -- guaranteed.

Pediatric radiology Fundamentals of Pediatric Radiology by Donnelly, L., Elsevier Science, St. Louis, 2001. Just buy it. This is one of the best little texts around: well organized, well written, and relevant to the boards and professional practice. Good differentials listed in each chapter. Pediatric Radiology Casebase: The Baby Minnie of Pediatric Radiology by Seibert, J., Thieme, New York, 1998. This is your best book for cases at this point in time. The pictures are of poor quality, but the discussions, management, and differentials are very well done. Pay close attention to the chapter on syndromes, as any disease entity containing the key phrase This rare congenital anomaly is fair game for the boards. Practical Pediatric Imaging: Diagnostic Radiology of Infants and Children by Kirks, D., Griscom, N., Lippincott, Williams & Wilkins, Philadelphia, 1998. Another classic. Great chapters on bone and the dreaded/loathed congenital heart disease. This book contains great diagrams of all the congenital hearts. More helpful for the written boards.

Breast radiology Breast Imaging Companion by Cardeosa, G., 2nd ed., Lippincott, Williams & Wilkins, Philadelphia, 2001. This book has it all -- screening, diagnostic, how to do procedures, BI-RADS stuff. Teaching Atlas of Mammography by Tabr, L., Dean, P., Tot, T., 3rd ed., Thieme, New York, 1994. A nice quick read for those trying to catch up. Good for practice of BI-RADS descriptors. Diagnostic Breast Imaging: Mammography, Sonography, Magnetic Resonance Imaging, & Interventional Procedures by Heywang-Kbrunner, S., Dershaw, D., Schreer, I., 2nd ed., Thieme, New York, 2001. A really nice, albeit expensive, book. Covers it all, including breast MRI. Well-written, but does not speak the BI-RADS talk.

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One note concerning mammo: This field likes to reference the literature rather than textbooks. So, on the oral boards, you can describe the ultrasound however you want, but if you say something such as, Stavros criteria for a malignant lesion include, it may help to get you out of the section early. Miscellaneous IRAD: Interactive Radiology Review & Assessment by Chew, F., Kline, M., Whitman, G., Lippincott, Williams & Wilkins, Philadelphia, 2000. This CD-ROM is a must do, some say just before the exam. Creative format allows a variety of interaction methods. Closest experience to the real thing. Duke Radiology Case Review: Imaging, Differential Diagnosis, and Discussion by Provenzale, J., Nelson, R., et. al., Lippincott, Williams & Wilkins, Philadelphia, 1998. An older but classic text. Good discussions and brief. Radiology Recall by Gay, S., Woodcock, Jr., R., Lippincott, Williams & Wilkins, Philadelphia, 2000. A simple little text that goes a long way toward getting you to where you need to be. Handy for a quick read before morning conference at all levels. Anatomy in Diagnostic Imaging by Fleckenstein, P., 2nd ed., Elsevier Science, St. Louis, 2001. A word of advice: before starting to study for any section, review the anatomy first. This book contains it all.

Miscellaneous documents The following are some documents that discuss general principles of boardsmanship that you may or may not find helpful. Take them with a grain of salt. They include the following: ReadySetGo! How to Prepare for the Oral Board Examination: The 20 Most Important Things to Know or Do by Schreiber, M., American Board of Radiology, Tucson, AZ. The document is available here at the ABR Web site. A copy of the exam schedule to give you an idea of how the day is structured.

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Review courses
The following is some information on a couple of review courses for the exam. It is your decision whether or not to attend one of these types of courses. Most will tell you it doesnt make you or break you. The Duke Review The most famous review course is the Duke review. It is very well organized, and you get to hear some of the leaders in radiology speak for a couple of hours on boards-directed topics. Is it worth $800? I think so. Do you have to attend the course? Not necessarily. I found it most helpful in the lectures on ob/gyn, which I didnt get much exposure to during residency. Also helpful were the evening case conferences. Tons of images are presented over the course of the week. It is kind of an endurance experience, however. Its biggest limitation is that you dont get to take cases yourself (they do provide the opportunity, but most go to the big lecture hall because they are able to show more cases). Below is the contact information: Debbie Sykes 919-684-7228 www.radweb.mc.duke.edu If you do decide to go, register early and get a room in the hotel where the conference is held. You dont have much free time to be driving back and forth between hotels. Theres a great gym next door, and in 2003 you could buy a weeks pass for $25, which is time and money well spent.

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Hot Seats Conference in Gainesville, FL I found this course to be the perfect compliment to the Duke review, which is usually held one or two weeks earlier than the Gainesville conference. Here, you do nothing but take cases. They sprinkle one or two hours of lecture here and there, but otherwise, its three days of cases. The course is limited to 100 participants, each broken into groups of 20. They cover all ten board sections, and they exposed you to cases you dont typically see (cardiac MR, ENT, lots of GU, and GI fluoro). They teach you how to take these cases. The University of Florida has lots of boards examiners on their faculty, and I think they consider this a warm-up for the actual exam, Youll definitely benefit from their direction. They provide critiques of your approach, and you get to work with fellow residents from around the country. Even though it sounds intense, its really not. I grew to like the Gators. They offer the course at a really nice facility, and the food was excellent. Below is the contact information: University of Florida 352-265-0291, ext 44317 205-467-3158 The course is expensive ($1,300). If you have the time and money, go for it, but register early (January), as it fills quickly.

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Scheduling review sessions

In-house review is perhaps the most debatable aspect of preparing for the oral exam. Do it however you wish, but realize that this is the most important aspect of preparing for the exam. Anyone will tell you that its not the Duke review or the ACR discs that get you into passing mode, but the review sessions that you undertake on your own and/or with your peers. Nothing beats taking the case yourself. If you get it, thats great and you can move on. If you miss it, thats great (or rather OK) too, because missing a case in public can leave an indelible mark on your psyche. And the only way you know whether or not you know it is by taking the case. No one person can coordinate all the reviews; it takes too much time and effort. We broke it down into section coordinators, with each of the seniors taking a section or two and being responsible for the reviews. We started in January, after the holidays, giving us 20 weeks before the oral exams. Everybody said this was starting early, but come late April or early May, you'll be glad you started early. Ten sections. Twenty weeks. Thats only two weeks for each section if you start this early. We placed the schedule on the Internet (calendar.yahoo.com), which allowed for communication with residents at our other facilities, which was key. Everyone knew to check the schedule here for changes, and it worked well. Some general comments: The reviews are reviews, not learning sessions. Going unprepared to a review is not high-yield. Also, the reviews aren't intended to be learning sessions. For every question that is asked, that is one less case the others will see. Talking while someone else is taking a case is unacceptable. A lot of people do it, and its really their parents fault for not raising them better. Take advantage of the fellows who are hanging around. Their memory of the oral boards is fresh in their mind, and they know what to emphasize.

During the last month, I enlisted anyone and everyone to practice with me, taking 10-12 cases in a row. This is key. It is what you will be doing in Louisville, and I highly

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encourage it. Its important that you get practice at doing this, and get to where youre doing cases fast. One word of advice that a reviewer provided: be careful with recalls, as they may prejudice you into seeing something thats not really there. This happened to me during one of the early review sessions, and its a good lesson to learn. Its OK to have an idea of what has been shown, but take each case on its own.

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An approach to individual cases

The following is a general outline on how to approach individual cases:

Approach:

Gunslinger? Modality description Terminology History-directed discussion Finding characterization Appropriate associated findings Positive / negative findings Mention extra topics ? extra quizzing Appropriate recommendation of other imaging

Discussion:

Differential:

Most likely first Appropriate without excess Stops when appropriate

Knowledge base:

Of #1 differential Of differential

Overall:

Degree of confidence Safe patient management

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Boardsmanship
The following is a compilation of advice given by various board examiners and fellows while doing the review sessions. Take it for what its worth. In retrospect, most of these admonitions were right on the money: Confine your discussion to the findings -- some cases you should respond to quickly (ruptured AAA). Never criticize the quality of a film. Demonstrate an organized approach. List three things in your differential diagnosis (ddx). Be prepared to answer the question: What do you think it is? Base your ddx on the images before you. Listing everything it could be shows memorization and insecurity rather than a focus on the case at-hand. Show a logical progression of thought. Be simple and practical. The whole idea is to recognize the findings, describe them, and synthesize them into a reasonable ddx. Look, think, and then speak. Its OK to say, I dont know. Speak Up! Put the last case behind you. Concentrate on the case in front of you. Get all you can from the plain films before requesting an additional study. Never give up. Think of the oral boards as a series of small speeches -- when you make a finding; be prepared to give a little talk. Avoid the tendency to shotgun, especially if youre doing well. Take each case on its own merit according to your own game plan. Say what you think the diagnosis is on the initial study. Then request a specific study to confirm what you think the diagnosis is (i.e. sagittal knee T2 with kissing contusions, then get PD image to evaluate ACL). If your finding is not confirmed on the subsequent exam, go back to the original study to look again for additional findings.

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Be as descriptive as you can. Make all the findings before launching into your ddx. Say what you think it is first. What do you want to see? Make a directed request for an additional study. Dont ask, Do you have any additional images? Ask for the specific study you want to see and why you want to see it. If you dont see a finding, describe as much as you can. Then you can say, At this point, I would check clinical indication for exam and request additional studies accordingly. Ignore the obvious finding at first. Do a quick search for secondary signs which may help you narrow the differential of the major finding (e.g., myxopapillary ependymoma). Know discriminators (if the patient has pain, think pseudotumor). Also refer to Helms MSK book (Fundamentals of Skeletal Radiology by Helms, C., 2nd ed., Elsevier Science, St. Louis, 1994.). Correlate anatomy with what you are studying. Some of the questions (your first few images in ultrasound -- guaranteed) are nothing more than straight anatomy. Know sagittal anatomy of brain. Make a targeted differential diagnosis for a specific age group -- let the examiner see why you are saying something (if this patient has a history of recent travel, I would be concerned for schistosomiasis). Give information to justify the category of disease you are considering. Contrast reaction/acute hemorrhage/herniation: Show that you recognize the severity of acute findings -- what will you do? Contrast reaction: I am running to the exam room, concerned about airway compromise or cardiovascular collapse, and calling a code. I am contacting the ER physician about impending herniation and recommending a neurosurgical consult. I would contact the referring clinician immediately concerning these findings. Remember: this is a test of competence, not of rote memorization. The examiner mainly wants to know if you are safe. Think of the experience as if you are moonlighting in an ER and the physician comes to you with a question. The orals are mainly about pattern recognition, and less so on the pathophysiology and details of a disease process. When taking a nuclear case such as a bone scan, recommend plain film or clinical correlation. Always have a cxr when looking at a VQ scan. If you think youve got it, give the ddx, and stop talking.

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Wilms tumor mets: The way to get a definitive diagnosis is percutaneous biopsy. Show you can manage the patient and that you are already thinking about the patient clinically. Recommend percutaneous biopsy, cystoscopy, etc. If you use the category of neoplasm, how would you prove it? If it is not a neoplasm, what else could it be? Usually go for neoplasm last, so as to not forget about the other categories (e.g., vascular, inflammatory, etc.). Words to avoid: dilatation (use dilation); serpentine (use serpiginous); IVP (use IVU). Delete the phrases It appears and I guess from your vocabulary. It makes you sound weak. The examiners are looking for (and will grade you on) your confidence. If a case comes up and you know what it is, be inwardly joyous but outwardly humble. Walk through it logically, and score as much as you can. You arent scoring points if youre not talking. If finished, wrap up, and look up. You must offer management. You get extra points if you do so.

Start taking cases now and cultivate these habits, as anyone will tell you that the bad habits you have will surface under the pressure of the oral exam. Get them out of your system sooner rather than later. Do it in morning conference rather than in front of the person who wrote the textbook.

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On taking the exam

The following is a helpful checklist to keep in mind the day of the exam, courtesy of Dr. Melissa Glantz: Know the details of transportation and your hotel. Plan for delays and mishaps. Know where you will get breakfast. Eat breakfast. Wear an appropriate suit. Do not carry a purse or briefcase. Greet the examiner and smile. Be sure the chair is in a comfortable position for you. Sit on the front half of the chair, feet flat on the floor, and sit forward. Do not touch the screen. When the first image comes up, repeat the section you are in to yourself. Give yourself a full five seconds to evaluate the image before speaking. Describe the study type, contrast used, part of the body, and projection. Be as descriptive as possible. Dont criticize the study quality. Be systematic. Do not act like a gunslinger, even if the answer is screaming out at you.

If you dont see a finding, start by examining the image and describing what you do see. Once you make the finding, listen to yourself describe it. Only make pertinent positive and negative statements that you may wish to expound on. Copyright 2004 AuntMinnie.com

For interventional procedures, memorize one way of doing it. Start your diagnostic diagnosis with the most likely diagnosis. Only give a few possibilities. Support each diagnosis with a confirmatory statement (i.e., If the patient has an elevated white count, I would favor PID. If the Beta is positive, I cannot exclude an ectopic).

If you would like to confirm or look for additional findings with another modality, suggest what you would normally do and what you expect to see on that study. The examiner may put up that study. Do not ask, Do you have a CT? If you screw up a case, let it go. Concentrate on the case before you. Examiners tend to start with an easier warm-up-type case and then move to harder cases. Many of the cases are the largest or worst case of X that you have ever seen -believe it. The ABR does not want this to be an eye test, so if it is the right location, age group, and imaging appearance, go with your gut. Practice the no-feedback rule. The cases will come down, and you wont know whether or not youre right. It is unnerving but will prepare you for the lack of positive or negative reinforcement you normally anticipate in boards. If you are let out before the first bell, you have definitely passed. Examiners are required to show you as many cases as possible if you are on the verge of conditioning/failing. You are rewarded for being a reasonable radiologist acting in a rational manner, reading the films at the level of standard care for a generalist. Always remember your section. Go with your first instinct. Learn when to shut up.

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