24006608 preparing for oral boards

8/9/2019 24006608 Preparing for Oral Boards

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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

24006608 preparing for oral boards

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