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Preparing for Oral Boards E. Steele, M.D. May 2006.

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Presentation on theme: "Preparing for Oral Boards E. Steele, M.D. May 2006."— Presentation transcript:

1 Preparing for Oral Boards E. Steele, M.D. May 2006

2 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

3 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

4 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

5 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

6 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?

7 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

8 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

9 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.

10 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

11 Pitfalls PPPPPP –prior planning… –You must practice OUT LOUD!!!

12 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….

13 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

14 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

15 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

16 Cookbook approach Using unfamiliar techniques Not calling neonatalogist at beginning of difficult OB case Forgetting Abx for heart lesions

17 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.

18 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

19 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!

20 Anesthetic planning Preoperative assessment Pre-op preparation: organ systems Premeds Monitors Choice of technique Induction Maintenance Emergence/Extubation Post-op

21 Pre-op assessment History and physical Labs Consults Studies: invasive and non-invasive

22 Organ systems Patient’s comorbidities Expected and anticipated problems Management

23 Monitoring Standard monitors Cardiovascular –A line –CVP –PA –Echo Neurologic –Twitch –ICP –SSEP

24 Anesthetic technique Many choices but each patient gets one (in general) Pick one and defend it Lay out your reasoning

25 Induction Agents Options Problems –Propofol may drop CO too much in this frail patient with AS

26 Maintenance Not much on how you’re going to maintain: air/iso/remi etc…. But critical incidents happen here –Hypoxia –Hypotension –Tachycardia

27 Emergence and extubation Not waking up? –Life-threatening: hypoxia, hypotension, hypoglycemia, brain bleed –Big hitters: drug, metabolic, neurologic Not ready to extubate? Transport issues

28 Post-op Pain Oxygenation/Ventilation Fluids Cardiovascular management

29 Critical Incidents List from Wright’s handout Mechanic’s Manual from Board Stiff Too Know your algorithms! Expect to see difficult airway and hypoxia

30 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

31 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

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