Just took the CE for the first time and passed. I found these forums to be helpful, so I wanted to chip in my experience. In short, I waited much longer than everyone advised, and also prepared much more than everyone advised, worked out ok.
I have 3 objectives with this writeup: a) give a review of the resources I used, because I felt the available information is inadequate, b) give an account of a delayed exam experience (postponed almost 3 years) so if anyone does that, they have a point of reference, c) bust myths and mysteries about the CE.
My exam: I was surprised to find my exam to be very straightforward. I felt pretty good about the scenarios; I definitely had a correct diagnosis, a reasonable treatment plan, and an answer for the complications in every scenario. Seven of the 12 scenarios were things that I'd expect a non-fellowship-trained general surgeon to do in a normal practice. The other 5 were reasonable to expect a general surgeon to have an understanding of. On the flipside, a) I definitely had to describe things that I've never seen or done before and b) they are definitely allowed to and allegedly have asked much more esoteric subject matter than what they gave me. One way to look at my experience is that I over-prepared and that the ABS is right - residency is all the preparation that you need. Another way to look at it is that I just got lucky with easy scenarios. A third way is that my preparation ultimately is what gave me the confidence to handle a broad range of scenarios, including the ones I got. I resonate with this third interpretation. I've always felt it was complete BS to say to people, "Be confident!" In my view, confidence is only generated out of success, typically from preparation.
Interesting data point: my session had 30 candidates. By the end of the week, 20 were certified, 10 were not.
Resources that I used: residency, Neff, Dimick, Zollinger's Atlas, Uptodate, Google, SCORE curriculum, Osler Audio CDs, Behind The Knife (BTK) podcast, mock orals, Pass Machine, Odyssey CE course, Osler CE course.
Preparation goals: I wanted to go through a couple things in their entirety, this ended up being Dimick, SCORE's curriculum, Osler Audio, BTK, Pass Machine, and Osler. I also compiled two things as I studied - 1) my own "review book," about 90 pages of typed notes that I took that covered all the operations listed in SCORE's curriculum, with workup & technical details that I personally would need help learning, and 2) a list of rat facts that I expected to have to memorize, like the energy doses for ACLS - about 120 flash cards. Finally, I didn't have a lot of other candidates around to practice with, so I tried to get as many simulated experiences as I could, listening to other candidates on Pass Machine / BTK, taking my local mock orals, and then getting 5 sessions spread across 3 courses.
I've scored the resources I used on a 0-100 scale:
Residency (85%, hard to rate since you don't have a choice in doing it): Residency is obviously valuable, also obviously required, but in my opinion, is not sufficient alone. Many people (the ABS) claim that residency is sufficient preparation for the boards. Clearly 100% of candidates have done residency and only 80% pass. My training hospital gave us experience from busy level 1 trauma to liver transplants to Whipples, and there is still a ton of stuff that we're officially responsible for on SCORE that I have never seen. This goes from the ridiculous (oophorectomy) to the reasonable (groin node dissection). Our very best resident in a decade failed his oral boards. I will point out that I probably averaged around the 40th percentile on ABSITEs, our program required 30th percentile.
Neff (30%): The standard review books including Neff, Safe Answers, and How to Win all had common threads to me: they weren't current enough for me to feel that they were authoritative; they weren't in-depth enough for them to use as a reference, they weren't comprehensive enough for me to try to read them cover-to-cover. There is some good material in all three, but I wasn't willing to put a lot of time/energy to bet on them. I used Neff as an appetizer to a topic - since it's concise & bulleted, it gave me a nice 60-second intro to a topic before I started to study it.
Dimick (70%): I like this review book the best, and it seems like most other people at the courses do too. I may be biased because I know many of the authors, but it seemed more reliable to have a real book from a large group of respected academic surgeons than a semi-professionally published book from a single author or two (Neff, Safe Answers, How to Win). They also touched on topics that are definitely in SCORE but no one really talks about, like neuroblastoma. It's not really possible to go into the full depth that everyone needs on every topic, but I thought Dimick got a very good balance between readability and depth. I read every page in this book, in part to give me some confidence that I had read something in its entirety.
Zollinger's (90%): for what it is - an atlas on operations, I found this more useful than any other resource on describing operations. Many operations were described in another resource but not in enough depth that I felt would be convincing if I were to simply say it myself. Zollinger made me feel like I really could do the operation myself, even if I had never see it before. The illustrations are excellent, and I took several of the valuable ones and put them into my own "review book" that I was taking notes in. Not every operation you need is in there, but many are. If you don't have a copy, a lot of libraries can get it for you.
Uptodate (90%): for most of the preoperative content we need, and actually some of the operative/postoperative content as well, I consistently found very concise, very accurate, and fairly deep information here. I understand not everyone has institutional access to this, but I honestly think it's worth buying a personal subscription during your prep period.
Google (70%): a lot of stuff is hard to find in any of the standard GS resources (what are the steps in organ procurement?). Never really sure if the answer I pull off Google is definitive, but I figured if none of the standard sources had the information and Google gave me something believable, it would probably be fine.
SCORE curriculum (90%): it's nice to have a comprehensive list of everything you could be tested on - including Operations, and Diseases/Conditions. However, it is somewhat frustrating that many things on there will probably never be on anyone's boards (posterior sagittal anorectoplasty for imperforate anus). I do think though, that it is a realistic goal to have something intelligent to say about all the topics, there's only about 300 items. It's not that hard to learn a couple steps for a cesarean section, esp. if you set aside as much time as I did. It is a source of comfort during those uncertain times to know that you have reviewed all the topics that the ABS claims to draw from; and also to know that when someone brings up a topic at a review course that "you could be asked on" (radiation proctitis), that you can feel some confidence about whether or not it really is in the curriculum.
SCORE (20%): the modules of SCORE, on the other hand, I found to be mostly useless. A huge percentage of operations in the curriculum have no linked resource in SCORE that explains how to do the operation. Many links go to a primary text that does not explain the operation in nearly enough detail to be useful on the oral boards. I gave this 20% because I felt it was a reasonable starting point, since it's supposedly developed in conjunction with the ABS, but I was disappointed by the modules many, many times.
Osler Audio CDs (50%): the CDs are meant for candidates taking the QE, so it's not quite as applicable to the CE. However, it's easy to listen to during a commute, so that's a plus. Also, there definitely are pearls that are useful for the CE; trauma, breast, and colon stood out in my memory as having a lot of utility.
Behind the Knife (30%): again, easy to listen to during a commute, and it's also free, so that's two pluses. However, there's really only 6 episodes that have mock scenarios, and the majority of them are done by residents who are not meaningfully ready for their CE. I recall one episode of residents who were about to take the CE - that was probably the best episode for preparation. I can say that one of my 12 exam scenarios were discussed on Behind The Knife.
Mock Orals (80%): this is totally hit or miss, so you can't expect this rating to be reproducible. The orals I took in residency were either too easy (sure, you can consult HPB and not need to say anything else about the liver) or inaccurate (you must know Clark's levels for melanoma). They were helpful to prepare for the style of the exam, but I didn't think I could really trust the level of difficulty. The ones I took at my current hospital happened to actually have 3 scenarios that were almost identical to what I got on my exam, they were the closest experience I had to the real thing out of everything I did. Also, my local mock orals gave us written feedback on every scenario with corrections that turned out to be very relevant to my actual exam. Finally, my mock orals in residency & my current institution did the best dress rehearsal, with suit-attire required, getting 4 scenarios in 30 minutes, and having examiners that I didn't know (from another local hospital).
Pass Machine (50%): Pass Machine is nice because you get online videos that are easy to watch at your convenience. The problem, stated by the course director himself when I asked, is that none of the candidates are prepared to take the CE. They're "all junior residents," according to the director. It can be dangerous to watch Pass Machine and think you can do better than them, because the reality is they would probably all fail the exam if they replicated their performance. Even the "model exams" where the candidate is an attending trying to show how to do the exam well, in my opinion, were not outstanding candidate performances. There is some value in watching the candidates suck and then hear the explanation of the content they missed. The final valuable asset of Pass Machine is that they have several PDFs with hundreds of potential cases and explanations - I think this would be useful to anyone who was doing practice scenarios with colleagues. For me, I set up my computer to give me random scenarios from the Pass Machine PDFs, and did 4-8 of them / day in the weeks leading up to the exam.
Odyssey CE course (70%): this course is managed, run, and produced by one guy, Dr. Odysseus Argy. If there is one guy for hire who knows more about the board than anyone else, it's probably him. He used to be an examiner, and he puts more effort into compiling and updating new cases & good answers than anyone else I know. Argy spends about 95% of his energy and 75% of the time on style, and leaves about 5% energy / 25% time on content. He religiously believes that all of us have all the content we need, and that if we just used his magic method of oration, that we would crush the exam. He believes that all of us have been programmed and brainwashed during residency and every other exam resource to memorize details and use crutch words that will unequivocally result in failure. The format of the course is that candidates come up, and after each misspoken word, Argy will stop them in mid-sentence and harass them in front of the audience for using the verbal misstep. These include using the words: "Ok", "perform [operation]", "I'm concerned", "differential diagnosis", "history & physical", etc. He argues that using these words don't add anything to your response and reflect that you're stalling or are unable to give a more precise statement. Saying "I'd examine the patient," is fatal; it is dramatically better to say "I'd feel for palpable masses in the liver."
After harassing the candidate for several minutes as they work through the first sentence of a response, Argy fills in the rest of the correct answer to the scenario. Towards the end of the course, you watch about 12 hours of a video of him lecturing about exam content. You're not allowed to video/audio record or use a computer to take notes during the video (pen/paper allowed). Even though he very strongly de-emphasizes content, I believe that his explanation of scenarios and the content review have a lot of valuable information, and that is why I gave the 70% score. His answers are also often derived from his consultation with several specialists in the specific scenario ("I asked 3 transplant surgeons and..."). He touched on many esoteric topics (peritoneal ice-saline lavage during malignant hyperthermia) that he says came up on real exams, although I didn't get anything remotely that esoteric. From a stylistic perspective, the things I did like and use from his course were a) using statements instead of questions ("I'd ask her age of menarche, first pregnancy, and menopause" instead of "When was her age of menarche?"), b) verbalizing my interpretation of information & thought process (although another examiner at Osler felt I did this too much), and c) video recording myself as I went through scenarios so I could watch & evaluate my style.
Argy has a Jekyll/Hyde personality, he will share very sentimental and humanizing stories, and he will also be a huge jerk to everyone for fairly trivial reasons. At least 2 of the 30 candidates cried during the course. The production of the course (website, payment, CME) is also run by him, which is to say it's produced at about the level of a 10-year-old. You can only pay by check, which you have to mail to him, which he then waits to clear, and then you can be registered after you've filled out multiple forms for his personal data collection. He'll send you a boilerplate email that has several typos or inaccuracies, with at least 6 different font types, and a massive amount of text that is both redundant and treats you like a child.
Finally, I'd take his evidence-based results with some salt grains. At my course, we circulated a list of names & contact information. There were 18 people on that list. By the end of the certifying exam season, 10 were certified, 2 could not be found in the ABS system, 6 were not certified.
Osler CE course (95%): of all the CE-specific review materials, I felt this was the best. They hold it in the 3 days leading up to each of the 5 certifying exams, and in the same city, so you prep at the course for 3 days, then go take the exam. At the course, every 30 minutes, a speaker will give a couple scenarios to a candidate, and then use those scenarios to teach their specific material. The subject matter is linked to their specialty, so they usually are a content expert. The pressure of being examined in front of a bunch of surgeon strangers is a reasonable proxy for the exam pressure, and some of the speakers do a reasonable job of trying to simulate the exam. However, the public sessions are different from the real thing in that the speaker is trying to cover their didactic material from the scenario, so they may touch on esoteric points and will basically never repeat scenarios or content, even though some scenarios are probably much more likely to come up than others. They also try a little harder in both private and public exams to trick you than I felt they did in the real exam. The course is about 29 hours and you'll hear around 100 scenarios, and you get at least one 30-minute exam session out of it (usually the one you do in public).
Osler is also where you'll hear the most candidates giving realistic performances. At Pass Machine, none of the candidates are really prepared for the exam; at Osler, virtually everyone is going to sit for the exam in 2 days - and there is a huge difference. At Odyssey, Argy doesn't let any of the candidates actually finish a scenario because he interrupts them in the middle of their first 2 sentences. So at Osler, there is a lot of value in hearing many well-prepared candidates giving answers to scenarios, some where you realize your answer was missing something, some where you see defensible alternatives to what you would have said, etc.
The most important reason I give Osler a 95% score is because almost EVERYONE does it. The course I took had 239 candidates in attendance. In 2017, a total of 1344 candidates took the exam. If you extrapolate those numbers, it's not a stretch to estimate that 90% of the candidates who are taking the exam were at the Osler course in the days leading up to it. So if you decide you're going to skip Osler, you have to ask yourself - do you want to be one of the 10% that didn't do Osler, or the 90% that spent the last 30 hours going over scenarios with each other and a bunch of experts in test prep?
I can understand that a lot of people feel like Osler didn't add much to their prep, because everyone is already mostly prepared by the time they are 3 days out from their exam. For those candidates, I still think that 30 hours of scenarios is going to give you some kind of boost. I actually took Osler 6 months before my exam, anticipating that I would find a lot of holes in my knowledge base and then use the time to make it up. Then I realized what a huge percentage of candidates take Osler, and that I wanted to take it again right before the exam, so I took it twice. The second time around, it gave me a lot more reassurance that I really didn't have any of the "wow, I'm glad I didn't have to do that scenario" moments because I had at least reviewed basically all of the topics they hit the second time around. Instead, I was able to focus more on the small details that could give a couple extra points (triple negative hormone status disqualifies you from Z11). The course was also a lot less exhausting the second time because I knew the schedule and most of the content; many candidates expressed significant physical and mental fatigue as the course wore on.
The other thing I did at my second Osler was their private sessions, which I think are more realistic since they don't have to teach an audience some set material based off the scenario. All 3 of my private sessions, the examiners felt I failed at least once scenario, but I felt the Osler exams were harder than the real thing, and they do say that's what they're trying for.
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Mysteries & Myths:
1.
The hotel: many people complain about having to stay at an overpriced hotel for the exam. Dr. Jo Buyske, the new Executive Director, gave several reasonable points about this during her briefing, specifically that they require a very high level of service from their hotels. This includes having many suites on a single floor, disallowing housekeeping during the exam, getting housekeeping before the exam at 5:45 am, etc. She said there's only 6 hotels in the country that can accommodate everything they request, and they make an exception to the suites-rule in Salt Lake City because the bedrooms are very big. Ironically, for however high their level of service, there was a massive line to check in at 3pm the day before the exam as all the Osler candidates shuttled over from the Osler hotel, which created a fairly awkward situation with all the candidates standing in line and the examiners who had just flown in looking stunned and appalled at the line that they were definitely not willing to wait in.
2.
The history & physical: some really old people advise to stall on the H/P, some aggressive new people say you are forbidden from asking for it. It is true that I didn't really need much H/P, I don't recall any cases being changed by what I investigated, but I did quickly touch on specific H/P information in several scenarios when omitted from the stem, and the examiners did not have any sign of annoyance by me mentioning them (I verified the HIV patient is compliant with anti-retrovirals). It is definitely true that you have to hustle through the cases, so I never spent more than 30 seconds on the H/P. Dr. Buyske did say that you should resist the temptation to start your remarks with questions - that the stem should have generally enough information for you to immediately move to some kind of action.
3.
Pretending: the courses create the notion that you have to pretend you can do a bunch of cases that you would never actually do, like parotidectomy, orchiectomy, liver transplant, etc. I had fully prepared to participate in this act of fantasy, but was surprised when Dr. Buyske actually said that a) it's ok to ask for a consultant if you would in real life, so that b) you don't walk out of the room and the examiners ask each other "would he really do a Boari flap"? I had pretended to do a Boari flap so many times in mock orals by that point that I honestly think I could do one in a pinch, so I was kind of surprised to hear that, but I did mention consultants once or twice during the exam because of that.
4.
Anything Else? Many advisers say that the "anything else you want to do?" question can mean something and can also mean nothing. I will say in my exam I got it at least twice, and both times there was something quite significant at the end of the case that I forgot and was reminded to add because of that question.
5. Critical Fail: there was a concept in the past where if you said something so inappropriate in one scenario, you would fail the entire exam. Dr. Buyske herself confirmed to me personally that this is no longer true. You can definitely fail a single scenario for something of that nature, and would mandate both examiners failing you on that scenario (instead of the two potentially having different scores), but it has no impact on the rest of the scenarios.
6.
Two Groups: it is definitely annoying that you have to report to a briefing before you find out the real time for your exam. For instance, they hold a 7am briefing, and you will either be assigned to the 8am session or the 10am session at that briefing. This can make a difference re: whether or not you are still checked into the hotel when you finish or if you want to stay an extra night, etc. This is the psychological effect that football teams invoke when they call a timeout right before a kicker goes for a field goal. Dr. Buyske did explain the rationale at least, which is that if someone screwed up and you're being examined by someone you know, then that gives them the ability to switch you and the other 5 people who have to switch because of it. She said in the very old days, the candidates had to just sit in the lobby for 3 days and someone would come down at any point in that time to pull people up. I ended up in the second group of the briefing; I did distract myself for bit of time by doing a dry run to walk to all the rooms I'd be examined at and by looking up the photos & bios of my examiners so I wasn't distracted by meeting them for the first time.
7.
Examiner Malignancy: Dr. Buyske indicated that they now put a significant amount of effort into standardizing their exams and making them fair. For instance, the examiners are not allowed to have the sun shining into your eyes so they have to pull the blinds, keep the ambient temperature relatively cool, etc. They also go through "a lot of training on implicit bias." In the prior era, she did confirm that there was an examiner who delivered the exam while having a bowel movement, that examiner "is still alive, but is no longer an examiner."
8.
Discussing cases: Dr. Buyske made an impassioned plea to not discuss the details of the cases, for the legal, ethical and professional implications. First that they are protected by ABS copyright, so sharing the cases violates that. Second, that they take a long time to develop (2 years per case) and are generated by surgeons who volunteer their time. Third, that she takes seriously the ABS' responsibility to provide a level of safety to the public, which is undermined when the cases are widely disseminated.
9.
Watch: you are advised to bring a watch, although I didn't understand why until I took the exam. It definitely is not for checking your time during your scenarios - I think the break in eye contact would be really distracting and the examiners are in a much better position to budget your time and pace than you are. The watch is for the time when you're in the hallways, either waiting for your exam to start or letting you know that you need to sprint up two floors and across 50 yards of hallway to get to your next room because your first room ran 4 minutes late.
10.
Pen & Paper: some people said you won't have it, our mailed instructions indicated we would, and the latter was true. The briefing room had a stack of pads and paper that several candidates (including myself) utilized. It did seem like the examiners were a little thrown off, they had to keep reminding themselves and me to make sure anything I wrote down had to stay with them. I debated on whether I'd use it because I didn't during my previous mock orals, but finally decided to use it during my Osler private sessions to try it out. I found it to be super helpful because it takes me a lot of mental energy to store and recall the long stems that are now the norm of the CE. It also helps me avoid asking things they already told me, which many mock examiners are critical of.
11.
Curve: this is more of a personal conspiracy theory, which I also hold for the QE. The ABS repeatedly claims that they do not curve their grading on the CE. However, Dr. Buyske specifically told us that there are tough examiners and easy examiners (which do not correlate with how they visually appear), and that their scores have to be adjusted accordingly. The fact that they adjust scores in any direction says to me that there is some target that they are shooting for, all of which says to me that when they fail 20% of us every year, it is a deliberate intent.
12.
Systematic: not really a myth, but was a personally important tip. After reviewing my feedback from all my mock orals, I found it was very important to me to keep a systematic approach to stay on track. The systems I found most useful were "H/P, Labs, Imaging, Medications, Operation" - I would often forget to give antibiotics or check a useful lab. I didn't always ask for more H/P, but according to Odyssey, you can get a couple points by explaining your interpretation of the H/P that has been given. "Name, Stage Treat," is a popular one for cancer, which actually isn't that true for several cancers that you operate on without a diagnosis (Wilm's, pancreatic, testicular, 25% of lung, etc). However, it is a good reminder to stage your cancer patients. "Primary (ABCDE), then Secondary (H/P) Survey" is a good pattern to articulate and follow for trauma patients.
13.
Take it right away: almost everyone told me to take my boards as soon as possible. I expounded on this and several other topics in my writeup for my QE experience in the "
Written (QE) exam experience" thread in 2016. Notably, in my own life, I had a lot more time and money 3 years out than right after residency. My institution's CME fund is quadruple what I was allocated as a fellow, and obviously my salary is much higher too. Bottom line - you don't have to take it right away to pass. I put it off for almost 3 years and it seemed to work out fine.
Good luck to everyone who takes this exam in the future. Feel free to PM me if you have specific questions.
). That being said, at any point it would have been fair game for them to ask me to describe or to go into more details. 
