CBPS II

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Beetlejuice7

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Any advice on preparation of Part II Foot Surgery CBPS? Already failed once because of physical exam.

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You were taught everything you need to pass boards in pod school (NBPME, ABPM, ABFAS, etc). Add the textbooks you've read on your own, the journals, residency group learning... and you are probably over-prepared. A quick refresh with PI manual is all I ever did for ABFAS or ABPM.

However, for the *CBPS* success, you need to be totally familiar with the format of that test - mainly the choice lists. You should do their practice cases many times, run through the whole PE/labs/imaging/dx/etc lists many times. Print out the lists and then study some more. For some parts (it was diagnostic tests... not sure if they revised it), they let you have way too many picks... but on others (mainly the dx and tx), you have to pick only the best. Those CBPS are as much about understanding the list choices and what they want, picking the 10 or 12 or 20 best for the PE or diagnostics or consult as it is actually figuring out the dx/tx for the the case at hand. You also need to get familiar with the search so that you know if it is 'stress xray ankle' or 'ankle stress xray' and if it's 'hallux fracture' or 'fracture hallux' or both so you don't waste time. Many peeps I know, even standard/fast test takers, run out of time on CBPS or have to rush to finish.

Examples that my co-residents and I came across: we don't do nuc med scans... but boards wants it. I don't waste MRI time and money when the dx is readily available from XR or PE... but boards wants it. I don't typically do joint ROM or CT when I know there is a basic fx from XR and PE... but boards wants it. I am not sure what a Ortellani test even is... but boards wants it. I don't tend to order fancy infection labs or inflammation labs (I do the basics and let IM or Rheum do the advanced)... but boards wants it. Basically, your physical exam (for CBPS) should have you doing and ordering basically every reasonable thing pertinent to that complaint. Do all vascular things if it's a vascular issue... all pertinent labs and imaging if it is infectious, all reasonable labs and tests consults if it's CRPS or neoplasm or something, etc. It is not too tough if you know the lists well. You have to stop thinking about what you want (and sometimes what makes sense!) and just think about what answers they are looking for. :oops:
 
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Use their online simulators and think of different scenarios while doing them. The online simulator might be a schwanoma in real life but picture flat foot, cavus foot, open fracture, charcot, osteomyelitis, bunion, osteoarhtritis, gout, etc, etc. Any scenario you can think of practice it and go through the motions. This helps you think ahead of time about what tests, labs, etc, etc you would order. This will really help you get fluent in the exam process.

Always read the chief complaint then start with imaging. Work backwards from there (PE, Labs). The xray will really help you narrow down what to chose/look for. "OK this is a charcot case" vs "Ok this is a fracture case"

They say dont shotgun. But I shotgunned.

Example without being too specific to avoid violating ABFAS TOS: Totally random case scenario that not necessarily will be on the exam. Lets pick something very common for our day to day practice: Charcot foot deformity.

Exam:
Pinprick, pedal pulses, ROM of the affected joint, Check equinus (thats a big one here), skin exam/wound exam, probe to bone,

Labs HgA1c, ESR, CRP, Procalcitonin, CBC, CMP, Uric acid,

Imaging: Xray, CT, MRI, Bone scan.

Procedures: Culture joint? Culture foot? PICC line?

Plan: Physical therapy, CROW boot, Wound debridement, Exostectomy, Internal fixation, external fixation, TTC nail, TAL (dont forget the equinus you diagnosed), below the knee amputation, admit hospital, non weightbearing, debride wound, wound vac, etc.

That is an example of shotgun approach to answers. Typically we would not order a CT, MRI, and bone scan. I probably wouldnt order uric acid for obvious charcot. Thats how I approached the exam and passed. Also something like nonweightbearing is obvious in our eyes but if you dont click it it didnt happen.

Its been awhile since I took the exam so the above may be out of date and is based off memory. Probably forgot to include some stuff but you get the idea.

- -

ALWAYS do a diagnostic block for osteoarthritis or foot pain in general
 
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Use their online simulators and think of different scenarios while doing them. The online simulator might be a schwanoma in real life but picture flat foot, cavus foot, open fracture, charcot, osteomyelitis, bunion, osteoarhtritis, gout, etc, etc. Any scenario you can think of practice it and go through the motions. This helps you think ahead of time about what tests, labs, etc, etc you would order. This will really help you get fluent in the exam process.

Always read the chief complaint then start with imaging. Work backwards from there (PE, Labs). The xray will really help you narrow down what to chose/look for. "OK this is a charcot case" vs "Ok this is a fracture case"

They say dont shotgun. But I shotgunned.

Example without being too specific to avoid violating ABFAS TOS: Totally random case scenario that not necessarily will be on the exam. Lets pick something very common for our day to day practice: Charcot foot deformity.

Exam:
Pinprick, pedal pulses, ROM of the affected joint, Check equinus (thats a big one here), skin exam/wound exam, probe to bone,

Labs HgA1c, ESR, CRP, Procalcitonin, CBC, CMP, Uric acid,

Imaging: Xray, CT, MRI, Bone scan.

Procedures: Culture joint? Culture foot? PICC line?

Plan: Physical therapy, CROW boot, Wound debridement, Exostectomy, Internal fixation, external fixation, TTC nail, TAL (dont forget the equinus you diagnosed), below the knee amputation, admit hospital, non weightbearing, debride wound, wound vac, etc.

That is an example of shotgun approach to answers. Typically we would not order a CT, MRI, and bone scan. I probably wouldnt order uric acid for obvious charcot. Thats how I approached the exam and passed. Also something like nonweightbearing is obvious in our eyes but if you dont click it it didnt happen.

Its been awhile since I took the exam so the above may be out of date and is based off memory. Probably forgot to include some stuff but you get the idea.

- -

ALWAYS do a diagnostic block for osteoarthritis or foot pain in general
Thanks for the response. Yeah, I think with the “new” CBPS they’ve gotten away from shotgun approach since that is what I did with Part I and passed first time versus taking the “new” CBPS II and failed. I’ve had many conversations with ABFAS via telephone and e-mail pertaining to the idea that it’s not about just picking as many items, but picking the items pertinent to that particular case.

Example of our discussion was how I wouldn’t have to pick appearance of the foot when there’s a picture of the foot there. If any of us have ever taken a podiatry board exam before, we know that we can’t trust any picture that is provided and many times the questions referred to a picture or image that isn’t even there!

it’s just frustrating with how difficult this whole process is and how many thousands of dollars it takes and how defeating it is when failure occurs.

Trying to knock out Part II CBPS, currently doing case review, and then hopefully be done with this whole time consuming and exhaustive process.
 
I passed all sections as well. I have a few thoughts on preparation as well as test-taking strategy.

Preparing for Multiple Choice: The single best preparation you can do is pay attention during surgery and show up for cases prepared. This will have you actively thinking and the subject becomes more than an academic exercise for you. The more you do this over 3 years, the less important it is to do practice questions.

I used boards by numbers for practice questions. I found the study notes unhelpful. It's good as a question bank in terms of directing you to subject areas where you are weak, but BBN is also outdated (too many questions about arthrograms) and overemphasizes eponyms and classification schemes. In any case, I found the multiple choice questions much harder on the exam (especially the RRA questions) then on BBN or the ABFAS practice exam or in-training exams. A colleague of mine used board vitals and I saw a few of their practice questions which were also pretty dumb.

Which Brings me to the Simulation Exam: This exam attempts but ultimately falls short of being a realistic patient scenario. While it's understandable why we would limit the examination to 10 maneuvers, certain presentations may have a broad differential dx and certain diagnoses require a thorough PE workup (e.g. Flatfoot recon). Personally, I think 15-20 maneuvers is a better allowance. My biggest issue is that in a real world scenario, you have the ability to ask the patient to point with one finger where it hurts, but we can't here (there's a way around this, see below under imaging). So clearly, the objective here is not to do what's best for your simulated patient but to optimize your score. The good news is that the test can be outwitted.

Imaging: This was the first tab I would go to when I was taking the test. In many cases, pinpointing the symptoms is unavailable from the history, but an MRI will automatically give the 2-3 slices with all the diagnostic information you need. I have to respectfully disagree with @Ankle Breaker about the shotgun strategy, because not only has ABFAS explicitly stated they will not penalize you for unnecessary studies, but shotgunning your imaging often ensures you maximize your diagnostic information and therefore your exam score. While I was sitting for the exam, I remember thinking on one case, "Sure I'll get a CT scan, even though I don't think it's necessary." Turned out CT images were available, though I'm not sure this equates to the scan being a graded point. While ridiculous, this "MRI first and ask questions later" strategy ensures you can proceed efficiently through the case. The best part is that you're allowed 10 imaging studies, so it's hard to imagine a scenario where you would hit that limit.

PE: Here's where you trade your shotgun for a sniper rifle. From the grading rubric for the ABFAS practice exam, it would seem that checking pedal pulses and sensation [syntax: "light touch"] are not graded points. Still, I think it's appropriate to do. Most of the time asking for "vitals" gets you all the vital statistics you need on an infected pt, though sometimes you'll get the dreaded "be more specific" which in my opinion should not deduct from your 10 maneuver allowance. Remember, use your imaging findings to direct your exam, which we obviously do not do in real life but remember, this is about maximizing points, and if they didn't want us to use this approach they wouldn't allow is to switch freely between the imaging and PE tabs. I almost always used 8-10 maneuvers, even though only 3 of them are graded for points.

Other PE pearls:
1) check for crepitus and lymph nodes on infection cases
2) ALWAYS range the ankle joint and follow it with a Silfverskiold exam if necessary. The equinus workup/dx/management can lead to massive point loss if you forget it.
3) Flatfoot: there are a lot of specific maneuvers here that add up to big points. Heel raise, hubscher maneuver, RCSP, palpating the sinus tarsi.

Labs: I shotgunned labs too. While I'm 90% sure this is not necessary, I would get routine preoperative labs on everyone. CBC, PT/INR. Vitamin D levels are also a nice touch, but I doubt a graded point. For some idiotic reason, BMP/CMP are not on the menu. Type "serum" and then pick off the individual electrolytes. Obtaining serum creatinine would theoretically have ramifications on the use of IV contrast in your imaging, but ABFAS kindly glosses over this issue within the confines of the simulation. All diabetic patients get fingersticks and HbA1c, all RA pts get ESR/CRP, ditto for infections plus blood cx and wound cx, alcoholics gets AST/ALT, and anyone where we have gout in the differential gets a UA. For the ladies, hCG. You have up to 20 choices, so the world is your oyster under this tab. Practice the simulation online and you can get your whole lab panel clicked off in under a minute.

Diagnostic Procedures: Careful here, because some of these procedures are more invasive and the potential to lose points exists. Wounds need to be probed [syntax "wound probe"]. Smokers and others with lousy pulses should get Dopplers, though that's never been a graded point on the practice test. Diagnostic blocks are easy points to add in any case involving nerve entrapment or arthritis. EMG for tarsal tunnel cases. For serious trauma cases, check compartment pressures. Soft tissue masses should be transilluminated, aspiration bx, and followed by incisional/needle bx.

Diagnosis: Self-explanatory, but don't forget equinus! Half the patients will have it!

Management: See the ABFAS practice exam to get an idea what they're looking for. I think this was pretty straight-forward, if you were thorough in your workup and diagnosis, the treatment plan follows logically. Make sure you know proper syntax, for instance you don't "consult" vascular, you "refer" to vascular. Finally, when in doubt, fuse the joint.

Read this post by Adam Smasher. Do exactly what he says. You will pass and if you don't it's because you didn't do exactly what he said.

But also do the practice exams because it will give you an idea of what dx/tx/labs/etc. they want for an infection case (for example). If you get an infection case on the actual exam, then you can bank on the dx/tx/labs/etc. that score you points will be the same as on the practice test.
 
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Thanks for the response. Yeah, I think with the “new” CBPS they’ve gotten away from shotgun approach since that is what I did with Part I and passed first time versus taking the “new” CBPS II and failed. I’ve had many conversations with ABFAS via telephone and e-mail pertaining to the idea that it’s not about just picking as many items, but picking the items pertinent to that particular case.

Example of our discussion was how I wouldn’t have to pick appearance of the foot when there’s a picture of the foot there. If any of us have ever taken a podiatry board exam before, we know that we can’t trust any picture that is provided and many times the questions referred to a picture or image that isn’t even there!

it’s just frustrating with how difficult this whole process is and how many thousands of dollars it takes and how defeating it is when failure occurs.

Trying to knock out Part II CBPS, currently doing case review, and then hopefully be done with this whole time consuming and exhaustive process.
I took it 2-3years ago. Has it changed since then?
 
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