Oral boards questions

[msgsk]

Hi guys,

I have the oral boards exam in a couple weeks and had a few questions for recent test-takers, if they are comfortable answering:

For the triple case, do you get three sheets of paper?

How much space does the stick figure take up on a page? I have an algorithm with boxes that I like to draw to keep me organized and just want to make sure I'll have enough space.

Besides the short training ABEM has on their website, any suggestions for the e-cases? Are the ultrasound images pretty straightforward?

Are the examiners pretty forthcoming? For instance, I'm doing a practice case of Fourniere's gangrene. If I ask for a full skin exam but don't specifically ask for the GU area, would they tell me the findings?

Thanks and any additional tips are greatly appreciated!

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[deleted859535]

Hi guys,

I have the oral boards exam in a couple weeks and had a few questions for recent test-takers, if they are comfortable answering:

For the triple case, do you get three sheets of paper?



Don't remember. Think so.



How much space does the stick figure take up on a page? I have an algorithm with boxes that I like to draw to keep me organized and just want to make sure I'll have enough space.



It's big. You'll still have enough space.



Besides the short training ABEM has on their website, any suggestions for the e-cases? Are the ultrasound images pretty straightforward?



Go to the "play"/orientation session the day before and get a feel for the layout and supplements.



Are the examiners pretty forthcoming? For instance, I'm doing a practice case of Fourniere's gangrene. If I ask for a full skin exam but don't specifically ask for the GU area, would they tell me the findings?



Forthcoming within reason. Being asked "what are you looking for?" is fair game, as is delivering exam findings as requested. I got both.



Thanks and any additional tips are greatly appreciated!

Answers embedded.

 

[RoyBasch]

You get plenty of paper with plenty of space to write notes if I recall correctly.

I would say if it's critical to the case, the examiners are NOT very forthcoming and your line of questioning will have to be very specific.

Example: The case is a 3 year old male with testicular torsion as final diagnosis. However, the chief complaint is "tummy owwie!" If you do not specifically tell the examiner you are doing a genital exam and specifically asking about the overlying skin, testicular lie, and tenderness, they probably will not give it to you.

Your example of Fournier's: You will probably have to specifically ask for a soft tissue exam overlying the perineum, and for the presence or absence of sign of infection such as erythema, induration, drainage, etc.

If you say "give me a full skin exam" the examiner might (but they might not) ask you to clarify with: "What parts of the body constitute a full skin exam for you?" and at that point you might want to specify, "We remove all clothes, roll the patient to examine the back and sacrum for wounds/ulcers and spread the lower extremities to examine the perineum for signs of infection such as erythema, induration, drainage, or tenderness."

That being said, there may be some inter-examiner variability. But in my experience if a certain exam finding is VERY key to the case (i.e. the rest of the case is easy afterwards) the examiner will only divulge it with very pointed asking.

In general, your threshold to do very good physical exams on patients should be very low. For example, on oral boards EVERY abdominal pain patient needs complete rectal and genital exam even if in reality your threshold for doing these exams may vary by case depending where the patient is tender and the history, etc.

If a vital sign is not given, its probably critical to the case. So if they give you a HR, RR, temp, and BP but not a O2 sat, ask for the sat it is almost 100% going to be abnormal, same with temp. If they don't give it to you, ask, it will surely be febrile or hypothermic.

Sometimes they like to give a subtle EKG finding that becomes obvious when compared to previous EKG, but the "old" EKG will not be provided unless you specifically ask.

 

[msgsk]

Thanks for the tips!

I have a 'script' of how I start off every case, and unless it's a very straightforward orthopedics case, I almost always start with placing a large bore IV and starting IV fluids and oxygen. In going through literally every Okuda case, that has served me well as the critical action is often to start fluids and oxygen.

Unless I'm concerned about volume overload (for instance an acute CHF exac) is that a reasonable way to start off every case?

Also, I've gotten into the habit of asking for an O2 sat on every case right from the start if not given.

 

[Angry Birds]

I'm also about to take the oral boards, but I've taken the AAEM course, which is a close approximation. So, my answers are based on that.

I'm doing a practice case of Fourniere's gangrene. If I ask for a full skin exam but don't specifically ask for the GU area, would they tell me the findings?

I can safely say that they will likely not tell you about the GU area if you ask for the skin exam. You not only have to ask for the GU exam specifically, but you also should notify the "patient" that you are going to do an exam of his genital region.

Thanks for the tips!

I have a 'script' of how I start off every case, and unless it's a very straightforward orthopedics case, I almost always start with placing a large bore IV and starting IV fluids and oxygen.

Unless I'm concerned about volume overload (for instance an acute CHF exac) is that a reasonable way to start off every case?

Personally, I wouldn't just shotgun the IV fluids, since you should have some thought process when ordering a
"medication."

Also, I've gotten into the habit of asking for an O2 sat on every case right from the start if not given.

You should immediately ask for a full set of vitals (which includes oxygen sat), as well as a finger stick glucose and a rhythm strip.

This is quite stupid, but this is how it is.

 

[msgsk]

Thanks for the advice! Do they often ask you for your interpretation of ekgs/xrays/CTs? Should you volunteer that information or if they don't ask, don't say your interpretation out loud? Especially if you're not sure about a finding. Obviously if it's a STEMI you say so...

 

[Birdstrike]

Thanks for the advice! Do they often ask you for your interpretation of ekgs/xrays/CTs? Should you volunteer that information or if they don't ask, don't say your interpretation out loud? Especially if you're not sure about a finding. Obviously if it's a STEMI you say so...

Don't forget to say, "What do I see? What do I smell?"

Smell of bitter almonds, ketones....

Petechial rashes....

And do practice test, after practice test, after practice test, with a past examiner. I never needed helped studying for tests and always tested well, but the oral boards are totally different and knowing the system, is as important than facts, maybe more. You go your whole career and never have a test like this, then throw this one at you. It's very passable, if you learn how the game is played.

 

[engineeredout]

Other than money, what is the point of this stupid exam?

 

[Angry Birds]

Thanks for the advice! Do they often ask you for your interpretation of ekgs/xrays/CTs? Should you volunteer that information or if they don't ask, don't say your interpretation out loud? Especially if you're not sure about a finding. Obviously if it's a STEMI you say so...

According to what I learned at AAEM, the answer to both questions is no.

 

[Birdstrike]

Other than money, what is the point of this stupid exam?

They’ll claim the oral boards are to evaluate your clinical judgement in a way a written test doesn’t. But I think it’s much less effective at doing that, than it is in separating you from your money. They can’t just say they’re charging you a couple grand and selling you a board certification. That transaction doesn’t pass the sniff test. But if they make you take yet another test, even if it adds no significant testing value beyond the tests they’ve already made you take, then, of course that makes the transfer of money in exchange for a board certification “legit.”

Why not add another exam, where you see patients and are observed by an examiner, live during an ED shift, where they grade your bedside manner, ability to meet metrics and “satisfy” patients?

After all, isn’t that an even “better way” to more directly and accurately evaluate your skills as a physician in 2018?

Perhaps we need to add this test to further prove our commitment to physician quality. And, oh boy, it’ll be expensive, because we’ll have to fly a medical test examiner to your ED for the practical test, as your expense of course!

And then, in 5 years, we must repeat it. To make sure you haven’t lost your skills. Oh, we’re doing such a good job!

Cha-Ching, cha-Ching, cha-Ching!

 

[RoyBasch]

Thanks for the tips!

I have a 'script' of how I start off every case, and unless it's a very straightforward orthopedics case, I almost always start with placing a large bore IV and starting IV fluids and oxygen. In going through literally every Okuda case, that has served me well as the critical action is often to start fluids and oxygen.

Unless I'm concerned about volume overload (for instance an acute CHF exac) is that a reasonable way to start off every case?

Also, I've gotten into the habit of asking for an O2 sat on every case right from the start if not given.

Yes these are probably good practices. In many cases giving O2 or fluids are "critical actions." Remember the "standard of care" on oral boards does not necessarily reflect current modern practice. For example, acute MI will always need oxygen; even though now you probably would not do it if the sat is normal. Boards will not be concerned with "hyperoxia" and further free radial oxygenation causing damage to injured myocardium or brain.

Even cases like a child with vomiting and diarrhea probably gets an IV, labs, and fluids, when in reality you might make an assessment based on their history and volume status on exam and if it seems mild try a PO fluid challenge first.

Also for many abdominal pain or surgical cases (final dx is say bowel infarction) placing a NG tube is a "critical action" although once again in reality I think many of us have gotten away from NGTs in the ER.

 

[RoyBasch]

Thanks for the advice! Do they often ask you for your interpretation of ekgs/xrays/CTs? Should you volunteer that information or if they don't ask, don't say your interpretation out loud? Especially if you're not sure about a finding. Obviously if it's a STEMI you say so...

Yes interpreting these studies is part of the test. Basically, everything you "think" you should verbalize. So any test you order, verbalize ordering it and then verbalize your interpretation, and a brief explanation of how that translates into the subsequent action.

Example: "I am ordering a chest x ray and EKG in this patient with chest pain. (examiner shows you the EKG) EKG shows ST elevations in the inferior leads II, III, aVF with reciprocal changes of STD in aVL. Normal sinus rhythm is noted. These findings are consistent with an inferior ST elevation myocardial infarction. Aspirin has already been given. Interventional cardiologist is to be notified stat about a catheterization lab activation."

One good thing about oral boards different from reality is the patients will always have an "emergency diagnosis" that will almost always require specialist procedure, surgery, intervention, etc. There won't be an equivocal case and the specialist will not push back. The EKG will show a clear cut STEMI and if you activate the lab the interventionalist will take them and that will be the successful end of the case. Another typical oral boards case is blunt abdominal trauma with hypotension and a grossly positive FAST exam. You will notify the surgeon who will promptly take the patient to the OR for an ex-lap, etc.

 

[msgsk]

Thanks for all the tips

I have a friend who's a neurology resident. He said they charged about $1500 for written boards and $1500 for oral boards. The year he graduated they did away with their oral boards exam. Guess how much the written one costs now? $3K.

 

[Birdstrike]

Thanks for all the tips

I have a friend who's a neurology resident. He said they charged about $1500 for written boards and $1500 for oral boards. The year he graduated they did away with their oral boards exam. Guess how much the written one costs now? $3K.

Outrageous, that they jacked up the price.

Still, paying $3,000 and having to take only one test, is better than paying $3,000 and having to take two tests.

Gives credence to my theory that they're essentially selling the certification for a price. There is clearly evidence there of a dishonest scheme to obtain money.

 

[miacomet]

Wear a suit. Ask about pregnancy status.

 

[Alvarez13]

Is there a fu*king lunch break?

 

[bravotwozero]

No, there isn't. I guess that's one thing about the oral boards that really does simulate real time ED working conditions!

 

[TooMuchResearch]

Is there a fu*king lunch break?

It's five hours.

 

[Angry Birds]

It's five hours.

This is unacceptable. I get hungry q2h.

 

[gutonc]

This is unacceptable. I get hungry q2h.

Can you order the patient in the case a turkey sandwich and then steal it from him?

 

[TooMuchResearch]

This is unacceptable. I get hungry q2h.

It says something about carrying a granola bar in your pocket or something.

So are there bathrooms available during the test?

 

[Angry Birds]

For epiglottitis in a child, the book (and even PEPID) says to intubate before getting an IV. So, just topical lidocaine and intubate??

In reality, wouldn't you want the IV in order to give Ketamine in order to intubate? (I guess you could give Ketamine IM...)

 

[msgsk]

The Okuda book didn't have a case for epiglottitis. I would guess you can say something like "while I'm setting up for the airway, have the nurse establish two IVs..."

I know the written boards answer is to take the child to the OR for intubation so there's no way I'd imagine you'd be doing this in the ED without an IV.

 

[msgsk]

Is there enough time to do a complete physical exam in the single cases? There doesn't seem to be when I'm practicing triple cases.

Also, are we expected to ask about medications, allergies, social history etc even if it doesn't seem relevant (say, a motor vehicle accident for instance - would it be enough to make sure there aren't blood thinners on board or ask the full history/social history)?

 

[TooMuchResearch]

Is there enough time to do a complete physical exam in the single cases? There doesn't seem to be when I'm practicing triple cases.

Also, are we expected to ask about medications, allergies, social history etc even if it doesn't seem relevant (say, a motor vehicle accident for instance - would it be enough to make sure there aren't blood thinners on board or ask the full history/social history)?

I thought they got rid of the triple. I am wrong?

 

[TooMuchResearch]

For epiglottitis in a child, the book (and even PEPID) says to intubate before getting an IV. So, just topical lidocaine and intubate??

In reality, wouldn't you want the IV in order to give Ketamine in order to intubate? (I guess you could give Ketamine IM...)

I'm not intubating a child with a treacherous airway by making them vomit with topical lido and then forcing a tube down their throat...

I do IM ketamine sedations in little kids. One quick IM injection probably won't make them lose their airway.

 

[Angry Birds]

I thought they got rid of the triple. I am wrong?

Yes i believe so. The triple remains.

 

[swamprat]

What I think is weird is asking about GU exam for every patient. AAEM course rec to ask the full exam for every patient so u dont miss anything

 

[TooMuchResearch]

Yes i believe so. The triple remains.

Bummer.

 

[bravotwozero]

guys, it's not that bad, really. way easier than the written exam. Just practice with a buddy from okuda or some other board review book. Or take AAEM's oral board review course if you're really worried (can deduct as IC), I did and felt pretty confident. While stressful, parts of the test were...amusing to say the least. I had a guy in complete heart block, that I told the examiner I was going to pace. I didn't give pain meds, so then the examiner says 'the nurse wants you to come see the patient' and there was a video clip of the guy writhing in pain LOL.

 

[TooMuchResearch]

Why does the Okuda book want me to call everyone's primary care doctor and stick my finger in everyone's butt? Why does it want me to a pelvic exam on an old lady whose chief complaint might as well be SMA occlusion?

 

[TooMuchResearch]

Sir, you are having a heart attack. I've spoken to the cardiologist, and they would like to do a procedure to open up the clogged blood vessel in your heart. Before you go for your life-saving procedure, I need to stick my finger in your butt to make sure your sphincter isn't loose and there isn't blood in your poop.

 

[Alvarez13]

It's five hours.

There's two 20 minute breaks in the session. I ate a bunch of blueberries and a pack of beef jerky during one of the breaks. There's beer available in the lobby for afterwards too.

 

[Angry Birds]

ABEM General really needs to do something about its consultants always being busy. But, at least they are really nice once you finally get a hold of them.

 

[Alvarez13]

ABEM General really needs to do something about its consultants always being busy. But, at least they are really nice once you finally get a hold of them.

And fix that damn ultrasound and CT machine.

 

[Apollyon]

ABEM General really needs to do something about its consultants always being busy. But, at least they are really nice once you finally get a hold of them.

Dr. Hart and Dr. Brane? Or was that Dr.Hipp?

 

[RoyBasch]

For epiglottitis in a child, the book (and even PEPID) says to intubate before getting an IV. So, just topical lidocaine and intubate??

In reality, wouldn't you want the IV in order to give Ketamine in order to intubate? (I guess you could give Ketamine IM...)

In reality as well as boards I probably would not place an IV for fear the increased agitation in a small child could cause them to lose their airway and preferentially have the patient taken to the OR for a gas-only induction by anesthesia with ENT standing by to cut if anesthesia cannot get the tube from above. If the patient loses consciousness in or before the ER from hypoxia/hypercarbia then at that point I would place the IV and attempt the airway in the ER while preparing for a TTJV and have ENT and anesthesia en route for backup.

 

[RoyBasch]

Sir, you are having a heart attack. I've spoken to the cardiologist, and they would like to do a procedure to open up the clogged blood vessel in your heart. Before you go for your life-saving procedure, I need to stick my finger in your butt to make sure your sphincter isn't loose and there isn't blood in your poop.

I think technically a rectal is considered a "Critical Action" for a fib prior to initiating anticoagulation (also a possible Critical Action) to verify there is no melena suggestive of a GI bleed.

Once again, boards does not equal reality practice.

 

[TooMuchResearch]

In reality as well as boards I probably would not place an IV for fear the increased agitation in a small child could cause them to lose their airway and preferentially have the patient taken to the OR for a gas-only induction by anesthesia with ENT standing by to cut if anesthesia cannot get the tube from above. If the patient loses consciousness in or before the ER from hypoxia/hypercarbia then at that point I would place the IV and attempt the airway in the ER while preparing for a TTJV and have ENT and anesthesia en route for backup.

Unless I'm willing to put the kid on an ambulance with a tenuous airway and no IV, I can't accomplish most of that scenario in some of my work places.