Surgery oral exam

[tvelocity514]

Hi everyone,

Current M3 here. Our school changed our final OSCE this year and now we are not having a final osce (because everyone was just getting a pass and no one was getting honors). We now have an oral surgery exam that is supposed to be a replica of the oral boards that surgeons have to do to graduate residency. From what I understand, I think a lot of the surgeons will be split in different rooms and you have a certain amount of time with each of them. Do they just give you a case and ask you what you do?

Because this is new, and none of my previous classmates have encountered this, I was wondering if anyone here could please shed some light on how surgery oral boards are and how best to prepare for them. Thank you!

Edit: I also talked with a breast surgeon who said that she would ask a couple of questions you could only know from doing residency in surgery. She stated she wouldn't count off for them if we got them wrong, but it would be a huge huge boost to our grade if we get one of them right. I'm sure it will be a little demoralizing when asked a question and I can't even think of a ballpark answer at all. I'm actually interested in surgery but I don't think my active interest plus studying of shelf material will enable me to get those per her statement. She said she had no idea how the rest of it would work but would be similar to her "general boards".


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[thedrjojo]

Hi everyone,

Current M3 here. Our school changed our final OSCE this year and now we are not having a final osce (because everyone was just getting a pass and no one was getting honors). We now have an oral surgery exam that is supposed to be a replica of the oral boards that surgeons have to do to graduate residency. From what I understand, I think a lot of the surgeons will be split in different rooms and you have a certain amount of time with each of them. Do they just give you a case and ask you what you do?

Because this is new, and none of my previous classmates have encountered this, I was wondering if anyone here could please shed some light on how surgery oral boards are and how best to prepare for them. Thank you!


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Almost certainly they will give you a case, 15 year old with rlq pain, 56 year old with a breast mass, and ask you to work them up. Your biggest focus will be on history and physical (always, always start with history and physical), making sure you ask the important questions/do the appropriate exams to help you figure out if this pain is appendicitis, kidney stones, ovarian torsion, etc. They will then want to know your differential, how you will go from there to further investigate, making you defend (why do you want a Cbc, what are you looking for and how will that change what you do, etc), and will then get you to make a treatment decision (surgery vs Antibiotics vs watching). Real oral boards spend a fair amount of time making the surgeon describe the procedure, different set ups, pit falls, etc, but I doubt you will have to do that. They may ask some anatomical features (what's the blood supply of the gallbladder? How do you identify if you are cutting the cbd vs cystic duct?) and then ask some post op questions (Ok, patient has a fever day 3, what are you worried about).

I think case files or nms surgery case book (my favorite study book) would be a great way to prepare, as well as seeing consults and presenting them to the residents and working thru them (which I always have my med students do, each consult is like a mini oral exam for them)

 

[tvelocity514]

Almost certainly they will give you a case, 15 year old with rlq pain, 56 year old with a breast mass, and ask you to work them up. Your biggest focus will be on history and physical (always, always start with history and physical), making sure you ask the important questions/do the appropriate exams to help you figure out if this pain is appendicitis, kidney stones, ovarian torsion, etc. They will then want to know your differential, how you will go from there to further investigate, making you defend (why do you want a Cbc, what are you looking for and how will that change what you do, etc), and will then get you to make a treatment decision (surgery vs Antibiotics vs watching). Real oral boards spend a fair amount of time making the surgeon describe the procedure, different set ups, pit falls, etc, but I doubt you will have to do that. They may ask some anatomical features (what's the blood supply of the gallbladder? How do you identify if you are cutting the cbd vs cystic duct?) and then ask some post op questions (Ok, patient has a fever day 3, what are you worried about).

I think case files or nms surgery case book (my favorite study book) would be a great way to prepare, as well as seeing consults and presenting them to the residents and working thru them (which I always have my med students do, each consult is like a mini oral exam for them)

Thank you so much! This is a huge huge help. I will read through NMS surgery casebook and make sure I'm able to do everything you listed. Thanks again!


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[SouthernSurgeon]

Every school does these a little different, so it can be a bit hard to predict.

I'd guess they will give you 2-4 cases, and since you're an M3 I'd bet they stick to the "Big" topics.

So I'd work to be prepared for:
1. Breast mass workup
2. Neck mass workup
3. RLQ pain or "abdominal pain" in general
4. Biliary disease (important to differentiate accurately between biliary colic, cholecystitis, choledocholithiasis, and cholangitis, as well as the differing treatments for each)
5. Cancers in general, probably colon/rectal
6. Trauma/Burn (ABCs and initial stabilizing of a trauma).
7. Vascular - AAA or peripheral vascular disease
8. Diverticulitis
9. Small and large bowel obstruction (may fall back into the cancer realm on this one...)
10. GI Bleeding (could go a lot of ways with this one...upper vs lower, peptic ulcer disease, etc)
11. Hernia

They may also ask you some postoperative management cases such as postop fever, low urine output, etc

NMS casebook is an old standby. Another good option if you can get online access through your school is "ACS Surgery: Principles and Practices". This book has chapters called "breast mass" "neck mass" etc. At the beginning of each chapter is a nice flow diagram that outlines the initial workup and treatment.


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For a sample ase it might go something like this...(I'll give you a sample of what I think is a "good" response)...this is probably excessive but reminds me of my own oral exam way back in the day.

Examiner: a 40 year old woman presents to the emergency department with mid-epigastric pain and subjective fevers. Her family noticed this morning that her eyes were yellow-tinged and urged her to seek care.

Response: First I would obtain vital signs and assess the ABCs. (Always assess stability in these cases - "ABCs" first everytime - sometimes for cases like GI bleeds or trauma they may want you to go over resuscitation).

Examiner: She is febrile to 102 degrees, but her heart rate and blood pressure are normal.

Response: Ok, then I would ensure we have adequate IV access and then proceed with a full history, focusing on timing of onset of symptoms, relation to food intake, back or chest pain, any changes in bowel habits, nausea or vomiting, or pruritus, recent weight loss, changes in mental status (etc)

Examiner: She reports that she has had some similar episodes of pain, particularly after eating fatty foods, but nothing this severe. Why do you ask about her mental status?

Response: Based on her presentation, cholangitis is high on my differential as she presented with pain, fevers, and jaundice (Charcot's triad ). I would worry about progression to septic shock if she had any signs of hemodynamic instability or mental status changes (Reynaud's pentad)

Examiner: Ok. She doesn't have any of those signs. What else would you like to do?

Response: I would take a family history, focusing particularly on history of cancer, biliary disease, or Inflammatory bowel disease. Then I would review her past medical and surgical history, as well as her allergies.

Examiner: No pertinent medical or family history, no prior surgery except a c-section.

Response: I would then perform a focused physical exam, focusing on the abdominal exam. I would palpate deeply in the right upper quadrant and try to elicit a Murphy's sign.

Examiner: What is a Murphy's sign? (*If you say something or use eponyms, be prepared to be called out on them)

Response: It is an inspiratory pause during deep palpation due to pain. To elicit this, I would place my hand under the costal margin and apply steady pressure, then ask the patient to take a deep breath in, watching for a wince or catch in their breath.

Examiner: Murphy's sign is negative. She is tender to palpation, mostly in the mid-epigastrium. What other studies would you like to get at this point?

Response: I would check labs, including a CBC and a comprehensive metabolic panel, as well as an amylase and lipase. I would also order a right upper quadrant ultrasound.

Examiner: CBC shows a mild leukocytosis. Her bilirubin level is 4.8, and her AST, ALT, and alk phos are all elevated. Right upper quadrant ultrasound shows a dilated common bile duct and a gallbladder that is distended and contains stones. How would you proceed with managing this patient?

Response: Based on her fever, I am concerned that she has cholangitis secondary to choledocholithiasis. I would start her on antibiotic therapy with gram-negative and anaerobic coverage. I would ask GI to perform an ERCP.

Examiner: Why an ERCP? Why not take her to surgery?

Response: An ERCP could be both diagnostic and therapeutic for her, it would provide source control by clearing her common bile duct of stones without the morbidity of a common bile duct exploration.

Examiner: Ok. ERCP is done and shows stones in the duct, which are successfully cleared. They perform a sphincterotomy. The patient improves on antibiotics and is ready to be discharged home. Would you like to do anything else at this point?

Response: I would recommend a cholecystectomy prior to hospital discharge to minimize the risks of recurrence.

Examiner: Ok. Have you seen a cholecystectomy before?

Response: No sir.

Examiner: Do you know what structures make up Calot's triangle?

Response: The cystic duct inferiorly, the common duct medially, and either the cystic artery or the liver edge superiorly - depending on which textbook you read.

Examiner: Ok good.

 

[tvelocity514]

Every school does these a little different, so it can be a bit hard to predict.

I'd guess they will give you 2-4 cases, and since you're an M3 I'd bet they stick to the "Big" topics.

So I'd work to be prepared for:
1. Breast mass workup
2. Neck mass workup
3. RLQ pain or "abdominal pain" in general
4. Biliary disease (important to differentiate accurately between biliary colic, cholecystitis, choledocholithiasis, and cholangitis, as well as the differing treatments for each)
5. Cancers in general, probably colon/rectal
6. Trauma/Burn (ABCs and initial stabilizing of a trauma).
7. Vascular - AAA or peripheral vascular disease
8. Diverticulitis
9. Small and large bowel obstruction (may fall back into the cancer realm on this one...)
10. GI Bleeding (could go a lot of ways with this one...upper vs lower, peptic ulcer disease, etc)
11. Hernia

They may also ask you some postoperative management cases such as postop fever, low urine output, etc

NMS casebook is an old standby. Another good option if you can get online access through your school is "ACS Surgery: Principles and Practices". This book has chapters called "breast mass" "neck mass" etc. At the beginning of each chapter is a nice flow diagram that outlines the initial workup and treatment.

Wow, thank you so much for taking the time to write out these helpful tips and an example! I am very grateful, and will definitely be utilizing this scenario as an example for future practice sessions that I try to re-create from the list of problems you have given me. I have emailed one of the librarians at our school to ask about the ACS access. Thank you so much!

 

[Winged Scapula]

I'm not sure who this "breast surgeon" is whom advised you that she would ask an MS-3 questions you would only know if you had completed a general surgery residency, but IMHO this would be very unusual. What's the point? At your level, the point is to assess whether or not you have a broad based general understanding of the field and how to recognize surgical problems and basic management, not stuff you would only know if you had completed a residency. <smh>

Another good book, which is often used for oral exams these years since it was released:Amazon product