The Boards

[GreatSaphenous]

With only 6 days to go till D-day, I have to admit to a little nervousness. I thought it might be nice to share a few high yield facts with each other. So if you have learned anything interesting recently please share. Here's mine:

A postop patient who becomes hypotensive, has a decline in sodium, and an increase in potassium is not septic, they have adrenal insufficiency.

A patient who received prior radiation and now has a 7 mm papillary thyroid cancer requires a total thyroidectomy (all do w/ radiation history).

Burns may result in a Curling ulcer; Brain injury rusults in a Cushing's ulcer (paper curls as it burns, patients with brain injuries spend their lives on cushions).

Who's next?

All for now, go back to your pastrami on rye.
I am the Great Saphenous!!!

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[ESU_MD]

Intra-aortic balloon pump: reduces afterload, increases coronary perfusion. inflates during DIASTOLE 40msec prior to T wave, deflates on p wave

good luck all. questions were very similar to ABSITE, so read the killer.

 

[JackADeli]

always repair the fracture before the neurovascular injury

take the splean [i.e. no conservative management] if concomitant head bleed.

 

[GreatSaphenous]

Here's another couple:

Never biopsy a solid renal tumor just resect.

There is no testicular hematoma; The kid with a testicular mass found after getting hit is the groin has a tumor. Again no biopsy, resect via an inguinal approach.

 

[JackADeli]

don't shave biopsy a skin cancer.... it may be melanoma and you need full thickness depth biopsy which is lost if you start with a shave.

 

[SLUser11]

With only 6 days to go till D-day, I have to admit to a little nervousness.

Good luck, man. I'm sure you'll do fine. After, all you are the Great Saphenous. Perhaps a lesser saphenous would struggle, but not you...

I don't really have any specific scenarios to offer, but I would just reiterate what you already know: these questions are not meant to be tricky, and like the ABSITE, I've been told that they're relatively straight-forward.

Let us know how it goes, and don't forget to drink a post-test beer with your pastrami and rye.

 

[GreatSaphenous]

Good luck, man. I'm sure you'll do fine. After, all you are the Great Saphenous. Perhaps a lesser saphenous would struggle, but not you...

Thanks, of course now if I fail I may have to change my name. If anyone else is preparing for Thursday here's a couple more tidbits:

A patient with a sudden increase in ICP may present with the "Cushing reflex" (respiratory irregularities, HTN, and bradycardia) that is a sign of impending herniation.

The major cause of death in FAP is duodenal CA; in gardner's syndrome it is abdominal desmoids.

 

[filter07]

take the splean [i.e. no conservative management] if concomitant head bleed.

I'm still a junior resident; what is the rationale for this? Risk of seizures --> increased risk of splenic hemorrhage?

 

[SLUser11]

The major cause of death in FAP is duodenal CA; in gardner's syndrome it is abdominal desmoids.

You mean the major cause of death besides colon cancer. Specifically for FAP, duodenal cancer is the most common malignancy after total proctocolectomy. Also, I don't know how deadly desmoid tumors really are, besides their ability to cause compression of adjacent organs. Of course, I've never actually seen one.

I'm still a junior resident; what is the rationale for this? Risk of seizures --> increased risk of splenic hemorrhage?

The concept there is that you can't follow an abdominal exam. Also, hypotension is poorly tolerated with simultaneous intracranial hypertension. However, I think I think in real life, there's a big portion of spenic lacerations associated with TBI can be treated conservatively.

 

[GreatSaphenous]

You mean the major cause of death besides colon cancer. Specifically for FAP, duodenal cancer is the most common malignancy after total proctocolectomy. Also, I don't know how deadly desmoid tumors really are, besides their ability to cause compression of adjacent organs. Of course, I've never actually seen one.

True the scenario presumes resection of the colon due to the polyposis, preferable before any invasive malignancy formed. I also have not seen a desmoid, but from what I have read they can be quite compressive and the intraabdominal ones aren't typically resectable.

 

[Smurfette]

Optimal time to operate on pregnant patients is 2nd trimester. No breast conservation if breast cancer while pregnant (unless in final weeks) as cannot get XRT.

Extraadrenal pheochromocytomas do not make epinephrine. Most common sites are organ of Zuckerkandl and bladder.

Thymectomy helps improve myasthenia gravis even if the patient doesn't have a thymoma.

Axillary node with adenoCA with unknown primary--> breast CA, do mastectomy (MRM).

Probably one more for the orals, but...

Perforated esophagus on EGD: if grossly perforated at cricopharyngeus or due to achalasia, do a myotomy opposite the side of your repair to fix the underlying problem. Must also enlarge perf'ed site to view true size of underlying mucosal defect before repairing.

I'm with you, GS...I keep trying to think of the boards as another ABSITE, but it's hard to not be paranoid. Just a few more days to go....

 

[JackADeli]

I'm still a junior resident; what is the rationale for this? Risk of seizures --> increased risk of splenic hemorrhage?

As noted previously, a patient with TBI is an unreliable exam to follow. The TBI will potentially be worsened by hypotension. Thus, following a splenic lac may be problematic. In 2010 (or 2000 when the current exam questions were probably written), the morbidity of a splenectomy is less then that of progressive TBI/second hit TBI.

 

[JackADeli]

Optimal time to operate on pregnant patients is 2nd trimester. No breast conservation if breast cancer while pregnant (unless in final weeks) as cannot get XRT...

I am not sure of the finesse points on this one and will leave to WS. But, There are differences in giving the chemo vs the XRT. Your not giving XRT in first trimester.... probably not the chemo either. You can operate anytime and start additional therapies later. But breast conservation is often an option for a pregnant lady.

I don't have the answer... I don't provide that care anymore. For the certyfing exam, that question is almost universal and worth reviewing.

 

[blue2000]

Optimal time to operate on pregnant patients is 2nd trimester. No breast conservation if breast cancer while pregnant (unless in final weeks) as cannot get XRT.

I've read two different answer on this in board review, especially in regards to second trimester malignancy. One says you have to do a MRM; the other says you can do a lumpectomy, chemo during second and third trimester and then rads after the patient delivers. If I get this questions on the test, I'm actually a little confused about what the board answer is...I think I'll stick to MRM, but if they give me both choices, it really seems like breast conservation is a realistic answer.

Also, stage for stage, pts who are diagnosed with breast cancer in pregnancy have the same prognosis as those who aren't.

 

[splapchole]

I passed the QE last year and I thought it was similar to the ABSITE...

Interesting factoids:

EKG is the best test to rule out blunt cardiac injury.(not ECHO)

Hypotensive patient after IVC filter placement could be (1) a massive PE or (2) clot caught in the IVC filter..to differentiate must check the CVP...IF low -- think thrombus caught in the filter and treat with fluids and catheter directed thrombolysis, IF CVP high- think PE.

M phase of cell cycle is most susceptible to radiation injury

BTW, anyone has tips/clues for the orals..I am planning on taking them in Nov

 

[njbmd]

BTW, anyone has tips/clues for the orals..I am planning on taking them in Nov

The questioners are all very experienced surgeons who want to make sure that you are a SAFE surgeon. The best advice that I received (and followed) was:

• Don't try to BS something that you have little experience with.
• Answer the question based with in your comfort zone. If you have completed a sound training program, you have the knowledge and experience to answer the question.
• Don't try to "impress" the questioners with your knowledge of something you have "read in the literature"; again, put yourself in the position of working with what has happened with the patient in front of you.
• The questioners are not out to "trick you" but to make sure you have the knowledge to work as a safe attending surgeon. Keep safety in mind and be conservative.
• Have some of your faculty "practice" some oral questions with you. All of those little pearls that you learned while operating will come in handy now. Practice calms your nerves but don't get rid of all of the nervousness.
• The best folks to question are the people who took and passed the exam last year. Find a few and buy them a drink while you pick their brains for their experiences.

The oral exam is very doable if you don't get crazy nervous and try to "read" the minds of the questioners. Listen to what you are being asked and answer based on what you know. Good luck!

 

[Winged Scapula]

Since several of y'all asked: There is the board answer and then there is the practice answer.

Presuming 2nd trimester and beyond, with invasive disease and not Stage IV-

Traditionally:

MRM was recommended and is still probably a "safe answer", however, it ignores the fact that sentinel node biopsy is standard of care (SOC).

More modern practices:

1) the use of radioisotopes in pregnancy is considered safe, therefore, one should consider simple mastectomy with sentinel node biopsy and possible axillary node dissection as SOC. Vital blue dye may not be safe (I do not use it in most cases anyway). This presumes that the woman wants a mastectomy and that she is clinically T1/T2 and N0.

2) for the woman who wants breast conservation, you *could* offer a lumpectomy and axillary staging followed by adjuvant chemotherapy and RT. She is no longer a candidate for brachytherapy due to the delay in RT intervention (even if she were, she would have to be done on protocol - NSABP-B39 and some Rad Oncs are uncomfortable, IMHO, with brachy in such young patients).

3) my preference is, regardless of what surgical intervention you plan, since most pregnant women with breast cancer are candidates for chemotherapy, is neoadjuvant chemo followed by whatever surgical intervention you and the patient agree upon.

The reason for my preference is (in no real order):

1) operating on the pregnant breast is painful - blood and milk everywhere. I used to be interested in it, until I did it.
2) very real risk of milk fistulae
3) these patients need systemic treatment - any post-op complications delay lifesaving systemic treatments
4) can see CCR and allow for breast conservation
5) gives the patient time to decide what she wants to do surgically, be tested for BRCA (which may change her surgical plan), see PRS
6) there is no good surgical reason to delay reconstruction in these patients generally

Bottom line:

1) no RT during pregnancy
2) first trimester breast ca - termination still offered, but if late first trimester, can delay neoadjuvant until 2nd trimester (by the time you do workup, get port in, etc.)
3) no methotrexate, only anthracycline based chemo
4) no vital blue dye but Tech 99 is considered safe
5) MRM is traditional answer but probably not best answer *in practice*
6) if any question includes RT during pregnancy, it is wrong
7) the boards are always several years behind - for the written boards there will be a right and a wrong answer according to the ABS; for the orals, as long as you defend your actions, YOU can be the determinant of what is right

Therefore, either MRM or lumpectomy followed by chemotherapy starting 2nd trimester and RT after delivery are appropriate although not how I would necessarily manage it in practice (but remember I have the benefit of newer data than ABS). You can also induce to deliver early and start treatments, but not before week 36.

 

[mochadoc]

Great thread. I'm about to take my Boards as well. I think I may have overdosed on Sespap questions. Is that even possible? Good luck to all my other fellow GS peeps who are about to do the QE as well.

 

[GreatSaphenous]

Great thread. I'm about to take my Boards as well. I think I may have overdosed on Sespap questions. Is that even possible? Good luck to all my other fellow GS peeps who are about to do the QE as well.

Thanks. Please share anything interesting that you have learned. Here's my facts for the day.

Rapid sequence intubation is LOVES, Lidocaine, Oxygen, Vecuronium (defasciculating dose), etomidate, and succinylcholine; in children it is LOAVES, just add atropine.

When doing a AAA remember if the patient has had a prior colon resection their marginal artery is not intact and they will likely need reimplantation of the IMA.

All for now, go back to your chicken marsala.
I am the Great Saphenous!!!!!

 

[SLUser11]

Awesome post. There's nothing more frustrating than reading all the different answers to questions on breast cancer in pregnancy.

Since several of y'all asked: There is the board answer and then there is the practice answer.

Presuming 2nd trimester and beyond, with invasive disease and not Stage IV-

Traditionally:

MRM was recommended and is still probably a "safe answer", however, it ignores the fact that sentinel node biopsy is standard of care (SOC).

More modern practices:

1) the use of radioisotopes in pregnancy is considered safe, therefore, one should consider simple mastectomy with sentinel node biopsy and possible axillary node dissection as SOC. Vital blue dye may not be safe (I do not use it in most cases anyway). This presumes that the woman wants a mastectomy and that she is clinically T1/T2 and N0.

2) for the woman who wants breast conservation, you *could* offer a lumpectomy and axillary staging followed by adjuvant chemotherapy and RT. She is no longer a candidate for brachytherapy due to the delay in RT intervention (even if she were, she would have to be done on protocol - NSABP-B39 and some Rad Oncs are uncomfortable, IMHO, with brachy in such young patients).

3) my preference is, regardless of what surgical intervention you plan, since most pregnant women with breast cancer are candidates for chemotherapy, is neoadjuvant chemo followed by whatever surgical intervention you and the patient agree upon.

The reason for my preference is (in no real order):

1) operating on the pregnant breast is painful - blood and milk everywhere. I used to be interested in it, until I did it.
2) very real risk of milk fistulae
3) these patients need systemic treatment - any post-op complications delay lifesaving systemic treatments
4) can see CCR and allow for breast conservation
5) gives the patient time to decide what she wants to do surgically, be tested for BRCA (which may change her surgical plan), see PRS
6) there is no good surgical reason to delay reconstruction in these patients generally

Bottom line:

1) no RT during pregnancy
2) first trimester breast ca - termination still offered, but if late first trimester, can delay neoadjuvant until 2nd trimester (by the time you do workup, get port in, etc.)
3) no methotrexate, only anthracycline based chemo
4) no vital blue dye but Tech 99 is considered safe
5) MRM is traditional answer but probably not best answer *in practice*
6) if any question includes RT during pregnancy, it is wrong
7) the boards are always several years behind - for the written boards there will be a right and a wrong answer according to the ABS; for the orals, as long as you defend your actions, YOU can be the determinant of what is right

Therefore, either MRM or lumpectomy followed by chemotherapy starting 2nd trimester and RT after delivery are appropriate. You can also induce to deliver early and start treatments, but probably not before week 36.

 

[Winged Scapula]

Awesome post. There's nothing more frustrating than reading all the different answers to questions on breast cancer in pregnancy.

Well that's because its uncommon enough to not have a standard of care so it can be frustrating. Many general surgeons in the community will never see one because they will be sent to specialists or the Big House.

Hopefully the written QE will be clear enough to pick 1 best answer; on the CE breast question (you will get one) all you have to do is be able to defend your answer.

 

[Azygous]

Great thread. Only a couple of days left! Just wanted to know what previous examinees thoughts were on the subspecialty questions and what was high yield for them. I know there aren't that many questions, but every question counts.

Since we're sharing tidbits here's mine for the day:

Post op Lap Chole Path shows adenocarcinoma into mucosa, nothing further. Treatment: Just observation. No need for resection of bed, etc. etc.

Good luck!

 

[45408]

Are the boards offered in one place, once a year? Or is it regional?

 

[Smurfette]

The QE (written) can be taken at most Pearson testing centers, all on the same day.

The CE (orals) are offered 4 times a year (I think), and each time is in a different city. The cities rotate, but the May version is usually (always?) in Chicago.

 

[Guile]

The QE (written) can be taken at most Pearson testing centers, all on the same day.

The CE (orals) are offered 4 times a year (I think), and each time is in a different city. The cities rotate, but the May version is usually (always?) in Chicago.

The new fellows here took the boards at a Prometric center, the same one where I took Step 1 and 2.

I didn't know the orals are only offered in one city for each testing. That must be one packed hotel even if it is x/4 of the graduating surgery residents at each testing.

 

[Buzz Me]

Usually at an airport hotel so that candidates can just fly in and out, no?

 

[Winged Scapula]

Usually at an airport hotel so that candidates can just fly in and out, no?

No.

The orals are usually at one of the most expensive hotels in town and not some cheap Sheraton at the airport. Having spoken to numerous residents over the years, it has always been this way. The PRS boards are the same way - can't have those attendings staying someplace the residents could actually afford.

Oh, and make sure you prices check on-line - the "special rate" for those taking the orals was more than what I got off of Expedia.

You also won't know the time of your examination until the day of, so don't book a flight out until the late afternoon/evening. I don't know anyone who just flew in and out - most people come in at least a day early to get relaxed, adjusted to the time change, etc.

 

[mochadoc]

Did anyone else feel like you were going through airport security before you were let into the testing room? We had to turn our pockets inside out, scan our index finger before going in or out of the room, and confirm it was indeed our pic on the screen each and every time. I literally started laughing seeing how I was the ONLY African American female in the testing center. Of course it's me on the screen I wanted to scream. It was a lot easier than I thought it would be. That could be good or bad. Anyway, I thought the ABSITE was very similar. Now the wait for the score begins.

 

[Smurfette]

I was a bit thrown by the "no headbands or hair clips" rule. WTF? Thankfully I wore a pony band which was "legal".

My finger scan didn't work all day. They'd keep trying to get it to work, and it wouldn't, so eventually they'd give up and let me in with my ID. They didn't try to scan a different finger or my palm though....they said protocol is to just check ID if the scanner malfunctions.

 

[45408]

I was a bit thrown by the "no headbands or hair clips" rule. WTF? Thankfully I wore a pony band which was "legal".

Because everyone know that hair clips are used to enhance neural function.

 

[80hrordude]

Did anyone else get an email from the ABS the day after the QE saying there were now open spots for the upcoming CE? Do u think this means I passed or is it just coincidence??

 

[Winged Scapula]

Did anyone else get an email from the ABS the day after the QE saying there were now open spots for the upcoming CE? Do u think this means I passed or is it just coincidence??

They do it every year.

They contact everyone who took the QE in August to alert you to register for the September CE.

It has no bearing on whether or not you passed.

 

[Smurfette]

I got my admission slip for the October CE two days after the QE....I think it's just standard...no "passed" or "failed" listed yet when I log into ABS website--it says "board certification status in progress" or something like that.

 

[GreatSaphenous]

Good luck, man. I'm sure you'll do fine. After, all you are the Great Saphenous. Perhaps a lesser saphenous would struggle, but not you...

I don't really have any specific scenarios to offer, but I would just reiterate what you already know: these questions are not meant to be tricky, and like the ABSITE, I've been told that they're relatively straight-forward.

Let us know how it goes, and don't forget to drink a post-test beer with your pastrami and rye.

Thanks to everyone who posted high yield facts. This may be a good forum to resurrect next year, but I won't need it as I passed baby!!!!

For next year's test takers watch out for pregnant patients and elderly ones with COPD who seemed to be on every third question.

All for now, go back to your pimento loaf,
I remain the Great Saphenous!!!!!

 

[mochadoc]

I passed. Booyah! Congrats to you too Great Saphenous.
I would add to read over Breast too!

 

[Skinny]

Pass!

Congrats to all!

 

[Smurfette]

Woo-hoo everyone!

Also passed...oral boards, here we come!

for next year's folks, add hand/upper extremity problems of every variety to that list...

 

[blue2000]

Passed

 

[maxheadroom]

Woo-hoo everyone!

Also passed...oral boards, here we come!

for next year's folks, add hand/upper extremity problems of every variety to that list...

What were the upper extremity questions?

 

[blue2000]

What were the upper extremity questions?

hmmm...can we discuss specific questions --- I know for the absite it's verboten, so I'm wondering whether it's a good idea to get too detailed for this. WS, you seem to be a center of all knowledge on these kinds of topics. Any ideas?

 

[Guile]

hmmm...can we discuss specific questions --- I know for the absite it's verboten, so I'm wondering whether it's a good idea to get too detailed for this. WS, you seem to be a center of all knowledge on these kinds of topics. Any ideas?

Of course you can't discuss questions verbatim. The test is copyrighted. However, you can get pretty liberal about "I had a question about xyz" without getting a slap on the wrist here.

So did everyone who took the test get their score back today?

 

[Winged Scapula]

hmmm...can we discuss specific questions --- I know for the absite it's verboten, so I'm wondering whether it's a good idea to get too detailed for this. WS, you seem to be a center of all knowledge on these kinds of topics. Any ideas?

PLEASE don't do this.

Its not just verboten for the ABSITE but for any product of the American Board of Surgery. That includes written and oral boards.

The ABS is very protective of their product/questions and while SDN will protect your privacy as much as we can, we have been subpoenaed in the past for information about users who post specific questions. Our legal counsel tells us we have to comply with such court ordered "requests".

There are also real cases of ABS revoking BC from physicians who were caught selling board questions.

Congrats to those of you who passed!

 

[Guile]

we have been subpoenaed in the past for information about users who post specific questions. Our legal counsel tells us we have to comply with such court ordered "requests".

Wow, did not know they went to such lengths. Good thing the RIAA and MPAA haven't had too much luck suing people based on IP addresses. I doubt those cases would go anywhere, but still, that would be a letter you wouldn't want to get from the ABS.

 

[Winged Scapula]

Of course you can't discuss questions verbatim. The test is copyrighted. However, you can get pretty liberal about "I had a question about xyz" without getting a slap on the wrist here.

Again, I would be careful.

The ABS is also unhappy with those "pretty liberal" descriptions of questions. Obviously a lot harder to prosecute but why would you take the chance?

 

[Winged Scapula]

Wow, did not know they went to such lengths. Good thing the RIAA and MPAA haven't had too much luck suing people based on IP addresses. I doubt those cases would go anywhere, but still, that would be a letter you wouldn't want to get from the ABS.

The ABS is very serious. One of the residents (PGY3 as I recall) PMd me when he received notification from the ABS that they were investigating him for posting ABSITE information and I informed him that SDN had been subpoenaed and that we could not discuss anything with him. Not sure what ever happened to him but don't recall ever seeing him post on SDN again.

And its not only IP addresses that we have - remember you have to register with email and many people use their academic addys or an email containing their name, a real birthdate and will sometimes post enough information over the years that you can figure out who/where they are. This is all subject to the discovery process.

I also recall a recent post here about the ABIM revoking BC from physicians who used a certain Board Review course.

 

[Smurfette]

What were the upper extremity questions?

I was intentionally being vague....I am not going to start paraphrasing questions for reasons WS stated--it's a slippery slope.

And I didn't get my score report yet, the ABS website simply says pass or fail and that our reports should arrive by next week.

 

[maxheadroom]

Sorry, didn't mean to stir up a hornet's nest of ABS thugs.

As a Plastics/Hand guy, I'm just intrigued about what they would ask on the ABS exam -- the General Surgery rotators on my service have not been very interested in upper extremity at all. Much as I wasn't interested in GI stuff when I was stuck in hell, I mean my prelim General Surgery time.

 

[45408]

Wow, did not know they went to such lengths. Good thing the RIAA and MPAA haven't had too much luck suing people based on IP addresses. I doubt those cases would go anywhere, but still, that would be a letter you wouldn't want to get from the ABS.

It doesn't even have to be a lawsuit/criminal sort of thing. They probably have all kinds of ways to keep you from using their "products" in the future (e.g., taking the ABSITE, your boards, etc).

 

[Smurfette]

Sorry, didn't mean to stir up a hornet's nest of ABS thugs.

As a Plastics/Hand guy, I'm just intrigued about what they would ask on the ABS exam -- the General Surgery rotators on my service have not been very interested in upper extremity at all. Much as I wasn't interested in GI stuff when I was stuck in hell, I mean my prelim General Surgery time.

Exactly! I think most GS residents don't really read up on hand/upper extremity stuff other than for vascular or other things that come up during reading for more "classic" topics. These types of questions probably stuck out more in my mind since I have less background knowledge on it.

 

[DocJockey]

Can someone please tell me what is the best way to pass the boards: What materials/references I need? What has worked for those who passed? Or what good courses are out there?
Thank you so much!