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Tips from Tom Elwood on the Orals

The most nervous day you'll ever have

Your best defense: be organized, be practiced.

You don't have to be smart, just safe.
Good exam answers prepare you for real life.
Examiner wants to hear you're safe, confident, have a backup plan, and in charge
Tell me:
- you've seen this
- you've thought about it and know the issues
- you know what to do in what order
- know when you're out of your depth
- you're in charge, and can coordinate people

Not the inquisition; no trap doors.

Picture a coffee table discussion with a senior member of your new group who just wants to hear what's the up-to-date approach - YOU are the expert.

Be organized

Here's some examples of how to structure an answer:

Give me an image of the "trunk and branches" of the tree, not a leaf or twig.
- Pre-op / intra-op / post-op
- Patient concerns / anesthetic concerns / surgical concerns
- Immediate, early, and late complciations
- Cardiac probs: contractility,rate,rhythm,afterload,preload
- Airway / Neuro / Resp / Cardiac / Heme / Endo / GI / GU-uterine / musculoskeletal probs / resusc / History / Exam / Lab / X-match / optimize / regional / consults / premed / airway (plan A+B) / drugs / induction / airway / machine / monitors / defib / induce / maint / emerge / disposition
Don't ask questions of the examiner- avoid closed-ended questions

Find ways to carry on "Assuming the airway exam is normal…"
or "As long as the heart rate was still <100.." not "what's the heart rate now?"
or "I'd send a Hct and lytes when starting the IV" not "Is he anemic?"
or "In the absence of contraindications, I would give…" not "Any allergies?"

The oral exam tests

clinical management (not trivia)
your ability to

make reasonable decisions especially making decisions in the face of conflicting requirements "What bothers me the MOST is…"
assess a situation rapidly
organize and apply your knowledge
be adaptable

how you justify decisions (emphasis is your rationale - there's usually not one 'right' answer)
if you can make a plan and stick to it - they may try to shake you from your position (don't abandon a technique because a single disadvantage is pointed out)
communication skills

Practice, practice, practice

Learn efficient ways of saying things, e.g. "I would perform my usual thorough preoperative evaluation, limited by the emergency of the situation, but paying particular attention to…" "Because of his potential neck trauma I would use in-line stabilization" "With my machine checked and drugs ready…" "My goals for induction would be…"
Give each other exams, and practice being interrupted constantly
Video camera (verbal mannerisms / excessive pauses)
Ask attending to quiz you (what case made you think hard recently, e.g. diff A/W)
Do practice orals after a night on call
Save a good reference for the last 2 days before the exam.

Common mistakes

Not doing first things first (History and Physical/ Airway first)
- surprisingly hard to learn!
Not showing the appropriate urgency (body language/"this is a life threatening situation")
Not stating pros and cons, not indicating if a choice is controversial
Pigeon-holing the question too early
Not consulting ICU/CCU/colleague, but, make sure you ask the consultant a specific question "I would ask the pulmonologist what risk of lung abscess rupture is"
Asking questions of the examiner, or criticizing examiner
Slowing pace with excessive lists
Tangential answer (consider repeating the question) Answer the question asked, not what you want to answer!
Airway - using definitive control when not needed
Unfamiliar with a common technique
Not asking surgeon for alternatives to planned surgery
Cookbook memorized approach (except trauma, disaster)
Using unfamiliar techniques
Not calling neonatologist at outset of difficult obstetric case
Forgetting antibiotics for heart lesions.

Presentation

Maintain eye contact
Not excessively informal, not tripping over formal terminology
Natural body language
If you get unraveled "I forgot to say earlier…" (don't let it pass)
"I'm not answering this the way I want…I want to restart from…"
Use short pauses to your advantage to reorganize your thoughts
If a pause becomes long, speak about the problem you're having, don't just pause.
A careful balance between going too slow (usual prob) and going too fast

Most people study intensively for 4 to 5 months.

Use a minimum number of books - don't panic and jump between a lot of texts.

Nuts and bolts of the actual exam:

Plan to arrive in exam city 36 hours ahead
too early and you go stir crazy, too late and it's too hectic
Order breakfast in your hotel room on day of exam
Dress conservatively and simply
Walk to exam room about 10 minutes before exam (seeing other examinees for any longer drives you crazy!)
You have 10 minutes to read the stem question and think out your answer
2 examiners on other side of desk in a standard hotel room (this has a surreal feel)
sit on the edge of your seat, be brazen and confident but not cavalier
they start right in, there's no time to waste, they'll interrupt and switch gears fast
many questions may have nothing to do with the stem question
many questions on postoperative management and out-of-OR situations
examiners may not give you any clue if you're totally wrong - 'stone-faced'
but they will help you - "Did you remember this was a full stomach?"
examiners are there to help you get through, not to trick you.