Residents in a Room

Episode Number: 62

Episode Title: APPLIED Exam Prep

Recorded: March 2024

(SOUNDBITE OF MUSIC)

VOICE OVER:

This is Residents in a Room, an official podcast of the American Society of Anesthesiologists where we go behind the scenes to explore the world from the point of view of anesthesia residents.

What I wish the examinee would know is that the examiners are also being graded.

Make sure you are finding your stress outlet, whether it be exercising or music or some creativity outlet, just as you were every day.

Do as many oral stems as you can. Talk them through. Do them with colleagues. Do them with faculty members.

DR. VINCENT BARGNES:

Welcome to residents in a room, the podcast for residents by residents. I'm Dr. Vince Bargnes, a CA1 at Stony Brook Medicine in Long Island, New York, and I also serve as the ASA Monitors Residence Review junior co-editor. We're here today at ASA's board meeting in Chicago with Dr. Sasha Beutler. Doctor Beutler is a program director, an examiner for the ABA, and the chair of the ASA Committee on Residents and Medical Students. She's going to talk to us about our Applied exams. I'm looking forward to learning from her. So welcome to the show.

Before we jump in, I'm going to ask my fellow co residents to introduce themselves.

DR. ABIGAIL SCHIRMER:

Hi, I'm Dr. Abby Schirmer, I'm a CA1 at the University of Florida and I am the current ASA resident component president elect.

DR. IMAN SOLIMAN:

Hi, I'm Doctor Iman SOLIMAN. I am a PGY1 starting anesthesiology at Hopkins this summer, and I am the secretary of the resident component.

DR. BARGNES:

Can you introduce yourself, Dr. Beutler?

DR. SASCHA BEUTLER:

Well, thank you, first of all, for inviting me today to discuss with you the applied exam and for the kind introduction. So my name is Sascha Beutler. I'm the program director at Brigham Women's Hospital. Originally, though I'm from Germany. I went to medical school there. I started training, actually, in trauma surgery, and then came to Brigham Women's Hospital to transition my career into anesthesiology, did my internship year and residency there, followed by critical fellowship at MGH. And then I was on staff at the VA for several years. I came to the Brigham back to work for the residency program more than a decade ago, first as the assistant program director, and now for the last three years I've been the program director. So thank you for having me here today.

DR. BARGNES:

Oh, it's our honor.

All right, before we jump in, we hear about so many exams: Basic, Advanced Applied Orals, OSCES, can you give us an overview of the exams after medical school? What exams do we face from the time we start residency to when we become attending anesthesiologist?

DR. BEUTLER:

To become a board-certified anesthesiologist, you have to participate in the so-called staged examination process. These exams are administered by the American Board of Anesthesiology, the ABA. The process is called staged because the exams take place at different stages of residency training, and there are a total of three exams that you have to pass successfully. So I will go through the three exams now just briefly to give you an overview.

So there is the first exam. That is called the Basic Examination. And it is a written test that is offered in June as well as November and December of each year. The ABA strongly encourages residents to take the Basic exam as early as possible during their training, which means for most of their residents, it is at the end of the CA1 year. A resident cannot graduate from training without passing the basic exam. Repeated failure may require an extension of clinical training and may be grounds even for termination from residency, so it is a pretty high-stake exam. So that's the first one.

Then there is the second examination and that's called the Advanced exam. It is also a written test. This one is offered in July And in January of each year. The earliest residents can take the advanced exam is only after completing residency. There is, though, a grace period of three months until September 30th for graduation, so therefore most residents take the advanced exam in July right after graduating from residency.

And now we actually come to the Applied exam and the focus of our discussion today. So that is the third of the staged exams. And the applied exam has two parts. So there is the traditional standardized oral examination. That's actually been in place since 1933. And we'll talk About that a little more as we come along in our discussion. And there is a second part. And that's the objective structured clinical examination. The so called OSCES. And the OSCE component was only introduced in 2018. It was introduced by the ABA with the goal to cover areas of our work as anesthesiologists that are not already covered by the other exams. So communication, professionalism, and technical skills. So after passing all three stages of the examination system, you can obtain initial board certification from the American Board of Anesthesiology.

DR. SOLIMAN:

Could you give us some more information on the Applied exam and what that looks like?

DR. BEUTLER:

Of course. So as I mentioned, the standardized oral exam has been administered for decades. Of course, over the decades, it has undergone significant modifications. The most recent evolution occurred actually in 2015, when the location was changed from hotel rooms to an assessment center that was built in Raleigh, North Carolina. So now everybody has to come to North Carolina to take this exam. The goal of the standardized oral exam is to assess your judgment, your adaptability, and your organization. It is not primarily geared to assess your knowledge. The assumption is made that your knowledge is already sufficient as you passed the advanced exam.

So from my perspective, there are few things that I want to share that you should probably know about the exam. First of all, of course it is an exam that has two parts, two 35 minute exams. Each of these exams has a vignette with a patient case. The first exam starts off with four topics about the intraop management, followed then by six topics on the postoperative care. And then at the very end of the exam, there are three unrelated short scenarios with questions. The second exam starts off with four topics on preoperative evaluation, and is then followed by six topics on intraoperative management. And then again, there are three additional short scenarios with questions. It is very important to know that this exam is very structured. The examinee is presented with these 13 different topics in each exams, and the examinee can score points on each of the topics. So therefore if you're not sure about one, just move forward. Do not worry. Focus on the next step. The exam is also very timed. For each of the intraop and postop topics, the examiners has 2.5 minutes only to examine this particular topic. The examiner is asked to strictly adhere to this timeline, not less, not more. So sometimes if you have answered a question to the point, there's still time left. If it takes more time for you to answer the question, sometimes there's not enough time, this may lead to a somewhat abrupt transition to the next topic. So that's the timing of the exam that you need to understand. Then it's also very scripted. So the examiners are asked to stay on the topic and at times probe for deeper for depth and breadth. However, examiners cannot invent topics. Now, most importantly, as an examiner, we are asked to avoid any nonverbal communication so that makes the interaction often very awkward, especially on the examinees side, and adds to the stress of the situation. As an examiner, we are strictly asked to avoid any head nodding any okay, any mhm. Any of those nonverbal communication that we normally are making part of our interactions. So this you will observe examiners staring at the wall behind you or staring at their iPad and not making any eye contact. So this often makes it a very awkward type of interaction.

DR. SOLIMAN:

Sounds very interesting. Like we have quite a lot to look forward to.

DR. SCHIRMER:

So you mentioned the ABA added OSCES in 2018. What problem were they trying to solve in adding this portion of the exam?

DR. BEUTLER:

As briefly mentioned previously, there are domains in medical competency that were not covered by the other exams. In particular communication and professionalism, as well as technical skills. But those are actually domains of higher level of medical competencies. So the ABA was looking for a way to introduce the assessment of these competencies into our examination process. So therefore the OSCES have really two types of stations. There are four stations that focus on your ability to communicate professionally. And there are three stations that are there to probe your technical competency. So total of seven stations for each of them eight minutes are reserved. And you have a transition time of four minutes.

DR. BARGNES:

Excellent. Now, Dr. Beutler, you did mention briefly the ramifications of a failure of the basic exam. What happens if you fail the applied exam.

DR. BEUTLER:

So the applied exam has two parts. And if you fail only one part, you only have to repeat that portion. The earliest you can repeat it is four months later. So you have to wait for that period to pass before you can repeat it. Now, once you've graduated from residency, you have a maximum of seven years overall to certify, which means to have all these three exams successfully passed. Therefore, the advanced exam and the applied exam, you have many times to repeat, but you have to stay within the seven years.

DR. SOLIMAN:

At this point, I think we've talked about the basic exam, the advanced, the applied, the OSCES. Could you tell us a little bit about the oral boards and what we can expect, and how you would recommend preparing for that?

DR. BEUTLER:

The standardized oral board, it is important for you to practice. Now practice out loud. You can record yourself. You can practice with a peer. It doesn't have to be a faculty member who is a board examiner. Remember, it is important to answer the question that is actually being asked, and there are many exam question examples out there. Do not avoid answering a question. But also, it has no need to make up additional information that would answer a different question. I believe the best way to practice is that you picture yourself in your work environment and with the patient, and then explain what you usually would do in your practice. Do not start doing things that you usually wouldn't do just because you're in the exam. And again, practice to be able to explain your reasoning behind your actions in a clear and concise manner.

DR. SOLIMAN:

Thank you for that advice.

DR. SCHIRMER:

How about the OSCES? What are your best tips for preparing for Oscars?

DR. BEUTLER:

So the Oscars are a little bit different because as we discussed, the content of the Oscars covers communication and professionalism and then technical skills. And it is important to note that the content of the OSCES is still evolving. New content is being added in the next few years. So, for example, starting in 2026, qualitative and quantitative neuromuscular blockade as well as fetal heart rate monitoring is added to the exam, as well as the interpretation of abdominal ultrasound images such as the pelvis gastric exam and the left and upper right quadrant exam. So to become familiar with the content that is still quite limited, tt is very useful for you to go on the ABA website. There are content outlines as well as videos that help you to understand what you will be tested upon.

DR. BARGNES:

Excellent. Now, Dr. Beutler, you mentioned reflecting on our day-to-day training during our exams. Is there something we should be doing, in particular in our clinical practice, to be more prepared when we take these tests?

DR. BEUTLER:

Yeah. So I believe for the standardized oral exam portion, the daily discussion with your faculty and your peers about the patient care that you're providing, that they are providing are key for the success. Ask questions. Share your thoughts. Listen to the reasoning of your faculty and your peers, how they prepared for the case, and then how they actually handled the situation. That will help you very much to prepare for this exam. For the OSCES, as we mentioned, it's a little bit different, especially for the technical part. Their, ultrasound skills are a key skill that you need to obtain, so be proactive and use ultrasound throughout your training whenever possible. This will be very helpful for you when you're at the exam.

DR. BARGNES:

Practice makes perfect, right?

DR. SOLIMAN:

I think you touched on the timeline a little bit in terms of what we can expect with these exams. How does that timeline change, if at all, for residents that are pursuing fellowship?

DR. BEUTLER:

The timeline is typically the same for residents entering fellowships or taking faculty position at an academic center or going into private practice. Most residents, as we earlier said, will take the advanced exam right in the summer after finishing residency and then within a year or one and a half years later, doing the applied exam.

DR. SCHIRMER:

So you mentioned some changes that we can anticipate for 2026. Are there any other changes you anticipate down the road for these exams?

DR. BEUTLER:

So the American Board of Anesthesiologists try, you know, administered the exam. But also drives the content. So I do believe it is the best resource to use the ABA website. It is frequently updated. When new content is added you will find that on the website. And as a very helpful information right from the ABA posted.

DR. BARGNES:

Now where do you see residents going wrong? As you are an examiner for the ABA. Are there mistakes you see often? What traps should we look out for as examinees?

DR. BEUTLER:

So I would say that is actually one of the myths right there for the standard oral board exam. Often examiners think there are traps built into the questions, but there really aren't. As we discussed earlier, the content is very scripted and it is determined long before the exam is actually delivered. And the goal is not to trap anyone. The goal is to assess whether the candidate is ready to practice as an independent anesthesiologist in the United States. Also, as an examinee, you feel very uncomfortable and awkward in the situation because of the way that the communication is not natural to us by leaving out nonverbal feedback. So never try to read anything into the way the examiner is conducting the exam. And then also remember, there are many points you can score. So it's like in real life when you're with a patient, when an IV didn't work, you need to focus on the next step in your care. The same in the exam. Move on to the next topic in your mind. And then finally, I do believe this exam is a lot about stress management and being able to function under stress. So the last few days before the exam, do not study, take off, sleep, eat, take an early flight so that you're prepared to deal with the stressful situation just as you do in the OR.

DR. SOLIMAN:

You've been an examiner for a long time now. Is there something that you wish we better understood about the examiners?

DR. BEUTLER:

Yes. And what I wish the examinees would know is that the examiners are also being graded. All these exams are video recorded and the examiners are graded on the way they deliver the exam. So the examiners are being audited whether they give a fair exam. And at the end of the week, sometimes there's a few weeks delay. The examiner receives a report about their strengths and their weaknesses. So believe me, you are not the only one stressed in the room. Also, what I would like to add is there is a myth out there that an examiner can just fail this exam because of one examiner. However, this is not accurate. You have four examiners and all the exams are video recorded, as we discussed, and graded how the examiner delivers this exam.

DR. SOLIMAN:

That's very reassuring. Thank you.

DR. BEUTLER:

Well, let me turn the tables before we conclude today. I'm curious to hear from you all. What other advice you might have heard how to approach this exam process.

DR. BARGNES:

Oh, now I'm in the hot seat. One of the pieces of advice I received for taking standardized tests, like these exams we've talked about, is to make sure you take care of yourself on a physical level, on a mental level, emotional level, spiritual level. However you take care of yourself, make sure you are finding your stress outlet, whether that be exercising or music or some creativity outlet, just as if you were any other day. And so you can function to your fullest for the many exams that board certified anesthesiologists take.

DR. SCHIRMER:

A piece of advice that is preached at my program is do as many practice oral stems as you can. Talk them through. Do them with colleagues. Do them with faculty members. We, as early as CA1s, have started to deconstruct stems and go through questions with faculty members just to start getting a glimpse of what the process is and what the type of questions are and how to answer them properly, because there is an art to it in directly answering the question, rather than going on a tangent and understanding the types of questions that will be asked.

DR. BEUTLER:

It sounds like you're getting good advice.

DR. BARGNES:

Well, Dr. Beutler, thank you very much for your insight into all these questions that we've asked you, and also for your commitment in educating residents for the many years that you've been doing it.

A special thanks to our listeners at home for tuning in to this episode of Residents in a Room. Be sure to catch us next time in Residence in a Room, the podcast for residents by residents.

VOICE OVER:

Leverage peer reviewed resources and an engaged community to further your knowledge and skills. Get answers to your questions. Tap into the latest coursework and learning delivery technologies developed by programs around the world, and see how you're progressing relative to your peers. Tell your director or coordinator to sign up your program for ASA’s Anesthesia Toolbox. Visit asahq.org/toolbox for more information.

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