How the Surgery Oral Board Exam Scenarios Deviate from Real Clinical Practice: General Issues

Exam Conditions can be unfamiliar

It is vitally essential for the candidate preparing for the Oral Board Exam in any surgical discipline (plastic, pediatric, vascular, colorectal, thoracic, general) to realize that the scenarios presented in the exam, although ostensibly based in reality, are, in fact, hypothetical and occur under mostly unrevealed, “exam conditions.” (Emphasis should be placed on the term “ostensibly.”)

There are several main aspects of the oral board exam for which the typical candidate is unprepared and which puts candidates off balance.  And an unprepared candidate is a compromised candidate. (There are many other issues, too, covered more extensively in Dr. Argy’s book, Demystifying the Surgery Certifying Exam, 2nd revised edition on Kindle.)

1. Exam scenarios have remarkable, in fact, unbelievable, time compression.
2. The high-stakes nature of the exam creates significant emotional pressure, which compromises candidate performance.
3. The examiners have unusual, non-reactive behaviors that significantly differ from how surgeons communicate with one another.
4. The exam format is unfamiliar and uncomfortable for candidates.

Exam Scenarios vs. Clinical Care

There are many ways in which exam scenarios deviate from the realities of actual clinical care, but here are the most basic ones:

1. Exam scenarios have remarkable time compression. The scenario is discussed from beginning to end, usually in seven minutes.  Laboratory and CT scan results are available in a matter of seconds.  The scenario could follow a patient from the beginning of their presentation, through an operative procedure, and then to complications that occur several years later, all within those seven minutes.
2. The high-stakes nature of the exam creates significant emotional pressure, which compromises candidate performance.  Having prepared with 5 years of surgical training (approximately 15,000-18,000 hours in residency) plus or minus a fellowship and clinical practice, candidates take a 1.5-hour exam, determining the difference between being board certified or not.  (Whether or not six strangers can evaluate anything meaningful and measurable about the clinical capability of a surgeon in the exam setting is another matter for a separate discussion.)  The professional and psychological consequences of passing or failing the exam are significant.  The awareness of these consequences creates emotional stress during the exam and activates the amygdala.  Amygdala activation then impairs exam performance by blocking three essential aspects of a strong exam performance: complex neocortical processing, high-level communication skills, and memory access.
3. As a group, the examiners have non-reactive, impassive behaviors, which are significantly different from the typical ways in which surgeons communicate with one another.
   
   Candidates find the non-reactive demeanor of examiners, usually described as “poker-faced,” to be particularly disconcerting.  This is understandable since the settings in which surgeons interact with each other involve discussion and exchange in a communication schema that is very familiar to candidates.  Such settings can be casual ones in the OR lounge, on rounds, at the scrub sink, in the Operating Room, or more formally, at Morbidity and Mortality, Grand Rounds, and other conferences.  
   
   Candidates expect and look for feedback from the examiners for many reasons, but here are the top three: first, because dialogue is part of our usual pattern of communication between surgeons, second, because candidates believe an exchange to be part of taking the exam, and third, because as residents in training, candidates were getting plenty of feedback from their attending physicians regarding the management of patients.  Rarely will candidates get such feedback from examiners in the Certifying Examination. (More details are discussed in my book, Demystifying the Surgery Certifying Exam, second revised edition, on Kindle.)
   
   Recognizing examiner behavior on the exam and adapting comfortably to it is essential to candidate success in navigating scenarios under exam conditions and achieving exam objectives. The well-prepared candidate will be able to adapt quickly and effectively to alterations in examiner behaviors or conditions in the scenario created by the examiner.   
4. The exam format is unfamiliar and uncomfortable for candidates.  The very forced, arbitrary format of the exam, with its unknown rules, non-reactive examiners, extreme time pressure, and high emotional pressure, are unrepresentative of the real world.  Candidate discomfort, uncertainty, and confusion diminish exam performance significantly.

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New scenarios require new skills

The interaction in the Certifying Exam between examiner and candidate is less interactive, less casual, and more stylized than interpersonal exchanges in real life. The Oral Exam demands a different and unfamiliar intellectual approach and communication schema from candidates. Creating and executing new communication patterns in these unexpected conditions is extremely difficult for most candidates unless they have prepared adequately in advance.     

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