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

All the exam scenarios deviate from the realities of actual clinical care because of the logistics of how the exam is constructed and conducted.  (These deviations are not deliberately intended to trick the candidate.)  To successfully navigating an exam, candidates need to be intellectually aware of these deviations but also, importantly, need to be prepared to handle them in a practiced, comfortable manner.

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• Candidates, not examiners, are responsible for moving an exam scenario forward. (This is suggested, but not clearly stated, on the American Board of Surgery website.) Candidates expect examiners to "lead" the candidate in a particular clinical pathway. In fact, the examiner accompanies the candidate down a pathway that the candidate initiates. If the candidate has difficulty moving a scenario forward, and the examiner needs to "prompt" the candidate to get the candidate moving, this is considered detrimental by the examiner when assessing the candidate's performance.
• Most scenarios are characterized by "incomplete information," with many aspects of a patient evaluation notably absent. Despite the missing pieces, there is enough information to move the case forward, and the candidate must decide what additional information is relevant and contributory to the case. (For example, a 70-year-old man has a 1.5 cm melanoma on his back. The candidate asks for a history of sun exposure. It is not "wrong" to get that information. Yet, since the patient has a melanoma, what difference does it make to the patient's care whether he had sun exposure as a teenager? What, therefore, is the logical reason to get that information? Is it wise to spend time getting information that is non-contributory under the tight time pressure of the exam?)
• No consultants are available to make clinical decisions for the candidate. In actual practice, a surgeon would consult a specialist in an area outside of the candidate's expertise or experience to offer suggestions for management. I have never seen the examiner allow a candidate to get a clinical management decision from a consultant. (That being said, if the candidate has already made a management choice, examiners usually allow consultants to be used as "technicians" to do procedures that the candidate does not do, such as give chemotherapy or do endoscopic retrograde cholangiopancreatography.)
• There is no live patient to look at. The patient is "imaginary." Significant amounts of information routinely "acquired" when entering a patient's room are notably absent from the exam. Never has an examiner shown a photo of a patient's appearance when a candidate enters the room, let alone a 10-second video clip. Valuable information like patient alertness, presence or absence of toxicity, oxygen saturation monitor readings and audio, hemodynamics, and much more are all absent. This "imaginary" situation is unfamiliar to candidates and can put the candidate at a serious disadvantage compared to what happens in the real world.
• The exam scenario may require candidates to discuss the diagnosis and management of conditions that candidates have rarely or never seen as if the candidate were actually taking care of patients with those conditions.
• The examiners often require candidates to discuss and describe surgical specialty topics and procedures that candidates have never seen or done in residency. This can include, for example, a hysterectomy, superficial parotidectomy, radical neck dissection, or an excision of a hydrocele. (Most of these are already in SCORE, but in recent years the ABS has indicated on its website that "The content of the CE is generally, though not exclusively, aligned with the SCORE Curriculum Outline." Therefore, more questions have appeared that are not covered in the SCORE curriculum.

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• All of the 12 cases in the Surgery Oral Board Exams of most surgical specialties are selected by the examiners. Candidates submit no case list to be able to take the Certifying Exam in any surgical discipline (except Plastic surgery.) Thus, there is no actual record of a patient with whom the candidate is familiar and can discuss management in reality rather than hypothetically. (In the Plastic Surgery oral exam, one of the three rooms is dedicated to actual cases the candidate has done and which have been submitted in advance. The other two rooms are cases selected by the examiners.)
• The exam venue is not a hospital, clinic, or office, but rather, historically, in a hotel room. Since 2020 and the Covid pandemic, the exam has been virtual via Zoom on a computer screen. (The virtual exam format has its disadvantages (numerous) and advantages (only a couple) for the candidate compared to the in-person exam.
• Scenarios have rapid and frequent variations in a patient’s course, which do not happen with real patients. In any given scenario, a candidate will manage between two and seven different versions of a single patient.  
• Scenarios can deviate from reality in some other strange ways, from impossible pathophysiology to impossible clinical situations. The initial reaction of a candidate to pathophysiological impossibilities is usually surprise, shock, disbelief, fear, panic or anger. (Or some combination of those.) However, none of these visceral emotions can adequately manage the moment to achieve exam objectives. Some approaches can be used to handle such situations capably and comfortably (and not confrontationally) that candidates can learn and master. Acquiring these skills is not easy or fast, but it can be done capably and comfortably without appearing confrontational. (Surgery is not easy either … until you learn how to do it properly.)

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Examiners have taken a few pages from Odyssey’s coaching methods in the last five years. This includes examiners occasionally suggesting that candidates visualize a specific family member when considering how to manage clinical scenarios and, occasionally, asking a candidate to specify what she/he is thinking or what a differential diagnosis might be.

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Under experienced guidance, candidates can be fully prepared for rapid changes in clinical pathways, be practiced in how to manage such changes, and be comfortable in handling variations to achieve exam objectives under exam conditions.