Preparing for Clinical Rounds and Board Examinations
Preparing for Clinical Rounds and Board Examinations
Most residents who completed a general surgical internship will remember the “five W’s” that can cause post-operative fever, including wind (pneumonia or atelectasis), water (urinary tract infection), walking (deep venous thrombosis), wound (wound infection), and wonder drug (drug reaction). Those that are undergoing or completed otolaryngology training will furthermore recall being asked to recount the auditory pathway and peaks of the auditory brainstem response, to describe the innervation and actions of the laryngeal muscles, or to discuss the reconstructive ladder, among many other questions in the clinic, on rounds, or in the operating room. Undoubtedly, these well-described and time-tested clinical pearls are critically important in the context of both examinations and everyday patient care, particularly to the resident trainee rotating through busy clinical services while trying to simultaneously read, learn how to operate, and provide the highest quality clinical care. Time is a luxury students and residents unfortunately do not have, and consequently they are best served by learning quickly, efficiently, and effectively.
We wrote the Cummings Review of Otolaryngology in an effort to provide a highly-efficient learning instrument to its readers. Clinical pearls such as the “five W’s”, “E.C.O.L.I.”, and the reconstructive ladder organize and compartmentalize information into packets that most anyone at this level of education and training can swiftly consume, digest and incorporate into their long-term memory. This book provides this compartmentalization of otolaryngology and all of its depth, breadth, and complexity, and offers readers the foundation upon which they can build and expand their fund of knowledge with articles, textbooks, and discussions with senior residents and attendings. Although this text will importantly augment the knowledge base of the reader in a systematic and organized manner, success on clinical rounds and on in-service and board examinations will be further optimized with better understanding of how to prepare for attending rounds and improved familiarity of the testing formats. This chapter provides a systematic approach to these tasks.
Familiarity with the format of oral exams will provide the infrastructure upon which the examinee can prepare for success. For most residents and medical students, written exams have been the mainstay of testing, with far less training in the oral exam format. To begin, the American Board of Otolaryngology oral examination takes place over a weekend in a hotel in the city of Chicago, Illinois, near O’Hare International Airport. You have the option of staying in the hotel, in a neighboring hotel walking or shuttle distance away, or in your own accommodations. Based on the first letter of your last name, you will have your exam on Saturday morning, Saturday afternoon, Sunday morning, or Sunday afternoon. At the exam, you receive a number and a list of five examiners who will likely be among the most prominent and published names in our field. Over 40 minutes, you will be tested on three cases in each of five rooms with different sub-specialty topics, which include head and neck surgical oncology, otology and neurotology, facial plastic and reconstructive surgery, and two general otolaryngology rooms. General cases encompass rhinology, sleep, allergy, pediatric otolaryngology, laryngology, and other general otolaryngology topics. One room will focus on allergy, rhinology, and sleep, and the other will focus on laryngology and pediatric otolaryngology. The examiners will be accessing your ability to discuss eloquently the diagnostic workups, treatment options, complications, and, at times, management of emergencies for each of the presented cases.
Success on the oral board exam depends on an ability to communicate an organized and structured thought process. Oral board formats are similar to the workup of a patient in a clinic. Points are attained by starting with the chief complaint and obtaining a thorough history of the present illness, past medical history, past surgical history, family history, social history, list of medications and allergies, and review of systems. After completing the full history, the examinee should ask to perform a physical exam, first asking for the patient’s vital signs. If there is an emergency, you will be expected to discuss basic life support and assess the patient’s airway, breathing, and circulation. A brief summary statement with pertinent information from the history and physical, along with a comprehensive differential diagnosis, should be provided at some point after the initial assessment is completed. Asking for additional information such as laboratory tests, imaging, and audiograms will also be necessary in many cases. Pathology is typically incorporated into several cases during the testing day. Imaging, pathologic slides, and test results will give you an opportunity to refine your differential diagnosis as needed.
As you discuss the case with your examiner, he or she may focus, narrow, expedite, or redirect your questioning if necessary. When medical treatment or surgery is indicated, you should be able to recite the various options in management, the risks and benefits of each, and the postoperative care protocols. You may need to recognize and manage complications in the postoperative setting.
Pearls for Success on Oral Exams
• Stay organized. You are provided a pencil and paper and are welcome to take notes as needed.
• Do not go directly to the diagnosis, even if it may seem obvious to you. Rather, the goal during a case is to obtain points (check marks) by logically moving through the workup of a patient and verbally stating all history questions you should ask, studies you should obtain, diagnoses you should consider, and treatment options you may offer. Demonstrate an organized and linear thought process.
• This review book provides you with the lists to be memorized so that you have easy access to what you want and need to say for many questions that may arise in your oral exam. If you are presented with a patient with hoarseness, simply recite the list of key history questions for a patient with hoarseness. If you are presented with a patient with ear drainage, ask the key questions to ask of all patients presenting to an otology clinic. If your patient has pediatric hearing loss, describe the list of tests you could offer and recommend to the parents. If you are performing parotid surgery and are asked how you would go about finding the facial nerve, simply recount the list of five ways to find the trunk of the facial nerve. If you believe that a rhinoplasty patient could benefit from an increase in tip projection, mention the three ways you could accomplish that. Memorizing the lists in this book will arm you with an organized and comprehensive depth and breadth of knowledge that will help you to remain cool, calm, and collected and succeed in your exam.