General Surgery Certifying Examinations You will need to be present only for one of the three days of the exam (Monday, Tuesday or Wednesday) and only for the morning or afternoon session (approximately 1/2 day). The entire session is 90 minutes for 3 stations. ABS data shows that there is no systematic, significant relationship between the CE fail rate and factors such as exam location, time of year, or the day and time of the examination. CE results are posted on the ABS website the day following the last day of the examination. Residents' performance on ABS examinations is one factor evaluated by the ACGME when reviewing a residency program's accreditation. Your program thus needs to continuously monitor the examination performance of its residents. No books, papers, briefcases or electronic devices may be brought into the examination sessions. You will not need to take notes during the sessions. The Examiners Two examiners are used in each of the three exam sessions to assure the validity of the examination. One examiner will be an ABS director and another will be an experienced ABS diplomate from the local/regional medical community. All examiners are surgeons in active practice and hold current timelimited certificates. The examiners are carefully instructed to evaluate each candidate objectively; they have no knowledge of a candidate other than his or her name. The ABS makes every effort to ensure that there are no conflicts of interest between examiners and candidates. The ABS verifies that candidates and examiners have never been at the same institution at the same time or have worked together in any venue. The Examination Candidates have already demonstrated sufficient knowledge of surgery by their successful performance on the QE. The purpose of the CE is to assess process thinking and judgment. All candidates are questioned across similar subject areas representing the breadth of general surgery. The cases presented are structured beforehand and constitute common problems seen in general surgery practice. Typically four cases will be presented to the candidate during each 30-minute session. Candidates should be able to answer not only what they would do and how, but why. Listen carefully to each case presented and respond with your own plan or actions to resolve it. The examiners want to find out what you would do in your own practice. Tell them what you would do, not what you think they may want you to say. Be prepared to defend your plans and actions with acceptable logic. If you honestly do not know anything about a problem, it is recommended that you say so. This will allow the examiners to proceed to other problems with which you may be more conversant. In particular, the examiner will assess: Can the candidate recognize a basic problem? Can the candidate gather and analyze data relative to that problem in a cost-effective and efficient way? Can the candidate use that data in an organized and logical fashion to arrive at a diagnosis? Can the candidate choose realistic, effective, and safe solutions (including nonoperative ones) to the problem? If multiple options are available for treatment of a given problem, can the candidate evaluate these logically and choose the one that is optimal and least hazardous to the patient? Can the candidate recognize the long-term risks/benefits of the solutions chosen? Does the candidate react in a prompt but flexible manner to alterations in the patient's course, e.g., disease or treatment complications? Does the candidate know the technical aspects of the procedures he or she will employ? Exam Results At the end of a 30-minute exam session, each examiner independently records a grade based on his or her evaluation of the candidate's performance. The ABS' decision regarding certification is not based upon any preset pass/fail rate, but solely upon the aggregate evaluation of the six examiners. Results are mailed and posted the day after the last day of the examination. How to Prepare The ABS believes that the best preparation for the CE is to "practice" taking oral examinations. You should ask a colleague, preferably a board-certified surgeon, to question you for two to three hours every week for several months. Practice not only the content of your answers, but also presenting your decision-making process in a clear, logical manner. Your examiner should probe deeply enough into your answers to make certain that you provide adequate information, and should critique your answers with regard to promptness, clarity, logic, and evidence of problem-solving ability. "I would advise reading management-specific text. I would also advise lots of practice in public speaking, conversing face-to-face with senior colleagues. Put the fear behind you." "I would encourage participation in as many mock oral exams as possible, along with targeted reading." "Do as many oral cases as possible with faculty, especially in their area of expertise." "Prepare early (3-6 months ahead). Practice scenarios often, daily during your last month." "I would recommend starting to prepare at least two months ahead." "Be sure to read and study throughout—cannot 'cram' and be a safe surgeon." "Read every day!" "Read broadly. Review practice guidelines at your institution." "Don't waste time on obscure diseases/scenarios; focus on broad general surgery topics." "Focus on core general surgery topics, not esoterica." "You need to study and review a broad spectrum of cases. Practice with a variety of people." "Don't forget to study common things. I studied all the rare things and didn't go over common diagnoses." "Practice talking through scenarios with others." "Learn to say what you are thinking; it doesn't come naturally." "Don't forget to read about your own specialty!" "Don't study minutiae; focus on the big picture." "Review bread-and-butter general surgery." "Don't study like you did for the QE. Focus on logical and well-organized problem solving." "Concentrate more on areas that you have not seen or experienced since residency." "Do mock orals with colleagues regularly to practice talking out loud and explaining yourself." "Practice explaining procedures in a quick, efficient manner." "Learn to speak about surgery out loud." "A course is not necessary to successfully complete this exam." Advice on Taking the Exam "Don't be nervous!" "Don't overthink things." "Know your plan and stick with it. Be confident and don't second-guess yourself." "Stay calm. Do not dwell on previous questions/rooms." "Focus on answering the questions." "Stay focused. Be systematic. Don't jump to conclusions." "Don't focus on the mistakes you made in previous questions." "Articulate your thoughts, be specific with an organized plan." "Approach cases like real patients." "Think like you are taking care of this patient in real life." "The exam is less about content and more about analysis and communication." "Would not have waited so long to take Certifying Exam—more than one year since Qualifying Exam." "Take exam immediately after training. Do not wait until after fellowship in another specialty." Comments About Exam "Appropriate for what I am supposed to know." "The questions were classic general surgery situations. I thought the exam was fair." "Overall fair questions/straightforward scenarios." "Appreciate examiners trying to keep examinees calm and at ease." "Not as bad as rumored." "I found my examiners to be very professional, neutral and pleasant." "Fair examiners, good debriefing prior to exam. I felt comfortable, like I was discussing with colleagues." "Pleasant experience overall despite my extreme anxiety." "I thought it was fair, well-conducted. I did not feel intimidated by the examiners." "Everybody was very cordial and polite. Not what I expected at all—very pleasantly surprised." "None of my examiners were mean; all were clear about scenarios." "I had a lot of fears but the examiners helped to the best of their ability to make me feel comfortable." "The examiners were very polite and made me feel at ease. Everyone was very professional but pleasant." The Top Ten Reasons Surgical Residents Fail The Oral Board Examination 1. You were not forced to demonstrate your surgical knowledge on a daily basis. Too few attending surgeons demanded that you articulate your "book knowledge" in a lucid and understandable manner on a daily basis. By the time you take the oral examination, you should have a mental "file card" ready to put on the table for every common surgical problem. The examiners call it a flow-chart, a practice algorithm or a decision tree. Please keep in mind that for oral examination purposes: The patient with probable appendicitis will not have appendicitis. The patient with probable acute cholecystitis will not have biliary tract disease. And, of course, you will not be able to find the colon lesion described by the itinerant endoscopist. Examiners are looking for surgeons who can articulate the principles of surgery in a clear and orderly manner. This should be a daily exercise. 2. Perhaps you considered probing questions by attending surgeons to be "pimping" or to be "harassment." Repeated pointed questioning by attending surgeons in and out of the operating room is the Socratic method of surgical education. This method has been around for thousands of years. There is a reason for its longevity: It works! Sadly, the Socratic approach has disappeared from many surgical services. Despite what you and your fellow residents may think, the goal of the Socratic method is to expose your surgical ignorance so that you can correct it. Anything less than the relentless exposure of your surgical ignorance is simply not education. 3. You assumed that a wrong answer would give rise to a warm and nurturing response by the attending surgeon who asked a question. Your errors of thought and action were met with gentle kindness and the softest of educational caresses. This approach, I am sure you now agree, turned out to be a lethal educational mistake. Surgical pathology is unforgiving. It can hurt your patient (and you) in ways you cannot imagine. You should fear making errors and should steel yourself to the harsh realities of a life in surgery. Remember: The necrotic splenic flexure tucked under the ribs of a 350-pound biomorph does not really care about your self-esteem! Many surgical programs are trying to provide a nurturing educational atmosphere delivered in a nonthreatening manner taking into account your psychosocial and ethnocultural background. Because of this philosophy, the attending surgeon who holds you to an objectively high standard through rigorous demands is accused of eroding your self-esteem. Please remember that a shielded surgical graduate who has been protected from the vicissitudes of surgical life is a weak graduate and ultimately a weak surgeon. Board examiners know this. They know that the product of prioritizing self-esteem over basic surgical knowledge is a graduate who feels great about knowing nothing. 4. You regarded attending surgeons as friends rather than surgical taskmasters. You are a hardworking, dedicated doctor. But when you function as a surgical resident, I do not want to be your friend. I have enough friends. My goal as an attending surgeon was to guide you and counsel you. You should have viewed the attending staff as a set of taskmasters. The taskmaster has mastered the task (in this case the discipline of clinical surgery). He has earned the right to honor you by delegating that task to you! Once the attending surgeon at a teaching facility becomes the resident's friend rather than the resident's taskmaster, the road to failure on the oral boards begins. You may have traveled down that road. 5. You were robbed of an essential part of surgical education by the AM admission phenomenon. This is not your fault. The AM admission policy--economically brilliant but educationally devastating--did you in. Formerly, every patient was admitted the day before surgery. Residents could take a detailed history in an unhurried manner. You could perform a complete physical examination and then synthesize the two. You could review the films and the lab data. In short, you could do, in a deliberate and educational manner, what is now reduced to a pressurized five minutes in a chaotic preoperative holding area. Many programs have valiantly tried to make up for this with clinics and physician office visits. Sadly, nothing can replace the time-honored one-on-one of the "night before surgery" resident evaluation. That is why you missed the questions on subtle physical signs, the significance of abnormal pre-op lab data and key historical points that might alter your surgical approach. 6. You did not appreciate the national consensus on surgical practice. Board examiners want answers that are right over the plate. Just because your hospital has a "center of excellence" for hyperhydrosis does not mean that hyperhydrosis is a national health problem! You must step back, look at a map of the United States and answer the question from a national surgical perspective giving a standard approach! Advanced laparoscopic procedures, indications for intestinal diversion, creative and innovative approaches to common surgical problems--these are not your primary answers unless you are directly and specifically asked about them. 7. Perhaps you did not look the examiner in the eye. Part of taking an oral exam is projecting an air of confidence. You must assume the demeanor of a confident surgeon. Carry yourself well. Picture a patient on a stretcher looking up at you. That patient wants to see a confident surgeon in charge of the situation. An examiner wants to see the same thing. Make eye contact! Let the examiner know who is in charge. 8. You believed that because of the 80-hour work week, surgical education should be less rigorous. Surgical educators are wrestling with the daunting task of teaching increasingly complex surgical care in less time. The 80-hour workweek, now the law of the land, is slowly transforming our profession into a trade. I have a lot of respect for tradesmen, but their lot is different than ours. The 80-hour week, with its attendant sign-outs, handoffs and the associated rhetoric of "post-call" and "not my patient," may have led you to believe that a kinder and gentler process of education was taking hold. Unfortunately for you (and your future patients), the entity we call surgical pathology never got the 80-hour work memo! The 80-hour week did you an educational disservice. You should have known that a surgeon whose job it is to test graduates would hold continuity of care as the main premise of surgical practice. Time and tide wait for no man. Neither does a bleeding gastroduodenal artery or an occluded appendiceal lumen! 9. You may have couched answers with the indecisive phrases, "I would consider..." or "One might do..." or "You could...." Tell me what you would do in definite and forthright terms. There is no difference in taking a patient to surgery, as we have done so many times, and telling an examiner that you would take the patient to surgery. You have done it; now tell us about it. Indecision, mental wavering and the stultified language of the faculty lounge have no role in your answers. Use the definitive "I would...." Make a move. Defend it. Live with the consequences. 10. You did not fully appreciate the educational potential of the surgical morbidity and mortality conference. We analyzed and discussed surgical complications every Tuesday morning. I told you the exam would be about complications. That is how you learn surgery! Yet every Tuesday, despite our discussions and debates, no one ever codified, memorialized and distributed all of the error and complication preventing points we made. Recommendations for a resident complications notebook, a discussion group based on the cases or written examinations based on these cases fell on deaf ears. Many programs do a disservice to residents by failing to provide them some method of learning from this most important hour of the surgical-educational week. Let me sum it up: Residents who pass the oral board examination are residents who regard surgical education as a daily synthesis of verbal expression, scientific study and the dynamic expression of both through the performance of operations.