What is Our Primary goal as Emergency Providers? The Best Answer is to Examine ABEM’s Model: Their 8 Performance Ratings for Passing the Oral Board Examination

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You might be surprised to know it is not much about the diagnosis but more about disposition and simultaneous acute intervention.  I have written a detailed account of the 8 performance ratings that rank you when you will take your oral board examination.  Learn them well.  They don’t come out and say this but if you look at the diagnosis it is only ¼ of 1 of the 8 performance ratings.  So it does not count for much because what counts is the process of how you move the patient to their disposition while simultaneously managing any acute or chronic but limb or life threat.

We always start the same way:  “When I walk into the examination room what do I notice?”  Here is a simple algorithm that is what we all should do when we see any patient.

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With practice we have already done the math for the IV when we “triage” the facts made available before we enter the exam room.  I will keep reminding you to memorize this simple little table.  I realize we are more obese now than ever.  This is based on ideal body weight.  Weights and ages jpg.png

Then there is a rapid primary survey that may not even involve touching the patient for the most part but I always touch the wrist and feel the pulse.  I always look at ventilation although we know this can be misleading much more than is discussed.  We simply cannot see ventilation because it is more than just chest wall rise it is the descent of the diaphragms as well as the function of gas exchange, specifically CO2 release into the alveoli.  We can’t see that but we measure the oxygen saturation which is highly variable when it is compared to actual oxygen tension at the top of the oxyhemoglobin curve…i.e., the flat part of the S-shaped curve we all know that compares pO2 on the X-axis to saturation on the Y-axis.  There is a wide range of pO2 values for any given saturation in this upper range.  Also, we cannot chest rise well through a gown.  Most physicians do fail to undress their patients briefly during a primary survey but this is a key error that we all should correct.  So if the patient is speaking, is speaking with oriented speech with no evidence of agitation or depression of mentation, has normal color (especially pink conjunctiva), a regular and strong pulse it is unlikely that they qualify as having a serious problem, right?  Nope.

Many elderly patients with acute MI and acute strokes can present as if they are normal or have intermittent symptoms.  Hypovolemic elderly patients may present with no sign until they vomit and fill a basin with blood or they have syncope from one dose of morphine for their back pain (which is really a huge bleed from a leaking ruptured abdominal aorta).  If you see red you need to give red (pRBCs); if you see pale as “Casper the ghost” you need to give red (pRBCs).  The Hgb may fool you and be falsely high and the patient with an acute hemorrhage does not tolerate acute hypovolemia from acute blood loss because they have not had the time to increase their total body 2,3 DPG which promotes a right-shift of the oxyhemoglobin curve.  This promotes oxygen release to the tissues.  A patient may present with a Hgb of 4 and have no distress because it is chronic.  Example: a patient with chronic vaginal bleeding from multiple fibroids has chronic anemia and finally presents with just “weakness”.  She is 45-years-0ld.  Why hasn’t she had treatment like a hysterectomy?  No one ever asked her why she refused surgery.  She refused because she wants another child because she lost her only child to sudden death syndrome and no one has ever established this fact.  But her right-shifted oxyhemoglobin is keeping her from dying.  Anyone else would likely die if their Hgb dropped this low in minutes from any cause.  Part of her care is does she believe she received the best care: this is called the “Health Outcome Score” and did the provider function with best practices and what is a countrywide standard of care for the U.S as defined in the core content by nation ACEP and ABEM?  This is separate from the interpersonal skill score.  Physicians often act abnormally in a simulation simply because of the most common fear:  the fear of public speaking.  One physician told me it is absolutely true he would rather donate one of his kidneys than to have to speak.  Speaking also defines what it is to be a physician.  You won’t know your tone, your rate of speech, your volume, until you practice simulations.  This is the key to passing: knowing the performance ratings, the general critical actions and knowing your “lines”, i.e., what you will say by actually practicing it.

A simulation is not the same as patient care it is highly charged with personal emotion for each physician.  I know this from testing over 12,000 physicians since 1989.  This is a common comment in private:  If i don’t pass I won’t have a job, I will not have money, starve and die.  This is often followed by tears.  We are just practicing at a program and this is the stress physicians bring to a classroom.  Why?  They assume they have to be perfect; they are in a divorce situation…the list of reasons is long.  They have such aberrant reasoning and behavior at times and it is always worse as we approach exam day.  I have had three programs: one is 3 month from the exam day: everyone is normal for the most part;  then one is 2 months from the exam day and some are now acting out.  The program that every demands because they feel they won’t remember anything from the program is to attend 2 weeks before this exam.  I have don’t it so many times and each time the hotel staff even notices all sorts of changes in behavior.  But the I will die scenario is mentioned at that last program by physicians who have been working for years.  It is a real phenomenon and the board does everything possible to be polite and fair to each candidate.  However, if an examiner acting as the patient in the live exam suddens has an outburst, it is there by design and you are to manage the patient.  Examiners do occasionally get frustrated by candidates.  I am certain of this.  It is human nature.  So just be yourself.  Do what you would normally do.

Now there are critical actions and that word alone (critical) charges up the emotional (limbic) capacitor of many, but this just means an action which must be done.  Consider it just a required action.  The IV if indicated, will always be a critical action but it includes, the size of the catheter, where it is placed, the type of IV fluid and size of the IV bag, (possibly the use of a pressure pump or level one infuser but by saying, “wide open, under pressure” is enough).  An old-device, hopefully no longer produced or used, the hand-held bulb device on the IV line is totally inadequate for a true resuscitative bolus.  However, they use the word critical because we are emergency physicians and whomever wrote the final draft could have chosen a less charged but equally useful term to define what they want to see to pass the phsysician.

Do not assume anything until you see the responses to your interventions if you have any and do not be afraid to intervene.  You can reverse morphine with naloxone.  But always think about how you will protect the patient for every intervention.  Never send the patient out of the department with hypotension.  An elderly patient may not display tachycardia from medication or an aging conduction system when a younger patient would.  Babies can’t talk but we know that by just a few weeks of age with a brain that is 80% water they can follow and tract their parents.  They should have a good suck response.  All of this means you can quickly perform a primary survey that is tuned to the type of patient based on age and presentation.  You must fully expose the patient if they are clearly in distress and cannot state their problem.  A foley catheter that drains 3200 mL of urine acutely will likely appear as a mass or pregnancy but in an elderly male you must know that prostate disease including prostate cancer must be considered at the same time as you manage a likely associated UTI from urinary stasis, and the most worrisome issue is severe hyperkalemia.  When you see urine think of potassium always.  Each liter of urine contains 35 mEq/L of urine when no diuretic has been given.  This increases to 80-90 mEq of potassium per liter of urine when you administer a loop diuretic like furosemide.  So the two end-organs the brain and the kidneys tell us if the patient is adequately perfusing and this is a major goal to establish in the primary survey and certainly one focuses on the obvious, if you see a huge lower abdomen and your schizophrenic patient is not talking you will look with the US probe while the nurse is placing the foley.  You don’t need a CBC right now but a bedside hand-held device that has been widely available that gives you the electrolytes would be ideal…the I-stat.  I don’t have any endorsement for recommending this but you have most of the lab you will ever need with this device for true emergencies.

Then you manage the hyperkalemia and there is a sequence for it.  You have done much already for the patient if the urinary catheter has been placed.  The comment that I have heard over and over that bleeding from the bladder when it suddenly decompresses, or the release of that amount of urine is dangerous is flawed thinking.  It has never been shown that there is a need to clamp a foley catheter.  Clamping any tube stops it’s function.  You are essentially releasing the contents of a “urinary abscess” until proven otherwise and you are starting to allow potassium to leave the body…two important functions.  Even more important from the patient’s perspective you are receiving suffering.  That is one of your primary functions.  RELIEVE PAIN AND SUFFERING defines a what it is to be a doctor.

Most of the steps that you take to manage the hyperkalemia are temporary.  I just heard in January 2017 in an ED that there is no reason to manage the hyperkalemia.  This is absurd.  The same doctor who is the director of that ED also did not get the patient to dialysis but the patient was anuric and had anasarca.  The potassium was as I recall around 7.5 mEQ/L.

Six attempts at a peripheral IV by the physician failed because it was clear on ultrasound he would fail…the veins were all sclerosed, not collapsing and small…even the brachial veins and trying with a very stiff central line introducer catheter led to failure each time.  That ED does not stock proper equipment for that type of vein catheterization.  Likewise they don’t have any covers for the probe for central line insertion and this is all not consistent with proper practices…not close so I did not use the words “best practices”…most of the time was spent arguing with the hospitalist to manage the patient and this happened with multiple patients so much so that administration came to the ED to have a conversation with the director.  If I had behaved like that i would lose that job as a locums provider and I would likely lose it as a permanent provider.  So I sound like I spend my time bashing emergency physicians.  Well I am repeating only what I witnessed.  None of it is acceptable and falls far below the standards we are to follow.  It is commonplace because people are more and more aggressive and angry and the state licensing bodies, the hospital credentialling process has become more and more onerous and time-consuming.  I waited on that position for 7 months!  I did not accept any work after that day.  I declined to work with that recruiting agency.  Now I wish to get back on track and tell you that you need to know this simple set of performance ratings by the time you are set for your oral examinations.  If you understand what they are scoring you are likely to score higher.  ABEM no longer publishes this data and the AOBEM has never published their testing/scoring criteria to my knowledge.  Every year hundreds of physicians do fail an oral exam and/or have to take and oral exam but do not know this information.  It will make you a better provider.  I said do not let a patient out of the department who has uncorrected hypotension.

Since 1991-1992 CT has defined what is called the flat IVC sign and it proves the patient is profoundly hypovolemic while they are in the scanner.  This is known as inappropriate data acquisition.  The algorithm is out of sequence because the hypovolemia should be corrected first.  I could give you virtually hundreds of these errors but for now the most important information is the performance ratings.  Knowing the exceptions to the rules about how we interpret data like vital signs affects the sequence.  A pulse of 90 is never normal.  It may not indicate your patient will succumb but it must be managed.  Otherwise you did not “maximize” your care.  That is another goal:  to efficiently maximize the care you are able to perform.  Our patient with anasarca needs a tunneled catheter (central line) for dialysis.  In the ED you will not be faulted for placing a central line to manage the hyperkalemia.  That would have been my first choice based on seeing the US images of all the peripheral veins.  It is not uncommon to have failure of an external jugular vein puncture.  These veins have valves and are more fragile.  Women have more fragile veins than men.  So this falls also under the category of problem-solving and lastly patient management.

MANANGEMENT OF HYPERKALEMIA

Knowing all the treatments and their sequence for hyperkalemia is required knowledge and you will be expected to show that you know this information without needing a reference.  This is common knowledge for any emergency provider and required knowledge!

Inhaled albuterol is first and can be continuous because it is so easy to do, next IV calcium (calcium gluconate 1 amp)  works as a direct antagonist to the potassium ion and works in 3-5 minutes, next intravenous bicarbonate 1-2 amps will promote the movement of potassium back into the cells (shift) and works in 5-10 minutes.  IV glucose 2 amps of D50W plus 10-20 U of regular insulin also cause shift of potassium back into the cells and takes up to 20 minutes to be maximally effective.  The foley was placed and is an initial promoter of potassium release also but administration of furosemide may induce a diuresis and this will promote a kaliuresis and is listed.  There is controversy about the use of kayexelate but it is still recommended and will bind potassium in the gut.  The definitive treatment is dialysis.  So the urgent phone call to the nephrologist is a first order because consultants are often for a multitude of reasons a delay.  By the time the EKG has normalized all of the measures will gradually reverse if the patient has not been moved to a dialysis unit…so this patient should be moved rapidly.  Knowing this is part of the clinical competence score and so timeliness in such cases is scored.  We talk about time is brain, time is muscle…etc.  We also have been told that any problem which presents below the umbilicus will not induce a cardiac problem…all sorts of such crazy pieces of advice will come from some attending.  When the bladder is so distended it may, in fact be superior to the umbilicus and the patient with BPH and a full bladder may even present in an SVT.  Not undressing the patient and giving multiple doses of verapamil may show the SVT will slow and then goes back up.  This scenario is very embarrassing and would be scored as a failure.  It includes a dangerous action.

 

AGAIN, HOW DO THE LIVE ORAL TEST SIMULATIONS BEGIN?

To begin, the examiner will introduce themselves and ask you to be seated.  Shake their hand and make eye contact.  A brief simple “Hi” will suffice.  Some candidates feel more comfortable, e.g., removing their jacket, do not hesitate to be in control.  You don’t need permission for that.  Do not appear weak.  Be politely aggressive because you are at work.  Next, the examiner will briefly present a simulated scenario and provide initial data on a card or paper and provide initial patient data that will likely be incomplete and it may or may not include all of the patients name, age, and all vital signs.  Be aware of a missing vital sign and request it.  You should make certain you understand what information has or has not yet been presented and what key information is truly missing, commonly it is the patient’s temperature, but it can be any of the triage information.  It is always your responsibility to obtain any missing or pertinent vital sign(s) data in a timely manner.  The examiner’s are instructed for two days what and what not to present for one encounter.

DR COLLMAN COMMENTS:  At my program I teach you  52 very complex simulations and I send you home with additional ones for self study and then we practice if a candidate feels the need at the test site the day before never any closer to the exam…it is the most practice and it will profoundly affect your clinical practice for years to follow in a beneficial way.  Do you think you can compete with that amount of practice if you are scored on a bell curve?  Now you are.  Previously the scoring did not include such a method…now you can fail the oral examination with what was previously a passing score if you fall below the mean of the group you are tested with on exam day.  I will also say, it is possible to prepare incorrectly and excessively and it is obvious to the examiner and this is why you prepare excessively to BE YOURSELF.  Back to vital signs:  you should “decode the vital signs” e.g., do I have a patient with hot or cold altered mental state as each has a different set of needs.  The more specific your care the better you will score. The initial examiner presentation may also include some of the circumstances regarding the patient’s admission to the ED.  Again this information is given to you either in verbal or printed form (you need to be prepared for both) or it may begin with something such as a rhythm strip as soon as you begin…and when is that?  Only when the examiner says, “Doctor, you may begin”.  He/She will start the timer (looking at their watch) behind a divider so you cannot see their data nor actions as soon as you begin writing anything on the blank page (a mannequin is typically  included on the  page and you should bring some number 2 pencils [see the board’s instructions that are sent to you prior to the exam].  Do not write anything, sit facing the examiner and make eye contact, they will have a “flat face affect for the entire simulation” and will not react unless they were instructed to behave in such a way that it is obvious it is how a patient might respond, e.g., if they are confused.

DR COLLMAN COMMENTS:  some examiners actually do get annoyed with candidates they want to pass [that is all of you] but who they cannot get to properly participate for many reasons…so practice.   They don’t provide visual cues that you are making any error as this would alter your behavior and “help you”.  They are not allowed to help you.  They can at any time stop an encounter if you appear ill.  They are vey kind to the candidates and are not there to fail anyone.  If an examiner appears quiet and polite when you sit down, he/she hands you your initial data sheet and then begins screaming, it is clearly by design…it is likely the patient, the mother of a child etc., and you should do what you normally do and not react to their behavior as inappropriate.  It is simply the simulation.  

Once the examiner asks, “Doctor do you have any questions about the examination process?”   (Candidate [CAN] RESPONSE is always:  “no”)”Doctor are you ready?”  (CAN RESPONSE is always:  “yes”).  He/she then states, “you may begin”.  I am repeating this because there is a time you are allotted and you must stop speaking when the examiner states, “Doctor the examination is now over”.  They may appear annoyed if you continue to speak.  

DR COLLMAN COMMENTS:  examiners volunteer and are screened to be examiners.  They are also excluded from being an examiner and awarded after administering a specific number of examinations.  They need to finish on time like you as they may have a flight to catch…all kinds of issues are at play.  They practice one single or triple simulation for no more than one to two days prior to administering it to you.  I have heard examiners on the elevator ask each other about doses because like everyone they forget something.  They had no idea who I was or I doubt they would have been talking about such an item but it has happened.  I am dressed in a sweatshirt and jeans and they have a suit and a nice lapel label which clearly identifies them as an ABEM examiner.  So realize examiners are just like you, afraid!  They know it is your life and your test and they don’t want to make an error that would affect how you function in the simulation.

You should have practiced nearly 100 simulations prior to this examination.  Everyone has a different threshold need of cases they need to rehearse to be confident, comfortable and knowledgeable to pass.  You find information deficits when you practice and some need to read a chapter or many to recall facts for this examination.  I cannot overstate this:  any candidate who can state how he/she wants a drip mixed and started and is mathematically correct is going to score higher than someone who tries to say, use your nursing protocol nurse.”  The examiner may state, “what protocol”.  They are giving you the maximum chance to show how much you really know.  Now, if you do not know something, you need to admit how you would solve this problem don’t just say or (even bother to say sorry I don’t know).  In reality day to day many physicians don’t know how to mix a drip of anything now: everything is by protocol or peripheral brain (on their smartphone and not in their head).  So they don’t know in day-to-day practice…but on exam day you need to know…because my candidates go to the exam with simple rules we rehearse and rehearse and you are being scored with them on the the curve now.  Now it is simple logic that a physician who knows more should score higher.  It has nothing to do with (my candidates versus you…it is just an example of what is really at issue).  Also, at some stations, a new examiner may administer the simulation and have an experienced examiner sitting adjacent.  If they make an error don’t worry, they know it and you will not suffer for their error in the scoring.  I also cannot overstate: do not practice if you attended my program with someone who did not.  You will be teaching and not practicing then.  It can harm your scores.  You need to focus on you.  If you have an equal, great.  Practice with them…but they must be your equal.

There may/may not be another person standing in the room who says nothing…they are an examination verifier and you do not address them.  They are there to make sure everything is validated as operating without bias.  New technology is also being used such as a computer simulator to show key data.  The examiner will assist you with this.  This is to make the encounter seem more realistic.  So you may have an actual monitor simulator device with an alarm, or a computer monitor as you would displaying a lead MCL1 or Lead II, a pulse, a pulse oximetry reading and BP all continuous as in real life.  From the point the examiner states, “You may begin”, it is your control, your demonstration of you that is critical.  Start speaking as you normally would, “when I enter [the exam bay, the room] what do I notice?”  That is enough! Wait for the response from the examiner.  This conversation is how the exam proceeds.  You speak, they speak.  If there is a question about anything you ask, or they ask…just like in real life situations.  

Before we proceed any further I would like to call your attention to the use of mnemonics (mnemonics, from the Greek, mnemonics, meaning, to remember).  At the beginning of an oral examination some candidates want to write down a mnemonic to help them remain organized.  As soon as you begin writing, i.e., if you pick up your pencil, your exam has started.  Don’t do it.  It does not appear professional.  Wait and write it down after the examiners say, “Doctor you may begin.”  You don’t do this at work so don’t do it at the examination.  I strongly advise you not to do this as the examiners prefer yo begin the assessment and management just as you would in real clinical practice.  The Board is attempting to determine actually how you evaluate and treat patients and not how well you memorized a protocol for a test.  They want to know the real you!  But you can’t go to the exam that way, you must rehearse, rehearse, rehearse.   Unless you speak on a regular basis about cases to a group such as M/M conferences, you will not have a clue what you will say in this environment until you practice every style and subject of a potential 11 case exam day.  So memorized, “I need a moment to write down my mnemonic” behavior will also count against you professionally in the eyes of the examiner.  In my program I will fill you with mnemonics, teach you the drips so you can state them with ease, but I don’t want the examiners to ever sense that you were prepared.  You achieve that state by your threshold number of cases.  You will know when that happens.  You feel confident.  I am yet to meet the candidate that did it all correctly without practice.  Not one in 12,000+ physicians.  Not myself either.  I will teach you how to use mnemonics so you write them down as you do them!  Then it is a list that proves what and what you did not do.  You are not allowed to keep your documentation and none of it is used in the scoring.  It is what you say that counts…nothing else but what you say and your “behaviors”.  You need to focus on what the examiner is saying throughout the simulation, and you have to have good time management which only comes through practice.  This is verbal time management.  Some people say words they don’t need to say.  Many do the opposite.  There is a balance you are looking for and it means you complete the basics and the definitive care you normally do all the way through disposition unless an examiner stops a simulation.  Sometimes they stop it when they have enough information they know they are passing you.  So don’t worry.

You are always verbally eliciting information from the examiner.  You can use grouped speech and ask for up to three things but the ABEM documentation will state you ask for one thing at a time.  If you speak slowly enough some examiners can handle three things: the size of the needle, where you are placing the needle and what fluid and fluid rate you want.  IVs are so important that they will always ask all of this information as soon as you say: “I want to start an iv”.  So just say want you want and leave that out.  “Nurse please start 2 number 16 G IV needles, one in each antecubital fossa and run them wide open using 2 1 Liter bags of warmed saline.”  Work on compacting your language.  It makes you look much more confident.  Note the tone and volume of your voice.  You can say the right words but sound awful still.  These should be a calm tone and voice.

Information that may be available if requested by a CAN:

Patient responses to history questions about their illness.  The examiner will use language that would be typical for the simulated patient.   No matter the circustances, you must be care to sound judgmental in your questions or you may have an examiner play the role of an angry patient.  Don’t use the word “Dear” or similar language this is a disaster.  Doctors do it at work, but I would never advise you to do this at work or on the exam.  You should initiate all truly “personal” or seemingly “strange patient question” with the caveat, “I have to ask you a personal question.”  You get points for this.  You might not think this is strange, but assuming someone is married could cause anger if they were not or just divorced or just lost a spouse and are a widow or widower.  So use these moments to display compassion.  You can use a qualifying statement (in your own words) that is clear you must “ask a set of standard questions you are required to ask of all patients, it is a hospital policy.”  Then you can ask anything and in theory the patient should be ok with any questions.  If they are not you need to address the issue.  it is part of 2 of the 8 performance ratings: interpersonal skills and the health outcome score…that is ¼ of you entire points! (See those below).  So asking the patient about marital status, sexual preference, just like you do in clinical practice when indicated, you might need to do on the exam.  Eliciting a history of a patient’s HIV status might be a emotional question but is asked without issue when you have used your qualifying statement above to prepare the patient…just like you normally do.

The examiners also provide simulated physiologic patient responses (some by computerize systems) some by just speaking.  Fore example, when you provide an isotonic intravenous fluid challenge in the setting of early hypovolemic shock due to an isolated gastrointestinal hemorrhage, the examiner the examiner might still respond with a report of either a decreasing or increasing pulse (ongoing hemorrhage) and/or an increasing or decreasing blood pressure.  If massive blood loss had occurred in the setting of a ruptured esophageal varix, the patient might need more than 4 units of blood in addition to the initial crystalloid replacement before the examiner will display normalized or correcting vital signs.  In addition this type of source tends to continue bleeding on examinations to allow you to show the maximum of your ability to manage a sick patient with a serious problem…because that is what you do in real life.  So be aware of the many potential dynamic situations which could suddenly affect the patients’s homeostatic mechanisms, overpowering them and producing a non responder in shock after your resuscitation and respond aggressively to continue to manage any problem until it is resolved.  There are points for medical management and be prepared for anaphylactoid reactions, anaphylaxis, ACLS, ATLS, PALS scenarios and all the algorithms of these books as all of them are real test simulations.  THEY ARE REQUIRED TO TEST YOU ON THIS INFORMATION.  IT IS WHAT YOU MUST KNOW AND KNOW WELL.

Examiners also provide verbal responses to questions regarding physical examination findings but never reveal them unless asked.  You have to have a method to know what you have asked and what you have not yet asked.  This is why you must rehearse the key data you and how you will mark it on the mannequin or on another location on the page.  These questions must be rehearsed and consistent yet focused for the chief complaint.  You must always ask questions about the “SICK ORGAN SYSTEM” and any immediately adjacent “ORGAN SYSTEM” or one that works or is affected in concert with the “SICK ORGAN SYSTEM” or chief complaint.  So your questions must be consistent and focused for information of body regions and organ systems the both relate to the chief complaint and what is known as the core emergency medicine history and physical exam for pediatrics and adults.  Sequence also matters, one would not ask about the pelvic examination data without already taking not of the abdominal examination.

How all of this will come to pass will depend entirely on the initial clinical presentation.  At the conference I wil show you how to prioritize a very simple algorithm to approach what I refer to all “Styles” of initial case presentations.  You will always begin each simulation with a request for the general impression of the patient from the examiner, e.g., “When I walk in the room what do I notice?”  There are three potential types or categories of responses from the examiner.

Information that is provided tells you the patient is basically well and not in distress:

“Doctor you see a 24-y-old female who is sitting comfortably on the stretcher.”

Information that is provided clearly tells you the patient is in some form of shock or distress:

“Doctor you see a 24-y-old female lying on the stretcher.  She is cyanotic and making snoring sounds.”

“Information provided by the examiner is inadequate to determine the patient’s state, i.e., their clinical “ABC status”-thus, you must ask additional questions about the A,B,Cs to make a determination (I call this the question mark [?] presentation.  Most assuredly, you will then receive information which allows you to decide you have a sick patient and you then must intervene first by going straight to the ABCs and you always start with airway…just like real life.  There is no situation where you start with breathing before airway and most of the time in real life you can do them somewhat simultaneously.  ON THE EXAM KEEP THEM IN SEQUENCE and state what you are looking for and correct each problem as it is stated.  Do not leave a problem unattended until you have gotten enough response data from the examiner that you have maximized the care of that issue to move to the next one.  So you generally go GI->A->B->C->D->E->F->G-> and back to H…the history in a very sick patient and you manage each letter problem in that sequence and you never leave out an item.  General impression, airway, breathing, circulation, disability exam, expose the patient (undress them), Foley, Gastric tube, completes the history.   Just as in real life you will have to verbally do a “shake and shout” to determine that a simulated patient is unresponsive.  Again, it is just like what you normally do at work everyday…the difference is you have to ask verbally and intervene verbally for each “letter” above.

Theoretically, the examiner may allow you to proceed with a proper protocol without pressing for a specific etiology for the patient’s condition.  Often the etiology is not initially established because there is no available historian at this point in time…just as in real life.

THE 8 PERFORMANCE RATINGS:  

Salt water everywhere and not a foley in sight, nor a patient!

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(ABEM SCORING METHODOLOGY for the ORAL BOARD EXAMINATION)

I.  DATA ACQUISTION:  The examiners are looking for complete and appropriate (efficient and cost effective) acquisition of the patient history, physical examination and laboratory data.  This rating addresses the question,  “Did the candidate collect the appropriate data required to correctly diagnose and managed the patient?”  Proper data acquisition also includes:

• Timely calls to family physician and consultants, information from the paramedics which must be requested by the candidate and will not be offered e.g., information about a motor vehicle crash scene, e.g., steering wheel bent, windshield smashed, dashboard depressed, condition of the patient at the scene, time to hospital arrival from time of the accident, any entrapment and delays (which greatly increase the risk for compartment syndrome) must be addressed by the candidate. Information from the patient, family members, friends, roommates, Medical-Alert type bracelets even information which may be found in the patient’s clothing or wallet could be present.

You may be penalized for failing to obtain vital information, obtaining unnecessary information, or increasing the risk of treatment.  An example is to send the patient for a CT scan without attempt(s) at aggressive resucitation of the patient to normalize the vital signs.  This is considered inappropriate data acquisition.  The flat inferior vena cava sign has been used as seen on CT scans in both pediatrics and adult cases in malpractice cases to prove that the patient was severely hypovolemic in the CT study because it appears as a slit and not round (the IVC) on the abdominal slices.  So if you do this on your exam: ask to send the patient to the scanner when they display recurrent hypotension, failure to respond to a fluid/blood resuscitation is a major issue.  This CT sign (flat or slit IVC)  is absolute proof a patient was not adequately resuscitated in live clinical practice…it is the equivalent of seeing a tension pneumothorax on a chest film…these should never be seen because they are a clinical diagnosis and management  that is done without a study!  A pulse of 90-100 is not normal in most and the elderly may not mount a tachycardia although they need blood, and this is missed on a simulation because the candidate did not interpret the appearance of the patient or failed to ask relevant questions.

A blood pressure in an adult of 89/60 is clearly not normal…do not send any patient to CT without a vigorous attempt to achieve and maintain a BP of >100 mmHg and a pulse of <100 or consider that the patient may need further resuscitation including immediate emergency surgery.  Prematurely sending a patient for a CT scan or other study before completing a comprehensive primary and secondary suvey, EFAST study in trauma in a multiple trauma simulation with recurrent or persistent hypotension would be considered inappropriate data acquisition.  The candidate will never be given he results of any study such as a CT scan early in the management of the case during the examination.  This is because the board is interested in your patient evaluation and interventions during the critical portions of emergency management, e.g., the resuscitative phase.  In addition, if you send a multiple true victim for a CT of the head without an appropriate physician in attendance, without appropriate resuscitative equipment or without correcting a known bleeding diathesis such as hemophilia the candidate may be heavily penalized for potentially a dangerous action.  This is all the board’s method of “silently directing the candidate” toward appropriate Data Acquisition, i.e., so such information as a CT scan, MRI scan, radiograph of the lumbar spine, CT of any region of the body for that matter is typically not available until AFTER the completion of the secondary survey and after the candidate has corrected hypovolemic and other forms of shock (e.g., obstructive shock as in tension pneumothorax).  Seeing a tension pneumothorax on a radiograph indicates inappropriate Data Acquisition and is a fail because it is a clinical diagnosis to be managed without a radiograph.

II.  PROBLEM SOLVING

You are being rated for your organization or method of data collection in relation to treatment decisions under a particular set of conditions in a simulation.  It will include at least two multiple patient encounters and a field test case (which is not revealed as such but the latter will not be a part of your score and is used to facilitate the design of future case simulations).  A multiple patient encounter includes three patients which you must problem solve and triage during their management over 45 minutes.  Thus, in all case simulations you must attempt to diagnose and treat in tandem, just as in live clinical emergency medicine.  This is to protect the acutely injured or medically ill patient of all ages categories.  Thus, the ABCs must be managed initially even though you may also need on occasion to obtain data to select among any reasonable alternative pertinent diagnoses that require acute management as well.  You are being rated for your ability to anticipate problems (e.g., requesting [by stating it] that you require appropriate airway equipment to be brought to the bedside and being as specific as possible based on the patient age.  OK….read this it is absolute truth…

Dr Collman comments:  I have tested over 12,000 physicians at my station and I can tell you this is a big issue (speaking in any tested simulation and appearing organized and appropriate) and many underestimate how they will behave, even the volume of their voice is often so off the sound like they might be yelling because they have adrenergic surge and do not even realize it (and why I videotape them), and the words they use are not how they normally speak due to their personal stress and that includes their personal current life issues just before the examination.  

Language also matters, do not use antiquated language such as “gurney” keep your language compact and this requires practice!  Knowing your “lines” is important for such an examination and there is an extensive primary/secondary survey (and you should choose your own words and own style of presentation to appear natural but there is nothing natural about such an oral examination for most of us.)  

You will have pediatric cases so you will need to know the normal vital signs e.g., what is a normal blood pressure 90th percentile for all age groups using the classic formula taught in PALS.  All of the problem solving in ACLS/BLS/PALS algorithms are potential simulations….expect at least one or even two such issues on your 11 simulated patients!

You will have to provide an accurate diagnosis in MOST cases not all (because diagnosis [Dx] does not score as more than ¼ of ⅛ th of all performance ratings (the Dx is only 1/32 of your score), and your medical approach must be thorough but disposition is more important than Dx.  Again, organization is important:  practice various case simulations both pediatric and adult of all organ systems (one or two are always abnormal on every case at minimum); thus, you should always include a focused history, physical exam, laboratory evaluation, special studies with resuscitation in tandem only as needed and only as is relevant to the primary CHIEF COMPLAINT.  A “shotgun approach” is not a good performance, a focused one is what they want. 

Any serious personal life issue is a risk factor for failing:  Getting divorced the same week that you take such an examination is a formula for failure.  I have seen people at private tutoring sessions the day before their exam when they are not acting themselves as they were months prior and they reveal such information.  It is better not to take such an examination under these conditions.  Use your common sense or call me if you have any concerns (561-305-8163) well in advance of your examination.

III. PATIENT MANAGEMENT

You are scored on your ability to make decisions  about treatment and the sequence in which your decisions were made.  This rating addresses the question, “Did the candidate treat or direct the appropriate treatment(s) throughout the simulated encounter?”  Thus, you must be able to rapidly verbalize your management using correct ACLS, ATLS, PALS algorithms and Base Station protocols.  You must be able to:

Verbalize correct ACLS medication doses (required knowledge that is memorized)

Be able to verbalize all ATLS maneuvers including an EFAST examination

Communicate with the paramedics even in a theoretical base station call, identifying yourself as the base station and you identify who you are and verify with whom you are communicating after each of your radio transmissions.

Divide you attention appropriately during a situation (multiple patient) encounter including providing appropriate individuals (nurses, consultants) to monitor, manage, or attend a patient while you direct you attention to other simulated patients…this is your “verbal triage.”

Appropriate referral and consultation are required for a passing management score.  You must call the appropriate specialist(s) in a timely fashion.  The examiner will play the specialist on the phone and you will provide a synopsis for them (a synthesis of the case..don’t recite vital signs) to succinctly bring the case to a conclusion/with a disposition.  Your synthesis (includes key facts of your evaluation/treatment and your intended disposition).  AGAIN  you do not want to recite a long list of vital signs and numerical lab values of all tests…only the information that is the pertinent positive information which determines disposition.   A list of vital signs does not tell the examiner anything about your understanding of the case simulation and that is what they need from you.  You also should PROVIDE the appropriate clinical DIRECTION to the consultant.  If you feel you did not complete a specific (and possibly critical action) this will be your last chance to initiate the treatment by stating it to the consultant.  Indicate what you did and what you want the consultant to do for the patient.   Consultants may “help” by recommending but mostly they will be asking if you left out an item about “anything else doctor”  …and when you hear this you need to stop and go top to bottom…sometimes a candidate forgets a basic like they never intubated the patient…as long as you can recognize and verbally state what you left out, the action is not missed.  It is as if it is out of sequence but not as if you omitted it which is a complete error enough to define a dangerous action or omitted critical action.  NOW CONSULTANTS DON’T AND CANNOT HELP BY SAYING, “WOULDN’T YOU LIKE TO INTUBATE THE PATIENT?”  ALL THEY CAN SAY IS ASK, ” ANYTHING ELSE DOCTOR?”

In theory it is possible there is nothing else…but in general you have missed something. The examiners have no time to waste on questions that are just “wasted air”  nor “filler time”.

IV. HEALTH CARE PROVIDED-HEALTH OUTCOME SCORE

You are being rated for your performance primarily form the patient’s viewpoint but with regard to current medical standards and known best practices.

This criterion asks the questions:

“Did the simulated patient receive timely and appropriate medical attention and care by the candidate?”

“Was the patent’s condition maximally improved by the medical interventions provided?” I cant use the word stabilized, I cringe at this word because no one is stable after an MVC and are intubated on a ventilator, with a chest tube, a traction splint and pelvic binder on their way to the OR and you tell the patient’s family they are “stable”…NEVER USE THIS WORD…not until they make it past day 30 post accident.  (and you are not involved then).  No multiple-injury patient is stable and many can die up to 30 days after injury.  Three injured organ systems usually is fatal.  Still…

For us on an exam, the patient should improve with appropriate and timely care, i.e., hypotension should resolve with fluid challenges, but realize you can have a nonresponder or one who responds and then deteriorates and needs the operating room.  Yes an arrhythmia should correct with the proper ACLS sequence but they may titrate you down the sequence maximally…i.e., multiple shocks plus drugs plus intubation before they convert the patient.  There will be patients who become worse with interventions and this is by design and you simply continue to manage and obtain the appropriate consultation only after you have truly done all that an EP can do.  Realize as in real-life a patient could die and you may need to even speak to an examiner as the family member(s).  All of it is fair game on this test because you do this in real life at work.

V.  INTERPERSONAL RELATIONS

Although good interpersonal skills may not be trulls critical to the successful management of a particular case, some individuals consistently receive a low score for this performance rating throughout all of their case simulations.  This has lead to overall exam failure even by as little as 0.01 (1/1ooth of a point) on a scale from 1.00 -8.00 final score for each casse.  To obtain the best score for this rating, realize that the examiners are scoring you for several qualities in dealing with the simulated patient’s psychological state and this induces anyone you might encounter in day-to-day clinical practice.  You should calm the patient before you perform any potentially  painful examinations like a pelvic or ear exam or even something simple like percussing a tooth.  You should always warn a patient PRIOR to performing any painful maneuver such as joint manipulation to assess mechanical stability or that you will perform a pelvic examination.  You would always do the latter exam in a patient who complains of a vaginal discharge and may have PID and you would “talk” the patient though each part of that exam.

This rating also evaluates your ability to manage true psychiatric conditions that may be present in some patients, as well as your ability to show concern and display skill in dealing with any other individual(s) you might normally encounter in the ED setting.  Be careful to be tolerant of any simulated patient with a “difficult” personality like those borderline patients you always see at night.   You would think this would be the easiest area to obtain the full credit of 1/8th of your score for each simulation but it is not true for many and the proof is I have seen their scoring sheets because they mail them to me when they receive them.  This is because people do to act like they normally do in a simulation and that is, again, why practice and rehearsing is vital!

VI. COMPREHENSION OF PATHOPHYSIOLOGY

Most of their questions (they all come at the end of the simulation) but if you demonstrate in your management you understand the pathophysiology, you may not have any questions.  That is always a good sign of a great score for that simulation!  The examiner will state that the management portion of the case is now over and you have a few questions or he/she will simply excuse you.  Like a judge in a court of law who must allow you the most vigorous defense of your arguments  realize that the examiner’s function is to maximize your score as a similar concept.  Thus, if you are excused with no pathophysiology question, this is again, always a great sign.

Dr COLLMAN COMMENTS:   I discuss this in detail but I still  get numerous calls  when the exams are over that a candidate and another and another…etc-had no pathophysiology questions and they are very concerned now.  Typical doctors.  Very Type A.  Still worrying and they have most likely passed based on this comment…especially when it happens in multiple room to the same candidate.   Conceptually the examiner has made up their mind often very early that you meet their criteria and they want you out in the world working with ABEM certification to prove you are GREAT!  No patho questions is like no pathogens.  It is in likely a very good thing; your infection, (your exam is healed, you are healed and it is over and you don’t have to go back for a decade and as long as you maintain all of your LLSA exams (lifelong self-assessment CME by ABEM and their other practice requirements every decade you just take a recertification exam of about 500 questions.  ⅓ of those questions are FTIs [field test items] so if you maintain your reading of each edition of Tintinalli (2500 pages)  or just come and visit Dr Collman ever few years, for 8-Days of him…you wil never have to worry or think about having a concern about failing.  It is impossible to fail if you are putting yourself through that updated education once or twice in a decade.  Seriously.  If your life is otherwise in order you will pass.  YOU may feel you don’t even need him; you may be absolutely right.  That is entirely your decision.  You can also just schedule some private tutoring time online with Dr Collman.  Call well in advanced, even a year in advance or further!  Do not procrastinate making that call if you think you want help.  He is one human.  There are thousands of you!  

OK BACK TO PATHOPHYSIOLOGY QUESTIONS:  Most are questions that are straightforward and require only brief discussion.  The examiners are rating you understanding of the pathophysiology of the cases and the scientific basis for the clinical procedures/exams/testing you requested, i.e., your actions.

These standardized questions are asked only to aid the examiner in assessing your comprehension because implementation of “routine” procedures without comprehension of the underlying cause – effect relationship is not considered acceptable.

Because of this evaluation you should be careful about spontaneously verbalizing you interpretation of any data of lab or films or strips unless requested, your actual response management is what matters.  If you verbalize an incorrect statement about a test or an EKG you may later be unable to describe the correct pathophysiology.   If you verbalize something incorrectly about a test and yet do the right thing it seem incongruous also to the examiner.  What was the basis for what you did in that situation then?  So it can harm your score.  It is bette only to interpret when requested.  It is possible that someone just memorized a routine of what they would do but do not understand why they completed what they did.

It is also an excellent opportunity to improve your score and possibly redeem yourself because of an earlier omission or management error.  You should then give as much information as possible as it relates to the specific simulation and issues.  NEVER just talk to talk…the examiners may be writing notes but they have asked the same question over and over and know what they need to hear.  You should leave the examiner with a good final impression by presenting established scientific doctrine.  If you absolutely don’t know the answer to a question before you answer think, take a moment…you may know the answer and are rushing…ultimately you may have to say you don’t know and would have to look up the answer and where.  If it is a medication dose, don’t guess, look it up.  and state where you would look.  I strongly urge you to read all of my pathophysiology questions and record your answers.  Manage your language and re-state how you will state what you want with the most compact language.  Listen to your actual answers and decide if you spoke in a logicaltion sequence and with adequate depth.

VII. RESOURCE UTILIZATION

LONG AGO, this score was only addressed on the multiple patient encounters.  Then in 1990, this performance rating was assessed on all encounters.  It evaluates your ability to  use available resources which you declare when you need them.  This is to aid and enhance your management.  It includes the health department, poison control center (for all poisonings even if you know the management because you must also report it), calling your pharmacy about a medication, e.g., to get the particular dose or caveats about a medication or the treatment of an unusual condition.  They move you along and say the proper dose is now administered if you use your resources and you may have to go through more than one to get an answer.  If you don’t know the dose of a medication never guess, look it up!  You will have to be honest and verbalize this but if you are truly prepared this never happens.  Take your time, some candidates have difficulty and almost refuse to answer a pathophysiology question by stating to quickly “I don’t know the answer.” It is common for the examiners to slow you down and say, “Doctor, why don’t you take a moment and think about it I’m believe you can tell me about this issue.”  It will be some form of kindness like this and it may be even up to three times stated in various ways.  Now if you say I don’t know three times, it is like baseball, you are out on that question.  Not out on your entire examination…just that question.  The examiner will then believe you cannot answer the question and excuse you.

Think about this…do you guess in live clinical practice?  Never.  So don’t do it on the examination.  Obvious guessing would label you as a dangerous clinician for that encounter.  So you should be prepared to calculate the proper dosages for all ACLS, PALS and life threats like anaphylaxis.  If you rehears and include the description of all of the ACLS infusions (Dopamine, Dobutamine, Diltiazem, Isuprel [few EPs actually ever use this drug], norepinephrine, epinephrine, nitroglycerin and nitroprusside you will absolutely stand out from many who don’t and this will definitely raise your management and clinical competence scores!  To maximize your score when starting a drug infusion, state how many mg of drug are to be placed in a specified volume of a particular solution, and how many microdrops or drops (depending on the drug) are to be infused over a specified period of time.  Here is are some old drugs very much still in use:  procainamide and lidocaine:  for a lidocaine infusion you would say, “Nurse mix 1 G of lidocaine in 250 mL of D5W and infuse this solution at 30 micro drops per minute (after the bolus order).  30 micro drops per minute would be a 2 mg/min drip for a 70 kg patient.  This is much more impressive than saying “Nurse begin a 2 mg/min drip of lidocaine.”  Imagine your surprise if the examiner asks, “how do I do that doctor?”  Go to the exam prepared for that simple question.  The examiners don’t know if you could correctly prepare a solution if the premixed solution at your hospital is not readily available.  Likewise, he/she does not know if you know the proper microdrop rate.  In large part candidates who display confidence and who are not making their head move rotating right and left (“it means you are confused”), don’t get asked any questions.  It is the ones who make it visible in their body posture and movements (and speech) who will incite an examiner to dig further and who will then ask.  CONFIDENCE matters because in the real world it matters to patients.  Patients often will ask for another physician when they don’t feel confident about their physician.  

Don’t leave out simple things like the chewed baby aspirin for your chest pain patient or the three doses of sublingual nitroglycerine.  It is great when you ask about contraindications like if you have seen the EKG and even a right-sided EKG that displays elevations of the ST segments in V4R, V5R and even V6R.  This is a right-sided MI which is often associated with an inferior wall MI of the heart and the septum.  Any drug that can lower blood pressure is contraindicated.  If you give such a drug expect more hypotension.  Stop the drug and give fluids.  That is the treatemt of this scenario before the cath lab…to maximize the Frank Starling effect of increased contractility.  When do you slow the IV in this situation…not when you see jugular venous distention.  Only if you hear basilar rales.  If you have an US machine available to you per the examiner…by all means use it and you can also prove the type of MI you are dealing with.  A large D-shaped RV that as large or even larger than the LV is seen in RV infarction when the patient is maximally resuscitated-it shows often poor contractility if it is a large area of involvement of the septum, inferior wall and the anterior wall of the RV.  So you would avoid ß-blockers, Ca channel blockers, nitroglycerin, nitroprusside and any other drug that can lower blood pressure when you have an RV infarction associated with some LV infarction such as IWMI (inferior wall MI).    

VIII.  CLINICAL COMPETANCE—Overall

You are given an overall rating of your expertise, knowledge, and skill.  The Board says this is the single most important rating of the eight scoring criteria and it asks, “All things considered, how good was the candidate in handling these types of conditions or problems?”  The National Board of Medical Examiners defines clinical competence as follows:

“The ability and/or qualities requisite for patient care, diagnosis, treatment, and management as distinguished from theoretical or experimental knowledge.”  Clinical competence includes such elements as skill in obtaining pertinent information from a patient, ability to detect and interpret symptoms and abnormal signs, acumen in arriving at a reasonable diagnosis, and judgment in the management of patients.

This rating is representative of the overall assessment of the demonstrated competence of the candidate to provide emergency health care in the specific categories of conditions presented in the simulated encounters.  General competence as an emergency physician is subjectively estimated from performance on all items on the examination.  The rating focuses on the examiner’s judgment of the level of your combined cognitive and procedural skills in providing emergency health care in this setting.  It includes your judgement, your clinical acumen, the diagnosis or diagnoses you considered and how you established them.  It all about the process than the arrival of the diagnosis.  The examiners are to avoid calculating an average of the previous specific ratings unless it truly reflects their subjective evaluation.  Minor errors can be discounted, but the examiners are instructed not to rationalize important errors and omissions.  Because clinical competence is the most subjective performance rating, it may, therefore, be the most important.  

Critical Actions

In addition to the eight criteria, there is a critical actions checklist to complete for each encounter.  Critical actions are management actions the candidate must perform to complete a particular simulated patient encounter successfully.  Each case is associated with four or five critical actions that form the design framework for that case.  For example, in a patient with a cardiac arrest due to ventricular fibrillation, the four critical actions might be:

Initiate CPR while calling for help (chest compressions fast and hard at 100 bpm x 2 min [ cycles] —> Treat Ventricular Fib w/defib {AED or in ED} —> Continue CPR-> Antiarrh med bolus and drip —> Treat bradycardia w/drug/pacer/underlying causes (H’s/T’s)

DR COLLMAN COMMENTS:  At the Oral Board Tutorial I present all of the algorithms that are life/limb threats and it took years to establish through reading what I thought the board would present as cases.  My cases include every scenario that has ever been examined and I established this by researching all of the core content for any discussion of key errors (iatrogenic errors) and patient presentations that kill or cause severe morbidity and or require very specific management.  ABEM has, since the year 1989 known all of my cases because I presented them to the chief examiner.  I was privately tutoring 18 candidates in “their hotel”, the Marriott Hotel in Chicago…he called it that.  After hours of me in a sweaty sweatshirt I had worn for a day and a half, and it was even stained with food because I am doing this for days and days prior to the exam (tutoring) the chief examiner looked completely through my 6 inch binder of cases.  He shook my hand and they passed 17 of those 18 people.  They knew who they were…one examiner was so inflamed that I was in the hotel that he took my client list from my door to the chief examiner who returned it to me.  So folks.  All he wanted was to know me and my cases and they are much, much more detailed than ABEMs.  That is fact.  I have 6 Days to make you into a professional speaker with all the algorithms.  If you are wise you will use months of time after you spend 6 days with me to review it all.

FINAL COMMENT

THE MOST CRAZY THING IS THAT DOCTORS WANT THE PREP RIGHT BEFORE THE EXAM….I WONT DO ANY PREP WITH ANYONE NO MATTER THE PRICE THEY OFFER UNLESS THEY HAVE BEEN TO MY PROGRAM.  IT WILL DAMAGE THEM FOR THE TEST BECAUSE ON DAY ONE AT THE COURSE I SEE ALL THE SAD FACES OF THE DOCTORS AT THE END OF THE DAY…SOME COULD ONLY VERBALIZE A PRIMARY SURVEY IN 15 MINUTES (NOT SOME THOUSANDS)…ALL GENIUSES BY ANY DEFINITION SINCE THEY ARE DOCTORS.  BUT THEY TELL ME THEY ARE STUPID.  THEY TELL ME THAT THEY WOULD TRULY RATHER DONATE A KIDNEY THAN TAKE AN ORAL EXAMINATION.  THEY WERE RAISED NO NO NO…NEGATIVITY AND NOTHING ABOUT HOW TO TURN ON THE BRAIN AND SELF-ACTUALIZE. THAT IS A RARE PERSON.  I HAVE SEEN A FEW…JUST A FEW.   PEOPLE CALL AND ASK FOR PERMISSION TO COME; WHAT?  CRAZY AGAIN.  I ASK “WHY?”  I JUST WANT TO KNOW IF YOU WILL ALLOW ME TO COME I AM CONCERNED I WILL LOWER YOUR PASS RATE.  I DON’T EVEN PUBLISH THAT…WELL I COMMENTED ON THE FIRST 18 ABOVE…SO MAYBE I DID.  BUT DO NOT BELIVE ANYONE WHO SAYS THEY HAVE A 100% PASS RATE.  EVEN IF YOU HAD THE BOARDS CASES, AND YOU STUDIED THEM…IT IS POTENTIAL TEST SUICIDE…BECAUSE IF YOU GET TO THE ANSWERS WITHOUT THE PROCESS YOU FAIL…AND HAVING THE ANSWERS WITHOUT THE PROPER PROCESS WHICH I TRAIN AND INSTILL IN YOU FOR 6 DAYS PLUS HOURS OF PRIVATE TUTORING FOR SOME…YOU KNOW HOW TO DO THE PROCESS AND IT IS EASY.  I HAVE ALL OF THE CRITICAL ACTIONS.  I HAVE ALL OF THE ALGORITHMS.  BUT I USED MY BRAIN TO ESTABLISH THAT FOR MYSELF YEARS BEFORE I SAT FOR THAT TEST…THEN I TOOK THAT KNOWLEDGE AND MADE IT INTO A PROGRAM…BECAUSE ONE PERSON ASKED ME FOR HELP, THEN ANOTHER AND THEN ANOTHER.  SO I SAW A NEED.  IT IS THAT SIMPLE HOW IT ALL CAME TO PASS:))

CONCLUSION:  BY THE TIME YOU ARE FINISHED WITH ME…YOU CAN EASILY OVERPOWER THE KNOWLEDGE OR ABILTY OF ANY EXAMINER AND YOU DON’T WANT TO DO THAT.  SO I HAVE TO REMIND YOU TO SLOW DOWN, EVEN DUMB IT DOWN…BECAUSE THEN YOU ARE SOMEWHAT VERBALLY “BIONIC.”  THAT IS THE DIFFERENCE BETWEEN TRAINING AND EDUCATION.  I TRAIN: WE PLAN AND WE REHEARSE REHEARSE REHEARSE.  IT IS WHAT I HAVE DONE ALL OF MY PERSONAL LIFE.   I REHEARSE UNTIL I KNOW THE TEXT THE CORE CONTENT PAGE BY PAGE.  “YOU GET TO KEEP WHAT YOU KILL”…THE NECROMONGER WAY FROM THE CHRONICLES OF RIDDICK…MAYBE THEY MEAN YOU GET TO PASS WHAT YOU TRAIN FOR… THE EMEDNATION WAY–FROM COLLMAN. :)))

One of the best study methods to prepare you for the oral board examination is to design your own simulated patient encounters.  You should create your own critical action checklist for a particular case and then actually verbalize your management of that case.  In doing so you will find that it is not difficult to determine which actions are probably “critical,” but quite a task to complete those actions verbally unless you are correctly and adequately rehearsed.  You should familiarize yourself with the Critical Actions lists and Quick Review Management sections near the end of the program syllabus.  YOUR ACCESS TO THE SYLLABUS REQURES THAT YOU STUDY WITH ME AT LEAST FOR ONE TIME IN YOUR LIFE FOR 6 DAYS.  I KNOW IT IS A BIG COMMITMENT, BUT THIS TIME-TESTED METHOD WORKS IF YOU SIMPLY PUT UP WITH IT.  IT IS THE MOST INTENSE EDUCATION YOU WILL EVER EXPERIENCE.  I AM NEVER CRUEL OR INSULTING…TO HELP YOU I NEED YOU FOR THAT MUCH TIME.   THAT IS JUST THE BEGINNING AND YOU WILL BE HAPPIER. THAT I CAN PROMISE.  YOU WILL FEEL CONFIDENT AND IT WILL BE BECAUSE YOU HAVE THE KNOWLEDGE AND THE VERBAL SKILL.  THIS IS PUBLIC SPEAKING.  IT IS STILL THE NUMBER ONE FEAR OF MOST AND PHYSICIANS ARE NO DIFFERENT.  THEY FUNCTION AT A VERY HIGH LEVEL BUT THEY ARE NOT SPEAKING…THEY ARE MOSTLY DOING…DOING…DOING.

So you must learn how to do what you normally do but being facile “verbally.”  One of your goals should be to manage each case without appearing too rehearsed.  To accomplish this, record your performance on a tape recorder and then listen to the cadence of your voice.  You should avoid sounding too “sing-songy or robotic.”  When you sit for your oral exam you need to sound as you would when you speak naturally.  Speech can be rehearsed, but the key is enough practice that you convert back to a natural voice after you learn all the potential statements you need.  It is also very compressed speech because you need time awareness and efficiency.  Initially most sound mechanical and it can be quite apparent when listening to a candidate order lab tests, pauses are important for natural speech.  You will frequently be required to order ten to fifteen lab tests in sequence.  Therefore, you should present those requests in a manner that depicts an active thought process on your part and not sound as if you ever use rote memorization or some “shot gun” approach.  Remember, the examiner will stop you and request confirmation of your orders if you do not speak clearly or if you are speaking too rapidly for him/her to write (over-powering the examiner).  If you can comfortably write your orders on what I call the flow sheet [aka the mannequin sheet] while speaking, you are interacting at the proper pace.

CURRENT KEY TRANSFUSION FACTS:  The most important blood test you should order in the primary survey of a hypotensive multiple trauma patient on an oral exam is NONE!  The type and crossmatch is not recommended in the 8th edition of the ATLS manual!  If you need to transfuse a patient most likely you have already rapidly administered 2L of isotonic crystalloid to an adult or up to 60 mL of isotonic crystalloid (NS or LR) to a pediatric victim.  Because of current ATLS recommendations, there should be no delay waiting for even type-specific blood.  If you request it on an oral exam and it is not immediately available you should use type O blood. Thus, no test is required.   You should use O negative blood in females of childbearing age (age 10-50 years).  Whole blood should be used massive transfusion.  (See the 8th or now 9th  edition of the ATLS manual.  If you have to administer blood you have identified a patient with a 30-40% blood loss, i.e., a class III or IV hemorrhage.  In these cases you should not wait for type-specific blood (which is available in about 10 minutes in most hospitals).  Fully crossmatched blood is not available for 40-45 minutes in most hospitals.  If your patient has already received crystalloid in the field, the need for blood may be immediate.  Ultimately, you will need to determine if your patient is a:

1).  “Crystalloid responder” i.e., a class I hemorrhage (acute blood loss of ≤750 mL [this corresponds to up to 15% acute blood loss].  A class I hemorrhage will respond to 2L of isotonic crystalloid and not require transfusion

2).  A Class II hemorrhage (acute blood loss of ≤20% blood volume) [≤1500 mL acute blood loss].  The majority of class II hemorrhage victims do not require transfusion.  However a responder who later develops recurrent hypotension is considered a transient responder and most likely will require acute transfusion.

3).  A Class III or IV hemorrhage:  both of these categories require 2L of isotonic crystalloid and transfusion.  These are patients with 30-40% acute blood loss.   An accident victim with bilateral femur fractures and no other injury could result in a class IV hemorrhage!

4).  Pediatric, athletic, and pregnant victims who present with signs of poor perfusion are most likely already in late shock with substantial blood loss.  The pediatric patient will maintain a normal systolic blood pressure until they are in late shock with substantial volume loss because of compensatory mechanisms like peripheral vasoconstriction and an augmented response to catecholamine release. They may even display an elevated systolic BP or a narrowed pulse pressure in early hypovolemic shock.  Once the child is hypotensive they generally require both crystalloid and blood.  Athletic victims may not displace an elevated heart rate as they have augmented stroke volume.  Their vital signs will be confusing because they may not display tachycardia as they have exercise-induced cardiac hypertrophy and are normally bradycardic (resting hr <60 bpm).  Finally, the pregnant patient in the third trimester has a hypervolemic anemia (substantially increased plasma volume compared to a slightly increased rbc volume).  If a 3rd trimester pregnant patient is hypotensive it implies late shock.  They require 1.5 x the standard resuscitation volumes for proper resuscitation.

Don’t forget about the obstructive shock of supine hypotension of pregnancy.  If the patient is obviously gravid by appearance, wedge the spine board to the left approximately 15°.  Blood can’t flow down the aorta and back up the inferior vena cava due to pressure from the enlarged uterus.  This phenomenon can be seen with a supine pregnant patient when the uterus is above the umbilicus (the location of the bifurcation of the aorta).  The uterine fundus can be palpated at the umbilicus at 20 weeks gestation.

4).  The elderly may not be able to mount a tachycardia in response to hypovolemia.  As with the athletic patient they may display confusing vital signs.  If they are on a drug such as a ß–blocker, they will have a blunted cardiovascular response despite significant blood loss (relative bradycardia).  The authors of the ATLS manual repeatedly discuss that physicians should not focus on vital signs but signs of end organ perfusion to make decisions about acute fluid/blood administration.  They rely on altered mentation (e.g., confused or obtunded), absent or diminished peripheral or pulses, diminished central pulses, pallor, and delayed capillary refill (children).

Once a urinary catheter is established (and the bladder is drained) also rely on new urine output and urine specific gravity to make decisions about further fluid administration.  Minimal normal values for urine output:

Infants:  1.0-2.0 mL/kg/hr U/O;

Toddlers and small children:  1.0 mL/kg/hr U/O;

Older children and adults: 0.5-1.0 mL/hr U/O.

Concentrated urine:  SG > 1.025 implies dehydration.  The only exception is the child with sickle cell anemia and isosthenia (iso = normal = only normal urine concentration as they have damaged ability to concentrate their urine despite severe dehydration…eg., their maximum urine concentration may be a SG of 1.015 despite severe dehydration.  Adults have a  maximal concentrating ability to create a urine SG of 1.035.  This decreases in the 7th decade of life.  Normal young-mid-age adults can produce a urine of 1200 mOsm/L; in the 7th decade this may be reduced to 800 mOsm/L.

As with transfusion, a blood or urine test is not required to establish pregnancy on many oral exam cases if you ask the right questions. Beyond 20 weeks, fundal height measured from the symphysis pubis establishes gestational age (in weeks),  ie., a 24 cm fundus (measured from the symphysis pubis to top of the fundus in cm) is a 24 week pregnancy.  If you think of a question ask it!  It is likely that you will forget and not get back to that specific question because of your own adrenalin!  Sometimes the problem is just the opposite…the stress of the exam causes some candidates to be sleep deprived and they are tired when they take the test.  So if you think of something…e.g., an intervention, do it or if it is a question-ask it.  Better to lose a few style points for being out of sequence than to miss a critical action.

When you manage a series of critical actions which represent a particular emergency algorithm, it is paramount that you demonstrate a timely, but ordered thought process.  For example, it is necessary that you decode the vital signs at the beginning of a multiple trauma algorithm (including the mechanism of injury) to determine if immediate resuscitative measures are indicated.  Try to establish the mechanism of illness in all medical cases for the same reason.  Otherwise you don’t  demonstrate a logical thought process.  If you are presented with an adult patient who has multiple injuries, a blood pressure of 80/60 mmHg and a pulse of 140 beats per minute, you should not hesitate to rapidly treat that individual for suspected hypovolemia.  To that end, you might establish two peripheral (forearm) 14-16 G IVs, administer a fluid challenge with isotonic crystalloid, and search for other causes of an impaired cardiac output state (the nonhypovolemic causes of hypotenion:  cardiogenic shock, tension pneumothorax, cardiac tamponade, neurogenic shock and sepsis).  Ideally, you should treat life threats first and place all patients on high flow oxygen (100%), a cardiac monitor, pulse oximeter and BP monitor.  You would also order a stat type and crossmatch for packed RBCs in anticipation of an  immediate need for red cell transfusion.  It is vital that you understand that completion of critical actions is not the only consideration in the scoring.  The examiner must also evaluate the sequence of your management.  Thus, you must demonstrate an appropriate temporal sequence when you perform critical actions.

As I stated earlier, you will participate in multiple Simulated Clinical Encounters, but one is not graded for certification.  All individuals will have two “triple encounters,” and five single encounters on the ABEM examination.  One of the singles is probably the field test case.  The AOA oral examination incorporates only two-patient (situation) encounters while the BCEM examination involves a total of five simulated encounters presented as two single clinical encounters and one triple situation encounter.

There are two ways to pass the ABEM oral exam:

Obtain an average score of 5.75 or higher.

With this method, each case is scored individually and each triple case is scored as three separate cases.  All the scores are averaged and the average score of all the cases must be 5.75 or higher.

All scores of 5.00 or higher.

The high and the low case scores are averaged.  The average of the high and low scores must be 5.0 or higher.  Each triple case score is counted as one case (an average value for the three cases).  The average of the cases on each triple must also be 5.0 or higher.  Lastly, each of the remaining individual cases must also be 5.0 or higher.

The only change to the scoring above is now in 2015 forward, how did you compare to your colleagues in your group.  If you fall significantly below the group you could fail with  mean score of even 5.29 of all cases.  Why?  If the rest of the group had a mean score of 5.38 it would be enough on the bell curve to eliminate you.  So you want all the points.  It is why it is so important to understand WHAT you are being tested on and how it is done.  I have given you some of that information here and I don’t believe it is published anywhere else now and I mean anywhere but here or at my programs…  So read and reread this and practice…and call me.  You will never regret it.  the ABEM ORAL EXAM MODEL

Scoring for the AOA and BCEM examinations incorporates virtually the same performance ratings.  They require essentially the same proficiency of case management for a passing score.  The BCEM has advised candidates that they must pass all five of the simulated encounters to pass that portion of the BCEM EM certification examination.

 

 

 

 

 

 

 

1 thought on “What is Our Primary goal as Emergency Providers? The Best Answer is to Examine ABEM’s Model: Their 8 Performance Ratings for Passing the Oral Board Examination”

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