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1. THE ABNS ORAL BOARD EXAMINA TION William T . Couldwell description of the American Board of Neurological Surgery (ABNS) requirements to be allowed to take the Oral Board Examination is provided in this chapter. The actual organization of the examination, including how examiners score each individual and the rigorousness of the process, are described. The ABNS Oral Board Examination is the final step in the certification process of an individual neurosurgeon by the Board. It is usually undertaken within 5  years of completion of residency or postgraduate fellowship train ing. The Oral Examination is administered twice yearly (May and November) by the ABNS in a central location, Houston, T exas. CANDIDA TE SELECTION AND CREDENTIALING; REQUIREMENTS f OR ELIGIBILITY f OR THE ORAL E x AMINA TION T o sit for the examination, a candidate must have completed a 7- year residency program approved by the Neuro surgery Residency Review Committee (RRC) of the Accreditation Council for Graduate Medical Education (ACGME). The candidate must have passed for credit toward certifi cation the ABNS written Primary Examination before the completion of residency. The candidate must then submit an application and be scheduled to take the examination within 5  years of completing the residency or have prior approval of the Board if this has not been possible for per sonal reasons (such as military duty). The candidate must also log and submit 150 consec utive, major, operative cases in which he or she was the attending surgeon of record. These cases will be reviewed by a current Director of the ABNS. Any queries regarding management or outcome must be addressed adequately to be approved to sit for the Oral Examination. Required letters of recommendation, evidence of Medical Licensure, and current hospital appointments are in addition reviewed before approval to sit for the examination. E x AMINA TION  f ORMA T The examination consists of three 1- hour sessions. Examinations are typically given Monday, T uesday and W ednesday. There are three pairs of examiners for each candidate, a different pair each hour. All 3 hours consist of a mixture of General Neurosurgery (both Cranial and Spine) and subspecialty areas such as Critical Care, Neurology, and Endovascular. The pairs of examiners in each hour consist of a current or former ABNS Director and a guest examiner, usually an invited, senior, well- established neurosurgeon with a his tory of training residents. During each hour, the candidates are examined on at least six clinical scenarios or vignettes (roughly 9 minutes per vignette). The topics covered in each hour are as follows: 1. Cranial Surgery and Extracranial V ascular Disease 2. Spine and Spinal Cord Pathology 3. Critical Care and Other “Other” includes neurology, functional and pain surgery, peripheral nerve surgery, and pediatric neurosurgery. The presentation of at least six vignettes is to the benefit of the candidate. If poor performance is noted on one vignette, the overall effect may be reduced. Examiners are instructed not to ask trick questions or questions that merely require regurgitation of purely didactic material. The objective of the examination is to find out what the candidate knows. Ultimately, the safety of the approach and management

nce is noted on one vignette, the overall effect may be reduced. Examiners are instructed not to ask trick questions or questions that merely require regurgitation of purely didactic material. The objective of the examination is to find out what the candidate knows. Ultimately, the safety of the approach and management 2 • G OODMAN ’S N EUROSURGERY O RAL B OARD R E v IEW described by the candidate is judged by the examiners, who are counseled not to dwell on weaknesses or strengths of the candidate, but instead to move on to other topics in order to explore the breadth of knowledge. During each vignette, an actual clinical encounter is simulated. The patient could be presented as seen in the emergency department, in the neurosurgical office, or in consultation in the intensive care unit, for example. An overall presentation of the history and examination is provided at the initial encounter. Candidates actively par ticipate in the process and are free to ask for data needed to solve the problems that are presented. Ultimately, the management plan is explored with the candidate, who is expected to provide the rationale for his or her decisions. Relevant test results and images are discussed and pre sented. The candidate is asked for a Differential Diagnosis, which includes the most likely diagnoses, as interpreted from the history, physical examination, and relevant tests. After presenting the Differential Diagnosis, the candidate is asked to provide an initial management plan, which may include a surgical procedure and thus would require the candidate to present the details of the surgical procedure. The candidate may also be presented with perioperative or intraoperative complications and be asked to provide a management plan. Postoperative management will be queried, and postoperative complications may also be pre sented for discussion. During the examination, the focus of the examiners will be on the judgment used by the candidate to solve the clinical problem. They are instructed to be open to alternative solutions that are reasonable and can be justified by the candidate. The examination is comprehensive— the candidate should be able to answer all questions regarding the entire spectrum of neurosurgical diseases presented, despite subspecialization of their practice. The metric for this is the spectrum of diseases that might be seen during a rou tine consultation in the office or when on- call covering an emergency room. GRADING For the purposes of grading, each vignette is considered on three separate tasks, Diagnosis and Management of the patient and relevant problem, and the handling of Complications relevant to the treatment. If no treatment is rendered, the candidate would be expected to describe in detail the natural history of the disorder. A single grade is given for each vignette in consideration of the candidate’s performance on the tasks. At the end of the hour, a composite grade is given. The composite grade is not necessarily an average of the six or seven vignettes presented; it is an overall assessment of the candidate as determined by the examiner. Candidates are judged relevant to the expected performance of a junior neurosurgical staff using the principles of sound neurosur gical practice. Specifically, attention is paid to any safety concerns during the management of the patient. Each candidate is graded on a four- point scale. Grade 3 is expected to be a passing grade, and grade 4 would be a passing grade.

erformance of a junior neurosurgical staff using the principles of sound neurosur gical practice. Specifically, attention is paid to any safety concerns during the management of the patient. Each candidate is graded on a four- point scale. Grade 3 is expected to be a passing grade, and grade 4 would be a passing grade. The grades given are as follows: Grade 4: Provides knowledgeable and safe answers Grade 3: Provides acceptable answers; has some knowledge gaps that would not affect patient safety Grade 2: Provides answers that demonstrate knowledge gaps that compromise safe care Grade 1: Provides dangerous and unsafe answers possibly owing to carelessness, a profound lack of knowledge, or a lack of professionalism It is important to emphasize that a grade of 2 is considered a failing score. A grade of 2 by either or both examiners could result in an overall failing grade. Grades are extracted after the examination in the fol lowing Subject Areas: 1. Cranial and Extracranial V ascular Neurosurgery 2. Spine and Spinal Cord Surgery 3. Critical Care and Other As mentioned earlier, “other” includes topics such as neu rology, functional neurosurgery, pediatric neurosurgery, and surgery of peripheral nerves. There is a strict requirement for passing each of these three subject areas. Again, the breadth of knowledge is examined to ensure a safe general practice for covering a general hospital emergency department or providing con sultation in a community practice. DISCUSSION Discussion of marginal candidates may occur at the end of examination sessions. Marginal candidates are those who present “on the bubble” and have a grade that may place

to ensure a safe general practice for covering a general hospital emergency department or providing con sultation in a community practice. DISCUSSION Discussion of marginal candidates may occur at the end of examination sessions. Marginal candidates are those who present “on the bubble” and have a grade that may place T HE ABNS O RAL B OARD Ex AMINA TION • 3 them at risk for overall failure. All of the examiners who contributed to the grade of the candidate in the respective subject area are asked to comment. Discussion is an edu cational experience for examiners and also a mechanism to give the benefit of the doubt to candidates in order to ensure that appropriate grades are given. PASS/ f AIL DETERMINA TION The ultimate pass/ fail grade (pass point) is determined by psychometric analysis of all of the data derived from the examination and examiners. This takes approxi mately 2 weeks after the examination to complete. The final grades are adjusted for the severity of examiner (both tough and easy), the difficulty of the questions, and the tasks (diagnosis, management, and complica tions). Candidates may be excluded from psychometric analysis if significant safety concerns are voiced during any one of the 3- hour sessions; a failing grade will be assigned by the Directors. OUTCOME Of  THE E x AMINA TION Candidates are notified of the outcome of the examina tion 2 to 3 weeks after the examination date. Successfully passing the examination will automatically complete the ABNS certification process. If the candidate fails to pass the examination, he or she will be eligible to retake it in subsequent sessions. The candidate may retake the Oral Examination twice before needing to retake the written examination and start the Oral Examination application process again. SUMMARY The Oral Examination process is an important final element in the certification process of a neurosurgeon by the ABNS. The format and execution of the examination are under constant deliberation by the ABNS Directors assigned to the Oral Examination Committee. Changes are implemented in the examination process if they are determined by Directors to be in the best interest of the examiners as they explore the knowledge base of candidates, including how candidates apply their knowledge to provide safe and rational care of patients. THE fUTURE There is active discussion amongst ABNS director on changing the format of the oral board examination. At the time of this publication, the changes discussed would continue to have three 1-hr sessions in which the candidate will be examined by 2 oral board examiners. The first hour will be general neurosurgery with an emphasis on types of cases that may present to the emergency department. In the second hour the candidate will be examined by oral board examiners in their area of sub- specialization, eg, endovascular, spine, brain tumors. The final hour will be reviewing 6 to 8 cases from the 150 cases that were submitted as part of the application process. This would include establishing an understanding for indications of the surgery and/ or complications.