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3. THOUGHTS ON TECHNIQUES IN ANSWERING ORAL BOARD QUESTIONS Allan D. Levi WHO ARE YOUR E x AMINERS? he American Board of Neurological Surgery (ABNS) board member is an elected official posi tion that is extremely important in helping to reg ulate our profession and one of the main purposes of which to conduct examinations of candidates who voluntarily seek certification, as well as to issue certificates to those who meet the requirements of the Board and satisfactorily complete its examinations. The examiners are either board members of the ABNS or guest examiners. Most examiners are chairs, program directors, or division chiefs and are in the 50- to 65- year age group. Each is likely to be an aca demic neurosurgeon and is highly specialized. They are responsible for providing cases from all areas of neurosur gery. They may ask their colleagues for some cases outside their specialty. There are standardized questions provided by the ABNS that each examiner will give each candidate. If the examiner “knows you”— you were a former resident or fellow in their program— they will recuse themselves from examining you. BREAKING DOWN YOUR APPROACH The discussion of answering techniques in case- based questions can be divided into two major areas:  content and style. If an individual is excellent in one area and has not at least mastered the other area, problems can ensue. An example would be a neurosurgeon who has a large clinical experience as a resident, fellow, and new attending and is well read and has prepared whole heartedly for the examination but is simply incapable of a logical thought process in stringing together the results of diagnostic studies, surgical plan, and management of complications. CONTENT The oral board is a test of your knowledge in all areas of neurosurgery, and you are responsible for each area even if you have subspecialized in a certain area. For example, if you are a fellowship- trained spine surgeon, it may be 8 or 9 years since you have treated a fourth ventricular tumor in an infant, but you are still clearly responsible for handling this type of case on your oral board. Because you have already submitted your cases to the board, they know your practice pattern; there fore there is no need to preface your answers with a statement such as, “I don’t do this kind of case.” In the past, the 3 hours of the examination were divided into spine, cranial, and other, with neurological cases sprinkled in between. Currently, you may see any aspect of neurosurgery in any of the hours, and you must pass each hour and each subspecialty. Gaining the experience and knowledge in neurosurgery starts when you are a medical student demonstrating your initial interest in neurosurgery and continues to the day of your examination. For all examinees, this represents thou sands of cases that you participated in during your training and in your own practice. Cramming the night before your oral board session simply does not make sense. In preparation for the examination, a general neu rosurgical text, likely Mark S.  Greenberg, Handbook of Neurosurgery, can provide a broad overview of all of neurosurgery. Selected readings from a specialty text may also be of value in covering areas in which you may be less versed.

session simply does not make sense. In preparation for the examination, a general neu rosurgical text, likely Mark S.  Greenberg, Handbook of Neurosurgery, can provide a broad overview of all of neurosurgery. Selected readings from a specialty text may also be of value in covering areas in which you may be less versed. 8 • G OODMAN ’S N EUROSURGERY O RAL B OARD R E v IEW Receiving practice questions from a senior partner or col league can also be helpful. STYLE Remember strategically that your responses need to be divided into the following categories: A. Diagnosis B. Management C. Complications DIAGNOSIS The examiners will present you with clinical vignettes that are short and to the point, possibly only a line or two. The absolute key is to proceed diagnostically in a logical fash ion, starting with a history, past medical history, or fam ily history as appropriate. It can be advantageous to ask a few directed questions that demonstrate your understand ing of the case and that can win you points. For example, in a patient with a cystic tumor of the spinal cord with an intensely enhancing mural nodule, you may ask whether the patient has a family history of von Hippel- Lindau disease; this immediately suggests that you are “on course, ” but asking for a family history of disease for each case may just waste valuable time. Next is the physical and neurological examination. In a trauma case, you many need to know more about the vitals, including airway, breathing, and circulation (ABCs), and about the level of consciousness, including the Glasgow Coma Scale score. The neurological examination presented will also be short, but asking questions that help to localize the lesion in the neuraxis will be helpful. Finally, additional imaging tests to the ones already presented may be needed, such as an angiogram, positron emission tomography, computed tomography, and a metastatic workup, may be required. Ideally, we always want to review all the radiologic studies and have excellent quality films, but only a certain number of films can be presented for any specific case. Y ou can ask for more, but almost always, the next slide is the next slide. Unfortunately, many times, the actual images were taken from converted 35- mm slides and hence are of relatively poor quality. Ask, but you may not receive. There are no trick slides, and it would be unlikely that the area of interest would be a small structure in the very corner of the film. Avoiding long periods of silence as you are gathering your thoughts is important. A  lengthy pause may in fact annoy your examiner. Instead of silence, viewing the films and describing what you see can help win you points. This would include looking at a magnetic resonance image of the brain or spine, describe the imaging sequence, noting whether gadolinium was given, and describing the location of the lesion. Even if you do not know the exact diagnosis or surgical plan, you can make headway. MANAGEMENT With respect to management, do not necessarily jump to surgery. Think wisely about the natural history. A lumbar disk without a significant neurological deficit will need adequate conservative treatment, including pain medica tions, antiinflammatory drugs, physical therapy, and possi bly epidural injections. Jumping to surgery without having described conservative care will not be viewed well. On the other hand, the examiners may ultimately want you to do surgery after an appropriate trial of conservative care, so do not be afraid to move forward with a surgical plan— after all, this is a neurosurgical examination. Continually send ing a patient back to physical therapy with a very large L4- L5 disk herniation, for example, may likewise disturb the examiner. When proceeding with surgery, also proceed logically.

ervative care, so do not be afraid to move forward with a surgical plan— after all, this is a neurosurgical examination. Continually send ing a patient back to physical therapy with a very large L4- L5 disk herniation, for example, may likewise disturb the examiner. When proceeding with surgery, also proceed logically. Think about anesthetic considerations, antibiotics, posi tioning, skin preparation, additional equipment, precor dial Doppler if you are operating in the sitting position, and so forth. Intraoperative electrophysiologic monitor ing, including somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs), may also serve as an important adjunct. SSEPs and MEPs are not considered standard of care in every spine surgery. Proponents against their use cite that if changes occur from a true intraopera tive neurological problem, it will be too late to do anything about it. I recommend their use in any high- risk cases, including intramedullary tumors, calcified thoracic disks, and cervical ossification of the posterior longitudinal lig ament. Changes in MEPs as opposed to SSEPs are more specific in predicting a post operative neurological deficit. Changes in latency as opposed to amplitude in SSEPs are more predictive of a postoperative neurological problem. Remember that there are many reasons for changes in the evoked potential monitoring, including but not limited to technical problems— leads that become detached, anes thetic agents, hypotension, and hypothermia, which can

ency as opposed to amplitude in SSEPs are more predictive of a postoperative neurological problem. Remember that there are many reasons for changes in the evoked potential monitoring, including but not limited to technical problems— leads that become detached, anes thetic agents, hypotension, and hypothermia, which can T HOUGHTS ON T ECHNIQUES IN A NSWERING ORAL B OARD QUESTIONS • 9 particularly effect SSEPs. Make sure to problem- solve technical issues before attributing the changes to a true neu rological problem. If you are being examined on a spine case, make sure to localize the area of the incision with fluoroscopy and ensure you are on the correct side for an asymmetrical spinal dis ease process. COMPLICA TIONS When complications ensue, and they will, be ready to jump in to the fray. Come in and see the patient, lay hands on, express your concern. Do not send your resident or nurse practitioner or delay the visit until Monday if the problems are occurring on the weekend. Also, make a well- defined plan for some of the following common complications that can be seen in neurosurgery. This way you can easily respond without generating too much stress (see Chapter 14). • Postoperative wound infection • Cerebrospinal fluid leak • Postoperative neuropathic pain • C5 nerve palsy • Status epilepticus • Postoperative cranial or spinal hematoma • Hyponatremia • V asospasm • Intraoperative aneurysm rupture— open or endovascular • Uncontrolled intracranial pressure • Brain swelling during operative exposure • Esophageal injury STYLE PITf ALLS A style pitfall is a burning desire of some candidates to demonstrate how “smart” they are to the examiner. This would include bringing in extraneous clinical information or cit ing articles that may not be relevant to the case at hand. This pressure of speech may lead the examiners to eventually pick up on something you say and take you down a direction you do not want to go, without getting you additional points. CITING PAPERS OR RE f ERENCES There are only a very few articles that you would want to cite during your oral examination in any particular sub specialty. Some examples might include the ST ASCIS, ARUBA, NASCET, and ISUA trials. The purpose of citing any references would be to help rationalize your manage ment strategy. TIMING Neurosurgical residency may last 7  years, with countless nights on- call, and you may be working in a neurosurgi cal practice for 3 to 5 years before you take the Oral Board Examination. But you have only three 1- hour sessions to be able to show your knowledge in all areas of neurosurgery to the examiners. Timing is everything. In general, you need to get through at least six questions in each hour. This translates to approximately 10 minutes per question. Answering only four questions in an hour will clearly put you at a major disadvantage in obtaining an overall passing score. DISAGREEING WITH THE E x AMINER Disagreeing with your examiner is not a good idea. Y our examiner is always right. In a famous case, an examinee detailed how the examiner had not read his seminal paper on the topic on which the presented case was centered. The examiners are there to help you, so listen carefully to their questions. Do not argue with them. Also, remember that there is often more than one correct answer for a par ticular case example— for example, anterior versus posterior decompression of the cervical spine. As long as you have a reasonable explanation for your approach, it, too, can be the correct answer. Resist the temptation to be dogmatic about a certain answer because you may see the opposite approach on the next slide the examiner shows you. There is more than one way to skin a cat— and the next slide is the next slide. Some responses not to consider are included— some in jest!

, it, too, can be the correct answer. Resist the temptation to be dogmatic about a certain answer because you may see the opposite approach on the next slide the examiner shows you. There is more than one way to skin a cat— and the next slide is the next slide. Some responses not to consider are included— some in jest! • Y ea— well how many have you done? • The hell with that monitoring crap. • Didn’t you read my seminal article on this subject?

, it, too, can be the correct answer. Resist the temptation to be dogmatic about a certain answer because you may see the opposite approach on the next slide the examiner shows you. There is more than one way to skin a cat— and the next slide is the next slide. Some responses not to consider are included— some in jest! • Y ea— well how many have you done? • The hell with that monitoring crap. • Didn’t you read my seminal article on this subject? 10 • G OODMAN ’S N EUROSURGERY O RAL B OARD R E v IEW • All bleeding eventually stops. • W e all gotta die someday. • I look forward to seeing y’all next year. THOUGHTS ON NEW TECHNOLOGIES Neurosurgery is in a constant process of evolution. I have been involved in teaching the Oral Board Examination course at the time of writing this textbook for 18  years. Over that period of time, there has been a dramatic change in the way we practice neurosurgery. Areas of growth that essentially did not exist 20  years ago include endovascu lar techniques for aneurysmal flow diversion and coiling, embolization of tumors and arteriovenous malformations (AVMs), endovascular treatment of vasospasm, clot retrieval for stroke, carotid stenting, focused radiation for tumors and AVMs, endoscopic techniques for skull base tumors, endoscopic third ventriculostomy, deep brain stimulation for Parkinson’s disease, complex spinal instrumentation, and minimally invasive and lateral approaches to the spine. Many of these procedures have been around for more than 5 years and are fair game to discuss. Y ou may have not been trained specifically to coil aneurysms, for example, but you should know the indications and principles for the proce dure, if not the detailed techniques. Oral board examin ers tend to be a little slower to adopt new technologies, so avoid discussing a technique that has been around for a very short time for which long- term follow- up data have not been published. Also, note that some procedures are much less frequently performed, for example, open aneurysm clipping— particularly basilar artery aneurysms, percutaneous cordotomy for cancer pain, and brachytherapy. DON’T LOOK BACK— KEEP LOOKING f ORW ARD Y ou are the master of your own destiny. Y ou will make mistakes during your Oral Board Examination. Some exam inees will come up with the desired response from the last case at the beginning of the next case. Don’t think about the prior case response because it will distract you from being on task with your current case. OCCASIONALLY CHANGING YOUR APPROACH IN THE MIDDLE O f A CASE IS OK While you are answering a case, the examiners may appear to be steering you away from a particular trajectory. Sometimes, it is acceptable to back out of your proposed approach. An example would be if you were evaluating and treating a “brain tumor, ” and while in the middle of sur gery to resect the “tumor, ” you begin to understand that the lesion is likely tumefactive multiple sclerosis. Y ou can indicate your further thoughts on the case and that you would instead recommend steroids and interferon and obtain follow- up magnetic resonance imaging in 3 months. If you are correct, the examiners will just move on to the next case. THOUGHTS ON A TTIRE A conservative dress code is likely the best policy:  dark suits for men and conservative dresses or pant suits for women. Do not distinguish your self by wearing jeans and a sweater to your Oral Board Examination. Keeping in mind religious or ethnic considerations, which are perfectly appropriate, it would be wise to show up clean shaven. W earing flashy jewelry, such as large gold watches or flashy necklaces, will separate you from the pack, but not in a good way. DOS AND DON’TS ON E x AMINA TION DAY • Do think of neurological diseases that might mimic the condition your are reviewing. • Do “be safe.” • Do think of potential complications and their management.

flashy jewelry, such as large gold watches or flashy necklaces, will separate you from the pack, but not in a good way. DOS AND DON’TS ON E x AMINA TION DAY • Do think of neurological diseases that might mimic the condition your are reviewing. • Do “be safe.” • Do think of potential complications and their management. • Don’t suggest procedures that you have never heard of. • Don’t try to pass the case to another colleague or service. • Don’t short- change yourself with time on your flight into Houston for the examination.