The case against requiring general oral examinations for subspecialists.

Structured case-based oral examinations are widely used in medical certifying examinations in the USA. These orals assess the candidate's decision-making skills using real or realistic patient cases. Frequently mentioned but not empirically evaluated is the potential bias introduced by the candidate's communication ability. This study aimed to assess the relationship between candidate communication ability and medical certification oral examination scores. Non-doctor communication observers rated a random sample of 90 candidates on communication ability during a medical oral certification examination. The multi-facet Rasch model was used to analyse the communication survey and the oral examination data. The multi-facet model accounts for observer and examiner severity bias. anova was used to measure differences in communication ability between passing and failing candidates and candidates grouped by level of communication ability. Pearson's correlations were used to compare candidate communication ability and oral certification examination performance. Candidate separation reliability values for the communication survey and the oral examination were 0.85 and 0.97, respectively, suggesting accurate candidate measurement. The correlation between communication scores and oral examination scores was 0.10. No significant difference was found between passing and failing candidates for measured communication ability. When candidates were grouped by high, moderate and low communication ability, there was no significant difference in their oral certification examination performance. Candidates' communication ability has little relationship to candidate performance on high-stakes, case-based oral examinations. Examiners for this certifying examination focused on assessing candidate decision-making ability and were not influenced by candidate communication ability.

Board Stiff Three: Preparation for Anesthesia Orals, with DVD, 3rd ed. Christopher J. Gallagher, MD. Burlington, MA: Butterworth-Heinemann, 2009. ISBN 978-0702030925. 440 pages, $74.95 (paperback). The 3rd edition of this oral board review book by Gallagher has benefited from the extensive updating of the previous edition, including a DVD with simulated oral board scenarios. The new edition is a unique combination of factual information, which describes both the old and new formats for the American Board of Anesthesiology oral board examination. The recently updated 3rd edition of this book is designed to assist the reader in making rational decisions when discussing various case scenarios. Most importantly, the reader is shown how to provide the examiners with answers that they can defend when questioned. The revised book provides the reader with a summary of the key items they need to study in preparing for the American Board of Anesthesiology oral board examination. For example, what pulmonary function tests could you order?; how to defend the use of a regional versus general anesthetic technique; and why the use of certain drugs are more easily defensible than others. Board Stiff Three discusses pre-, intra-, and postoperative management issues. Importantly, the book facilitates the readers’ understanding of the application of physiologic and pharmacologic principles to the anesthetic management of patients undergoing a variety of surgical procedures. It also simplifies the pathophysiology involved in specific clinical scenarios, improving the readers’ knowledge base such that their decision making is more logical. Board Stiff Three is organized in a perioperative (i.e., pre-, intra-, and postoperative) question and answer format and provides enough specifics to be a valuable oral board preparation tool. The book contains much useful oral board review information, and more importantly, explains “how to play” the oral board examination game. Because most physicians have limited experience in taking oral examinations, reviewing specific clinical scenarios and appropriate responses should facilitate the examinee’s learning curve in preparing for this unique type of examination. On the other hand, an important criticism of this book relates to Chapter 15. This chapter contains an assortment of stem questions and “grab bags.” Unfortunately, most of this material did not provide answers. Nevertheless, the session does provide the reader with some helpful hints and updates. Reorganizing Chapter 15 into a question and answer format would be more useful to the candidate preparing for the oral board examination. In addition, the humorous aspects of the book add little, if any, real educational value. Furthermore, whereas the DVD is highly technical, the author missed an excellent opportunity to demonstrate real oral examination scenarios. In summary, this book is a useful study guide for those in the oral board examination preparation process. The next edition of the book should limit the number of treatises and include more general instructions for how to improve one’s oral board examination skills. A critical review of actual oral examination case scenarios would be a useful addition to the DVD. Roya Yumul, MD, PhD Anesthesiology Residency Program Director Cedars-Sinai Medical Center Los Angeles, CA [email protected] Ronald H. Wender, MD Academic Chair Department of Anesthesiology Cedars-Sinai Medical Center Los Angeles, CA [email protected]

Oral practice examinations: are they worth it?

This is a book written by British authors to assist United Kingdom anesthesia registrars in preparing for their oral board examination in the specialty. It is not specifically designed for the American Board of Anesthesiology (ABA), but rather is a generic guide to important information for ABA oral board preparation. Although there are no stem questions or new format questions to study (unlike the popular oral board preparation book entitled Board Stiff), this book does have significant value as a study guide for the oral board examination. The Structured Oral Examination in Clinical Anaesthesia: PracticeExamination Papers consists of 10 complete sets of structured oral examinations. Each set is subdivided into 2 sections, clinical anesthesia and clinical science. Each clinical anesthesia section is composed of 1 long and 3 short cases, and relevant clinical information for each long case is presented. Each clinical science case is composed of 4 key topics: applied anatomy, physiology, pharmacology, and physics of equipment used in anesthesia practice. This book is designed to assist the reader in making rational decisions when discussing various case scenarios. Most importantly, the reader is shown how to assess their knowledge and provide answers that they can defend. Each structured oral examination long case is composed of a scenario, relevant material such as history, clinical presentation, laboratory results, electrocardiograms, chest radiographs, echocardiographic findings, pulmonary function test results, and a series of questions and answers. Each question provides the reader with answers organized by organ system. At the end of each long case scenario, key points and further reading materials are provided. Each long case is followed by 3 short cases that are composed of a short scenario with a series of questions, answers, key points, and a reading list to provide readers with additional breadth and depth of information related to the topic. The short cases reviewed represent more diversified topics that also appear regularly on the examination (e.g., emergency cesarean delivery, head injury, myasthenia gravis, latex allergy, and acute and chronic pain issues). The long cases provide the reader with helpful hints, updates, and key points on how to manage various clinical scenarios. Answers are provided for all questions at the end of each long case. Although this book contains a unique combination of information, it does not describe the format of the ABA oral board examination. The Structured Oral Examination in Clinical Anaesthesia is organized in a perioperative (i.e., pre-, intra-, and postoperative) format and provides enough specifics to be a valuable oral board preparation tool. A critical review of actual oral examination scenarios would be a useful addition to the book. In addition, reorganizing the 10 cases into a stem question format (i.e., question and answer) would be helpful to the candidate preparing for the ABA oral board examination. In summary, this book is a useful study guide for anesthesia trainees in the oral board preparation process. The book contains much useful review information, and more importantly, explains how to proceed with a differential diagnosis, with in-depth discussions of likely causes, diagnostic procedures, and treatment modalities. Reviewing specific clinical scenarios, specific questions, and appropriate responses should facilitate the examinee's learning curve in preparing for their oral board examination. Our major criticism of this book relates to the fact that it is not written as an ABA oral board preparation book in contrast to Board Stiff. However, it does provide more useful academic material than Board Stiff and is a useful study guide for the oral examination. Roya Yumul, MD, PhD Ronald H. Wender, MD Department of Anesthesiology Cedars-Sinai Medical Center Los Angeles, California [email protected]

Oral and long case clinical examinations are open to subjective influences to some extent, and students may be marked unfairly as a result of gender or racial bias or language problems. These concerns are of topical relevance in South Africa. The purpose of this study was to assess whether these factors influenced the marks given in these examinations. Final-year surgery examination results from the University of Cape Town from 2003 to 2006 were reviewed. These each consisted of a multiple choice paper, an objective structured clinical examination, a long case clinical examination and an oral examination. The marks of 604 students were analysed. Students who spoke English as a home language performed better in all examination modalities. Female students scored slightly higher than males overall, but they scored similarly in the clinical and oral examinations. There were significant differences in the marks scored between the various population groups in all examination modalities, with white students achieving the highest scores, and black students the lowest. These differences were most marked in multiple choice examinations, and least marked in oral and clinical examinations. We could find no evidence of systemic bias in the oral and clinical examinations in our department, which reinforces the need for ongoing academic support for students from disadvantaged educational backgrounds, and for those who do not speak English as a home language.

Dental caries and periodontal disease are highly prevalent in the Japanese adult population. Oral examination is an effective method to find various oral health problems in their early stages. However, workplace oral examination is not common in Japan. The purpose of this study was to examine the relationship between receiving workplace oral health examination, including oral health instruction, and oral health status in the Japanese adult population. This study was performed using data from 4,484 Japanese employees aged 35-74 yr. The proportion of teeth with a probing depth (PD) ≥4 mm and the number of decayed teeth were used for periodontal disease and dental caries parameters. The subjects were asked by questionnaire about past experiences with workplace oral health examination. The subjects who received a workplace oral health examination every year had better periodontal health status than those receiving an examination for the first time. The odds ratio for having ≥10% of teeth with PD ≥4 mm in the subjects who received workplace oral health examination every year was 0.63 (p<0.05) after adjustment for age, sex, smoking habits, tooth-brushing habits, routine visits to dental clinics, number of missing teeth, and oral hygiene status, in a multivariate, multinomial logistic regression analysis. On the other hand, no significant relationship was found between workplace oral health examination and number of decayed teeth. These results suggest that workplace oral health examination accompanied by oral health instruction may be effective for maintenance of periodontal health.

Mayo Clinic, Rochester, Minnesota. grim.kendra@mayo.eduThe Structured Oral Examination in Clinical Anaesthesia: Practice Examination Papers. By Cyprian Mendonca, M.D., Carl Hillermann, Josephine James, and Anil Kumar. TFM Publishing Ltd., Shrewsbury, United Kingdom, 2009. Pages: 558. Price: $70.00. ISBN-10: 1903378680; ISBN-13: 978-1903378687.While reading The Structured Oral Examination in Clinical Anaesthesia by Cyprian Mendonca (Consultant Anesthetist, Department of Anesthesia and Pain Services, University Hospitals Coventry and Warwickshire) et al ., I envisioned sitting across from an equally motivated trainee and passing the book back and forth as we quizzed each other. According to the preface, this scenario is consistent with its intended use. The aim of the book is to help the reader assess his/her strengths and weakness in oral examination skills, including not only clinical knowledge but also organization and timing.The book consists of 10 oral examinations, each of which has a clinical anesthesia section and a clinical science section. The clinical anesthesia component contains one long case and three short cases, whereas the clinical science section includes four distinct topics. The long clinical cases begin with a detailed stem followed by “examiner's questions.” Each question is followed by an organized and concise answer. The questions range from specific case management, procedural concerns to disease pathophysiology that are neatly broken down by organ systems. The answers offer a clear review and example of how to organize the spoken answer on the oral examination.The text is easy to read and engaging. The cases realistically reflect common concerns in anesthetic practice and become enjoyable to reason through. However, questions in the oral board examination and in this book may have multiple correct answers. This book typically gives one answer and explanation, without offering alternatives. An explanation of why the given answer is the most correct may be helpful. In addition, trainees using this book outside the United Kingdom may be frustrated by frequent references to medications not available in other countries, including the United States. An alternative medication is not typically recommended; if the trainee does not already know a substitute medication, they must refer to another book.Anatomic locations and procedures are well described in a concise and systematic approach. Although detailed and thorough, these descriptions may not appeal to visual learners who would benefit from pictures and diagrams. For instance, the section on insertion of chest tube is detailed but may benefit from a diagram. There are few pictures and diagrams throughout the book, and some of these have poor resolution because of black and white shading. The x-rays are well visualized within the case presentations.The book is intended to give comprehensive answers for oral examination questions. The answers at times are not structured in the order followed during real clinical scenarios. For instance, in the case of umbilical cord prolapse, which is a fetal indication for emergent delivery, the first answer lists obtaining a blood sample for multiple studies, including electrolytes. In that critical situation, the examiners may be more interested in hearing the second and third interventions listed, which are maternal oxygen and manual umbilical cord decompression back into the vaginal vault, respectively.Overall, this book accomplishes its goals of being a tool for oral board candidates to evaluate their strengths and weaknesses in both clinical anesthesia practice and general medical knowledge. The book is formatted similar to the oral board examination to provide familiarity. The answers are both concise and organized as they may be spoken during the examination. The book will be an excellent tool for individual learners or for a small study group. Parallel use of a reference book may be useful, especially to reference medications and pictures or diagrams as needed. I would recommend this book as part of an oral board preparation study plan and will use this book in preparation for my future oral board examination.Mayo Clinic, Rochester, Minnesota. grim.kendra@mayo.edu

PurposeWe investigated correlations between the findings of oral examinations and panoramic radiography in order to determine the efficacy of using panoramic radiographs in screening examinations.MethodsThis study included patients who visited dental clinics at National Health Insurance Service (NHIS) Ilsan Hospital for checkups during 2009–2015 and underwent panoramic radiographic examinations within 1 year prior to the oral examinations. Among the 48,006 patients who received checkups, 1,091 were included in this study. The data were evaluated using the Cohen kappa and interrater agreement coefficients. Accuracy, sensitivity, and specificity were calculated using data from the panoramic radiographs as true positive diagnoses.ResultsThe interrater agreement coefficient for occlusal caries was 28.8%, and the Cohen kappa coefficient was 0.043 between the oral and panoramic radiographic examinations. Root caries and subgingival calculus were only found on the radiographs, while gingival inflammation was found only by the oral examinations. The oral examinations had a specificity for detecting occlusal dental caries of 100%, while their sensitivity for proximal dental caries and supragingival calculus was extremely low (14.0% and 18.3%, respectively) compared to the panoramic radiographic examinations. The oral examinations showed a relatively low sensitivity of 66.2% and a specificity of 43.7% in detecting tooth loss compared with panoramic radiography.ConclusionsPanoramic radiography can provide information that is difficult to obtain in oral examinations, such as root caries, furcation involvement, and subgingival calculus, which are factors that can directly affect the survival rate of teeth. It therefore seems reasonable and necessary to add panoramic radiography to large-scale health checkup programs such as that provided by the NHIS.

The American Board of Thoracic Surgery: Update

This study investigated the relationship between candidate's proficiency in communication/organization and ability measures derived from judges' oral examination ratings on a medical specialty certification examination. Judges who rated candidates on the oral examination also provided a separate rating for candidates' communication/organization skills. ANOVA was used to examine differences among levels of communication/organizational skills with respect to candidates' ability measures on the oral examination. There was a statistically significant increase in oral examination measures for candidates with higher levels of communication/organization skills. This supports the hypothesis that candidates who were more proficient in organizing and presenting their responses were more likely to have better performance on the oral examination. Given communication and oral examination ratings were provided by the same judges, future research should investigate whether these preliminary findings generalize to situations in which communication ratings are obtained from independent ratings during and outside the oral examination.

People with special needs have high unmet oral healthcare needs, partly because dentists find it difficult to access their oral cavity. The Oral Accessibility Spatula aims to improve oral accessibility. This prospective multicenter interventional open-label non-randomized patient-self-controlled trial assessed the ability of the spatula to improve the oral accessibility of special-needs patients during dental examinations. The cohort was a convenience sample of minor and adult patients with special needs due to physical, intellectual, and/or behavioral disorders who underwent dental check-up/treatment in five French tertiary hospitals/private clinics in 2016-2018 and evinced some (Venham-Score = 2-4) but not complete (Venham-Score = 5) resistance to oral examination. After inclusion, patients underwent oral examination without the spatula and then immediately thereafter oral examination with the spatula. Primary outcome was Oral Accessibility Score (0-12 points; higher scores indicate visualization and probing of the tooth sectors). Secondary outcomes were patient toleration (change in Venham-Score relative to first examination), safety, and Examiner Satisfaction Score (0-10; low scores indicate unsatisfactory examination). The 201 patients were mostly non-elderly adults (18-64 years, 65%) but also included children (21%), adolescents (11%), and aged patients (3%). One-quarter, half, and one-quarter had Venham-Score = 2, 3, and 4 at inclusion, respectively. The spatula significantly improved Oral Accessibility Score (4.8 to 10.8), Venham-Score (3.1 to 2.6), and Examiner Satisfaction Score (3.4 to 7.2) (all p<0.001). There were no severe spatula-related adverse events. The spatula significantly improved oral access, was safe and well-tolerated by the patients, and markedly improved oral examination quality.

BackgroundPeople with special needs have high unmet oral healthcare needs, partly because dentists find it difficult to access their oral cavity. The Oral Accessibility Spatula aims to improve oral accessibility. This prospective multicenter interventional open-label non-randomized patient-self-controlled trial assessed the ability of the spatula to improve the oral accessibility of special-needs patients during dental examinations.MethodsThe cohort was a convenience sample of minor and adult patients with special needs due to physical, intellectual, and/or behavioral disorders who underwent dental check-up/treatment in five French tertiary hospitals/private clinics in 2016–2018 and evinced some (Venham-Score = 2–4) but not complete (Venham-Score = 5) resistance to oral examination. After inclusion, patients underwent oral examination without the spatula and then immediately thereafter oral examination with the spatula. Primary outcome was Oral Accessibility Score (0–12 points; higher scores indicate visualization and probing of the tooth sectors). Secondary outcomes were patient toleration (change in Venham-Score relative to first examination), safety, and Examiner Satisfaction Score (0–10; low scores indicate unsatisfactory examination).ResultsThe 201 patients were mostly non-elderly adults (18–64 years, 65%) but also included children (21%), adolescents (11%), and aged patients (3%). One-quarter, half, and one-quarter had Venham-Score = 2, 3, and 4 at inclusion, respectively. The spatula significantly improved Oral Accessibility Score (4.8 to 10.8), Venham-Score (3.1 to 2.6), and Examiner Satisfaction Score (3.4 to 7.2) (all p<0.001). There were no severe spatula-related adverse events.ConclusionThe spatula significantly improved oral access, was safe and well-tolerated by the patients, and markedly improved oral examination quality.

Perform a death-defying act: The 90-second oral cancer examination

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Organization of a comprehensive anesthesiology oral practice examination program: planning, structure, startup, administration, growth, and evaluation