Oral Exam FAQ
This section provides information about how the oral exams are conducted, examiner expectations, prompting and other frequently asked questions.
Canadian Anesthesia Oral Exams
ASSESSMENT OF DECISION MAKING
Why is there a need for the Royal College Exam? Isn’t successful completion of an anesthesiology residency adequate?
The short answer is ‘No, completing a residency is not adequate’. It has been well documented that completing a program does not imply competence. One of the more compelling arguments is the concept of ‘Failing to Fail’. There is a reluctance for supervisors to give under performing residents a ‘failing’ grade because of the possible negative implications. This can be as simple as hurting someone’s feelings to complex as lawsuits. Underperforming residents can complete their training yet never receive a failing evaluation. A summative assessment at the end of training provides the assurance that newly finished anesthesiologists are working above a minimal standard.
Why is there an oral exam in the Royal College Exam?
The best way of determining a candidate’s competence to practice anesthesiology would be a work place assessment. To obtain an accurate assessment, a candidate would require more than just one person’s opinion, likely 3 or more. Another issue is the management of infrequent, high acuity situations. Each assessor would have to observe a candidate manage more than one life threatening event. Lastly, the assessor should not be known to the candidate so the assessor would have to travel to the candidate’s site. In short, having assessors visit candidates for several days to weeks for over 100 candidates each year is simply impossible.
The oral exams are created to be discriminative of candidates who would be considered ‘competent’ working in a Canadian Health Care Authority. They are not meant to determine excellence. The questions describe clinical scenarios that meant to be challenging to any practicing anesthesiologist. Candidate must describe their concerns, how they would assess and/or manage the clinical scenario. The examiner uses a competency framework and their own clinical experience to judge the appropriateness of a candidate’s response to the scenario.
Okay, I know it isn't a real word but neither is 'entrustable'. Examsmanship is the skill of taking an exam. A candidate may be brilliant with years of experience, but if they cannot describe their concerns and actions, an examiner cannot determine if they are competent.
When beginning to prepare for the Royal College Exams, residents frequently say that they know what they want to do but don't know how to articulate their thoughts. As an examiner, I can't assume a candidates intent. For example, let's say that a scenario requires a careful induction of anesthesia. If a candidate states they would induce with 100mg of Propofol, Fentanyl 250 mcg and 100mg of Rocuronium, I would not consider that to be a careful induction. If the candidate articulates that they concerned about the induction, and their intent is to conduct a carefully titrated induction but giving Fentanyl 250 mcg and allow appropriate time for onset (10 min) followed by incremental delivery of Propofol, assessing for loss of consciousness, up to 100mg followed by Rocuronium 100mg for paralysis, I would be much more comfortable that the candidate was being careful at induction. The induction drugs and doses are the same but how the answer was delivered was different. The second answer was more articulate and organized. Examsmanship.
The challenge with examsmanship is that it feels like a waste of time. The knowledge content required is overwhelming. Spending time on how to describe your thoughts may seem wasteful, but it is not. When actually taking the exam, peoples anxiety can get the best of them. You don't want to fail because you couldn't get the words out. Practice, practice practice. Get as many oral exams as you can. After receiving a practice oral exam, 'rehearse' your answer until you can deliver it without hesitation or mistakes.
Again, you can have all the knowledge but if you can describe your actions, you can't answer the question.
The "Exam Answer"
I frequently have residents ask 'What is the 'Exam' answer for ____ situation?" To be blunt, the exam answer is what you would actually do if that ____ situation was on your OR table.
There is a false sense that what you would do in practice is different than what you state in an oral exam. The Canadian Anesthesia Exam Board puts a lot of effort into having a diverse representation of anesthesiologists from across the country. A significant proportion are from academic centers but there are examiners from community practices as well as non-Canadian trained anesthesiologist who have established a full practice in Canada. The exam board generates new exam oral questions each year and they are reviewed by the board for fairness. The examiner from a community practice of 30,000 has the same input as an examiner from Ottawa.
The exam questions are meant to be challenging. This is partly done by creating situations that are in conflict with 'standards or guidelines'. It is important to see how candidates navigate these situations. An example of this is an unstable C-spine which would typically be managed by an awake fiberoptic intubation to assure the patient remains neurologically intact. If this same patient is non-compliant because of intoxication or diminished cognitive ability, an awake fiberoptic is not likely going to be successful. The 'exam' answer is the discussion about the challenge provided, possible ideal management, more additional less-than-ideal options, their pros/cons and finally what would be the safest compromise in YOUR hands. If I had a candidate that would stubbornly only do an awake fiberoptic, I would fail them on that question.
I have heard many horror stories about how brutal examiners can be. They are not evil but in fact are trying to be fair. The intensity of the exam, or more accurately, what is riding on the exam, clouds candidates perceptions of examiners.
Examiners are told to be neutral in demeanor as anxious candidates can easily misinterpret our prompts or gestures to move the exam along. For example, a candidate has been asked to list their anesthetic considerations for the first stem of a question. Usually it is meant to be a short reply before launching into the bulk of the question that is still to come. If a candidate is still trying to think of considerations at the 4 minute mark, they should be prompted to move onto the next stem as they may not have enough time to finish the question. If I prompted the candidate with a statement like 'That's great, so lets move forward...', it can become a big problem. The candidate could interpret 'That's great' as the response was great vs that is enough. It is possible unsuccessful candidates could challenge their results on the basis that the examiners told them they were doing well during the question. The same concerns apply to nodding (as if in agreement), saying 'yes, yes...' or even smiling.
Candidates may also look closely at body language or facial expressions as an indicator of how they are doing. If an examiner were to sneer or roll their eyes at a candidates response, most would assume the examiner did not like the answer.
Examiners as asked to avoid prompts or body language that could be misinterpreted. We are asked to maintain a neutral posture and facial expressions. The examiners want to see you do well but we are not suppose to show it. Unfortunately, a neutral facial expression is not comforting, and with the anxiety of writing the 'big' exam, some find it down right 'evil' looking but nothing could be further from the truth. The examiners are good people who want to see you do well, we just can't show it.