Board Review Strategy

Preparation for your Podiatric Board Exam - Part I

John Schuberth, DPM

This is the first part of a three part lecture by Dr. Schuberth on board preparation Detailed step-by-step analysis of the "points to pass" for each practice question is provided along the way.

Goals and Objectives
  • Author
  • John Schuberth, DPM

    Chief, Foot and Ankle Surgery
    Kaiser Foundation Hospital
    San Francisco, CA

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  • Lecture Transcript
  • Jack Schuberth: Hello, everyone. My name is Jack Schuberth. I’ve been asked by the present group to assimilate a presentation on the preparation for the podiatric board examination process, which you’re all going to enter into in the near future. The purpose of this presentation is multifaceted. First and foremost, I hope to demystify the entire process ranging from the type of preparation that should be done to the mentality of a certifying body. In most cases, that’s going to be the American Board of Podiatric Surgery, do that final question on that fateful Sunday morning in June. Certainly each of you has known a prior candidate for this examination and any interaction with your colleagues or prior candidates has likely feel some misconceptions. These misconceptions can breed fear and trepidation and limit one’s capacity to prepare and ultimately one’s performance on the examination. Hopefully, we’re going to dissolve those misconceptions in the next hour. Once we eliminate all of the rumor and hearsay, it will enable the candidate to gain some confidence and build upon it for a successful venture in Chicago. Knowing a so-called truth will help one focus their energies on passing the exam and not on other bits of nonsense. To accomplish these goals, I intend to do it through the process of perspective. Although perspective is just that, it will provide the candidate with a view of the landscape that is not necessarily their own and may prove to be invaluable particularly for those of you that are open-minded. Although this is not a legal document, some sort of disclaimer is necessary. It’s my understanding that some mechanical changes have been made to the way the examination is administered also those revolving around the exam on a computer-based format. Although I believe the information you’re about to hear is accurate and up-to-date, we cannot be responsible for any changes or settle differences that may appear when you actually sit for the examination. This presentation is based on my assimilated perspective of being involved in a certification process and my individual mentality on the educational metric. Furthermore, I believe that this information will be invaluable to most of you. But obviously, it doesn’t come with a warranty for passing the examination. Lastly, I need to disclose that I am in no way affiliated with the American Board of Podiatric Surgery or any other testing body other than being board certified by ABPS. In addition, I’m not presently participating in any other review courses. You might be wondering then why do you even want to sit through this potentially boring and non-visual presentation if I’m not really part of the American Board of Podiatric Surgery. First of all, it would be unethical for me to participate if I were one of the so-called insiders. I do have a rather extensive and broad history in the same examination. My most recent appointment was I was an evaluator for the entire exam process. Essentially, we were charged with monitoring and evaluating the examiners that we were administering the questions to you, the candidates. Our main thrust was to strive for consistency and fairness amongst all of the examiners so that the test was visibly fair. This experience helped me appreciate the interactions between the examiners and examinees and help those in these dichotomous positions to be closer to the common goal and that is becoming board certified. I also served as chairman of the rearfoot and ankle committee for three years and I sat on the written foot surgery committee for an additional three years, and lastly as a regular member of the rearfoot and ankle oral committee. Hopefully, this experience can be distilled down to some advice that may assist each every one of you in passing the exam. If nothing else, you can appreciate the perspective from which I based my comments. First misconception that many of you may posses revolves around the mentality of ABPS. It comes as no surprise that separation of the haves and have-nots evokes a sense of exclusion or even elitism to many. Particularly those of you have that have not passed or even taken the examination. It’s just human nature but it’s diametrically opposed to reality. For all of my years, ABPS has fostered a process of inclusion and not one of exclusion.


    They’re really not trying to keep people out, rather, they want to let those in that are qualified into the so-called fold, although a rather complex subject somewhat argued that it is the mission of any testing organization to protect the public. Whether you accept it or not, there is a moral and ethical responsibility for all of us to protect the public and humanity from unqualified surgeons. Whether any of you believe whose ultimate responsibility that is, it’s not important. What is important is that the testing process is designed to confer competency or certification on the competent and exclude those that don’t possess the competency. Now of course competency is a broad term and can be interpreted in many different ways. For those design to mean practice safely not saving the world. This is the system we have and we need to accept it, although the test administration process varies from specialty to specialty. The bottom line is segregation of those that have the qualifications and those that don’t. ABPS must uphold that doctrine. The second misconception on the core of the ABPS philosophy, involves the issue of logic. I can assure you that the thought process is indeed logical. Many spend or even waste too much time on studying the oddball cases or those rarely encountered, or worst those situations published once in a literature many years before. Zebras are part of the zoo but not part of the exam. The test is based on situations that you’re going to encounter everyday in practice. If you have a surgical practice, the questions you’ll see will be a broad slice of your own clinical encounters. Now that’s not to say that each component or phase of the question will follow a predictable pathway or even a path that would be chosen by you. Certainly there can be a twist but it won’t be an esoteric twist. It may just be unpredictable but certainly not outside the realm of reality. The last point to make about the mentality of ABPS revolves around a contemporary flavor of the examination subject matter. In particular, treatments that are merely historical or even archeological are not considered as correct answers for clinical problems. Just because it was done at one time in history, does not validate it as a correct approach to a clinical problem. Think current. For example, 20 years ago, when I took the exam, the surgical treatment of Charcot arthropathy with an external fixator simply wasn’t done nor where IM nails used for tibiotalocalcaneal fusions. These procedures are more contemporary way of handling an old disease. Now please don’t get the wrong idea that other time-honored options are not satisfactory approaches. They are but you’ll be expected to know the contemporary methodologies. The exam process will honor the classic way of treatment so long as it is not obsolete. As you were aware, the written test is a vital component of the overall assessment of each candidate. There is not really a foolproof strategy for taking this test and there’s really not much to say about it. Typically it evokes less trepidation amongst test takers because the format is so familiar. You’ve all taken multiple choice tests before so there is less of an unknown. The second thing is that there’s no time pressure to perform. You can indeed take your time within reason before answering. It is I understand it the newer computer adaptive testing modality, there is less potential to go back, so to speak. The written test is designed to test factual material or your collective fund of knowledge. It’s not designed to capture your thought process or your cognitive thinking abilities, which are vital to becoming a competent surgeon. The vast majority of questions are on subjects that are not controversial because it’s more difficult to predict the answers and validate the question, yet this should not suggest that the questions are really easy. The straightforward nature of the question really helps the testing body validate the responses. For example, one question varies poorly in post-test analysis, the question may be excluded from grading. There’s maybe a flaw in the way the question was written. This is a distinct advantage to the candidate and a credit to ABPS.


    It speaks to the concept of inclusion rather than exclusion. You really need to know what most other candidates would be expected to know given the same situation. Bad questions are examined, reworded if possible, or simply discarded from the pool. Remember that this test is about what you know and no one is out to trick you. The proverbial one best answered doctrine prevails and seems simplistic. Sometimes we rely too much on academia and not enough on logic and common sense. I always find it helpful to read the question. Before I look at the choices, I try to predict the answer. If it was there as one of the choices, it’s probably the right one. If not, I can rely on the process of elimination to find the correct answer. Again, this is a rather elemental maneuver for any student but should be an integral part of the item analysis. When all else fails, relying your instinct and your fund of knowledge, remember, it’s only one question and others may have the same issue with it. One of the pitfalls I had seen in the past is candidates trying to overread the question. This often serves to increase stress which in turn clouds their rationale thinking process. Chances are overwhelming that there is no multidimensional thought process required to answer the question, that is, provided you know the material. The more common sources of questions is classification systems. Now ostensibly, this is rather annoying, because it requires the candidate to memorize seemingly useless list of trivia that have little clinical purpose. However, as we develop our careers and practice habits, we slowly realize that these schemes are important. They are important not from the standpoint of sheer memorization but important because of their clinical utility. As such, the most commonly used classification schemes are fair and frequent test material rather than listing all of these so-called common schemes. I think it is important that one practice to recognize the various components of each of these schemes. In other words, instead of memorizing the five Hawkins’ stages of talar neck fractures, once you’d be able to look at an x-ray of a talar neck fracture dislocation, you’d be able to instantly recognize the stage of the injury, or one may say, well, you have to know each stage to answer the question and that is indeed true. But the emphasis on that perspective is away from rote memorization and more in a clinically useful approach. Translates to the test, it’s much easier for a candidate to go from instant recognition to picking out the answer from a list other than keeping a bunch of details perfectly clearing your mind. Along those lines, I’d suggest that if you have a study group, get pictures of each stage or whatever scheme you’re studying, whether it’d be ankle, talar, calcaneal fractures, or any other subject, and quiz one another on recognition and identification. In fact, the test is more likely to do this than simply ask what joints are dislocated in a Hawkins for talar neck fracture. The oral exam is the real deal, the one that gives us all the sense of uncertainty. Unless you’ve taken this exam before, it’s quite intimidating because mainly the fear of the unknown. The unknown causes fear in everyone. The discussion of the oral exam should really start by dispelling some of these fears and bringing out of the unknown. Many of you may not realize that the oral exam is much like a residency interview but of course the stakes are higher. You’ve all answered questions on a clinical case scenario before. The oral exam here is not that much different. In fact, each question is really based on real case histories. These cases are supplied by the examination’s committee members but are modified for purposes of the examination. What does that mean? It means that you don’t necessarily have to figure out or perform the exact same surgical procedure that the supplier of the question material did. In fact, you will never really know whose patient it was that was the subject for that question. Remember that each question is crafted to go down a certain pathway and that pathway is carved by the examinations committee.


    The question is broken into multiple components so that you can refocus in the middle of the question if need be and get completely back on track. The components are often standard steps in solving the clinical problem. For example, diagnosis, treatment, diagnostic test, et cetera, et cetera, et cetera. Each step for the grading standpoint is independent of the others. These steps along the way are frequently called the points to pass. This incremental process makes grading of the exam much easier and more uniform and objective. Each candidate must give the same answer for each component of the question even though it is administered by a different examiner. I will say more about the points to pass later. But realize that if you actually do the work, you should be able to answer the question. If your case repertoire was embellished or lack dimension, you may be in trouble. Although the credentialing process is supposed to weed out those with a shallow scope of experience, it may not be perfect particularly those studying for the hindfoot and ankle examinations. In other words, if you have a versatile practice and do not do procedures based on a pigeonhole mentality, the breadth of experience should be adequate to get you through the questions. Naturally, this doesn’t always prove to be true but there’s nothing that you can do about it other than have a good fund of knowledge. Several important concepts to grasp regarding the oral exam. We’ll go and introduce some of these now and then discuss them in detail as we proceed here. First and foremost, realize that the examiner is on your side. He or she has no vested interest in failing you. It’s really true that there is no incentive other than one’s personal pride and sense of integrity for the examiner to participate as an examiner. There’s no financial incentive for the examiner. In fact, they sacrifice their time away from home to be in Chicago. Each examiner undergoes training. The overwhelming message to each examiner is to give the candidate a chance to pass. You all have to get past the notion that the examiner’s motive is to fail you or even create a hostile environment. This is definitely not true. Secondly, don’t try to guess what the points to pass are for a given question. This is not your task and it’s really impossible to predict. Some of the points to pass will be rather obvious and others are not so obvious because they are so simple. A good example comes to mind. A patient with an ankle fracture dislocation comes into the emergency room. A point to pass may be simply checking the foot for pulses. Some of you think, well, of course I’m going to check the pulses, but you don’t say it because it’s so blatantly obvious. Try to put yourself, or at least your mind, into the emergency room in front of the patient instead of in a hotel room and just say what you would do, obvious or not. Another important concept is that there are no points to fail. Even if you commit a blatant act of malpractice in the course of a question, you cannot be failed on that basis. True, you may miss that particular point but you can still pass the question in spite of the demise of the hypothetical patient. Lastly, you should learn to become a good listener. Listening skills are not the forte of many surgeons, but it should be in the test arena. Listening skills are the most important quality for successful completion of the examination. Key in words that the examiner says as they are likely to provide the key to the question. One must be attentive at all times. If possible, try to maintain control of the question and more importantly of your thought process. As we’ll discuss later, some examiners joust the candidate for the control and others will be rather stoic. Again, not something that you can control but you can control your attentiveness. It is critical to remember that positive responses to any question that you ask, almost always mean something. They are not meant to mislead the candidate. For instance, if you ask for allergies and the examiner responds that there is an anaphylactic reaction to penicillin, start to prime your mind for a question on the alternatives to cephalosporins for the treatment of infections. Although the allergy could occur in a real life situation and that patient that has a totally unrelated problem, it’s not the American Board’s policy to throw distractors at the candidate. Secondly, if there is a positive response to any visual aid or diagnostic test, then be assured that it means something relative to the scoring of the exam.


    Now in the real life situation, the candidate or surgeon can order any test he or she desires relative or not and you’ll get the results, but it does not translate to the exam process. Although that may be the modus operandi in the future, when the computer adaptive oral exams are the norm, it is not that now. Be aware that when you are presented with visual aids, there is probably something that is of importance to answering the question. One of the biggest mistakes I have observed in those people taking the exam is the method of information gathering. It is somewhat surprising given that each of you has the tools to do it better. The first and probably most important point is that you should ask the examiner exactly what you would ask a patient in a real life encounter. Instead of asking is there anything pertinent to the medical history or is there anything I need to know about the patient’s history, ask more realistic questions. You certainly, when you say that to the patient, “Mrs. Smith, what is your pertinent medical history?” First of all, the examiner is directed not to give you that information based on open-ended questions. Ask questions that are directed toward establishing a complete patient profile. Again, just as you would back in your office. I have seen candidates, waste tremendous time on the review of systems. Yes, it’s somewhat important, but don’t ask every little detail that may be on your office registration form. A good examiner will redirect you if you go down this errant path. But don’t count on it. Instead, ask more appropriate questions or do a focused review of systems. Lastly, don’t spit out predetermined phrases. This will only show your mechanistic mentality and not showcase your problem-solving mentality. Are those the right questions, how can you ask a few well-chosen questions and get a wealth of valuable information? First, be logical and don’t act like a robot. Again, predetermined recitals are not likely to get you what you need. Ask a question like, “Do you have any illnesses that you are being treated for or that you know of?” That way, the examiner is obliged to give you all of the info relative to what the patient knows. Now of course patients often come to you because they don’t know what their presenting condition is but they certainly know what they’ve been treated for in the past. Again, a positive response usually means something pertinent. If the examiner tells you the patient is perfectly healthy, move on. The second question to ask, “Are you taking any medications?” This will disclose a lot that may have been missed in the review of systems or the past medical history and can clue you in to the diagnosis. For example, the patient is on methotrexate. Be assured that there is a malignancy or some rheumatoid disease as part of the history or that you may need to take precautions about wound healing when you operate on the patient. Lastly, ask about allergies as it is a common test arena with respect to alternative antibiotics. The physical examination is a very simple process in the oral exam, if you are organized. Remember to place yourself in the realm of having the patient in front of you. Partition your brain to think about the question but also about the fictional patient. Again, rely on positive results. The examiner will not give you distractors. If you ask for the pulses and are not palpable, don’t ask why but be placed on alert that you may have to work this patient for PBD or other cause of diminished circulation, depending on the clinical scenario. These positive results will influence either the diagnosis, treatment or outcome, and more importantly is often a point to pass. One of the more useful tips for the physical examination is to compose a visual picture in your own mind. Transpose yourself to your own office with the patient in the chair. In some instances, a picture of the patient as they present will be given to you. If so, study it carefully and reread the question to know the history and the presenting appearance together. If there is no picture, simply ask what does the foot look like? And you may or may not be given a valuable clue. Once you have a general picture in mind, start to ask some general questions followed by specifics. Refine your followup questions based on positive responses. Again, parameters that are normal are not designed to throw you off. Normal is just that. Remember that esoterics are unlikely combinations of signs and symptoms are simply not part of the exam process.


    Let’s start to break down the physical exam into the usual components starting with the vascular examination. Here it is useful to ask specific questions in a standard sequence. Simply ask, what are the pulses? If the examiner wants you to be more specific, they will ask. But they shouldn’t do that unless there is something more specific that’s important to answer the question. In which case, you would say, well, what are the pulses to the dorsalis pedis, posterior tibial, peroneal, popliteal, and femoral arteries? Another vital component to any vascular exam is the capillary refill time. You certainly check these on each patient when you’re examining them on your office, don’t omit it here. If the examiner simply stops you and says the vascular exam is normal, believe him or her and move on as they were trying to get you through this question. The whole component of the physical exam is rather simplistic. Remember that you are being tested as a foot and ankle surgeon and not as a neurologist. However, that doesn’t absolve one from doing a good examination. The first question that I like to ask is this, are there any sensory deficits to light touch, sharp-dull discrimination or vibratory to the upper or lower extremities? This way you get a lot of potential information with one simple question. You should follow that with a simple question on muscle tone. Next, inquire about the reflexes. Remember to refine followup questions based on positive responses, that is, any result that is abnormal. If the examiner tells you that the Achilles reflex is absent, be aware. This is a key to a vital component of the test known as a point to pass. As far as muscle testing, ask a broad question such as, are there any defects or weaknesses to muscle testing if I tested each and every extrinsic muscle of the foot? A simple question but worth it. Lastly, ask if there are any asymmetries to the neurological and muscle testing exam. As you can tell, it’s not the quantity of the questions that you ask but the quality. Ask questions that will yield information without chewing up valuable time. Musculoskeletal component of the examination is probably the most difficult of all, because there’s so much potential information that is familiar to us as surgeons, yet we should try and condense this down to the problem at hand. Along that line, don’t act like a robot but focus on the clinical problem, for details after you asked some well-chosen questions. For example, it’s helpful to ask, what is the range of motion of the ankle, subtalar, and midtarsal joints? Then ask is there any difference with the knee flex or extended in the ankle joint range of motion? With these two questions, you will figure out the overall position and posture of the foot and the presence or absence of equinus. Then, if it’s forefoot alignment problem such as metatarsalgia or hallux valgus problem, you can ask for the range of motion of the first ray. Another bits of information that may be important and pertinent. There is no need to ask the range of motion of any or all of the joints in the case of the fracture. It simply doesn’t make sense and even the most staunched biomechanist in the crowd would have to agree. Again, focus your exam as if you were actually treating that particular patient. Again, you must rely on asymmetries. They can tell you a lot. The dermatological portion of the examination is probably the simplest because there is usually little pertinence to the surgical procedure. Most often, this component is covered nicely by supplying the candidate with a photograph of the foot or ankle. Although you can often tell from the picture what is going on, it is difficult to portray the characteristics of a skin problem by a photo. You should really ask about the major qualifiers if there’s a particular lesion in the photo or it is part of the stem of the question. Although you can see color, you can’t see nodularity or heat, so ask about it. Remember, the goal of the physical exam is to envision a clinical picture in your head about the hypothetical patient. At the end of this line of questioning, you might say to yourself, okay, we have a 35-year-old healthy female with an allergy to Xylocaine, with a one year history of worsening sub second metatarsalgia and enlarged first metatarsophalangeal joint in 10 degrees of equinus. This summary should encompass all the positive findings that you have elicited so far. Everything else you can assume to be normal and most likely will not be part of the followup questioning by the examiner.


    At this point, you’re now ready to order some tests to help with the diagnosis. Diagnostic studies can be a huge can of worms. But what’s in common sense, you can sort it all out. Basically, the number one rule is that if you ask for it and they give you the result, which is almost always an abnormal result, it’s probably important. If the examiner tells you what is not available, then it is simply not needed to make the diagnosis or formulate a treatment plan for that particular part of the question. But you shouldn’t make the assumption that just because it is not available and you might happen to want to order that in your own practice that it is not part of the particular diagnosis. For example, many people order an MRI for any patient who presents with posterior tibial tendon dysfunction for the purposes of classification. If you have a patient in this examination with a collapsing flatfoot or pain in the medial arch and you asked for an MRI and told it’s not available, it doesn’t mean that you are not dealing with a PT tendon dysfunction. All it means is that the MRI is not part of the question, so get over it. Many candidates think that if they order every feasible tests or even these unnecessary tests, they will eventually get all of the necessary information to answer the question, the so-called shotgun approach. That may work but time is a factor. Good examiners will actually lead you away from this mentality and may ask you to formulate a differential diagnosis based on what you’ve already garnered. This is a good clue that there are no more diagnostic tests necessary to complete that part of the question. Bad examiners may not lead you away but they simply won’t be able to give you the test results or one that you asked for if it isn’t important. The default answer is that it’s not available. Now that’s certainly may change as computer adaptive testing becomes more incorporated into the ABPS test, but for now one mustn’t worry. In any board certification exam for foot and ankle surgeons, radiographs are an integral portion of that exam process and certainly in your everyday practice. When you ask for an x-ray, obviously you should expect to be asked to read it. The best approach for reading an x-ray in this examination arena is to be systematic so you don’t overlook anything regardless of how obvious it may seem. First and foremost, you should read the x-ray as if you were a radiologist. Remember that boring radiology rotation, the radiologist would begin by saying “These are the DP and lateral standing radiographs of the left ankle of a 35-year-old female. The overall alignment is good and the bone density is consistent with the patient’s age. The soft tissues are of normal density and there are no erosions, fractures, or dislocations noted. The joint spaces are well preserved.” This is exactly what you should say, out loud, when the examiner gives you an x-ray and ask you to interpret it. If the examiner is looking for more specific material, they will ask for it but most often they want you to actually read the films. The second phase of the radiographic interpretation is that from the perspective of a foot and ankle surgeon. Here you can get specific and discuss those features that are pertinent to the case. These angles and dangles often determine the procedure selection. You just go and have to be disciplined and regimented. Even though you may just do one or two type of bunion operations, and believe me, this is the standard of practice throughout much of the United States irrespective of any other radiographic parameters, you must read the x-ray as a foot and ankle surgeon. This concept of looking at x-rays from a foot and ankle surgeon in more detail by delving into the so-called standard foot deformities. For example, on a bunion deformity, we know that we need to look at the intermetatarsal angle, the length pattern of the metatarsals, the proximal and distal articular set angles, the hallux valgus angle, the sesamoid position, cortical hypertrophy of the second metatarsal, and so on. In other words, things that you do every single day of your professional life. This is how most people evaluate an x-ray. Now don’t get confused into thinking that each surgeon out there uses each of these criteria for procedure selection, hardly the case. Remember that this is an artificial situation and the point to pass maybe is mundane is reading the angles and dangles.


    This mentality can get carried away of course. Confine your discussion to those issues at hand because the questions would have been crafted to go exactly that way. The vast majority of instances, abnormal conditions on x-rays are blatantly obvious. They are not judgment calls. The other popular radiographic parameter or evaluation point is that the determination of the level of deformity. For example, you should all be able to determine the apex of a cavus foot or the apex of a tibial leg deformity. It's often the correct choice of surgical procedure is directed at the level of the deformity. Now, this isn’t really a difficult task but if you haven't done it by drawing lines on the films, you should probably learn how before you sit for this examination. You can be assured there will be some trauma on this examination. It seems to be one of the more intimidating concepts for many examinees. Most likely, this is because most practitioners do not see trauma on a daily basis yet this slide contains some valuable tips to reading a radiograph when trauma to the foot or ankle is involved. The first qualifier to determine is whether the fracture is open or close. This is not often evident on the x-ray itself and may or may not have been disclosed during the history or presentation of the physical findings. Nevertheless, once you get an x-ray, ask if the injury is open or closed. Although technically not a radiographic parameter has helped to characterize the injury properly. Needless to say, the treatment of open fractures is distinctly different than the closed ones. Next, determine the region of the bone. For the long bones of the foot and leg, there is the diaphysis, metaphysis and the epiphysial regions. In the adult, of course, we don’t often refer to the epiphysial region. What is really meant is the joint. First think of what region of the bone or fracture is located and then determine whether it is intraarticular or not. Does it enter the joint? If so, say something like a long spiral fracture of the distal fibula that enters the joint or is intraarticular. For the nontubular bones of the foot, you'll have to know the anatomy. Basically, the cuneiforms and cuboid only have a body in six sides and a proximal and distal articular surface because essentially a cubic shaped or six-sided bone. The talus and calcaneus of course have their own unique features that have to be committed to memory but the principles are the same. Now if you should describe the fracture's morphology, whether it would be transverse, spiral, sagittal, oblique or vertical. Next, determine if the fracture is displaced. Say nondisplaced, minimally displaced, grossly displaced. Next comes angulation. A displaced fracture can be angulated or not but a common mistake is improperly describing the angulation. In general, the distal fragment is described relative to the proximal fragment not the other way around. Remember that this is just arbitrary but it is the convention that is accepted all over the world. If a hallux fracture occurs and there is a dorsal angulation, the examinee should describe it as a dorsally angulated midshaft transverse fracture of the hallux and that can only mean one thing. Comminution is next. This merely describes the number of pieces in general and gives the listener some idea the amount of energy absorbed during the injury process. All of these parameters should be easily described by each candidate as they often form the basis for the standard classification systems. As we discussed in the written exam, the oral examination also incorporates classification schemes. And it's likely they ask you to recognize one or more of the stages of the commonly used classification schemes. Practices recognition based on actually looking at the x-ray and not regurgitation of the academic information published in a book somewhere. Source of consternation, this is subject of tumors. Since we're not musculoskeletal tumor specialist and these conditions are so uncommon. A few of us will have much practice in dealing with this entity. Yet again, we can condemn some of the important features downing to a skill set that will help you through this examination. Tumors are further segregated because the radiographic terminology is so unique and that further confuses people. Although we cannot cover the fine details of musculoskeletal radiology here in this context, don’t worry because the exam won't expect you to perform to that level either.


    What is expected is an understanding of the radiographic characteristics of tumors and you should be able to recognize and describe those features. In turn, the differentiation between benign and malignant tumors should easily follow. Let’s start with the term lytic. Lytic of course means that the tumor is dissolving normal bone and it can only do that if it is advancing rapidly. Rapidly that the repair process cannot keep up with the destructive process. The net result is a loss of bone taken away by the tumor. The lytic process highly suggests the malignant process. A blastic tumor, on the other hand, deposits bones. But this does not universally mean that it is benign. A notable exception is metastatic prostate cancer which frequently goes to bone and actually deposits bone makes the x-ray appear more white because of the increased calcium. The term permeative is self-defining where the tumor process seems to permeate the entire skeletal structure without actually carving out big chunks of bone. Although difficult to describe verbally, the candidate should consult a standard textbook of radiology for examples of this phenomenon. A homogenous appearance on x-ray is again self-defining where the entire region of the tumor has a consistent finite appearance. Again, those scenarios referred to a fundamental textbook on radiology. Let’s take a more refine look at the radiological assessment of bone tumors. These features are really just descriptors of the radiographs. Candidate should be expected to read these features but not necessarily make a definitive diagnosis of the tumor type on a radiographic basis. First, look and see if there is any periosteal new bone. This occurs as the tumor tries to escape the bone and actually lifts the periosteum off of the diaphysis or metaphysis. It’s analogous to a closing base wedge osteotomy. When we strip off the periosteum just prior to perform in the osteotomy, the body reacts by depositing bone. Similar to describing fractures, note the regional location within the bone, whether it be diaphyseal, metaphyseal or periarticular. Although fractures can occur anywhere in any location, most tumors have a predilection for one area or another in a given bone. Note the relative position to the cortex of the medullary canal. Is there any encroachment? Lastly, note new site to the examiner, whether there are any calcifications or stippling. Remember that you only need to recognize these features and it is not expected that you’d be able to positively identify a particular tissue type by memorizing the myriad of possible tumors with certain radiographics or features. Think in terms of generalities but be able to recognize features, a prevailing theme in the board certification process. Now that we have discussed the elicitation of all pertinent historical and fiscal findings as well as diagnostic data, it’s time for a diagnosis. You should have noted that this is no different from clinical practice. History, physical, diagnostic test and then diagnosis. In the setting of the exam, it is often a point to pass but not always. But in case of this, the examiner will often ask you for a differential diagnosis. You should formulate one but make it a logical one. In the past, candidates would just spew off anything that came to mind and it was not based on any elicited information. Presently, this tactic is discouraged by limiting candidate to a finite number of so-called guesses. For example, the examiner may say, “Give me the four most likely diagnoses for that particular tumor.” You get four choices and anything after that doesn’t count, so be thoughtful before you answer whether there is a differential for a tumor or any other subject. It sounds like a broken record but use common sense. Don’t list two benign tumors and two malignant once in the same differential. It doesn’t make any sense and most likely will cause you a point to pass. If asked for a differential and the examiner says something along the lines, “Is there anything else that this could be or do you know one more?” It usually means that you did not get the answer that they were looking for or the so-called point to pass. The examination question is not really that difficult because you only need to come up with the rational approach to the problem. In general, the board is not interested in nonsurgical options but most candidates mention them anyway.


    Most of the time, the examiner will remind that you are sitting for a surgical board certification not a nonsurgical certificate. The ABPS appreciates the tremendous diversity of surgical solutions to problems and I support that diversity. Yet, of course, that does not give you or any other candidate to do whatever they please if it is out of the realm of good medical practice. You need to be in the ballpark. A good example of this is the treatment of the hallux valgus deformity with a 22-degree intermetatarsal angle. Although, we may have all done one in the pass on the unique circumstances, a distal osteotomy would not be an acceptable answer. Yet most likely, any proximal base osteotomy would be appropriate whether you are bias towards closing base wedge osteotomy, a Lapidus procedure or any of the crescented type modifications. Although some surgical latitude is allowed, try and stick with mainstream answers. Some candidates have questioned certain responses based on the fact that a procedure has been published. Although many things have been published, unless it is considered to be common practice, it’s probably not going to be on the list of acceptable answers just because it occurred in a literature. You should also remember at the standard of practice is a legal term and doesn’t translate 100% to the testing situation. In general, the standard of practice is far more tolerant to latitude than the examination but not to the point of being overly restrictive. To reiterate, think mainstream not on proven procedures. It will pay off in the final grade. Once you declare a treatment plan for the hypothetical patient, you may be requested to justify that option. It all boils down to criteria. Another example comes to mind. A rigid hammertoe cannot be repaired with a flexor tenotomy, even though you may have tried it in the past. It simply doesn’t make sense. If you say tenotomy and the examiner says, “Can you justify that?” you’d better be prepared to do so. Examination can be as individualize as the type of suture you prefer to close a wound. But there should be some process that will maximize your performance on test day. Most of you don’t need to be reminded that each candidate has been preparing for years for this exam and this is really the most vital interval. The year or so before the exam should be utilized to solidify what you spent four to seven years learning, not trying to cram in new information. If the credentialing process is valid and I believe that it is then you will have enough knowledge even without studying to pass the exam. The goal should be for you to have the knowledge readily available to give to the examiner. If you want to sense, know everything but can’t reproduce it at the time it is needed, you probably aren’t going to succeed. Many candidates have tried to elaborate grids and methods to try and determine what is vital information to have on hand for the exam yet no one can really tell you exactly what that information is. It’s impossible to figure out and learn everything that might be on the test. Therefore, in my mind, aggressive study programs are not that helpful. It seems more prudent to study the essentials of foot and ankle surgery or at least each component of foot and ankle surgery. Make sure that you know them cold and can provide it on demand. There are numerous books available for the essentials and I believe that they are more valuable than a reference textbook. Many people like to use McGlamry as their study guide for the American Board Examination. Even though that this book is the most comprehensive in its field, it does not stratify the material and the need to know, the nice to know and that of historical interest. The book simply wasn’t written for that purpose. Similarly, I think the text on specific subjects are not that meaningful for preparation. For instance, reading an entire book on dermatology or a book on clubfoot has far too much detail for the purposes of the examination. Focus on the essentials and diagnosis of treatment of clubfoot. What are the options, complications, fast casting philosophies. Fortunately, the board has gotten away from eponyms and discourages their use. Yet knowledge of some of them are necessary because they are so ubiquitous in our field. Some, but not all of them are the Hawkins Classification, the Austin Bunionectomy and the Hoffman panmetatarsal head resection. The best advice I can give to any of you is to rely on recognition.


    Practice with the group of fellow candidates, testing one another and being able to identify fractures, tumor descriptions or other clinical examples. This will be far more valuable than studying from books throughout the year. There are many good board review courses poured on throughout the year. Some of them are good and others are not so good. If nothing else, select those that will give you the opportunity to take some mock oral questions. A good course will give you a post test analysis of how you did, how you could do better and what to work on. They are only as useful as the credentials and experience of the faculty. Remember that the info and advice that they give you is just their opinion and it is no different than listening to my opinion right here now. When the time for the exam actually approaches, make thorough and careful plans to get to Chicago. If you can afford to do so, it would be ideal to plan to arrive early, even an entire day early. As you may or may not be aware, traveling to Chicago even in the summer time can be quite unpredictable. Flight delays due to weather is quite common and it would be very stressful to endure any disruption in your plan. I can recall numerous instances of massive delays trying to get in and out of Chicago. If you’re going to visit Aunt Tillie, that’s one thing. But for something of this level of import, it would be preferable to build in a cushion. Lastly, I would recommend strongly that you stay in the actual hotel that the exam is held on. Some candidates try to stay with friends or relatives to save a little money but it’s really not worth it. You want to synchronize your environment and minimize variables. When I took the exam 20 years ago, I too tried to save some money by staying with my mom who lives about 30 miles from the hotel. Just look what happened, even though I departed in my rental car at ample time at 5:30 in morning, there was a massive traffic problem. Little did I anticipate major road construction at 5:00 a.m. on a Saturday morning. I vividly remembered driving like a mad man running every single red light so that I could be on time. I was literally just 10 seconds early and proceeded to take the exam. The examiner was just about ready to declare me a cancellation as I emerged in the state of dishevelment. Needless to say, I was a bit stressed for my first three questions. The message is stay in the hotel. Reason to travel early to Chicago is the potential time zone differential. This may be more applicable to those candidates that will travel on an easterly direction to get to Chicago but the time differential may play with your biologic clock regardless of where you originate. Again, generally not a big deal but given the increased stress, the differential may be potentiated. You should also try and resume your normal habits to Chicago as much as you can. Minimize the variables and acclimate yourself to the things that you like to do. For me, as long as I have a good coffee in the morning, I could be anywhere. But back then, a coffee in the hotel was abysmal and I doubt that it’s any better now. Don’t act like a hermit and incarcerate yourself from one’s hotel room as it will only increase your anxiety. Now, I realize that many of you may actually prefer to seclude yourself and that is fine if that’s what you like to do. But the message is do what you’d normally do at home in your new environment. It is a common sight around test time to observe many candidates carding their own books trying to stuff an even more information up to the point of no return. This practice cannot be helpful as it is unlikely to be productive study time. Yet it may be a comfort blanket for some. But think carefully before you try to study up to the last minute. Another source of variables is your diet. Stick with food that you know you can tolerate, so as not to upset your physiology. Going on for Chicago pizza if you’ve never have it before should be reserved for after the examination. Although rather obvious, sitting in the conveniently located bar in the hotel just to relieve stress is a dumb idea. You know that it’s very difficult to have just one, so why even test it. Don’t drink in test, it is lethal. Lastly, try and get plenty of sleep so that your brain is functioning in all cylinders. Taking sedatives and other pills if it is not part of your routine just for the sake of falling asleep is risky and can lead to a hangover phenomenon. In the exam, assume your normal habits and try to treat it like any other day. But more importantly, don’t study. Try to relax. You’ll find that the first cut is always the deepest.


    That is, once you get through the first question, you’ll have a revitalized sense of zeal and want to tackle each of the remaining questions. The shell of the unknown has been penetrated and you undoubtedly feel the sense of relief now that you know how it works. One thing to constantly keep in mind that one miserable question does not mean that you failed the exam. I’ve observed candidates with a sense of doom after emerging from a room with a difficult question. Remember that it’s absolutely impossible to predict how a question will fair and you really don’t have any idea what the points to pass were. Sure you may be disappointed with your performance but don’t fret, you may have actually pass that question. Another source of stress occurs amongst other candidates when one compares notes after a block of questions. It can only serve to heighten your angst because your fellow candidates don’t know any better than you do. Keep your thoughts to yourself. If anyone talks about the examiners, is the key to their individual success on the examination, the rumor is that the examiner can influence whether you pass or fail depending on his or her methods and reputation. This is probably one of the more common misconceptions regarding the exam process. Although some examiners may have a specific reputation as a so-called stickler, there is really no basis for that reputation as it relates to the exam. You need to forget about who is across on you and concentrate on the question. Don’t get hang up on the examiner or his or her habits. Believe it or not, each examiner is carefully monitored to read out those who do not perform according to strict standards. The examiners are taught to leave their own personalities at home and avoid interjecting their own biases and feelings into each question. By the same token, don’t try to read the facial expressions or body language of the examiner. As it does not correlate, interact normally and focus on the material. Some examiners may be overly directive and others may be more quiet than you prefer. Yet that is the part you can’t control. The other point is that each examiner is trained and directed to actually help you get through each question and each examiner has his or her own way of doing that. Some talk more than others. If you entered a room with the mentality that the examiner is on your side, you’ll be doing yourself a big favor. If you sensed that you’re heading for doom in the middle of the specific question or you get completely lost, just stop and ask the examiner to refocus you. He or she will know how to get you back on tract. Don’t panic, remember that the points to pass are independent. There is not cascade of failure if you miss one. You can get all of the others. It’s actually rather comment to not know one small component of each question, don’t worry. Lastly, the worst thing you can do in a moment of confusion or drawing a blank is to remain completely mute. Talking out loud is better because many examiners will use that keyword or phrase that you may mumble into a keyword a chance to refocus you. Now, of course, you don’t want to bubble nonsense if you don’t know. But talking out loud is better than silence with all the other things being equal. Finale, after the exam, realize that you did the best you could. Don’t fret about it because you can’t do anything about it. Many candidates take solus by criticizing the examination or the examiners but it is really a meaningless mechanism to cope with the process. The exam is incredibly fair, an ABPS takes extraordinary efforts to be sure that it is fair and administered smoothly. You have to realize that your final grade may not be as dismal as your posttest assessment. Wait until you get your result and then you can reflect back on the process, analyze your performance and use it as an educational experience even if you fail. There are indeed sophisticated analyses conducted by ABPS which are designed to ensure that there are no poor questions or poor question components. Again, this demonstrates the commitment for the fairest exam possible. It is indeed an artificial situation and no one would argue with that. But that is all we have to confer certification and it is practiced widely across all specialties. Lastly, you should congratulate yourself, you finished. Hopefully, the comments that you’ve heard here will enhance your comprehension of the exam process, provide some insight and lastly, instill some confidence. Thanks for listening.