Douglas R. Bacon, M.D., Editor

A Message From Baltimore

Taking the oral examination in the American Board of Anesthesiology (ABA) certifying process is one of the most universal of experiences for anesthesiologists; few physicians leave the oral examinations without a story to tell. As the lines of this editorial are written, I have just returned from a week in Baltimore, Maryland, and the ABA oral examinations. For a junior examiner, the week is grueling and filled with highs and lows that, as a candidate, cannot be imagined. For many of us, it is a week of vacation time spent in service to our specialty. For me personally, it is the one professional activity that I feel has the greatest impact on the future of anesthesiology. By acting as an examiner, I am part of the process that continues to define the specialty within American medicine.

There are many misconceptions about the oral examinations. The first, and perhaps most widespread, is that the examinations are unfair. I disagree on several levels. As one who helps write ABA questions, including oral examinations, I can attest that stem questions and selected topics are taken from daily experience in the operating rooms, critical care units and pain clinics. Several cases may be combined so that there is sufficient material about which to examine a candidate. There is a strict effort to ensure that questions are neither too hard nor too easy or that the areas of questioning do not stray too far from the case.

It has been claimed that the examination is used to weed out international graduates from becoming certified by ABA. Nothing could be further from the truth. Great effort is expended so that all candidates are given a fair examination. Examiners are audited at random by ABA directors to ensure that the examination given is objective and just. Grades are scrutinized for fairness, and grades are weighed by the examiner’s history of being a “hard” or “easy” marker. On an individual level, each examiner with whom I have worked made a great effort to be sure that any language difficulty did not get in the way of the examination or the final grade. For those with documented speech impediments or other problems, special examinations were arranged to allow the candidate more time. Simply put, the candidates sink or swim on the merit of their answers, not where they received their training or the place of their birth. In point of fact, the examiners have no idea where the candidate trained, and every effort is made before the examination to ensure that examiners and candidates do not know each other.

The larger question of whether there should even be an oral examination continues to surface. As a candidate, I was sure that there was no good reason for it. Yet in the years between becoming a diplomate of the board and an examiner, the wisdom of the examination became more apparent. As anesthesiologists the one thing we need to do, perhaps more than any other specialty, is to consult with a wide variety of physicians, operating room personnel, nurse anesthetists, nurses, respiratory therapists and many others. As a bridge between the internist and the surgeon, we often have a foot in both camps, understanding the need for surgery yet also the need for further medical evaluation. In the fine art of negotiation, which is needed often in an anesthesiology practice, a knowledgeable anesthesiologist must describe the encountered problems and back up his or her plan with sound principles grounded in a firm scientific foundation. In essence this is what the oral examination is about. It is not about one giving a particular drug or utilizing a specific technique, but rather why this drug or technique is better based upon all the available evidence. When the clinical condition changes, the candidate needs to be able to adapt to the new circumstances and decide if a change in technique, agent or something else is warranted. These principles are at the core of the examination, which mirrors everyday practice.

The process itself is somewhat artificial. There is no operating room, no ranting surgeon and no scheduling person pushing to keep room utilization up. The intraoperative and postoperative portions lack a real patient and setting, yet the intensity of the examination transcends location. The answers given also may not represent what would happen in the “real world.” When ABA was founded in 1938, certification consisted of three parts: a written essay, orals and the practical examination. For the third examination, the candidate paid the travel expenses of the examiner to observe the manner in which he or she practiced! It was one way, however, to see how anesthesiologists practiced in their “normal environment.”

In the end, why bother to spend a week of vacation away from home and family in a hotel room asking questions? Why support an oral examination when many other specialty boards have moved away from the format? I examine because I believe that it is important for the specialty of anesthesiology. We, as anesthesiologists, need to be able to present ourselves as rational physicians and not just “keepers of the potassium gate,” as Sherwin Nuland, M.D., described anesthesiologists at the beginning of his Lewis H. Wright Memorial Lecture at the ASA 1999 Annual Meeting in Dallas, Texas. In an age of rapid results and computer-based testing, what happens in the oral examinations may count for more in our specialty than all the articles ever written. It is up to the judgment of anesthesiologists, in a very fair, structured format, as to whether the candidate is ready to be a board-certified specialist. It is our future, and I have a role, however minor, in determining what that future will be like.

After a week in Baltimore, between standing at Fort McHenry, seeing the birthplace of the national anthem and sitting in a hotel room asking questions of bright, energetic, young physicians, I am convinced that the future of my specialty, anesthesiology, is as strong as the flag that waved over the fort almost 200 years ago, which remains an inspiration to me.

Editor’s Note: The opinions expressed here are those of the editor and do not represent the American Board of Anesthesiology.

— D.R.B.

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