he last 100 years have seen sweeping changes in the relatively young specialty of anesthesiology. In the early years of ASA’s existence, our specialty was under the purview of surgeons and other physicians. Through the hard work and dedication of early pioneers in our field, though, anesthesiology has grown into one of the most respected specialties in all of medicine. And there is perhaps no better way to showcase anesthesiology’s maturation process than by following the growth of its certification process.

In 1931, the American Medical Association did not recognize anesthesiology as a separate specialty and classified anesthesiologists as “surgeons specializing in anesthesia,” preventing them from being recognized by a national examining board. When the New York Society of Anesthetists became the American Society of Anesthetists in 1936, however, it met the requirements of a specialty society that was “national in character and members” and could be considered a section of AMA. So in 1939, the first documented written examination was administered, and anesthesiology’s stature in medicine was to improve steadily through the decades, as was the method by which anesthesiologists were certified.

In 1977, the examination evolved into the same format that continues to be used today — with residents and certification candidates both taking the written examination and only certification candidates sitting for the oral examination. Today, the In-Training Examination continues to serve as a valuable tool to monitor the growth and knowledge of residents and to help anesthesiology educators record the strengths and weaknesses of their students.

Here is a sample of In-Training Examination questions over the years.

1976:

Each of the following drugs owes its pharmacologic actions to receptor site competition with another drug or neurotransmitter EXCEPT:

A. atropine
B. propranolol
C. hexamethonium
D. physostigmine
E. phentolamine

The highest relative humidity is found in which of the following anesthetic breathing systems?

A. circle
B. Ayre’s T piece
C. Ruben valve
D. Fink valve
E. Jackson-Rees modification of Ayre’s “T” piece

Which of the following can be considered simple digital computers?

1. hand calculators
2. Abacuses
3. digital watches
4. turnstile counters

A=1,2,3 B=1,3 C=2,4 D=4 E = All are correct

1994:

Current standards of the American Society of Anesthesiologists for basic intraoperative monitoring during routine general anesthesia include:

1. continuous quantitative assessment of blood oxygenation
2. availability of a means for continuous measurement of body temperature
3. continued evaluation of heart rate and blood pressure at a minimum of every five minutes
4. continuous analysis of end-tidal concentration of inhalational anesthetics

If the low pressure alarm of an anesthesia circuit is broken, which of the following monitors will provide the earliest indication of a disconnected ventilator hose?

A. fail safe system
B. infrared capnography
C. nitrogen analyzer
D. oxygen analyzer
E. pulse oximeter

Which of the following is the most likely cause of increased incidence of right ventricular failure in patients with morbid obesity?

A. chronic hypoxia
B. chronic silent pulmonary
aspiration
C. chronic silent subendocardial
ischemia
D. decreased vital capacity
E. increased pulmonary blood flow

A=1,2,3 B=1,3 C=2,4 D=4 E = All are correct

The following are testimonials given from anesthesiologists from various years about how they prepared for the examination, what the examination means to them and how it impacted their careers.

Richard J. Kitz, M.D., Henry Isaiah Dorr Distinguished Professor of Anaesthesia, Harvard Medical School: 1962.

I read every issue of Anesthesiology and outlined those articles that seemed most important. Then I framed questions that I thought I might be asked by ABA examiners concerning the content. I also perused many volumes of Anesthesia & Analgesia as well as the British Journal of Anaesthesia but not with the same intensity. I had been a resident and then was on the faculty at Columbia Presbyterian so I had routinely participated in many weekly clinical case conferences and formal lectures, which were excellent preparation. I also read again several books, including Introduction to Anesthesia and A Practice of Anaesthesia, among others.

---

Robert K. Stoelting, M.D., President, Anesthesia Patient Safety Foundation: 1969.

I doubt if there is a truly unique strategy for preparing for the written and oral examinations for board certification.  For as long as I can remember, my preparation for examinations has been similar.  Read as much relevant material as possible, highlight and critique the highlights until a summary of information is distilled into a few pages of notes.  These notes then serve as the review process in the days immediately before the examination.  An unrelated habit that I have always followed is never wait until the last minute to begin preparation (for the written and oral board examinations, it was a culmination of reading, note gathering and clinical experience that spanned the entire residency) and always be well rested (“early to bed”) prior to the examination.

---

James M. Riopelle, M.D., Staff Anesthesiologist, Charity Hospital of New Orleans: 1983.

We had a great program (Mohammod Naraghi, M.D.), and the chairman cross-examined us all the time.  It was enough preparation for the boards.

---

David B. Glick, M.D., Assistant Professor, Anesthesia and Critical Care, University of Chicago: 2004.

Preparing for the ABA certification exams (or How I Learned to Love the Bomb).

My impression of the ABA certification process is that the written exam is intended to test the applicant’s knowledge of the field of anesthesia in a reasonably comprehensive fashion. The oral examination, on the other hand, is supposed to test applicants’ ability to apply that knowledge as well as their ability to communicate their understanding of the field to others in a manner appropriate to a consultant in the field. As such, I tailored my studies for each of the exams to these separate goals.

My preparation in the year leading up to the written exam included a review of the basic textbook of anesthesia that I had read through in my CA-1 and CA-2 years and the taking of notes on each of the chapters. These notes (which filled about 70 handwritten pages) were reviewed several times in succeeding months. I then read through one of the commercially available review texts, taking notes in the margins as I read. During this time, I also worked my way through a book of board-style questions, reading the accompanying answers carefully and noting concepts or connections I had previously been unaware of. In the final month before the exam, I reread the review text with special attention to the sections I had highlighted and my notes along the margin. During the week before the exam I reviewed my notes from the textbook one final time and reread my notes in the margins of the review text.

My preparation for the oral exam was quite different. I found the review texts that emphasized content to add little to what I had already prepared for my written exam. On the other hand, the practice “exams” (some only 10 or 15 minutes long) that the more senior members of our faculty were willing to take me through made me much more confident heading into the exam. I used every opportunity with residents, fellow faculty or even unsuspecting family members to offer organized and complete answers to questions about the scientific bases and clinical concerns of anesthesia.

Finally (I am certain to the satisfaction of all my friends, colleagues and residents), I spent the final week before the exam working through sample oral exams on my own, practicing how to organize my answers and to speak at a comfortable pace. I was so revved up from the 50 or more practice exams that by the time the oral exam came, I was genuinely excited to have someone to finally listen to my answers.

---

Jill E. Beland, M.D., Pediatric Anesthesiology Fellow, University of North Carolina Hospital: (Takes test in Fall 2005)

To prepare for the written board exam I used 1) “Big Blue” — Essentials for the Anesthesiology Written Board Examination, written by Jensen, 2) Anesthesia, a Comprehensive Review by Hall and Chantigian and 3) Anesthesiology PreTest Self-Assessment and Review by Curry. I also attended a board review course. Finally I researched all of the keywords I had missed from the anesthesiology in-service from the past year. My serious studying began five months prior to the boards, and it was worth every minute when I got my passing score!

I am scheduled to take the oral exam this September. I am using 1) “Big Red” by Jensen and 2) Board Stiff Too: Preparing for the Anesthesia Orals, by Gallagher, Hill and Lubarsky. I am scheduled to attend an oral board review prep course this fall.

---

Mack A. Thomas, M.D., Clinical Professor of Anesthesiology and Surgery, Louisiana State University Health Sciences Center: 1979.

I actually had very little time to prepare as I was in a busy practice. I basically read Miller’s textbook. The oral exam is the most stressful for most folks. I frequently have practitioners who ask for some direction and will sit with them and give a “mock” oral and give some direction as how to plan to respond during the oral. My advice, for what it is worth, is as follows: Evaluate the patient’s medical problems especially from the reserve point of view, then what will be the impact of the proposed surgical procedure; is there any need for any specialized monitoring other than the standard ones, i.e., invasive monitor as arterial line, central vascular access? Then, based on the preceding info, decide the type of anesthesia that is the best fit for the patient.

---

Rebecca H. Welch, M.D., Staff Anesthesiologist, Nemour’s Children’s Clinic, Orlando, Florida: 1991.

Anesthesiology has both written and oral boards. Written boards take place soon after finishing residency. I saved some money during my residency, so I had the luxury of taking off a month or so between residency and the board examination. Of course, like most residents, I also had to move to a new city and settle into a new home during this time period. I quickly developed a routine of rising and getting myself ready in the morning. Then I would sit down with my books and papers for study until lunch time.

I had organized myself to cover all the major topics in the time I had off. I’d spend some time unpacking and organizing in the afternoon, and then back to the books.

There are also several books that you can buy with helpful study suggestions, sample questions and concise reviews of anesthetic topics. It was fun to spend some time with some of these books for another perspective.

The oral examination is challenging because you have to have good verbal skills as well as knowledge. Several months before the exam, I reviewed the various topics in anesthesiology as before but with a more case-oriented approach. For this exam, I enrolled in a course that simulated the oral exam and then gave feedback on ways to improve. I also spent time studying and quizzing with others who would also be taking the exam.

---

Kraig S. Delanzac, M.D., Founding Partner, Anesthesiology and Perioperative Medical Consultants, L.L.C., and Attending Anesthesiologist, Slidell Memorial Hospital, Slidell, Louisiana: 1998.

I completed my residency in 1997 and sat for my written boards in July 1997. For the written boards, I did not take a review course but instead based most of my study preparation on the reading I had done throughout my residency. I valued the ASA in-service examinations and fine-tuned my reading based on the keywords I received from the examinations. In the months leading up to the written examination, I continued reviewing and re-reading smaller texts such as Basics of Anesthesia by Stoelting and Miller and Anesthesia and Co-Existing Disease by Stoelting and Dierdorf. I successfully completed my written board examination on the first attempt.

In April 1998, I sat for my ABA oral examination in Atlanta, Georgia. I felt lucky to have only a very short period between my written board date and my oral examination. I continued to build on my written board preparation. Although I was never a fan of review courses, I was advised that an oral board review course would be very helpful. I purchased an oral board prep course and began reading and re-reading the written information known as “Big Red.” I supplemented this information with standard anesthesiology textbooks. I also scheduled two oral board review courses, one very early to assess my progress and the second the weekend prior to the board to focus in on the information. The outlining and presentation skills I learned in the course were not only useful for organization, but the courses did wonders for my confidence level. I passed my oral examination on the first attempt and became ABA Board Certified in Anesthesiology in April 1998.

---

James F. Weller, M.D., Staff Anesthesiologist, Bethesda North Hospital, Cincinnati, Ohio: 2003.

We had relatively formal oral exam practice sessions twice yearly throughout my residency at Hopkins. During my faculty year, I had the opportunity to function as the “junior board examiner” during practice sessions for the residents. I found these to be immensely helpful. The universal wisdom, to which I would attest, is that you MUST practice OUT LOUD!

One of our senior faculty (Myron Yaster, M.D.) organized a weekly board review session on Sunday mornings. The CA-3s and fellows actively preparing for the exam would meet at Myron’s house on Sunday mornings for about eight weeks prior to the exam. He paired us up with a partner to practice with during the week. Once out in private practice, I re-read Stoelting’s Anesthesia and Co-Existing Disease text. I also used Board Stiff.

Despite these areas of formal study, I think the most valuable preparation came from my daily interactions with faculty mentors during my residency. I learned with time to rationalize why I would approach a given scenario in a given fashion and to defend my choices on the basis of evidence whenever possible. When it came time to sit for the actual exam, I was able just to put myself into the situation and tell the examiners what I would honestly do.

---

Ronald D. Miller, M.D., Professor and Chair, University of California-San Francisco, Department of Anesthesia and Perioperative Care: 1970.

We finished our residency in 1968, at which time the written boards were conducted.  Soon thereafter I was sent to Vietnam for one year by the U.S. Navy as an anesthesiologist to take care of Marines and associated casualties.  My available tools were written material (i.e., review materials, journal articles and one text).

I then devised a method to prepare for the oral boards.  After reading a section, I would devise questions (i.e., usually the subtitle was turned into a question).  I then recorded my verbal answer and analyzed its content.  When listening to my verbal answers, I was uniformly discouraged as to how diffuse and unorganized my answers appeared to be.  I then would repeat these answers until being satisfied that they were concise and well organized.  I believed an ongoing commitment was better than trying to “cram” for the oral boards.  As a result, I scheduled approximately eight hours or more per week, every week, for one year in Vietnam.  I gradually covered the entire spectrum of anesthesia.

When I compared my early first answers with the more recent ones, it was very clear that my answers gradually evolved into being precise and well organized.  I credit this process with not only facilitating my being prepared for the oral boards but also facilitating my communication skills for clinical and academic anesthesia and eventually my chairmanship.