THE ITE: It’s that time of the year...

Amanda Xi, MD | PGY-4

For many anesthesia residents, this time of year can mean many positive things: joy in time spent with family and friends, a moment to relax and recharge away from the hospital, or a sense of accomplishment over the challenges you scaled during the first half of the academic year and looking forward to making 2019 even better. However, for many interns and CA1s, the upcoming in-training exam (ITE) may put a damper on the season. Just when the clinical portion of being a resident seems manageable, they throw yet another multiple-choice exam at you. And while it seemed like there was never enough time to study as a medical student, many of us quickly realize that residency adds another layer of complexity in finding time to be a good clinician, read textbooks and relevant articles, all while having a life outside of the hospital. Luckily, the ITE (and the BASIC) are very manageable exams.  I was not required to take the ITE as an intern, however when I started CA1 year, I had a number of basic questions about the exam. Let’s start with the basics:

What is the ITE?

The ABA [American Board of Anesthesiology] defines it as:

"The ITE is a computer-based exam with 200 multiple choice questions that is administered each year to all physicians enrolled in anesthesiology residency training programs. Residency programs administer the four-hour exam at their sites. Please contact your program for more details on the next administration.”

The exam is typically administered in February. You get up to 4 hours to complete 200 questions. The breakdown of questions by subject matter can be found on the ITE Blueprint document. Your department arranges for the testing site - unlike the BASIC, which is through a Prometric center. Another helpful document is the Knowledge Gaps Report which has compiled the 2016, 2017 and 2018 topics that many residents answered incorrectly.

Scoring is scaled up to 50. Along with your score report, you will receive a percentile table which gives you your percentile for level of training.

Does my performance on the ITE even matter?

This depends on what you mean by "matter." If you do poorly on the ITE, it may be a reflection of your performance on the written boards in the future. I've heard a lot of talk about fellowships using the ITE as a standardization scale to compare applicants. Ultimately though, it should matter to you since it's an assessment of your knowledge that can help target your studying as you progress through residency. If you direct all of your energy toward studying for this exam and do poorly, you have a chance to recognize that what you were doing wasn't working. It also allows Program Directors to identify residents that may need a little more encouragement to read or resources to review.

How am I really going to balance work and studying?

I remember feeling overwhelmed during medical school with balancing coursework and studying for the Step exams, shelf exams, and OSCEs. Now that I've finished three years of residency, I can say that it has been much harder to find time to keep up with studying as a resident. Perhaps you're in a program that only works 40-50 hours; in that case, it shouldn't be too hard to find time to crack open a book or peruse the latest issue of Anesthesiology. As your hours approach 80, the amount of energy you have to think about doing review questions or opening an intimidating textbook... is minimal.

So, here are a couple of my thoughts on the matter:

• Reach out to senior residents in your program for tips; ultimately, most anesthesia residents end up using the same few resources (see later section on specific resources and my thoughts on them), but the question you have to ask yourself is whether you study in a similar manner to the seniors you're asking. If you learn by reading textbooks, ask which ones to pick up. If you learn through didactics, ask which lectures are the best to attend and which ones you will have to seek alternate resources on. If you learn by question banks, determine the best order for you to purchase and complete them.
• Hours worked varies substantially between residency programs, but there will always be rotations that are lighter on hours. Ask your colleagues which ones those are and use that time wisely. Consider creating a study schedule for easy months to give yourself concrete reading and review question goals [e.g. finish 1 chapter of M&M daily, finish corresponding Hall questions].
• A lot of learning can be done through clinical work; make sure to take advantage of your attendings to ask questions about why they do a particular practice and if there is any data to support it. During long cases, you can look up papers or textbook chapters related to the procedure or pathology you are caring for.
• If you had a rough call or day in the OR and don't get studying in, don't perseverate on it. Move on, recognize that the best laid plans often go awry and tomorrow is a new day.

What resources are out there?

There seem to be a million different Anesthesia board review, question banks, online sites and prep courses available. Not all resources are created equally, and most of them come at a cost. If you’d like to see a very long list of resources, please visit my original blog entry on this subject.

The most popular resources to prepare are as follows:

Online

OpenAnesthesia: A classic online resource with a question of the day and what you really need to know on keywords.

Review Books:

The Classics: Baby Miller and M&M. Take your side on which style you like better, but these are the first and foremost textbooks to read through during the course of your residency. If you’ve been able to read through most of at least one of these books, you’re off to a good start! Make sure to use this alongside some sort of question bank to test what knowledge has really stuck.

Anesthesia: A Comprehensive Review: (also known as Hall’s) This is still a relevant question book, though some of the questions may feel a bit outdated. Many of my colleagues that reported finishing this resource did very well on their ITE and subsequent board exams. I personally struggled to get through the book; perhaps I would’ve done better with the app version.

TrueLearn: If you ask most anesthesiology residents today, they’d be familiar with, or are currently using TrueLearn to review for the ITE/BASIC/ADVANCED. It’s the closest thing to UWorld for anesthesiology exams. The question bank can be pretty pricey, but if your institution is willing to purchase it on behalf of the residents, there is a huge discount.

ACCRaC: I think most people are familiar with ACCRaC now, but it’s an awesome podcast. Play it during your commute or while cleaning the house and absorb some important anesthesia concepts! Most of the earlier episodes are a great basic review of topics that often appear on board exams (though, like many resources, there are a few errors in the earlier ones).

In conclusion - you’ve made it this far, so I have no doubt that you’ll continue to progress. Even if your first ITE performance is below your goal, see it as an opportunity to improve. Hopefully this was a helpful guide! For the original blog post this article was based on, visit my blog at blog.amandaxi.com. And feel free to email me at [email protected] with any questions. Good luck!

Pictured above from the ASA mtg in San Francisco: Amanda Xi, MD; Ammu Thampi, Susheela, MD; Brian Alexander, MD; Priyanka Ghosh, MD; Steven Young, MD; Jimin Kim, MD; Richard Gao, MD; Katelyn Devine, MD; Arun Karuppiah, MD; Jason Kung, MD