Enhance Your Practice Podcast
ASPS Enhance Your Practice Podcast series serves as an educational appetizer for Plastic Surgeons and Office Professionals looking for practice management information on-the-go. It covers next steps early in a career; financial planning; staffing; med spas; starting a private practice; and much more.
Enhance Your Practice Podcast
EP 81: IRF Edition: Board Exams in Plastic Surgery: Clinical Prep Strategies
Join us for this International Residents Forum Edition of EYP! From practical skills to theory, board exams test it all. Learn how residents prepare for clinical components, with tips, resources, and experiences from those who’ve been there.
Host: Armin Edalatpour, MD
Guest: Robert X Murphy, Jr., MD
Hello, and welcome to the ASPS International Residence Forum podcast. On today's episode, we'll be talking about board exams in plastic surgery and clinical prep strategies. This topic is a big stressor usually for residents as they start to finish their residency and get ready to start a practice and be able to get their board certification, especially for being able to get accredited hospitals and start working. So I think this would be a good episode today to kind of get some more information and get some tips out there for the residents that are getting ready to take their boards. So on today's episode, we're lucky to be joined by Dr. Murphy to talk about the board exam strategies. I'll turn the mic over to Dr. Murphy to introduce himself.
SPEAKER_00:Thanks so much there, Armin. Yeah, good morning all. My legacy is through having spent a career at uh Lehigh Valley Health Network in uh in Pennsylvania. Um I've uh in my life, in my couple decades of work, I've been a uh a program director for or assistant director for the entirety of my career. Um I've had the ability to to get out and about in the world to to talk about education, to uh to see how different areas and regions educate their uh their trainees during my time as the uh president of the American Society of Plastic Surgeons and uh President of the International Confederation of Plastic Surgeons. So um so it's always been a uh an area of uh great interest to me. It's uh been an area where I've seen a lot of evolution over the last couple decades. Um and uh and it's something that uh we owe ourselves as a profession to make sure that you know that we train the train folks in the way that prepares them best to be great uh great physicians and great uh plastic surgeons because after all it's our ultimate duty to make sure that the patients that we care for um receive the best quality care we can. So an incredibly important topic, and I'm very honored to be the one to be able to speak to that today with you, Armin.
SPEAKER_01:Awesome. Well, welcome. Uh we'll jump right into it. So um, can you talk a little bit about the board um plastic surgery board uh process um in the US and the components of it, and then if the if you know any differences between what we have in the US and what other um residents do around the world um at different countries?
SPEAKER_00:Sure. Um well I mean the the board process in the US, the board exam process in the US is uh has evolved um as well as it has in the rest of the world. So uh but the basic format has remained the same uh over the last uh last many many years. The basic format being uh in preparation for the boards. Uh every year during your training, there's uh there's an in-service exam which which ensures that you're getting the basic uh knowledge uh about anatomy, physiology, um, uh technical components of the of the uh of the practice of plastic surgery to make sure you have the knowledge base to be a competent plastic surgeon. And competent is different than proficient. After you, after this kind of preliminary stage, as you get to the latter part of your training in senior residency years, um, you then come to the point where uh there's a written board examination, which is kind of the culmination of all the information that you've had to garner over the six years of training, uh, and that you've been tested on uh during those uh years of training through the in-service process. And then finally, uh there's an oral board examination, which uh in the U.S. assumes that if you've passed the written examination, that your knowledge base uh is uh sufficient and that in the oral boards the focus is uh are you a an ethical and um and competent plastic surgeon uh in how you practice uh uh the profession, because the oral boards is given after you've uh you've been out in in your practice, out of training for for a little while. So it's uh even though the board process itself is uh kind of uh two-phased, uh two-phased uh process. Uh when I'm talking to my residents, I talk about it as being you know basically uh six years of training and uh and a couple years being out. So it's it's not quite a decade's worth of uh of intellectual uh commitment, but uh but it is uh it is something that that counts on your growth both as uh both from a pure didactic and knowledge base, but also your maturation uh over the course of years as a as a practicing surgeon.
SPEAKER_01:No, that's great. I I um I agree with that. Um and kind of off of what you just mentioned, is there, do you think, uh one component of the board exam, whether it was the written or the oral, that you find candidates tend to underestimate and maybe not prepare well enough for, especially if we're talking about international students who are coming um from outside of the US and not really familiar with um the board process?
SPEAKER_00:Yeah, that's that's a good question. Um, you know, because I think that you know, obviously being an American educated and American-trained educator, um, you know, I think from the one side we can see that um um the you know the the competence that we all take for granted is you know the people going to medical school are the ones who've been able to buckle down and and be very high achievers during their undergraduate years. Uh the folks in medical school to get through have to go through very rigorous, you know, rigorous, strenuous, scientific, uh focused uh academic curriculum. Uh and then you know the in-service, uh the in-service focuses on those those factual uh type of learnings that are important for our specialty. So we we kind of take that for granted, and you know, happily um there's enough material that's out there, either in the form of you know, direction from your program directors, uh from being able to resource old in-service examinations and by able to uh to resource the uh ASPS ednet resources. Um I don't think people take that part of the examination process for granted per se, um, because it's it's kind of what we've been used to from the time you were in high school to you know the the time you finished your training. I think what people maybe underestimate a little bit is is the fact that the you know the the clinical-based um examination, the oral boards, is is not just about knowing what nerves come through the optic foramen or what innervates uh certain muscles uh or what the vascular types of certain flaps are, um but that there's there's a practice and uh there's a practice and a uh an approach to a patient that goes into how one performs an operation and takes care of a patient. Um and so it's it's the whole milieu of what it means to be a practicing uh ethical and competent plastic surgeon independently, um that uh that's hard to really feel comfortable with going into the uh the oral examination because it's the first time you've been asked to take an examination. It's not based on based completely on fact, um, but wherein facts are assumed, competence and facts are assumed, but really wants to try to look at the individual and how the thought processes go, um how they handle would handle stress if something were to be not quite the way they um they had proposed uh and the like. So it's it's it's being comfortable in in your approach to uh to layered and complex thinking as opposed to a simple question and answer approach.
SPEAKER_01:No, that that's uh great. And um I I think uh you have um brought up a few good points. Um and one thing that I keep hearing you saying is you know, being an ethical and um competent uh plastic surgeon. And me myself, I'm in the last year of my training and getting kind of uh starting to prepare for boards and both written and oral. And I I do hear this a lot as well, especially, you know, uh as my mentors tell me, is one of the reasons that residents don't pass or the candidates don't pass the board exam, is um on ethical cases, or they're they did something that wasn't ethical, or the answer that was given. So can you talk a little bit more about that? How how do you think candidates should prepare prepare for these ethical or professionalism scenarios during um like their case prep uh period um to get ready for these oral boards?
SPEAKER_00:Well, I if if I if you'd allow me, Armin, I'd I'd like to kind of rephrase the question in a way because I don't think someone someone should prep to be ethical, right? And I'm I'm sure that's I'm sure you'd agree on that. I think absolutely I think what somebody has to prepare in is um if we talk about how the American boards are given, right? So the American boards are are there are some known cases, uh, and then there are your cases. So uh so in the known cases, the board examiners will sit down in a room and will show you pictures and say, okay, what's you know what's your diag and you would have to then you would then have to to to go through a series of uh thought processes and be able to impart to the examiners that one you understand the diagnosis, uh two, um you uh you think this is the problem with it, three, this is the surgery that I would go through to fix that, four, this is what I do during the post-operative phase. So it that's the one point. What differentiates uh the higher level that you refer to is um you also have cases that are taken from your own practice. Uh and this is where things has this is where things um go a little arrive sometimes, in that one, um sometimes cases that are selected are cases that are complications, things that did not go right. Um and that's not, you know, I think there's a defensiveness that we all have when we're taking exams and in front of, you know, mentors or in front of people who are are highly placed or wrote the textbooks. Um, there's a defensiveness and a wanting to defend. Um and really what we're what we're looking for as examiners when we're going down the cases of complications isn't necessarily justification. It's more to understand how you handled that, um, what your thought process was and then how you proceeded um to take care of the patient. Um, you know, one thing would be, one red flag would be is if someone had a couple of complications and the solution to every complication was they would refer to a colleague. Um that kind of would have an examiner say, well, you know, why, you know, why would you do that? If it's the of course, if it's a highly complicated reason, that would be the best thing to do. But but um you know, what's your what's your criteria, what's your threshold for wanting to to hand off a patient that you know is your responsibility. There's good reasons, by all means, if someone's far more complicated, far more competent in a complicated situation, by all means that's the best thing to do. But just what are your thought processes there? The other thing, and I think that this is where you did, you know, you referred to the ethical, is that um plastic surgery, you know, in its most globally global terms, is a is a market a market sensitivity Googling uh terminology that that applies to us, of course, as as the 8,000 board certified plastic surgeons of the ASPS and the other 4,000 or 4,500 international members of ASPS, and then the other board certified in their own countries, uh plastic surgeons globally. Um but it's a you know, board certification is is a reflection on a lot of things. And that's a it's a very competitive world within our own specialty. Then add in the other specialties who participate in cosmetic or plastic surgery, and market pressures are very, very significant at times. And what um you know and and and people entering practice or and certainly as people evolve their practice, you know, these market pressures are are you are uh a source of significant concern uh how you enter into a market as being someone who whose skill and professionalism is taken seriously and and is attractive to people seeking that type of service. So there's you know, there's you know, the the want to be recognized as a board certified plastic surgeon and the use of certain terms like board eligible, for example, and advertis advertisements um not really endorsed by by uh the American Board of Plastic Surgery. Um how you structure some of your uh advertisements uh also might call into question um uh you know how you're approaching this as a as a professional as a professional who provides a a high-level service or as a technician who is merely interested in in generating patient throughput. Um and then of course you know the ethics of of how you how you um not necessarily what you bill, but what billing practices are, or in addition to advertisements, uh billing practices, or how you do handle your complications. So those are the things where it really gives the examiner an ability to have some insight, not just what your technical competence is, but what type of person you you are uh and do you represent the profession and the specialty well, and do you uh you know, do you do what is ultimately in the best interest of uh of your patients, which is, you know, you know, where there's the Hippocratic oath, the oath of Maimonides, um, you know, is the principle by by which we we enter medicine, take an oath, and then are charged with being a very privileged small set of the population who's entitled to do very invasive and dangerous things on our our fellow citizenry. So um, you know, the the the cautious, um, the ethical, the thoughtful uh approach is is really what um the second part and of the oral examination is all about.
SPEAKER_01:Well that makes sense. And uh yeah, I appreciate you re rephrasing the the question and and kind of what everything you said is is very important. Um so I'm gonna shift our focus to board prep. Um so are there any strategies you've seen from your the residents you've trained or you know, recent uh board uh uh certified plastic surgeons that have recently just put past the boards of um tools or um resources they've used. I know you know for me I've been told there are mock oral exams um often offered by you know regional um societies that you know I can participate in. I've heard you know creating a group of three, four different residents and practicing together. I know there are several courses available that that people can take. So I guess have you heard one is better than the other or any tips um of how to prepare for these?
SPEAKER_00:Well, you know, the thing uh the thing that um I always recommend to the residents that I've trained over the years, Armin, is is not to look at the boards as a two-day event as two days in your career and kind of uh approach that in an all-in, but as just all in as much as we're going to do you know very intense studying or preparation around those two days, you know, it's it's part um part in garnering the knowledge over time. So you reference a lot of very, very um good, good um resources. So I know the one that um the one that we've used uh to great advantage uh in ours. Has been the following. I mean, first, you know, when we give our didactic lectures over the course of the six years, one of the things we like to do is at the end of the lectures is highlight potential by having one of the faculty moderators or one of the more senior residents moderating the session to actually select a couple questions, either from old board exam, old um in-service exams or or from the ASPS uh ednet. And uh at the end of the at the end of the lectures, you know, put out some of those questions so people can start thinking of what uh you know what the important topics might be with contained within any um with any lecture that that we have. Um and then of course, you know, as as anyone who's been in training for any amount of time, you know, when you're when you're sitting across the table doing a case with the attending, the the the over-the-patient discussion of what you're doing, you know, and and and memorializing that at the end of a case, you know, what was come, you know, you come out and you sit down with the attending, or if not the attending, you sit down by yourself and say, well, what were the what were the two things in this case that I came away with that were different than what I thought was going to happen or different than I planned, or was unique about the case. So I usually like to to to take away after any interaction something that made that specially, especially you know, worthwhile or different from from what you'd seen or heard about or prepped for before. So that's that's the you know the base of that. And then of course you prep for the in-services. And as you get to your senior year when you're taking the writtens, it's uh what uh what our folks do is internally um they do um as just as you say, they have they have sessions where they'll they'll get together and they'll go through for a half an hour, you know, or an hour old in-service exams uh and take sections of old service exams. And just the the mind and muscle memory of taking exams on plastic surgery, just that seems to improve people's um my you know, my trainees' comfort level uh with the exam itself. Uh and then also they come away with um you know uh uh additional knowledge base to take those exams well. Um with regard to how to prep for the the oral exam, um this is one this is one that um I I I think is a very important thing to do is just like I said at the end of a case to take down you know the one or two things that made a difference. The the other thing is when you're prepping for a case, you shouldn't just be prepping for, okay, I'm gonna have to dissect around the hypoglossal nerve uh and I'm gonna use 10-o nylon to do this uh microvascular anastomosis. But the other thing I like to do when I'm over over a patient or or after a case is um when I'm discussing with things is okay, what if? I like to play what if or whys, and I like to ask three questions on what if or three whys. What if this wasn't as you thought about it, or what if this went wrong? Because what I like to tell the the folks I teach is it's not going into a case and knowing what to do when things are great. It's going into a case and being prepared for what to do if something goes wrong. Um so that there's no panic and you're prepped for it, and you know, and everybody around you is prepped for it. So um so I think that's a helpful technique as you're doing your cases during training to say, well, if this goes wrong, if this happens, what am I going to do? You know, and that preps you for your how to think about cases going into the oral exam. That's gonna be how the examiners are going to approach the questions and the cases that they present to you. And then I do think that uh I I did find personally myself and most of my trainees have found that uh that the one uh one of the oral board prep courses is often helpful just for that, to teach you how to organize your thoughts, how to organize your books. Um not that you couldn't do it by yourself, but there's often a comfort level in knowing that there's there's a uh a template, not a template, but a manner of approaching both the preparation for the exam and the uh preparation for the um uh for how to put together your books, um your case books that's uh that many people find helpful. And and again, uh you refer most people to the uh ASPS ednet or the old board prep course that uh that's given at the uh I th I believe it's in August.
SPEAKER_01:Yes. The uh the dreaded uh case logs and uh the books. So can we talk about that for a sec? I know this is probably a much broader topic than for this podcast, but um I is there any strategies that you suggest um to effectively organize them? I know again, people dread making these. There's pictures you have to take, there is documentation that you have to put together. Um, and I know again talking about how to do this is as a broad topic, but just maybe a few tips of how to effectively organize it if you have or know of any ways of doing that.
SPEAKER_00:Yeah, I I think that's a great question. And um and uh happily uh plastic surgeons and the mindset of most plastic surgeons is we are kind of OCD and we're kind of meticulous to begin with. So that's a help. But what I what I've seen by being by being helping my residents, but by being an examiner over the course of the years is um the best thing to do is not is not to delegate. Um the best thing to do is to is to be that compulsive individual um so that you know so that you you've you routinize for the time that you're that you're out in practice and you know you're the 18 months of uh accumulation um uh of cases you're gonna be going through there, that that you um that you routinize that you do get pictures of everybody. You routinize the fact that um it's probably best to do your dictations, um, particularly since you're starting out right when you're done with the case, so that you can dictate with the with the a clear recall of what happened. Um it's also one of the things that gets into the the billing or ethical. There's never a billing question on what you charge, there's always a billing question if the wrong code is used or something like that. And and the excuse is, well, my office manager does my billing for me is not acceptable. So so to own the relationships and own the case preps and and do the dictations right away, and and even if your office manager manager does the coding, to check the codes, um, you know, to assure the fact that that how how things go out represent the way that you would have them um you know be submitted to an insurance company. Um and then you know the the the uh uh you know the actual format of the case is pretty prescripted by the you know the board. So it's it's not how you put them together, it's how you stay uh abreast of fulfilling all the requirements, and then that you know that when you go and make the record requests you're you're you know you're comfortable with the fact that most of the things are going to be there and you're not gonna have to try to trace something down or something's not absent. Um so that you own the case from start to finish. Um and you know, in some ways electronic medical records are are the bane of people's existence, but in some ways they because if they're too if they're too cursory, if they're too formatted and they don't give some color give you the opportunity to some color or detail around the dick the dictation, it's it it's has its own issues. But if you build out templates in such a way that you do have the ability to be descriptive and you make sure you're covering all your bases, uh then that's uh that can be helpful and make um makes things more systematized. So the more you can build your your system from your first patient interaction to to your discharge of your patient uh so that it just becomes muscle memory and computer memory, um the less pressure you'll have to make up for the fact that there may be missing components of a case that the board might find might be requesting and would be important for you to have all the all the information at fingertips.
SPEAKER_01:No, those those are really good tips, and and I've heard actually mostly exactly the things that you've mentioned, and the biggest thing I keep hearing is the billing part, especially like if you work at a huge hospital system and you have a team of billers that you know you've never met before and they're just working behind the scenes to bill these cases, it's becomes very important to go back and make sure you review all of that, you approve them appropriately and you know what's being built. So um appreciate that. Um, so as kind of we're getting towards the end, I wanted to move away from all the clinical stuff. Um, I know we've been talking about the red board and the oral boards. Do you have any um tips or what do you think any what non-clinical skills can play a significant role in helping people pass the oral boards? Anything any anything that people can work on or kind of be on the back of their mind as they're going through this process?
SPEAKER_00:Yeah, I think uh again, part of my part of my academic slash institutional pedigree is is is analytics and quality and the like. And um I did refer to it briefly before, but I think one of the things that makes for a good plastic surgeon is that by our very nature we are problem solvers. And and what helps I think our minds um evolve and mature in that regard is, you know, again, you know, to get through medical school and to get into you know through parts of residency, we have to be very, very skilled at fact recall. But what sets what sets I think plastic surgery apart is our is our creativeness, our um our ability to respond to problems that other people find daunting. And and if you take away from I referred to it before as the what-ifs or the whys, if you take away from um from the business world and operational management uh insights, there there are um quality and efficiency theoretical constructs called Six Sigma, um Toyota Lean and the like, and and that's what they encourage. They encourage folks not to get trapped into the routine that I've done, you know, uh a thousand carpal tunnels, um, but you know, this on the thousand and first, there's this bizarre-looking tumor that's extending from the distal forearm through the carpal tunnel that that's giving you the the sense of the numbness and tingling, right? It's the it's the playing kind of a mind game with yourself about the in the under Toyota lean, it's you're so you're supposed to be asked yourself five whys to any problem. Uh under Six Sigma, it's it's slightly different. But the idea is to not just accept the face value of a case, not just accept normal procedure, but but but be prepared for the what-ifs or um um or why did or understanding if something if something doesn't make sense to you and you ask why, there could still be two other whys underneath that first cursory answer that would get you ultimately to the to the uh insight that you would need. So um I I think do not become do not become creatures of habit in plastic surgery. Always play a little mind game with yourself to to try to be prepared for something different. Um because in doing that exercise, when something is presented to you as a consultant that is different, you'll have the uh you'll have the ingrained um intellectual fluidity to be comfortable in that ambiguity and to and to be creative and to come up with with different answers to to problems for which there is usually one answer, but in this certain circumstance that answer doesn't apply because the CT angiogram showed the pedicle wasn't good or something like that. So always always as you're evolving and maturing in your training, when you're um when you're developing that intellectual skill set, always always visit the gray um and not just uh and not just the light around uh around the cases that you'll you'll be dealing with. And I think that'll serve you well not only for your oral boards, but but how you approach problems in life and and certainly how you um how you practice good plastic surgery over several decades.
SPEAKER_01:Amazing. Well, um I want to give a special thank you, Dr. Murphy, and our listeners uh for coming on today's show to talk about board exams in plastic surgery. Um as I mentioned earlier, this is a huge stressor for residents and and candidates that are going through the board process. And I hope uh this episode gives some uh tips and strategies and ways that uh can help reduce the stress as you're going through the board process. Uh thanks again for joining us on the International Residence Forum podcast. Be on the lookout for the next episode if you're a resident or fellow in plastic surgery. We encourage you to join the ASPS International Residence Forum. It's a place where you can connect with peers across continents, across educational resources, and be part of a global community committed to professional growth. Thanks again for turning into the ASPS International Residence Forum podcast. Be sure to catch our next episode. See you then.