X. Format of the Oral Examination:
Two weeks prior to the oral examination, the candidate should send two printed copies bound only by a clip of their case presentation and also send one digital / scanned copy of the exact same case materials in PDF format. The candidate will have been provided with a postal mailing address as well as an email address, respectfully, for delivery of these materials. Candidates will also have submitted a form on which they selected the “hypothetical” category for their second oral examination. Together with this material, the candidate must also submit the two bibliographies of published literature that will be utilized for both oral examination categories specific to their choice of case to be presented and to be discussed in the examination of a “hypothetical” case. A general information notice and the case selection form will be sent to the candidate at the time of the application deadline with information concerning when and where to send this information. On the day of the examination, each candidate will be asked to report approximately 15 minutes before their examination is to be conducted. It is highly recommended that the candidate wear professional attire, such as a suit, as recognition of their professionalism. Prior to beginning, the format of the examination and the issues discussed in this memo will be reiterated. Just prior to the first examination, the candidate will then proceed to the room for the first examination session. The 30 minute period starts with the candidate making the brief summary discussed above of the case they have brought to present at the examination. After this, the two examiners will then ask questions about the case, testing the judgment and adaptability of the candidate and expertise in interpreting neurophysiological data. Aside from specific questions about the materials brought, the general question categories to be asked will be predefined by the Board. Some of these questions may revolve around aspects that actually happened within the specific presented case, and other questions will be hypothetical in nature (What if ... happened?). Again, the major reason for the candidate to bring and present a case is to insure the candidate has a maximal opportunity to feel comfortable in the discussion of the case in what is an artificial environment.
The focus of questions that might be asked about the cases includes attempts to deal with the following situations and issues:
- preoperative considerations
- outcome data and value of monitoring, specific to the chosen case based on peer-reviewed published literature
- why and when to monitor
- anesthesia choice
- identify critical areas of the surgical procedure and basic operation sequence and procedures
- knowledge of risks and benefits of surgery
- choice of modality (rational and evidence for specific modalities of monitoring in this specific case)
- evidence in support of chosen modality/modalities
- waveform interpretation
- technical problems
- trouble shooting and machine problems
- dealing with deteriorating responses
- decision making without adequate data
- notifying the surgeon when problems arise
- appropriateness of networking
- supervising multiple rooms with concurrent IONM cases
- remote monitoring versus in-person monitoring
- when should you be directly involved in communicating with the surgeon
- IONM technologist supervision
- medico-legal issues
- documentation and ethics
Examples of the types of specific questions that might be asked, for example, for a scoliosis case might include:
- Of TcMEP, SSEP or spinal stimulated (MEP) responses, which test is the most useful? Why?
- If you could only monitor one IONM modality, which would it be? Why?
- If you chose lower extremity SSEPs, would posterior tibial nerve or common peroneal nerve be best? Why?
- If the surgeon requested that you used these, what are your responsibilities for informed consent?
- What should the patient be told and by whom?
- If you chose to place an epidural recording catheter for these responsibilities, what should the patient be told?
- Does the actual surgical procedure or instrumentation make a difference in your choice of monitoring modalities?
- Would an anterior procedure be monitored differently than a posterior procedure? Cite literature to support your decision
- How would monitoring be different if pedicle screws were used rather than sublaminar wires?
- Assuming a posterior thoracic procedure with rods, hooks, sublaminar wires and/or pedicle screws, what do you tell the anesthesiologist about your needs in the operating room?
- If muscle recordings are planned, what are the needs regarding muscle relaxation?
- Are these needs different for monitoring pedicle screws as opposed to transcranial motor evoked responses?
It is important to note that some questions will involve problems during the case (whether they actually happened or not)?
The ability to respond to the following example questions will assist in assessing the “adaptability” of the candidate. Examples of questions include
- During the surgical release of ligaments, the amplitude of the cortical SSEP becomes reduced over a 20 minute period. How much amplitude reduction is safe?
- How could you determine if this problem was related to anesthesia agents?
- Would median nerve SSEP, as compared to ulnar nerve SSEP, have any value here? Why?
- Does it matter if the latency is unchanged or prolonged?
- When do you notify the surgeon?
- Would your concern be different if the response change occurred over 3 minutes rather than 20 minutes?
- During placement of sublaminar wires a sudden, complete unilateral loss occurs in the cortical SSEP. How would you localize the level of the SSEP conduction loss?
- When told, the surgeon is convinced that they have done nothing unusual and wants you to recheck. What do you do if the problem is persistent and the surgeon refuses to change his procedure?
- What do you document and what traces should you save?
- Should you continue monitoring ?
After the completion of the first 30 minute examination, the candidate will be given a case scenario from the category and case type they have chosen for the hypothetical case and will have a 15 minute break to collect their thoughts about this case scenario. At the appointed time they will be invited back to the examination room where the hypothetical examination will revolve around the case scenario provided by the Board. This scenario will include a short description of the case but neither includes a great deal of detail or actual data. In fact, the case will be hypothetical in nature and allow discussion of preoperative planning of a consultant nature. The discussions can then move to a discussion of monitoring and problems that might occur during monitoring.
An example of such a case could include:
Scoliosis: A 24 year old woman presents for posterior instrumentation and correction of idiopathic Scoliosis. She has developed weakness in her left leg prior to surgery and has limited exercise tolerance due to shortness of breath.
In both 30 minute examinations, a five (5) minutes remaining warning will be announced by the Board Observer at the 25 minute point in each examination. The end of the first 30 minute examination period will be signaled by the Board Observer. Even if in mid-sentence, the candidate should politely cease the conversation and will be escorted outside the examination suite to the waiting area. During this time they will be presented with their hypothetical case and can begin to prepare. Also during this time the examiners that have just completed the first oral examination will conduct their scoring. Each examiner will conduct the scoring independent of the other examiner in the 15 minutes between examinations. Examination scoring is a complex weighting of the different components of the oral examination, with certain aspects having more importance than others. The examiners will not discuss the exam or candidate until after rendering their score. When the time for the second examination arrives, the candidate will be invited to return to the examination room. The second examination will be similar to the first except that the case scenario will be chosen by the Board for the case type and category chosen by the candidate. The candidate will be given the short scenario to review at the start of the examination prior to questioning. Also similar to the first examination, the questioning will be divided approximately equally between the two examiners and also follow question categories established by the Board. The five (5) minutes remaining warning and the end of the 30 minute examination period will similarly be signaled by the Board Observer following which the candidate is free to leave. At the conclusion of both Oral examinations, each candidate will have been given four independent examination scores
The questioning format for the second examination is similar to the questions listed above with the specific questions molded to be relevant to the specific case type and category. Obviously there is no real case or tracings (like the presentation brought by the candidate) so all of the questions will be of the “what if” type. Within each examination session, the questioning will be divided between the two examiners as the examiners feel appropriate. The question categories and examination format will be pre established by the Board so as to provide consistency between the examinations. As such, the first examiner will ask the first question and then continue asking related questions until the answer to that first category is sufficiently explored. In general, the examiners will likely have some minimal expectations for how a good candidate should respond to each question, although the reasoning is more important than the answer as often no single clear answer will be apparent. The candidate can provide the best answer by listening to the question and simply answering that question without trying to guess what the question is about. In general, the most important aspect of the answer will likely be why the response given was chosen and how this is justified based on published literature and evidence-based medicine. In other words, in giving the answer the candidate should “think out loud” to show their reasoning and refer to specific sources and literature. Although the aim is to ask questions that assess the judgment and adaptability of the candidate, it is inevitable that some knowledge questions must be asked as the specific knowledge relevant to the question will form the basis of why the specific recommendation or judgment was rendered. In order to cover a maximal amount of material, it is important that the candidate’s answers be succinct. The ability to keep the answers short and to the point will demonstrate the ability of the candidate to readily focus on the important aspects. This will also allow the examiners to move on to other aspects of the questioning as it is important for the examiners to comprehensively cover a large number of questions during the examination (but not necessarily all the questions). If the candidate is unable to answer a question, it is best for the candidate to say they cannot answer that question to allow the examination to move on to different questions that they can answer. Although not answering too many questions will cause the examiners to down grade the candidate, an occasional non-answer is to be expected due to the artificial nature of the examination. During the examination it is important to recognize that the examiners will be taking notes. These notes will be used at the end of the examination to render a score by evaluating the importance of each question to the overall score (i.e. heavily weighting important aspects and down playing aspects of lesser importance).
In both oral examinations, the candidate should be aware that a third (or more) ABNM Director will be in the examination room to act as the official Board “observer”. The Board observer will keep time for the examination and will evaluate the performance of the examiners to insure quality and consistency between examinations. The Board observer will not contribute directly to the examination process and the candidate should ignore their presence. The Board implements the observer policy to insure a high quality examination is provided to all candidates. Though the Board observer will not interrupt or participate in the examination, each observer will render their opinion about the quality and fairness of the examination process at the Board Meeting Certification of Examination results.