Deliberate Exam Practice with Alex Craven

Welcome to First Incision, the podcast about preparing for the General Surgery Fellowship exam. I'm your host, Amanda Nikolic. So we have a very special episode of First Incision today. Alex Craven is back to run us through some practice scenarios to help us think about how to actually prepare. purposely for this exam. Let's do our team timeout. Our patient today is preparation for the general surgical fellowship exam.

And the operational topics we're going to be covering today include identifying your strengths and weaknesses in order to focus on preparing and not ignoring those parts of preparing for the fellowship exam, as well as deliberate practice. and some practical exercises to start thinking about different ways of answering questions and different ways of thinking about answering questions for the exam that you can start doing even today.

So thank you so much today for coming onto the podcast. We are lucky enough to have Dr. Alex Craven back who has done a couple of amazing episodes about exam preparation. And also we have a new guest today, Dr. Steve Kunz, who is in my study group and has kindly offered to come a bit into the firing line with me today.

So we might start off, given we already know a little bit about Alex, by asking Steve to tell us a bit about himself. So I'm a set for trainee with the Austrian Northern Hub with a... a varied history towards the entry into surgery. I sort of diverted into cardiothoracics for a little while and critical care as well. So while the surgery is my first love, I just try and keep a broad interest otherwise.

In terms of general surgery, I like things that just metre the diaphragm, so upper GI is a really strong area for being guided in the past due to Alex's strong mentorship as well. And outside of work, I enjoy rock climbing, I enjoy cooking, I enjoy looking after my cats, and I've got a new three-month-old kitten that we'll probably feature sometime later in the episode. His name's Nedjom.

Nedjem, I like it. Where's that from? It's the Egyptian, it was the first named cat and it's become the Egyptian word for sweetness or pleasant one, but the fact that it's also the acronym for the New England Journal of Medicine wasn't lost on us. So I'm going to hand the reins over to Alex now, who's going to guide this episode a little bit. So over to you.

All right. Well, just to be clear, you're still very much in charge, Amanda. I might start with the usual disclaimer, which is I am an expert only in the exam that I sat and no one else's exam. So if anything... that comes out of this is helpful great use it plagiarize it be free to take it anywhere you like but if it is unhelpful or if you're just listening to this thinking this is not going to be helpful for me then put it back on the shelf and move on to something else

The first thing I wanted to follow up on, I think last time you and I talked, Amanda, we touched on the idea of this being an exam about your weak links rather than your strong links. And that's my feeling and my opinion from sitting it, but I think it's also the impression I get from the communication from the college. They're not looking for subspecialty professorial knowledge in any area of the exam, but they're looking for...

people who are well-rounded and can deal safely and effectively with anything that could foreseeably come up in the early career of a young consultant general surgeon. And I think that's very much about... weak links not having weak areas that are going to let you down in the exam and in real life and so i think we talked about well my experience was figuring this out

probably about a month before the exam and thinking, wow, I've got some big holes to fill, but perhaps that that might be more useful for people sitting in the exam if this is how they initially approach the curriculum, deliberately looking for weak links. And so I thought just as an exercise, maybe we could look at where we all see our weaklings. We all think about content first and foremost. And so the area that I think for me was really intimidating.

a year out from the exam was breast surgery as a whole discipline. I had not really done a breast term and I just felt like whenever I was... in front of someone quizzing me, there was always someone sitting behind me that could tell you, you know, that could read that histopathology report and tell you exactly what needed to happen.

down to which choice of chemotherapy. And I was so far behind that. And every time I would suggest an answer, someone would say, oh, no, no, but their nodes are this. And I just felt so behind people.

and so that was really my area of weakness now as it turned out I was very lucky to be placed in an excellent breast unit for the term that I set the exam and that sort of took care of that so that's my first advice is if you if you really think there's an area of weakness just go and do a term in in that and and that'll sort it all out but When I got into the breast, you know, I realised that actually it wasn't breast surgery. The anatomy was actually pretty clearly defined.

fairly easy to get your head around. I recently heard an excellent summary in about 15 minutes that covered pretty much everything you'd need to know for the exam. But the issues that I was dealing with was it became... clear to me that my oncology was very weak. And suddenly it occurred to me that that wasn't just the breast cancer thing. Actually, all the areas that I thought I was strong in...

If I was to be honest with myself, my oncology was weak and also my knowledge of genetic syndromes was also very weak. And it just so happened that, I put it to you, that that's probably more prominent. in decision-making around breast cancer than it is in other areas. So I thought I'd invite you guys to have a look at, you know, talk to me about the areas of content that you were finding worrying, challenging, concerning.

I guess let's also talk about what is it about that area and does it translate across other areas of content. Now I asked you guys to make a list. So have you done your homework? Problem is my list is quite long. That's because you're a type A personality and an overachiever, as is 90% of the cohort. And you're going to tell me or, you know. If you start with that you're too much of a perfectionist, we're just stopping right here, Amanda.

Well, given Steve has volunteered to come onto the episode, I will volunteer him to go first, although there's two cats that are interrupting his podcasting at the moment. But once he's recovered from that, take it away. So one of my biggest areas of weakness is probably head and neck and in particular anatomy. So touching on what you'd said before, that anatomical deficit that I find.

is more than just that, trying to work out the variances of your recurrent laryngeal nerves or what structures you expect to find to guide a successful submandibular resection. Building on that, it's probably because at my core, I'm like a kinesthetic learner. I enjoy learning by actually doing things, by appreciating.

reosophers during laparoscopic cholecystectomy by looking for the vagal trunks during a hiatal dissection. But if I've not been in that operative scenario or I can't necessarily appreciate the nuances behind... why I'd be looking for the origin of the innominant on a CT chest before a thyroidectomy, then I find it hard for that content to try and stick.

which then sort of feeds into actually doing, like practising operative fevers for situations that I haven't been in because not only do I have the anatomical data to present well.

But I feel like I'm on shaky ground with that anatomy to begin with. That exposes a common issue with the exam. So there's a couple of things there. I think you touched on an awareness of your preferred... and preferable learning style um i think i would consider myself similar in regards to the strengths in my learning i was never a list person i was a do and explain it later type person um

And that's a good thing to know. The area of, as you say, if you can't, head and neck, if you can't learn the anatomy, then a lot of the operations just become a bit of a... a rote learning exercise rather than a true explanation that's read up and the other thing that you touch on which is a very common problem in this exam is explaining operations that you haven't even seen

based on a textbook description and doing so in a way that you're trying to suggest to an examiner that you would be competent to do that even though you might be thinking i would absolutely call someone else And so I think that it's good. I like that you've seen that, okay, well, this is a problem in head and neck, but not necessarily only head and neck. And I think that what that then allows you to do is as you go through the curriculum.

Just know the stuff you've seen and done and the stuff that you have. How you approach that is up to you. For those of us that learn by doing, drawing anatomy can be a really useful tool. because it is kind of a doing thing, even if what you're visually producing is nothing like reality. The process of making your mind put something on paper that matches a true object in life is actually...

a practical exercise that can aid with learning. If I can plug the Stanford Heritage Anatomy series of videos with one Richard Schnell, who is... possibly the most phenomenal anatomist I've ever seen. And this is a guy that starts with a chalkboard and draws the bones in white, starts putting muscles on top, and then with three colors of chalk. beautifully represent an area of anatomy. I encourage you, Steve, to have a look at his head and neck drawings. It's out of this world.

Yeah, and that's one suggestion for me, but maybe find things that work with your learning style and do that. If rote learning is not your thing, don't rote learn. Have you got any content areas you want to talk about, Amanda? Too many. I definitely had some anatomy stuff on my list, so head and neck, vascular and peripheral limb anatomy, which...

Even though I taught anatomy, I somehow managed to choose to avoid the shifts where I would have to recover upper and lower limb anatomy because I hated it so much and I regret that now. So we do that. We do that. And so this is another thing. I think if you look at the curriculum and highlight this as an area of weakness, then just maybe it makes it a bit harder for you to skip across.

The other things I had were a couple of topics that I feel like I have a mental block to, which are melanoma and sort of sarcoma.

And those sorts of ones where there's all these new treatments and there's no real clear just sort of summary anywhere and the thought of having to dive into all of that just seems overwhelming. What is it about those areas that... worries you this the melanoma sarcoma stuff i think the same thing you were blocked with with breast cancer and that the oncology side of it that you know stuff that we can't see or feel that are surgeons

really is just this sort of theoretical thing, I feel will be difficult. And because it's such a cutting edge area, I don't know how I'll talk about the area. But at the same time, I guess... as a general surgical exam, we're not going to need to know the minutiae of all of that. But I know, like you say, as my type A personality, I'll probably end up down a rabbit hole of different treatments.

I think one thing to remember is that the exam is written a pretty long way out. I think we talked about this as well. When they mark someone, there's areas that are clearly right or wrong. And there's areas of controversy. And really, if an area is still controversial or so new that the clear pathway hasn't been decided, then...

really the only way to be marked wrong for that is not appreciating that it is controversial. But I think the fact that you guys have identified it this far out means that now... You can go and address that until you're comfortable. So the next thing about weaknesses that I thought we could talk about is types of questions because there's the content part and as you guys are probably aware.

both working with me from my talk i'm not a content person i'm not a knowledge person so there are many types of questions in the exam and you guys may not have done a lot of practice yet but are there any sort of questions that intimidate you you know in those practice sessions what's the sort of question that you're like oh I hate it when they ask it like that

No, I guess the types I'd said were mainly anatomical spots because it sort of leads, again, leads into that first deficiency. Beyond... Beyond that, I think my analysis of my weakness is still such that it's all content-based. So the...

The ability to work out the difference between a good synthesis question versus a knowledge question is sort of non-existent. I don't feel like I know what I don't know just yet. So I put it to you that as you go forward... probe for you know notice when a question makes you uncomfortable even though you may know the content like i hated list questions You know, if someone ever asked me the three causes of this or the four options, if anyone ever gives me a number, I'm terrified. I mean...

Some would argue it's because Alex hates right and wrong questions. He'd rather kind of fudge his way through type questions and that's probably reasonable. But I used to hate that list of... What are the causes of pancreatitis? Can I just tell you the story of the pathogenesis? Because, you know, like I just get stressed about this. I used to hate trying to remember that stuff. Amanda, do you have any types of questions?

I thought a similar thing to Steve in that it's pretty early to know exactly, but one thing that I really struggle with and I struggle with preparing for the interview as well is the sort of question where it gives you this really broad... where there's so many different potential pathways depending on so many different factors and trying to figure out how to structure that. And I figured that would probably come up in the long answer questions more than anywhere else.

And I found one the other day. I was reviewing large bowel obstruction. It was a case of a patient who presented with a large bowel obstruction. And the question was, what...

What is your management of this patient? And then in brackets, it just said operative description, not required. But it depends on so many things and figuring out how to... structure that and how to comment on all those different variables in a way that doesn't just make you sound like you're all over the place is something i think i definitely need to practice more yeah and then synthesize all that in 10 to 12 minutes it's a nightmare yeah you got a strategy for that

I guess I'm starting to... try and make assumptions so rather than saying at each level if this if this if this then that and then if this and this and this if that trying to be more like assuming this this is what I would do and then getting all the way to the end of that pathway and then assume

this, this is what I do to try to make it a little bit more structured, which is hard because most of the time we approach things as history, exam, bloods, management, you know, so it's just a different way of thinking about it and I obviously have to practice that skill.

All right, and then the last thing I wanted you guys to think about is sort of your own personal strengths, weaknesses, likes, dislikes, and how that might affect, one, you're preparing for the exam. and two, your performance in the exam. So Steve, you talked about, you know, that kinesthetic learning. That's probably a really useful thing for you. It's probably not a bad idea for you to go.

And just try and get into any operation you think you might have to explain. Knowing that if you go there once, that'll probably be enough to get you over the line. What about weaknesses? What about things that might slow you down and stop you from preparing well? From a purely logistic perspective, it's the dead time between leaving home and getting to work in the setting of the 45-minute.

commute both ways in conjunction with either a feeling of fatigue at the beginning or fatigue at the end that makes it easier to just turn the radio on rather than actually use that time productively. with podcasts like the one currently being recorded, that same sort of almost distraction or lack of discipline echoes at home. So it's easy to be distracted by.

reading up on what's happening with COVID or by going through a patient's blood or preparing for the following week at work and using that as a justification towards avoiding study. Isn't clinical... Duty is just the best excuse. So much so. Flip that around. You've got 45 minutes twice a day with no patience. Yeah, no cats to crawl across your books.

Is there anything you do with that? Put your headphones in, turn on the voice recorder on your phone. The first 10 times you do it, you'll hate the sound of your own voice. Wanda Stelmack, who all of you know quite well, she's in. stunningly good surgeon and an excellent leader. And her advice, she recounted to me her time recording herself answering questions.

and then listening to her answers and critiquing her own answers. And I put it to you that that might actually be a good use of your time. And then you can listen to yourself on the way home and think what you've missed, what you did well. what you change i did a lot of it and it certainly it will encourage brevity in your answers amanda what do you think about the way you learn the way you do things so in terms of preparation

The thing that I thought about that I probably need to get better at is not focusing on the details so much, so trying to get the bigger picture in. And then from a performance point of view, I'm trying to practice.

pausing after the questions asked and trying not to talk so fast that my brain doesn't have a chance to catch up with what my mouth is saying which happens a lot and I must say that the podcast has been really helpful for that because you know i do have to think about what i say and i feel like that's being so far a really good practice tool start noticing these things when you answer questions you know and recording them is a good way to do it

that's right okay so that's enough about weakness so the other thing i think we were going to do was do a little deliberate practice stuff all right so deliberate practice so we talked about this last time it's the idea of practicing in a way that is deliberately aimed at changing your performance in a specific area. So Amanda, you mentioned pause and think. So what would a deliberate practice exercise for pause and think look like? Well, you told me one that...

You did, which is you made the people you were studying with make you stop and go one, two, three, four, five before you started talking. So you can do that with a timer. Five seconds is a really long time. But the other thing that you can do is just when people are answering questions and you think they jumped in too early, stop them, pick it up, get on them early. That immediate feedback thing works pretty well. Let me ask you guys, what...

Do you think you would like to change about the way you instinctively answer questions or the way you're answering questions at the moment? I find that with the questions that are given to me, I'll often go down quite a, like I'll talk myself into a corner. in terms of going down into infinite detail about one small aspect rather than sort of demonstrating that I've considered the whole or that I can go from that broad down to narrow.

type discussion. So the thing I think you're trying to say is you don't want to find yourself down a rabbit hole where there's a number of options. choose one, get in depth before explaining how you get to that option. So if we flip that around, what would be the positive of that? Like what do you want to see? What do you want to see rather than what you're trying to avoid?

I want to show the examiner that I've got a structured response, that I've got all of the drop-down menus present and I'm able to sort of pick one, say, small bowel obstruction, soft abdomen, this is what I do. This is what I do. Yeah. So it sounds like you're describing to me that you want those key decision points.

And those key bits of information that are going to turn a complex situation into a series of simple yes-nos. So two things about that. One is I think that's a very effective way to answer a question. And it's to be able to spell out rather than the content and the options from the point of view of the decision-making.

the idea that there are decisions to be made rather than options. Does that make sense? Because options is a list, whereas decisions to be made are clear. It's the difference between how are you going to manage this splenic injury? Well, my options are A, B, and C. It's the difference between that and, well, it depends on whether the patient is stable. Are there any other injuries? And what's the grade of the splenic injury?

I think that's sort of a more mature answer. And then you can go through, and with that information, I can choose between immediate splenectomy, conservative management, or embolization, you know. Then I think that sounds like a nice way to answer a lot of questions, not every question in the exam, but that does sound like that. So that's probably something we could look at even practising.

We can even do it now. It might be a bit weird, a bit intimidating. But this is something that was taught to us in an excellent tutorial. I think it was by Phil Smart who talked about the idea of having... a stack of flashcards in your head that are really just decision-making algorithm. And you just pull out your difficult duodenal stump algorithm. You pull out your...

more bowel obstruction algorithm, you pull out your large bowel obstruction algorithm, you pull out your diverticulitis algorithm, et cetera, et cetera, et cetera. And you say to the examiner, the key bits of information I'm chasing are this. And I think maybe, Amanda, this might also be another way to address that whole, holy crap, there's a lot of information here. What's important? What's not? What needs to be my answer?

what can sit on the shelf and I can add it to my answer if I've got time, particularly like in those shorts, for instance. So we played a bit of a game called It Depends. The first part of this game is to get used to the idea that there is no one answer. But the second part of it depends is it depends on what. And usually that's only two or three things.

So what I might do is ask you both a few scenarios and you can tell me it depends and then I'm going to ask you on what. And I just want, you know, key topics. So here's a patient with blunt trauma and a splenic injury on CT. What is your management? The first part of the answer only has one possible right answer. It depends.

It depends. Thank you. Good. Good. It depends. Why? Whether the patient is stable or unstable. Absolutely. What are you going to do about the spleen in an unstable patient that's bleeding to death? Take it out. You can put it in a bucket, 100%, with you all the way. Yeah, okay, so stable or not stable suddenly goes on our list, okay? Yeah, cool. What else do you want to know from all of that? The grade of the injury. Yeah, grade of injury, grade of splenic injury. Why does that matter?

Gives you information about the likelihood of that needing intervention or settling by itself without any intervention. Yeah, exactly. Exactly. Good. Yeah. Does that make sense? Can you see how when I ask you...

there's a splenic injury, what are you going to do about it? The mature answer will be, look, there's only a couple of key bits of information I need here to make that decision. And in the exam, the examiners are waiting for those key bits of information. You can just give them the stuff you know they're going to want.

and then move on you are performing lab collie and find a unexpected stone in the common bile duct what would you do about it yeah The factors that my approach to colidoccal thiasis, to unexpected colidoccal thiasis, involves the physiological state of the patient, the difficult... how difficult the dissection of callos has been, how large the cystic duct itself is and the facilities that my institution has available.

And that's pretty much it. So in a situation where we have easy access to something like ERCP, innovation that may have a narrow... cystic duct that's not amenable to colloidocoscopy, then in that situation, trying to get it down from below rather than for a transcystic expiration is valid. Whereas... in a situation where a patient may be physiologically or anatomically unfit to the ERCP, like previously on wide gastric bypass, then in that situation...

inclined towards a formal transistic exploration. Yeah, and that's a perfectly valid answer to have. I don't think transistic exploration is on the do's in the curriculum. It wasn't when I set the exam, so that's fine. Really, it's only two or three things that are going to make that decision. You know, morphology suitable, ERC possible, not possible, duct blocked, not blocked. You've got three binary answers.

But if you've got a few key things that help you make your decision, then you're going to make a safe decision. A patient comes to see you with an inguinal hernia, what are you going to do about it? It depends on whether the patient's symptomatic or asymptomatic.

Beautiful. Agreed. The size of the hernia? Does it? I guess you'd be more inclined to repair a large inguinal scrotal than a small asymptomatic hernia? Fair enough. Yep. Whether or not the patient has had... previous surgery as well as their body habitus good because you i think you're thinking about lap versus open there aren't you yeah cool yep you know are they fit for surgery maybe i don't know

But, yeah, I agree. But the key that you've touched on there is pretty much symptomatic or not, there's nothing else that's going to change your mind about. Do you know what I mean? Like that, you know, you could talk about. taking a history and how long it's been there and is it reducible or not and has it ever got incarcerated and ever had a small bowel obstruction blah blah you can spend your whole life talking about this inguinal hernia or you can just say look

Is this causing you trouble? Is it not causing trouble? And what do we know about symptomatic inguinal hernias? They get worse. They cause trouble. They cause problems. So we're going to fix it. What do we know about asymptomatic inguinal hernias? You know, we've got a pretty big study that told us that we could wait until the patient was symptomatic.

Perforated duodenal ulcer. You've got a stable patient with gas under the diaphragm. What do you do? In a stable patient, you could make the argument for conservative treatment, so mesogastric tube, IV PPI, IV antibiotics. and then to observe them. The markers that would indicate that this has failed and they require an upgrade in their treatment would be failure to progress, the progression of their clinical signs indicating ongoing sorting.

That's pretty much it. Yeah, so when I say to you, you know, what are you going to do about this stable patient with 50, you rightly figured out that this was a question about conservative management of perforated heptic ulcer disease. Do you have criteria for... managing perforated peptide also today not off the top of my head so now you have an objective when you're attacking this topic

And so that's the other reason why I like these sort of exercises where you go through a lot of content really quickly aiming to just frame little questions because then you can start mapping out for yourself. goal-derived study objectives rather than let's cover peptic ulcer disease. You can walk in there with let's find an algorithm for management of peptic ulcer disease or

Let's go in there and find an algorithm for workup of peptic ulcer disease. Or let's go in there and find a way to quickly explain the pathophysiology of peptic ulcer disease. And then let's close the book and go and work on something else. And you can do that with all of your topics. And I don't know about you, but that to me sounds like more worthwhile study than open the chapter on.

you know, peptic ulcer disease in some pathology textbook and then move on to eight operations for it in some surgical technique book, none of which you've performed before and you don't really know which one to choose when. That sounds like hard work to me. But go and find out what people think are good ways to manage peptic ulcer disease and come up with my own plan. That seems like a worthwhile study for me. And that actually seems like something that might help me going forward in my career.

And with that unbelievable advice and really practical ways of thinking about preparing for the exam, that is where we left this episode. Alex is going to give us a little summary about what he really wanted us to get out of this. exercise. And I'm sure that you will all be just as grateful as I am for his expertise. As well as join me in thanking Steve Kunz for coming into the firing line with me today, as well as for being such an amazing study buddy and helping me get ready for this exam.

At the end of the day, I think the idea I was trying to get across from all of this was by looking at our weaknesses in the areas of content and then looking at what is it about that area of the content that is a weakness for me and then just screening the rest of the content, the rest of the syllabus to make sure that that doesn't apply in other areas.

is probably a good way to prioritise study. And it may be different from different members of your group. And in that case, as we talked about, Steve, if you deliberately choose those areas... that are a weakness to you and use them as a teaching topic where you teach the rest of your group something they probably already know, that is probably a good...

and option for covering this. But certainly, if nothing else, go through that syllabus, identify your weaknesses, and screen the rest of the syllabus with every weakness and just get them down and prioritise those. Because that's what's going to trouble you in the exam, not lack of in-depth knowledge about anything. The other thing was the weaknesses in technique. Identify.

types of questions that intimidate you and practice them more often than the types of questions that you like and it's a big trap in study groups we love doing operative descriptions in our study group we loved it we loved it so much that we would practice that to the exclusion of everything. And then think about your own personal strengths and weaknesses and apply them in deciding how you're going to go about doing it.

In regards to the deliberate practice exercises, I think look for criticism. And often you get content criticism rather than anything else. You need to know more about this. You need to explain that better. blah, blah, blah. But occasionally you will get technique criticism from the people you're talking to, from the surgeons that you're talking to. And when you get that, hold on to it and file it away.

You really should talk more as if you're in the driver's seat. You really need to summarize the situation better. You should stop and think about your answer more, whatever it might be. Use that and then go and take that. develop an exercise for yourself and train you out of, train yourself out of whatever habit was impairing your performance. It depends was when we worked on being in the driver's seat, I think is one.

Early on, I got a lot of criticism about giving this wishy-washy idea of the options rather than putting myself in the position of the decision maker and making choices and decisions. And when it's done well, it sounds like you're already at the other side of the exam. And I think that's why it's such a popular technique. So that might be another one that you can practice a month to do.

Just fire a lot of questions at each other and just keep hammering being in the driver's seat. You just get so used to it, it suddenly becomes automatic. And also... hit the biggest range of question types and content types you can. The other exercise that as a deliberate practice is we talked about the shorts and trying to figure out what we're going to do.

How are we going to answer such a large question? And again, another tip from Wanda was we had exercises where we'd just sit down and just plan the answer. That's all. Give yourself one minute. Look at the question.

Plan your answer in dot points. I'm going to cover this. I'm going to cover this. I'm going to cover this. Done. Move on. Next question. Swap notes. Figure out who structured the answer better than you, who structured the answer worse than you, stuff that you forgot to put in, stuff that you didn't. You can get through a huge range of content doing that but also when you sit down for that short and you hit that short that you haven't covered before and you're like, whoa, there's a lot in this.

then you're automatically very good at planning that answer. So it's really a technique. It's a great way to cover heaps of content, but it's a really good technique. And then when you've done all this, you'll have a list of stuff that... was hard to practice because you didn't have the content. And then you have a way to go and chase content. So we talked about chasing down specific information, knowing.

what answers you need to find rather than what content you need to cover. And for most of us, that's a better way to approach the enormous amount of reading. is to know specifically what do I need to find from this rather than let's go and memorize this chapter. It's time to close up. Thanks for listening to First Incision. If you have any comments or feedback, send us a message at firstincisionpodcast at gmail.com or follow us on Instagram at firstincision. Happy studying!