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IX. Design of the Oral Examination:
In total, each candidate will have two 30 minute oral exam sessions with a 15 minute break between the sessions. Each session will be conducted and examined by 2 individuals who are current ABNM Directors and are DABNM certified. Thus, a total of 4 different ABNM Directors will examine each candidate. The Board will attempt to assign examiners for each candidate such that no conflict of interest with the individual candidate being examined will exist. Most specifically the examiners cannot have participated in the training of the candidate and should not be employed by the same, or competing, institutions and should be able to be unbiased in their examination. Preferably the examiners should not know the candidate, but this is unlikely to occur in all situations. Since the goal of the oral exam is to assess judgment of the kind needed in the operating room during monitoring, the format will involve questions similar to those that could occur during a surgical procedure. Although they will inevitably involve knowledge of anatomy, physiology, anesthesia and surgery, and IONM outcomes literature, the questions will focus more on the application of this knowledge in a surgical case and the interpretation of clinical neurophysiological data. It is important to stress that the oral examination is not only a test of knowledge; each candidate has sufficient knowledge as demonstrated by having passed the written examination. The oral examination questions will seek to assess judgment, appropriateness of the monitoring approach, interpretation of data and application of monitoring and will assess adaptability when problems occur. The focus of questioning will frequently revolve around the reasoning and thoughts involved in arriving at an answer or resolution of the problem. A requirement of each of the two oral examination sessions (below) is that the candidate must be able to justify and explain decisions by referring to published literature and/or evidence-based medicine. Occasionally the questions may border on controversial areas where the answer may be “gray” or not firmly established. In essence, the exam will specifically test those aspects of data interpretation that extend beyond the technical aspects of monitoring and determine if the candidate has developed sufficient reasoning power and has a command of the relevant IONM literature to make informed, intelligent decisions and to properly interpret neurophysiological data. To accomplish this, the first 30-minute test period will revolve around a presented, real surgical case and the second 30 minute test period will deal with a hypothetical surgical case, respectfully. To make this most effective, the candidate will submit a case they have monitored in person or remotely in the capacity of the interpreting neurophysiologist, for the first examination period – termed the presented case. The applicant must document in the Case Report and demonstrate in the Data Records of the presented case, the occurrence of significant events that occurred during the surgery and associated communication that occurred between the neurophysiologist and the surgical and/or anesthesia teams. These events must be represented by significant changes in the neuromonitoring, i.e., electrophysiological, data and must not represent routine, drug-induced neuromonitoring data changes. Furthermore, a low threshold from stimulation of a spinal pedicle screw does not qualify as a significant event. The examiners will review the submitted case prior to the examination period so as to allow the candidate a maximal opportunity to demonstrate the insight and judgment requested. In addition, the submitted case allows the candidate to demonstrate the quality of their data and documentation as well as their professionalism. A hypothetical case will be provided by the Board for the second 30 minute examination period. The two examinations will involve two different types of cases and/or monitoring. For the purposes of the examination, the Board has generally divided IONM surgical cases into the four broad categories (I – IV) shown below. The candidate will choose to be examined in two of these categories. The case chosen to be presented by the candidate will define the category of the first examination. The candidate will then choose the category that they prefer to be examined for the second examination of a hypothetical case.
The categories and cases used for the oral examination are:
| I. Spine |
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III. Intracranial |
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A |
Scoliosis |
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A |
CP Angle/Post Fossa Tumor |
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B |
Thoracic Stabilization |
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B |
Large Skull Base Tumor |
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C |
Lumbosacral Pedicle Screw Fusion |
|
C |
Pituitary Tumor |
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D |
Cervical Fusion |
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D |
Intracranial Lesion/Tumor |
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E |
Spinal Cord Tumor |
|
E |
Micro-Vascular Decompression of a Cranial Nerve |
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F |
Tethered Cord |
|
|
|
| |
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|
|
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| II. Vascular |
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IV. Intraoperative Diagnostics |
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A |
Carotid Endarterectomy |
|
A |
Brachial Plexus/Peripheral Nerve |
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B |
Intracranial Aneurysm |
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B |
Epilepsy/Electrocorticography |
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C |
Thoraco-Abdominal Aortic Aneurysm |
|
C |
Functional Neurosurgery |
Presented Case: As one example, if a candidate should choose to present a case involving spinal surgery (category I), then they must choose a case for the second hypothetical examination from one of those listed in categories II, III, or IV. The candidate should not only specify the category (e.g. II, III, or IV), but should also specify which type of case in the sub-category (e.g. A, B, C, etc). Furthermore, candidates repeating the ABNM Part II-Oral exam cannot choose to present a case from the same sub-category that was selected for a previous examination. For example, if the candidate had previously chosen to present a Spine case involving a cervical fusion (Category 1, Sub-category D), future exam selections for the presented case must exclude Category 1, Sub-category D.
Hypothetical Case: A candidate who chooses to present a Carotid Endarterectomy case (category IIA) must choose a case for the second examination from categories I, III or IV since the carotid surgery is in category II. The choice of the category and type of case (A-C or D) for the second “hypothetical” examination should be made at the time that the materials for the first, presented case, are submitted to the Board on the form that will be provided. A brief case scenario from the chosen second category for the examination will be provided by the Board within the category and case chosen by the candidate. Furthermore, candidates repeating the ABNM Part II-Oral exam cannot choose a hypothetical case from the same sub-category that was selected for a previous oral examination.
In order to fulfill the requirement of each of the two oral examination sessions that the candidate must be able to justify and explain decisions by referring to published literature and/or evidence-based medicine, candidates will be required to submit a bibliography of at least ten published articles that are specific to the value of IONM for each of their two chosen cases. These two bibliographies will be submitted by the candidate prior to the Oral examination and will be available to the candidate and used in both Oral examinations to justify and explain decisions by referring to the cited published literature.
The case presented by the candidate is extremely important, not only for setting the framework for the first examination, but also as a means of demonstrating the professional nature of their monitoring. This case should be sent to the ABNM Chairman in print form and also in a digital PDF format, at least two weeks prior to the examination so the examiners have time to review the presentation. In all material included in the presented case, a font size of 12 point or larger must be used for all text. No hand-written notes will be accepted. All IONM data acquired in the case must be included. As discussed below, the first examination will be a short presentation of the case followed by directed questions about the case or judgment aspects involved in that case, or one similar to it. Finally, the type of case will serve as the framework for “what if” questions that will complete the first examination.
The real case presented by the candidate should include several basic essential elements. During the first few minutes of the first examination period the candidate will be asked to describe the operative procedure used, to describe the IONM modalities chosen for the case and to describe the significant event that occurred. The candidate will in addition, be required to provide an interpretation of the baseline data in the context of the patient presented. Therefore, it is recommended that a one page overview of the case be included in the materials. Such a report might give a brief description of the patient (i.e. age, relevant medical history and neurologic symptoms and findings), the proposed surgical procedure, the monitoring modalities used and the anesthetic management requested. Further, all significant intraoperative IONM events must be noted in the overview. This serves as an excellent means of summarizing the case for the purpose of the initial case presentation to the Board. The presentation must provide all data / all waveforms obtained in the case and show the OR record keeping, documentation as well as the interpretation of the case as a whole. The data / waveforms should serve to demonstrate the quality of the monitoring data as well as all of the monitoring modalities used. As significant changes in the electrophysiological data must be included in the presented case, the relevant tracings/waveforms/data should be identified so they can be a focus for discussion. It is highly recommended that the waveforms chosen comply with the individuals institutions’ Policies and Procedures for IONM and also represent the highest degree of quality possible as these will reflect the professionalism of the candidate. The candidate should also include the report they wrote after the case for the purposes of their own records and any documents placed in the patient’s medical record. The ability to make a succinct presentation within a few minutes is important for demonstration of the ability to highlight the salient aspects of the case. It is important to note that to maintain patient confidentiality the candidate MUST remove all patient, surgeon and hospital identifiers from all materials brought to the examination and failure to do so will result in material being disqualified. The case chosen to present need not be a particularly complicated case or a case where some unusual aspect makes it special. Some candidates feel that it is important to bring an “interesting case” or a case where they did some unusual form of monitoring. Actually, to the contrary, since the case demonstrates the professionalism of the candidate, the case and its documentation should be representative and showcase the very best data and professional documentation of the candidate. Hence, unusual or interesting cases do not improve the presentation, and may actually raise issues of documentation or practice that may work against the candidate. The candidate should also choose the presented case based on the category in which they wish to be tested and one where the documentation and waveforms demonstrate the highest professional standards as well as a thorough knowledge of the pertinent literature.
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