Stress Control Techniques and their impact on exam candidates’ performance in Oral Board Exams.

The oral board examination, administered by the American Board of Anesthesiologists, is designed to assess an anesthesiologist’s level of competency after completing residency training. An anesthesiologist can register for their oral board examinations after completing residency training, as well as both the BASIC Exam and ADVANCED Exam. The oral board examination is divided into two parts: the Traditional Standardized Oral Examination (SOE) and the Objective Structured Clinical Examination (OSCE). The SOE consists of two 35-minute exam sessions that evaluate a clinician's ability to solve patient scenarios. The OSCE consists of seven eight-minute sessions related to communication, professionalism, and technical skills. Unlike multiple-choice exams, both oral board exams simulate real-time clinical encounters, challenging clinicians to apply their knowledge of medicine to make decisions under pressure while maintaining composure. Ultimately, the examiners desire to evaluate a clinician’s ability to navigate complex perioperative problems, manage crises, and articulate their decisions in a structured and professional manner.

For anesthesia residents, oral board exams determine their future ability to practice medicine, their career mobility, and their professional credibility. Success on oral boards exams is determined not only by one’s knowledge and preparation, but also by one's ability to manage stress throughout the exam. Employing effective stress management techniques can enhance one’s cognitive clarity, facilitate effective communication, and improve the ability to anticipate clinical scenarios. Thus, learning to manage stressful situations is not only essential for anesthesiologists to pass oral boards, but crucial for an anesthesiologist to maintain control of a patient’s hemodynamics throughout surgery. In this article, we will discuss evidence-based stress control techniques to help anesthesia residents excel on their oral boards, including simulation-based practice, cognitive reframing, structured communication, breathing and physiological regulation, and healthy lifestyle choices.

Simulation-based practice exams or mock oral exams are an excellent opportunity for residents to practice under pressure before their actual exams. These practice scenarios expose residents to a similar stressful environment, allowing them to realize how they will react and how they can improve upon their mistakes. Similarly, simulation-based exams provide residents with an opportunity to practice dealing with unpredictable scenarios. On exam day, a myriad of topics can be tested, and residents need to be able to navigate their way through each one, regardless of whether they have encountered it throughout their residency training. Simulation-based practice helps residents develop familiarity with scenario-based questions, as they typically do not experience a similar exam style before oral board exams. A survey conducted in 2008 on Canadian anesthesiology residents showed that as trainees progressed through their residency and engaged in simulator sessions, their anxiety in the operating room, as well as when supervisors observed them, decreased. Participating in simulator-based exams will enable residents to receive feedback from their attendings on how to approach specific scenarios, thereby improving their clinical acumen and increasing their ability to predict the types of scenarios they will encounter on exam day. Lastly, the California Board of Anesthesiologists advises anesthesia residents to treat each of their cases throughout their residency as if it were an oral board exam scenario, and to question why they are making each decision. Such a level of reflection will strengthen one’s clinical acumen and prepare them for their oral boards at the end of residency training.

In addition to engaging in practice-based exams, residents can benefit from reframing these exams as an opportunity to consult on a patient or teach their peers about a case. Reframing the situation can help lessen the pressure the examinee feels. A 2020 study of students’ anxiety during math examinations found that utilizing cognitive reappraisal decreased the participants' amygdala responsiveness to stimuli that elicited negative emotions and increased their accuracy compared to the control group. This process can be mirrored in oral board examinations, where the stress is high and time adds pressure as well. Structured communication is just as important when formulating oral board answers, because residents need to demonstrate to examiners that they have a rationale behind their answers and can communicate their thoughts effectively. The California Board of Anesthesiologists recommends that examinees practice aloud their structured responses and include rationales for their decisions, so that on exam day, they are able to justify their decisions to the examiners.

Oral board exams induce high levels of stress for examiners, and stress can manifest in physical forms such as perspiration, tachycardia, and mental fog. The American Board of Oral and Maxillofacial Surgery recommends that examinees perform breathing exercises to maintain a calm state of mind. Some of the techniques that can be utilized include diaphragmatic breathing, which activates the parasympathetic nervous system to promote relaxation. Additionally, examinees can practice box breathing by inhaling for a count of four, holding for a count of four, and then exhaling for a count of four. This technique has been shown to counteract the “fight or flight” sympathetic response. Lastly, examinees who have tried breathing techniques and are still experiencing manifestations of anxiety can try a beta-blocker such as propranolol. Using a beta-blocker would mitigate physical symptoms such as a racing heart, sweating, or trembling.

In addition to stress mitigation strategies, examinees must realize that their success on oral boards is not only determined by their studying, but can also be impacted by the level of support from their system. Examinees should aim to have a multifaceted support system, including family members to lean on during tough examination preparation, mentors to reach out to for advice, and a daily study schedule to pace out their studying. Lastly, attending debriefing sessions where examinees can receive feedback has been shown to reduce stress markers and allows for cognitive processing of the interactions in the simulation scenarios. A study conducted in 2009 found that anesthesiology residents were calmer after debriefing with those who were evaluating them, as evidenced by lower heart rates and a decrease in subjective anxiety.

Success for examinees taking their oral board exams depends on several factors outside of possessing the foundational knowledge of anesthesia. One of the most critical and often overlooked aspects is stress management. Without the proper stress management techniques, examinees can suffer from mental fog, delayed response times, and convoluted answers. By utilizing strategies such as practicing with simulation-based oral exams, reframing oral board exams as an opportunity to practice, engaging in breathing techniques, and ensuring they have a strong support system, examinees can increase their chances of passing their oral board exams and decrease the stress associated with the experience. Residency programs ultimately want their residents to pass their oral boards; therefore, reaching out to the program coordinators for guidance during stressful times may also be an option.