Board Review Tidbits

[MUSIC] Welcome back everyone, this is Sam. And this is Karine and we are two octux. So this week's episode is going to be a little bit different and we are going to be focusing on how we prepared the days leading up to our board exams. We both took our board exams last year and so the stress leading up to the exam is certainly freshen our minds how we've repaired, how we did that cram, but we did some last minute tidbits is right here in our forefront. We also remember kind of a lot of the questions or the topics that were asked on our board exams. So we're going to give you guys kind of our lowdown on what to expect and how you guys can prepare in the last few days. So it's important to know that the actual exam is four blocks for each the him day and the oncology day and each block is 60 questions for a total of 240 questions. And in terms of the top four oncology topics based on the blueprint, 14% of questions are GI, 13% are breast, 12% are GU and 11% are long. And the top hematology topics based on the blueprint has actually 35% base of neoplasm hematology topics. Yeah, I think using the blueprint to your benefits going to really make the most of the last few days. So hit those high yield topics and definitely hit malignant hematology because not only is it a big chunk of the he board exam, but it's also the on court exam. And so some generalized advice in addition to this is know that these tests are back to back days this year and previous years sometimes you have a day in between. And so in future years actually fellows can take the board exams in third year. I don't know if that's a pro or a con, but it's an option for people moving forward. And in the days leaning up to our board exams, the big things that both of us did is we reviewed our cheat sheet. So those handwritten cheat sheets, one page on each topic, we flipped through those. We also reviewed high yield topics as we mentioned above based on the blueprint of both of these ABIM exams. And we both did some test style questions with mixing up the categories. So instead of doing an entire chunk of 20 breast questions, we did these test blocks rose a breast question, a prostate question, then a he and question kind of to get your mind wrapped around. You're going to have different topics thrown at you each question and how to kind of get used to that style. And so the next thing we're going to talk about is a few high yield topics for both the onc and the he and boards and we're going to start with the oncology boards. And so one high yield topic that both a Korean and I talked about when we walked out of our test was stage two and three non small cell lung cancer. We both felt like there was many questions, even in each section on this stage two and three non small cell lung cancer. And so just to review the stage and the treatments for you guys, stage one is less than four centimeters lymph node negative and you treat that with surgery or radiation stage two, if it's greater than four centimeters less or greater than four centimeters, but less than seven centimeters. And then for stage three that is greater than seven centimeter tumor having multiple nodules in the same or the Ipsilateral lobe, having N2 disease or N3 disease, you treat these stage threes with chemo or chemo radiation followed by surgery. And so you do chemo radiation followed by the year of devalue map also remember the adjuvant chemotherapy regimens if the patient has squamous cell, we generally use this platen plus gym side bean or dose of tax all. And if the patient has ad no carcinoma, we use this platen plus pomegranate in those vignettes. And so this is the month leading up to the oncology exam, I focused heavily on the highest yield solid tumor. So that was a lot of GI questions, a lot of reviewing GI, a lot of breast review and then again a lot of lung review. And then I covered some high yield points in breast cancer because as we saw that is commonly tested fields of the exam. And so one of the ways that you can get to the things are going to ask you about would be to open the NCC and guidelines and controls search the word category one in all of those most common tumor types. And so before the category one things that come up under the breast section, I'll break it down in terms of adjuvant and then metastatic. So in adjuvant systemic therapy for her to positive that are that have positive ones nodes or tumors more than one centimeter, you're going to need to give new adjuvant or adjuvant chemotherapy. And then the other regimens will contain craft to the map for those her to positive and for the smaller tumors, you can get away with just trust to the map with pack of tax. But in those larger tumors, you're going to do AC followed by TH remember the AC is Adrian, my son. Michael phosphamide in this setting and then the TH is the trust to ZMAB with the H being pack of tax. So sorry, the T being pack of tax. And then for even larger tumors are those with positive ones knows you may even favor AC followed by THP with the P being the for to ZMAB that is added definitely remember that if someone gets new adjuvant chemo in the her two setting. There's residual disease you will give TDM one in the hormone positive adjuvant setting consider the 21 gene PCR as they known as on could type and remember the cut off for score an age. So for those that are post men appausal with the gene score less than 26 those women do not need chemo just endocrine therapy for those that are pre men appausal with an archetype less than 16 no chemo just endocrine therapy. Remember that those with that are hormone positive with many positive lymph nodes such as more than four acts of axillary lymph nodes if they have clinically detected internal memory lymph nodes. If they have those further lymph nodes like infraclavicular or superclavicular those will all need chemotherapy. And then remember the endocrine therapy joint is for pre men appausal is either the moxifen or an aromatase inhibitor plus ovarian suppression and for post men appausal and aromatase inhibitor is preferred. For those triple negative patients remember that all those with positive lymph nodes or tumor more than one centimeter need chemo therapy and it's that AC plus T regimen. And for those some smaller tumors can get away with just TC which is those attacks will be cyclophosphamide. And for those that receive new adjuvant chemo that are triple negative remember that if there's residual disease you can give capside to be. And then in the metastatic setting some category one high yield points are that if someone has bone met you should be giving bone protective therapies such as this phosphinate or denosa map. Remember that first line aromatase inhibitor or full vestra plus CDK for six if you're you are positive. Remember that now the preferred second line in her to positive metastatic is trust to the map directs the can and it does have that rare toxicity of special interest which is interstitial lung disease. And remember that for any tumor that is BRCA one or two you have the option of a prop inhibitor and breast cancer those are a laparib and talazoparib. But in any other tumor types that are BRCA positive we also have approvals with these drugs. And then we certainly felt like we had a lot of questions on inflammatory breast cancer so in the localized setting remember that new adjuvant therapy is preferred followed by mastectomy. Yeah and I think the mastectomy is the big key once there is no breast sparing surgery for the inflammatory breast cancers that definitely was a question for us. And so switching gears to the hematology boards now. Big thing for this is if you're more onc minded like me and cream the hea boards at least gave me more anxiety on the onc boards I feel like I had a better grasp on and to be honest I focused a lot of my hea board studying on the malignant hea questions and those topics. Again the malignant hea is a large chunk of both exam days there is malignant hea on both the oncology boards and then also the hematology boards and it's actually the largest chunk of the hematology boards. The benign hea topics I actually studied them earlier on in my studying plan so it was more my July August. And I did a quick review of the cheat sheets leading up the month to week prior to the test just because I knew that was not my strong soup but I needed to brush up on them quickly. And so I'm going to be back for the morning of I have to tell you guys I reviewed the hemoglobin electrophoresis PowerPoint and video that was provided by the ash board of you series is a free board of you series I hope you guys have all used it already. And doctor Alice Ma has put together the best review of hemoglobin electrophoresis that I have ever encountered. So we'll do a full episode on this soon, but doctor Maz review really is hand down the best and I or Karin and I think we'll never do it justice. But briefly just to remember normal hemoglobin has two alpha chains and two beta chains hemoglobin A is alpha alpha beta beta hemoglobin A2. 2 is alpha alpha delta delta. Himoglobin F is alpha alpha gamma gamma. And the normal hemoglobin makeup that we usually have is hemoglobin A is about 95 to 98 percent. Hemoglobin A2 is about 2 to 3 percent. And hemoglobin F is 1 to 2 percent in an adult. And so the hemoglobin opethies that you absolutely need to know how to diagnose based on electrophoresis includes all of the thalassemias. Hemoglobin S, hemoglobin C, hemoglobin E, sickle cell trait as well as sickle cell disease, hemoglobin lapor and hemoglobin constant springs. Because I tell you there was a lot of these questions on our hematology boards in each of this section. So if you review one thing and benign him the day or few days before, I think that it should be a hemoglobin electrophoresis. Yeah, I definitely agree very highly tested and I'm going to cover two other features of benign hematology that we felt were highly tested as well and maybe certain things that we don't necessarily see that often on a day to day. And so one of the things I really loved was SAMs Von Willebrand review. So if you want to get the question right, remember that the type 1 and 3 are the quantitative defects with one being a partial defect and three being a complete defect. Whereas all of the type 2 Von Willebrands are qualitative issues involving the membrane factor. And I really love SAMs nomonic with type 2a having large and intermediate size multimmers which are absent. And so she remembers this by thinking of a type A personality, individual folding multimmers so they're making them very small and compact. So there's no large or intermediate size multimmers. The type 2b, she remembered b being biting up the platelets and you'll have trombocytopenia because of this. And because of this, you will never give DDAVP as it will cause a release of more defective on Willebrand factor and will worsen the trombocytopenia. And then type 2n in this on a test looks like hemophilia A and will likely present like a female because unlike hemophilia A it's not X linked. And so she remembered this by the n being non male hemophilia. And then finally type 2m is very rare with variable bleeding. And there's a pronounced decrease in Von Willebrand factor activity but all the multimmers are present. So she remembered this with the n standing for multimmers which are normal. And so you can listen to the full episode which we cover all of the different diagnostic criteria and treatment but this was definitely something that you can commit to memory and get those couple questions right. And another section that we haven't covered yet in an episode but we did feel like this was highly tested. Our hematology congenital bone marrow failure disorders. And I would definitely rewatch that ash lecture on these disorders the day before if you can. So one thing to remember is that all of these bone marrow failure disorders have an increased risk of AML as well as solid tumors including spleen mastell carcinoma. And some of the features for some of the most commonly tested ones are that for disc care totals congenital. Remember that you're going to have skin and lung findings. And that is characterized by pulmonary fibrosis, skin and nail findings, cirrhosis and the diagnostic workup is telomere length analysis and the treatment includes androgen therapy like Danazol. The second highly tested bone marrow failure disorder is vancogninemia and that is characterized by gonadol abnormalities, short digits, hearing loss. They can have cafeo-laith thoughts and you are going to diagnose this by chromosome breaks and lymphocytes and the treatment is also androgen. The third disorder is diamond black fan and for this one you have primarily arithroid abnormalities and you can also have thumb and cranial facial abnormalities, increased heart defects like VSD and you'll find an increase HBF. And the diagnostic lab is arithrocyte baminate and the treatment is steroids but not antigens. And do not accept that diamond black fan with schwamen diamond they both have the word diamond in there. Schwamen diamond is primarily an issue with neutropenia not anemia like diamond black fan and schwamen diamond also have pancreatic insufficiency as well as failure to thrive. And one of the ways that I remember this is that the Chicago black cocks, so black cocks black fan, the jerseys are red so it is primarily an issue with red cells. I think it is very happy. As a Chicago black socks fan I enjoy that one. And so one last thing that I both wanted to cover is that for both exams oncology and hematology, there's a few other categories that aren't necessarily based around a topic of a malignant hemedysia or a solid tumor. And those are things like know the black box warning for drug toxicities. These are the big toxicities that everyone walking into their boards should know and they're the most tested toxicities. I say this because the boards are really trying to keep in the words of one of my prior teachers and during fellowship, they're trying to keep the dangerous drivers off the road. So you want to know those black box warnings so you aren't ever going to give someone those and also they're heavily tested. Another big topic that you guys should just review quickly is clinical research methodology. Know what a phase one trial is. Know how that they're built. Know how to interpret a hazard ratio and understand and tend to treat analysis. This is something you guys can quickly brush up on. It's things that you guys know and have seen time and time again so you can get all those questions right. Another topic is ethics. These are generally common sense type questions. So I don't necessarily think you need to stress or study for them per se, but keep in mind that ethics is going to be on there and you're going to see those questions. Along those same lines is know the times in oncology that we recommend surveillance. It's not a lot. And so therefore those are going to be the tested scenarios where surveillance would be the right answer or observation. Also know when to recommend best supportive care and this is mostly based on having a worse econ performance status. So know when not to harm someone with our treatments, even though you have good intentions in mind, know when to call best supportive care and palliative care. Also haven't gotten to this topic either, but again supportive care. So the risk factors for chemotherapy related illnesses, how to treat, how to manage those toxicities of hormone therapy and both men and women. So those are going to be big questions that they're going to ask. Mostly common sense things that we've all encountered, but we'll do maybe some further episodes in the future. And then one last thing that we want to talk about is wellness. You know, you guys are walking into another board exam. This is not your first board or board style exam. We've been through many of these. They're long, they're tedious days staring at a computer screen in a proctoring center. So make sure you guys are sleeping while you're eating while you're getting regular exercise and fresh air. Do not forget these things you've heard many times now because this is another board exam. Don't ignore the things that you know you should be doing. Also remember, there's no true cramming for boards. The day is leading up to these exams should really be for light reviewing, getting yourself in a good mindset, trying out to cram, rewatch every video, you can't redo every question. So this is just a mental relaxation of yourself. And remember the pass rates are pretty darn high for these. This is in your favor. So try to walk in, you know, confident you guys can do this. You guys will pass this. Yeah, I definitely agree. Don't forget about wellness. And so we're wishing everyone the best of luck on the boards if you're taking them this year and please let us know if you found any episodes particularly helpful. If you do take them, we'll not be releasing a new episode next week, but happy Thanksgiving to all. If you celebrate and we will be back with more new exciting content in December. And as always guys, thank you so much for listening. Feel free to reach out to us with comments or suggestions for further episodes on our Instagram or Twitter to onks. [BLANK_AUDIO]