Absite Smackdown! · Episode 54: You Just Took The Test & Aren't Confident...Now What?


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Jessica: Hey, y'all welcome back. It's me, Jess, your host of the Absite Smackdown podcast. I'm here today with Dr. David Kashmer. Hi Dr. David!

Dr. Kashmer: Jessica. Good to be back with you again.

Jessica: Thanks for coming on. So I'm pretty excited today because yesterday everyone took the Absite test.

Dr. Kashmer: Well, yeah, mostly, across the country, you know, it's actually given at different times over like a two week interval, so different general surgery residency programs take it at different times, but really one of the earliest you can take it is January 28th. So like you said, very recent, but a couple of programs may still be left to go.

Jessica: Oh, okay. I didn't realize that. I thought it was one test date. So you taught me something new today.

Dr. Kashmer: Yeah. And it's actually really important because the American Board of Surgery looks for irregularities in testing. Meaning, you know, if a general surgery residency program on the West coast takes it later than someone on the East coast and they talk, and there's now a disproportionate number of correct answers on the West coast, that may mean something. So that's why in one of the earliest talks that we do for the Absite Smackdown Review, we talk about how important it is to just play the game straight. You know, don't violate the ethics policy. Not that you would anyway, but really just focus on letting it be the test it is for you and what you know, and your preparation.

Jessica: Right. Okay. Awesome. So I think what we were going to talk about today is you just took the Absite and you don't feel confident...now what do we do?

Dr. Kashmer: Yeah, Jessica, the Absite exam is really an interesting test. Just a couple of questions on either side, you know, better than your group or worse than your group changes your percentile performance a lot, at least usually most years. And so, you know, it's very common to finish your Absite or when you get to things like surgical critical care boards, you take the test and you say, "Oh man, I don't know if I passed that, even though I studied so hard." So yeah, this is all about what to do if you just took the Absite exam and you just don't feel confident with how you did on behalf of your general surgery program. I think it's a timely topic obviously, and it's something good to cover for our surgical resident colleagues out there.

Jessica: Okay. 'Cause obviously there's a difference if you don't just take the examination one time, it's not one and done, you have other shots at it. And so, you know, what would you say is the different between your first time to take it your last time to take it? Your reaction or how you feel about how you did.

Dr. Kashmer: I know what it was for me my first time. I pretty clueless. but not clueless so much about the content that was on there. I was clueless about basic things like, "Hey, make sure your schedule is such that you're not on call the night before. If you can help it." My first time I took it, I was kind of micro-sleeping during the test. You know, I saw it coming, but this call schedule was what it was and it was made. And you know, you can try to switch off, but everybody and their brother knows when the Absite is and they won't want to switch on. So, you know, other people had requested vacation or just done something to make sure they weren't on call. And I wasn't that savvy. I was focused on doing the clinical work that was in front of me as a resident.

Dr. Kashmer: you know, in our program you would have charts delegated to you from the upper year residents. And so I remember going to medical records one night with literally 200 charts. And these were paper charts mostly with, I don't remember how many signatures. These were like 10 or 20 signatures each just for the verbal orders, that, you know, you are not necessarily the doctor for. And they would often require discharge summaries to dictate too. So I got very quick at it and that was useful, but I'm telling you this because everyone else was much more savvy about system level things than I was. So I kind of ran into that buzzsaw and I know how it feels to finish the test and think "Oh man, I don't know. I don't know if that was my best performance." And then correct it for the future. Like everything it's sort of not exactly always about where you start, it's where you finish. And so learning from your mistakes is key. Just as an attitude in life, I think, but it definitely applied to this. So I remember that feeling about how it was the take the test and then say, "Oh man, I don't know." And I remember how I responded. So that's how it is to feel not confident after you've taken the examination.

Jessica: Well, I have several thoughts just from that entire paragraph. One, you know, talking about paper charts and going to medical records, which no one has to fall on that sword anymore because that doesn't even happen. That's not a thing. All digital. They will never understand that. Where are you going to have to check out the x-rays like, can we get x-rays for the doctors that have come back? They don't know what that's like. But what was your feeling after? When you walked away and said "I don't feel confident. I don't think I did well." What did you do? What was your plan?

Dr. Kashmer: I hadn't really explored what may happen if I didn't do well. That's because I'd always been fine with tests and I'd studied for this one, somewhat, not as much as I'd like to, and not as much as I eventually did, but I thought, okay, it would be reasonable. I also want to say something quick about the medical records. You're right. There are no paper charts. You can't show up at 10:00 PM to medical records, you know, and have this happen to you. But, I wonder whether with the electronic records if residents delegate these things to each other, or if they just sign it, I don't know how exactly it works nowadays in different programs. In the three or four I've worked with, I know how that worked. But I'm not sure in programs across the country. If you know, the interns still get thousands of things in their inbox or whatever.

Dr. Kashmer: And by the way, clearly this is a sore spot. Before I go on charts, the day count on the charts would be, like 50, 60 days, a hundred days. So when they would come to you, they would automatically be late. And so they never stopped just because it switched doctors. So you would show up with a hundred charts, all overdue and you just have to stay and power through it with a cup of coffee, until like 1:00 AM, you'd be doing charts and you know, you're not on call or anything. Clearly I learned a lot from it and maybe haven't gotten over it completely yet, but I'll tell ya, as far as how I felt after and what I did for the exam...I said, okay, I need to plan this better next year. And I also felt that I need to share this experience eventually with other people to help them avoid the minefield I fell into.

Dr. Kashmer: Now, some of that is just from having good programs for medical students and having medical students have a surgical rotation that shows them really what the exam is. They can learn much more, much better than I did for whatever reason what was coming. They, probably in other programs, they may not have the same experience. Maybe they know better about the exam than I did, coming through my program. Odds are. I at least I hope so. So I had several plans and one plan was okay, eventually long-term, I'm going to share the experience. That's kind of what Absite Smackdown is. Okay. Second is let me do some reading about this and see what other people do. And since the time I was a resident and, you know, since that time people have done research and talked about things like how taking a vacation in the same month of the Absite is associated with a higher score.

Dr. Kashmer: There are studies on it now, and we share those via Absite Smackdown, because I think it's the right thing to do. In some of our chapters and here on the podcast, you guys have been nice enough to let me share it. In fact, that's why I do all this and take the time. It's just to help people be better surgeons or, have a better training experience than I did. I think that's important. Not that mine was bad. Don't get me wrong. It trained me to be very good at, you know, certain things. and especially things like wading through the paperwork, in addition to the cognitive and technical things you need as a surgeon. So anyhow, one of the things was I've got to share this long-term too. And let me do some reading about what's associated with a good Absite score. There wasn't much out there then. And then third it's, I've got to set things up next year for success. I need to do better than this in my next year. Both study-wise study plan wise. And, I need to do better in planning my time around the Absite exam for things like call or the rotation I'm on. If I can change that. So that's what I did.

Jessica: Right I think this can be kind of a hard topic because a lot of people don't want to admit to the struggle or feeling like they didn't do good, you know, admitting any type of failure in the field can be frowned upon. And so walking away from this test and just having that negative feeling like I didn't do well and feeling panic to not being able to talk about it, you know, everyone needs to understand this is not, it's not the last time. There's so much more, you can do that. You can move forward from this and what you can do. And just not feeling alone in that. Like, I don't think people really like to talk about when I don't didn't do well. And this know it gives an opportunity.

Dr. Kashmer: Well, there's an old line that "good judgment comes from bad judgment" and there's a certain component to experience with all of this in addition to training. and I think the key is to show that you've improved over time. One of the challenges is, you know, we know certain things about the Absite. If you score less than 35% at any time during residency, you're at a statistically significant increased risk not to pass your qualifying exam, the written exam on the first try. It doesn't mean you're not smart enough, or even you didn't study enough. It's just a statistical marker of risk. But you know, in one of our other blog entries and podcasts, we talked about the fact that when you do the math, when you take that evidence and you use the odds ratios from it, you calculate that. In fact, even if that happens to you, you're still more likely to pass your qualifying exam than you are to fail it.

Dr. Kashmer: You're at an increased risk to fail, but don't get me wrong. Overall, even with that, you're still more likely to pass on the first try than you are to fail. We did the math with it. You don't hear that part of the story when people have this happen to them, you just have their program usually really focused on some type of plan to make sure they do better and it can be, it can really push them toward the anxiety part of that Yerkes-Dodson curve that we talked about in the last podcast-that performance curve. So bottom line is, yes, you're right. That's not something people love to talk about and none of us as surgeons do, but a lot of it's an opportunity to, you know, do better and have the next group that comes through training be positioned better than we were when we came through training originally.

Jessica: Right. Exactly. Or you just have to step back from them for a moment and figure out why do I feel like I didn't do well? Is it because I was on call? Is it because I didn't sleep? Did I not know the material? Did I not study appropriately? You know, there's so many factors to it and figuring out why you don't feel confident, what went into that, and then being able to correct it are all key. That's really the key in moving forward, because you will have to move forward.

Dr. Kashmer: Right. Yeah. And in the moment, you're not sure, you know? You feel like, "I should be able to handle a night of not sleeping or sleeping minimally before I take the test." You feel like, "Okay, that's going to be part of Surgery. How much of it was that? And if I knew the material better, would I have been able to overcome that? Would a better review have helped? Would I have not done the micro sleep thing?" I don't have the answer. When you're in that moment, there's a component of "How much is me, how much is the situation?" You don't have the best perspective on it because you're in the middle of it. So then it can become like an all-hands on deck thing where you say, "Okay, I'm going to study and review better."

Dr. Kashmer: I'm going to try to set my schedule better. I'm going to just do it all because I don't know what matters. I don't think that's the wrong approach, but that is a very common one. And then the program you're in will often put you on a not exactly remediation, but a study plan to try to make sure you do better in the future. They want the best for you, but that can be tough too, because it, it can basically be time. It can be time with the program director or the assistant program director. And that can just take up more time and not be super high yield. And it can feel pejorative. Not that it, it does always don't get me wrong. but that may not feel great. It can feel like you're, you know, doing one-on-one tutoring with your teacher because you're stupid. Even if you're not. Clearly these surgical residents have gone through medical school. So I don't have an easy answer. And I'm not saying every program does it the same for when a surgery resident performs poorly. They don't, but it's easy to see how it can feel that way. And that can make it a really tough situation.

Jessica: Right. I mean, you only know from your experience, not just as a resident, but being a program director, how you handle it. Every general surgery resident is different. They learn differently, they study differently. You know, it's just making a plan and re-assessing yourself and doing better. I mean, at the end of the day, that's all you can do.

Dr. Kashmer: You know, it is. And I think, just to speak with the previous program director hat on, remember we talk about this all the time on here. The Absite exam was originally designed to tell the programs how well they were educating. So if you have a resident who you feel doesn't perform, you have to ask yourself how much of this is me? How much of it is our program? You know, some programs don't even let residents be on call the night before the Absite. No resident is on call. That's tough to me too, because that sort of is like saying, well, you're not going to be smart enough if you're on call the before. That's a dangerous precedent in Surgery. Some may interpret as saying: when it's really important and you have to take this test, well, there's no call the night before. But a lot of programs do that.

Dr. Kashmer: I'm not saying it's wrong at all. What I am saying is that it was stunning to me when I saw other programs do that. That's a great idea for how to make sure it's fair for everybody who takes the test. But then I thought, well, what statement does that make about call? And whether we really are smart enough after call. There are lots of studies showing no difference in performance and outcomes from surgeons who are post-call. So if we're going to stick by that, well, I mean, then shouldn't someone be on call? It did happen to me again during residency and that time it went differently, because of some different things I did. I was prepared for it, and I think that it made me better.

Dr. Kashmer: The bottom line is here that it's a complex issue. As a program director, the Absite is a referendum on our program and faculty. I know I'm talking a lot, obviously I feel strongly about it.

I want to add another thing too: in programs that are small, where you have three categorical residents...when one doesn't pass or do well, you know, what does that say about your program? That's a 30% poor rate or when one doesn't pass their boards, that's a 30% rate of not passing their boards on the first time. You just don't have a big enough sample and just one is a real problem. What does that mean? Is the program not good overall? Does it have an issue with its faculty? I don't know. I don't know the answer to this, but I'm saying for small programs, that can be really tough situation. When you have a one resident who under-performs compared to what they can do. Tough situation.

Jessica: All right. Well guys, thanks for tuning in with us. And again, this episode was about: So you took that Absite. You don't feel great about it. What do you do next? Thanks. And we'll be back soon. Thanks David, for being on here, I'm glad you're passionate about it. Thanks for being on.

Dr. Kashmer: Jessica. Appreciate you having me on as the cohost now regularly. And, you know, I think we're hitting some good topics around the time of the Absite.

Jessica: Thanks guys. Remember #AbsiteSmackdown!

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