The knowledge of the test-taker regarding the details of numerous treatment interventions gets tested on the board exams. It is important to know the situations in which to select a specific treatment intervention. In addition to this, you should also have knowledge of the details of particular treatment interventions. Therefore, the question is: “how much knowledge should one have regarding the details of various treatment interventions for the purposes of board exams?”
There are certain treatment interventions that are delivered only by a specific subset of practitioners; alternatively, patients get referred to specialists for these procedures. For the purpose of board exams, you are considered to be a general and average practitioner in your specialty. Considering this, what is the level of knowledge that you are expected to have about treatment interventions that may not be administered by yourself?
One way of answering this question is to find out what amount of information is required to obtain informed consent from a patient. If you are recommending a procedure as a part of the work-up or the treatment, and yet are not going to administer the procedure yourself, it is still important for you to have enough knowledge about the procedure in order to obtain an initial informed consent from the patient. Here are some examples of the facts that you should know:
- The basic concept of the procedure. How may the procedure assist in establishing a diagnosis or treating the condition? What effects would the procedure have on the patient’s body?
- What are the benefits and risks associated with the procedure?
- What alternative treatment procedures are available, and what are the benefits and risks associated with them?
- What are the benefits and risks of no treatment?
Following are a few examples:
- A general surgeon who does not perform renal transplantation himself should still have a basic level of knowledge of the details of the procedure.
- An anesthesiologist who is not a specialist in the management of anesthesia during lung transplantation procedure is still expected to have basic knowledge regarding the procedure.
- An internist who refers many patients to cardiologists for percutaneous coronary intervention (PCI), but does not perform the procedure himself, should still know about the indications, procedure, benefits, and risks of PCI.
Example from General Surgery: What do you need to know regarding renal transplantation
On the general surgery boards, a general surgeon is expected to know the following details about renal transplantation:
- Indications of renal transplantation:
- Any condition that leads to end-stage renal disease (ESRD) such as diabetes, hypertension, glomerulonephritis, etc.
- Renal tumors
- Main concepts of renal transplantation:
- The transplanted kidney may be placed heterotropically in one or another iliac fossa.
- The inferior epigastric vessels are ligated, and the peritoneum is swept superiorly for the extraperitoneal bed to be revealed, into which the transplanted kidney will be placed. The iliac vessels are then mobilized.
- The renal vein is anastomosed in an end-to-side fashion to the external iliac vein.
- The arterial anastomoses may be performed end-to-side to the external iliac artery or in an end-to-end manner to the divided internal iliac artery.
- The ureter is anastomosed to the urinary bladder via the formation of a ureteroneocystostomy.
- The transplant bed, as well as the subcutaneous tissues, may be drained to prevent the accumulation of lymph or serosanguinous fluid around the kidney; however, many surgeons no longer place drains routinely.
- The skin is closed using a subcuticular absorbable suture.
- Absolute contraindications of renal transplantation:
- Active sepsis
- Uncontrolled psychosis
- Active drug dependence
- Current uncontrolled malignancy
- Positive T-cell CDC crossmatch
- Any medical condition with an extremely shortened life expectancy (i.e., <1-2 years)
- Potential surgical complications of renal transplantation:
- Wound infection
- Wound dehiscence
- Transplant vascular thrombosis
- Bleeding from vessels in the renal hilum
- Anastomotic hemorrhage
- Renal artery thrombosis
- Renal vein thrombosis
- Transplant renal artery stenosis
- Urinary leaks
- Ureteral obstruction
This may seem like a lot of information. However, if you are a renal transplant surgeon, you would have much more knowledge, as is exemplified by the list given below. The knowledge about these items, however, would not be required for a general surgery board exam.
- During renal transplantation, the inferior epigastric artery may occasionally be preserved and used for the revascularization of small polar arteries.
- The end-to-side arterial anastomosis is technically easier and usually is the method used in cadaveric renal transplantation.
- The number of anastomoses should be minimized if there are multiple renal vessels.
- The Politano-Leadbetter technique, which involves a transvesical ureteroneocystostomy, is the traditional method of ureteral anastomosis. However, most of the surgeons now favor the extravesical ureteroneocystostomy onlay, which is a technically simpler procedure.
Barlow AD, Nicholson ML. Kidney Transplantation Surgery. In: Feehally J, Floege J, Tonelli M, Johnson RJ. Comprehensive Clinical Nephrology. 6th ed. Philadelphia: Elsevier; 2018. pp. 1174–1185. Ch. 103.