Treatment Algorithms in General Surgery Board Exams

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Clinical knowledge is primarily tested in medical board exams. Commonly asked questions on the general surgery board exams assess the knowledge regarding treatment interventions. The following three different aspects of treatment can be tested:

• Specific treatment intervention details
• Treatments by disease variants and in specific populations
• Treatment algorithm

This post is focused on treatment algorithms. Treatment algorithms are described as an ordering of treatment interventions in ranks starting with first-line treatments followed by second-line, third-line, and fourth-line treatment interventions, eventually ending at the last-line treatment intervention.

On the exam, some questions describe a case vignette in which the patient shows an indication for first-line treatment, and the response options available have a first-line treatment intervention as an option.

Such a question is usually easy, as it only assesses knowledge of first-line treatment interventions. It would be an appropriate question for rare disorders, for which only basic understanding of clinical management is needed, or a common disease that is mostly treated by a physician from a different specialty, for which you are required to have basic knowledge of disease presentation, assessment, and management. For example, a general surgery condition can be tested on orthopedic or neurological surgical boards, or a vascular condition can be tested on general surgery boards.

Another type of question can be a case vignette that assesses the knowledge of treatment interventions at lower ranks in the order of the algorithms; for example, second-line, third-line, fourth-line, and so on. These questions can be structured in two different ways.

The first method is to include the information in the question regarding the patient, making clear that first-line treatment intervention is not an indication. For example, the question may describe a patient with an allergy to a first-line treatment intervention and has responded poorly to it in the past, or the patient had a severe adverse reaction from a prior trial of the first-line treatment intervention. Therefore, you are given a reason in the question to seek treatment interventions other than the first-line in the response options available.

The second method is that the question may force you to pick a second-line or lower treatment intervention by not giving an option with first-line treatment in the list of available response options for that question. The stem describes a case for which a first-line treatment intervention would be chosen if available, but the response options lack any first-line treatment interventions. Hence, forcing you to choose the best response option from the ones available.

Example Exam Question from General Surgery

A 55-year-old woman presents to the clinic with complaints of increasing bloating, nausea, and dull, diffuse abdominal pain for the past two days. She had passed a small amount of diarrheal stools followed by the absence of flatus and bowel function. She underwent total hysterectomy ten years ago. On examination, there is a lower midline laparotomy scar, and abdomen is diffusely tender. The patient is vitally stable. What is the next step in the management of this patient?

1. Exploratory laparotomy
2. Pass nasogastric tube
3. Initiate IV fluids
4. Order abdominal radiographs
5. Advise dietary changes and follow-up after one week

Question Explanation

The above patient is most likely suffering from small bowel obstruction, according to her presentation, possibly due to adhesions from previous abdominal surgery. Order abdominal radiographs is the correct answer and should be the next step in the management of this patient because the patient is vitally stable. Exploratory laparotomy is incorrect because it is indicated in clinically unstable patients with suspected small bowel obstruction, which is not right for this patient. Pass nasogastric tube is incorrect, as it is indicated if radiographs show signs of complete or partial obstruction. Initiate IV fluids is incorrect because it is indicated if radiographs or scans reveal signs of complete or partial obstruction. Advise dietary changes and follow-up after one week is incorrect and is not indicated in patients presenting with signs and symptoms of small bowel obstruction.

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