1. ABCRS Question Writing Workshop Key Concepts Explained…. Najjia N. Mahmoud, MD Division of Colon and Rectal Surgery University of Pennsylvania

2. 2 Definitions  Key Concept: Webster’s Dictionary: –A general notion or idea; conception –An idea of something formed by mentally combining all its characteristics or particulars; a construct ABCRS: –Describes the phenomenon or “idea” the question is designed to test.

3. 3 Why are key concepts important?  They provide an “organizing principle” around which a question(s) can be constructed.  They are consistent between tests and through time. Aging concepts can be discarded and replaced as evidence accumulates  Multiple testing/educational providers can use them.  They should test knowledge that we believe is absolutely essential, but not necessarily exclusive to colorectal surgery.

4. 4 What are key concepts NOT?  Statements of fact “the rectum is in the pelvis” “the arterial supply to the right colon is the ileocolic artery”  Minutiae, trivia, non-core information “aspiration pneumonia is most likely to be right-sided” “the waveform of an arterial line is influenced by position”

5. 5 How are key concepts used?  The use of key concepts is evolving: In past, we used them to define ABCRS written board questions only Going forward, we will use them for: –ABCRS written board questions –ABCRS oral board questions –CARSEP –CARSITE –CREST –PDA curriculum  Key concepts will be: Open access –We want the trainee/test-taker to understand what ABCRS/ASCRS defines as “key knowledge.”  ABCRS written and oral board questions will remain secure

6. 6 Communication concerns  Problems with communication in 2015 Texting/email General degradation of clear communication  Testing is different than texting High stakes situation Shorthand is NOT universally understood (except for ) Ambiguity is unacceptable  Key Concept format is important Must be grammatically correct –Periods, capital letters, agreement! –Brevity –One concept at a time! –Active vs passive voice –The question must fit the concept and vice versa –IS THE CONCEPT REALLY KEY?

7. 7 Top 5 list of most common problems!  Too long and wordy (passive voice issues)  Compound sentences with multiple concepts embedded  Poor grammar, spelling, punctuation  Non-core or key knowledge—minutia  KEY CONCEPT does not relate to the question written!

8. 8 Active vs passive voice  Passive voice: “The exam was failed by one third of the applicants.” “The brakes were slammed on by her as the car sped downhill.” The action is performed upon the sentence subject  Active voice: “One-third of the applicants failed the exam.” “She slammed on the brakes as the car sped downhill.” The sentence subject performs the action  What happens when the voice changes from passive to active???? Brevity Clarity

9. 9 Active vs passive voice  “Leak testing should be performed when creating a left sided anastomosis.”  “ A left sided anastomosis should be leak tested.” The active voice is shorter and more succinct!

10. 10 Example: “active” vs “passive” voice  A patient with resected Stage III colon cancer should undergo adjuvant chemotherapy. VERSUS  Adjuvant chemotherapy is recommended in Stage III colon cancer.

11. 11 Examples  Oophorectomy is advised for grossly abnormal ovaries or contiguous extension of the colonic cancer but routine prophylactic oophorectomy is not necessary.  What is the problem?  The key concept should test only ONE concept. Resist the urge to combine concepts. Make two questions!  How do we fix it?  Invasion from a contiguous colon cancer mandates en bloc oophorectomy.  Routine oophorectomy in post-menopausal patients is not indicated.

12. 12 Examples  The half-life of argatroban is 50 minutes.  What’s the problem?  Not conceptual—statement of fact  Not key knowledge Important, BUT—not something that could differentiate a board certified colon and rectal surgeon from a general surgeon or internist.

13. 13 Examples  biopsy suspicious anal lesions—rule out cancer/Crohn’s dz  What’s the problem?  Poor grammar.  The intent of biopsy is implied. The question can be shortened by not stating the obvious.  What’s the fix?  Suspicious anal lesions should be biopsied.

14. 14 Examples  Severe anal pain that cannot be diagnosed in a bedside exam requires an exam under anesthesia to allow for proper diagnosis and treatment.  Good concept—too long!  Active vs passive voice  Severe anal pain requires exam under anesthesia.

15. 15 Examples  Management of anorectal disease often involves an algorithm that starts with conservative measures and progress to more aggressive ones as more conservative measures fail.  What’s the problem?  Nonspecific  Long  Repetitive  Can it be fixed?  Unsalvageable because it does not include a specific key concept.

16. 16 Examples  For patients that require surgical resection for CUC, segmental colectomy should typically be avoided  What’s the problem?  “CUC” (abbreviations/acronyms should be avoided)  Tangential to the point of the concept  Declarative voice better  What’s the fix?  Surgical management of ulcerative colitis is total proctocolectomy.

17. 17 Examples  CUC patients may have an acute flare-up of C. diff colitis and CMV and this should be ruled out.  What’s the problem?  Abbreviations!  The aim of the concept is unclear—cause and effect are uncertain. Is the “flare-up” from infection or from UC?  What’s the fix?  C. difficile and cytomegalovirus infection should be ruled out in a patient with inflammatory bowel disease and acute inflammation.

18. 18 Examples  Functional problems, especially FI, constipation, and evacuation disturbance, frequently persist despite correction of the prolapse.  What’s the problem?  Long compound sentence  Not concise  Prolapse of what? Not specific!  What’s the fix?  Surgical repair of rectal prolapse may not improve functional outcomes.

19. 19 Examples  A biopsy should be performed on any suspicious anorectal lesion that fails to heal after treatment to rule out unsuspected Crohn’s disease or malignancy.  What’s the problem?  Long and wordy  Passive  Not specific (anal, rectal)  What’s the fix?  Nonhealing anal lesions should be biopsied.

20. 20 We are here to help!  Confusion about assignment  Lack of clarity on our part  Questions about the process…..  CALL or email: Najjia.mahmoud@uphs.upenn.edu 215.219.7880 THANK YOU!