The Art of the Viva: Mastering the Oral Board Examination

The Oral Board Examination (Viva Voce) is the final gatekeeper. It is a unique beast, distinct from the written exam. The written exam tests what you know; the viva tests who you are as a surgeon.

Are you safe? Can you make a decision? Can you handle pressure? Can I trust you with my mother's hip replacement?

This guide breaks down the psychology of the viva and provides structural frameworks to handle any question, even when you don't know the answer.

The Psychology of the Examiner

Examiners are human. They are tired, they are bored, and they want you to pass.

• The "Safe Surgeon" Threshold: The primary goal of the exam is to screen out dangerous candidates. If you are safe, you pass (Score 5-6).
• The "Colleague" Threshold: To score high (7-8), you must engage the examiner as a peer. You must demonstrate nuance, acknowledge controversy, and justify your decisions.

The 3 Golden Rules

1. Listen to the Question: If they ask "What are the complications?", do not list the indications. Answer the specific question asked.
2. Pause: Take 2 seconds before answering. It shows you are thinking, not regurgitating. It calms your adrenaline.
3. Structure: Never give a shopping list answer. Use a framework.

Universal Frameworks

1. The Trauma Framework (The "Resus" Approach)

Use this for ANY acute case (fracture, infection, compartment syndrome).

• Emergency: "I would assess this patient according to ATLS principles, ruling out life-threatening injuries."
• History: "I would take a focused history regarding..." (Mechanism, comorbidities, timing).
• Exam: "I would examine the limb, specifically looking for..." (Skin condition, Neurovascular status, Compartments).
• Investigate: "I would obtain orthogonal X-rays..."
• Classify: "This is a [Classification] fracture."
• Plan: "My management depends on patient and injury factors. Options include..."

2. The Elective Framework

Use this for OA, instability, deformity.

• History: Pain, Function, Instability.
• Exam: Gait, Look, Feel, Move, Special Tests.
• Imaging: X-ray (Weight bearing!), MRI/CT if indicated.
• Non-Operative: (Always start here!) Physio, Analgesia, Injections, Modification.
• Operative: Indications, Options (Joint preserving vs Replacement), Risks.

3. The Basic Science Framework

"Tell me about Bone Morphogenetic Proteins (BMPs)."

• Definition: "BMPs are members of the TGF-beta superfamily..."
• Mechanism: "They work via..." (Chemotaxis, Mitosis, Differentiation).
• Clinical Use: "They are FDA approved for..." (ALIF, Open Tibia).
• Complications: "Risks include..." (Heterotopic ossification, Radiculitis).

4. The "Complications" Framework

"What are the complications of a Total Hip Replacement?"

• Don't list randomly. Group them:
  • Intra-operative: Fracture, Nerve injury, Bleeding.
  • Early Post-op: Infection, DVT/PE, Dislocation.
  • Late: Loosening, Wear, Late Infection.
  • General: MI, Stroke, Death.

Verbal Jiu-Jitsu: Handling Difficult Situations

The "I Don't Know"

Never lie. They will smell it.

• Bad: Guessing wildly.
• Good: "I cannot recall that specific classification at this moment, however, my principles for managing this injury would be..." (Pivot back to safety/principles).
• Better: "That is outside my immediate knowledge base. I would seek senior advice or consult the literature before proceeding." (Shows safety).

The Aggressive Examiner

Some examiners play "Bad Cop." They interrupt, frown, or challenge you ("Are you sure about that?").

• Tactic: Do not get defensive.
• Response: "I recognize that is a controversial area. While X is an option, in my hands, I believe Y offers the safest result because..."
• Hold your ground: If you are sure (e.g., compartment syndrome requires release), do not back down just because they challenge you. They are testing your conviction.

Body Language and Presentation

• Sit forward: Engage.
• Hands: Keep them visible and still. Do not fidget.
• Eye Contact: Look at the examiner, not the floor.
• Dress: Conservative suit. Look like a consultant.

Conclusion

The viva is a game of confidence. You have done the work. You know the medicine. The exam is simply a performance to demonstrate that knowledge. Structure is your safety net; when the pressure hits and your mind goes blank, fall back on your frameworks.

Clinical Pearl: The most common cause of failure is not lack of knowledge; it is starting surgery without mentioning the soft tissues or the patient's comorbidities. Treat the patient, not the X-ray.