Hello, and welcome to the 2020 ACOM Occupational Medicine Board Review course. As most of you know, this was to be the course offered at the 2020 AOHC, but unfortunately had to be canceled because of the coronavirus pandemic. We hope that in this virtual course, we'll offer you the same content and material as we do in the regular course, and we'll be around virtually in person during a time that this course goes on. So come on aboard and participate in the board review course for 2020. We'll briefly introduce the faculty. I'm John Meyer. I teach and practice at the Celikoff Centers for Occupational Health at Mount Sinai. I'm currently the residency director there and have directed residencies at other schools of public health and hospitals for the past 20 years. Francesca Litto joins me. She is currently the medical director for the Norfolk Southern Corporation and has been the residency director at the Uniformed Health Service University and at Johns Hopkins School of Public Health prior to assuming her current job. We'd like first to point out what this course can and can't do. What we'll be doing in this course is helping you assess your current knowledge of occupational medicine, including coverage of areas that you may have forgotten or incompletely covered in the past. We'll outline the major content areas of the exam and tell you what to emphasize in reviewing, and we'll give you an idea of what the most important facts and concepts are that generally show up on the exam. Now this will be a specific occupational medicine board review course. We're not going to cover epi and biostats, health services research, preventive services, and the material that show up on the core examination. For those of you who are taking the course for the first time or first-time certifiers, some of the material will be recommendations for review texts, but we're not going to talk about those specifically. So by contrast, here's what we're not going to be able to do. I already mentioned we're not going to provide a review of concepts and knowledge in the general preventive medicine and public health area. In other words, what shows up on the core exam. We can't anticipate every kind of question that they're going to throw at you. We'll cover most of what gets outlined by the ABPM in their course outline, but occasionally they'll throw you curveballs, and it's just hard to anticipate what they do with that. Most of all, we're really going to assume that you have seen this material before, that you've seen it in your residency training or that you saw it in residency and subsequently in practice, but the assumption is that you have learned most of this material somewhere and that this is really a course refresher. A lot of it's going to seem like drinking from a fire hose because we will go on through things fairly quickly, but I think it probably helps us to assume that most of this material has been seen somewhere before. For those of you recertifying, the one thing I really can't do is provide you with numbers on what the pass rates are. I don't know of anybody who's failed the recertification examination, so that's why we estimate that at least 95% and probably very close to 100% have passed the recert exam to date. What they're really trying to do in an underserved specialty is to check up on you at various times. Right now, it's every 10 years that you can demonstrate continuing mastery of content and with the other requirements for recertification, be able to safely, effectively, and knowledgeably practice as an occupational medicine physician. In other words, they're not looking to get people out of the specialty. The key word here is if you're taking the recertification exam to relax. The exam now is given by computer, both the primary boards and now the recertification examination. For the primary boards, you generally go to a testing center. There's 150 questions on the core examination, which is general preventive medicine, including epi and biostats, and 150 questions in the occupational medicine specialty. It takes a full six hours to complete the exam. For the recertification examination, it's 100 questions. You can now take an electronically proctored examination from your office or home. These are all specialty occupational medicine questions, and again, relax. You don't have to relearn epi and biostats. So the question on everyone's mind is, of course, what do I study? And we're going to cover that in the next couple of slides. For those of you taking the primary boards, the questions generally come from preventive medicine practice with a high representation of questions on epidemiology and biostatistics, less so on clinical preventive medicine, but they have the whole range of preventive medicine material on them. The other thing of note is, for those of you taking the core, they have emphasized infectious disease, particularly infectious disease epidemiology, along with some clinical preventive measures, including vaccinations. For occupational medicine, 60% is clinical occupational medicine. This includes occupational diseases and disorders, along with some toxicology. The remainder of the exam, which covers a really wide range of materials, is on industrial hygiene, things like exposure assessment and hazard recognition, along with the administrative practice and systems-based practices unique to occupational medicine. This is going to include things like drug testing, CDL examinations, disability management, and work fitness. Willie Sutton was a famous bank robber in the 1930s Depression era, and some reporter once asked him, Willie, why do you rob banks? And his answer was very simple, because that's where the money is. So where's the money in studying for the med boards? Where do you get the most bang for your buck? If you're a first-time taker and initial certification, you want to really study epi and biostatistics very well, secondarily clinical preventive medicine. If you're taking the OCMET examination, of course, clinical occupational medicine, along with toxicology, is going to be the area to put in a lot of effort, because that covers more than half of the exam in total. Those of you recertifying in occupational medicine are going to ask, what's new on the exam? What's different in the exam since I took it 10 years ago, since I took it 10 years ago and 20 years ago? Couple of things. There's probably more emphasis on clinical occupational medicine and some change in emphasis. They do emphasize the traditional toxicology, the metals, the solvents, asbestos, and silica, along with pesticides. But there is more clinical OCMET, particularly in the musculoskeletal area. There's more about asthma as a pulmonary disorder, rather than the dust diseases, and things like indoor air quality, travel medicine, and infectious disease. There is more emphasis across the past 10 years ago on things like transportation medicine and CDL exams, which have really grown into their own in the past decade or so, things like drug testing and management of disability. As I mentioned, it's probably about the same, and there's always going to be classic occupational medicine toxicology involving lead, mercury, and the standard metals, solvents, pesticides, and dusts. Because the nature of OCMET practice has changed a bit across 10 and 20 years, there probably is less about the administrative aspects of corporate occupational medicine and probably somewhat less about agencies and regulations. And environmental medicine is generally left for the core examination now, rather than the specialty OCMET. A common question about the boards is what the cutoff date for new knowledge might be, and the board really doesn't say this. However, what we do know is that exam questions are in the pipeline for about a year to 18 months, and they're being constantly revised, edited, reviewed for accuracy and the like. So a safe recommendation would be that anything that has come up new in the past year to a year and a half, maybe even two years, or that isn't well accepted won't be on the examination. You certainly will not see questions about coronaviruses in October, even though it's a big and the biggest problem occupying us now. For those of you taking the core examination, you should probably review the MMWR recommendations on things like vaccination, updated TB treatment and the like. And anything that's come out in the recommendations line in the MMWR that's a year or so old would probably be fair game for the morning or the core exam. So just to review a little bit more, we always get asked what the questions are like, and the board has moved more towards asking second-order questions, and that means they're looking to make a connection from what you know about toxicology or epidemiology into clinical med or to reason backwards from what you know of clinical medicine into the toxicology of the materials. This replaces that earlier focus on first-order questions, and what that means is that the single right answer depended on your memory only. So just to enlarge on that a little bit more, esoteric toxicology was a common complaint around first-order questions, so here's a typical question. They would ask you what the clinical finding of a green tongue meant in terms of exposure, and of course you probably, in a split second or two, decided that vanadium was the answer to that question. It's pure memory, and how many of us have really seen a green tongue anyway? The point of the second-order question is that they want you to integrate material between clinical medicine and epi or toxicology, so here's a typical question in which they don't necessarily give you either the disorder or the exposure. A farmer is seen in the local ED, and he's shocky, in cardiac and respiratory distress. He's tachycardic, and he appears jaundiced. First labs show a hematocrit of 18, and his urine dip is positive for hemoglobin. They let you know his most recent task had been to clean out his cattle dipping tanks, and then they present you with a choice of the most likely cause, and here's the list of the most likely causes. Most of them are associated with work on a farm, but beyond that you have to decide which among them might be relevant. And these second-order questions follow a two-step process. First ask yourself what's the disease or disorder being outlined, and then what are the exposures that are associated with that type of occupation, which are as well associated with the disease that you came up in step one. So first step, ask yourself what's the disease. What little information they've presented to you here is suggestive of massive intravascular hemolysis, right? The guy's got a low hematocrit, the guy has hemoglobinuria, and he's tachycardic and in shock. So part B, which one of these are associated with the work? Organophosphate pesticides are used as insecticides in dipping. Arsenical pesticides, choice C, also used as insecticides in dipping. Pyrethrin gas isn't used on farms, but it is a byproduct of arsenic pesticides, and pyrethrin pesticides are also used as an insecticide in dipping. So four out of five of these are potentially used as pesticides in dipping. The one you can right away exclude is hydrogen sulfide, because its association on farm is not with insecticides, but with pumping out manure pits. So that leaves us with four potential answers. However, only one of them is associated with the disease, if we go back to our deciding that this was related to massive intravascular hemolysis. So OP pesticides are not. They're associated with autonomic nervous system dysfunction. Remember the mnemonic dumbbells, but we'll look at that later on in the course. Hydrogen sulfide we already excluded, but it's a chemical asphyxiant. Arsenical pesticides don't have a lot of acute problems, except for nausea and vomiting. We're mainly concerned with the chronic disorders from that. And choice E, pyrethrin pesticides, have pretty low acute toxicity. There's skin and respiratory irritants, but don't send you to the ED like the example we've shown. So only arsenic gas is really associated with our diagnosis of acute intravascular hemolysis. So to put that all together, what we've got is arsine gas inhalation. It's associated with the disease of acute hemolysis. It's associated with the work, which is cleaning out the dip run after the farmer used arsenical pesticides. And what's happened there is that there was interaction of acids from the water and the washing up with arsenic from the pesticide, which formed arsine gas or arsenic trihydrogen and caused the intravascular hemolysis we've seen in the example. This is rather a roundabout way of getting to the answer, but I wanted to demonstrate how the second order questions work and to see how you can put that information together, even in the fact that you haven't been given necessarily the specific toxicant nor the specific disease or disorder. So when you're studying, you want to integrate this information, as we saw in the last set of slides, about the question. Think about occupations. Think about their work practices and think about what they're being exposed to. Think about the routes of exposure. Some things are inhaled, some things are absorbed through the skin, and some might be ingested. Their mechanisms of action, which is the toxicology that you may have learned about these materials and what clinical manifestations, in other words, what diseases or disorder they cause. And always remember too that we're a preventive medicine specialty, so our focus is going to be on control of toxicants and adverse exposures and preventing them in the first place. I don't want to spend a ton of time on the materials that you need to read and review. Much of this information is also in the course syllabus. We'll touch on a few areas here. The best clinical and programmatic text for review is still going to be Ledoux, the current occupational and environmental medicine out of the Lange series book. This has gone through a number of editions and is still going to be the best book to review from. There are other sources for the materials that come in the boards, and because the ACOM occupational medicine practice guidelines cover musculoskeletal disorders in particular, the board in the recent past has drawn many of their questions for MSDs from the ACOM guidelines. These may be available to you in a variety of formats, but you may want to cast an eye on those. We'll discuss these a little more in detail when we get to the lecture on musculoskeletal disorders. The big texts like Rahm, Rosenstock, and Cullen are great for references. They're not going to be very easy to study from, particularly if you're trying to absorb a lot of material in a short period of time. Many of you find that answering a lot of multiple choice questions and reviewing the answers is a helpful adjunct to reading and reviewing. Many of you find that this is the easiest or best way of studying. There haven't been many good question banks. More recently, we have put out a self-assessment tool which incorporates 240 multiple choice questions with explanations that's offered through ACOM. The link to this is down here on the slide, and you can get 35 CME and MOC credits through working through all of those problems. For those of you like preventive medicine review, the Varkey book from the Mayo Clinic also includes PrevMed as well as occupational medicine questions. Back in my day, the ATSDR put out a number of case studies in environmental medicine. These are really good reviews for many toxicants. They have a lot of Q&As embedded within the case studies. Most of them are online. You can still get them in hard copy or CD-ROM through the ATSDR. These are really good for primary board takers to review. In addition to the general textbooks, there's a lot of specialty topic review materials on health services, on the DOT medical examination, and on drug testing. These books are probably too detailed for the boards, and Dr. Liddow in particular is going to summarize a number of them in her slides here, but many of you will be going into practice where you have to do CDL exams, drug testing, and other occupational management, so they might be good to avail yourself of for your practice, even if you don't spend a lot of time studying them for the boards. There's some good stuff in the journals way back. This might be a little dated by now, but most of it's still good. The American Journal of Industrial Medicine put out an issue on occupational medicine practice guidelines for common diseases and disorders. The JOEM continues to publish an occupational medicine forum section in which questions in practice are addressed, and one good but not well-known feature is in the Aviation Medicine Journal, Aviation Space and Environmental Medicine. There's a column in it monthly called You're the Flight Surgeon, and this is generally made available free online. They answer a question usually having to deal with fitness for duty or some physiologic problem that might be of concern in aviation and space medicine, but there's a lot of overlap with fitness for duty aspects of occupational medicine, and so this is well worth reading also. For those of you taking the primary boards, there's really only one text to go to, and it's Katzweil-Delmar-Lukin. It's known as Jekyll's Epidemiology, Biostatistics, and Preventive Medicine. Read the chapters, work through all the problems, know your two-by-two tables in your sleep, and you will pass the Epi and Biostats part of the core exam with no trouble at all. For first-time certifiers, you should also get a look online at the Preventive Service Task Force recommendations, look at the most current and up-to-date recommendations, and as well, take a look at the MMWRs, particularly the recommendations and reports, particularly in areas like vaccination or treatment of some major infectious diseases, particularly tuberculosis, but also hepatitis and blood-borne pathogen disorders. Some basic housekeeping material, if you spend more than one minute struggling with a question, just put it aside, mark it for review, and return to it later. Something else you see might jog your memory about it. There's no penalty for guessing wrong, so put down an answer, any kind of answer. It's not the SATs, so they won't take off for a wrong answer, and most educational psychometricians tell you that you should change your answer only if you're really sure of the new answer. You generally get the first answer right the first time. So just some last and final thoughts for this before we engage with the rest of the course. Start reviewing now, go slow and steady, take the course and figure out what you don't know first and review that material, and then at the very end, you can brush up on the material that you feel a little more comfortable with. As I mentioned before, integrate the material, especially what you know about toxicology and some degree epidemiology with what you know on clinical occupational medicine and try and make connections between the two of those. Those of you taking the primary examination, of course, review epi and biostats, buy the Jekyll book and work through all the problems, and that will get you through the exam fairly readily. For recertifiers, you may not have seen a lot of musculoskeletal questions in the past, but you want to cover that well as that's becoming an increasing part of occupational medicine practice as well. The boards will cover that a bit more than they used to before. And throw in all your test-taking skills, relax, make sure you read the questions, mark the ones you don't know and come back to them, and I think most everybody is going to do just fine. And those of you recertifying, of course, you have to study this material and review the material, but you can be reasonably assured that you're going to pass.

virtual course introduction

2020 ACOM Occupational Medicine Board Review

coronavirus pandemic

course objectives

exam format

study materials