Wont beat a dead horse, but allow me to echo what a ****ty exam this is - all the way from proportion of content tested to the way it's tested.
I passed thankfully. For those who didn't, it feels like a punch in the gut, and makes you feel like a very very small, degraded human being. This feeling will persist well into next six months. I would recommend rip it like a bandaid, and tell everyone who needs to know that you didn't pass; get it over with. Nobody should be made to feel this way, especially not hard-working, otherwise bright physicians who've done great all their lives. I say this because I've been in a similar position for other tests.
I'm here to give my meagre 2 cents on day 2 for the most part - prep ideas, and my (estimate of) coding. I didn't score as highly as some of the other folks here, but scored between 1-2 SD above mean on Day 1 and (f*ing surprisingly) almost 2SD above mean on Day 2 (makes you really wonder about this exam, seriously). Again, these are things that worked for me, may not necessarily be for you or may not necessarily be RIGHT for that matter. So be gentle.
Background: recently had finished IC fellowship at busy program. echo boarded the year prior. Scored 1SD above avg on ABIM, just a smidge above avg on echo boards.
TL;DR:
EKGs: Cautious coding. No more than 4 findings coded for unless deathly necessary. F*k the atria. Know pathologies and patterns inside out. Know reasonable number of criteria.
Echo: Careful but not restrictive coding. Avg 4-7 findings coded for. Know pathologies inside out, try to see multiple representations of all pathologies. Apparently general cardiologists read congenital echos all day, everyday, so be prepared to be tested as such.
Cath: Let em rip. Code like a boss. Avg code variable, simply dependent on what you're seeing. Be creative (ie observant), and don't just code what you see. Code what you 'dont' see (read details below).
Misc: Don't waste time after finishing day 1. Don't cry, don't spend an hour calling people and cursing the exam, don't come on SDN to say 'wtf?!' and then wait for responses. Grab lunch, take a shower, and hit the books. A LOT of what you review last day may be tested (bias). For me, that included Card-Onc, congenital and HTN stuff. Carry on for details.
Re: Coding - EKGs
Those motha****ng EKGs.
- Stems are not very helpful unless they mention stuff that was mentioned above - dialysis, SCD presentation etc. So learn to read EKGs by looking at them, recognizing patterns, and coding accordingly. Okeefe (OK) is WAY to generous in his stems.
- I did OK (about 1/2 of the website). I did EKG source high yield EKGs only. And I listened to the mayo guys EKG video x2, once night before the exam speed x2. I also attended OK's twitter thing and marked the EKGs he mentioned were high yield. Its a LOT of them, but those you should have down pat.
- I coded MOST cautiously w/ EKGs. My rule was no more than 4 findings coded. So I always thought of it as spending a code. If I run out of codes, I'm screwed, so I only coded for something that was worth coding. In order to code for a fifth thing, I literally had to BEG myself. "Please, for f**'s sake the finding is RIGHT THERE, just one more dammit are you BLIND? This could save a goddamn life!" Only then would I grudgingly allow another code.
- With that little rule, I always coded
1a) Rate (know Ok's 16 vs 17 beats / QRS vs P-waves concept inside out - if its NOT a 100, its NOT sinus tachycardia. Mark NSR and move on with your life; on occasion I used the EP concept of HR = 60,000 / cycle length in ms to corroborate - because there were f*ing EKGs which were smack in the middle of 96-105bpm and it boiled my blood during the exam thinking I could lose or gain a point because of this ****TY distinction).
1b) and rhythm (must know Oks sinus definition and how to identify lead misplacement within that definition; practice ALL the heart blocks x2)
2) one MAIN finding (eg wenkebach)
3) one SUPPORTING finding (eg LVH)
4) one ADDITIONAL related / unrelated but obvious finding (eg LVH related ST change or axis)
If you use this process (TM) you are likely to get PASSING scores on MOST EKGs (which was literally my aim here) cos I HATE the negative marking concept
The 5th code, that I would beg myself to mark, was most frequently with multiple MIs
- You MUST know the quickies. Ie the segment in the coding sheet that has pathologies. Brugada, WPW, hypo / hyper whatever. Most of them are QUICK 2-code EKGs. Sinus rhythm, WPW, BAM - cant code ST-T waves, cant code MI, cant code bundles, f*k the atria. Done. NEXT.
- It doesn't hurt to know lots of criteria for the findings, however beware only those equipped to use those criteria appropriately should use them. Otherwise you'll be finding **** that's not there (I'm looking at you, low f*king voltage). I would posit that you know enough to know when something is glaringly obvious. That being said, you really should know a lot of the criteria and just use it sensibly. It'll help in real life too, even if this exam doesn't judge you for it.
Re: Echo coding
Lord have mercy. WTF is up w/ all the congenital.
If you're taking (or sadly, retaking) this exam, watch mayo's congenital videos x2. Night before, zoom through on mute just the clips and try to pick up the findings.
- I feel my colleagues who had just taken echo boards were a lot more comfy. One year out of boards, I was rusty and could only recall f*king ARTIFACTS which I had crammed for echo boards. They don't test artifacts on gen boards because clearly we've already acquired mastery over that petty **** and need to focus our energies on reading several congenital echos a DAY.
- Some pictures are ****ty, some are ok. You can not go clip by clip BUT you can go 'click by click', and you can slow down to 1/2 speed which helps too.
- I did Mayo echo; I did EKG source (also has echo) - did all those echos, they're pretty good, have good explanations.
- Anyway. I coded a lot more liberally with echo's. Read: liberally, not carelessly. Avg number of codes: 4-7
- Think of it as having an Interventional Fellow's salary as opposed to a Medical student doing a side-gig to survive. So I'm comfortable, but I know my limits.
1) I coded EF for MOST cases.
2) Rarely commented on LV /RV size and thickness unless it was in my face (think super dilated CM or crazy HCM or case of PE)
3) Skipped diastology unless it was relevant (think constriction etc). Don't go around f*king thinking about ****. That's not what they want you to do.
4) All valve disease was mild/mod UNLESS in your face severe
5) KNOW all the PATHOLOGIES. Go over the coding sheet and if its a disease you should know what it looks like from the front, back and upside down. In hindsight, would have reviewed the same pathology from different sources. Eg hypereosinophilia look at the mayo echo, look at EKG source's echo, then look at youtube or something for the same thing so that you can recognize it in your sleep
6) Time moves a LOT FASTER during the ECHO section. Still have jitters from when I realized how much little time I had left mid-way through echos.
Re: Cath coding
Step aside b*chs, DADDY's home.
I kid you not, I coded like there was no tomorrow. I scored the best here compared to the other two. So being at 2SD, it makes me REALLY wonder - was there MORE to be coded that I didn't code for?! (doubt it, but who knows) or did I lose out on some points by overcoding (more likely). Regardless, i'll take the W.
- Eg, Prox LAD disease? code it. Circ ostially occluded? code it. RCA no disease, mid-RCA stent patent, gives collaterals to circ and LAD, code it, code it and code it baby.
- The RULE I had for CATH CODING was simple: its the worst thing(S) about each vessel. This statement is more profound than you think. You have to body-shame the **** out of EACH vessel as MUCH as you can, legally.
For example: they ONLY show a LIMA being injected, that's attached to the distal LAD that has good runoff to the apex, and flows partially retrogradely too. No disease anywhere in the distal LAD or in the graft. DONT just code "Bypass graft - LAD" and move on, because that's all you can technically code on the coding sheet from what's being shown. But, for f*k's sake, the worst thing(S) about each vessel. You need to be a bit more creative. Look at everything. Why did the vessel not fill retrograde all the way to the LM? Why did it stop mid-way? Mid-LAD is probably obstructed. Boom, code 'Total occlusion - LAD'. Is there a stent hanging in what should be the LAD and there's no retrograde filling through it? Boom, code 'Stent: occluded - LAD'. Are there collaterals from apical LAD filling the RPDA? Boom, code it.
If this same vessel filled retrogradely to the LM but had ****ty tight diffuse mLAD disease and didn't fill towards the circ? BODY SHAME EVERY VESSEL. LAD is ****ty, code severe stenosis - LAD. Why is there no flow down the circ? Total occlusion - LCx. Are there collaterals going from LAD to mid-Circ however there's a stent in proximal circ? Collaterals - Circ. Stent-occluded - LCx, code it and code it.
- Of course these are just made up examples. Point is, code everything you see. Now if you're not good with cath films, I hear EKG source has cath films too. Do those a bunch of times and code big picture, you will PASS cath section.
- I can not emphasize how important it is to REVISIT the cath images once you're done coding all.
- Every time I did a second look, I found something more to body shame. Special shout out to myocardial bridging - brought to you by the makers of gen boards who seem to be just fascinated by bridges, the least f*king consequential finding in cath. But you'll see it, and you'll catch it and you'll send over a big f*kyougram by coding it. Because if a general cardiologist ever misses a myocardial bridge on a cath film, alas, all is lost. All is lost...
Misc Tips:
- Day/evening before the exam is VERY crucial, do NOT waste your time, grab a quick lunch and hit the books again. Have a running (realistic) list of things you want to eyeball / review quickly during your prep and cross it out as you go. I saw a LOT of stuff on day 1 AND 2 which I would've just guessed if I hadn't reviewed.
- As per standard advice, know the coding sheetS (plural) inside out. You will get stressed, and strained for time, and you will stare at the clock ticking while you keep hunting for the right code (I know cos I f*ing did that), and you will curse yourself for not knowing the sheet better. Particularly for echo.
- Some EKGs have movable calipers. Some don't. People say don't waste time with calipers. I would say become really really familiar with using them so that you're facile enough to use em during the exam without wasting time. They helped me root out some wenkebachs and flutters here and there.
This went longer than intended. Apologies. Will create a TLDR.
Remember - "Success is not final, failure is not fatal: It is the courage to continue that counts." - Winston Churchill
Good luck
