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Hello Everyone, it has been a while since I posted
this is an old post of mine that has been very helpful to a lot of people so I would like to bring it back
however, I have made THE VIDEO VERSION OF THIS STRATEGY, and I provided some update as well!
the video is completely free, you can choose to read this, or, you can go ahead and watch the video!
here is the link for the video:
www.yuliusharyadi.com
this is my old post, enjoy!
Hi everyone, I am making this new thread about test taking strategies.
The reason why I am doing this is because I felt that test taking strategies are very rarely discussed. you can always find good source for materials like kaplan, uw, fa, etc, but these will not improve your test taking skills per se. I know kaplan/ becker discuss some test taking strategies, but as far as I know, they dont go into very detail, its more like helping you with the thought process rather than the actual techniques.
IMO, there are 3 things that you need to get great score:
1. understand the materials
2. memorize it
3. apply your knowledge, which is including test taking skill
I put these in order... you will have to understand first, then memorize it, then apply it. you will have hard time to memorize something that you dont understand, and its impossible to apply a knowledge that you dont even know..
this is my personal opinion: you can get 240 with perfect memorization, 250 if you understand difficult concept really well, and 260 if you have great test taking skill. So materials makes you pass or get a good score, while test taking skill gives you a great score. (of course if you lack knowledge and memorization, you can compensate with test taking skill). People who has excellent score usually has great test taking skills, and my personal belief is that they actually do these techniques naturally/instinctively without realizing it. when you asked these people how did they do that, most of the time they would not be able to describe it to you.. So what I am trying to do here is to describe those abstract mind, make it more concrete and understandable. therefore people who has lack of test taking skills will able to do the same thing, and hopefully, achieve great score.
these are going to be the topics that I would like to cover:
1. steps in doing questions in general
2. time management
3. test taking strategies of specific topic: ethics, calculation, biostat, physiology, pharm, microbiology, pictures, fast ecg approach, journal/trial/ads question, etc (will add more as we go)
These are the steps in general of how to do a question properly, this should always be done in order
1. read the last line
2. read 2-3 lines before the last. if you got the big picture of the question, jump to step no 5. if you have not got the big picture, then move to step no 3
3. read the first line, make sure you got the age, gender, and chief complaint. then read the rest of the qs stem while paraphrasing it, and highlight abnormal labs
4. combine the information you got and get the big picture
5. RECALL STEP. read the last line again, then recall information regarding what the question is asking. think of an answer, then pick the answer that closest/similar with what you want
In the next post I will explain what we are trying to achieve for each steps and I am sure you will get a better understanding why we do it in that order.
1st step: Reading the Last Line
(some qs that I posted here basically comes from uworld sample qs, but I change it to not get copyrighted. the concept still the same though.. if you want to see the full qs you can go to uworld website and find the sample qs there..)
Why reading the last line is the first step to do? why not reading from the above and got the story in a more chronological way? lets use this question as an example:
a 31 yo woman comes to the emergency department with palpitations and shortness of breath. she had insomnia, increased anxiety, diarrhea, and weight loss since these past couple months. Her past medical history is significant for asthma which is well controlled with her albuterol inhaler, gestational diabetes, preeclampsia, atrial septal defect which is not corrected since her birth, and chronic migraine. Physical exam reveals a pleasant woman in no acute distress, lungs are clear to auscultation bilaterally, fixed splitting was found. TSH and FT4 was sent with showed the following results:
TSH 0.02
T4 14
her b-hcg is negative. intravenous propranolol is given. in addition to its beta-receptor blocking activity, propranolol is likely to benefit this patient by affecting which of the following?
a. prevent the production of thyroid antibodies
b. synthesis of thyroxine
c. inhibit peripheral conversion
d. prevent t3 to bind to its receptor
Now, who cares if the patient is female, male, old, young? who cares if she has asthma or migraine? I dont care, and nor should you.. the question is clear: what is another propranolol mechanism of action related to thyroid condition? that is the only thing you need to recall! so answer would be C
this question is a great example how reading the last line allow you to focus only at the necessary information, recall only the important information, get you oriented immediately, and SAVE A HUGE AMOUNT OF TIME.
a little note:
in step 1 you will have more chance to meet these type of question where you can read the last line and got the idea what is the question actually asking.
you will encounter less number of this questions in step 2 ck, and even less in step 3. most of the question FORCE YOU to read everything. therefore, step 2 ck / 3 require advanced test taking skills than step 1.
question:
a 6 d old boy came to ED because cant eat for 8 hours. he was unable to open his mouth, his hands are clenched. mom is an immigrant, and delivered at home. physical exam reveals increase muscle tone, arching of the back, dorsiflex feet. umbilical cord is dirty with soil on it. what is the most effective strategy to prevent this condition?
a. vaccination of pregnant women
b. antibiotics early
c. vaccination of the baby right after birth
d. immunoglobulin
e. breastfeeding early
if you read the last line, you can see that if you know what "this condition" is, then you might know how to prevent it. this is another example how reading the last line make you focus on what information is necessary to answer the quetion. the location of the information that you need usually located at the 2-3 lines before the last , which is our next step..
2nd step: Read 2-3 lines before the last to get the big picture
in above question, if you read 2-3 sentences before the last, you should be able to figure out that "this condition" is tetanus. if you cant figure that out, that means there is a lack of knowledge.
now as you can see, once you know its tetanus, try to read the last line again, and now the question changed: instead of how to prevent "this condition", it becomes : how do we prevent tetanus in newborn babies? at this point, since you already got the big picture of what the qs is asking, you jump to step no 5, the recall step.
The recall phase is purely a knowledge test. Try to think of an answer before looking at the answer choices, and pick the answer that rephrase what you want. in this case, you should recall that the best way to prevent tetanus in babies are vaccination to the mother, therefore A is the best answer. (if you dont know the answer, that is not the end of the world. the next step is to rule out, which I will discuss later on)
not all question can be done in 3 steps (last line, 2nd-3rd line before the last, recall and answer)like above. sometimes you will need to start reading from above in order to get the necessary information. lets use this question as an example:
A 66 yo M comes to the office with nausea, loss of appetite, fatique, and marked weakness. his medical history is significant for hypertension, diabetes, hypercholesterolemia, and CAD post CABG treated with lisinopril, amlodipine, statin, and aspirin. the patient also has polymyalgia rheumatica, for which he was on prednisone for 12 months, but he stopped taking the medication 7 days ago because he was unhappy with the weight gain. temp afebrile, BP 110/65 mmHg, HR 100x/min, RR 20x/min. his face is round and plethoric, there is excess supraclavicular fat deposition. labs as follows:
Na 132
K 4.1
CL 95
HCO3 25
BUN 18
cr 0.6
Ca 9.8
glucose 70
cxr is unremarkable. which of the following biochemical abnormalities is most likely to be present in this patient?
a. low acth, low aldosterone, low cortisol
b. low acth low aldosterone
c. low acth and low cortisol
d. high acth and low cortisol
e. high acth and high cortisol
Lets use the steps I mentioned above to approach this qs:
step 1, reading the last line: which of the following biochemical abnormalities would present in this patient?
step 2, read 2-3 lines before the last. face is plethoric, round, excess supraclavicular fat deposition. cxr unremarkable
based on these 2 steps, the information that we got is: patient seems to have excess cortisol level. the question is, would we know the answer just based on that? well, actually no.. because cushing syndrome can be caused by lots of things: taking excess exogenous cortisol, lung tumor secreting acth, pituitary tumor, adrenal tumor. so which one is it? we dont know yet, and therefore, you need MORE INFORMATION.
Does this means that it much better to read from above in the very beginning for this particular qs? the answer is NO.. if you read the first line, what you have is a middle age man with vague symptoms (nausea, loss appetite, weakness). if you read the last line and 2-3 line before the last, you oriented immediately that this is about cushing syndrome, and you just need to know what cause this patient to have cushing, and then you will be able to answer the question.
ok so this question force us to move to the 3rd step: read the first line, make sure you got the age, gender, and chief complaint. then read the rest of the qs stem while paraphrasing it, and highlight abnormal labs
I will discuss this tomorrow
3rd step (and 4th). read the first line, make sure you got the age, gender, and chief complaint. then read the rest of the qs stem while paraphrasing it, and highlight abnormal labs
First, focus on these 3 main information: age, gender, and chief complaint
for above qs it would be: 66 yo M with non-specific symptoms: nausea, loss appetite, fatique/weak.
then read the rest of the qs stem while paraphrasing, DONT READ WORD PER WORD, but try to rephrase it using your own word in your head, and highlight abnormal labs only. it will pretty much become like this:
66 yo M with nausea, loss of appetite, fatique, and weakness, on multiple heart meds, on prednisone for 12 months, stopped 7 days ago, round pleothoric face, supraclavicular fat deposition. now vital signs is ok. hyponatremia, hypochloremia.
now convert it into a single big picture: this is a case of pt taking steroid chronically, then stopped!
now once the big picture is obtained, you go to the recall step. dont forget to always read the last line again and rephrase the qs, it will become something like this: in a pt that taking chronic steroid then suddenly stopped for 7 days. what would be the the biochemical changes of this patient? (acth and cortisol and aldosterone)
now its time to recall and its just a matter of your knowledge. at this point, if you got it wrong, it means that you have lack of knowledge (understanding or memorization) of feedback mechanism. again, you have to think of an answer first and find the one that closest to what you looking for..
a little note:
combining all information and converting it into one single big picture requires some skill. there are some questions that you might not get the big picture at all, and usually happened in step 2ck/step 3 where the question is so vague. one way to improve this skill is to have better knowledge. for example, if I say there is a 16 yo M with infection of lung three times last year, and UTI 2 times 2 years ago, and sinusitis 5 times, + platelet of 56.000, and rash, what would be the big picture? yes, its Wiskott aldrich. people who does not know wiskott aldrich will never be able to put everything together. so again, the skill to combine information into one big picture relies partly in your knowledge.
Now we have finished the general steps of doing a question, we will move to the next section tomorrow, which probably what most of you are waiting for:
how to rule out answer choices and how to deal with 50:50.
Hi everyone, I am sorry I skipped yesterday, kinda busy. so lets continue our discussion
once you did your 3rd step, got the big picture and into the recall phase, there will be 3 possibilities:
1. you know the answer right away
2. you cant rule in anything
3. you are in 50:50 situation
lets discuss possibility no 2 first : you cant rule in anything. this means that you have a lack of knowledge regarding the topic being asked, but dont give up yet, you may still able to answer the question by ruling out.
what you need to do is to read every single options and recall all information that you know related to that options. lets make a simple question:
Which of the following is the side effects of amiodarone?
a. livedo reticularis
b. bluish vision
c. red man syndrome
d. decrease FEV1
pretend that you dont know what is the side effects of amiodarone, then you are going to start ruling out:
1.what is the meds that cause livedo reticularis and what are the conditions that cause it? you may recall it can be caused by amantadine, choleterol embolism, and some vasculitis
2.what cause bluish vision? its viagra
3.what cause redman syndrome? its vancomycin
therefore only 1 options left, and thats gotta be the answer: D
as you can see, its much faster if you know what are the side effects of amiodarone: PFT, LFT, TFTs, and smurf skin. if you see decrease fev1, then you can just click it and move on to the next qs rather recalling information for each options.
its always better to rule in then rule out. ruling out takes huge amount of time and effort . usually a common mistake most people do is once they have the answer they like, they still try to rule out the other options just to be sure. I personally think this is not a good idea , here is why:
1. once you already think of an answer and it fits with one of the options, that is most likely going to be the right answer.
2. there is a very small chance that you are going to change your answer if you already think of an answer and find it among the options.
3. if you do change your answer, you will most likely to get it wrong.
so you see there is no point of try to rule out once you already rule in! 1. you will get it right, 2.you will rarely change it, and if you change it, 3. you will get it wrong. so just click the answer that you want and move on! if ever the habit of ruling out comes back, always remind yourself with the 3 facts I mentioned above.
now, if you cant rule out until you reach 50:50 situation, then its very unlikely to get the qs right, pick something and move on. but most of the time you will at least reach 50:50 situation.
to be honest with all of you, 50% of the qs in the real test are 50:50( at least for me). And for the other question, its not like I am 100% certain what the answer is, there always gonna be some doubt. so this makes 60-70% of the time you are somewhat in 50:50 situation, which is HUGE! There are couple tips you can do when you are in this situation:
1. never pick an answer that you never heard of
I think most of you have heard this before. if the correct answer is something that you never heard of, then you will never get that qs right at your current state, dont feel so bad about it. learn from that qs and dont make the same mistake again, your score will definitely go up.
2. always pick an answer that you can reason better
instinct vs logic, its always a difficult thing. let me tell you what, always go with logic, and you will have more consistent score. when your instinct get you to the right answer, thats just luck. dont click an answer just because you think its the right one, you need to have a reason. this also important when you become a doctor, you dont want to prescribe medicine just because you feel that is right, but because it makes sense. so get used to train your brain to make decision. this also correlate with the next tips
3. pick an answer that, even if you got it wrong, you will have the least regret
if you choose an answer by instinct , and you got it right you might feel good. but if you got it wrong, you will feel very stupid. there is no reason to click on that answer, why would you pick it? if you have good reason to pick an answer, and you got it wrong, then most of the time there is some part of knowledge that is missing, thats why you got it wrong. there is no regret, since again, at your current state of knowledge, you would never get that qs right. read, learn, and dont make the same mistake again. this lead to the next tips
4. always focus with what you know
there is no point dwelling in information that you cannot process. just focus with information that you know, and go with that. its somewhat difficult for me to really explain it to you, hopefull these two examples would help you to understand:
I had a student once, we encounter this qs about herpes. history seems like herpes, for me the pictures was obvious, but for him it wasnt. And he picked non-herpes answers!! this does not make sense at all. why would you change your answer based on a picture that you are not even sure? you should just focus on what you know (the history), not dwelling on the pictures you are not even sure, and even worse, make a decision based on that! there is no point in processing information that you dont even know. if that particular information is a critical information to answer the qs, then you will never be able to answer it with your current state of knowledge, accept it.
let me explain why my student (or some other people) did above mistake. this is because of lack confidence in their knowledge. they were thinking subconciously that there is something they dont know, so they pick the other options. so the solution is simple, have a good knowledge. how to make sure you have good knowledge? welll, if a certain topic never mentioned in UW or FA, then very low percentage of people will know it..so understand and memorize UW and FA really well! have confidence in your knowledge, so you can apply the technique: focus with what you know.
5. if there is one thing that does not fit, ignore it.
this is actually a tips for getting a big picture rather than 50:50 although it can help with the 50:50 as well. lets make a simple qs:
44 yo F with shoulder pain, blurry vision, headache, and jaw pain. what is the most likely diagnosis?
the most likely diagnosis in this case is temporal giant arteritis. but wait, she is 44 yo F! isnt temporal giant arteritis hit >50 yrs old? usually even 60 or 70.. well, in this case, its still giant temporal arteritis, because there is only one thing that does not fit: pt's age. so just ignore it. however, if there are 2 things do not fit, the chance you miss something is big, so reconsider your big picture.
6. recall further, then search more information in the question
this is actually what I called as a "lengthened recall phase" that usually happen in step 2 ck/3, but you will encounter some qs in step 1 that require this. lets use below qs as example:
A 57 yo F with past medical history of drug abuse, ckd not on dialysis, hypertension, diabetes type 2, admitted to psych unit due to mania. she was found to be bipolar. her BP is 140/78 mmHg, HR 95, afebrile, RR 20x.. lab results showed wbc of 8000, hb of 9.8, platelet 160k, creatinine of 1.9, BUN 45, Na 143, Cl 101, K 4.3, Ca 7.8, Albumin 2.8, HbA1c of 7.8%. ECG showed Sinus rhythmn with qtc of 500 msec. which of the following is the best treatment for her bipolar disorder?
a. lithium
b. valproic acid
c. haloperidol
d. chlorpromazine
e. triamterene
1st step --> reading the last line. best treatment for bipolar disorder.
at this step actualyl the qs becomes very clear, its just tx for bipolar, so you dont have to go to the 2nd step, you should recall first. the treatment would be lithium, atypical antipscyhotic, or valproic acid. I strongly believe in step 1 you will only encounter one of above drugs as the answer. so I am using step 2 ck qs to make my point here. as you can see at this point you are in 50:50 situation, because there are 2 drugs for bipolar disease: lithium and valproic acid. both drugs definitely can be use in bipolar! so there must be something in the qs that tell you which is better than the other. at this point you should recall further what is the difference between lithium and valproic acid in terms of MOA, clinical use, and side effects:
1. lithium MOA is not clear, we cant use that. clinical use for bipolar only. you should know that it has narrow therapeutic range, ckd may be a problem. side effects; diabetes insipidus, tremor, neurotoxicity, ebstein anomaly in pregnant woman.
2. valproic acid MOA is inhibiting Na channel in the brain, it has antiseizure activity as well. side effects woould be thrombocytopenia, alopecia, liver failure, teratogenic effect.
by recalling further, you can see that there are some information you need to look for in the qs stem. this is the time to got to your 2nd and 3rd step to find those information, here is some thought process in this qs:
if this patient has some neuro issues probably lithium is not a good thing, if she is pregnant, probably is not good either. if she has hypernatremia it might not be a good thing because lithium can cause diabetes insipidus. for valproic acid, if the pt has seizure history as well this can be 2 birds in one stone, if patient has thrombocytopenia or liver failure already its not good, and not good for pregnant woman either.
all the things that I mentioned above are all negative in this patient: she has normal Na level, she is not pregnant, she has no seizure history, she has no thrombocytopenia or liver failure. she got one thing though: renal failure. and lithium has narrow therapeutic range. at least that one fits, so the better answer here is valproic acid.
I have to emphasize again that this is not a typical qs of step 1, but its one way to approach a 50:50.
7. if its a 50:50 memorization thing, then the first thought is always correct. skip the qs and come back.
for example, you forgot which chromosome cystic fibrosis gene is located. you are between chromosome 17 and 7. the first thought you have most likely to be the correct one. dont stay in the question too long because your brain might play trick on you and your first thought becomes blurry. one trick to make it more clear is to skip the question altogether. when you come back, you will have less biased mind for a couple seconds, get your first thought and click the answer.
8. if all above fails, then **** it, click whatever and move on. it is not the only qs in the world, let it go..
I believe I have some other tips that I can share but I dont have it on top of my head currently, I will add more as I can recall more tips.
next topic would be TIME MANAGEMENT
TIME MANAGEMENT STRATEGIES
in a block of 40 qs and 1 hour time, you want to do 2 runs in 1 block. in the first run your speed should be less than equal to 1 min/qs. this is very possible to do, because in the first run your focus is to find qs that only require 2 step process: getting the big picture (by reading last line, 2nd-3rd line before the last, or reading and paraphrasing), then (easy) recall and answer the qs. if the question require you to do more than that, then SKIP IT!
another way to say this is to SKIP questions that:
1. hard to recall
2. force you to rule out
3. put you in 50:50 situation
Let me say this one more time, your goal in the first run is to:
1. hunt for easy questions and 2. getting the big picture for the difficult qs!
when I say SKIP, it means you LEFT IT BLANK. NEVER PICK AN ANSWER THEN FLAG IT. the reason is to keep the qs unbiased. if you already pick an answer (based on your half-made judgment/reasoning) and you come back, you will feel reluctant to change it because the rule is not to change your first answer. Keep it unbiased by keeping it blank!
some of you may raise a question then: so when should I flag a qs? well, basically never.. but I do flag question.. when I accidentally click on something and realize that the qs should be skipped from the first place..this just to give a sign that I should come back to this qs later.
Now, if you have moderate- good knowledge, you should be left with <15 qs unanswered. So mathematically:
there are 40 qs total, you do 1 min/qs, so in the first run you spent 40 min with 20 min left. very rarely you can be perfect with 1 min/qs, so usually you will have 15 min left with <15 qs unanswered.
if you end up having >15 qs unanswered, then either its a very difficult block, or you definitely lack knowledge. please go study more..
during your first run, always check your time! for example, if you are in qs number 7, then your time should show 53 min left! check your time especially after you felt that you spend too much time on a question!
in the 2nd run, your job is to finish the rest of the qs by using the general steps I mentioned in the previous post. since you already got the big picture, you only need jump straight to the rule out or 50:50 techniques. during this 2nd run, you should not spend more than 1 extra min per question. Have you ever heard the more time you spend in a qs, the more likely you got it wrong? this is very true.. if you encounter a qs that you cant figure out after 2 min, then accept it, you are most likely to get that qs wrong. click whatever and move..
let me tell you this: most people with good test taking skills subconciously do above techniques (2 runs). they just skip a qs right away when they know its hard, they come back and redo the qs. Nobody told them what are the advantage of doing that, they just do. let me explain the advantage of 2 runs:
1. the idea of having 2 runs is to distribute the time correctly: you spend less time in easy question, and spend more time in the hard ones.
imagine if you have 7 min to do 5 questions. lets say question no 1,4,5 are easy, while qs no 2 and 3 are difficult. assume that you require 1 min to do easy questions, and 2 min to do the hard ones.
if you dont skip the qs, whats gonna happen is you are going to do qs no 5 with 1 min left, which is anxiety provoking and increase the risk to get an easy question wrong (imagine 80% of people got it right and you got it wrong..this will decrease your score very significantly!). if you you skip no 2 and 3, you will have 3 min left when you engage qs no 5.. after you answer qs no 5, you come back to qs no 2 and 3 with 2 min left. now even if you got it wrong, its a hard qs which will not hurt your score that much. hope this makes sense..
2. getting a epiphany. for some reason, you have more chance to get an epiphany when you attempt a qs the 2nd time. This means you increase your chance of getting a hard question right!
3. you actually do a question much faster by skipping it rather than dwelling with it.
4. you have the peace of mind that you actually already saw all the qs, it gives you less anxiety when you see the difficult qs the 2nd time. imagine if you have 1 min left with 1 qs left that you have not encounter before. its much better to have 1 qs left with 1 min left but at least you have the big picture ready!
Now I have to discuss the last possible scenario: what if on the 1st run I got 18 qs unanswered with 13 min left?!
if you are in this situation, guess 5 qs very quickly, so you will be in 13 min left with 13 qs. basically, just adjust the best you can so you left with 1min/qs for the 2nd run. I have been in this situation many times, the key is just to have the mentality to get the job done: answer all question with good judgment.
again its very rare you will be in this situation as long as you have good knowledge, it should be <15 qs with 15 min left.
little tips: during the exam, you will definitely get this sense of losing focus. you dont know what you are reading, your mind move to another place, or something like that. This episodes are very hard to avoid, but can be reduced. the trick is to not force refocusing yourself, but to skip to the next qs. if you still not focusing on the next qs, skip it again. just keep skipping until you regain your focus. once you regain your focus, come back immediately to the qs you just skipped, and surprisingly, the previous qs becomes very easy for you (if its truly easy).
another tip to keep focus during exam is to create a habit: like repositioning your glasses, or rubbing your shoulder, or whatever. this is very commonly done by professional athlete. for example, you can check how Rafael Nadal always touch his nose and correcting his hair on both of his ears before serving. you can create your own. do this when you lose focus or everytime you go to the next question. its just a mental trick to your brain.
ok, so in summary for time management strategies:
1.do 2 runs, 1min/qs
2.first run is to hunt for easy question or getting big picture for difficult qs
3.skip the difficult qs completely
4.2nd run is to apply rule out or 50:50 techniques. extra 1 min/qs
5.adjust your time as needed
alright everyone, basically we finished the main test taking strategies.
Please feel free to ask any questions!
Posted from USMLE step 2ck thread:
Step 2 ck / 3 Recall phase
The general steps approach is pretty much the same for step 2ck/ step 3, its just that you require more time to finish all the steps. The first big difference between step 1 with 2ck/3 is the recall phase.
step 1 usually only require simple recall. for example, if you got the big picture that patient has huntington, probably these are the answers for each possible question:
which chromosome: chromosome 4,
movement abnormalities that you can find: chorea,
genetic terms: anticipation,
another disease that has similar pathogenesis: other trinucleotide repeats diseases,
sstructural brain abnormalities you can find: caudate nucleus,
most common cause of death: suicide,
amino acid that accumulates: glutamate.
for step 2 ck/3, the recall process are more complex and time consuming. lets use this qs as example
a 56 yo M admitted to ED with sharp, left sided chest pain for the last 48 hours. pain is worsened with breathing, relieved with leaning forward. the intensity is 8 out of 10. He also complaints of faitique, 3 pounds weight loss, nausea, and vomiting a couple of times over the last several weeks. he had NSTEMi 1 year ago and got 2 stents placed in RCA and LAD. His other medical problems include diabetes type 2, hypothyroidim, Chronic kidney disease, hypertension, hyperlipidemia, depression, and peripheral neuropathy. His medications are aspirin, clopidogrel, carvedilol, lisinopril, and atorvastatin, levothyroxine, gabapentin, and amitryptilline. he is temperature is 97 F, BP 140/80 mmHg, HR 95 x/min, RR 20x/min. ECG showed normal SR with T wave inversion in lead V5 and V6. lab results as follow:
Hb 8.2
wbc 8k
platelet 200k
glucose 260
Na 132
K 5.6
HCO3 16
BUN 97
Cr 5.2
Trop 0.011 (normal)
which of the following is the most appropriate therapy for this patient chest pain?
a. colchicine
b. hemodialysis
c. heparin infusion
d. naproxen
e. pericardiocentesis
lets follow our steps:
1st step -> reading last line: which of the following is the most appropriate therapy for this patient chest pain?
- from this line you should know that if we know the nature of the chest pain, then we might know whats the best treatment for this patient. so you should focus on gathering more information regarding his chest pain
2nd step ->reading the 2-3 last line: you can start reading from medications list, or the vital signs, does not matter, you will find NOTHING here. the T wave inversion can mean ischemic or cardiomegaly, does not really tell exactly that this pt has MI, we need more information. so we have to move on to our 3rd step
3rd step -> read the first line, find gender, age, and chief complaint. then paraphrase while reading, and highlight abnormal labs.
in this part, you should be able to get that the patient has classic pericarditis signs: sharp pain, relieved by leaning forward. if you dont know this, again, you have lack of knowledge, there is nothing to do with test taking skill.
so now you got at least the angle of this question (its not a full big picture yet!just an angle): pericarditis. carefully read the last line again, you should notice then the qs will become: what is the treatment of pericarditis? this is the time you should recall.
Now what would your answer be? well, the correct answer is : it DEPENDS. and this applies to most of step 2 ck question, your answer is always: DEPENDS. so you are not recalling a single information, you are recalling several information that you need in order to answer the qs.. and this is a very important point! let me explain to you why:
do you realize how long the question are, the amount of information given to you, and the amount of distractions in step 2ck/3? How do you know that an information is important or distractor? the answer is, you dont! you will never know an information is important or distractor until you came up with an ANGLE! once you decide on your angle, only then, you can see whether an information is useful. and knowing which information is useful comes from knowledge.
lets use above qs as an example. we got our angle: treatment of pericarditis. and the answer in this qs is depends.. but depends on what? well, you should recall that it depends on the ETIOLOGY.
so what are the etiology of pericarditis? these are some of it:
post MI pericarditis
dressler syndrome
viral pericarditis
autoimmune pericarditis from connective tissue disease
bacterial, like TB pericarditis
autoimmune pericarditis from rheumatic fever
uremic pericarditis
if the pt has viral pericarditis, we give nsaid and colchicine. if the pt has post MI pericarditis, then usually aspirin is a better choice of NSAID combined with colchicine. if its TB pericarditis, antibiotics would be a good one. if its autoimmune, steroid would be a good choice. if its refractory pericarditis, steroid also a good one. if its uremic, hemodialysis would be the best choice.
oh and dont forget, what if this pt has pericarditis with effusion that leading to tamponade? then pericardiocentesis would be the best answer right?
in above case, the pt had stent 1 year ago and it would be too long for dressler or post MI. there is no rash, joint pain, RBC cast to justify connective tissue disease. pt is not an immigrant and you do not want to assume. not enough symptoms to justify rheumatic fever either. so the best etiology would be uremic pericarditis and that is our full big picture! hemodialysis becomes the best answer. the best way, again, is to include rather than excluding. if we found high BUN and pericarditis in the qs, it would be uremic pericarditis. you dont need to exclude one by one like how I did above, I am just giving an example how we should think. just keep the information that you need to look for at the back of your mind while you are reading.
I have shown you the recall process in step 2ck/3 are more complex and time consuming: we have to recall the concept of "different etiology in pericarditis lead to different treatment", you have to recall what are the etiologies and CLUES/INFORMATION that leading toward a certain etiology, find it in the qs, and then recall the treatment itself. Some question even require you to do an additional step: CLINICAL JUDGMENT, we did not do this part for above qs, its not required.
step 1 has less distractions, very straight forward, most of the time you just need concepts and memory to answer the qs. however, in step 2 ck (and even more in step 3), lots of information and distraction, qs becomes so vague that you dont even know what you are reading require you to carefully read and analyze the qs.
I dont believe there is such thing as a trap question. I think its a knowledge proble. you dont know which important information to look for, thats why you felt trapped when you got it wrong (for example, did not pay attention the pt allergic to penicillin). this also lead to rereading the question unnecesarily, feeling like you miss something. I have some students that, after he thinks of an answer and pick it, he went back reading the qs again and again just to make sure he does not miss "something". I always ask them, what information are you looking for? they would answer, well I dont know, probably there is something.. well, so basically you are looking for something you dont even know. whats the point? you have to know what you are looking for, if not, you are just wasting your time.. again, you need to have BOTH an angle and knowledge to know if an information is important or just a disctraction.
so in conlusion: in step 2ck/3, the recall process is lengthened due to the needs to recall which information that you need, reread the qs again to find those information, and sometimes, make clinical judgment.
this is an old post of mine that has been very helpful to a lot of people so I would like to bring it back
however, I have made THE VIDEO VERSION OF THIS STRATEGY, and I provided some update as well!
the video is completely free, you can choose to read this, or, you can go ahead and watch the video!
here is the link for the video:
Free USMLE Test Taking Strategies
Free USMLE Test Taking Strategies video training. Boost your score instantly! Covers general approach to USMLE question, Elimination strategies, down to two strategies, and time management strategies.
www.yuliusharyadi.com
this is my old post, enjoy!
Hi everyone, I am making this new thread about test taking strategies.
The reason why I am doing this is because I felt that test taking strategies are very rarely discussed. you can always find good source for materials like kaplan, uw, fa, etc, but these will not improve your test taking skills per se. I know kaplan/ becker discuss some test taking strategies, but as far as I know, they dont go into very detail, its more like helping you with the thought process rather than the actual techniques.
IMO, there are 3 things that you need to get great score:
1. understand the materials
2. memorize it
3. apply your knowledge, which is including test taking skill
I put these in order... you will have to understand first, then memorize it, then apply it. you will have hard time to memorize something that you dont understand, and its impossible to apply a knowledge that you dont even know..
this is my personal opinion: you can get 240 with perfect memorization, 250 if you understand difficult concept really well, and 260 if you have great test taking skill. So materials makes you pass or get a good score, while test taking skill gives you a great score. (of course if you lack knowledge and memorization, you can compensate with test taking skill). People who has excellent score usually has great test taking skills, and my personal belief is that they actually do these techniques naturally/instinctively without realizing it. when you asked these people how did they do that, most of the time they would not be able to describe it to you.. So what I am trying to do here is to describe those abstract mind, make it more concrete and understandable. therefore people who has lack of test taking skills will able to do the same thing, and hopefully, achieve great score.
these are going to be the topics that I would like to cover:
1. steps in doing questions in general
2. time management
3. test taking strategies of specific topic: ethics, calculation, biostat, physiology, pharm, microbiology, pictures, fast ecg approach, journal/trial/ads question, etc (will add more as we go)
These are the steps in general of how to do a question properly, this should always be done in order
1. read the last line
2. read 2-3 lines before the last. if you got the big picture of the question, jump to step no 5. if you have not got the big picture, then move to step no 3
3. read the first line, make sure you got the age, gender, and chief complaint. then read the rest of the qs stem while paraphrasing it, and highlight abnormal labs
4. combine the information you got and get the big picture
5. RECALL STEP. read the last line again, then recall information regarding what the question is asking. think of an answer, then pick the answer that closest/similar with what you want
In the next post I will explain what we are trying to achieve for each steps and I am sure you will get a better understanding why we do it in that order.
1st step: Reading the Last Line
(some qs that I posted here basically comes from uworld sample qs, but I change it to not get copyrighted. the concept still the same though.. if you want to see the full qs you can go to uworld website and find the sample qs there..)
Why reading the last line is the first step to do? why not reading from the above and got the story in a more chronological way? lets use this question as an example:
a 31 yo woman comes to the emergency department with palpitations and shortness of breath. she had insomnia, increased anxiety, diarrhea, and weight loss since these past couple months. Her past medical history is significant for asthma which is well controlled with her albuterol inhaler, gestational diabetes, preeclampsia, atrial septal defect which is not corrected since her birth, and chronic migraine. Physical exam reveals a pleasant woman in no acute distress, lungs are clear to auscultation bilaterally, fixed splitting was found. TSH and FT4 was sent with showed the following results:
TSH 0.02
T4 14
her b-hcg is negative. intravenous propranolol is given. in addition to its beta-receptor blocking activity, propranolol is likely to benefit this patient by affecting which of the following?
a. prevent the production of thyroid antibodies
b. synthesis of thyroxine
c. inhibit peripheral conversion
d. prevent t3 to bind to its receptor
Now, who cares if the patient is female, male, old, young? who cares if she has asthma or migraine? I dont care, and nor should you.. the question is clear: what is another propranolol mechanism of action related to thyroid condition? that is the only thing you need to recall! so answer would be C
this question is a great example how reading the last line allow you to focus only at the necessary information, recall only the important information, get you oriented immediately, and SAVE A HUGE AMOUNT OF TIME.
a little note:
in step 1 you will have more chance to meet these type of question where you can read the last line and got the idea what is the question actually asking.
you will encounter less number of this questions in step 2 ck, and even less in step 3. most of the question FORCE YOU to read everything. therefore, step 2 ck / 3 require advanced test taking skills than step 1.
question:
a 6 d old boy came to ED because cant eat for 8 hours. he was unable to open his mouth, his hands are clenched. mom is an immigrant, and delivered at home. physical exam reveals increase muscle tone, arching of the back, dorsiflex feet. umbilical cord is dirty with soil on it. what is the most effective strategy to prevent this condition?
a. vaccination of pregnant women
b. antibiotics early
c. vaccination of the baby right after birth
d. immunoglobulin
e. breastfeeding early
if you read the last line, you can see that if you know what "this condition" is, then you might know how to prevent it. this is another example how reading the last line make you focus on what information is necessary to answer the quetion. the location of the information that you need usually located at the 2-3 lines before the last , which is our next step..
2nd step: Read 2-3 lines before the last to get the big picture
in above question, if you read 2-3 sentences before the last, you should be able to figure out that "this condition" is tetanus. if you cant figure that out, that means there is a lack of knowledge.
now as you can see, once you know its tetanus, try to read the last line again, and now the question changed: instead of how to prevent "this condition", it becomes : how do we prevent tetanus in newborn babies? at this point, since you already got the big picture of what the qs is asking, you jump to step no 5, the recall step.
The recall phase is purely a knowledge test. Try to think of an answer before looking at the answer choices, and pick the answer that rephrase what you want. in this case, you should recall that the best way to prevent tetanus in babies are vaccination to the mother, therefore A is the best answer. (if you dont know the answer, that is not the end of the world. the next step is to rule out, which I will discuss later on)
not all question can be done in 3 steps (last line, 2nd-3rd line before the last, recall and answer)like above. sometimes you will need to start reading from above in order to get the necessary information. lets use this question as an example:
A 66 yo M comes to the office with nausea, loss of appetite, fatique, and marked weakness. his medical history is significant for hypertension, diabetes, hypercholesterolemia, and CAD post CABG treated with lisinopril, amlodipine, statin, and aspirin. the patient also has polymyalgia rheumatica, for which he was on prednisone for 12 months, but he stopped taking the medication 7 days ago because he was unhappy with the weight gain. temp afebrile, BP 110/65 mmHg, HR 100x/min, RR 20x/min. his face is round and plethoric, there is excess supraclavicular fat deposition. labs as follows:
Na 132
K 4.1
CL 95
HCO3 25
BUN 18
cr 0.6
Ca 9.8
glucose 70
cxr is unremarkable. which of the following biochemical abnormalities is most likely to be present in this patient?
a. low acth, low aldosterone, low cortisol
b. low acth low aldosterone
c. low acth and low cortisol
d. high acth and low cortisol
e. high acth and high cortisol
Lets use the steps I mentioned above to approach this qs:
step 1, reading the last line: which of the following biochemical abnormalities would present in this patient?
step 2, read 2-3 lines before the last. face is plethoric, round, excess supraclavicular fat deposition. cxr unremarkable
based on these 2 steps, the information that we got is: patient seems to have excess cortisol level. the question is, would we know the answer just based on that? well, actually no.. because cushing syndrome can be caused by lots of things: taking excess exogenous cortisol, lung tumor secreting acth, pituitary tumor, adrenal tumor. so which one is it? we dont know yet, and therefore, you need MORE INFORMATION.
Does this means that it much better to read from above in the very beginning for this particular qs? the answer is NO.. if you read the first line, what you have is a middle age man with vague symptoms (nausea, loss appetite, weakness). if you read the last line and 2-3 line before the last, you oriented immediately that this is about cushing syndrome, and you just need to know what cause this patient to have cushing, and then you will be able to answer the question.
ok so this question force us to move to the 3rd step: read the first line, make sure you got the age, gender, and chief complaint. then read the rest of the qs stem while paraphrasing it, and highlight abnormal labs
I will discuss this tomorrow
3rd step (and 4th). read the first line, make sure you got the age, gender, and chief complaint. then read the rest of the qs stem while paraphrasing it, and highlight abnormal labs
First, focus on these 3 main information: age, gender, and chief complaint
for above qs it would be: 66 yo M with non-specific symptoms: nausea, loss appetite, fatique/weak.
then read the rest of the qs stem while paraphrasing, DONT READ WORD PER WORD, but try to rephrase it using your own word in your head, and highlight abnormal labs only. it will pretty much become like this:
66 yo M with nausea, loss of appetite, fatique, and weakness, on multiple heart meds, on prednisone for 12 months, stopped 7 days ago, round pleothoric face, supraclavicular fat deposition. now vital signs is ok. hyponatremia, hypochloremia.
now convert it into a single big picture: this is a case of pt taking steroid chronically, then stopped!
now once the big picture is obtained, you go to the recall step. dont forget to always read the last line again and rephrase the qs, it will become something like this: in a pt that taking chronic steroid then suddenly stopped for 7 days. what would be the the biochemical changes of this patient? (acth and cortisol and aldosterone)
now its time to recall and its just a matter of your knowledge. at this point, if you got it wrong, it means that you have lack of knowledge (understanding or memorization) of feedback mechanism. again, you have to think of an answer first and find the one that closest to what you looking for..
a little note:
combining all information and converting it into one single big picture requires some skill. there are some questions that you might not get the big picture at all, and usually happened in step 2ck/step 3 where the question is so vague. one way to improve this skill is to have better knowledge. for example, if I say there is a 16 yo M with infection of lung three times last year, and UTI 2 times 2 years ago, and sinusitis 5 times, + platelet of 56.000, and rash, what would be the big picture? yes, its Wiskott aldrich. people who does not know wiskott aldrich will never be able to put everything together. so again, the skill to combine information into one big picture relies partly in your knowledge.
Now we have finished the general steps of doing a question, we will move to the next section tomorrow, which probably what most of you are waiting for:
how to rule out answer choices and how to deal with 50:50.
Hi everyone, I am sorry I skipped yesterday, kinda busy. so lets continue our discussion
once you did your 3rd step, got the big picture and into the recall phase, there will be 3 possibilities:
1. you know the answer right away
2. you cant rule in anything
3. you are in 50:50 situation
lets discuss possibility no 2 first : you cant rule in anything. this means that you have a lack of knowledge regarding the topic being asked, but dont give up yet, you may still able to answer the question by ruling out.
what you need to do is to read every single options and recall all information that you know related to that options. lets make a simple question:
Which of the following is the side effects of amiodarone?
a. livedo reticularis
b. bluish vision
c. red man syndrome
d. decrease FEV1
pretend that you dont know what is the side effects of amiodarone, then you are going to start ruling out:
1.what is the meds that cause livedo reticularis and what are the conditions that cause it? you may recall it can be caused by amantadine, choleterol embolism, and some vasculitis
2.what cause bluish vision? its viagra
3.what cause redman syndrome? its vancomycin
therefore only 1 options left, and thats gotta be the answer: D
as you can see, its much faster if you know what are the side effects of amiodarone: PFT, LFT, TFTs, and smurf skin. if you see decrease fev1, then you can just click it and move on to the next qs rather recalling information for each options.
its always better to rule in then rule out. ruling out takes huge amount of time and effort . usually a common mistake most people do is once they have the answer they like, they still try to rule out the other options just to be sure. I personally think this is not a good idea , here is why:
1. once you already think of an answer and it fits with one of the options, that is most likely going to be the right answer.
2. there is a very small chance that you are going to change your answer if you already think of an answer and find it among the options.
3. if you do change your answer, you will most likely to get it wrong.
so you see there is no point of try to rule out once you already rule in! 1. you will get it right, 2.you will rarely change it, and if you change it, 3. you will get it wrong. so just click the answer that you want and move on! if ever the habit of ruling out comes back, always remind yourself with the 3 facts I mentioned above.
now, if you cant rule out until you reach 50:50 situation, then its very unlikely to get the qs right, pick something and move on. but most of the time you will at least reach 50:50 situation.
to be honest with all of you, 50% of the qs in the real test are 50:50( at least for me). And for the other question, its not like I am 100% certain what the answer is, there always gonna be some doubt. so this makes 60-70% of the time you are somewhat in 50:50 situation, which is HUGE! There are couple tips you can do when you are in this situation:
1. never pick an answer that you never heard of
I think most of you have heard this before. if the correct answer is something that you never heard of, then you will never get that qs right at your current state, dont feel so bad about it. learn from that qs and dont make the same mistake again, your score will definitely go up.
2. always pick an answer that you can reason better
instinct vs logic, its always a difficult thing. let me tell you what, always go with logic, and you will have more consistent score. when your instinct get you to the right answer, thats just luck. dont click an answer just because you think its the right one, you need to have a reason. this also important when you become a doctor, you dont want to prescribe medicine just because you feel that is right, but because it makes sense. so get used to train your brain to make decision. this also correlate with the next tips
3. pick an answer that, even if you got it wrong, you will have the least regret
if you choose an answer by instinct , and you got it right you might feel good. but if you got it wrong, you will feel very stupid. there is no reason to click on that answer, why would you pick it? if you have good reason to pick an answer, and you got it wrong, then most of the time there is some part of knowledge that is missing, thats why you got it wrong. there is no regret, since again, at your current state of knowledge, you would never get that qs right. read, learn, and dont make the same mistake again. this lead to the next tips
4. always focus with what you know
there is no point dwelling in information that you cannot process. just focus with information that you know, and go with that. its somewhat difficult for me to really explain it to you, hopefull these two examples would help you to understand:
I had a student once, we encounter this qs about herpes. history seems like herpes, for me the pictures was obvious, but for him it wasnt. And he picked non-herpes answers!! this does not make sense at all. why would you change your answer based on a picture that you are not even sure? you should just focus on what you know (the history), not dwelling on the pictures you are not even sure, and even worse, make a decision based on that! there is no point in processing information that you dont even know. if that particular information is a critical information to answer the qs, then you will never be able to answer it with your current state of knowledge, accept it.
let me explain why my student (or some other people) did above mistake. this is because of lack confidence in their knowledge. they were thinking subconciously that there is something they dont know, so they pick the other options. so the solution is simple, have a good knowledge. how to make sure you have good knowledge? welll, if a certain topic never mentioned in UW or FA, then very low percentage of people will know it..so understand and memorize UW and FA really well! have confidence in your knowledge, so you can apply the technique: focus with what you know.
5. if there is one thing that does not fit, ignore it.
this is actually a tips for getting a big picture rather than 50:50 although it can help with the 50:50 as well. lets make a simple qs:
44 yo F with shoulder pain, blurry vision, headache, and jaw pain. what is the most likely diagnosis?
the most likely diagnosis in this case is temporal giant arteritis. but wait, she is 44 yo F! isnt temporal giant arteritis hit >50 yrs old? usually even 60 or 70.. well, in this case, its still giant temporal arteritis, because there is only one thing that does not fit: pt's age. so just ignore it. however, if there are 2 things do not fit, the chance you miss something is big, so reconsider your big picture.
6. recall further, then search more information in the question
this is actually what I called as a "lengthened recall phase" that usually happen in step 2 ck/3, but you will encounter some qs in step 1 that require this. lets use below qs as example:
A 57 yo F with past medical history of drug abuse, ckd not on dialysis, hypertension, diabetes type 2, admitted to psych unit due to mania. she was found to be bipolar. her BP is 140/78 mmHg, HR 95, afebrile, RR 20x.. lab results showed wbc of 8000, hb of 9.8, platelet 160k, creatinine of 1.9, BUN 45, Na 143, Cl 101, K 4.3, Ca 7.8, Albumin 2.8, HbA1c of 7.8%. ECG showed Sinus rhythmn with qtc of 500 msec. which of the following is the best treatment for her bipolar disorder?
a. lithium
b. valproic acid
c. haloperidol
d. chlorpromazine
e. triamterene
1st step --> reading the last line. best treatment for bipolar disorder.
at this step actualyl the qs becomes very clear, its just tx for bipolar, so you dont have to go to the 2nd step, you should recall first. the treatment would be lithium, atypical antipscyhotic, or valproic acid. I strongly believe in step 1 you will only encounter one of above drugs as the answer. so I am using step 2 ck qs to make my point here. as you can see at this point you are in 50:50 situation, because there are 2 drugs for bipolar disease: lithium and valproic acid. both drugs definitely can be use in bipolar! so there must be something in the qs that tell you which is better than the other. at this point you should recall further what is the difference between lithium and valproic acid in terms of MOA, clinical use, and side effects:
1. lithium MOA is not clear, we cant use that. clinical use for bipolar only. you should know that it has narrow therapeutic range, ckd may be a problem. side effects; diabetes insipidus, tremor, neurotoxicity, ebstein anomaly in pregnant woman.
2. valproic acid MOA is inhibiting Na channel in the brain, it has antiseizure activity as well. side effects woould be thrombocytopenia, alopecia, liver failure, teratogenic effect.
by recalling further, you can see that there are some information you need to look for in the qs stem. this is the time to got to your 2nd and 3rd step to find those information, here is some thought process in this qs:
if this patient has some neuro issues probably lithium is not a good thing, if she is pregnant, probably is not good either. if she has hypernatremia it might not be a good thing because lithium can cause diabetes insipidus. for valproic acid, if the pt has seizure history as well this can be 2 birds in one stone, if patient has thrombocytopenia or liver failure already its not good, and not good for pregnant woman either.
all the things that I mentioned above are all negative in this patient: she has normal Na level, she is not pregnant, she has no seizure history, she has no thrombocytopenia or liver failure. she got one thing though: renal failure. and lithium has narrow therapeutic range. at least that one fits, so the better answer here is valproic acid.
I have to emphasize again that this is not a typical qs of step 1, but its one way to approach a 50:50.
7. if its a 50:50 memorization thing, then the first thought is always correct. skip the qs and come back.
for example, you forgot which chromosome cystic fibrosis gene is located. you are between chromosome 17 and 7. the first thought you have most likely to be the correct one. dont stay in the question too long because your brain might play trick on you and your first thought becomes blurry. one trick to make it more clear is to skip the question altogether. when you come back, you will have less biased mind for a couple seconds, get your first thought and click the answer.
8. if all above fails, then **** it, click whatever and move on. it is not the only qs in the world, let it go..
I believe I have some other tips that I can share but I dont have it on top of my head currently, I will add more as I can recall more tips.
next topic would be TIME MANAGEMENT
TIME MANAGEMENT STRATEGIES
in a block of 40 qs and 1 hour time, you want to do 2 runs in 1 block. in the first run your speed should be less than equal to 1 min/qs. this is very possible to do, because in the first run your focus is to find qs that only require 2 step process: getting the big picture (by reading last line, 2nd-3rd line before the last, or reading and paraphrasing), then (easy) recall and answer the qs. if the question require you to do more than that, then SKIP IT!
another way to say this is to SKIP questions that:
1. hard to recall
2. force you to rule out
3. put you in 50:50 situation
Let me say this one more time, your goal in the first run is to:
1. hunt for easy questions and 2. getting the big picture for the difficult qs!
when I say SKIP, it means you LEFT IT BLANK. NEVER PICK AN ANSWER THEN FLAG IT. the reason is to keep the qs unbiased. if you already pick an answer (based on your half-made judgment/reasoning) and you come back, you will feel reluctant to change it because the rule is not to change your first answer. Keep it unbiased by keeping it blank!
some of you may raise a question then: so when should I flag a qs? well, basically never.. but I do flag question.. when I accidentally click on something and realize that the qs should be skipped from the first place..this just to give a sign that I should come back to this qs later.
Now, if you have moderate- good knowledge, you should be left with <15 qs unanswered. So mathematically:
there are 40 qs total, you do 1 min/qs, so in the first run you spent 40 min with 20 min left. very rarely you can be perfect with 1 min/qs, so usually you will have 15 min left with <15 qs unanswered.
if you end up having >15 qs unanswered, then either its a very difficult block, or you definitely lack knowledge. please go study more..
during your first run, always check your time! for example, if you are in qs number 7, then your time should show 53 min left! check your time especially after you felt that you spend too much time on a question!
in the 2nd run, your job is to finish the rest of the qs by using the general steps I mentioned in the previous post. since you already got the big picture, you only need jump straight to the rule out or 50:50 techniques. during this 2nd run, you should not spend more than 1 extra min per question. Have you ever heard the more time you spend in a qs, the more likely you got it wrong? this is very true.. if you encounter a qs that you cant figure out after 2 min, then accept it, you are most likely to get that qs wrong. click whatever and move..
let me tell you this: most people with good test taking skills subconciously do above techniques (2 runs). they just skip a qs right away when they know its hard, they come back and redo the qs. Nobody told them what are the advantage of doing that, they just do. let me explain the advantage of 2 runs:
1. the idea of having 2 runs is to distribute the time correctly: you spend less time in easy question, and spend more time in the hard ones.
imagine if you have 7 min to do 5 questions. lets say question no 1,4,5 are easy, while qs no 2 and 3 are difficult. assume that you require 1 min to do easy questions, and 2 min to do the hard ones.
if you dont skip the qs, whats gonna happen is you are going to do qs no 5 with 1 min left, which is anxiety provoking and increase the risk to get an easy question wrong (imagine 80% of people got it right and you got it wrong..this will decrease your score very significantly!). if you you skip no 2 and 3, you will have 3 min left when you engage qs no 5.. after you answer qs no 5, you come back to qs no 2 and 3 with 2 min left. now even if you got it wrong, its a hard qs which will not hurt your score that much. hope this makes sense..
2. getting a epiphany. for some reason, you have more chance to get an epiphany when you attempt a qs the 2nd time. This means you increase your chance of getting a hard question right!
3. you actually do a question much faster by skipping it rather than dwelling with it.
4. you have the peace of mind that you actually already saw all the qs, it gives you less anxiety when you see the difficult qs the 2nd time. imagine if you have 1 min left with 1 qs left that you have not encounter before. its much better to have 1 qs left with 1 min left but at least you have the big picture ready!
Now I have to discuss the last possible scenario: what if on the 1st run I got 18 qs unanswered with 13 min left?!
if you are in this situation, guess 5 qs very quickly, so you will be in 13 min left with 13 qs. basically, just adjust the best you can so you left with 1min/qs for the 2nd run. I have been in this situation many times, the key is just to have the mentality to get the job done: answer all question with good judgment.
again its very rare you will be in this situation as long as you have good knowledge, it should be <15 qs with 15 min left.
little tips: during the exam, you will definitely get this sense of losing focus. you dont know what you are reading, your mind move to another place, or something like that. This episodes are very hard to avoid, but can be reduced. the trick is to not force refocusing yourself, but to skip to the next qs. if you still not focusing on the next qs, skip it again. just keep skipping until you regain your focus. once you regain your focus, come back immediately to the qs you just skipped, and surprisingly, the previous qs becomes very easy for you (if its truly easy).
another tip to keep focus during exam is to create a habit: like repositioning your glasses, or rubbing your shoulder, or whatever. this is very commonly done by professional athlete. for example, you can check how Rafael Nadal always touch his nose and correcting his hair on both of his ears before serving. you can create your own. do this when you lose focus or everytime you go to the next question. its just a mental trick to your brain.
ok, so in summary for time management strategies:
1.do 2 runs, 1min/qs
2.first run is to hunt for easy question or getting big picture for difficult qs
3.skip the difficult qs completely
4.2nd run is to apply rule out or 50:50 techniques. extra 1 min/qs
5.adjust your time as needed
alright everyone, basically we finished the main test taking strategies.
Please feel free to ask any questions!
Posted from USMLE step 2ck thread:
Step 2 ck / 3 Recall phase
The general steps approach is pretty much the same for step 2ck/ step 3, its just that you require more time to finish all the steps. The first big difference between step 1 with 2ck/3 is the recall phase.
step 1 usually only require simple recall. for example, if you got the big picture that patient has huntington, probably these are the answers for each possible question:
which chromosome: chromosome 4,
movement abnormalities that you can find: chorea,
genetic terms: anticipation,
another disease that has similar pathogenesis: other trinucleotide repeats diseases,
sstructural brain abnormalities you can find: caudate nucleus,
most common cause of death: suicide,
amino acid that accumulates: glutamate.
for step 2 ck/3, the recall process are more complex and time consuming. lets use this qs as example
a 56 yo M admitted to ED with sharp, left sided chest pain for the last 48 hours. pain is worsened with breathing, relieved with leaning forward. the intensity is 8 out of 10. He also complaints of faitique, 3 pounds weight loss, nausea, and vomiting a couple of times over the last several weeks. he had NSTEMi 1 year ago and got 2 stents placed in RCA and LAD. His other medical problems include diabetes type 2, hypothyroidim, Chronic kidney disease, hypertension, hyperlipidemia, depression, and peripheral neuropathy. His medications are aspirin, clopidogrel, carvedilol, lisinopril, and atorvastatin, levothyroxine, gabapentin, and amitryptilline. he is temperature is 97 F, BP 140/80 mmHg, HR 95 x/min, RR 20x/min. ECG showed normal SR with T wave inversion in lead V5 and V6. lab results as follow:
Hb 8.2
wbc 8k
platelet 200k
glucose 260
Na 132
K 5.6
HCO3 16
BUN 97
Cr 5.2
Trop 0.011 (normal)
which of the following is the most appropriate therapy for this patient chest pain?
a. colchicine
b. hemodialysis
c. heparin infusion
d. naproxen
e. pericardiocentesis
lets follow our steps:
1st step -> reading last line: which of the following is the most appropriate therapy for this patient chest pain?
- from this line you should know that if we know the nature of the chest pain, then we might know whats the best treatment for this patient. so you should focus on gathering more information regarding his chest pain
2nd step ->reading the 2-3 last line: you can start reading from medications list, or the vital signs, does not matter, you will find NOTHING here. the T wave inversion can mean ischemic or cardiomegaly, does not really tell exactly that this pt has MI, we need more information. so we have to move on to our 3rd step
3rd step -> read the first line, find gender, age, and chief complaint. then paraphrase while reading, and highlight abnormal labs.
in this part, you should be able to get that the patient has classic pericarditis signs: sharp pain, relieved by leaning forward. if you dont know this, again, you have lack of knowledge, there is nothing to do with test taking skill.
so now you got at least the angle of this question (its not a full big picture yet!just an angle): pericarditis. carefully read the last line again, you should notice then the qs will become: what is the treatment of pericarditis? this is the time you should recall.
Now what would your answer be? well, the correct answer is : it DEPENDS. and this applies to most of step 2 ck question, your answer is always: DEPENDS. so you are not recalling a single information, you are recalling several information that you need in order to answer the qs.. and this is a very important point! let me explain to you why:
do you realize how long the question are, the amount of information given to you, and the amount of distractions in step 2ck/3? How do you know that an information is important or distractor? the answer is, you dont! you will never know an information is important or distractor until you came up with an ANGLE! once you decide on your angle, only then, you can see whether an information is useful. and knowing which information is useful comes from knowledge.
lets use above qs as an example. we got our angle: treatment of pericarditis. and the answer in this qs is depends.. but depends on what? well, you should recall that it depends on the ETIOLOGY.
so what are the etiology of pericarditis? these are some of it:
post MI pericarditis
dressler syndrome
viral pericarditis
autoimmune pericarditis from connective tissue disease
bacterial, like TB pericarditis
autoimmune pericarditis from rheumatic fever
uremic pericarditis
if the pt has viral pericarditis, we give nsaid and colchicine. if the pt has post MI pericarditis, then usually aspirin is a better choice of NSAID combined with colchicine. if its TB pericarditis, antibiotics would be a good one. if its autoimmune, steroid would be a good choice. if its refractory pericarditis, steroid also a good one. if its uremic, hemodialysis would be the best choice.
oh and dont forget, what if this pt has pericarditis with effusion that leading to tamponade? then pericardiocentesis would be the best answer right?
in above case, the pt had stent 1 year ago and it would be too long for dressler or post MI. there is no rash, joint pain, RBC cast to justify connective tissue disease. pt is not an immigrant and you do not want to assume. not enough symptoms to justify rheumatic fever either. so the best etiology would be uremic pericarditis and that is our full big picture! hemodialysis becomes the best answer. the best way, again, is to include rather than excluding. if we found high BUN and pericarditis in the qs, it would be uremic pericarditis. you dont need to exclude one by one like how I did above, I am just giving an example how we should think. just keep the information that you need to look for at the back of your mind while you are reading.
I have shown you the recall process in step 2ck/3 are more complex and time consuming: we have to recall the concept of "different etiology in pericarditis lead to different treatment", you have to recall what are the etiologies and CLUES/INFORMATION that leading toward a certain etiology, find it in the qs, and then recall the treatment itself. Some question even require you to do an additional step: CLINICAL JUDGMENT, we did not do this part for above qs, its not required.
step 1 has less distractions, very straight forward, most of the time you just need concepts and memory to answer the qs. however, in step 2 ck (and even more in step 3), lots of information and distraction, qs becomes so vague that you dont even know what you are reading require you to carefully read and analyze the qs.
I dont believe there is such thing as a trap question. I think its a knowledge proble. you dont know which important information to look for, thats why you felt trapped when you got it wrong (for example, did not pay attention the pt allergic to penicillin). this also lead to rereading the question unnecesarily, feeling like you miss something. I have some students that, after he thinks of an answer and pick it, he went back reading the qs again and again just to make sure he does not miss "something". I always ask them, what information are you looking for? they would answer, well I dont know, probably there is something.. well, so basically you are looking for something you dont even know. whats the point? you have to know what you are looking for, if not, you are just wasting your time.. again, you need to have BOTH an angle and knowledge to know if an information is important or just a disctraction.
so in conlusion: in step 2ck/3, the recall process is lengthened due to the needs to recall which information that you need, reread the qs again to find those information, and sometimes, make clinical judgment.
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