Monday, January 23, 2006

step 3 prep[zt]

ani - 11/16/05 23:49

I took my Step 3 last weekend and thought I should write a post to help people sitting their exam in the near future. I will write my full experience and answer questions regarding my preparation when I get my results but for now will concentrate on the exam.

Step 3 is the most practical of all the Steps and sort of puts you in the position that we have all been in real life, with a patient in front of you and figuring what to do. Any doctor who has practiced clinical medicine will feel more at home with this exam compared to the other Steps. Many questions reflect things doctors really face in day to day life so it is not an exam worth panicking about and you should feel relatively at ease. That is not to say it is an easy exam…it is not that either.

I found that of all the MCQ questions I probably confidently knew the answer to 40-50%, 25% to 30% I was not certain but could make an educated guess, and another 20-25% I had no clue or could only narrow the responses to two and then had to make a wild guess. Unlike experience of others, I did not find much similarity between the questions and those on USMLEworld. A few questions (below 10%) I would say I had encountered on USMLEworld. What though is similar is the length of questions. And also because many USMLEworld questions are so badly written, if you are used to teasing those out then the real USMLE questions will be relatively easy to understand.

I found time to be a major constraint in the exam. This may partly be because most of my blocks were from the office or health center setting. As I have been a hospital doctor for last 14 years who has never worked outside hospital, I found the office questions rather difficult to reason out and many of the scenarios or questions were strange to me. The hospital and ER blocks were much smoother and I did not have constraints on time, but unfortunately they constituted less than a quarter of my exam. The result is I ended up always rushing against time by the end of the blocks. Concentrating for 8 hours is extremely difficult which was part of the problem and on two or three occasions I dozed off momentarily while staring at the screen (I had been at work in hospital till midnight the day before). There were a lot of ethics questions but if you have been a practicing doctor then many are scenarios you would have encountered in real life and if you stick to your instinct most would be okay. Also a lot of epidemiology – if this is not your strength then do not waste time on them as some will take you minutes to resolve and it is best to forgo that point and spend the time on other questions (for me epidemiology is a strong area so I always worked them out).

General tips I will give on handling MCQ

1) Use the highlighting tool. I think this is the most important way you can a) stay awake b) stay focused and c) keep from making silly mistakes due to not reading the question properly. As you start to read a question you never know where it will end, so just take the marker and mark out key elements of the history, exam, abnormal findings and anything unusual that shouldn’t be there. For example, if it said something harmless like ‘she stopped her job as a nurse 3 weeks ago’ or ‘four years ago she was admitted for stomach pains’ then be suspicious and highlight such phrases because those phrases have no business being in the vignette, except that they are there for a reason. In contrast stuff like vitals are of no importance unless abnormal. Once you do this then go to the question, the bits you have highlighted in yellow stand out and you will be surprised how many apparently innocuous phrases are the clinch to the answer; and if you were to take that phrase out (i.e. if you failed to notice its importance) the question would have a totally different answer (which would also be among the listed options).

2) Do not dwell on questions you don’t know. If you don’t know the answer then no point reading and rereading it, just guess and move on. If you can narrow it to 2 options just guess one of the two and move on. Reading it more won’t do anything than increase your frustration and leaving you fighting against the clock as you get to end of block.

3) Do not dwell on questions if you do know the answer. You will occasionally come across questions that you know you know but for some reason cannot figure out. Do not waste 3 or 4 minutes trying to get this one mark. Mark the question, guess and move on. If you have time at the end then come back to it. Else the time you spend on that Q will hurt you later when you find you have 6 minutes for last six questions. You will then hurry over the last six and could end up failing them all just because you had spent too much time trying to get a single mark.

4) Do not dwell on questions you fail. Do not think too much about questions you have failed; as you go through the exam and see the same theme resurface, you will realize you failed the question first time around. Mourn when you get home. It serves no purpose now other than to distract you and make you more prone to future errors.

5) Learn from previous questions. You will be surprised how many questions have similar themes and how many answers can be derived from questions you have encountered in earlier blocks. Of course often you will learn from a subsequent question that you failed the earlier one; regroup and pick the correct answer this time. Many questions too are repeated. I must have had 5 questions each on two particular neuropathies. I even saw exactly the same (dermatology) photo but with slightly different vignettes on each occasion. When you see things in one question that may help in future then right it down on your board for future reference. When you see the same option or theme repeated then it is likely that that is the correct answer (and you failed it earlier); just regroup and get it right this time. Write down the normal values for lipids – these will feature again and again.

6) Guess intelligently. There are some cardinal rules. If you do not know the answer and there exists an option which says ‘do nothing’ then pick this; sometimes you will be wrong but majority of times you will be right. If you do know the answer and there is another option that says ‘do nothing’ then seriously reconsider your answer. If your answer is option A then hesitate and read through for you may see a better option, because there may be an even better ‘best next step in management’. Or you may find a more specific answer e.g. (A) may be abdominal XR and (D) erect chest and abdomen XR. If there is a strange option that seems to have no reason to be there then this is likely the answer. For example if you have a question on how to manage what looks like an MI, the usual options to expect are cardiac cath, troponin, aspirin, atenolol, lasix, cxr etc. If amongst the options you see something strange like electrophysiological study then read the question again and be careful that what you are dealing with is not an MI but something else like WPW syndrome. Always look hard at the simpler options seriously (like TSH, urinalysis) before you consider sophisticated ones (like MRI). Before you pick the second best answer (because the best has not been provided), look for different ways of describing the same thing – that you don’t see your first choice answer doesn’t mean it isn’t there; for example eponymous names may not be used or a mechanism of action rather than a drug name or a pathological description rather than a disease name. It is EASY to answer questions correctly even when you do not know what the question is asking. If you can guess correctly on even a quarter of questions that you do not know then you seriously enhance your chances.

The first night.
Do not despair after your first day. No matter how bad you have performed it is still recoverable at this stage. Remember most who fail will fail with 70 to 74 so a little extra effort could be the difference between pass and fail. On the first night try and work to limit the damage of the first day. Personally I went through Aster notes (and it paid cos on the second day I had at least 5 questions that I came across night before) and also USMLE CCS cases. Keep your spirits up and hope tomorrow will be a better day.

The second day MCQs I found better (most people do) – I think they want to ease you into the CCS.

Personally this was my Achilles heel. At least 3 cases I could not get to the bottom of the diagnosis. And the patient was better but not quite right. The pediatric cases were my major problem. My advice to you is when you go in write some things down on your board before you start the CCS on things you must not forget. Like Counsel every case, change location, toxicology in ER cases, pregnancy tests in females etc. I was stunned cos I had 3 cases where the solution to the case came from a test I had ordered innocuously, and had I forgotten to order that test then I would have got nowhere. One patient with vague symptoms ends up pregnant, another HIV positive, another hypothyroid etc. And it was so easy to have forgotten to order the test and be led down the wrong path. Of course two, I could not solve cos there was clearly something I should have asked for which I didn’t. This part of exam is more like a computer game. Try and keep calm. At one point when I reached a dead end I became frantic and lost control and started requesting every test under the sun I could think of which surely didn’t help my case (often met with response the patient is too young and cannot co-operate for this test). Other thing I found is most cases have accessory issues so do not feel comfortable that you worked out they have carpal tunnel syndrome– they might also have peptic ulcer. Another problem I had is I did not advance the clock enough so try and keep up with that.

Take breaks wisely between blocks. When you have a bad block stop and take a break – it is easy to become frustrated and then it becomes self-perpetuating. When things look gloomy, think of it this way. You are not the worst doctor in the world. There are others doing the same question that are finding it as difficult or more difficult than you. There is always someone worse than you. If the block is difficult, maybe it is difficult for everyone. If you are an IMG remember there are many American graduates that are nowhere near as good a doctor as you and if they all pass the exam then so can you. It is a game, just play by the rules and hope for the best – I am doing just that now. Wish you luck.



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