How to Ace the NBME Shelf Exams, In-Training Exams and Your Boards.

Ok, now that I have your attention, let me share something with you. I’m going to show you how to maximize what you learn from the “school” we call rotations in medical school and residency so you can be an awesome master clinician. And, yes, it’s going to help you with your exams, so stay with me.

Clinical rotations are a strange blend of learning and work. You learn from the work, but we all forget that the work is not the purpose of these clinical experiences. The purpose of rotations is to be able to “practice” medicine (as a student) and then master the art of your specialty (as a resident.)

There are six basic principles to learn medicine, and then learn your specialty …and on the way ace the exams:

  1. Remember it’s school.
  2. At the beginning of each rotation, decide what topics you need to learn during the rotation and make a list.
  3. Take notes. All the time.
  4. Figure out how you will store your notes so you can find them quickly and organize them for review.
  5. Go through the notes you make every day to review them and then store them in your system.
  6. You can’t learn medicine from a review book (yes, including UWorld)

Somewhere around the beginning of my third year of residency, I was sitting in the “dome” (the chief resident’s “office” above OR 1 in our County Hospital) when Fred, one of my fellow 3rd years, walked in. He sat down and started to look through a stack of 3×5 cards so I asked him what he was doing. We all knew that he had scored the highest in our class on the ABSITE (the surgery in-service exam) and I was about to find out why.

REMEMBER IT’S SCHOOL

Fred figured out from day one that there was no way he was going to be able to study like he did in college and during basic sciences. Instead of hours to sit and read, it had to be flexible “on the job” learning.

This mindset is probably the single more important thing to cultivate. It’s the thing that drives you to constantly ask questions about why things are done the way they are and then go look up the answers.

Photo credit

 

AT THE BEGINNING OF EACH ROTATION, DECIDE WHAT TOPICS YOU NEED TO LEARN DURING THE ROTATION AND MAKE A LIST. 

Your list can be pretty simple, or more complex, but it needs to be enough.

First hint – There is a curriculum that has been defined for your rotations. Everything your professors have decided should be taught should absolutely be on your list.   (By the way….If it’s in the curriculum, it has to be part of an objective. If there is an objective, it has to be linked to a test question)

Second hint – There is no way in medical school that “surgery” (or any specialty) can be covered in 8-12 lectures. The same is true for your rotations in residency. You have to do more.

This is one time that an example may be better than a formula. Let’s say I’m a brand new clinical student on my core surgery rotation….

Photo credit 

 Step 1. Find a textbook of Surgery and make a list of the topics from the chapters. A spreadsheet may be best for this, but any kind of list will do. 

For example, our library has Sabiston’s Textbook of Surgery (20th edition, 2017) on line:

 

 Step 2. Breathe deeply. There are 72 chapters and no, you are not going to read all these pages.

Man carrying books

 Photo credit 

Step 3. Create a schedule to SKIM every chapter during the rotation. Look only at the “big picture” i.e. headings, section titles, diagrams, tables. Your schedule should leave the last week or two free. So, for example, if your rotation is 2 months long, plan to SKIM 12 chapters a week to get them done in 6 weeks.

 Photo credit 

 Step 4 – Now we get to the real deal (remember, this is graduate school and/or specialty training).

List the sections on your spreadsheet.

As a student, you won’t read every section – unless they are very general (Acute Abdomen, for example) or if you have a patient with that particular problem. Here’s what it might look like:

 

TAKE NOTES. ALL THE TIME.

After I learned Fred’s system, I always kept a stack of blank 3×5 cards in my pocket. Like him, for the last 3 years of my residency, I made notes ALL the time.  Here’s the kind of notes we are talking about:

  1. Reading textbooks or other curricular readings. Take the time to make the notes and make them well so you never have to go back to the chapter to review it.
  2. On rounds when someone teaches an important point (e.g. the 7 things that keep a fistula from closing)
  3. During Grand Rounds
  4. During conferences
  5. When you look up a paper to read about a patient
  6. And – most important – what you learn from specific patients. Do NOT put the name of the patient or their MRN (HIPPA). But, do put specifics that help you remember the patient (e.g. pt that always wore a red baseball cap and had a tattoo of a dragon)

As you can imagine, once I started this system, I was making 10-20 notes a day. It is remarkable how much you learn in a given day… and how it’s almost instantly gone if you don’t write it down.  In three years I filled up two boxes with cards. These cards were the only thing I reviewed for my Board exams.

 

FIGURE OUT HOW YOU WILL STORE YOUR NOTES SO YOU CAN FIND THEM QUICKLY AND ORGANIZE THEM FOR REVIEW

This is why using a notebook isn’t the best way to keep notes on rotations. You’ll take them chronologically and, unless you have an amazing index at the back with all the key words and pages listed, you’ll never be able to find a specific note.

The key is being able to “file” the notes so you can find them.  For the 3×5 system, leave a blank square at the top to put the topic you’ll use to file them.

I used anatomy as the basis for my filing system. So I would use a pencil (so I could change it later if I needed to) to put the topic in the box.  For example

Pancreas, pancreatitis

Appendix, neoplasms, carcinoid

This is very old-fashioned (but very effective) system.. I personally think there are better ways to do this now using scanning, cloud storage, key words and tags.  For some ideas, check out this post.

What doesn’t work well is to try to type notes on your phone.  What REALLY doesn’t work is to make notes and then decide to copy them, type them or somehow redo them later. (It never happens).

 

GO THROUGH THE NOTES YOU MAKE EVERY DAY TO REVIEW THEM AND THEN STORE THEM IN YOUR SYSTEM

The key to learning (as opposed to memorizing for a test) is review. Simply filing the cards means you are reviewing them. Plan to pull them out to look at them (and all the work you accomplished!) every week or two.

More importantly, when you see a patient with pancreatitis 5 months from now on a different rotation, pull the cards you made on this rotation. You’ll find you have 20 or so cards (or card equivalents) on pancreatitis … a review of the Surgery textbook, notes from Grand Rounds, the 3 patients you saw with pancreatitis that taught you about the disease and a few pearls you learned on rounds from your chief resident.

 

YOU CAN’T LEARN MEDICINE FROM A REVIEW BOOK (YES, INCLUDING UWORLD) 

I’m really serious. Not only will you suffer when you are taking care of patients, you won’t do as well on the tests (despite what the upper level students or residents tell you).

Remember the last two weeks of the rotation that you saved?  Now’s the time to pull out the review books.  It’s a wonderful way to review what you have learned from your skimming and patient oriented reading.  It’s also a great way to identify gaps and look up information.

p.s. Take more notes while you are doing this.

p.p.s Review all your notes, including the ones you make from the review books.

p.p.p.s Review them again.

Link to the Wikipedia article about the forgetting curve

Leave a Reply