Studying for the In-Training Exam

Posted on January 30, 2021 by marylbrandt

Every year every resident in the United States takes an exam (called the In-Service or In-Training exam) that covers all of their specialty. It’s meant to be a formative exam for residents and their programs, which means it’s supposed to let everyone know which areas need more focus. Unfortunately, because there are numbers associated with this test it has become a higher stress exam than it should be, especially for residents who are applying to competitive sub-specialties.

First a word to Program Directors. When you think about this test there are only three categories for the results

1) Possibly at risk to pass the boards (< 10^th% ile?)

2) Going to do fine (11-79^th %ile)

3) Extraordinary test takers who really know the info (>80%ile)

This is a comprehensive (and long) exam that often has a VERY narrow bell-shaped curve. What that means is an incorrect answer on 2 questions (some years) can drop a resident up to 10%ile points. Doesn’t it seem silly to think that 70^th%ile is somehow “better” than 60^th% or 50th%ile? (I’m looking at you, subspecialty PDs)

Now for my colleagues in training. You stressed about this exam, you “crammed” (yes, we all did it – even those of us who know it’s stupid) and now you are breathing a sigh of relief that it’s over…

Take a good break from studying. For the next two weeks, use all the time you would have been using to study to binge watch something on Netflix, read a few novels you’ve been meaning to read, or do whatever gives you rest and joy. Then….

Put this in perspective. At the end of your residency, you will be launched into the wonderful, scary, amazing world of practice. You want to know that you know enough to do this, right? So back away from the idea of the In-Service exam as a pain in the gluteus, and see if you can think about it as a formative exam. Which leads me to…

Learn About Deliberate Practice. The best way I’ve found to think about deliberate practice is to understand how musicians practice. I wish I could remember where I read this so I could properly attribute it (please let me know if you know!), but here’s the best example I’ve found to understand deliberate practice – Serious amateur musicians and professional musicians practice a similar amount of time… say 2 hours a day (for the sake of this discussion). But how they practice differs. The amateur will play the piece from beginning to end multiple times, occasionally stopping to repeat the stanza that trips them up. The professional will play it once or twice, spend an hour on a stanza that trips them up, then start over. That’s deliberate practice. Taking the things that are hard (or you don’t like) and repeating them until they aren’t hard.

So, putting this all together, here is what I suggest you do to get ready for the In-Training Exam:

Step 1: Make notes.

Take one of the major textbooks in your field and make a spreadsheet of every chapter, topic, and subtopic in the book. Your goal is to make notes on every topic in the book from March 1^st to December 1^st. Start with some simple math… March 1st to December 1st is 39 weeks, so take the total number of topics in your text book and divide by 39 to set your weekly goal.

Photo credit

But you won’t start with page 1 and work sequentially to page 846. (Yes, for those not in medicine, the books are usually that long). When you are on call, and you admit a patient with pneumonia, read the chapter about pneumonia and make notes to store in Google Drive? EverNote? OneNote? It doesn’t matter as long as they are in the cloud and searchable. If you hand write notes that’s ok, too, just use an app like Scannable to turn them into PDFs and store them on the web (don’t forget the keywords and/or tags so you can search for them when you are reviewing). What should the notes look like? You graduated from college and medical school, so I’m betting you have a system that works for you. But, if you’ve never heard of it, take a look at the SQ3R system for studying. (Spoiler, it really works.)

Photo credit

A few other words of advice. It is VERY helpful to link your notes to a specific patient. You’ll remember everything much better; I promise. So, mention the patient with COVID pneumonia who always wore their yellow baseball hat… but don’t put any PHI in your notes so you don’t get in HIPPA trouble. Also, don’t limit yourself to notes from the textbook. This system allows you to make and store notes when you read an article, learn a pearl on rounds, create a mind map, use questions banks, or do a presentation…

Photo credit

Step 2: Deliberate practice. There will be sections of your textbook that thrill you. Parasites? For some reason we are all fascinated by them. Coagulation cascade? Not so much. Recognize that it will always be easier to learn about parasites than the intrinsic and extrinsic pathways. (Unless you are going into blood banking, in which case I apologize). Which means you need to spend more time on the coagulation cascade. Darn. #DeliberatePractice

The fundamental thing that differentiates learning (for your patients) from memorizing (for the test) is repetition. Your goal is to see everything you need to learn at least 5 times, spaced over at least 3 months. If it’s a topic that is difficult for you, it will probably be more times over a longer period of time. #DeliberatePractice

Photo credit

One of the best ways to learn specific pieces of information you need to know (like the coagulation cascade) is to use an app like Anki or other flashcard apps. The advantage of these apps is they force you into spaced repetition (remember the minimum of 5 times over 3 months?), but if you are more comfortable with the old-fashioned (but effective) analogue system of actual flash cards, go for it!

But – write this down and put it over your desk – You can’t learn to practice medicine from Anki. You may be able to learn the coagulation cascade and the ratios for Massive Transfusion Protocols… but you won’t learn how to care for a patient who is bleeding out. That’s why you read and that’s why you are in residency.

Another great way to learn something is to teach it. Put together a brief presentation and handout for your medical students on the coagulation cascade… and make notes about their questions, who was there (maybe even a team photo?) before storing your handout with your other notes.

Step 3: Review. This system builds in review of everything you learned over the year (by reviewing it at least 5 times over at least 3 months, remember?) but for next year’s In-Training Exam, plan to take a full month before the exam to stop making notes. Spend this month before the exam to go through question banks, review your notes, and memorize the coagulation cascade. 🙂

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

Posted on April 14, 2017 by marylbrandt

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:

Remember it’s school.
At the beginning of each rotation, decide what topics you need to learn during the rotation and make a list.
Take notes. All the time.
Figure out how you will store your notes so you can find them quickly and organize them for review.
Go through the notes you make every day to review them and then store them in your system.
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 3^rd 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:

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.
On rounds when someone teaches an important point (e.g. the 7 things that keep a fistula from closing)
During Grand Rounds
During conferences
When you look up a paper to read about a patient
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.