Jarrod Smith, MS-4

1
NBME Subject Examination Strategies

• Jarrod Smith, MS-4
• May 2010

2
NBME Subject Exams

• During 3rd year, you will have to successfully
  pass a subject exam for completion of each
  clerkship.
• Exams include Psychiatry, Surgery, Pediatrics,
  Medicine, Obstetrics/Gynecology, and Family
  Medicine.
• Ob/Gyn requires a score at the 22nd percentile to
  pass.
• Family Medicine requires a score at the 4th
  percentile to pass.
• The other 4 clerkships require a score at the
  11th percentile to pass.

3
Exam Format

• Exams are paper and pencil format.
• Each exam contains 100 multiple choice questions.
• 130 minutes is allotted for each exam.
• That works out to 1.3 minutes per question.
• Clinical vignettes vary in length.
• Common lab values will appear on the front and
  back covers of the exam booklet.

4
Exam Strategy

• Begin each item by reading the question at the
  end of the vignette.
• Scan the answer choices and familiarize yourself
  with them.
• Read the entire vignette looking for clues to
  answer the question.
• By doing this, it allows you to know what you
  are looking for when reading the vignette. If
  you do not do it this way, you end up reading the
  vignette blindly.

5
Sample

• The following few slides contain a sample item
  from the NBME Subject Examination guide.
• These slides will demonstrate the aforementioned
  techniques.

6
Read the Question

• A 37-year-old woman comes to the physician
  because of a
• 3-year history of intermittent, mild, diffuse
  abdominal
• cramps and bloating. Her symptoms occur after
  meals and
• are relieved with bowel movements. She also has
• constipation four to six times monthly. She says
  the
• constipation resolves spontaneously, but she
  sometimes has
• diarrhea for 1 to 2 days afterwards. She has not
  had any
• other symptoms. She has no history of serious
  illness and
• takes no medications. Examination shows no
  abnormalities.
• Which of the following is the most likely
  diagnosis?
• (A) Collagenous colitis
• (B) Colon cancer
• (C) Diverticulosis
• (D) Inflammatory bowel disease
• (E) Irritable bowel syndrome

7
Answer Choices

• A 37-year-old woman comes to the physician
  because of a
• 3-year history of intermittent, mild, diffuse
  abdominal
• cramps and bloating. Her symptoms occur after
  meals and
• are relieved with bowel movements. She also has
• constipation four to six times monthly. She says
  the
• constipation resolves spontaneously, but she
  sometimes has
• diarrhea for 1 to 2 days afterwards. She has not
  had any
• other symptoms. She has no history of serious
  illness and
• takes no medications. Examination shows no
  abnormalities.
• Which of the following is the most likely
  diagnosis?
• (A) Collagenous colitis
• (B) Colon cancer
• (C) Diverticulosis
• (D) Inflammatory bowel disease
• (E) Irritable bowel syndrome

8
Clues in Vignette

• A 37-year-old woman comes to the physician
  because of a
• 3-year history of intermittent, mild, diffuse
  abdominal
• cramps and bloating. Her symptoms occur after
  meals and
• are relieved with bowel movements. She also has
• constipation four to six times monthly. She says
  the
• constipation resolves spontaneously, but she
  sometimes has
• diarrhea for 1 to 2 days afterwards. She has not
  had any
• other symptoms. She has no history of serious
  illness and
• takes no medications. Examination shows no
  abnormalities.
• Which of the following is the most likely
  diagnosis?
• (A) Collagenous colitis
• (B) Colon cancer
• (C) Diverticulosis
• (D) Inflammatory bowel disease
• (E) Irritable bowel syndrome

9
Answer the Question

• A 37-year-old woman comes to the physician
  because of a
• 3-year history of intermittent, mild, diffuse
  abdominal
• cramps and bloating. Her symptoms occur after
  meals and
• are relieved with bowel movements. She also has
• constipation four to six times monthly. She says
  the
• constipation resolves spontaneously, but she
  sometimes has
• diarrhea for 1 to 2 days afterwards. She has not
  had any
• other symptoms. She has no history of serious
  illness and
• takes no medications. Examination shows no
  abnormalities.
• Which of the following is the most likely
  diagnosis?
• (A) Collagenous colitis
• (B) Colon cancer
• (C) Diverticulosis
• (D) Inflammatory bowel disease
• (E) Irritable bowel syndrome

10
Example

• Reading the question first, answer choices
  second, and the remainder of the vignette last,
  allows the person taking the exam to know what he
  or she is looking for in the vignette.
• This is not the only technique. This was simply
  the most common technique when students were
  polled.

11
Question Banks

• It is imperative to do practice questions in
  preparation for the subject examinations.
• It would be a good idea to buy a 1 year
  subscription to USMLEworlds question bank.
• These questions are very similar to that seen on
  subject examinations.
• Practice questions are the most important factor
  for subject examination success.

12
The Exams

• Each of the subject examinations has its own
  flavor.
• Some tend to have longer vignettes(psychiatry,
  medicine).
• Others tend to have shorter vignettes(family
  medicine, ob/gyn).
• The following slides will focus on each of the 6
  exams, including subject material, resources,
  sample questions, and tips.

13
Family Medicine Subjects

• General Principles 1-5
• Organ Systems 95-99
• Immunologic Disorders 5-10
• Diseases of the Blood and Blood-forming Organs
  5-10
• Mental Disorders 5-10
• Diseases of the Nervous System and Special Senses
  5-10
• Cardiovascular Disorders 10-15
• Diseases of the Respiratory System 10-15
• Nutritional and Digestive Disorders 10-15
• Gynecologic Disorders 5-10
• Renal, Urinary, and Male Reproductive System
  5-10
• Disorders of Pregnancy, Childbirth, and the
  Puerperium 1-5
• Disorders of the Skin and Subcutaneous Tissues
  1-5
• Diseases of the Musculoskeletal System and
  Connective Tissue 5-10
• Endocrine and Metabolic Disorders 5-10
• Physician Task
• Promoting Health and Health Maintenance 15-20
• Understanding Mechanisms of Disease 20-25
• Establishing a Diagnosis 35-40

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Family Medicine Exam Basics

• The family medicine subject examination is like a
  mini USMLE Step 2 exam.
• One must be proficient at medicine, pediatrics,
  surgery, ob/gyn, and psychiatry to do well on
  this exam.
• For this reason, a passing score is set at the
  4th percentile.
• Clerkship lectures are helpful for the exam, but
  other resources must be used.
• If this is one of the last subject exams of 3rd
  year, less studying is needed.
• If this is one of the first subject exams of 3rd
  year, more studying will be needed.
• Questions are not written by family medicine
  physicians. They are written by internists,
  pediatricians, surgeons, etc

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Family Medicine Resources

1. USMLE Step 2 Secrets
2. Boards and Wards
3. Case Files Family Medicine
4. Current Diagnosis and Treatment in Family
   Medicine.

16
USMLE Secrets
Short and too the point, but contains quite a bit
of information. Question and Answer
format. Chapters separated by medical
specialty. Contains a few black and white
photos. Not a comprehensive resource. The
subject examination could easily be passed if
using only this resource.
17
Boards and Wards
Offers succinct summary of all major topics
covered on the subject exam. Outline format,
similar to the notes distributed during 2nd year
of medical school. Contains many full color
photos of dermatologic conditions and other
photos. Breadth of information is great, but
contains little depth. May need to reference a
larger textbook at times. Excellent resource for
the subject examination and USMLE Step 2. Easily
reviewed the week before the shelf exam.
18
Case Files
To properly prepare for the family medicine
subject exam, you would need to study from all
case file books. This book contains a smattering
of subjects not covered in the other case files,
such as prevention. Not comprehensive enough to
be used as a sole resource for the subject exam.
19
Current Diagnosis and Treatment in Family Medicine
Very useful for the in-house family medicine
exam. Not as useful for the subject exam. Very
long, but contains good information. Would be
helpful with the shelf exam only if you started
reading it at the beginning of the
rotation. Could not be easily review the week
before the subject exam
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Recommended Strategy

• Start reading and annotating Boards and Wards at
  the beginning of the rotation.
• Use a textbook of your choice to annotate if you
  feel the information is not deep enough.
• Read Step 2 Secrets if you have time.
• Review the annotated Boards and Wards the week of
  the exam.
• Do 50 USMLEworld questions per week. These
  should cover all of the subject areas and
  specialties.

21
Medicine Subjects

• General Principles 1-5
• Organ Systems 95-99
• Immunologic Disorders 5-10
• Diseases of the Blood and Blood-forming Organs
  5-10
• Diseases of the Nervous System and Special Senses
  5-10
• Cardiovascular Disorders 15-20
• Diseases of the Respiratory System 15-20
• Nutritional and Digestive Disorders 10-15
• Gynecologic Disorders 1-5
• Renal, Urinary, and Male Reproductive System
  10-15
• Disorders of the Skin and Subcutaneous Tissues
  5-10
• Diseases of the Musculoskeletal System and
  Connective Tissue 5-10
• Endocrine and Metabolic Disorders 5-10
• Physician Tasks
• Promoting Health and Health Maintenance 10-15
• Understanding Mechanisms of Disease 20-25
• Establishing a Diagnosis 40-45
• Applying Principles of Management 20-25

22
Medicine Exam Basics

• The medicine subject exam very closely mimics the
  material that medical students were taught during
  2nd year of medical school.
• It is advantageous to have this rotation towards
  the beginning of third year, so the material from
  year 2 is still fresh.
• This exam is 2nd in the amount of testable
  material, with family medicine being first.
• The exam is not hard to pass, but is fairly
  difficult to break the 80th percentile.

23
Medicine Resources

1. Step Up to Medicine
2. Case Files Internal Medicine
3. Blueprints Medicine
4. High Yield Internal Medicine

24
Step Up to Medicine
Very thorough. Outline format. Separated by
body systems. If its not in this book, it will
not be on the exam. Very long and can take a
very long time to read. Need to read more than
once in order to really take in all of the
information contained in this book. Impossible
if reading is not started the first week of the
rotation.
25
Case Files
Presents common internal medicine subjects in the
form of clinical vignettes similar to the subject
exam. Relatively complete. Probably the 2nd
best internal medicine subject exam
resource. Not as much info as Step Up. Not
separated into body systems, just random cases.
26
Blueprints
Presents common internal medicine subject in
paragraph format. Not as informative to Step
Up Comparable to Case Files, just a different
format. Contains practice questions at the end
of the book. Could easily pass the exam using
this resource.
27
High Yield
Not a complete resource by any means. Contains
high yield, useful topics for the exam. Do not
use this as your sole resource unless you really
know your stuff or you are in a serious time
crunch. Great if used as an adjunct to another
book, especially the week before the exam.
28
Recommended Strategy

• Begin reading Step Up the first day of the
  rotation, and read it everyday.
• Try to get through it twice before the subject
  exam.
• Do USMLEworld questions everyday, to prepare
  yourself for the length of the vignettes.
• If you are in a time crunch, read Case Files.
• If you are in a serious time crunch, read High
  Yield.

29
Ob/Gyn Subjects

• General Principles 1-5
• Gynecology 45-49
• Promoting Health and Health Maintenance 5-10
• Understanding Mechanisms of Disease 15-20
• Establishing a Diagnosis 15-20
• Applying Principles of Management 5-10
• Obstetrics 45-49
• Promoting Health and Health Maintenance 5-10
• Understanding Mechanisms of Disease 10-15
• Establishing a Diagnosis 15-20
• Applying Principles of Management 10-15

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Ob/Gyn Exam Basics

• The clerkship lectures are very high yield when
  it comes to the Ob/Gyn subject exam.
• Much is expected from students on the Ob/Gyn
  rotation, and students know more than they
  realize when it comes time to take the subject
  exam.
• The information tested on this exam is very
  specialized, so the material learned during 2nd
  year isnt very useful.

31
Ob/Gyn Resources

1. Blueprints Obstetrics and Gynecology
2. Case Files Obstetrics and Gynecology
3. High Yield Obstetrics and Gynecology

32
Blueprints
Contains high yield ob/gyn subject matter in
paragraph format. Very thorough
resource. Contains practice questions at the end
of the book. No easily reviewable during the
week before the subject exam.
33
Case Files
Presents common internal medicine subjects in the
form of clinical vignettes similar to the subject
exam. Relatively complete. Probably the 2nd
best ob/gyn subject exam resource. Good section
on STDs Slightly less complete than
Blueprints. Not separated logically, just random
cases.
34
High Yield
Excellent, succinct summary. Great tables and
graphs to demonstrate key concepts. Should be
used in conjuction with another resource. Only
use as a sole resource if you are extremely
confident in you ob/gyn knowledge.
35
Recommended Strategy

• Start reading Blueprints or Case Files at the
  beginning of the rotation.
• Read before each lecture, the corresponding
  section in your chosen book.
• Begin reading High Yield two weeks before the
  subject exam, and get through it twice.
• Do USMLEworld questions throughout the rotation.
• The required text for the rotation isnt very
  useful for the subject exam.

36
Pediatrics Subjects

• Normal Development 5-10
• Organ Systems 90-95
• Immunologic Disorders 5-10
• Diseases of the Blood and Blood-forming Organs
  5-10
• Mental Disorders 1-5
• Diseases of the Nervous System and Special Senses
  5-10
• Cardiovascular Disorders 10-15
• Diseases of the Respiratory System 10-15
• Nutritional and Digestive Disorders 10-15
• Gynecologic Disorders 1-5
• Renal, Urinary, and Male Reproductive System
  10-15
• Disorders of Pregnancy, Childbirth, and the
  Puerperium 1-5
• Disorders of the Skin and Subcutaneous Tissues
  1-5
• Diseases of the Musculoskeletal System and
  Connective Tissue 5-10
• Endocrine and Metabolic Disorders 5-10
• Physician Tasks
• Promoting Health and Health Maintenance 5-10
• Understanding Mechanisms of Disease 25-30
• Establishing a Diagnosis 40-45

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Pediatrics Exam Basics

• Clerkship lectures are pretty useful resources,
  especially when it comes to developmental
  milestones and vaccination schedules.
• Dr. Pino does an excellent review the week before
  the subject examination.
• This test tends to be heavy in microbiology and
  infectious diseases.

38
Pediatrics Resources

1. BRS Pediatrics
2. Blueprints Pediatrics
3. Case Files Pediatrics
4. Dr. Pinos Mega Review

39
BRS
Very complete resource in outline format. Very
cumbersome book. Has everything that could ever
be tested on the subject exam, but would be
difficult to use unless you are very
dedicated. Excellent tables and charts. If
ambitious, you could obtain gt90th percentile
using this book.
40
Blueprints
Contains high yield peds subject matter in
paragraph format. Very thorough
resource. Contains practice questions at the end
of the book. No easily reviewable during the
week before the subject exam.
41
Case Files
Presents common pediatric subjects in the form of
clinical vignettes similar to the subject
exam. Relatively complete. Probably the 2nd
best subject exam resource. Not as much info as
Blueprints. Not separated into body systems,
just random cases
42
Dr. Pino Review
Dr. Pino does a mega review towards the end of
the rotation. Contains very high yield subject
material. Almost word for word the same material
that Dr. Pino teaches during the USMLE Step 2
Kaplan course. Not complete, but very high yield.
43
Recommended Strategy

• Begin reading Blueprints at the beginning of the
  rotation.
• Do USMLEworld questions throughout the rotation.
• Attend Dr. Pinos review and cram that material
  in the last few days leading up to the subject
  exam.

44
Psychiatry Subjects

• General Principles 5-10
• Organ Systems 90-95
• Mental Disorders 75-85
• Mental disorders usually first diagnosed in
  infancy, childhood, or adolescence
• Substance-related disorders
• Schizophrenia and other psychotic disorders
• Mood disorders
• Anxiety disorders
• Somatoform disorders
• Other disorders/conditions
• Diseases of the Nervous System and Special Senses
  10-20
• Physician Tasks
• Promoting Health and Health Maintenance 1-5
• Understanding Mechanisms of Disease 10-15
• Establishing a Diagnosis 55-65
• Applying Principles of Management 15-20

45
Psychiatry Exam Basics

• The clerkship lectures are very useful for this
  subject examination.
• This exam focuses on diagnosis of mental illness
  and less on treatment.
• Know the DSM criteria for diagnosis of mood
  disorders, personality disorders, etc
• Watch out for mental illness caused my a general
  medical condition. This almost always appears a
  couple of times on the exam.
• Know all of the psych drugs.

46
Psychiatry Resources

• First Aid for the Psychiatry Rotation
• Case Files Psychiatry

47
First Aid
Succinct summary which is relatively
complete. Outline format. Contains high yield
facts in all areas of psychiatry.
48
Case Files
Presents common psychiatry subjects in the form
of clinical vignettes similar to the subject
exam. Relatively complete. Rivals First Aid as
best resource More info than First Aid, but may
be overkill. Not separated logically, just
random cases
49
Recommended Strategy

• Pay attention to the clerkship lectures.
• Begin reading Case Files at the beginning of the
  rotation.
• Do USMLEworld questions throughout the rotation.
• Begin reading First Aid two weeks before the
  subject exam.
• Get through First Aid two times before the exam.

50
Surgery Subjects

• General Principles 1-5
• Organ Systems 95-99
• Immunologic Disorders 1-5
• Diseases of the Blood and Blood-forming Organs
  5-10
• Diseases of the Nervous System and Special Senses
  5-10
• Cardiovascular Disorders 10-15
• Diseases of the Respiratory System 10-15
• Nutritional and Digestive Disorders 25-30
• Gynecologic Disorders 5-10
• Renal, Urinary, and Male Reproductive System
  5-10
• Disorders of Pregnancy, Childbirth, and the
  Puerperium 1-5
• Disorders of the Skin and Subcutaneous Tissues
  1-5
• Diseases of the Musculoskeletal System and
  Connective Tissue 5-10
• Endocrine and Metabolic Disorders 5-10
• Physician Tasks
• Promoting Health and Health Maintenance 1-5
• Understanding Mechanisms of Disease 20-25
• Establishing a Diagnosis 45-50
• Applying Principles of Management 25-30

51
Surgery Exam Basics

• This test contains far more internal medicine
  than one might expect, therefore it is
  advantageous to have completed internal medicine
  before taking this exam.
• Know IV fluid management, diagnosis of acute
  abdomen, trauma survey.
• Be able to tell when a patient is truly in danger
  of dying (vital signs, etc)
• There are a few questions on orthopaedics,
  vascular surgery, urology, etc

52
Surgery Resources

• Case Files Surgery
• NMS Surgery
• PreTest Surgery
• Pestana Review Notes
• It should be noted that Surgery Recall is an
  excellent resource for case preparation, but it
  is not a good tool for the subject examination.

53
Case Files
Presents common surgery subjects in the form of
clinical vignettes similar to the subject
exam. Relatively complete. Probably the 2nd
best surgery subject exam resource. Not as much
info as NMS. Not separated into body systems,
just random cases
54
NMS
Large resource in outline format. Very complete,
but could be somewhat cumbersome to
complete. Contains general surgery as well as
subspecialty chapters. This could be used as a
sole resource.
55
PreTest
Excellent question book that mimics the questions
on the subject exam. Far more useful than
USMLEworld for the surgery subject exam. Read
the question and the explanation. Absolutely not
intended to be a sole resource.
56
Pestana
Dr. Carlos Pestanas Kaplan notes for surgery are
extremely high yield. This is regarded as the
Holy Grail of surgery resources. It is hard to
come by, because it is supposedly illegal to sell
these. They are available on eBay and other
websites, it just requires some searching.
57
Recommended Strategy

• Begin reading NMS at the beginning of the
  rotation if you wish to do extremely well.
• Use Case Files if you just want to pass.
• If you can get obtain the Pestana notes, use them
  as well.
• Do questions from PreTest, because the USMLEworld
  surgery questions focus too much on subspecialty
  surgery and not enough on general surgery.

58
Final Remarks

• The common theme for subject exam preparation is
  doing timed practice questions.
• This is the only way to accurately simulate the
  actual exam.
• In addition to questions, you must find a
  resource you like.
• Most resources are good, you just have to find
  one or two for each exam that fits your study
  style.

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• And most importantly

60

• RELAX!!!!!!!!!!!