10 common mistakes when preparing for the shelf exams and USMLE

10 common mistakes when preparing for the shelf exams and USMLE

How to ace Shelf Exams and USMLE Series

I’m an Internal Medicine physician, an Assistant Professor at Brown University, a USMLE STEP 2 CK tutor with a decade of teaching experience, and an author of a USMLE STEP 2 CK textbook encompassing all topics for the boards (Thieme: A WIN series for USMLE available online and in bookstores). In addition, I scored in the 99th percentile on all the 3 USMLE STEP exams and am currently creating an online USMLE question bank.

I completely understand how daunting it feels to prepare for the shelf exams and USMLEs — a mountain of information to learn, questions with confusing choices that make it difficult to pick the “best” answer, and, on top of all that, a strict time limit!

I hope that avoiding the following 10 common mistakes will help you get higher grades in your shelf exams and USMLE step 2 :

1. Not focusing on “LEARNING” to make the right diagnosis. (Acing both shelf exams and USMLE step 2 is all about learning to make the diagnosis in NBME-style multiple-choice questions. )
2. Not focusing on making the right diagnosis first before proceeding to answer the question.
3. Not making the management steps black and white.
4. Not focusing on the last line of the question.
5. Not using memory techniques enough.
6. Not doing Pomodoro.
7. Not doing Pamodoro properly.
8. Not taking care of one’s body.
9. Not getting a Coach.
10. Not using the IRIS steps.

Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.

Mistake number 1: Not focusing on LEARNING to “get the right diagnosis.”

Acing both shelf exams and USMLE step 2 is all about learning to make the diagnosis in NBME-style multiple-choice questions.

Most students come to me for help, saying my “Test-taking skills” are poor and I need to improve them. What it means specifically is that the student hasn’t learned the art of making the diagnosis because most shelf exams and USMLE step 2 questions require you to make the diagnosis first.

Then, only you can answer the following common questions based on your diagnosis.

• ​​ The most common risk factor/s of that diagnosis
• Basic pathophysiology (e.g., temporal lobe atrophy in Alzheimer’s disease)
• How to treat the condition? E.g. for Alzheimer’s patients, the 1st line DRuG is Donepezil, Rivastigmine, or Galantamine, not memantine or vitamin E.
• Complications of the diseases or the side-effects of its treatment

To master the art of making the right diagnosis, learn by clustering different conditions with similar features and then take note of the features that set them apart.

Example 1:

A cluster of proximal muscle weakness

• Proximal muscle weakness + hoarse voice + weight gain + hyporeflexia in all extremities = Hypothyroidism
• Proximal muscle weakness + hirsutism + easy bruising = Cushing syndrome
• Proximal muscle weakness+ rash around eyesor on top of knuckles= Dermatomyositis

Example 2:

The cluster of seronegative arthritis and their common features:

Seronegative arthritis is a group of inflammatory joint conditions in which the rheumatoid factor is negative and is associated with HLA-B27.

Example 3: How to approach an immunodeficiency board question?

Click on the following links to practice this method more:

• Practice 1
• Practice 2

Remember, no matter how prepared you are, you will always feel uncertain about some questions, and that’s okay. Just use your best judgment, flag it, and move on. Chances are that you might have a fresh perspective on the question when you come back to it later.

Mistake 2: Not focusing on making the right diagnosis first before proceeding to answer the question.

Don’t fall into the trap of reading the question stem and then trying to reason through each of the answers before committing to a diagnosis, which is inefficient, as it leads to many back-and-Forths.

The most efficient way to answer the majority of questions is to follow these steps:

• Read the question stem and highlight the pertinent findings.
• Focus on your highlighted portions of the question stem. Those are the puzzle pieces that you need to connect to figure out the diagnosis.
• Choose the answer based on your diagnosis.

There might be an infinite number of ways to go from point A to point B, but there is only one shortest path.

Finding the shortest path frees up some time to do other activities in our limited number of hours in a given day. So, try to maximize efficiency.

On the opposite spectrum, I have seen some students thinking through each diagnostic possibility in each pertinent positive of a question (e.g., hmm, the patient had a recent travel trip, meaning it could be TB, infection, etc.). This will result in time loss. Just highlight the pertinent positives as you are reading the question, and only at the end, connect the highlighted dots to make the diagnosis (! Don’t create a differential diagnosis out of each dot).

i have seen a student read six lines and have thought about multiple diagnoses already. 7th line there is the diagnosis- so it doens’t make sens

Mistake number 3: Not making the management steps black and white.

Example 1: A 50 y/o M patient is diagnosed with cirrhosis. What is the best next step in management?

1. Colonoscopy
2. Upper GI endoscopy
3. CEA

To answer this question, students must know that all patients with cirrhosis must have a screening upper GI endoscopy to look for varices. Screening colonoscopy in patients with cirrhosis is not of clear-cut benefit (cirrhosis is an irreversible liver disease with a poor prognosis).

Another example: A 35 y/o M patient is found to have asymptomatic hypercalcemia of 12.5 mg/dl. Further test reveals primary hyperparathyroidism. What is the best next step in management?

1. Denosumab
2. Parathyroidectomy
3. Regular calcium lab follow-up
4. Urinary alkalinization

To answer this question, you must know the indications for management steps of hyperparathyroidism.

There is no way around these questions, and no test-taking skills are needed except knowing the management steps in black and white.

Mistake number 4: Not focusing on the last line of the question.

Example:

Question 1: A patient presents with acute exacerbation of multiple sclerosis. What is the best next step in management to prevent further exacerbations?

1. Methylprednisolone
2. Azathioprine
3. Glatiramer
4. Mycophenolate mofetil

Question 2: A patient presents with acute exacerbation of multiple sclerosis. What is the next best step in management to treat this exacerbation?

1. Methylprednisolone
2. Azathioprine
3. Glatiramer
4. Mycophenolate mofetil

For question 1- the answer is 3 (glatiramer). For question 2, the answer is 1 (Methylprednisolone). The last line of the question determines the answer.

Another Example: A patient presents with features of dermatomyositis with facial heliotrope rash and proximal muscle weakness.

Question 1: What is the best next step in diagnosis?

Question 2: What would likely confirm the diagnosis?

1. Muscle biopsy
2. Electromyogram (EMG) and nerve Conduction Study (NCS)
3. Creatine kinase, ESR, and CRP
4. Mycophenolate mofetil

For question 1- the answer is 3 (Creatine kinase, ESR, and CRP). For question 2, the answer is 1 (biopsy).

Again, the last line of the question determines the answer.

Mistake 5: Not using memory techniques enough.

Don’t build buildings without foundations. Don’t use rote memorization.

Use (or even better, create your own) memory associations/mnemonics whenever possible.

Memorizing various pieces of medical information (for example, differentiating features of diseases, management steps, cut-off values, etc.) is key for acing an exam. Use memory-retaining techniques and tools, such as associations, mnemonics, and the popular flashcard app ANKI.

Example:

New onset ascites generally require diagnostic paracentesis. The two most important things you look for in ascitic fluid are SAAG and neutrophil count.

• SAAG (serum ascites albumin gradient) = serum albumin concentration — (minus) albumin concentration in ascitic fluid
• What is the cut-off of SAAG? 1.1.
• How to remember? SAAG: “AA”= “1” and “1” because “A” is the 1st alphabet. So, the important SAAG value is 1.1.
  Elevated SAAG (>1.1) is elevated portal pressure.

* Ascitic neutrophil count of ≥ 250/mm3 is diagnostic of spontaneous bacterial peritonitis.

Example 2:

How to tackle questions of Congenital Adrenal Hyperplasia?

Here is a link to a practice question on Congenital Adrenal Hyperplasia (to integrate what you learned).

Here is a link to information on one of the students’ favorite tools: Anki cards. I also advise students to make their own Anki flashcards (based on UW incorrect, cross-referencing your chosen book as you make the cards). This reflective and integrative act of making cards is one of the best ways to retain information.

Memory retention in order of effectiveness and longevity

1. Understanding the topic (try to understand the disease process and pathophysiology) -e.g., why is MVO2 low in septic shock?
2. Associative memory techniques
3. Rote memorization

Mistake 6: Not doing Pomodoro is a massive loss in productivity

Pomodoro (RAM refreshment) technique: Do 25 minutes of focused study prep time (with no distractions like your cell phone or TV), followed by 5 mins break. Then, refresh and repeat. (Some students prefer 50 mins study time and 10 mins breaks.)

Pomodoro breaks your work(study) time into portions and gives some rest time for the brain to come back much more refreshed. This provides the much-needed reset to your productivity decline after 25 to 50 mins of study (improving overall efficiency and preventing burnout).

Here is a link to a great Chrome extension for this. It also measures your total study time.

Don’t stop using Pomodoro after medical school. Use it for the rest of your life (work, book-writing,…. !)

Mistake 7: Not doing Pamodoro properly.

I have seen some students working on their computers during this 5–10 min break. This isn’t RAM refreshment. (Get up from that chair, go out of that room, and de-strain your eyes and your body posture!).

Every 4–5 rounds of Pamodoro, you might need to take a longer break (e.g., 30 mins).

Every 6 days of study, take at least 1/2 day off; go kayaking, fishing, hiking something nature related- (prevents burnout)

Mistake 8: Not taking care of one’s body

You are a mental athlete. Do what athletes do.

Take proper care of your physical and mental health -Since I love mnemonics, here’s another one! SEE well to do exams well: Sleep, Eat, and Exercise:

• Sleep well: at least 7–8 hours every day to recharge your body at night (Don’t partially charge your phone overnight only to run out of battery by noon)
• Eat healthy foods and avoid bad foods.
• Exercise regularly

Here is a link to an article that elaborates on this further.

Every 6 days of study, take at least 1/2 day off; go kayaking, fishing, hiking something nature related- (prevents burnout).

Mistake 9: Not using a COACH

All athletes have coaches; why don’t we?

“ Studies have reported that getting tutoring raises test scores by up to 12 percentage points. “

There is no shame in asking an expert for help to improve any areas of weakness. When I go on my snowboarding trips, I always seek a few snowboarding lessons to accelerate my learning process.

You can get online shelf-exam-USMLE tutoring/mentoring or seek a well-qualified shelf-exam USMLE tutor through your university.

Has there ever been any Olympic athlete who won a gold medal without the help of a coach?

Disclaimer: I tutor on the Wyzant online platform. Here is a link to a $40 OFF for your first class.

Mistake 10: Not using the IRIS steps

Input, Reflect, Integrate, and Share — in order to master the shelf exam and USMLE topics.

Reading a book (for example, 7 Habits of Highly Effective People) but not reflecting on it and not integrating it into practice will result in the “illusion of learning.” Similarly, it is extremely crucial to practice IRIS to perfect your craft of shelf exam and USMLE preparedness.

Books serve as a great base camp for your knowledge ascents. Choose any USMLE book- a comprehensive book you can reflect upon — for annotation, highlights, and other important notes/personalized mnemonics.

• For Step 1, there is a consensus of a clear-cut winner being First Aid for Step 1.
• For Step 2, go to your university library (online/virtual), scan a few of the most popular books, and find one that fits your style. Then, stick to the “chosen one” for your learning journey.

FYI- the textbook I authored (Thieme: A WIN book) is also a concise yet thorough book you may utilize for Step 2 CK or Step 3. Check it out

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