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Stem

Certification and Recertification Exam Review CME Resources

Clinical (Critical) Thinking Donald J. Sefcik, D.O., FACOEP

Learning Objectives

Upon completion of this portion of the review course, the participant should be able to:

1. Describe the PANCE "Item Blueprint". 2. Compare and contrast ''Norm-referenced" and "Criterion-referenced" examinations. 3. Discuss "Passing Thresholds". 4. Discuss "computer-based" testing (CBT). 5. List and describe common test-taking skills

• Familiarity with question formats • Critical reading of questions and answers • Answering questions in a timed environment

6. List and describe common test-wiseness skills • Time-management techniques • Error-avoidance techniques • Deductive-reasoning skills

7. List and discuss methods to optimize "guessing" on standardized tests. 8. Describe methods to:

• Select textbooks and study aids • Improve one's memory and enhance recall • Create student-generated, focused learning guides

A 48 year-old male with chest pain .......... . Radiates into his arm; Smoker; Hypertensive; Taking "cardiac medications" ..... EKG demonstrates ST segment elevation ..... .

Options

A) Podagra

B) Pleuritis C) Costochondritis

D) Pericarditis E) Myocardial Ischemia

Standardized TestingScoring Analysis

Norm-ReferencedRaw Scores are converted by using a reference group

ExampleMean of Reference group converted to 500Standard Deviation of group canvertedto 100A11 other scores then converted to this standard.

Results: 67Yo of scores:400-600 (500 +/- 1 SD)97Yo of scores :300-700 (500 +/- 2 SD)99% of scores:200-800 (500 +/- 3 SD)

Pass/Fail Threshold -** If use I SD below mean:

-t6%

"Failare" -84o IPASSI

MEAN

Criteria-ReferencedIndependent Standards-Setting C ommittee

** Passing Threshold established BEFORE the Examination.

* * All may pass. . ...or. . . . . . all may fail. . . . . ...

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Test-Items

Multiple Choice Formats

1. A-Type Items

o Commoniy referred to as: Multiple Choice euestions. Majority of Certifuing Examination euestions

Tlrpical Question

STEM: A 35 year-old male presents to your faciiity with..... ..

OPTIONS: (Letters)* Correct Answer or Best Answer* Distractors (incorrect options)

Stem may be a question.. Requires a completed thought.. Pay attention to objective.......most likely, etc.r Generally are written in the positive.

Words such as: Except; Least; Not; etc. are avoided.

Stem may be a vignette.r Short scenario --i sg^t.^"e-, or le€! {ti - S z % ). Long Scenario

KEY: Focus on the associated variables. .. ....and what you are being told.

2. B-Type Items

r Commonly referred to as: Matching euestionsr Minority of Certifying Examination Questions

Tygical Ouestion Set

OPTION SET: Organized around a theme

MATCHING ITEMS : Q.trumbers)

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Test-Takine Skills

1. Think like the Test Constructor

Test Ouestion Constructor's Task

Common Format (Type A). Stem - Presents the problem (question)

o Responses (answer and distractors)* One Correct answer ot BEST qnswer

* Distractors

a. One choice obviously incorrectb. Two choices reasonable (peripheral to topic)c. Two choices correct (but one is BEST answer)

2. Think like a "test-wise" test-taker

Test-Taker'sTask

a. Get rid of the Obviously Incorrect answer

Probability alone now (4 choices remain) = 25%o correct response

b. Split the remaining four responses into reasonable (2) vs correct (2)and disregard the two reasonabie responses

Probability alone now (2 choices remain) :50%o correct response

c. Select the BEST answer of the two remaining choices

Just like "Dffirential Diagnosis"

Example

A 52 yearold male with shorhress of breath"Hurts more to take a deep breath".....No history of trauma; pain is not reproducible with palpation... . ..Pulse oximetry (room afu) : 88%; Percussion reveals tympany; trachea is deviated......

Options

A) erosive arthritis

B) pathologic rib fracture C) costochondritis

D) tension pneumothorax E) pulmonary embolism

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3. Test Taking Principles

A. Focus on the stem.... it sets the task !!!(finding the BEST answer)

B. Read ALL options before recording your answer.(avoid partly correct responses)

C. Go with your instinctive feeling.(you picked it for a reason)

D. Once you decide an alternative is incorrect, do not consider it again.

E. Avoid "READING INTO" the Question(the stem sets the task)

F. When GUESSING is the ONLY alternative:

1. General Alternative -If fow of the five options are very specific and one very general....Often, the more generai option is the correct response.

2. Longest Alternative -Often, the exam writer wants to be sure you have enough information torecognize the correct answer.

3. Opposites & Similar Alternatives -If two choices are very similar, usually the correct choice is NOT one ofthem. The correct response IS often one of two opposites.

4. Grammar Agreement -The stem and responses should be grammatically correct.....Singular stem should not be completed with a plural option.

5. Specific Determiners -The implication of absoluteness (Always, Never, Must, None, On1y.,.)is often incorrect. Words that permit exceptions (seldom, usually, oftenperhaps, etc) are more commoniy associated with the correct response.

6. Rank Order -When a list of numbers or oorank ordering" exists, the correct response isoften somewhere in the middle,

7. Which of the following "sets"........A.W&X; B.Y&Z; C.X&Y; D.Y&Z; E.x&Z

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lnitial PresentationEmergency Tx

Continued Tx Follow-up

1. History-TakingPhysical Examination

a. Pertinent H/PE* Pathognomonic* Risk Factors

b. Techniques* SignslTests

2. LaboratoryDiagnostic Studies

a. Selection

b. lnterpretation

c. Predicted results

3. Most Likely Diagnosis

a. Based on data* Verbal* Pictorial

4. Prognosis (Severity)

a. Current Status

b. Projected Status

c. Consultants

5. Therapeutic Management

a. Medications* Drug(s) of Choice" Contraindications* Side Effects* lnteractions

b. Screening

c. Prevention

6. Scientific Goncepts

a. Pathophysiology* Etiology" Manifestations

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Disease Pharunaitis lnitial PresentationEmergency Tx

Gontinued Tx Follow-up

1. History-TakingPhysical Examination

a, Pertinent Hx/PE* Pathognomonic* Risk Factors

b. Techniques* Signs/Tests

30 million cases/year12-15% see by prov

Sore ThroatVoice Changes/AirwayFever & Assoc. Sx

Oropharynx examUvula Posiiion

WorseningDroolingDehydration

Sequela

Rheum feverOtitis MediaPneumonia

2. LaboratoryDiagnostic Studies

a. Selection

b. lnterpretation

c. Predicted results

Rapid Strept ScreenCulture & Sensitivity

" Mono spot* CBC (Lymph #s)

L l-t'lo ,;r rr\it€ tv'rt e'lv4 tr\.ir ' l)tpl-f t

3. Most Likely Diagnosis

a. Based on data* Verbal" Pictorial

Viral (most likely)

* Strept* Mono (etc)* STD

[Uvular Deviation][Post. Adenopathy][Splenomegaly]

4. Prognosis (Severity)

a, Current Status

b. Projected Status

c. Consultants

Self-limiting (most)

5. Therapeutic Management

a. Medications* Drug(s) of Choice* Contraindications* Side Effects* lnteractions

b. Screening

c. Prevention

Symptomatic* Fever* Pain* Hydration

Antibiotics (?)

HygieneHand washing

6. Scientific Goncepts

a. Pathophysiology* Etiology* Manifestations

lnflammatory changes

* Rubor* Dolor* Tumor

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Disease Mvocardiallnfarction

lnitial PresentationEmergency Tx

Gontinued Tx Follow-up

1. History-TakingPhysical Examination

a. Pertinent Hx/PE* Pathognomonic* Risk Factors

b. Techniques* SignslTests

Chest Pain* Location* Severity* Character. Radiation* Associated Sx

CV Risk - HTN, DM, CigChol, Fam Hx

Body HabitusDiaphoresisMonitorsVital Signs

. Ophth Sx

. 53 Gallop

. 54 Gallop* Rales/JVD

2. LaboratoryDiagnostic Studies

a. Selection

b. lnterpretation

c. Predicted results

EKGPulse Oximetry (ABG)Cardiac MarkersCXRcBcOthers

Cardiac MonitorsMarker EvolutionEKG Evolution

3. Most Likely Diagnosis

a. Based on data* Verbal* Pictorial

Based On HXEKG

12 Lead EKG changesCXR Changes

Atypical Chest PainNoncardiac Etiology

4. Prognosis (Severity)

a. Current Status

b. Projected Status

c. Consultants

Complications* Electrical

- Arrhythmias* Mechanical

- CHF- Valvular

* Cardiac Arrest

Pulmonary EdemaContinued/Evolving

Cardiologist

5. Therapeutic Mana

a. Medications. Drug(s) of Choice* Contraindications* Side Effects* lnteractions

b. Screening

c. Prevention

SupportiveMinimize damageTx Complications

NTc (SL, tV,..)AspirinMorphineHeparinThrombolytics

Angioplasty/Etc

ReocclusionSerialData

Risk Factorreduction

Family Hx

CardiovascRisk FactorReduction

6. Scientific Concepts

a. Pathophysiology* Etiology* Manifestations

Thrombosis (most)

lschemic changes EKGEnzyme evolutionElectrical I rritability

lnflammationCHF Mechanism

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Level Tasks Skills

Knowledge Gather informationEncode informationUnderstand Information

ReadingListeningObservingMemorizing

Application Use Knowledge to Gain Knowledge Retrieve informationProblem-solveCommunicate

Testing Success

Learninq Skills

The Process

lnformation

-

Knowledge --t+

Retrievalt?tRemembering: Sforage Retention Access

lf the PANCE/PANRE required the following to answer a question.....

Quesfion -+ Recognition of factual information + Answer

This would be just fine, BUT, in reality, the process is more like:

Quesfion *Recail* lnterpretation* Conclusion(s) + Answer

Recommended Reading:

Applying Knowledge to Gain Knowledge (Chapter 2: pages 40 - 79)Learning and Teaching in MedicalSchoolMark E. Quirk, Ed.D.tsBN - 0-398-05925-X

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Rememberinq

StorageStudying HabitsLearning StyleOrganization

lnformation

I

I

+

Knowledge

I

I

IRetrieval ..r.,...

lr" a

RetrievalAssociationsUnderstandingCues

RecognitionLess activeFactualcue presentRepetitionCramming

Tactical Approach

A. What to Memorize ?

1. Utility - What will be usefulto me ?

2. Probability - Do I have enough time to learn it ?

B. How to Focus Attention ?

1. Environrnent without distractions

2. Find meaning in the material

3. Understand the Fundamental Principles

RecallMore activeProblem Solvingcue absentBridgesStrategies

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Self-Directed Learninq Methods

1) Do a Needs Assessment

a. Determine what you would like to be able to do** Many students skip this step

b. Take old examination/Practice Examinations** Decide what you know/can do

c. Determine the Difference between A & B** YOUR needs

2) Develop a Strategy

a. Choose your methods to meet your needs** Reading** Studying Methods

. Acronymso Chunking (group related items - increase associations). Picture it (draw it)

o Total-time Hypothesis (Herman Ebbinghaus - 1880s)

Repeating the next day (distributive trials) -Reduces the time required to "relearn it" and increases memory

. Understand it (Harry Maddox - 1964)

Meaningless Facfs memorized -Day 5=recall -40o/oDay 30 = recall < 1Q o/o

Principles Understood -Day 5=recall >95%Day 30 = recall > 90 o/o

*" Question and Answer Sessions*" Worksheets** Other

3) Self-Evaluation

a. Be sure you are "closing the gap"

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References

1) Quirk, ME. How to Teach and Learn in Medical School.Charles C. Thomas - publisher. 19940-398-05925X

2) Maddox, H. How to Study.Fawcett Premier. 1963. (28th printing 1993)0-449-30011-0

3) Higbee, KL. Your Memory. How lt Works and How to lmprove lt.Marlowe & Company.20011-56924-801-X

4) Sorgen C. Acing Recertification. PA Today. January 1999:21 23

5) Silverstein S. How to Remember More High-Yield Facts that Most Residents ForgetResident & Staff. 2001;47(6):64-66

6) Moser, RL. Primary Care for PhysicianAssr'sfanfs: Se/f-Assessmenf and Review.McGraw-Hill. 2001. 2nd edition.

Over 1000 new, referenced questions and explanations.

7) www.nccpa.net/

The page to visit to check for any recent changes in the PANCE/PANRE examinations.

8) www.nccpa.net/irnases/Test%20Committee%20Handbook.pdf

The page to visit to review the NCCPA - Test-Writing Guide

9) www.nbnre.ore/PDF/200 I iwe.pdf

The page to visit to review the Nafiona I Board of Medical Examiners - Test-Writing Guide

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