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

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

A)
B) D)

Podagra Pleuritis Pericarditis C) Costochondritis E) Myocardial Ischemia

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Standardized Testing
Scoring Analysis

Norm-Referenced
Raw Scores are converted by using a reference group Example Mean of Reference group converted to 500 Standard Deviation of group canvertedto 100 A11 other scores then converted to this standard.

Results:

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

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

-t6%
"Failare"

-84o

IPASSI

MEAN

Criteria-Referenced
Independent 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.

. . r r .

Requires a completed thought. Pay attention to objective.......most likely, etc. Generally are written in the positive. Words such as: Except; Least; Not; etc. are avoided.

Stem may be a vignette.

Short scenario Long Scenario

--i

sg^t.^"e-, or

le! {ti

Sz

KEY: Focus on the

associated variables. .. ....and what you are being told.

2. B-Type Items

r r

Commonly referred to as: Matching euestions 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)

. o

Stem

Presents the problem (question)

Responses (answer and distractors)

* One Correct answer ot BEST qnswer * Distractors

a. One choice obviously incorrect

b. 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
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......

A 52 yearold male with

Options

A) B) D)

erosive arthritis

pathologic rib tension

fracture

C) costochondritis E) pulmonary embolism

pneumothorax

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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 to recognize the correct answer.
3. Opposites

& Similar Alternatives If two choices are very similar, usually the correct choice is NOT one of them. 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, often perhaps, etc) are more commoniy associated with the correct response.
6. Rank Order -

When a list of numbers or oorank ordering" exists, the correct response is often somewhere in the middle,
7. Which of the following

A.W&X; B.Y&Z; C.X&Y; D.Y&Z; E.x&Z

"sets"........

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lnitial Presentation Emergency Tx

1. History-Taking

Continued Tx

Follow-up

Physical Examination
a. Pertinent H/PE * Pathognomonic * Risk Factors
b. Techniques

* SignslTests

2. Laboratory Diagnostic Studies

a. Selection b. lnterpretation c. Predicted results

3. Most Likely Diagnosis

a. Based on data
*

* Pictorial

Verbal

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 Presentation Emergency Tx

30 million cases/year 12-15% see by prov Sore Throat Voice Changes/Airway Fever & Assoc. Sx Oropharynx exam Uvula Posiiion

Gontinued Tx

Follow-up
Worsening Drooling
Dehydration Sequela Rheum fever

1. History-Taking

Physical Examination
a, Pertinent Hx/PE

* Pathognomonic * Risk Factors

b. Techniques

* Signs/Tests

Otitis Media
Pneumonia

2. Laboratory

Diagnostic Studies
a. Selection b. lnterpretation

Rapid Strept Screen

Culture & Sensitivity

c. Predicted results
3. Most Likely Diagnosis a. Based on data * Verbal " Pictorial

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

" Mono spot * CBC (Lymph #s)

Viral (most likely)

* Strept * Mono (etc) * STD

[Uvular Deviation]
[Post. Adenopathy]

[Splenomegaly]

4. Prognosis (Severity)
a, Current Status b. Projected Status

Self-limiting (most)

c. Consultants
5. Therapeutic Management

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

Symptomatic * Fever * Pain * Hydration

Antibiotics (?)

Hygiene Hand washing

* lnteractions

b. Screening

c. Prevention
6. Scientific Goncepts

lnflammatory changes
* Rubor * Dolor

a. Pathophysiology * Etiology

* Manifestations

* Tumor

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Disease

Mvocardial lnfarction

lnitial Presentation Emergency Tx

Chest Pain * Location * Severity * Character
*

Gontinued Tx
Body Habitus Diaphoresis
Monitors Vital Signs . Ophth Sx . 53 Gallop

Follow-up

1. History-Taking

Physical Examination
a. Pertinent Hx/PE * Pathognomonic * Risk Factors
b. Techniques

. Radiation

Associated Sx

. 54 Gallop

* SignslTests

CV Risk - HTN, DM, Cig

* Rales/JVD

Chol, Fam Hx
EKG

2. Laboratory Diagnostic Studies

a. Selection b. lnterpretation

Pulse Oximetry (ABG) Cardiac Markers

CXR

Cardiac Monitors Marker Evolution

EKG Evolution

cBc
Others

c. Predicted results 3. Most Likely Diagnosis

a. Based on data
*

Based On HXEKG
12 Lead EKG changes

Atypical Chest Pain

Noncardiac Etiology

Verbal * Pictorial

CXR Changes

4. Prognosis (Severity)
a. Current Status b. Projected Status

Complications

c. Consultants
5. Therapeutic Mana

* Electrical - Arrhythmias * Mechanical - CHF - Valvular * Cardiac Arrest

Pulmonary Edema
Continued/Evolving Cardiologist

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

b. Screening

Supportive Minimize damage Tx Complications

Reocclusion
SerialData

Risk Factor
reduction

NTc (SL, tV,..)

Aspirin Morphine Heparin

Family Hx Cardiovasc Risk Factor

Reduction

Thrombolytics Angioplasty/Etc

c. Prevention 6. Scientific Concepts a. Pathophysiology * Etiology * Manifestations

Thrombosis (most)
lschemic changes EKG
Enzyme evolution Electrical I rritability

lnflammation
CHF Mechanism

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Testing Success Learninq Skills Level Knowledge Tasks

Gather information Encode information Understand Information

Skills
Reading

Listening Observing Memorizing

Application

Use Knowledge to Gain Knowledge

Retrieve information Problem-solve Communicate

The Process

lnformation

Remembering:

--t+ Sforage Retention Access

t?t

Knowledge

Retrieval

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 MedicalSchool Mark E. Quirk, Ed.D. tsBN - 0-398-05925-X

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Rememberinq Storage Studying Habits Learning Style Organization

lnformation
I

+
Knowledge

Retrieval Associations Understanding Cues

I
Retrieval
..r.,...

lr"
Recognition
Less active Factual cue present Repetition Cramming

a
Recall More active Problem Solving cue absent
Bridges Strategies

Tactical Approach

A.

What to Memorize ?

1.

Utility

What will be usefulto me ?

2.
B.

Probability

Do I have enough time to learn it ?

How to Focus Attention ?

1.

Environrnent without distractions Find meaning in the material

2.
3.

Understand the Fundamental Principles

10

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Self-Directed Learninq Methods

1) Do a Needs Assessment

a.
b.

Determine what you would like to be able to do ** Many students skip this step Take old examination/Practice Examinations ** Decide what you know/can do Determine the Difference between A & B ** YOUR needs

c.

2) Develop a Strategy

a.

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

. o . o

Acronyms Chunking (group related items Picture it (draw it)

increase associations)

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

Meaningless Facfs memorized

Day 5=recall -40o/o

Day 30 = recall < 1Q o/o Principles Understood

- 1964)

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"

l1

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References

1)

Quirk, ME. How to Teach and Learn in Medical School. Charles C. Thomas - publisher. 1994 0-398-05925X Maddox, H. How to Study. Fawcett Premier. 1963. (28th printing 1993) 0-449-30011-0 Higbee, KL. Your Memory. How lt Works and How to lmprove lt. Marlowe & Company.2001 1-56924-801-X Sorgen C. Acing Recertification. PA Today. January 1999:21 23

2) 3) 4)

5) Silverstein S. How to Remember More High-Yield Facts that Most Residents Forget
Resident & 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) 9)

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

The page to visit to review the NCCPA

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

Test-Writing Guide

The page to visit to review the Nafiona I Board of Medical Examiners

Test-Writing Guide

t2