SECTION K: BOARDS AND BOARD REVIEW

Note: This section is from The House Officer's Survival Guide: Rules, Laws, Lists and Other Medical Musings, by Lawrence Martin, M.D. It is written for doctors in training, but will also be of interest to medical students, and practicing physicians who must take recertifying exams. Unlike most other sections of Survival Guide, this one will not be of much interest to the general public.

1. Assume nothing. You may be the world's best clinician or surgeon, compassionate, caring, even highly thought of by your colleagues and professors. No matter. The boards will test what you know. If you don't know much, you will fail. For most boards the pass rate is about two out of three. Don't be part of the lower 1/3.

2. Start intensive study at least one year before the exam date. Do not wait until the last minute (or the last month). One year ahead of the exam date, fantasize that the exam is next week. Panic. Then relax. Lucky you: you have a whole year!

3. One year before the exam date identify two important sources and begin to review them. These should be: a) a comprehensive textbook in your speciality area, and b) any official review materials promulgated by your speciality organization. For internal medicine, the textbook is usually Harrison's or Cecil's, while the official specialty material is the American College of Physicians' Medical Knowledge Self Assessment Program (MKSAP), updated regularly. The textbook need not be read cover to cover; instead, sections you feel uncomfortable with should be closely reviewed, while other sections can be skimmed or ignored. In contrast, every sentence of the specialty-recommended study materials should be scrutinized and learned to the point of full understanding, using whatever outside sources are necessary (e.g., journal review articles).

4. Take notes and make lists of what you read. Unless you have a truly photographic memory, you will remember little of what you read. Reading a paragraph in June for a September exam is of no help if you don't remember it. Make lists of material that you view as potentially important, especially if the subject is mentioned in the specialty-recommended materials; review your notes continually as you get closer to the exam. Examples of lists you might make for an Internal Medicine exam: the specific differences between rheumatoid arthritis and lupus erythematosus; the classes of antibiotics and what they are used for; the causes and workup of thrombocytopenia.

5. Take a comprehensive review course. Ideally, the course should be spread out during the year, but a one week intensive course is also helpful if taken at least six weeks ahead of the exam, so you can review the course syllabus in depth. Use the course syllabus to augment notes that you prepared from the two primary sources.

6. Stay focused. Commit a certain number of hours a week to study and don't allow yourself to become sidetracked. Studying only five hours a week as a senior resident for 9-12 months (less than one hour a day) should serve you well for any board exam.

7. Don't worry about what is in the medical journals. A recurring myth is that board exams emphasize recent journal articles. Not so. The boards emphasize widely accepted information, which means textbook knowledge, not the latest journal reports. Make sure your study materials are current and ignore the latest in journal research. The main value of medical journals (for board review purposes) will be selected review articles on clinical subjects.

8. Take care of your patients. Sir William Osler wrote: "Taking care of patients without reading is like going to sea without sails; reading without caring for patients is like never going to sea at all." Tis true, tis true.

Test-Taking Tips (for multiple choice tests)

1. Remember: it's just another test. You've probably taken hundreds of tests in your career, and done well on them; how do you think you got to where you are?

2. Answer all questions as you come to them, leaving unanswered only those you are really uncertain about; return to them later. Don't dwell excessively on a question if you don't have a clue to the answer. Better to leave it blank than spend too much time on it, to the exclusion of others.

3. Always write your answers on the computer-scored sheet as soon as you make a decision; never write your answers on another piece of paper with the intent of later entering them on the computer sheet.

4. Everything in the question is there for a reason, either as positive or negative information; don't assume anything is unimportant. Make sure you assimilate everything in the question thoroughly before committing your answer. And don't jump to conclusions; an obvious answer on first reading may be just as obviously wrong on a second reading. Read each question at least twice so you don't miss anything.

5. Most board exams use single answer, multiple choice questions that usually take one of three formats.

I. Single-best answer, where the correct answer is the only one that makes a medically-correct statement

EXAMPLE: The hematocrit measures the:

a) number of blood cells

b) volume percentage of blood occupied by red blood cells

c) hemoglobin content expressed as a percentage

d) hemoglobin content in mg%

e) none of the above

Only b) fulfills a medically-correct statement.

II. Single best answer, where the correct answer is the only one that does NOT make a medically-correct statement.

EXAMPLE: The EKG tests for all of the following except:

a) heart rate

b) cardiac arrhythmia

c) ischemic injury to the myocardium

d) renal function

e) heart block

All answers make a medically-correct statement except d), which is therefore the right answer to this question.

III. True-False, where any of the choices given may either be true or false.

EXAMPLE: Available in pill or tablet form (is)are:

1) verapamil

2) nitroprusside

3) propranolol

4) dopamine

5) dobutamine

There are really five separate questions here; each choice a-e may be true or false. Thus you can score anywhere from 0 to five points with this question.

5. A more difficult type of multiple choice question is where there may be one, none or more than one correct answer; if you incorrectly assess any single part you miss the entire question. Converting the above question to this type, it reads as follows:

EXAMPLE: Available in oral (pill or tablet) form (is)are:

1) verapamil

2) nitroprusside

3) propranolol

4) dopamine

5) dobutamine

ANSWER

A) if only 1 is correct

B) if only 1, 2 and 3 are correct

C) if only 1 and 3 are correct

D) if only 4 is correct

E) if all are correct

Now suppose you know that verapamil and propranolol are available in oral form, and that dopamine and dobutamine are not, but you're unsure about nitroprusside; you could miss the entire question even though you know four out of five pieces of information. Obviously, this type of question is not very popular with test takers (and fortunately is used less and less often by test givers). Anyway, the correct answer is C.

6. Become familiar with the types of test questions by studying any materials specifically prepared for board review that are in test-question format; use the questions to then focus your reading on any weak areas. This method is apt to be much more useful than simply reading about a subject without having a specific question in mind.

7. All the test savvy in the world will not help if you are not prepared. Be prepared, read the questions carefully and you will do well.

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THE LECTURER (poem)

Tell us what we need to know.

Please don't bore us with your show.

Your slides, dear sir, put one to sleep.

The words you use are way too deep.

The problem, alas, is clear to see,

You address a special fraternity.

Who know the line, arcane reference;

But none of them in this audience.

Solution? None, I fear.

You're too insensitive to hear

What all of us show so well.

You've simply lost us, truth to tell.

Polite we'll be and clap the end.

And hide the message we wish to send.

Applause is for one reason, true

Thank God, dear sir, you are through!

What is the Internet? It is a vast array of tens of thousands of computers worldwide, each linked to all the others through some common software. The computer can be a large main-frame in a university or government agency, or a small personal computer residing in someone's home or office. When people operating these computers have information they wish to share with the world, they direct it to the Internet. That, in fact, is how you are reading this page. The file for my book The House Officer's Survival Guide, from which Section K (Boards and Board Review) comes, is stored in a computer in Cleveland, under the Mt. Sinai Hospital of Cleveland account. Anyone in the world (with an internet connection) can access it, as you have done.

At present almost all information on the internet is free to anyone with a reasonably fast computer and modem, at least 14.4K baud rate and preferably faster. (The minimum computer configuration needed to access the Internet by a single user is much less than what is needed to place information on the Internet for the world to access.)

Many medical articles are in print about what's available on the internet. One published recently is "Medical Resources and the Internet," by J. Michael Kramer, M.D. and Anne Cath, M.D. (Archives Internal Medicine April 22, 1996;156: 833-842). This article lists many medical usenet groups, which are discussion groups on a variety of topics, and also several world wide web (www) sites that offer medically-related materials.

Accessing the Internet

For novices, the Internet is most easily accessed through one of the commercial on-line providers; the big three are America On-Line (1-800-827-6364), CompuServe (1-800-848-8199) and Prodigy (1-800-886-3449). Perhaps that is how you got to this section. If so, then you know that each service charges a small fee per month for Internet access. The services also provide much proprietary content, i.e., content available only to its subscribers (whereas the Internet is available to anyone with the requisite hardware and communications software).

Perhaps the second-easiest method of accessing the Internet is through an Internet-only provider, of which there are many, including those provided by AT&T, GNN (a division of America Online) and Netcom, as well as innumerable local access proivders. Internet-only providers offer (usually) unlimited access for a fixed fee per month. The prices, number of companies offering the service and quality of the service change frequently.

A third way to access the Internet, generally not the most convenient but certainly the cheapest, is through your public library; some libraries even allow you to connect via your modem at home.

Internet Addresses -- Medical Links

To obtain a glimpse of what's available on the world wide web, check out the several Internet "addresses" below; each provides a mountain of medical information. Click on the underlined words in color to connect to the site. (Note that Mt. Sinai's home page contains many connections to medical sites; it is at mtsinai.org.)

If you want to connect at a later time, without going through this section, write down the internet address for insertion into the rectangular box that appears on all internet screens when you first connect to the internet. Each address begins "http:// . . .". If the box already has an address in it, replace it with the http:// address you want, then press the return key and you will reach the site; any typo, no matter how slight, will invalidate the address, so type it exactly as seen, including lower case (except when capital letters are shown).

Doctor's Guide to the Internet
http://www.pslgroup.com/DOCGUIDE.HTM DOCGUIDE.

Medconnect's Interactive Educational Programs
http://www.medconnect.com/finalhtm/intacedu.htm Medconnect.

Virtual Hospital, University of Iowa
http://indy.radiology.uiowa.edu Virtual Hospital

Martindale's Health Science Guide
http://www-sci.lib.uci.edu/%7Emartindale/HSGuide.html Martindale's

University of Washington Teaching File
http://www.rad.washington.edu Univ. of Wash.

New England Journal of Medicine
http://www.nejm.org NEJM

Physicians Online Home Page
http://www.po.com POL

Search Engines

Http stands for hypertext transfer protocol and html stands for hypertext markup language. Hypertext is sort of a general term relating to the fact that any portion of a text passage in one computer program can be linked to any portion of a text passage in any other computer program in essence, one of the fundamental attributes of the Internet.

To bypass arcane addresses, you can also get to any site by using one of several Internet indexes, called 'search engines'; they are available through all providers and go by names like

• ALTAVISTA
  
• LYCOS
• YAHOO
• HOTBOT
• WEBCRAWLER

Search engines generally don't require you to type in anything but regular English words: no back slashes or periods. For example, to get to Virtual Hospital you would type, in the box that appears on any search engine screen, "Iowa and Virtual Hospital."

This method is not as specific as using individual addresses, as you will retrieve many sites with similar words in them. Search engines have a way to go, and one of the most exciting areas of software research is in developing "intelligent" search engines, ones that know you, and what you are likely looking for. Right now search engines are too indiscriminate, way too broad, and include literally thousands of items for many simple searchs. However, with time the engines will improve, and so will your abilities to conduct an effective search. I recommend you click on one or two of them and experiment with searching some topic, the more specific the better.

Some Specific Sites

As for some of the specific sites, Doctor's Guide to the Internet is more of a compendium of sites than a strict guide; it includes a sub-compendium called Complete Internet Medical Resources, at:

http://www.pslgroup.com/MEDRES.HTM
Complete Internet Medical Resources

MEDRES.HTM includes many other sites, such as medical schools around the world hooked up to the Internet. Both Doctor's Guide and Internet Medial Resources aim to become encyclopedic in scope.

Martindale's Health Science Guide is yet another encyclopedia of sites, and features several "Centers": for medicine, dentistry, allied health sciences, public health and other fields. The Center for medicine, called Martindale's Virtual Medical Center, has the following address:

http://www-sci.lib.uci.edu/%7Emartindale/Medical.html Virtual Medical Center

In Virtual Medical Center you can click on numerous sites, such as Cardiology; in Cardiology, for example, you can find the ACLS algorithms.

In Medconnect's Interactive Educational Programs you can find sites dedicated to board review in primary care, and educational programs on emergency medicine. In Virtual Hospital you can find multi-media programs on a variety of topics, including pulmonary embolism (which shows high-quality lung scans). Likewise, the University of Washington Department of Radiology has placed extensive teaching files on-line.

Abstracts of articles from current and recent New England Journals are on line, and you can order the full text of any article for a fee (by mail or fax). Another site, Physicians Online, is proprietary and not part of the Internet (just the home page is); however, the service is available free to all physicians. You register by providing your DEA and social security numbers. POL includes free medline and drug information searches, and a number of other useful physician-oriented services.

And More Sites

Most medical schools have their own home page, as do many: hospitals, departments within medical schools, libraries, medical journals, etc. The number of medical sites seems to grow daily. Some more examples: Case Western Reserve University School of Medicine
Welch Medical Library of Johns Hopkins University
Anesthesia Dept., Univ. of Queensland, Australia
Morbidity and Mortality Weekly Report
National Library of Medicine
Physiology and Medical Aspects of Scuba Diving

A Great Commercial Site

There are many sites on the Internet that sell items mail by order, and one in particular is worth browsing: the world's largest bookstore, http://www.amazon.con Amazon.com.

Physically located in Seattle, Amazon.com carries over a million titles, several times more than the largest retail outlet. Browse their "stacks" online to find almost any book in print, including many medical books. If the book is in their Seattle warehouse, Amazon will ship it within two or three days; if it is in their catalog only, they will order it for you.

* * *

There is a wealth of information on the Internet, and the enthusiasm the world wide web has generated seems justified. Still, there are several problems inhibiting its greater use to physicians and the general public. These problems include: data transfer is too slow with current technology, particularly for pictures; there is an overload of "junk" on the Internet, cluttering the searches and making it difficult to find what you really want; many of the sites you read about are non-operative when you try to access them; and, incompatible technologies among web browsers often make the text and pictures appear different to different users.

The Internet will continue to change and improve with time, and these problems should all be resolved (for example, through fiberoptic cable for fast data transfer, and highly sophisticated search engines to eliminate the junk and find what you need quickly). At some point the effort will be worthwhile and, probably, fairly routine. Certainly, to be able to find the information you want, when you want it, almost instantly, can be very gratifying.

Dr. Martin is Chief of the Division of Pulmonary and Critical Care Medicine, Mt. Sinai Medical Center, One Mt. Sinai Drive, Cleveland, Ohio, 44106 (Phone 216-421-3708; FAX 216-421-6952).

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