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Board Preparation: Training for a Marathon, not a Sprint 

Created January 10, 2017 by Patrick C. Beeman, MD
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The first key to success on the boards is using practice questions to develop your “hunch reflex.” If you’re a second year medical student, “kinda-sorta” thinking about a certain test you’ll have to take in about six months, and you haven’t already begun using USMLE/COMLEX-style practice questions in your study, you should start now. Even if you’re just half way through first year, start incorporating the following advice into your study plan: questions, questions, questions!

Which questions should you use? There are a number of newer and older guard questions banks offering excellent multiple choice practice questions (MCQs) which can be integrated easily with your coursework throughout the preclinical years. Or you can buy a hardcopy book of USMLE practice questions from one of the top medical education publishers. The source of material doesn’t matter so much as doing boards-style practice questions so you can train your mind to think in the way required for success on the boards. The point is: do something now.

Don’t make the mistake I did as a medical student and wait to incorporate this study strategy into your board-preparation “long game.” I didn’t really discover “practice questions” until later in second year, and I really wish I had used them sooner. Both using MCQs and then writing practice boards-style questions made me so much more efficient in study, a little more confident walking into my USMLE and NBME shelf exams, and even decreased my testing anxiety to a certain degree.

If using practice questions as part of my own study plan helped train my “hunch reflex,” writing boards-style MCQs made me feel like I knew what questions were going to be on the test before I sat for the exam. But you don’t have to get a job writing MCQs to develop this confidence. Of course, you can’t really know the exact questions that are going to be on your particular administration of a standardized exam, but what you can know is what makes a good question.

Learn What Makes a Good Multiple Choice Question
You can learn to discern why certain things will never show up on the boards because the only way to formulate a question about them is to write one that is verboten, one that doesn’t meet the high standards that the NBME and NBOME require of for MCQs used on their actual exams.

Learning to recognize the factors that contribute to the goodness or badness of a question can help guide your study and assist you in constructing a mental map both of topics that will likely show up and how those topics will be tested on the exam. Acquiring some skill in this area can be used repeatedly throughout your medical career for the many, many tests you’ll be required to take.

Discerning What’s Testable versus What’s Not: An Example 
So let me give you a brief example of what I mean. Say you read the following stem:

A 13 year-old-male presents for evaluation of gait abnormality and weakness. His past medical history is unremarkable. Family history is significant for a maternal uncle who has an unknown disease that made him wheelchair-dependent as a child. Vital signs are within normal limits. Physical examination is significant for distal limb weakness, impaired proprioception, and pes cavus deformity. Which of the following is the most likely diagnosis?

A) Becker muscular dystrophy
B) Duchenne muscular dystrophy
C) Hereditary motor and sensory neuropathy
D) Talipes equinovarus

The answer for this one is choice (C), hereditary motor and sensory neuropathy (commonly known as Charcot-Marie-Tooth disease, or CMT).

This disease is the most common inherited neurologic disorder. Classic findings are distal muscle weakness (presenting initially with foot drop), pes cavus (high arches) deformity, absent deep tendon reflexes, and impaired proprioception.

CMT is actually a syndrome with over 30 genetic causes some with X-linked recessive, others with autosomal dominant, and still others with an autosomal recessive inheritance pattern. It is classified into multiple subtypes determined by the kind of inheritance, the underlying pathophysiology, and particular neurons affected. It’s a little complex to say the least. There are demyelinating types. It’s all very messy.

That being said, pretend you’re the head honcho in charge of the boards. If you were going to include a Charcot-Marie-Tooth disease question on a test meant for a general medical license, how would you write it? What material would you include in the stem? If you wanted to see if someone could recognize this, how would you frame the interrogatory?

Based on the little information about CMT which I mentioned above, do you think it’s likely that you’re going to get a question interrogatory like one of the following?

The most likely inheritance pattern for this patient’s disease is

A) Autosomal dominant
B) Autosomal recessive
C) Multifactorial
D) X-Linked recessive

OR

This patient’s symptoms are most likely caused by

A) a defective muscle protein
B) apoptosis
C) autoimmune demyelination
D) axonal degeneration
E) Schwann cell degeneration

These questions are unlikely with reference to Charcot-Marie-Tooth disease. Why? Consider how low-yield it would be to require medical students to know the answers to these queries. That might be something important for a neurology resident, but the disease is too variegated in its presentation to get into all the types and subtypes for a general medical licensing exam. There are just too many etiologies, too many genes, and too many sundry clinical presentations.

To be sure, the above interrogatories might be appropriate for other diseases, e.g. a defective muscle protein, dystrophin, causes Becker muscular dystrophy and its absence causes Duchenne muscular dystrophy. The same goes for inheritance: dystrophin is encoded on the X-chromosome. So asking about these things in relation to Duchenne or Becker muscular dystrophy makes some sense.

In fine, certain diseases lend themselves to certain questions. So as you study Charcot-Marie-Tooth disease, you wouldn’t waste your time learning about its inheritance, characteristic findings on muscle biopsy, pathophysiology etc. The most return you’re going to get on your study investment—remember there’s a law of diminishing returns when it comes to studying—is to remember only the highlights that lend themselves to being the answer to a high quality question.

Putting It All Together
So how might CMT show up on a board exam?

Perhaps, a vignette about nonspecific muscle weakness (with no classic differentiating
factors that would make you choose Becker or Duchenne Muscular dystrophy) and a vague but positive family history that asks which diagnosis is most likely (this tests your knowledge of Charcot-Marie-Tooth disease as the most common inherited neurologic disorder) and is a schema board exam question writers can use to test epidemiologic facts (because boards-style MCQs must have a clinical vignette, you aren’t going to see a standalone question asking you “The most common cause of X disease is…”)

Similarly, you could conceive of the boards people presenting a vignette that states a patient is diagnosed with CMT and asks the examinee which finding is most likely on physical exam (with a list of findings including “pes cavus” deformity). Or perhaps an examination item that describes only some of the features of Charcot-Marie-Tooth disease but shows a picture of pes cavus deformity and then asks which diagnosis is most likely.

At the same time, you know that certain related diseases (i.e. the ones in a reasonable
differential diagnosis for CMT) are going to influence the question writers, so you need to
know what differentiates Charcot-Marie-Tooth disease from those with similar
presentations or findings. What diseases are similar? What makes CMT stand out? For boards success, you have to really pay attention to the unique aspects of diseases with overlapping presentations. The locus of good MCQ construction is found here. It’s where question writers draw their material. And it’s where you should focus your study.*

Further, you know that for a condition like CMT, they aren’t likely to ask about treatment because there really isn’t a single modality or drug that is given to cure or treat this disease (like azithromycin treats chlamydia or a combo of ceftriaxone/azithromycin treats gonorrhea). So you don’t want to waste time learning or thinking about the treatment.

Want to do well on your board exams? Start using practice questions as part of your study as early as possible during first or second year. Pay attention to how practice questions for a given topic are constructed by writers and use those insights to seize upon the highest-yield material likely to be tested. It’s always going to be somewhat of judgment call deciding what is likely to be tested versus what is not. But making judgments about the relevance or irrelevance of information is basically what clinical judgment and being a doctor is all about. And… it’s half the battle when it comes to thinking like a question writer and succeeding on the boards.

*Note that I’m not saying this is all you should study or know. My point is that this is what you should know in particular for board exam preparation. “Real” life medicine is much messier than what can be placed into a paragraph-long clinical vignette.

About the Author
Patrick C. Beeman, MD is a board-certified obstetrician and gynecologist. He is also the co-founder of InsideTheBoards, which aims to help students learn to think like board exam question writers. He hosts the ITB Podcast which features interviews with leaders in the board-preparation space, board-exam study advice and tips, as well as high yield practice question dissections. He has contributed to the Case Files series as well as three major board preparation question banks and even served as the director of content for a major osteopathic licensing and shelf examination question bank prior to launching InsideTheBoards.

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