The Top 4 Mistakes Students are making in their ISP in 2012

(Noted by Limited Improvement after the 2nd NBME Practice Test)

So far in this ISP season, I keep getting different versions of the same question:

Student: After taking my 2nd NBME practice test, I’m seeing minimal improvement. Why is this? I can’t figure it out. I’m using the Step 1 Method and I’m reading first aid after questions or at the end of the night. I feel so defeated, because I’m working hard but not seeing results.

Answer: Now although this may not be your situation, you can definitely benefit from the strategies that follow. After discussing with many 2012 students with this problem, the reasons are 4 fold.

Students say that they are using the Step 1 Method (S1M), but after further digging, they still don’t know what it means. Just looking at the first aid after doing questions alone is not the entirety of the S1M.

#1 – Students are not using the Step 1 Method Framework

After every question, you should ask yourself if you know the S1M framework (recapped at bottom of post) for that topic. This will prepare you for most questions the Boards Examiners can ask you about that topic. When you only learn the element of the framework that was tested in the qbank question, the only time you’ll get questions right is if the Boards ask about that same element. This is memorization. I can guarantee you that most of you won’t get the exact same questions on your real test. I can guarantee that you will see the same topics tested, but the Boards Examiners will ask 2nd and 3rd level questions about other elements of the framework. Further, they will present hypothetical scenarios (e.g. a new study drug) and experiment based questions that test the fundamental concepts. These will require you to understand the underlying phenomenon and memorization alone will not help you here.

After doing a single question on a particular topic (e.g. Cystic Fibrosis, Aortic Dissection, Beta-Blockers), you should go through the S1M Framework, and annotate the missing elements in the First Aid. Thus, the first time you encounter a topic, you should spend a considerable amount of time (up to 15 min) fleshing out the framework. Further, as you leave the question on that topic, you should ask yourself, “Do I know the framework for this topic.” The second time you get a question on that same topic, you should have a much higher likelihood of answering it correctly, because you have already reviewed the entire framework. Many students do not take the time to do this valuable activity. In general, students get overwhelmed with the amount of work that they have to do, and they just fly through questions without asking themselves if they learned everything. You should continually be testing yourself in your head, “Do I know the framework for xyz topic.”

# 2 – Students are not practicing the Principal of Free Association

If you have to ask what this is, you should go watch the online module! The Principal of Free Association is based on the premise that most topics belong to a larger class of topics that all share similar characteristics. The frameworks for these topics only differ in a few elements. As you can see, this is a great opportunity for Board Examiners to test the depth of a student’s knowledge.

For example, what’s the difference between Dermatomyositis and Polymyositis? Sjogren’s syndrome and Mixed Connective Tissue Disease? Limited and Diffuse Scleroderma? You should be able to compare these across the S1M framework and point out the similarities and differences. You would have learned these subtle differences and similarities if you had done Free Association for Connective Tissue Disorders.

When the Board Examiners want to test the depth of your knowledge, they will make these similar topics the wrong answer choices along with the right answer choice. Students often find themselves left choosing between two answer choices because their knowledge base (usually rooted in memorization) does not go far enough.

In order to master these gray areas, you should not only learn about topics in isolation, you should also attempt to associate each topic with similar topics and be able to compare their similarities and differences at will. This is the Principal of Free Association. If you get very good at this, the amount of free association that you can do is unlimited. You can compare bacteria which have similar toxin mechanisms, then those that have capsules, then those that have vaccines associated with them, then those that cause same disease processes, etc. Very quickly, you will find that there is an association that you know exists, but you can’t make the connection. That is a hole in your knowledge base. Many students will feel rushed and shrug off that hole to do more questions. We want you to stop and make that association.

In short, watch the online module if you have not already.

# 3 – Students still don’t understand how to do Practice Test Analysis

If you have to ask what Practice Test Analysis is, read the post on Practice Test Analysis! Some students either see a limited score increase, no score increase, or their score goes down and they immediately feel hopeless. Then, they are confused and don’t know what happened. They will look at the score report and see bars going up and down, with no rhyme or reason. Further, students are not obtaining the enhanced feedback, so they have no idea which questions they missed.

If you practice the analysis, you will take a screen shot of the latest nbme and paste it on top of the first nbme. This will allow you to easily go back and forth between topics. You should simply go from topic to topic to see if it went up or down. It’s as simple as that. This will tell you the story of what happened. Every time a student sends me two individual score reports, I know instantly that they are not practicing the correct analysis.

The reason why a topic has gotten stronger or weaker is not magic: you either got questions right or you got them wrong. Once you have realized a topic has gotten weaker, look at the enhanced feedback to see which questions you missed in those categories. Many students immediately feel a sense of hopelessness and confusion when they get a score report back and they did not improve in areas that they already reviewed. Think of it this way, would you rather find out that you are weak in an area during the test, or before the test when you have time to correct your mistakes. Further, when you take a look at the enhanced feedback and see what questions you missed, it is often that one question touched on many topics peripherally and will be included in those score bars. Sometimes students make silly mistakes that do not reflect their knowledge base.

When a student’s score in a particular topic does not increase after review, it is most commonly due to Problems #1 and #2 reviewed above. Put simply, students are not reaching a deeper level of understanding. They are not practicing the full process of the Step 1 Method, yet they are expecting to see results. Memorization alone will not get you a great score on this test; you must think like the Boards examiners and connect ideas, topics, frameworks, and processes. We believe the program is simple, but not easy. It takes more effort to do the S1M framework for every question and free association for every topic, than to just do several questions at a time.

#4 – Students are not reviewing strategically

We recommend a few forms of strategic review during your ISP. These are recapped below. We most often see students not doing the daily and pre-NBME review.

Daily – As mentioned above in the Principal of Free Association, you should constantly be forming pathways and connections between topics. Often times, you will vaguely remember that a connection exists between the topic you are currently covering, and a previously covered topic. Many students will overlook this spark of memory, and continue doing questions. We want you to stop and make that connection. This will likely require you to review a topic previously covered to make this connection. This is okay, and you should be doing this on a daily basis, multiples times a day.

Weekly – At the end of the week, you should spend no more than 1-2h just flipping through your central text reviewing the text and annotations of the topics you covered that week. This last review will solidify topics before moving on to the next weeks’ topics. The key to memory retention is repetition. When you see concepts multiple times in multiple formats, you will have a much higher likelihood of retaining that info. Remember, review is the rule. You should anticipate forgetting information and will need to rehash the various pathways frequently.

Prior to an NBME – Prior to taking an NBME exam, you should briefly review topics that you have not seen yet, or those you have not seen in a while. You should do this by simply flipping through these sections in the central text to remind you what the main topics in each section are. Thus, when you are tested on these concepts the information will be more readily available. This should not take you longer than ½ a day and again can be done efficiently in a few hours.

Comprehensive Review – Read our post on the CRP. At the end of your ISP, you should spend 10-15% of your total ISP time reviewing all topics one more time in an integrative fashion using questions and your central text.

S1M Format for Doing Questions:

Step 1: Do questions one by one (Question blocks should be focused -- subject/systems based -- not random)

Step 2: Read and understand the answer explanation and answer choices after attempting the question

Step 3: Read the corresponding section in the central text after reading the answer explanations

Step 4: If the key info is missing, annotate the section with the key 4-5 word association found in the question regarding the right answer (avoid annotating regarding wrong answer choices)

Step 5 (optional): If you need more clarification, go to your supplemental source, emedicine, etc as needed

The S1M Framework (What you need to know for the Boards):

1) Presentation

2) Mechanism/Pathogenesis

3) Course/Complications

4) Treatment/Diagnostics