THE CRAMMER
STUDY GUIDE
THE CRAMMER
A CRAMMER’S GUIDE TO BOARD PREPARATION
Cramming may not be optimal for exam preparation, multiple-choice questions. Take practice tests. If
but it may be inevitable. If the date of your certifica- you haven’t taken a test recently, train yourself for
tion or recertification exam is fast approaching, and computerized test-taking.
you are just beginning to study, there’s still time for
you to benefit from a strategic approach. Study with cases and case-based questions: You
might think that studying via cases-based questions
It turns out that you are in good company. People won’t cover enough ground fast enough for you.
with high intelligence find out early in life that cram- But case-based questions are a good use of your
ming — an intense period of focused study shortly time — and not only because they make up the
before an exam — can get them over most academ- majority of most boards. Case-based questions
ic hurdles. Cramming is further ingrained by the engage your mind more actively than textbooks or
“learn-and-dump” approach to teaching and testing lectures, and such “active learning” is deemed best
during the first two years at some medical schools. for knowledge retention. The problem-solving we
apply to a specific patient’s needs is how we learn
The good news is that if you are actively engaged in our daily practice. It also is consistent with the
in clinical practice, you are learning constantly. clinical reasoning required for a board exam, more
Every day with your patients prepares you for so than a recitation of facts.
boards, and each act of clinical reasoning is a rein-
forcement of your knowledge. As you move forward Use the “blueprint” for your board’s exam to guide
into studying, you can derive confidence from what you: The American Board of Internal Medicine,
you already know. for example, makes available online the blueprint
that guides creation
With self-knowledge and the right tools, you can of its exams. In this
make the most of the time available. Advances in case, the blueprint
cognitive science have produced new understanding
of how best to learn and study, with corresponding
tactics to help even the most time-pressed studier.
Better still, new study aids for physicians incorporate
these techniques for efficient, targeted preparation.
COMBINE “BEST PRACTICES” FOR
STUDYING WITH COMMON SENSE
For most of us, true lifelong learning and board
preparation requires augmenting our knowledge
with focused time to read and study. Even if you
are only a few weeks from your exam, you can still
integrate “best practices” with common sense ap-
proaches. Here’s how:
Learn how to take the test: Knowing how to take a
particular test is essential to a positive outcome
and can be accomplished in a short time frame.
For most boards, it is essential to practice with
case-based questions and to master the art of
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directs the percentage of questions in specific med- As cognitive science has shown in recent years,
ical content categories (i.e., 14 percent cardiology, passive learning is not particularly effective, and
broken down further into the number of questions knowledge gained in a one-time, intensive review
about ischemic disease, arrhythmias, etc.) and in tends to decay rapidly in the absence of effective
cross-content categories (i.e., 10 percent geriatric consolidation.
medicine). Studying in sync with the blueprint is
time-efficient. Question banks: These have become an essential
tool for board preparation, bolstered by evidence
Self-assess: How we think we’re doing — that is, our that answering questions and retrieving knowledge
judgments about our own learning and memory — from memory actually boosts knowledge retention.
affects the outcome. Called “metacognition,” this Question banks appeal to Crammers who can work
ability to recognize your own strengths and weakness- through a mountain of questions in an intensive
es helps you prioritize what to study. A practice test at study session. And they are useful for studying in
the outset will help with self-assessment. Be honest short bursts, wherever and whenever you have a
with yourself about what you do and do not know. few free moments. Ideal questions require case-
Then, consider a study tool that can quickly review based problem-solving (for active learning) and are
the topics you know well — so you can focus your mapped to your exam blueprint.
remaining time on weaker, but high-priority, areas.
Use adaptive learning: The most effective question
What doesn’t work: If your time is short, and you banks use “adaptive learning,” a technology that
like the idea of cramming in a lot of learning at once, serves questions based on your prior responses.
a review course may sound appealing. Unfortunately Algorithms determine which questions to present
review courses are one-size-fits-all, tend not to to you, depending on your past correct or incorrect
adapt to your strengths answers. This creates a reliable “metamemory” to
and weaknesses, guide your study. The most sophisticated question
and lull you banks move quickly through topics that you already
into thinking know and make efficient use of study time by fo-
you must cusing on areas where you were once solid and can
be learning relearn quickly.
when you’re
not. Reflection: Reflecting as you learn is a key principle
for maximizing study time. And it can be built into
a good study tool. When you find out that you’ve
just answered a question incorrectly, the negative
experience tends to increase your attentiveness
and create a powerful opportunity for new learn-
ing when your mind is most open to suggestion.
When a question bank offers useful feedback after
a wrong answer — and you read and process the
information — you have capitalized on a learning
moment.
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The power of repetition: Repetition is also important STREAMLINE YOUR STUDY
to create a strong scaffold for your learning. You
may think you don’t have time to go over material No matter how little or how much time you have to
more than once. But it has become clear that repeti- study, if you approach a test of generalized knowl-
tion and re-exposure to material is a powerful strate- edge such as the ABIM boards thinking that you
gy to consolidate learning and maximize retention. must master every nuance, you’ll feel like you’re
drinking from a fire hydrant. These suggestions will
Avoid a linear plan: If you march through the cur- help to streamline your approach.
riculum topic by topic, you may get stuck on a topic
and run out of time before studying other key areas. What to study:
Instead of covering just half the material at 90 per- •• Well-established treatment guidelines from
cent depth, you are better off if you cover 90 percent national organizations for common diseases
of the material at 50 percent depth in your first pass such as type 2 diabetes, hypertension, asthma,
at it. This leaves you time to circle back to topics to and hyperlipidemia.
reinforce and expand upon what you know.
•• Screening guidelines, such as those for breast,
Think in pictures: Try to use a study aid that stim- colon, and cervical cancer.
ulates the visual side of your brain to recognize
•• Specific physical findings that can be diagnostical-
clinical features of disease through radiologic
ly useful, such as knee maneuvers and murmurs.
images, photographs, and EKG tracings — which
may appear in board exams. •• Problems that are frequently encountered in a
practicing physician’s office, such as sinusitis,
Pace yourself: You may not have the stamina that depression, migraine, chronic pain, COPD, etc.
you had in medical school, and long study sessions
probably are not the best for retention anyway. Short •• Be ready to recognize un-
and repeated bursts of studying are optimal for common presentation
learning. of common diseases,
but only typical
Embrace the process: With your intense focus, a presentations of
Crammer tends to dive into the process of learning. uncommon diseases.
That works in your favor. A positive attitude will take
•• Anticipate common
you far, and you may even find that new study tools
drug interactions.
are fun to use. With little time and a lot at stake, why
not embrace the love of learning that got you into
medicine in the first place?
An alternative to cramming?: If you are still several
months from your examination, you have time to re-
think your self-definition as a Crammer. It is widely
accepted now that the most effective learning occurs
over time, called “spaced learning” or “distributed
practice,” and is better than trying to learn a lot at
once. For boards and for your practice, repetition
and re-exposure are especially helpful for knowledge
that is weak or was learned some time ago. Technol-
ogy can help you adopt this more deliberate learning
style, to maximize your learning efficiency.
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In the days before an exam, review common lists
of facts:
•• Basic formulas for gaps and gradients and
acid-base interpretation.
•• Simple associations that are readily forgotten
but specific, such as autoantibodies associated
with various rheumatologic conditions or how to
interpret hepatitis B virus serologies.
Keeping up with the latest controversies and treat-
ments through journals and other means is import-
ant for lifelong learning. But these topics are less
likely to appear on a board exam:
•• Ongoing controversies. Because questions must
have a solid evidence base behind them, you’re
fairly safe to rule out moving targets.
•• New therapeutics (and diagnostics) that are less
than a year or so old. Questions must be written
and vetted in advance, so new treatments and
topics will take a couple of years to be worked
into a certification exam.
•• Advanced therapeutics that ordinarily would
be in the realm of a specialist (such as bone
marrow transplantation or managing a
dysfunctional pacemaker).
And of course, use only study materials you can
trust. They should incorporate current guidelines
with an evidence base; be created by a high-quality,
authoritative source; and have been subject to expert
peer review.
THE FINAL COUNTDOWN
Once the exam is just a day or two away, it is time But until those final few days, make the most of
to step back. Last-minute cramming may under- your study time. For Internal Medicine, the pass rate
mine your confidence if you find yourself in areas of for first time recertification was 84 percent in 2012
uncertainty. And a good night’s sleep (or two) will (down from 92 percent in 2008), and 85 percent for
serve you better than extra cramming. On the day the initial certification exam. Use your time — start-
before, step away from preparation entirely and do ing now — to help yourself land on the right side of
something you enjoy. those percentages.
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References Interviews
Bell, DS et al. “Knowledge Retention after an Online Tutorial: Teresa Carter, Associate Dean, Professional Instruction and
A Randomized Educational Experiment among Resident Faculty Development, Virginia Commonwealth University
Physicians.” J Gen Intern Med 23(8):1164–71. School of Medicine.
Carey B. “Forget What You Know About Good Study Habits.” Trish Kritek, Associate Professor, Division of Pulmonary and
New York Times. Sept. 6, 2010. Critical Care Medicine, Associate Medical Director of Critical
Care, University of Washington Medical Center.
Kornell N, Hays MJ, Bjork RA. “Unsuccessful Retrieval
Attempts Enhance Subsequent Learning.” Journal of Graham T. McMahon, Executive Editor, NEJM Knowledge+;
Experimental Psychology 2009, Vol. 35, No. 4, 989–998. Associate Professor of Medicine and member of the Academy
at Harvard Medical School.
Schwartz BL, Son LK, Kornell N, Finn B. “Four Principles of
Memory Improvement: A Guide to Improving Learning
Efficiency.” The International Journal of Creativity and Problem
Solving 2011, 21(1), 7–15.
Storm BC, Bjork R, Storm JC. “Optimizing retrieval as a
learning event: When and why expanding retrieval practice
enhances long-term retention.” Memory and Cognition 2010,
38(2), 244–253.
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