#TipsforEMexams: Dr. Rob Woods shares his EM Exam Tips

#TipsforEMexam Series

In the last post of this series, I (Dr. Teresa Chan) nominated a few people to blog about their EM exam tips for final year residents sitting their exams this year.  Dr. Nadim Lalani of USask already added his tips in the comments, but I also formally nominated Drs. Rob Woods (#USask) & Heather Murray (#QueensU).

I now present you our first respondent:

***

Name:  Rob Woods, Survivor of the 2007 RC emergency medicine exam.

Where are you now?
University of Saskatchewan Residency Program Director

Here are my five EM exam tips for getting through the RC EM exam:

1. Imagine every difficult airway scenario you can.  Think how you would manage it.  Take one shift per month, and imagine if you had to intubate every patient you saw (regardless of their chief complaint) based on 3 different scenarios (facial trauma with head injury, upper airway obstruction from tumor or inhalational injury or infection, respiratory failure from lung pathology – asthma, pneumonia, etc.).  Then imagine option A and B are not possible.  Yes usually airway plan A works, and asthmatics get better with bronchodilators, and UGI bleeds stop on their own, and seizures stop with one dose of Benzo’s, but that’s not how exams work.  They need you to demonstrate your depth of knowledge of topics.

Woods' Textbook of Emergency Medicine2. Quality is better than quantity.  My wife and I wrote our exams (Pediatrics for her) in the same year, with a toddler, with no family in town.  We had 2-3 hours per day to study, that was it.  Knowing how much time you have keeps you focussed on a manageable amount of content.

3. No new material 6-8 weeks leading up to the exam.  Just consolidate. It’s a marathon, not a sprint.  What you study in September, will be forgotten by spring.  You can only fit so much in that brain.

4. Study with your peers.  Rob Keyes and I were the only 2 in our year at the UofA.  I can’t imagine not having had him to meet up with weekly to go over content, do practice exams, and vent about how frustrating the year can be sometimes.

5. Writing has greater retention than typing.  Make your own textbook (see pic).  I made my own textbook in the 6 weeks leading up to the exam.   Many people have seen it, the residents borrow it.  They often say, ‘you should publish this!’.  I say, the value was in making it, not reading it.  Make your own.

-Rob

 

Rob’s nominations:

Chris Hicks

Aaron Sibley

 

 

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post #TipsforEMexams: Dr. Rob Woods shares his EM Exam Tips appeared first on BoringEM and was written by Teresa Chan.

#TipsforEMexams: Dr. Rob Woods shares his EM Exam Tips

#TipsforEMexam Series

In the last post of this series, I (Dr. Teresa Chan) nominated a few people to blog about their EM exam tips for final year residents sitting their exams this year.  Dr. Nadim Lalani of USask already added his tips in the comments, but I also formally nominated Drs. Rob Woods (#USask) & Heather Murray (#QueensU).

I now present you our first respondent:

***

Name:  Rob Woods, Survivor of the 2007 RC emergency medicine exam.

Where are you now?
University of Saskatchewan Residency Program Director

Here are my five EM exam tips for getting through the RC EM exam:

1. Imagine every difficult airway scenario you can.  Think how you would manage it.  Take one shift per month, and imagine if you had to intubate every patient you saw (regardless of their chief complaint) based on 3 different scenarios (facial trauma with head injury, upper airway obstruction from tumor or inhalational injury or infection, respiratory failure from lung pathology – asthma, pneumonia, etc.).  Then imagine option A and B are not possible.  Yes usually airway plan A works, and asthmatics get better with bronchodilators, and UGI bleeds stop on their own, and seizures stop with one dose of Benzo’s, but that’s not how exams work.  They need you to demonstrate your depth of knowledge of topics.

Woods' Textbook of Emergency Medicine2. Quality is better than quantity.  My wife and I wrote our exams (Pediatrics for her) in the same year, with a toddler, with no family in town.  We had 2-3 hours per day to study, that was it.  Knowing how much time you have keeps you focussed on a manageable amount of content.

3. No new material 6-8 weeks leading up to the exam.  Just consolidate. It’s a marathon, not a sprint.  What you study in September, will be forgotten by spring.  You can only fit so much in that brain.

4. Study with your peers.  Rob Keyes and I were the only 2 in our year at the UofA.  I can’t imagine not having had him to meet up with weekly to go over content, do practice exams, and vent about how frustrating the year can be sometimes.

5. Writing has greater retention than typing.  Make your own textbook (see pic).  I made my own textbook in the 6 weeks leading up to the exam.   Many people have seen it, the residents borrow it.  They often say, ‘you should publish this!’.  I say, the value was in making it, not reading it.  Make your own.

-Rob

 

Rob’s nominations:

Chris Hicks

Aaron Sibley

 

 

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post #TipsforEMexams: Dr. Rob Woods shares his EM Exam Tips appeared first on BoringEM and was written by Teresa Chan.

Boring Question: Which low risk C-spine rule is best?

A Case:

A 32-year-old female was the driver in a simple rear-end motor vehicle collision at about 40km/h.  She was wearing a seatbelt and her airbags did not deploy.  She extricated herself from the car.  When EMS arrived, she was walking.

On examination by paramedics, the young woman denied paraesthesias. She did complain of midline C-spine tenderness; as a result, she was boarded and collared prior to transport.

She is now on a stretcher in your emergency department.

The Clinical Question:

Which clinical decision rule (Canadian C-spine vs. NEXUS) should you use to asses this patient?

The Analysis:

The Canadian C-Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study Low-Risk Criteria (NEXUS criteria) are clinical decision tools developed to help us decide when blunt trauma patients require C-spine X-ray.  The CCR was developed by Steill and colleagues in 2001. Since then, the CCR has been validated for use in the emergency department, at triage, and by paramedics in the field.  It uses 3 primary factors to determine whether a given patient needs imaging: 1) Is there any high-risk factor that mandates radiography? 2) Is there any low-risk factor that allows safe assessment of range of motion? 3) Can the patient actively rotate his or her neck 45° right and left? (See Figure 1)  Strict exclusion criteria eliminate some of the ED population. (See Table 1)

Figure 1.  Canadian C-Spine Rules
(Diagram has been re-designed by the BoringEM.org team for clarity – click on the diagram to link to a higher-resolution version of the picture)
Figure 1

Table 1.  Canadian C-Spine Rule Exclusion Criteria
Age < 16Minor injuries and not fulfilling inclusion criteria
Glasgow Coma Scale score <15
Grossly abnormal vital signs
Injury > 48h old
Penetrating trauma
Acute paralysis
Known vertebral disease (ankylosing spondilitis, rheumatoid arthritis, spinal stenosis, previous spinal surgery)
Return visit for reassessment of same injury
Pregnant

 

The NEXUS criteria was developed by Hoffman and colleagues in 1998 and is validated for use in the ED.  It consists of five low-risk criteria; if the patient does not meet all five criteria, he or she requires C-spine x-rays.  These criteria include: No posterior midline cervical spine tenderness; no evidence of intoxication; normal level of alertness; no focal neurologic deficit; and no painful distracting injuries. (See Figure 2)  “Intoxication” and “level of alertness” are further defined in the original paper; these criteria and “painful distracting injury”, however, must be interpreted by the attending physician. The only exclusion criteria are patients with penetrating trauma and those who had a C-spine x-ray for reasons other than trauma. The NEXUS criteria are simple to use and can be widely applied to the ED patient population.

 

Figure 2.  NEXUS Criteria (i.e. Table 2, from Hoffman et al. 1992)

1.  No midline tenderness.

2.  No focal neurologic deficits.

3.  Normal alertness.

4.  No intoxication.

5.  No painful distracting injury.

The sensitivity of both rules for detecting clinically significant C-spine injuries in their own validation studies were 100%.  A recent systematic review, however, found sensitivities for CCR and the NEXUS criteria of 90-100% and 83-100%, respectively. Furthermore, one study directly comparing the two rules showed better diagnostic accuracy for the CCR.  Both rules, if applied appropriately, have the potential to reduce imaging rates (by 44% for CCR and 36% for NEXUS criteria).

As a final caution, although the NEXUS criteria have no age limitation, clinicians must beware of its use in the elderly.  A recent study found a reduction in NEXUS criteria sensitivity from 84.2% to 65.9% in elderly patients (age ³65) with acute blunt trauma when compared to non-elderly patients.  Physicians should have a low threshold for CT in this population.

Bottom line:

When compared to the NEXUS criteria, the CCR is slightly more complicated and has stricter exclusion criteria, but it has higher sensitivity.

Physicians should be aware of the populations to which these rules apply and can benefit from knowledge of both.  Patients that may not be evaluated adequately with one tool can potentially be evaluated with the other. Both the NEXUS criteria and the CCR should be used as tools, not rules. And as always, clinical judgment and appropriate interpretation are key.

…. Back to the Case

Back to the case. Using CCR, the patient has no high-risk criteria, and she has at least one low risk criteria allowing assessment of active range of motion (ambulatory on scene, simple rear-end motor vehicle collision). When assessed, she can rotate her neck 45° right and left. She does not require imaging.

By NEXUS criteria, however, she requires imaging due to midline C-spine tenderness.

Challenge:  Based on the above information – What would you do?  Answer below!

 

 

Reviewing with the Staff  |  Dr. Rob Green  (Click here to expand)

The use of appropriate radiologic investigation is important for patient diagnosis and management in the ED.  Some evidence demonstrates that the use of radiologic investigations (especially CT scans) which may prolong patient time in the ED and increase exposure to radiation.  Studies which limit radiologic investigations in low risk patients while “not missing” significant diagnosis are very important to our practice.

The CCR and NEXUS are 2 of these studies, both with positives and limitations outlined above – clinicians need to be aware of each study and utilize based on their patient and practice environment.

Thankfully, we have high quality studies to support limiting C-spine X-rays in low risk patients.

Rob Green, BSc, MD, DABEM, FRCPC, FRCP(Edin)
Professor, Dalhousie University
Medical Director, Trauma Nova Scotia
Department of Critical Care Medicine
Department of Emergency Medicine

 

References (click to expand)

Derivation NEXUS

Hoffman, J. R., Wolfson, A. B., Todd, K., & Mower, W. R. (1998). Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS)Annals of emergency medicine32(4), 461-469.

Validation NEXUS

Hoffman, J. R., Mower, W. R., Wolfson, A. B., Todd, K. H., & Zucker, M. I. (2000). Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. New England Journal of Medicine343(2), 94-99.

Derivation CCR

Stiell, I. G., Wells, G. A., Vandemheen, K. L., Clement, C. M., Lesiuk, H., De Maio, V. J., … & Worthington, J. (2001). The Canadian C-spine rule for radiography in alert and stable trauma patientsJAMA286(15), 1841-1848.

Validation CCR

Bandiera, G., Stiell, I. G., Wells, G. A., Clement, C., De Maio, V., Vandemheen, K. L., … & Worthington, J. (2003). The Canadian C-spine rule performs better than unstructured physician judgment. Annals of emergency medicine42(3), 395-402.

Coffey, F., Hewitt, S., Stiell, I., Howarth, N., Miller, P., Clement, C., … & Jabbar, A. (2011). Validation of the Canadian c-spine rule in the UK emergency department setting. Emergency Medicine Journal28(10), 873-876.

Vaillancourt, C., Stiell, I. G., Beaudoin, T., Maloney, J., Anton, A. R., Bradford, P., … & Wells, G. A. (2009). The out-of-hospital validation of the Canadian C-Spine Rule by paramedics. Annals of emergency medicine54(5), 663-671.

Stiell, I. G., Clement, C. M., O’Connor, A., Davies, B., Leclair, C., Sheehan, P., … & Wells, G. A. (2010). Multicentre prospective validation of use of the Canadian C-Spine Rule by triage nurses in the emergency department. Canadian Medical Association Journal182(11), 1173-1179.

Systematic review

Michaleff, Z. A., Maher, C. G., Verhagen, A. P., Rebbeck, T., & Lin, C. W. C. (2012). Accuracy of the Canadian C-spine rule and NEXUS to screen for clinically important cervical spine injury in patients following blunt trauma: a systematic review. Canadian Medical Association Journal, cmaj-120675.

NEXUS in the elderly

Goode, T., Young, A., Wilson, S. P., Katzen, J., Wolfe, L. G., & Duane, T. M. (2014). Evaluation of cervical spine fracture in the elderly: can we trust our physical examination? The American Surgeon80(2), 182-184.

Author information

Alana Hawley
Resident Contributor at McMaster University
Resident Physician, McMaster University Royal College Emergency Medicine Program

The post Boring Question: Which low risk C-spine rule is best? appeared first on BoringEM and was written by Alana Hawley.

Boring Question: Does this medication cause long QT? (with Bonus: Tiny Tips!)

The Clinical Case

A 70-year-old female presents to the emergency department with new palpitations and 2 syncopal episodes, witnessed by her son. These episodes have started within the past 10 days. Her past medical history includes diabetes, hypertension, depression, dyslipidemia and atrial fibrillation. She is a long-standing diabetic and is followed by a nephrologist for her diabetic nephropathy. Her medications included: metformin, atorvastatin, aspirin, warfarin and sertraline. She was recently seen in hospital for similar symptoms and sotalol was used for her atrial fibrillation.

On physical examination, her vitals were:

Temp: 37.2, HR: 130, RR: 18,  BP: 144/72, O2: 97% on room air.

On examination, she was alert and orientated to time, place and person. Her neurological assessment, which included cranial nerve examination, power assessment, fine/gross touch discrimination and cerebellar evaluation was unremarkable. Her cardiac examination revealed an irregularly, irregular pulse with a systolic murmur at the apex without radiation. Her respiratory examination revealed good air entry bilaterally. Atrial fibrillation was confirmed on 12-lead ECG. Her QTc was calculated to be 500 ms.

 Your attending asks you which of the patient’s medications may be the cause of her syncope?

The Clinical Question

What is the QT interval on an ECG, why is it important to assess and which medications cause QT interval prolongation?

Background

The QT interval is measured from the start of the QRS complex to the end of the T wave on an electrocardiogram (ECG) (1). The interval represents ventricular depolarization and subsequent repolarization, which is dependent on positively charged ions. The rapid inflow of positively charged ions (sodium and calcium) results in normal myocardial depolarization (1). When this inflow is exceeded by outflow by potassium ions, repolarization occurs. A malfunction of these ion channels results in an intracellular excess of positively charged ions, resulting in QT interval prolongation (1). This can be the result of a congenital defect in the ion channels, pharmacologic agents and changes in a patients electrolyte levels (1).

The QT interval is influenced by the heart rate of a patient. In cases of a slower heart rate or bradycardia, the QT interval can be prolonged. In cases of a faster heart rate, the interval can be shortened. As a result, the Bazett formula can be used, where the QT interval is divided by the square root of RR, generating a corrected QT or QTc (1). The normal QTc is less than 440 ms (2). Any value over this is considered prolonged. If the interval is more than 500 ms, it is considered moderately prolonged and any value greater than 550ms is considered markedly prolonged (2).   NB: For more details on how to calculate QT intervals, I highly suggest you consider reviewing Al-Khatib et al (2003) which demonstrates the corrected QT calculation in both normal sinus rhythm and atrial fibrillation.

Some signs and symptoms for patients who may have prolonged QT on an ECG can include dizziness, syncope, congenital deafness and palpitations (3). The workup can include ECG, additional cardiac monitoring, full electrolytes including extended lytes, toxicology screen and imaging such as echocardiography (3).

QT prolongation typically occurs from a congenital cause, medication or electrolyte abnormalities such as hypokalemia. Congenital etiology for patients with prolonged QT can include an autosomal recessive form associated with deafness (Jervell and Lange–Nielsen syndromes) or an autosomal dominant form not associated with deafness (Romano–Ward syndrome) (3). There are several medications that have also been associated with prolonged QT intervals.

The Tiny Tips:  The “Anti” list & The “SAD Qu-pid” Mnemonic

In attempting to remember these drugs, several mnemonics have been generated.

One is the ‘Anti’ mnemonic, where one can remember some of the broad classes to consider:

anti-arrhythmics
anti-psychotics
anti-emetics
anti-depressants
anti-infectives

 

Another is known as the “Sad Qupid” mnemonic.

Sotalol

Amiodrarone

Disopyramide

Quinidine

Procainamide

The table below highlights some of the medications that have the potential to cause a prolongation of the QT interval.

Screen Shot 2014-09-06 at 5.57.02 PM

Table 1-Adapted from Al-Khatib et al 2003  (For more up-to-the-moment lists, qtdrugs.org)

Very probable refers to more than 50% of respondents in this paper stating they would check an ECG prior to starting the medication. Probable is 40-49% of respondents indicating their preference to check an ECG with improbable referring to 40-49% of respondents stating that they did not feel the need to check an ECG before starting the medication.

Returning to the case

When initiating therapy for a patient with a medication that is known to potentially cause QT prolongation, an assessment of risk and benefit must be considered. It is also important to understanding the drug’s pharmacology and clearance prior to prescribing. For instance, a medication that has renal clearance such as Sotalol needed to be prescribed with caution in a patient with impaired renal function.

It is also imperative to understanding the risk factors which include elderly women, advanced heart disease, patients with history of sudden death and those on complex drug regimens that can influence modulate drug elimination (4). Patients on the above listed medication should also be warned to inform a health provider of symptoms such as syncope or new palpitation. In high risk situations, more serial ECGs can also be considered to assess the patient (4).

 

Reviewing with Staff:  Dr. James Ahn |  Click here to reveal

Dr. James Ahn, MD (University of Chicago, Associate Program Director)

As the article states, the main concern of long QT is torsades de pointes, which is a largely preventable disease in emergency medicine. The main issue with long QT is the recognition of this potentially deadly ECG abnormality. Although understanding the Bazett formula is useful and we are taught to naturally mistrust computer interpretations, the interval calculations provided are accurate and will save time for the provider. As mentioned above, the dangerous zone for a prolonged QT beings after 500ms.

Providers will undoubtedly obtain ECGs in a history concerning for ischemia and hypothermia. However, physicians should have a low threshold to obtain an ECG in situations without classic indications as these can scenarios can prolong the QT interval. For example, any scenario where the patient may have electrolyte abnormalities (e.g. gastroenteritis), increased ICP (e.g. intracranial hemorrhage), or troublesome medication administered should have an ECG obtained

Seemingly, every medication can prolong QT and memorizing these can prove to be as confusing as the coagulation pathway. However, providers should be aware of certain commonly prescribed medications, such as anti-emetics, antibiotics, and antipsychotics, that can prolong the QT interval. For more esoteric drugs, a website such as qtdrugs.org can be helpful – this site in particular organizes medications in order of likelihood to prolong QT.

In summary, maintaining vigilance with ordering ECG and the QT interval can prevent torsades de pointes in vulnerable patient populations.

 

References

1. Al-Khatib SM, Allen LaPointe NM, Kramer JM, Califf, RM (2003).What Clinicians should know about the QT Interval. JAMA. 289: 2120-2127

2. Wong K, Ubogagu E, Francis D. (2010) Cardiology to Impress: The Ultimate Guide for Students and Junior Doctors. London. Imperial College Press

3. Schaider JJ et al. (2010) Rosen and Barkin, 5 Minute Emergency Medicine Consult. New York. Lippincott Williams and Wilkins

4. Wood AJJ. (2005). Drug Induced Prolongation of the QT Interval. NEJM. 350: 1013-1022.

 

 

Author information

Jatin Kaicker
Jatin Kaicker
Jatin Kaicker is a Family Medicine resident at McMaster University.

The post Boring Question: Does this medication cause long QT? (with Bonus: Tiny Tips!) appeared first on BoringEM and was written by Jatin Kaicker.

Tiny Tip: PREeclampsia

Preeclampsia is a common complication in pregnancy, affecting 3-5% of pregnant women in the general population, and up to 25% of pregnant patients with pre-existing chronic hypertension [1].

It’s common enough that you’re likely to see it in the emergency department if you are rotating through a site without a primary obstetrics triage area. It’s important to recognise preeclampsia early in the emergency department, because unrecognised it can lead to eclampsia and increase the risk of early induced labour, placental abruption, and foetal growth restriction [2].

 

The classic preeclampsia triad can be remembered using the mnemonic PRE:

P roteinuria

R ising blood pressure

E dema

 

If you’ve done a urine dipstick in the emergency department, you can reasonably suspect significant proteinuria with a result of 1+. Formal diagnostic criteria require a 24-hour urine collection showing 0.3g/day or 30mg/mmol in a random urine sample [3].

If you suspect hypertension in the emergency department (systolic blood pressure 140 mmHg or diastolic pressure 90 mmHg), be sure to confirm by taking at least 2 measurements in the same arm, waiting at least 15 minutes between measurements [3].

As for edema, swelling of the legs and feet is pretty common in pregnancy, but residents and staff in obstetrics and gynaecology tell me that facial swelling is the hallmark of preeclampsia edema…and it can happen overnight, so it’s usually noticed and reported by patients and partners!

Reviewing with the Staff (by T. Chan)

Staff Review by Teresa Chan MD FRCPC

Thanks for the great piece, Luckett. One thing I wanted to call out was to ensure that readers remember one key clinical pearl: It’s good to remember what preeclampsia looks like so that you can treat it! Therefore, I have two bonus tips that I would like to highlight:

 

BONUS TIP #1:

Remember, (full) eclampsia should be treated with magnesium sulphate (2014 SOGC recommendation 116) [3]. Magnesium sulphate should also be given to preeclamptic patients with severe preeclampsia (2014 SOGC recommendation 117) and may be considered as prophylaxis in women with non-severe eclampsia and at least one of the following symptoms [3]:

  • severe hypertension,
  • headaches/visual symptoms,
  • right upper quadrant/epigastric pain,
  • platelet count < 100 000 × 109/L,
  • progressive renal insufficiency,
  • elevated liver enzymes (I-C)

Please note that this list is VERY SIMILAR to the HELLP syndrome, but slightly different – and thus learners should be flagged to the obvious confusion that this might cause. (Good thing you have previously also reviewed HELLP for Tiny Tips recently! :D)

 

BONUS TIP #2:

The dose of Magnesium sulphate for prophylaxis of eclampsia is 4 g IV load (over 20 min) and then 1 g / hr [4].

References:

1. Seely, E. W., & Ecker, J. (2011). Chronic hypertension in pregnancy. New England Journal of Medicine, 365(5), 439-446. PMID: 24637432

2. Arulkumaran, N., & Lightstone, L. (2013). Severe pre-eclampsia and hypertensive crises. Best Practice & Research Clinical Obstetrics & Gynaecology, 27(6), 877-884. PMID: 23962474 

3. Magee, L. A., Pels, A., Helewa, M., Rey, E., von Dadelszen, P., Audibert, F., … & Sebbag, I. (2014). Diagnosis, Evaluation, and Management of the Hypertensive Disorders of Pregnancy: Executive Summary. Journal of obstetrics and gynaecology Canada: JOGC= Journal d’obstetrique et gynecologie du Canada: JOGC, 36(5), 416-438.  PMID: 23962474

4.  Altman, D., Carroli, G., Duley, L., Farrell, B., Moodley, J., Neilson, J., & Smith, D. (2002). Do women with pre-eclampsia, and their babies, benefit from magnesium sulphate? The Magpie Trial: a randomised placebo-controlled trial. Lancet359(9321), 1877-1890.  PMID: 12057549

Author information

Sarah Luckett-Gatopoulos
Sarah Luckett-Gatopoulos
Junior Resident Editor at BoringEM
Luckett is a resident at McMaster University. Newbie to the #FOAMed world. Interested in literacy, health advocacy, creative writing, and near-peer mentorship.

The post Tiny Tip: PREeclampsia appeared first on BoringEM and was written by Sarah Luckett-Gatopoulos.

#TipsforEMexams: Exam Study Tips Series

As September arrives, my thoughts always turn towards memories of being in school.  The fun, the initial excitement… but then… with memories of school comes memories of exams.

Inspired by the “How I work smarter series” this series will outline study tips for EM exams. They may seem a bit targeted towards the Canadian RC emergency medicine exam (because that’s the exam I wrote), but  I’m hoping that most of the tips from this series will generalize towards the CCFP-EM or even ABEM exams though.  Also, much like ALiEM’s “Work Smarter” series, the writer will tag his/her friends to see if they can create a similar post, so I hope that eventually we will tag people with different backgrounds and perspectives, all whom have conquered various examinations. On Twitter we’ll use the hashtag #TipsforEMexams to track the conversation.  Hopefully with everyone’s help we can get a great assortment of exam study tips.

So without further ado, here are my tips:

#TipsforEMexams

Name:     Teresa Chan, Survivor of the 2013 RC emergency medicine exam

Where are you now?
Assistant Professor, McMaster University. BoringEM Managing Editor

 

Five tips for prospective examinees:

1. Organize yourself – Random studying will make you case-by-case smarter, but programmatic studying will be more important as you start to study for examinations. Remember, the point of the exams is to ensure you have a broad understanding of key emergencies – and as such, it is advantageous to work through a good list of topics. Taking Rosen’s, Tintinalli, and other key textbooks, I compared their content to my program’s academic half day schedule to augment what I had learned over the past 3 years. Then I stuck to this study schedule, 2-3 topics at time – summarizing, reviewing, extracting what I could into my notes. I’m super duper glad I did this audit since there were several areas that were missing from my end-of-PGY-3 notes that ended up being on my exam.

2. Start early (if you can) – I started studying for the RC exam in PGY4. That’s not to say I didn’t study before then, but I was more opportunistic about studying around cases and things that were clinically relevant from my shifts or rotations. In PGY4 though, I sat down at least 2-3 times per week and powered through various topics, brushing up my study notes, reading and gathering materials (key papers, etc.). In PGY5, we turned up the heat, going through all these materials again once more.

3. Study social – Group studying has been proven in a number of studies to be highly beneficial for learning outcomes. Likely this stems from collaborative learning – forcing participants to practice and revisit external representations of the knowledge they hold to be true. Regardless of HOW it works (that’s why I started Masters in Health Professions Education), you merely need to know THAT it works and harness this for its advantage. This means orienting your life to ensure that you can meet up and discuss your material with others – aligning study topics or practice questions is key. Moreover, don’t fool yourself about tandem studying (i.e. studying alongside someone else quietly). That is NOT group studying, and doesn’t help your learning in the same manner.

4. Use the Cloud – It pays to have a back up of your notes. My study group had a group study Google Drive where we shared and collaborated on exam study notes. (Nerdily, we wrote it up as a brief educational report in CJEM.) We also made a set of one-page mock oral case scenario guides and exchanged them via this Google Drive. Beyond that, I sometimes studied with colleagues via Skype or Google Hangouts (e.g. my friend Janice all the way in Vancouver or my friend Serena in the neighbouring city). This made it much easier to study with others, while never having to change out of my pyjama pants.

5. Drilling yourself is important too, but make it fun! – I’ll be honest, by March of my exam year, I was pretty exhausted and extremely bored – and yet I still felt compelled to study every waking moment. As such, I decided to channel my energies into gamifying my studying. I had created about 1000 flash cards with various important lists from Rosen’s… But they were just sitting there. Enter the Flash Card Advent Calendar (Figure 1). I set up my flashcards in roughly equal decks of materials, and then I put a surprise task at the bottom of each deck (i.e. Buy and eat your favourite cupcake! Go watch a movie!).  This made my last few weeks of studying far more interesting.

 

Figure 1:  The Exam Flash Card Advent Calendar

FlashCardAdventCalendar

 

Tag! You’re it!

I would now like to ask the following tow people to submit their five exam tips.

1. Rob Woods

2. Heather Murray

 

Author information

Teresa Chan
Managing Editor at BoringEM
Emergency Physician. Medical Educator. #FOAMed Supporter, Producer and Researcher. Assistant Professor, Division of Emergency Medicine, Department of Medicine, McMaster University. + Teresa Chan

The post #TipsforEMexams: Exam Study Tips Series appeared first on BoringEM and was written by Teresa Chan.