NBME Subject Examination Strategies

JARROD SMITH, MS-4 MAY 2010

NBME Subject Exams

During 3rd year, you will have to successfully pass a

subject exam for completion of each clerkship. Exams include Psychiatry, Surgery, Pediatrics, Medicine, Obstetrics/Gynecology, and Family Medicine. Ob/Gyn requires a score at the 22nd percentile to pass. Family Medicine requires a score at the 4th percentile to pass. The other 4 clerkships require a score at the 11th percentile to pass.

Exam Format
Exams are paper and pencil format. Each exam contains 100 multiple choice questions. 130 minutes is allotted for each exam. That works out to 1.3 minutes per question. Clinical vignettes vary in length. Common lab values will appear on the front and back

covers of the exam booklet.

Exam Strategy
Begin each item by reading the question at the end of the vignette. 2. Scan the answer choices and familiarize yourself with them. 3. Read the entire vignette looking for clues to answer the question.
1.

By doing this, it allows you to know what you are looking for when reading the vignette. If you do not do it this way, you end up reading the vignette blindly.

Sample
The following few slides contain a sample item from

the NBME Subject Examination guide. These slides will demonstrate the aforementioned techniques.

Read the Question

A 37-year-old woman comes to the physician because of a 3-year history of intermittent, mild, diffuse abdominal cramps and bloating. Her symptoms occur after meals and are relieved with bowel movements. She also has constipation four to six times monthly. She says the constipation resolves spontaneously, but she sometimes has diarrhea for 1 to 2 days afterwards. She has not had any other symptoms. She has no history of serious illness and takes no medications. Examination shows no abnormalities. Which of the following is the most likely diagnosis? (A) Collagenous colitis (B) Colon cancer (C) Diverticulosis (D) Inflammatory bowel disease (E) Irritable bowel syndrome

Answer Choices
A 37-year-old woman comes to the physician because of a 3-year history of intermittent, mild, diffuse abdominal cramps and bloating. Her symptoms occur after meals and are relieved with bowel movements. She also has constipation four to six times monthly. She says the constipation resolves spontaneously, but she sometimes has diarrhea for 1 to 2 days afterwards. She has not had any other symptoms. She has no history of serious illness and takes no medications. Examination shows no abnormalities. Which of the following is the most likely diagnosis? (A) Collagenous colitis (B) Colon cancer (C) Diverticulosis (D) Inflammatory bowel disease (E) Irritable bowel syndrome

Clues in Vignette
A 37-year-old woman comes to the physician because of a 3-year history of intermittent, mild, diffuse abdominal cramps and bloating. Her symptoms occur after meals and are relieved with bowel movements. She also has constipation four to six times monthly. She says the constipation resolves spontaneously, but she sometimes has diarrhea for 1 to 2 days afterwards. She has not had any other symptoms. She has no history of serious illness and takes no medications. Examination shows no abnormalities. Which of the following is the most likely diagnosis? (A) Collagenous colitis (B) Colon cancer (C) Diverticulosis (D) Inflammatory bowel disease (E) Irritable bowel syndrome

Answer the Question

A 37-year-old woman comes to the physician because of a 3-year history of intermittent, mild, diffuse abdominal cramps and bloating. Her symptoms occur after meals and are relieved with bowel movements. She also has constipation four to six times monthly. She says the constipation resolves spontaneously, but she sometimes has diarrhea for 1 to 2 days afterwards. She has not had any other symptoms. She has no history of serious illness and takes no medications. Examination shows no abnormalities. Which of the following is the most likely diagnosis? (A) Collagenous colitis (B) Colon cancer (C) Diverticulosis (D) Inflammatory bowel disease (E) Irritable bowel syndrome

Example
Reading the question first, answer choices second,

and the remainder of the vignette last, allows the person taking the exam to know what he or she is looking for in the vignette. This is not the only technique. This was simply the most common technique when students were polled.

Question Banks
It is imperative to do practice questions in

preparation for the subject examinations. It would be a good idea to buy a 1 year subscription to USMLEworlds question bank. These questions are very similar to that seen on subject examinations. Practice questions are the most important factor for subject examination success.

The Exams
Each of the subject examinations has its own flavor. Some tend to have longer vignettes(psychiatry,

medicine). Others tend to have shorter vignettes(family medicine, ob/gyn). The following slides will focus on each of the 6 exams, including subject material, resources, sample questions, and tips.

Family Medicine Subjects

General Principles 1%-5% Organ Systems 95%-99%

Immunologic Disorders 5%-10% Diseases of the Blood and Blood-forming Organs 5%-10% Mental Disorders 5%-10% Diseases of the Nervous System and Special Senses 5%-10% Cardiovascular Disorders 10%-15% Diseases of the Respiratory System 10%-15% Nutritional and Digestive Disorders 10%-15% Gynecologic Disorders 5%-10% Renal, Urinary, and Male Reproductive System 5%-10% Disorders of Pregnancy, Childbirth, and the Puerperium 1%-5% Disorders of the Skin and Subcutaneous Tissues 1%-5% Diseases of the Musculoskeletal System and Connective Tissue 5%-10% Endocrine and Metabolic Disorders 5%-10% Promoting Health and Health Maintenance 15%-20% Understanding Mechanisms of Disease 20%-25% Establishing a Diagnosis 35%-40% Applying Principles of Management 20%-25% Childhood 5%-15% Adolescence 5%-10% Adulthood 65%-75% Geriatric 5%-15%

Physician Task

Distribution Across Age Groups

Family Medicine Exam Basics

The family medicine subject examination is like a mini USMLE

Step 2 exam. One must be proficient at medicine, pediatrics, surgery, ob/gyn, and psychiatry to do well on this exam. For this reason, a passing score is set at the 4th percentile. Clerkship lectures are helpful for the exam, but other resources must be used. If this is one of the last subject exams of 3rd year, less studying is needed. If this is one of the first subject exams of 3rd year, more studying will be needed. Questions are not written by family medicine physicians. They are written by internists, pediatricians, surgeons, etc

Family Medicine Resources

USMLE Step 2 Secrets 2. Boards and Wards 3. Case Files: Family Medicine 4. Current Diagnosis and Treatment in Family Medicine.
1.

USMLE Secrets
Short and too the point, but contains quite a bit of information. Question and Answer format. Chapters separated by medical specialty. Contains a few black and white photos. Not a comprehensive resource. The subject examination could easily be passed if using only this resource.

Boards and Wards

Offers succinct summary of all major topics covered on the subject exam. Outline format, similar to the notes distributed during 2nd year of medical school. Contains many full color photos of dermatologic conditions and other photos. Breadth of information is great, but contains little depth. May need to reference a larger textbook at times. Excellent resource for the subject examination and USMLE Step 2. Easily reviewed the week before the shelf exam.

Case Files
To properly prepare for the family medicine subject exam, you would need to study from all case file books. This book contains a smattering of subjects not covered in the other case files, such as prevention. Not comprehensive enough to be used as a sole resource for the subject exam.

Current Diagnosis and Treatment in Family Medicine

Very useful for the in-house family medicine exam. Not as useful for the subject exam. Very long, but contains good information. Would be helpful with the shelf exam only if you started reading it at the beginning of the rotation. Could not be easily review the week before the subject exam

Recommended Strategy
Start reading and annotating Boards and Wards at the

beginning of the rotation. Use a textbook of your choice to annotate if you feel the information is not deep enough. Read Step 2 Secrets if you have time. Review the annotated Boards and Wards the week of the exam. Do 50 USMLEworld questions per week. These should cover all of the subject areas and specialties.

Medicine Subjects
General Principles 1%-5% Organ Systems 95%-99%

Immunologic Disorders 5%-10% Diseases of the Blood and Blood-forming Organs 5%-10% Diseases of the Nervous System and Special Senses 5%-10% Cardiovascular Disorders 15%-20% Diseases of the Respiratory System 15%-20% Nutritional and Digestive Disorders 10%-15% Gynecologic Disorders 1%-5% Renal, Urinary, and Male Reproductive System 10%-15% Disorders of the Skin and Subcutaneous Tissues 5%-10% Diseases of the Musculoskeletal System and Connective Tissue 5%-10% Endocrine and Metabolic Disorders 5%-10% Promoting Health and Health Maintenance 10%-15% Understanding Mechanisms of Disease 20%-25% Establishing a Diagnosis 40%-45% Applying Principles of Management 20%-25%

Physician Tasks

Medicine Exam Basics

The medicine subject exam very closely mimics the

material that medical students were taught during 2nd year of medical school. It is advantageous to have this rotation towards the beginning of third year, so the material from year 2 is still fresh. This exam is 2nd in the amount of testable material, with family medicine being first. The exam is not hard to pass, but is fairly difficult to break the 80th percentile.

Medicine Resources
Step Up to Medicine 2. Case Files: Internal Medicine 3. Blueprints: Medicine 4. High Yield Internal Medicine
1.

Step Up to Medicine
Very thorough. Outline format. Separated by body systems. If its not in this book, it will not be on the exam. Very long and can take a very long time to read. Need to read more than once in order to really take in all of the information contained in this book. Impossible if reading is not started the first week of the rotation.

Case Files
Presents common internal medicine subjects in the form of clinical vignettes similar to the subject exam. Relatively complete. Probably the 2nd best internal medicine subject exam resource. Not as much info as Step Up. Not separated into body systems, just random cases.

Blueprints
Presents common internal medicine subject in paragraph format. Not as informative to Step Up Comparable to Case Files, just a different format. Contains practice questions at the end of the book. Could easily pass the exam using this resource.

High Yield
Not a complete resource by any means. Contains high yield, useful topics for the exam. Do not use this as your sole resource unless you really know your stuff or you are in a serious time crunch. Great if used as an adjunct to another book, especially the week before the exam.

Recommended Strategy
Begin reading Step Up the first day of the rotation,

and read it everyday. Try to get through it twice before the subject exam. Do USMLEworld questions everyday, to prepare yourself for the length of the vignettes. If you are in a time crunch, read Case Files. If you are in a serious time crunch, read High Yield.

Ob/Gyn Subjects
General Principles 1%-5% Gynecology 45%-49% Promoting Health and Health Maintenance 5%-10% Understanding Mechanisms of Disease 15%-20% Establishing a Diagnosis 15%-20% Applying Principles of Management 5%-10% Obstetrics 45%-49% Promoting Health and Health Maintenance 5%-10% Understanding Mechanisms of Disease 10%-15% Establishing a Diagnosis 15%-20% Applying Principles of Management 10%-15%

Ob/Gyn Exam Basics

The clerkship lectures are very high yield when it

comes to the Ob/Gyn subject exam. Much is expected from students on the Ob/Gyn rotation, and students know more than they realize when it comes time to take the subject exam. The information tested on this exam is very specialized, so the material learned during 2nd year isnt very useful.

Ob/Gyn Resources
Blueprints: Obstetrics and Gynecology 2. Case Files: Obstetrics and Gynecology 3. High Yield Obstetrics and Gynecology
1.

Blueprints
Contains high yield ob/gyn subject matter in paragraph format. Very thorough resource. Contains practice questions at the end of the book. No easily reviewable during the week before the subject exam.

Case Files
Presents common internal medicine subjects in the form of clinical vignettes similar to the subject exam. Relatively complete. Probably the 2nd best ob/gyn subject exam resource. Good section on STDs Slightly less complete than Blueprints. Not separated logically, just random cases.

High Yield
Excellent, succinct summary. Great tables and graphs to demonstrate key concepts. Should be used in conjuction with another resource. Only use as a sole resource if you are extremely confident in you ob/gyn knowledge.

Recommended Strategy
Start reading Blueprints or Case Files at the beginning

of the rotation. Read before each lecture, the corresponding section in your chosen book. Begin reading High Yield two weeks before the subject exam, and get through it twice. Do USMLEworld questions throughout the rotation. The required text for the rotation isnt very useful for the subject exam.

Pediatrics Subjects
Normal Development 5%-10% Organ Systems 90%-95% Immunologic Disorders 5%-10% Diseases of the Blood and Blood-forming Organs 5%-10% Mental Disorders 1%-5% Diseases of the Nervous System and Special Senses 5%-10% Cardiovascular Disorders 10%-15% Diseases of the Respiratory System 10%-15% Nutritional and Digestive Disorders 10%-15% Gynecologic Disorders 1%-5% Renal, Urinary, and Male Reproductive System 10%-15% Disorders of Pregnancy, Childbirth, and the Puerperium 1%-5% Disorders of the Skin and Subcutaneous Tissues 1%-5% Diseases of the Musculoskeletal System and Connective Tissue 5%-10% Endocrine and Metabolic Disorders 5%-10% Physician Tasks Promoting Health and Health Maintenance 5%-10% Understanding Mechanisms of Disease 25%-30% Establishing a Diagnosis 40%-45% Applying Principles of Management 10%-15%

Pediatrics Exam Basics

Clerkship lectures are pretty useful resources,

especially when it comes to developmental milestones and vaccination schedules. Dr. Pino does an excellent review the week before the subject examination. This test tends to be heavy in microbiology and infectious diseases.

Pediatrics Resources
BRS Pediatrics 2. Blueprints: Pediatrics 3. Case Files: Pediatrics 4. Dr. Pinos Mega Review
1.

BRS
Very complete resource in outline format. Very cumbersome book. Has everything that could ever be tested on the subject exam, but would be difficult to use unless you are very dedicated. Excellent tables and charts. If ambitious, you could obtain >90th percentile using this book.

Blueprints
Contains high yield peds subject matter in paragraph format. Very thorough resource. Contains practice questions at the end of the book. No easily reviewable during the week before the subject exam.

Case Files
Presents common pediatric subjects in the form of clinical vignettes similar to the subject exam. Relatively complete. Probably the 2nd best subject exam resource. Not as much info as Blueprints. Not separated into body systems, just random cases

Dr. Pino Review

Dr. Pino does a mega review towards the end of the rotation. Contains very high yield subject material. Almost word for word the same material that Dr. Pino teaches during the USMLE Step 2 Kaplan course. Not complete, but very high yield.

Recommended Strategy
Begin reading Blueprints at the beginning of the

rotation. Do USMLEworld questions throughout the rotation. Attend Dr. Pinos review and cram that material in the last few days leading up to the subject exam.

Psychiatry Subjects
General Principles 5%-10% Organ Systems 90%-95% Mental Disorders 75%-85% Mental disorders usually first diagnosed in infancy, childhood, or adolescence Substance-related disorders Schizophrenia and other psychotic disorders Mood disorders Anxiety disorders Somatoform disorders Other disorders/conditions Diseases of the Nervous System and Special Senses 10%-20% Physician Tasks Promoting Health and Health Maintenance 1%-5% Understanding Mechanisms of Disease 10%-15% Establishing a Diagnosis 55%-65% Applying Principles of Management 15%-20%

Psychiatry Exam Basics

The clerkship lectures are very useful for this subject

examination. This exam focuses on diagnosis of mental illness and less on treatment. Know the DSM criteria for diagnosis of mood disorders, personality disorders, etc Watch out for mental illness caused my a general medical condition. This almost always appears a couple of times on the exam. Know all of the psych drugs.

Psychiatry Resources
First Aid for the Psychiatry Rotation 2. Case Files: Psychiatry
1.

First Aid
Succinct summary which is relatively complete. Outline format. Contains high yield facts in all areas of psychiatry.

Case Files
Presents common psychiatry subjects in the form of clinical vignettes similar to the subject exam. Relatively complete. Rivals First Aid as best resource More info than First Aid, but may be overkill. Not separated logically, just random cases

Recommended Strategy
Pay attention to the clerkship lectures. Begin reading Case Files at the beginning of the

rotation. Do USMLEworld questions throughout the rotation. Begin reading First Aid two weeks before the subject exam. Get through First Aid two times before the exam.

Surgery Subjects
General Principles 1%-5% Organ Systems 95%-99%

Immunologic Disorders 1%-5% Diseases of the Blood and Blood-forming Organs 5%-10% Diseases of the Nervous System and Special Senses 5%-10% Cardiovascular Disorders 10%-15% Diseases of the Respiratory System 10%-15% Nutritional and Digestive Disorders 25%-30% Gynecologic Disorders 5%-10% Renal, Urinary, and Male Reproductive System 5%-10% Disorders of Pregnancy, Childbirth, and the Puerperium 1%-5% Disorders of the Skin and Subcutaneous Tissues 1%-5% Diseases of the Musculoskeletal System and Connective Tissue 5%-10% Endocrine and Metabolic Disorders 5%-10% Promoting Health and Health Maintenance 1%-5% Understanding Mechanisms of Disease 20%-25% Establishing a Diagnosis 45%-50% Applying Principles of Management 25%-30%

Physician Tasks

Surgery Exam Basics

This test contains far more internal medicine than

one might expect, therefore it is advantageous to have completed internal medicine before taking this exam. Know IV fluid management, diagnosis of acute abdomen, trauma survey. Be able to tell when a patient is truly in danger of dying (vital signs, etc) There are a few questions on orthopaedics, vascular surgery, urology, etc

Surgery Resources
Case Files: Surgery 2. NMS: Surgery 3. PreTest Surgery 4. Pestana Review Notes
1.

It should be noted that Surgery Recall is an excellent resource for case preparation, but it is not a good tool for the subject examination.

Case Files
Presents common surgery subjects in the form of clinical vignettes similar to the subject exam. Relatively complete. Probably the 2nd best surgery subject exam resource. Not as much info as NMS. Not separated into body systems, just random cases

NMS
Large resource in outline format. Very complete, but could be somewhat cumbersome to complete. Contains general surgery as well as subspecialty chapters. This could be used as a sole resource.

PreTest
Excellent question book that mimics the questions on the subject exam. Far more useful than USMLEworld for the surgery subject exam. Read the question and the explanation. Absolutely not intended to be a sole resource.

Pestana
Dr. Carlos Pestanas Kaplan notes for surgery are extremely high yield. This is regarded as the Holy Grail of surgery resources. It is hard to come by, because it is supposedly illegal to sell these. They are available on eBay and other websites, it just requires some searching.

Recommended Strategy
Begin reading NMS at the beginning of the rotation if

you wish to do extremely well. Use Case Files if you just want to pass. If you can get obtain the Pestana notes, use them as well. Do questions from PreTest, because the USMLEworld surgery questions focus too much on subspecialty surgery and not enough on general surgery.

Final Remarks
The common theme for subject exam preparation is

doing timed practice questions. This is the only way to accurately simulate the actual exam. In addition to questions, you must find a resource you like. Most resources are good, you just have to find one or two for each exam that fits your study style.

And most importantly

RELAX!!!!!!!!!!!