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Tips For The Physicians Licenszcdcxure Examination1





TIPS FOR THE PHILIPPINE PHYSICIANS LICENSURE EXAMINATIONS by: James Philip G. Esteban, MD General Tips The best preparation for the board exams is still the preparation you made during med school because no matter how hard and how long you study during the 2-3 months before the board exams, it is impossible to cover and remember EVERYTHING. Don’t get me wrong. I think 2-3 2-3 months should be enough to read up on the essentials for each of the 12 subjects, enough nd rd even for 2  or 3  readings. But, come exam time, there WILL BE questions that you never really read in your reviewers or, even if you had, you most likely already forgot after just 1 pass through. Even with the best testmanship abilities, you won’t stand a chance against these questions unless you  were able to recall seeing it in a mama book, or recall discussing it during a preceptorial, or recall hearing about it in endorsements and rounds, or recall your patient’s history, PE and lab results. I can’t emphasize enough how much these little things  ACTUALLY helped me during my exam. During the Basic Science Years Transcriptions are brief, to-the-point and, more importantly, would assure a passing mark with the least possible effort. Sample exams can save your life with even less effort. But, I think these should just be used to enhance your studying. It will REALLY help a lot if you spend time reading the mama books during the first 2-3 years of medical school. And, seriously, the first 2-3 years is the best time to do so for the simple reason that these are the years when you STILL CAN. Come clerkship and internship, it will be very difficult, if not impossible, to open the mama books and sift through the tons of information they contain. That’s why the baby books, the Recall series, the black books boo ks and all those condensed reviewers are such a hit – hit  – because  because they only tell you the stuff you NEED to know. As a clerk and an intern, do you really need to know the molecular biology behind this and that? At the very least, all you need to know are the things that will guarantee that the patients under your care get better and ACTUALLY LIVE to tell others about your brilliance. What then is the relevance of reading the mama books? They expand your STOCK KNOWLEDGE. A sound stock knowledge base founded on 5 years of medical school is more priceless and indispensable than 6 straight months studying for the boards. First, stock knowledge will let you  – as  – as it did to me – me – answer  answer questions you never really encountered in all of the 2-3 2- 3 months you’ll spend reviewing. reviewi ng. Second, all the subjects build upon each other. While reviewing, I saw how much overlap there is among all 12 subjects. Your stock knowledge will be the glue that will link everything together. During Clerkship and Internship Let’s face it, if you fail fail to read the mama books during the first 2-3 years of med school, then the odds of getting around to  ACTUALLY reading them during clerk ship and internship is already close to nil. In all of our 5 years in medical school, we probably spend the least amount of time studying during clerkship and internship. And, for obvious reasons, too. During pre-duty, pre-duty, it’s just too hard to find the motivation. During duty, it’s just too hard to find the time. During post post--duty, it’s just too hard to muster the strength. Even so, there are still a lot you can do to help you study. The idea is to adapt your studying to your rotations and clinical experiences: - Read the baby books, the black books, and whatever reviewers you have.  Even if they are most of the time incomplete, they still pack a lot of REALLY USEFUL information. - Read up on your rotation. If you’re rotating in IM, read Harrison’s or Washington. If you’re in Pedia, read Nelson’s or Harriet Lane. If you’re in Surgery, read Surg Recall or Snell’s Review of Anatomy. It Anatomy. It is always easier to understand – understand  – and consequently REMEMBER – REMEMBER  – something  something if you see and hear about it everyday. - Read up on your patients. The wealth of patients you see in the ER, OPD and wards is unbelievable. If you manage to read up on even just half of them, the amount of information you’ve already accumulated is already staggering. Our IM and Pedia exams were quite clinical and a lot o f the cases were the same ones as my patients. Never mind that I don’t remember the minutest details about the case and the disease. Most of the time, just the slightest recall that I saw this particular case before was enough to make the answer stand out from the choices - complete with blinking neon lights. - Attend endorsements and rounds. Think about it this way: the 2 months I spent listening in the OB summary rounds (ok, not really EVERYDAY, not even most days of the week) already gave the answers to about 40% of the OB questions. And do I still need to emphasize how the chief resident tends to repeat the same things over and over again? After Graduation But, if you’re part of the majority like me, odds are we never really read Moore and Berne and Lev y from cover to cover back in the day. Chances are we never spent our waking hours during clerkship and internship slaving in front of a book. Med school is, and should be, fun. You can never go back to the time when your anatomy groupmates had a night out while you decided to study for an exam that’s still 2 weeks away, or during that time when your blockmates went to the beach but you stayed behind to do advance readings for the next rotation. Like me – and, likely, the person beside you – a good 80% of your studying (maybe I exaggerate) for the boards will be in the 2-3 months immediately before the exam. And like me, you most likely also know that 2-3 months is barely enough and should be maximized the best way possible. - Make a schedule and stick by it. I know you’ve heard about this piece of advice a million times, but I have to repeat it because it’s THAT important. If the time you allocated for a particular subject is up, move on to the next subject. Avoid extending by 1-2 days just to finish a subje ct because, for all you know, all those “cheat days” you squeezed in could easily add up to 2 weeks in the final stretch before the boards. Those 2 weeks are CRUCIAL.  Also, don’t forget to squeeze in time for much-needed R & R. You can do staggered, weekly R & R’s or – similar to what I did – you can lump together all your vacations and out-of-town trips then study straight afterwards. It’s your call. Here’s a summary of my schedule: May June July Week Week Week Week 1 2 3 4 Out-of-Town: Batanes ANATOMY Out-of-Town: Palawan Graduation Activities Week 1 BIOCHEMISTRY Week 2 PHYSIOLOGY Week 3 PATHOLOGY Week 4 MICROBIOLOGY Week 1 PHARMACOLOGY Week 2 Week 3 SURGERY PEDIATRICS Week 4 OB-GYN INTERNAL MEDICINE n Week 1 August Week 2 Week 3 Week 4  I concentrated on the basic sciences first because I wanted to know about the basics and use these as foundation for the clinical sciences. It worked well for me – because of the overlap among the subjects, it became much easier for me to understand all the clinicals. better understanding  less time spent studying time spent reviewing for other subjects   more I decided to spend less time in OB-Gyne and IM because these are my strongest subjects and I felt I can survive with less studying 2  Reading for Week 1 LEGAL MED BOARD EXAMS nd 2  Reading for Week 2 PREV MED BOARD EXAMS - Decide whether you’ll do a second or even a third reading. You have to make this decision early on because it nd SHOULD be part of you scheduling. Personally, I would suggest that, at the very least, you do a 2  reading. You can spend so much time studying, memorizing and making mnemonics for all your subjects. But trust me, after 4 subjects or so, you will be really lucky to remember EVEN HALF of all the mnemonics you made previously. You need to refresh yourself eventually. nd nd - Think of ways on how to make 2  reading faster and more efficient. Your 2  reading should NOT be a mere nd repetition of your first reading, and, ideally, the amount of time you will spend in your 2  reading should not be more st than half of the time you will spend for your 1  reading. Thus, you have to be creative and resourceful in thinking of nd nd ways on how to make your 2  reading a lot quicker and a lot more efficient. The idea behind having a 2  reading is to refresh you of the must-knows and the high-yield topics, and to enlighten you on the concepts you found hard to st understand during your 1  reading. What I did was make personal, computerized notes for each of the subjects. I made a lot of summary tables and diagrams, made a list of the “most commons” and “gold standards,” and emphasized the must-knows by putting them in boxes. I made sure that each set of notes can be finished within a day of studying since I intended to allocate only 2 nd weeks for my 2  reading (12 days for 12 subjects). I also wrote heavily on the margins of my reviewers, so I can nd concentrate on these rather than the actual text when the time came for my 2  reading. Overall, I was very pleased with my notes; I would say each set of notes had an approximately 80% yield per subject in general. - Decide whether you’ll use sample exams or not. Decide also how muc h sample exams you will attempt to answer. Answering sample exams seems easy and quick, but it W ILL take a lot of your tim e. Going through all the available sample exams can easily take away a WHOLE WEEK from your schedule. Consequently, you need to decide whether you will use sample exams and by how much. Personally, I suggest just answering 1 sample exam per subject just to give you an idea of where you stand. What I did was to set goal scores per subject (usually about 80%) then answer the sample exam to see if I reach those goals. For me, the sample exams were just confidence boosters and reality checks; I never used them as actual study materials. For sure, out of the THOUSANDS of questions in the sample exams, there WILL BE repeats in the boards (but I wouldn’t really know since I never used them much). But, the amount of time you will spend scouring through all those nd questions (I’d say about 2 days) may very well be the same amount of time you will spend doing a 2  reading. If you ask me, the MINIMUM yield of doing an additional reading far exceeds the MAXIMUM yield of all the sample exams – combined. Of course there are always exceptions to the rule! Know which subjects are NOTORIOUS for repeat questions and make sure to study the sample exams for those subjects. During our exams, those were the Legal Med and Prev Med exams. I regret not studying the Prev Med sample exam; I lost a good 16 points because of that slight omission (yes, I counted). - Determine what kind of reviewer works best for you. My strategy was to read as much of the mama books as I can since it jives with my study habits (before, I worked best by starting with the mama books then reinforcing it with the transcriptions and sample exams). Sure, it ate so much of my time, but I reasoned that I need to read up on something at least once to stand a chance. If I recall reading even the slightest bit about a particular topic, I can always rely on good old testmanship to help me out. Testmanship is indeed VERY HELPFUL, but remember that testmanship requires some stock knowledge and some degree of familiarity to be useful. Remove those and you are no longer utilizing testmanship. You are gambling and relying on sheer luck. It also helps to ask for advice from people who already took and passed the boards. It also helps very much if you have trust on the person you’re asking. After the last day of internship, I asked Dr. Phillippe Chionglo (UPCM 2009), Dr. Tom Lo (UPCM 2009, Top 4) and Dr. Joseph Villanueva (UST 2008, PGI 2009, Top 6) about their recommendations per subject, the pros and the cons with each reviewer, the format of each reviewer (i.e. is it in bullet or paragraph form), and the approximate yield of each reviewer. I’d say I heeded a good 50 -60% of their advice. The rest, I decided on my own. Ultimately, your choice of books and reviewers would depend on the study habit that works best for you. Are you the type who prefers the bulleted and outlined kinds or the type who prefers reviewers in paragraph form? Are you the type who wants to go straight to the must-know, high-yield information or the type who prefers to know something of everything? Are you the type who is fine with baby books and concise reviewers or the type who needs to read the mama books? - Decide whether you will enroll in a review class. This decision will again depend on your study habits. But, first a short discussion on what I think are the pros and cons of a review class. I never enrolled in a review class for the board exams, but I did teach review classes for college entrance exams previously for more than 3 years. In a way, I have an idea where I’m coming from. Pros gives you a structure with which you can base self-studies Cons less time spent with self-studies gives you an impetus to study on a regular basis attending the class is no guarantee that you’ll listen and stay awake – the supposedly productive hours you spend may easily turn into idle time professors teach you mnemonics and tricks on how to answer difficult questions classes cost a lot of money hearing your teacher and seeing visuals aid in memory retention (more sensory modalities engaged, the better) I didn’t enroll because I know for a fact that I have the nasty habit of sleeping in class no matter how much coffee I have or how engaging the professor is. By sleeping in class most of the time, I effectively would have cut my total studying time IN HALF since I would only get to study by myself at night. On the contrary, I can stay awake for very long periods of time if I study on my own. By experience, I also know that I understand and remember concepts better if I read through them because I develop my own ways of structuring and relating different pieces of information in my head. I figured that, had I attended a review class, I would have to adapt to the professors’ ways of organizing information. That MAY or MAY NOT work for me. It’s going to be a hit-or-miss kind of thing. - Pray. Well, to tell you the truth, I didn’t really pray since I’m agnostic. But, if praying gives you confidence, calmness and peace of mind, then I’m all for it. The Books I Used Anatomy Mama Snell - Mama Snell is intimidating because, let’s face it, it’s BIG and it’s THICK. But, it’s actually quite an easy read since there are a lot of photos and the diagrams, which me ans that the text isn’t really very long. - Useful parts of Mama Snell are the sections on clinical, radiographic and surface anatomy since these parts are absent in the baby version. In addition, the board exams as of late are becoming heavier on clinical questions, so it helps to invest in these areas. Baby Snell - When I started to run out of time for Mama Snell, I decided to concentrate on Baby Snell then supplement it with the clinical parts of Mama Snell. The content is actually kind of similar, but Baby Snell’s format is more on tables, bullets and outlines, which doesn’t really work for me. - If you’re the type who prefers bulleted and outline forms, then I suggest reading Baby Snell then supplementing it with the clinical sections of Mama Snell. High-Yield Anatomy - High Yield is incomplete when it comes to the basic anatomy stuff, but its discussions are very easy to understand and remember. - Discussions on clinical correlations are highly recommended. There are a lot of stuff in HighYield which you will not find even in Mama Snell. Unfortunately, for our board exams, all of these books turned out to be VERY LOW YIELD. It appeared that the highest yield would be Surgery Recall and Schwartz  – again, emphasizing the need to study EVERYTHING and watch out for those OVERLAPS. Physiology Biochemistry Microbiology Pathology Mama Guyton - I read this in line with my strategy of trying to read as much as I can. Though, in hindsight, I should have skipped this and mastered BRS Physiology instead. This book is just TOO LONG. - There are sections here that are not present in BRS Physiology, and I suggest you read through these. While Guyton is text-rich, I don’t think these sections should take more than a day: 1. Exercise and Sports Physiology 2. Space and Aviation Physiology 3. Deep Sea Physiology 4. Hematopoietic System BRS Physiology - Apart from the stuff in Guyton not found in this book, I would have to say that BRS Physiology is still the BEST reviewer to read for Physiology. Make sure you master it. Lippincott - I think this book strikes a balance between being high-yield (read: not just Digging up the Bones) and being concise (read: not like Harper’s). It’s also very nice that Lippincott has hard -core Biochem stuff like detailed pathways and chemical structures, and at the same time has clinical correlates like particular metabolic diseases. Overall, I was very happy to have read this book; I think it had a 70-80% yield during our board exams. High-Yield Biochemistry - I read this concurrently with Lippincott during my more praning  moments. It basically contains the same information as Lippincott’s, give or take a couple of non-essential terms. Piece of advice: do NOT do as I did. I suggest you skip this book and concentrate on Lippincott instead. Microbiology MRS - The only book I read, and I must say, a VERY GOOD choice. It’s concise and to -the-point, yet still packed with a lot of information. The diagrams and the mnemonics are very, very useful. Robbins Basic Pathology - Pharmacology Hands down, this is the BEST BOOK I’ve read for the ENTIRE BOARD EXAMS - Recall that there’s Mama Robbins and then there’s Fetal Robbins. This was my Sister Robbins. Since the publisher just released a new version, Goodwill put the outdated version – in all its original, colored and glossy-paged glory, for only PhP 600. It was a steal considering that the new version is not really very different (yes, I checked page per page  – well, at least in a few random pages). - The great thing about Robbins is that it contains basically everything you need to know for Pathology and a lot of what you need to know for all the clinical subjects. Robbins is the book that overlaps the MOST with all the subjects. - The only downside is that this book is A LOT LONGER than BRS Pathology. But, trust me, the additional time I spent with this book was more than enough to compensate for my gaps in IM, Pedia, Surgery and OB-Gyne. Just to give you an idea: I only managed to read 2/3 of Pedia, but I was able to snatch an 86 due to a GREAT deal to what I was able to read in Robbins. Kaplan’s Review of Pharmacology - Another LONG book, but another worthwhile read. - Pharmacology IS pharmacology, drugs ARE drugs, and this book got it all. I suggest concentrating on the mechanism/s of action of drugs and drug groups since the discussions on this aspect of drugs are often simple, concise and to the point. - Adverse reactions, on the other hand, are a different story. Kaplan tends to mention them all, so there is a lot of overlap. It becomes VERY DIFFICULT to determine the classic adverse events for each drug. What I did was to list each adverse reaction per drug then cross out all those with considerable overlaps with other drugs. Ultimately, I end up with about 1-2 adverse reactions per drug – not too difficult to manage. Surgery First Aid for the Absite - The great thing with this book is its comprehensive approach on each surgical condition. It has a little bit of everything: embryology and relevant anatomy, “most commons,” a little on pathology, gold standards in diagnosis, the ideal surgical management. It also has a lot of summary tables that highlight similarities and differences. - While this book seems like a good choice in theory, in reality the yield was rather LOW. I guess that’s part of the peculiarities of  the Philippine board exams – you don’t really know where the examiners get the questions. Surg Recall - Surg Recall deceives you into thinking that it’s a short book and an easy read. I was misled into thinking that I can finish reading it in 2-3 days. But, at 700+ pages of PURE INFORMATION, it needs a lot of time reading, understanding and memorizing. - My initial plan had been to read the Absite then supplement it with Surg Recall. Unfortunately, I ended up finishing only a third of Surg Recall due to time constraints. In hindsight, I should have spent more time to actually finish Surg Recall. While the yield in the boards isn’t really high, I did get a number of questions from what I was able to finish in Surg Recall. Pediatrics Year after year, Surgery is the subject that draws the most complaints for being the subject that no one really knows where the questions came from. Personally, I believe it’s either from Mama Schwartz or Mama Sabiston. But, come on, who’d REALLY read those? I think the best strategy for Surgery is to read the Absite, Surg Recall and the other books for the other subjects. I remember seeing quite a handful of questions on Physiology, Anatomy, Pathology and Pharmacology. Sayang din yun. Nelson’s Review of Pediatrics - This book is TOO LONG and TOO WORDY, and to tell you the truth, very LOW YIELD. I was very disappointed that I spent close to 5 days actually reading this book. AVOID AT ALL COSTS. Harriet Lane - During the last few days studying for Pedia, I switched to Harriet Lane after being disappointed with Nelson’s. In hindsight, I think I would have done much, much better had I read Harriet Lane from the very beginning. It has information on epidemiology, common signs and symptoms, “gold standards,” and treatments. There are a lot of summary tables, diagrams and flowcharts that make understanding stuff a lot easier. - There are 2 downsides to Harriet Lane: 1) it’s still quite long (but, not as long as Review of Pediatrics); I think it would still take 5 days at the least to finish it, and 2) it’s TOO CLINICAL. Some questions in the Pedia exam went back to the basic sciences  – Physio, Patho and Pharma – which would be impossible to answer with Harriet Lane alone. Pocket Pedia -  A lot of people I know swear by Pocket Pedia: it’s really short and, they say, very high yield. Personally, I didn’t find it very high yield. Maybe it’s because I was only able to read slightly more than a quarter of it. OB-Gyne  Among all subjects, I think Pedia is the one where I was the LEAST prepar ed. I just didn’t know where to start and what to study. Truthfully, I think 2 things saved Pedia for me – first is Robbins (I can’t really get over how much I LOVE this book) and second is the entire Pedia rotation in PGH. Baby Williams - I started making my OB notes back during clerkship and internship, so I didn’t really need to read a lot in Baby Williams, save for the few chapters I failed to take down notes in. For all the others, I relied on my notes – all based on Mama Williams – which were very high yield already (70-80%). - While Baby Williams as a whole IS long, the must-know topics are NOT. I suggest skipping all the chapters on the medical complications of pregnancy, except the ones on Gestational DM and Hypertension. OB-Gyne Black Book - Since I already had OB notes from before and from Baby Williams, I didn’t rely on the Black Book as my primary study material. Rather, I just used it as a supplement to reinforce the notes I already had. - However, I did use the Black Book as primary reading material for its GYNE part. We must admit, while our clerkship and internship rotations are strong in the OB part, it’s quite lacking in the GYNE part. Even the summary rounds had little to say about gynecologic cases. Internal Med Legal Medicine High-Yield OB-Gyne - I read this book ONLY for its sections on GYNE. Like other reviewers in the High-Yield series, it is both easy on the eyes and easy to understand. It is actually possible to finish this book within a day. True to its name, it is indeed HIGH YIELD. I would say close to 90% of the Gyne questions in the exam may be found somewhere in this book. First Aid for the Step 2 CK - Like other books in the First Aid series, this book has a comprehensive, little-bit-of- everything approach for each disease. It has something to say on relevant anatomy, epidemiology and “most commons,” pathologic findings, gold standards in diagnosis, and different forms of management. It helps that it’s concise and to-the-point, with a lot of summary tables. - IM has, through the years, been known as the most multi-disciplinary of all the subjects. So, expect to see questions on Physio, Pharma, Patho and Microbio. Remember to cover for these overlaps. Summary of Legal Medicine and Medical Jurisprudence - This was my primary study material. Some people say it lacks a lot of information, but I personally think that it has pretty much everything we NEED to know. Solis Textbooks on Legal Medicine and Medical Jurisprudence - I tried reading the textbook from cover to cover initially, but abandoned the stupidity after less than a day. I reserved this book as reference material for conflicting information in the Summary, for questionable answers in the sample exams, and for questions that I just don’t know the answer to. Prev Med Mang Lito Sample Exam - The ONLY sample exam I studied for the boards after hearing reports that the board exams from the previous year was almost completely lifted from this set. We all know that Legal Med is one of the subjects NOTORIOUS for a lot of repeat questions. - Remember, though, that source sample exams CAN change from year-to-year, so be prepared for the possibility that a new set of sample exams be used next year. If you are an August taker, what you can do is ask the February takers about the nature of their exam  – there is a good chance of “similarities”. UE Prev Med Notes - We all know that we NEVER had any formal Prev Med classes (except for Clinical Epidemiology st nd back in 1  and 2  years). So, honestly, I think any Prev Med reviewer – be it UST, UERM or PLM – should be fine. I chose the UE Prev Med Notes because I was able to borrow the complete set from a blockmate from UERM and because I heard rumors that the Prev Med exam would be lifted from it (by the way, the rumor turned out FALSE). Had I seen my blockmate from UST first, I would most likely have studied the UST notes. Sadly, the UE Notes turned out to be LOW yield because the questions were lifted from the PreTest book. A good 40+ questions came from PreTest, and about 10+ questions came from the UE sample exam. I must say that the Prev Med exam, like the Surgery Exam, is notorious for questions that you just have no idea as to their source/s.