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As 2015 comes to a close, we are thrilled to announce the upcoming launch of the PANCE / PANRE exam Question Bank and Flashcard platform on Knowmedge to help Physician Assistants prep for the board exam.

Similar to the Internal Medicine question bank, the PANCE / PANRE QBank will integrate questions, flashcards, and mnemonics. The Knowmedge PANCE / PANRE question bank will incorporate 1,500 questions, 3,000 flashcards, and over 500 medical mnemonics. Our QBank will cover all the major categories from the PANCE blueprint:

Cardiology

Dermatology

EENT (Eyes, Ears, Nose, Throat)

Endocrinology

Gastrointestinal / Nutritional

Genitourinary

Hematology

Infectious Disease

Musculoskeletal

Neurology

Psychiatry / Behavioral

Pulmonary

Reproductive

The current flashcards platform will be expanded to include an additional 3,000+ PANCE / PANRE related flashcards. The new flashcards will include a multitude of question forms including direct questions, multiple choice, true / false, and fill-in-the-blank questions. If you already have a subscription to the Internal Medicine flashcards platform, the additional PANCE flashcards will be included at no additional cost! (Note: The categories / questions for both exams are very similar so cross studying will only help you!)

Other changes coming

In addition to the launch of the PANCE / PANRE exam prep platform, we have made some important changes to the existing Internal Medicine Question Bank / Flashcard platform which will be updated at the same time. There are a few major changes:

As a new subscriber, you will get access to 50 free Internal Medicine Question Bank practice questions. This is an increase from the 20 free questions subscribers get today.

Subscribers to the Flashcards platform will also see an increase of free questions from 50 to 200!

The question bank Q&A page will be redesigned to more prominently display the flashcards and mnemonics associated with each question. This was done after hearing back from subscribers and watching how the Knowmedge community interacted with the QBank.

We expect to launch the new platform, along with the enhancements, by the end of the year!

If you don’t hear from us before then… Happy Holidays / Merry Christmas to you from the entire Knowmedge Team!

Thank you for being a part of the Knowmedge Learning Community!

Knowmedge Team

In addition to the minor changes between categories, the blueprint now contains additional detail not found in the previous blueprints. Previously the ABIM had provided detailed conditions that could be seen on the exam for each of the major subjects (e.g., Cardiology / Mitral Stenosis). The new blueprint takes this a step further and indicates the level of importance (high, medium, low) regarding each of the following aspects the conditions that could be seen on the exam:

Diagnosis

Testing

Treatment / Care Decisions

Risk Assesment / Prognosis / Epidemiology

Pathophysiology / Basic Science

In medical school, the three multiple endocrine neoplasia (MEN) syndrome types hardly take up a couple of Powerpoint slides during your endocrinology course. During Internal Medicine residency, you may see one case during your three years…if you are lucky. Even as an internist with a storied career spanning decades, you’ll be able to count on a single hand the number of patients with any of these syndromes. Yet, for some reason, USMLE Step exams, Internal Medicine shelf exams, and the ABIM board certification and recertification exams all love to test students, residents and attending physicians on this concept. Indeed, it appears on the ABIM blueprint syllabus under the heading “Polyglandular disorders” of the endocrinology section. The roughly 2% of questions on the topic may not seem like a lot but it could make the difference between a passing and failing score on the ABIM exam. I recall in medical school first reading of the three syndromes and being puzzled by the goofy numbering: I, IIa, IIb. It seemed almost as ridiculous as renal tubular acidosis (RTA) categorization. Yet, I figured since the boards tend to favor rare conditions, especially syndromes, it probably made sense to learn these three. However,  I sensed I needed a mnemonic. First Aid for USMLE Step I surprisingly at the time didn’t have any tips for remembering the diseases found in each one so I ended up creating my own. The first thing I noticed as I read the list of disorders is that they all begin with either an M or a P:

Parathyroid hyperplasia

Pituitary tumors

Pancreatic islet cell tumors

Pheochromocytoma

Medullary thyroid cancer

Marfanoid habitus/mucosal neuroma

MEN type I features the top three:

MEN Syndromes – Type IMEN type IIa shares Parathyroid hyperplasia but, instead of Pituitary tumors, has Pheochromocytoma. Medullary thyroid cancer completes the triad. Thus, we can say that MEN type IIa has 2 Ps and 1 M.

MEN type IIb has both Pheochromocytoma and Medullary thyroid cancer in common with MEN type IIa. The third disorder begins with an M: Marfanoid habitus/Mucosal neuroma. Therefore, MEN type IIb has 1 P and 2 Ms.

MEN Syndromes – Type I, II, IIII’m sure others have used a similar approach but I hadn’t come across it before I started studying. It’s not a slam-dunk mnemonic since you still need to know which Ps and which Ms fall within each type but it at least gives a framework to guide you. Personally, I remember that Pheochromocytoma is in IIa and IIb because it involves very high blood pressure readings and thus is more at home in the higher number types. And how do you remember that Medullary thyroid cancer, instead of Marfanoid habitus, is in IIa and IIb? Medullary “meddles” in both types.

The American College of Physicians (ACP) hosted its 2014 Internal Medicine annual meeting in Orlando, Florida this past April. Dr Geraldine E. Menard, an associate professor of the Department of Medicine at Tulane University School of Medicine, presented high-yield General Internal Medicine concepts as part of a review of the ABIM syllabus. Those key take-home teaching points have been adapted and summarized here, with Knowmedge visuals. As we continue with #GeneralInternalMedicine Week, we present five topics: Biostatistics, Smoking Cessation, Alcohol Screening, Strep Throat, and Sinusitis. Biostatistics

A test that has high Specificity is used to “rule in” a condition when the result is positive; whereas a high Sensitivity is used to “rule out” a condition when the result is negative test. A favorite mnemonic your friends at Knowmedge use is “SPin” and “SNout”.

A test provides the most useful information when the condition has an intermediate disease prevalence (30-70%) or intermediate pre-test probability.

Data can be skewed by being presented as an impressively large risk ratio. If the absolute risk reduction (ARR) is small, the intervention isn’t particularly effective.

The number needed to treat (NNT) is simply the inverse of the absolute risk reduction (ARR) as in NNT = 1/ARR. NNT represents the number of people who are required to undergo treatment before one person benefits.

The similar-sounding number needed to harm (NNH) is the number of people who are required to undergo treatment before one person is harmed by the treatment.

Relative risk confidence level should not contain the value 1. If it does, that means that the treatment may or may not be effective.

8 Pulmonary & Critical Care Pearls for the Internal Medicine Shelf and ABIM Board Exam

Pulmonary disease and critical care are an extremely important part of the Internal Medicine Medical Clerkship and ABIM Board exam. According to the ABIM exam blueprint, questions testing pulmonary disease topics comprises ~10% of the exam. That places it second only to cardiology’s 14% in terms of relative percentage.

1. ABGs do not need to stand for AnyBody’s Guess The next time you see an arterial blood gas (ABG) on a practice or actual exam question, don’t start searching for the “Panic” (or “Skip”) button. Determining diagnoses based on ABGs can seem daunting at first but by following a simple yet systematic approach, we can tackle these questions without difficulty. Click on the link to our previous

“How to Handle ABGs on the ABIM Board Exam”

and after reviewing the 5 easy steps, it won’t be long before you look forward to ABG questions on the exam. 2. Obstructive or Restrictive? That is the question surrounding Lung Disease To distinguish between obstructive and restrictive lung disease, the first value to look at on the pulmonary function test (PFT) report is the Total Lung Capacity (TLC), which is defined as the volume of air contained in the lungs at the end of a maximal inspiration.

Sarcoidosis

Idiopathic Pulmonary Fibrosis

Hypersensitivity Pneumonitis

Pneumoconiosis

ABPA

Churg-Strauss Syndrome

Asbestosis

Silicosis

Berylliosis

Obesity

Kyphosis

Myasthenia Gravis

Guillain-Barre Syndrome

Muscular dystrophy

3. The Mnemonic “CHAD PARS” helps recall the major causes of bronchiectasis.

C – CYSTIC FIBROSIS

H – HYPOGAMMAGLOBULINEMIA

A – ALPHA 1 ANTITRYPSIN DEFICIENCY

D – DYSKINETIC CILIARY SYNDROME

P – PNEUMONIA

A – ALLERGIC BRONCHOPULMONARY ASPERGILLOSIS (ABPA)

R – RHEUMATOID ARTHRITIS

S – SJOGREN’S SYNDROME

4. Not all that wheezes is asthma…but it sure is important for the ABIM boards and medicine shelf exam Frequency of asthma symptoms provides the necessary information for proper classification of this reversible obstructive lung disease (defined by greater than or equal to 12% increase in the FEV1 after use of an albuterol inhaler). Only then can we determine the best treatment for the affected patient in an exam vignette. This slide (click on it for enlarged view) conveniently depicts the criteria for intermittent, mild persistent, moderate persistent, and severe persistent asthma, along with their recommended treatments. ABIM Exam Pearls: Asthma Treatment and Diagnosis

5. Similarly, mastering COPD classification (using the GOLD criteria) and treatment is essential Unlike asthma, COPD is an irreversible condition. Administering the bronchodilator albuterol will not increase FEV1. GOLD (Global Initiative for Chronic Obstructive Lung Disease) criteria is the primary method used to diagnose and identify the severity of COPD. A diagnosis of COPD should be considered for any patient over the age of 40 who has any of the following conditions:

Dysnea that is persistent, worsens over time and gets worse with exercise

Chronic cough

Chronic sputum production

History of exposure to risk factors (Tobacco smoke, smoke from home cooking, occupational dust, chemicals)

Family history of COPD

FEV1/FVC ratio less than 70% is an indication that there is an airflow limitation and, thus, COPD. The spirometric criteria for a diagnosis of COPD is a post-bronchodilator FEV1/FVC ratio less than 70%. FEV1 will tell us the intensity of the COPD which can be characterized into four stages:

Stage I (Mild):  FEV1 > 80% of predicted value; Rx: Short acting Bronchodilator as needed with or without Ipratropium

Stage II (Moderate): 50% ≤ FEV1 < 80% of predicted value; Rx: Short acting Bronchodilator as needed with long acting bronchodilator around the clock with or without pulmonary rehab

Stage III (Severe): 30% ≤ FEV1 < 50% of predicted value; Rx: As above for moderate COPD plus Inhaled steroids

Stage IV (Very severe): FEV1 < 30% of predicted value (or FEV1 < 50% of predicted value plus chronic respiratory failure); Rx: As above for severe COPD plus Long-term oxygen therapy for at least 15 hours daily. Surgical intervention should be considered.

The slide below (click for enlarged view) reveals the cut-off criteria for the different stages. ABIM Exam Pearls: GOLD Criteria for COPD

Other indications for Oxygen therapy in COPD patients are:

PaO2 less than 55 mm Hg or Oxygen saturation less than 88% OR

PaO2 less than 59 mm Hg or Oxygen saturation greater than 88% with evidence of Cor pulmonale (Right ventricular dysfunction) or secondary erythrocytosis (hematocrit greater than 55%)

6. IgE and Eosinophil levels help us distinguish ABPA, Hypersensitivity pneumonitis, and Churg-Strauss syndrome ABPA →  Increased IgE levels and increased peripheral eosinophils >10% →  Rx with steroids HYPERSENSITIVITY PNEUMONITIS →  IgE levels and peripheral eosinophils are normal → Remove offending agent CHURG-STRAUSS SYNDROME →  IgE levels are normal, peripheral eosinophils >10% →  (Clue: asthmatic patient with increase peripheral eosinophils and a foot drop) → Management with steroids 7. Light’s criteria will guide you to correctly identifying Pleural Effusions as either exudative or transudative Broken down into Transudative and Exudative effusion. Remember that for Transudate, all of the following need to be met. If all are not met, then the patient has an exudative effusion. ABIM Exam Pearls: Light’s Criteria

Transudate effusions include conditions such as: CHF, Nephrotic syndrome, Cirrhosis, Hypothyroidism

Exudative effusions include conditions such as: Neoplasm, Infection, RA, SLE, Esophageal perforation, Pancreatitis, and Dressler Syndrome

8. Bronchoalveolar lavage (BAL) findings can help narrow down, if not nail, the diagnosis.

Increased Neutrophils → think Idiopathic Pulmonary Fibrosis

Increased CD8>CD4 → think Hypersensitivity Pneumonitis

Increased CD4>CD8 → think Sarcoidosis

Increased Eosinophils → think Eosinophilic pneumonia

Positive Silver Methanamine Stain → think Pneumocystis Jiroveci in patients with HIV

Inclusion bodies → think CMV pneumonia

Not just budding journalists; writer’s life offers lessons to medical students and residents too A rumble spread through the media world last Thursday when, just hours after moderating a panel for The New York Times, the veteran journalist David Carr collapsed on the newsroom floor. He was rushed to St. Luke’s-Roosevelt Hospital, where was pronounced dead. An entire Sunday edition of the newspaper could be printed exclusively of all the tributes paid to Carr on social media, television, message boards, etc. In the days following, I’ve read about the wealth of life experiences spanning his darkest days full of violence, drugs, and alcohol through his addiction recovery attempts and finally to his rise as an authoritative journalist. Along the way, I was struck by how many medical problems Carr unfortunately suffered from beyond crack cocaine, which seems to be what every media outlethighlights.

Cocaine Use

In his 2008 memoir “Night of the Gun”, Carr with tremendous candor shares with his readers his fight against lymphoma, his bout of necrotizing pancreatitis, the knee surgery to remove his right meniscus, and his family history of lung cancer. I thought to myself, as Carr himself would say, “Someone should write a story about this.”

In the book, he accurately describes Hodgkin lymphoma as “a good cancer if it is your turn”. He stated at the time of his diagnosis that it is “curable if found in its early stages”, which is true. But since his diagnosis the malignancy is now highly curable no matter at what stage it presents. Most individuals usually present with a painless enlarged lymph node or the presence of a mediastinal mass on imaging in relatively young adults. 30% of patients have “B symptoms” which include fevers, night sweats, and weight loss.

Hodgkin Lymphoma

Carr’s diagnosis of lymphoma was somewhat unique, like just about everything about him. He had been recovering from a right knee accident on an icy outdoor staircase that required surgical removal of the meniscus.

Meniscal Tear

A few weeks of wearing crutches to avoid placing pressure on the right knee led to what Carr initially thought was hypertrophy of his neck muscles on the weight-bearing left side. The following morning though in the timespan of just hours, he noticed that the left half of his neck was even bigger than the night before. As he candidly wrote in his memoir, “Lemme see, uncontrolled growth right over my lymph nodes. I think I got a little touch of cancer here.” Carr underwent a neck biopsy and a bone marrow biopsy that confirmed the disease and he started undergoing treatment.

Hodgkin lymphoma treatment is as follows:

Localized disease treatment entails radiation therapy (with or without chemotherapy)

Advanced disease treatment entails combination chemotherapy (6 cycles of ABVD: Adriamycin, Bleomycin, Vinblastine, Dacarbazine)

In general, Hodgkin lymphoma treatment is easier to remember than Non-Hodgkin lymphoma in which histology plays a crucial role. There is one notable exception to this general rule: For patients with CD20 positive Hodgkin lymphoma, Rituximab is added to the treatment plan.

Despite the large size of his lymphoma, Carr was diagnosed with localized disease. The rounds of radiation therapy Carr underwent resulted in dropped head syndrome, a relatively rare complication: “My neck is chronically bent…because of the nerves and muscles that hold it loft are compromised, shot out by all the radiation I absorbed so many years ago,” he wrote in Night of the Gun.

Patients who undergo treatment of Hodgkin lymphoma are at risk of developing late secondary malignancies which include Non-Hodgkin lymphoma (NHL), leukemia, or solid tumors; at the time of his death, Carr had lung cancer, also the same disease that took his mother’s life

Specifically, the autopsy report listed small cell neuroendocrine carcinoma and its complications as a cause of death.

Paraneoplastic Syndromes in Lung Cancer

Other after-effects of Hodgkin treatment include heart disease, which was also cited as being present on autopsy performed this weekend due to the suddenness of his death. Carr had enough risk factors—such as cigarette smoking and cocaine use—that the radiation he endured was not the lone culprit but it likely contributed.

In addition to lymphoma, he was diagnosed with necrotizing pancreatitis in 1999, sending him to the hospital for 16 days including the ICU for 4 days. With incomplete resolution of the pancreatitis, he endured further complications including a pancreatic cyst and insulin-dependent diabetes mellitus (usually seen in the most severe cases).

Pancreatitis Complications (click for enlarged image)

Carr’s passion for mentoring young minds has been well-documented. But, even he would be surprised to read that those students and residents preparing for a career in medicine would extract some take-home points from his life experiences. RIP, David Carr.

The Knowmedge Internal Medicine Question Bank giveaway begins February 16th!

Hello everyone! My name is Nick Mephis. As the winner of the last Knowmedge challenge, I’ll be running the upcoming Facebook challenge and am pumped up to get started testing some High-Yield and key Internal Medicine concepts that YOU WILL see on your Boards. Having won a 3-month subscription to Knowmedge’s IM Qbank last year and gone through all 900+ Qs, I can be sure you guys/gals are going to enjoy learning and competing with your colleagues the coming weeks. We’re excited to kick off another Knowmedge Internal Medicine Question Challenge for all our Facebook followers starting on Monday, February 16th! Here’s how it works:

Each day, between 6am – 9am EST, we’ll post a medical question on the Knowmedge Facebook page

Submit your answer in the comments section and earn points for each question

We’ll add up the points each night at midnight EST and publish a weekly leaderboard Sunday night EST identifying the week’s top scorers

At the end of the month, the participant with the highest overall point total will receive a free 3-month Knowmedge subscription and bragging rights!

4 Points: Awarded to the first person who answers the question correctly

3 Points: Awarded to all participants who answer the question correctly

1 Point: Awarded to all participants who answer the question incorrectly

1 BONUS POINT: Awarded to all participants who “Share” the question with their facebook friends and help us spread medical knowledge! *

1 BONUS POINT: Awarded to all participants who “Like” the question

If you’re not already a fan on Facebook, simply like us and join in the challenge!

It’s not every day you get an email from the American Board of Internal Medicine (ABIM) with the subject line: “We got it wrong. We’re sorry.” Yet, that’s precisely the email heading that greeted thousands of ABIM diplomats in their in-boxes yesterday. The email (which can be found in its entirety below) opens with an acknowledgement that the ABIM prematurely launched the new MOC requirements that shifted the once-every-10-years certification process to a more continuous one without a consideration of how it would be practically implemented. I was present at a widely attended MOC talk last April at the American College of Physicians (ACP) convention in Orlando, Florida. The hour-long-session was standing room only by the time I walked in and I arrived 10 minutes early. It was moderated by Dr. Richard Baron, president and chief executive officer of the ABIM. Physicians were absolutely furious and voiced their frustration loudly and clearly. To his credit, Dr. Baron handled the line of at least two dozen attendees lined up to ask him questions in a calm manner and reassured folks that they were actively reviewing each component of the proposed changes. The best source of information for discovering what changed with the February 3rd email blast Dr. Baron sent is the FAQ page of the ABIM site. You can find it at: http://www.abim.org/maintenance-of-certification/moc-faq/default.aspx In short, here’s what this announcement means for you:

No worrying about the Practice Assessment, Patient Voice and Patient Safety requirements for at least two years. While this idea to place full focus on patients sounds like a good one, private-practice physicians—especially those in solo practices—were simply ill-equipped to implement a project like this while trying to take care of their daily load of patients.

No more “Meeting MOC requirements” next to your status on the publicly accessible ABIM site. Instead, it’ll read “Participating in MOC.” This is not just semantics. Some of the most emphatic complaints were about the wording patients would associate with their physicians if they weren’t enrolled in the MOC program.

An update to the Internal Medicine MOC exam to better reflect what physicians in practice are doing.” Those changes begin this fall. Knowmedge will present more information as it becomes publicly available.

Fee Freeze. To assuage fears that the MOC plan was simply a money-making scheme, the ABIM declared that the $1,940 enrollment fee (which can be paid at a $194 annual rate) will not increase through at least 2017.

If you’re interested in reading more about the reaction on social media and the restitance to MOC, below are a couple of good articles:

Medscape: ABIM on MOC: ‘We Got It Wrong’

The Voice in the Ear: Who’s Sorry Now? The ABIM, That’s Who

And now, that email sent by Richard J. Baron, MD, MACP (President and Chief Executive Officer American Board of Internal Medicine) in its entirety:

Dear Dr. XXXXX:

ABIM clearly got it wrong. We launched programs that weren’t ready and we didn’t deliver an MOC program that physicians found meaningful. We want to change that.

Nearly 80 years ago, the American Medical Association and the American College of Physicians founded the American Board of Internal Medicine (ABIM). ABIM was charged with distinguishing the discipline of internal medicine from other forms of practice by creating uniform standards for internists. Those standards have evolved over the years, reflecting the dynamic nature of internal medicine and its more than 20 subspecialties.

A year ago, ABIM changed its once-every-10-years Maintenance of Certification (MOC) program to a more continuous one. This change generated legitimate criticism among internists and medical specialty societies. Some believe ABIM has turned a deaf ear to practicing physicians and has not adequately developed a relevant, meaningful program for them as they strive to keep up to date in their fields.

ABIM is listening and wants to be responsive to your concerns. While ABIM’s Board believes that a more-continuous certification helps all of us keep up with the rapidly changing nature of modern medical practice, it is clear that parts of the new program are not meeting the needs of physicians like yourself.

We got it wrong and sincerely apologize. We are sorry.

As a result, ABIM is taking the following steps:

Effective immediately, ABIM is suspending the Practice Assessment, Patient Voice and Patient Safety requirements for at least two years. This means that no internist will have his or her certification status changed for not having completed activities in these areas for at least the next two years. Diplomates who are currently not certified but who have satisfied all requirements for Maintenance of Certification except for the Practice Assessment requirement will be issued a new certificate this year.

Within the next six months, ABIM will change the language used to publicly report a diplomate’s MOC status on its website from “meeting MOC requirements” to “participating in MOC.”

ABIM is updating the Internal Medicine MOC exam. The update will focus on making the exam more reflective of what physicians in practice are doing, with any changes to be incorporated beginning fall 2015, with more subspecialties to follow.

MOC enrollment fees will remain at or below the 2014 levels through at least 2017.

By the end of 2015, ABIM will assure new and more flexible ways for internists to demonstrate self-assessment of medical knowledge by recognizing most forms of ACCME-approved Continuing Medical Education.

Please visit our FAQ page for more information about these changes. I do want you to know that, since the changes being made are significant, it will take time until your individual status page is updated on the ABIM website.

ABIM is changing the way it does its work so that it is guided by, and integrated fully with, the medical community that created it. However, I know that actions will speak louder than words. Therefore, ABIM will work with medical societies and directly with diplomates to seek input regarding the MOC program through meetings, webinars, forums, online communications channels, surveys and more. The goal is to co-create an MOC program that reflects the medical community’s shared values about the practice of medicine today and provides a professionally created and publicly recognizable framework for keeping up in our discipline.

As the first non-academic physician to lead ABIM, I am particularly proud of my 30 years in private, community practice, and I see this letter to you as a start – a new beginning. The ABIM Board of Directors, staff and I are fully committed to doing a better job – to ensure that ABIM and MOC evolve to better reflect the changing nature of medical practice.

It remains important for physicians to have publicly recognizable ways – designed by internists — to demonstrate their knowledge of medicine and its practice. Internists are justifiably proud of their knowledge and skills. However, the current MOC program can and should be improved.

Over the next few months, you’ll see communication from me and ABIM leadership, asking about your vision for internal medicine, the MOC program and your opinions about what it means to be a doctor today. We have also created “Transforming ABIM”, a Google+ Community that you can join, to ask questions and share ideas, and a blog

I have heard you – and ABIM’s Board has heard you. We will continue to listen to your concerns and evolve our program to ensure it embodies our shared values as internists.

Thank you for your input and feedback – and for the important clinical work you do each and every day.

Sincerely,

Richard J. Baron, MD, MACP

President and Chief Executive Officer

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Internal Medicine Board Review Flashcards - Nephrology / Urology Flashcards www.knowmedge.com/internal-medicine-flashcards

Do you know the answer? How confident are you?

Last year, I felt like a rising star.  I started my chief year, applied to cardiology fellowship, and was ready to take the boards.  I felt great, studied hard and long and did MKSAP twice.  When I got that I had failed, I was completely devastated, crushed, immediately went into depression.  I could not work, my relationship with my fiancé suffered, and I felt alienated. I wanted to quit and end it all.   I didn’t know what to do.  I had to pretend everything was ok for interviews and for my colleagues, when really it was not.

  My Program Director got me help and guidance, I got treated for anxiety and ADHD, and then I started reading Harrison’s. Probably the best thing I ever did along along with Harrison Board Review Questions.  Additionally, I sought counseling and I started working out.  And not just any work out, I bought P90x.  I needed to regain myself in order to survive this ordeal.   I also had strong family support as well.

  Later, I then received help from a mentor who taught me how to approach questions. Read the storm first, then the answers, and then the question vignette.  GENIUS!  Everything started to improve, so I looked for more practice questions.  I ended up with USMLE World, Knowmedge, and Medstudy questions.  I also had the ACP board review course, which helped some.  During this time also I reviewed old material, tables, Medstudy cards, and Board Basics.

  However, I still felt very alone within my own program, my PD became less of an advocate for me, my own cardiology program told me I wasn’t a strong candidate because despite my 3 years of slavery for their program through research, I still felt alienated by my colleagues, and my engagement eventually fell apart.  I hit rock bottom.

  Fortunately, a month after I failed, I prematched into Cardiology; one stressor was removed from the list.  Additionally, my scores and knowledge improved substantially through reading and practice questions because I learned medicine and I learned how to take test questions.  I could easily tell a difference in my clinical care.

  So where does Knowmedge fit into all of this?  I thought the questions were good, but my favorite aspects were the answer videos, the Twitter feed tips, and the last minute board review outline.  All of these were great additions to my preparation, but I was still nervous and quite frankly scared.

  So where did Knowmedge score big with me?  It scored big through Sunir.  Knowmedge allows you to give feedback for questions and you get a very quick response.  I had a lipid question I contested based on new guidelines, Sunir’s reply was quick, sincere, and personable. In fact, for whatever reason, I reached out to him for help and guidance.  Sunir didn’t have to write back to me, he didn’t have to give me personal guidance or coaching via email, he didn’t have to email me Knowmedge links to help me towards my preparation.  He didn’t have to do all this on a Saturday.  I reached out to him on a Saturday morning and from that point on he was available to listen and guide me up to the date of my test.

  By the day of my test, I had felt armed and ready.  My family came to visit to help me with daily living before my test.  I packed a hearty bag full of snacks and lunch, did yoga the night before, and got up to take my test.  I was nervous, but ok relieved that this would hopefully all be over.  After 8-10 hours of questions, with push-ups, yoga, food, and a quick nap, I was done with the test.

  The months go by and you after failing that the test results come back the first week of October.  I knew I wasn’t going to check them at work.

  October 6, 12:30 PM, I get the email.  Turned my phone off, finished clinic, be honest made up a lie to go home a little early to check my score.  Trembling, nervous, running round, waiting for my computer to turn on.  I didn’t even bother logging into the ABIM website, I just typed my name to see if I was board certified.  It said YES!  It was over, I screamed and hollered through the roof called everyone, celebrated with a bottle of champagne, danced the night away by myself in my living room, and called a girl I just met to celebrate.

  So here I am now, 4 months into cardiology fellowship and I reflect back to what happened to me last year.  To sum it up, worst year ever.  However, I am a very strong and smart cardiology fellow, probably much smarter than I would of been had I passed last year.  Do I wish I had passed last year, duh of course, but this happened for a reason.

  Sunir said it very well, studying for boards is a marathon.  If you think you can get away with one source, you are a damn fool.  You need to learn the medicine, the pathophysiology, clinical manifestations, diagnosis, and the guidelines.  Every source out there is a good review, is it everything you need, absolutely not.  You also need to stay healthy and have sound peace of mind.  Exercise, workout, do yoga, eat and live well.  Finally, believe in yourself, develop grit.

  To you interns and residents that read this, you need to read Harrison’s and you need to read guidelines (USPTF guidelines).  That’s is it period.  This is how to learn medicine.  You need to spend the time and invest in yourself.  Do what your program tells you to do, but learn from the smartest people in the world, the people who wrote our current guidelines and Harrison’s textbook.  Use your I service exams as a guide, DO NOT blow them off, and that’s a personal lesson.  Avoid the bad habits of others, quick and dirty can get you into trouble before you it’s too late. Do medicine correctly, learn it the right way.

  I read everyday, Braunwauld, Grossman, Oh, or cardiology Circulation or JACC guidelines daily because of my experience.  I take my cardiology inservice exam next week.  I see the bear, he is big, he is nasty, and he will try to make me feel dumb.  I have three years to train and, this time, I will be ready.

  Best of luck to everyone,

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Study with over 4,000 Internal Medicine Flashcards

The Knowmedge Internal Medicine Board Review Flashcards set is filled with direct questions, as well as True / False and fill-in-the-blank cards. You will also find images in many of the answers!

Retain key facts through spaced learning repetition

You’ve probably heard the phrase “Repetition is the key to success”. The Knowmedge spaced learning algorithm will tell you not only what to repeat but when to repeat it! It’s a truly personalized learning experience focused on making sure you retain what you study.

Learn more about the science behind spaced learning.

Find the Flashcards you’re looking for with ease

Struggling with cardiology? We got you covered. Filter your Flashcards by subject and practice only the ones you want. The Internal Medicine Flashcards set contains over 4,000 Flashcards covering all the major subjects.

Create or upload your own sets of Flashcards!

Do you keep your own Flashcards in Excel? Through Knowmedge, you can upload all the cards you want, save your own sets and practice them whenever and from wherever you want!

Share your favorite Flashcards with friends!

Challenge your friends with the Knowmedge Internal Medicine Flashcards. Share your favorite through email or on any of the major social media platforms!

See how you stack up against your peers!

Ever wondered how you’re doing compared to your peers? Ever single one of our Flashcards come with stats to show you how your peers performed on that particular card, and our Dashboard shows you how your peers are performing overall.