Clinical Vignettes in the USMLE and how they affect your review process

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Clinical Vignettes are increasingly becoming more common and important not just in Step 2 and Step 3 but even in Step 1. Increasingly, it is not enough to just memorize important medical facts, but to recognize how these facts apply in real life practice of medicine. The use of clinical vignettes also tests your ability to recognize diseases in a clinical setting, a critical skill in actual clinical practice.

What are Clinical Vignettes?

Clinical Vignettes are based on the fact that certain signs and symptoms or patterns of signs and symptoms occur more often in a particular disease process. If a sign or symptom is almost always associated with a certain disease it is called diagnostic or pathognomonic for that disease. Now the pattern of signs and symptoms we learn from textbook is usually the classical type. In actual practice, we rarely see classical signs and symptoms.

The USMLE is aware of this fact, therefore its use of clinical vignettes in Step 1 is different than in step 2 and 3. In step 1 cases are almost always classical in presentation. The cases may sometimes be uncommon or rare (this is because some Basic Science concept are represented by rare syndromes) but almost all are classical in presentation.

Cecil’s Textbook of Medicine states that most cases we encounter in clinical practice will be common cases with typical presentation, then common cases with atypical presentations, then uncommon cases with typical presentations, then least of all, uncommon cases with atypical presentation. Both Step 2 and Step 3 reflects this fact with more common but atypical case and uncommon but typical presentations.

This should guide how we study depending on what Step we are taking. For Step 1, be aware that uncommon cases can be tested although you can stick to typical or classical presentations. In Step 2 and more so in step 3 the emphasis will be on common cases although you will find a lot of atypical presentations in both.

How do we review for Clinical Vignettes?

Normally, we learn clinical vignettes by first looking at a certain disease, then the common signs and symptoms for that disease. But in the exam as in real life, you get the patient with signs and symptoms and you have to deduce what disease the patient have.

The most effective way to review for this is to have clinical cases presented and you try to guess what the disease is. Therefore, UCV (Underground Clinical Vignettes) is not a very good resource as they are organized by disease with a list of symptoms. A better one is Pretest Physical Diagnosis as they are presented as clinical vignettes. The key is to identify the disease rather than try to answer the actual questions given as they tend to be a bit simplistic. 2 other drawbacks is that most cases are common and classic, so you don’t get trained to diagnose uncommon and atypical presentations.

It is important therefore to train yourself to diagnose based on clinical vignettes in order to do well in the USMLE. We will talk about how to do that in another post.

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