Mastery, Know and Familiar applied to USMLE review.

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Note: I wrote this sometime ago to help out somebody who was having difficulty in her review. It was posted in prep4usmle. It illustrates the use of the concept of Master, Know and familiar in preparing for the USMLE.

This part is especially for gigiMD.                           

Just like any diagnostic exam, our quick and dirty evaluation has its share of false positives.

While most people who have a KA, KR or TP problem really have a KA, KR or TP problem. A minority have a mixed problem, combination KA,KR or KA, KR, TP problem. They often evaluate themselves to having a KR or TP problem and so missed out that they also have a partial KA problem.

I had thought of discussing this when we reach the KR portion of the discussion, but judging from gigiMD’s post, I felt I should address this immediately. One symptom is inability to raise your grade even with repeated qBank drills. A pure KR problem should be remedied promptly by answering huge number of Q’s. Failure to raise grade,or extremely small increments of grade increase in relation to number of Q’s done points to a KA deficit.

There are a few more concepts we need to understand in order to know why this is the case. I’ll discuss this here before we go back to discussing KA further.

In order to understand this we need to go back to the concept of mastery, know and familiar. We can divide our Knowledge Level (KL) of particular concepts as Mastery level, know level and familiar level.(In reality, there is more than 3 levels, but limiting to 3 levels make for easier discussion.) We can also divide question difficulty(QD) to 3 levels, Mastery, know and familiar. A question is easy, fair, hard or impossible(experimental questions!!) for you depending on the QD level of the question in relation to your KL level of the particular concept being tested.

A table follows:

Question Difficulty Level(QD)
Knowledge LevelMasteryKnowFamiliar
MasteryFairEasyVery Easy
KnowHardFairEasy
FamiliarImpossibleHardFair

To further illustrate: let’s take the drug Valproic Acid.

All information available on it is as follows:

Broad Spectrum Antiepileptic that acts by Enhancing GABA accumulation, Inhibiting repeated neuronal firng by actions at Na channel, and inhibition of low threshold (T-Type) Ca channel. DOC for Myoclonic sz. Alternative for Partial and Generalized Tonic Clonic sz, Absence sz. Tx for Mania Side Effects, dose related anorexia, nausea, vomiting and idiopathic hepatotoxicity. Teratogenic (Spina Bifida) Hepatic Metabolism.

At KL of Mastery, you know and can easily recall all the above facts when presented with a question. (Of course, you need to know more than what’s presented above incl. mechanisms, clinical presentation, etc. to be considered as having mastered the above concept, but for the purpose of illustration, I’ve kept it simple.)

A question presented at QD level of Mastery would need most or all of the above information to be answered quickly and your KL is at the right level to answer it. Questions presented at Know or Familiar QD levels would be a walk in the park for you.

At KL of know, the following information is easily recalled by you:

Antiepileptic that acts on GABA, Na and Ca Channel. DOC for Myoclonic Sz. Alternative for other sz. Side Effects, Gi, hepatotoxicity, teratogen.

You probably can recall this subset of information either because:

a) You read all the data as presented on the first case but decided to remember only the above facts. You mastered it at the KA Phase but only know it at the KR phase. You have the potential to raise your Level to mastery at the KR phase by doing lots of questions.

b) You can recall the above topics, because you used a source that presented only the above facts. You know this topic both at the KA and KR phase.

You may be able to answer questions presented at the know and familiar QD level but you can only answer questions presented at the mastery level under the ff. circumstances.

a) Given enough time, you may be able to recall having read some of the information before that will enable you to choose one answer over another. You may need to find some clues in the question stem, but you eventually arrive at an answer that have a fairly reasonable chance of being correct.

b) You need even more time because you had used an abbreviated source as your main review and the only way you can remember any of the more obscure information is because a couple of years ago you had the opportunity to use the drug and did some minor reading.

Nonetheless, the common denominator you need is time, which is a precious commodity indeed in USMLE.

At the familiar level all you know is Valproic Acid is an antiepileptic.

At QD level of Familiar this is fine, since they usually give enough information and clues in the stem to help you (as illustrated earlier in my exam) or the other choices are so obviously wrong(because your KL level for all the other choices is obviously higher) that you can clearly pick the right choice. At other QD levels, it will obviously be extremely difficult and you will need lots and lots more time and lots more clue in the stem to get the answer right.

If you had KA this in mastery level, you can remedy this in the KR phase by doing lots of questions. But if you KA this at familiar level, questions are of no help.

So why is it important to have a KL level higher than the qd level the question was presented at the exam?

You could imagine the situation in the last 3 or 4 blocks of the examination, when fatigue makes concentration and recall a little harder. You need to read the questions twice because you don’t get it the first time. It takes longer to recall the answer even if you’ve mastered it. So if your KL level for a lot of the question is at a lower level then the QD level it’s presented, not only will you get a lot of it wrong, you’ll run out of time.

The situation when you are answering the Qbank at home or in the library is more like the situation when you are doing the first 3 or 4 blocks of the actual exam. And if you are only getting 65% of the questions right, you can extrapolate what is happening in the last 3 or 4 blocks and understand why the end result is what it is.

The problem of KL levels is a combination KA and KR problem. You may have mastered the concept at the KA phase but only know or are familiar about it in the KR phase, in which case its a KR problem. But if you did not master it at the KA phase, you cannot master it at the KR phase. which makes it a KA and KR problem.

So it is possible for you to think you only have KR problem because all the questions are familiar to you, but you can still fail because you do not know and have not mastered enough concepts to pass the exam at the qd level presented in the actual exam although you are familiar with almost all of them.

To remedy an inappropriate KL level problem, you may need to go back to KA not just KR.

So gigMD, I believe that your problem is a KL problem. It’s primarily a KR problem but with a KA component. You have not mastered enough concepts at the KA phase that you cannot master the concepts at the KR phase even after doing lots of Q’s. So if I were you this is what I would do.

First, I would do qBanks and FA to improve recall on concepts that I have mastered at the appropriate KL level.

But I would supplement it with the ff.

Since Pathology and Pathophysiology is 40% of the exam, I will increase the amount of concepts I have mastered in this subject. And if you have time, concentrate on the other 2 which is Micro-Immuno and Pharma.

So how do you master a topic. This is one quick way I use. It cycles you directly pairing KA and KR on a subset of topic for quick mastery.

For Patho, you can use BRS Patho, either big or small Robbins and Review of Pathology.

Read and try to master or know the topics in BRS Patho one chapter at a time. Answer the review q’s in BRS for a quick recall test. Less than 90% correct, reread the areas you got wrong. Next open to the appropriate chapters in big or small Robbins. Read and try to master or know the topics covered in BRS patho as discussed in Big or small Robbins (this is impt as BRS is weak in pathophysio which is remedied in big and small Robbin’s) For all the rest just scan and familiarize yourself with them. Then if you are fairly confident that you know and/or mastered the right amount of info, Do the q’s in Review of Pathology. The actual number of Q’s you need to do right depends on your goal. I set a standard 90% for myself or else I repeat the entire chapter. Actually needed to repeat only 1. However, in your case it’s up to you, You can put a lower standard, 75 or 80%. But not too low so as not to make the whole exercise useless. Then go on to the next chapter.

Remember don’t read everything. If you already feel you’ve mastered a topic at the appropriate level, skip it or just scan through it, slowing down only on topics you need to master.

How do you decide which topics to master. Well, that’s a judgment call. For example, you know you have to master ulcerative colitis and Crohn’s disease. For lung CA. Master Squamous and small cell and know the rest, etc. However,if you studied the topics the way I described, you will tend to come out of it mastering what needs to be mastered, knowing what needs to be known and familiarizing yourself with the rest, since the authors would emphasize and repeat what is important and the exam will test for the more important concepts.

Can I use Kaplan Qbank or the other Qbank for the KR part of this mastering process? My answer would be no. The reason is that your KA and KR session files the info into your KB in a topic by topic manner which makes it easier for you to extract the information in a topic by topic manner. The actual examination requires you to recall information in a random manner, which makes recall more difficult even if you’ve mastered the topic. There is an exercise that can train your brain to be more efficient in random recall and I will tackle that subsequently. Use Kaplan Qbank only in random timed manner as there are other less expensive Qbank you can use. Why this is so I’ll explain when we reach the TP portion of the discussion.

Look at your USMLE score report and see which subject you are weaker, Micro-Immuno or Pharm and if you have time tackle them in that order.

For Micro-Immuno a good source is Levinson and Jawetz. Rarely is there a book which lets you master and know the right info all in one book. Don’t wait to finish the whole book before tackling the exam at the rear of the book. Tackle it immediately after you finish appropriate sections. Set minimum passing scores, reread areas you got wrong.

Should I master for example viral classification. Well for the purpose of the USMLE, I think you should just know it. If you’ve sat for the exam, you know that they never just present the classification of the virus (eg. non-enveloped, icosahedral, single stranded Positive sense RNA virus) They usually give other clues. However, Kaplan Qbank tends to give some questions giving only the viral classification in the stem. So you only need to know this fact to answer the USMLE Step but you need to Master this to answer the Qbank.(Does this mean Kaplan QBank is inappropriate? No. Actually if Kaplan Qbank does not do this, it will not be as effective as a review source. I’ll explain in a subsequent post why this is so.) Actually Kaplan notes emphasizes mastering classification which is consistent with the way it is presented in their QBank.

For Pharma, the gem is Katzung’s review. The best way to learn pharma, is to master the prototype drug, know difference between prototype and other major drugs and be familiar enough with more obscure derivative as belonging to this class of drug. Although that may not be the best way to recall it, so Flashcards are very useful in this regard. Most questions in the USMLE allows you to conclude that a particular class of drug is the correct answer for example SSRi. In the list there is only one SSRI, if it’s the prototype, well and good but sometimes, it’s an obscure derivative belonging to that class of drugs.

With Katzung, you know what info to master at the appropriate level. It tells you what prototype to master, What major derivatives you have to know and what obscure derivative you just have to be aware belongs to that particular class. However, the information in Katzung Review does not allow you to master a particular agent, but only know it. You’ll need either Lippincott or Big Katzung to master particular drugs.So get Katzung review with either Lippincott or Big Katzung as supplement.The exam in Katzung Review at the end of each chapter is an appropriate KR material for mastery.

For all the rest, just do q’s for them. Even Q’s will raise your mastery level in both KA and KR, especially if you take time to repeatedly read the explanations to the answers. But at a much slower pace then the method I’ve outlined.

I call this “Master the Big Three Know the Rest” Protocol. Appropriate for “patients” almost passing the exam, or for those who want to do well but do not plan to ace it.

Now how do you increase your ability to recall random facts very fast?

Well first get a qBank with large source of Q’s, can even be obsolete. BSS, Rapid Review come to mind. Then try to answer blocks of 50 questions in 30 minutes or less without reviewing any of your answer. This way:

1. you train yourself to read questions fast
2. you force yourself to come up with answers fast or move on if you don’t know instead of wasting time in a particular questions.
3. You force yourself to recall information faster in a random manner.

Of course you will initially fare poorly doing questions in this manner. The difference initially between doing it this way and the slower way with complete review is as much as 20% or 10 correct answers. But as you get used to it, the difference will narrow.

That is the way I did it with USMLE CD Q’s, 30 minutes no review, so my actual score maybe higher than the ones I got.

When I was doing NBME and Kaplan, I usually finish first round answers between 25 to 30 minutes. Giving me 30 to 35 minutes to review my answers. On average, I get 74% of the questions right the first go and the review adds an additional 12% since I tend to change 6 answers from wrong to right in subsequent reviews. I also tend to change 1 answer from right to wrong so my average comes out 84%.

In the actual examination, I finished first round in first block in 24 minutes flat. By the 4th and 5th block, I was running over 30 minutes. By the 6th and 7th Block with fatigue taking its toll, I was doing 41 minutes. Either way I didn’t find finishing the block a problem. Faulty recall due to fatigue was the main problem.

So gigiMD, hope these recommendations help. I’ll tackle the rest of KA, KR and TP in my next post.

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