We talked about the importance of Clinical Vignettes in reviewing for the USMLE. You can review the post here. Now we will discuss how to train yourself to diagnose cases based on clinical vignettes.
As stated previously, we usually learn clinical vignettes by starting with the disease and then finding out what signs and symptoms are associated with the disease. This is just fine when starting out, but eventually you have to be able to do it the other way around. Given a pattern of signs and symptoms, you must be able to deduce the disease process involved. This is the way clinical vignettes are presented in the exam and that is the way your patients will present to you.
Difficulties with clinical vignettes will be most pronounced in Step 1 and Step 2 CK. By the time you take Step 3, your clinical experience will be more than enough that clinical vignettes will probably be a minor problem. Step 1 will have lots of uncommon cases but presentations will usually be classical or typical. While Step 2 CK will have mostly common cases but with unusual and atypical presentations.
Since most questions will be in clinical vignette format, you have to diagnose the case first before you will be able to answer the questions that are subsequently asked, be it a basic science question, treatment or diagnostic exam. So if you can’t diagnose it, you probably will miss the answer even if you know the actual fact being tested. For example, if someone has just told you we are talking about Hepatocarcinoma, you would know the pathophysiology of the disease. As it is, you must recognize from the clinical vignette that we are talking about Hepatocarcinoma or you would miss the pathophysiology question entirely. 😐
Now normally in clinical practice, we can depend on doing differential diagnosis and selective examinations (both physical and diagnostic) to rule in or rule out a disease process. But in the examination, you have only a minute or so and therefore, you cannot do differentials, you have to be able to recognize patterns in diagnosing clinical vignettes. 🙄
So how do we train ourselves to recognize patterns in diagnosing clinical vignettes?
- After studying them the traditional way (by looking at diseases and their signs and symptoms), write them up the other way around by listing signs and symptoms and see if you could identify the disease.
- Use a review book like Pretest Physical Diagnosis, except only try to identify the disease entity the clinical vignettes is depicting. Be aware though that only common diseases in classical presentation is presented in the Pretest.
- Rely on Kaplan and/or UW Qbank to provide you with enough practice in identifying clinical vignettes.
- Use any combination of the above methods.
My suggestion is depending on how much difficulty you have with clinical vignettes adjust your study accordingly. Personally, I have never had problems with clinical vignettes, but I have found many people who were creamed because of this problem. 🙁 For most people, number 3 may be enough, but for others doing combination of the above will be better. For example, you could decide to drill using Pretest. For those not covered in pretest (esp. Step 1) write up some flashcards listing signs and symptoms and guessing the disease process involved. Then use the Qbank to finalize your review.
Notice, I don’t recommend Underground Clinical Vignettes. This is because I feel it is too expensive with little proven benefit. But that is only my opinion. 😉 Feel free to disagree. Til next time …