Deciding to Succeed

Steven R. Daugherty, Ph.D.
Director, Education and Testing
Kaplan Medical

Succeeding on the USMLE means making decisions. The exam does not ask you to tell what you know, rather it asks you to make decisions based on that knowledge. It is decisions that are tested. Knowledge is assessed only by inference. You must know critical details; however, these details are means to an end, not the end in themselves. At the end of each exam question is a decision. Your performance on the exam rests not with what you know, but how you make decisions.

Decisions on the USMLE have some essential parallels with medical decisions in the real world, but also some critical differences. Real world medical decisions and USMLE questions both involve some of the same knowledge. Both require the integration of content of a number of subject areas to solve the presented problem. Both require the capacity to sift presented information to decide what matters and what does not matter.

But real world medical decisions and USMLE decisions are vastly different in their consequences. In the real world, if you make a bad medical decision, you could kill a patient, or at least cause avoidable pain and suffering. If you make a bad decision on a USMLE question, then you simply get the question wrong. Now, getting a question wrong is something you want to avoid, but you must admit that the consequence is a lot less traumatic and a lot less enduring.

Because the consequences of your decisions are different on the USMLE, your decision processes must be different than those in the real world of medicine. In the real world you must strive for certainty. If you are not sure, get sure. If you need more information, get it. Because life and death may be hanging in the balance of your decision, it is vital that you seek as much certainty as possible. In the real world you strive to get as close to 100% certainty as possible in order to assure yourself that you are making a decision that you and your patient can live with.

On the USMLE, you will rarely attain this level of certainty. You simply do not have the time. You must learn to make decisions you can live with without having the time you would like to allow that feeling of certainty to emerge. On the USMLE you must learn to make decisions, not when you are 100% sure, but when you are 51% sure. Fifty-one percent sure is when you think maybe you have the answer but you are still not sure. That "maybe" IS the decision! The added time you spend on the question after that point is not going to improve your score, but simply allow you to feel more comfortable with the decision that you have already made.

Train yourself to make a decision and move on. Do not wait for certainty. Read, decide, and move. There is another question waiting for you. Remember that, at the end of the day, what matters is not whether you get this particular question correct, but rather your total score across all the questions you face.

If you find yourself short on time during the exam, you will not gain speed by reading faster, but by deciding sooner. Your reading speed is essentially a constant for the exam. No matter how much you may want to read faster, you really can't. You can't read faster, but you can decide faster.

The time we spend making decisions is really composed of two parts. The first bit of time is about thinking and choosing. The second bit of time is simply dedicated to feeling good about the decision we have already made. This second part of the process does not make our decisions better, but merely helps us feel better. Forget about feeling better. You do not need to feel better to do well on the exam. You need to make a decision, live with it and move on to the next question.

When you think that you may have identified the best answer, you most likely have. Make the choice and stick with it. Stand with the courage of your convictions and in the confidence of your ability to decide. Learning to make these kinds of decisions is the key to attaining that USMLE score that truly reflects your abilities.

Can You Name It?

Mechanism of Action:

• This agent is a nondepolarizing neuromuscular blocking agent with a rapid to intermediate onset depending on dose and intermediate duration. This agent acts by competing for nicotinic cholinergic receptors at the motor endplate. This action is antagonized by acetylcholinesterase inhibitors, such as neostigmine and edrophonium.

Indications:

• This agent is indicated for use in inpatients and outpatients as an adjunct to general anesthesia to facilitate both rapid sequence and routine tracheal intubation, and to provide skeletal muscle relaxation during surgery or mechanical ventilation.

Route of Administration:

• Solution for IV injection: 5 mL and 10 mL multiple dose vials containing this medication for injection (10 mg/mL)

Selected Adverse Effects:

• CV (arrhythmia, abnormal electrocardiogram, tachycardia); GI (nausea, vomiting); Respiratory (asthma, bronchospasm, wheezing, or rhonchi); and General (rash, injection site edema, pruritus)

Selected Drug-Drug Interactions (Drug + Other medication =):

• + Inhalation anesthetics, enflurane > isoflurane > halothane = enhanced activity of other neuromuscular blocking agents
• + Aminoglycosides; vancomycin; tetracyclines; bacitracin; polymyxins; colistin; sodium colistimethate = enhanced neuromuscular blocking action
• + Quinidine = recurrent paralysis may occur

Special Considerations:

• Contraindications: Hypersensitivity to this product.
• Warnings/Precautions: Only administer under the supervision of experienced clinician; use carefully in patients with myasthenia gravis or myasthenic (Eaton-Lambert) syndrome, possible anaphylaxis, long-term use has not been studied; Pregnancy category C; Dosage adjustment may be required in patients with clinically significant hepatic disease, use cautiously if used for rapid sequence induction in patients with ascites; malignant hyperthermia may occur.

Drug of the Month: Rocuronium bromide (ZEMURON ®)


Researching Which Programs to Apply To

Once you have decided on a specialty, it is time to begin looking at various sources of information about programs within that specialty. Many specialty organizations maintain databases on accredited programs, searchable by state/location. Often, the listed program names are links to individual program websites. Alternatively, you can use the official database, called FRIEDA, which lists all accredited programs in all specialties and is searchable by many criteria. The data in FRIEDA is always fairly accurate, but is updated most frequently during the active months of the matching cycle (September-March).

Another source of information about good programs to apply to is your own network of IMG physician colleagues and the staff at your Kaplan Center. These individuals usually have a working knowledge of where other IMGs found program interest, either in the form of offered interviews or where they actually matched.

Your own research can lead to other prospects by making use of the Unfilled Position lists from previous cycles of the NRMP match. We suggest that you limit this to the 3 most recent match years because program policies and their openness to IMG applications do change over time. Most medical school reference libraries will have copies of the Unfilled Position List booklets, or the booklets may be ordered online at the www.nrmp.org website. Once you obtain the lists, scan within your specialty of interest to find programs that have not always filled in the 3 previous matches. In the lists, this is indicated by subtracting the program Quota number from the Filled number listed for each program. Programs which have experienced problems in filling all the positions offered in the match are often more receptive to considering internationally trained applicants.

Once you have identified a number of programs that look interesting and potentially open to IMG applicants, visit their individual program websites to read about what they offer.





Musculoskeletal Mystery

A 21-year-old college football player complains of pain and swelling in his left thigh. He states that his thigh has been swollen ever since he was tackled hard at a football game 4 weeks ago. Evaluation at the time revealed mild bruising but no fractures. An x-ray performed now reveals a circumscribed radiodensity with central lucency in the distribution of the vastus lateralis muscle. This ossific density appears to be distinct from the femur, and no fracture is identified. A follow up x-ray performed 4 weeks later showed more ossific material centrally with no fracture. Which of the following is the most likely diagnosis?


(A) Extraskeletal osteosarcoma
(B) Lipoma
(C) Malignant fibrous histiocytoma
(D) Myositis ossificans
(E) Stress fracture

The correct answer to the question above is: D.

1. Although important to exclude, extraskeletal osteosarcoma occurs in older individuals, is not preceded by trauma, and does ossify initially at the periphery.
2. Lipomas can develop in the young adult, but not so rapidly and do not ossify.
3. Malignant fibrous histiocytoma is a soft tissue tumor with a variety of cell types. The angiomatoid variant occurs in young adults. It is an unlikely diagnosis given the history.
4. CORRECT: This is a classic presentation for myositis ossificans. As the name indicates, it is formation of osteoid matrix within the muscle. Although often associated with a preceding traumatic event, this is not always the case. In the initial stages, myositis ossificans presents as an area of soft tissue swelling. As the bone matrix is laid down and the trabeculae are mineralized, the lesion becomes visible on radiographs. The process of ossification begins peripherally and progresses centrally until the entire lesion is ossified. Excision is usually curative.
5. Stress fractures may initial be radiographically occult, but are usually seen on later films. They are also not associated with soft tissue lesions.