STUDYING TIPS FOR THE PANCE AND PANRE
(LESSONS MY MOTHER TAUGHT ME)
As a professor and lecturer of PA board reviews, I am around students who voice their concerns to me all the time about passing the PANCE. As a practitioner that has take the recertification (PANRE) twice, I also understand the unique concerns of a practicing clinician. Some of the concerns are similar and some are unique to each. For example, both the student and the practitioner are prepared enough.
Practitioners taking the PANRE who specialized in specific fields are concerned if they can retain the information even though they don’t use most of it clinically anymore. Students wonder if they have studied enough and did enough questions to be truly ready or are often confuse that what they saw and learned on rotations aren’t what the exam questions seem to reflect. My mother and I hope to answer some of these concerns in part 1 of Studying Tips for the PANCE and PANRE.
First, about my mother. She is a retired beautician. 6 years ago I signed up for my first recertification and told my mother in passing conversation. With the busy life I led, I completely forgot about it. But what we find trivial, our parents tend to remember in great detail (thank goodness). So I am home on the day of my exam and she calls me to wish me good luck on my exam. I ask her what is she talking about and she reminds me 3 months ago, I told her I had to take the exam on that day. I jumped out of bed, got dressed, tried to study on the way to the testing center and took my first PANRE. I was lucky that my background in internal medicine and emergency medicine helped me to pass. But it made me realize that I took a great chance by not studying. Despite not having any medical background, things my mother taught me throughout the years are helpful in studying for the PANCE & PANRE using her quotes from song, the bible, things she made up on the spot while yelling at me, etc.…..
I came home from school in the winter and wanted to play outside. And since the sun went down faster during the winter, my mother would say:
“Your money is time, so spend it wisely and your play time is up when the streetlights come on"
After graduating and before taking the PANCE, PA students have all the time in the world to study (though many of them argue against that notion). For practicing PA’s, free time is like a Pink Star Diamond, extremely precious and exceedingly rare!! So when you do find the time to study, you have to maximize that time so that you get the most out of the study time.
“By failing to prepare, you are preparing to fail" – literally!!
She may have stolen that one from Ben Franklin, but she loved to say it. You have to spend some time studying in order to pass the PANCE or the PANRE, especially for what I call the “Silver-Star PA’s" - those who have been practicing over 20 plus years or close to retiring but still have to pass the PANRE to continue practicing (even if its only for a few more years). The earlier you start, the more time you have to prepare. Even if it means studying for that half an hour that it takes you to get to work on the commuter rail, or during down time at work etc.
“Look both ways before you cross!!"
Just as important as it is to set aside time, learning how to divide that study time is important to maximize the effectiveness of your studies. Most people are aware of the PANCE blueprint and for those of you who aren't, the NCCPA website has graciously provided us with a blueprint which breaks down the exam percentage by organ systems. They even go one step further as to provide us with all the details of the things that comprise that organ system. So your study time should reflect that. Your goal is to be comfortable with at least all the topics within each organ system with at least 80-85% to ensure a pass rate. You should study all of them, but if you are limited on time, then you should use the percentage to help govern how you spend the allotted time, spending more on the topics or organ systems that have a higher percentage. If you have an understanding of most of the major topics, then you can focus the time on the stuff you don’t feel comfortable with.
You should be the most comfortable with what I call the “Fabulous 5" otherwise known as the topics that take up a passing percentage of the boards: 1. Cardiology (16%), 2. pulmonary (12%), 3. Gastrointestinal/nutritional (10%) Musculoskeletal/Rheum (10%), and 4. EENT (9%). This accounts for 57% of the material on the boards, so in studying, your time should be maximized on studying these topics to ensure a passing score. Now I know you are thinking that is the fabulous four instead of five and you are right. The fifth one is the one I call the silent giant – Infectious disease. I call it the silent giant because in the percentage, it only comprises 3% (which seems like barely nothing) but in reality, there are many infectious topics in all of the other organ system areas that are classified under the organ systems that deal with infectious disease: ex. Influenza in pulmonary, meningitis in neurology, viral exanthems in dermatology, bacterial gastroenteritis in GI etc. So infectious disease takes up a bigger bulk than the percentage the blueprint describes.
Once you feel comfortable in those topics, then you can use the time to study the other topics as well to boost your score and better your chances of passing.
Now this does not mean that poor little hematology that only accounts for 3% should be forgotten about because for those who failed by a few points, that small hematology section could have pushed them over to the pass section, so the little subjects count as well to provide you with a protective passing cushion.
Many people are well aware of the breakdown by organ systems and look for it but then get hit by the “task-area" truck coming from the other direction because they failed to look both ways. The truck is the other component that many people either forget to look at, ignore or don’t even know exists when looking at the blueprints. I can’t tell you how many times students tell me they didn’t look at pharmacology because they “weren’t good at it" and they figured they would do well on the PANCE/PANRE without it. Pharmacology makes up a whopping 18% of the exam!!! How do I know this??? Because when you “look the other way" you realize the NCCPA also gives us another gem in our preparation arsenal: the exam breakdown by task areas.
The site also breaks down what comprises each of the task areas. The exam is broken down by specific topics, which is crucial for maximing your studies. So when you are studying the organ systems this is how you should focus your studies in those particular systems. Pharmacology has the highest percentage when it comes to task areas.
HOW TO STUDY:
Everyone is completely different and so your study techniques should reflect your personal level of retention, style of learning or preference. Whatever your technique is, it should involve some sort of 1) reading/viewing and 2) practicing questions as an active way to test what you are retaining.
1. Reading is important because most students and practitioners fail to read enough and that is the foundation to passing. In reading, the goal should be to memorize what you need to. What I have found fundamentally true is that the more that you understand, the less memorization that it takes to understand concepts and it also helps you to cross reference other topics. For example understanding that acetylcholine in the neuromuscular junction promotes nerve conduction transmission, promotes digestion in the GI tract, promotes urination in the GU tract and promotes constriction of the pupil in the eyes will help understand the drugs better. Acetylcholine muscarinic receptors cause SLUDD-C (Salivation, Lacrimation, Urination, Defecation, Digestion, Constriction of the pupil). This helps to understand a myriad of diseases or use of medications. For example: cholinergic drugs can be used in Sjrogen’s (a disease that causes dry eyes and dry mouth) by promoting salivation and lacrimation, anticholinergic drugs can cause glaucoma (by dilating the pupil and closing off the angle), anticholinergic drugs can be contraindicated in BPH (because it promotes urinary retention), & anticholinergic drugs can be used to treat diarrhea (they slow down the GI tract). It explains that increased activity of acetylcholine can cause tremor in Parkinson’s (due to decreased dopamine), so anticholinergic can help with the tremor. All based on a simple understanding of the basic physiology you can make connections across organ systems. So don't only read to memorize, also read to understand!
2. Questions are helpful because they allow you to apply what you have learned so that you are able to see what you understand and what you still struggle with. Another reason why questions are so beneficial is in understanding the explanation of the correct answers. Sometimes we pick the right answers for the wrong reasons, which may have gotten us a correct answer, but could lead to a wrong choice selection where it counts most, on the exam. So when you get an answer right, still read the explanation to solidify the material you already know and to see if your train of thought was in line with the thought of the question writer, which will enhance your exam taking techniques. Also reading the explanation of the wrong choices gives you a studying snippet of the other 4 wrong choices. So in essence, with reading the explanation to that one question, you just studied five diseases. Most people just look to see if their answer was right and then move on. It is much more effective to read it even if you got it right. Repetition promotes retention. In writing questions, some of the choices are easy to eliminate and then some can be eliminated with some minor thought. However, there is often times when you left with what I call “the dreaded duo." Those are the two final choices you are left with where you are unsure which of the two is the correct answer. Understanding the similarities in diseases and the critical differences are one of the main things the exam questions are looking to see you are able to elucidate. For example:
A 65-year-old patient has a harsh systolic crescendo-decrescendo murmur that radiates to the neck and is best heard at the right upper sternal border. The murmur decreases with inspiration and the valsalva maneuver. Which of the following is the most likely diagnosis?
a. pulmonic stenosis
b. aortic stenosis
c. mitral stenosis
d. aortic regurgitation
e. hypertrophic cardiomyopathy
In trying to answer this question we can already eliminate choice C (Mitral stenosis) and choice D (aortic regurgitation) because we remember by our cardiac mnemonic “AR MS rest" that aortic regurgitation and mitral stenosis are diastolic murmurs and the vignette says the murmur is systolic. What the remaining three choices have in common are that they are all systolic murmurs. So now you have to look at the clues in the stem to start weeding out the incorrect answers. With more consideration, we can weed out Choice E (hypertrophic cardiomyopathy) despite the fact that the murmur of HCM sounds very similar to aortic stenosis because we know that decreased venous return (ex. performing the Valsalva maneuver) decreases all left and right sided murmurs (with the exception of hypertrophic cardiomyopathy). So valsalva would increase the murmur of hypertrophic cardiomyopathy (even if you didn’t remember that the murmur of HCM does not radiate to the neck). Now when left with the dreaded duo, you use the clues to determine the answer. Both aortic stenosis and pulmonic stenosis can sound similar but you remember from physiology that inspiration increased blood flow to the right side (so the blood can get oxygenated) so inspiration would increase the right side flow and thus the murmur of pulmonic stenosis (decreasing the murmur of aortic stenosis) as well as the fact that pulmonic stenosis would be most commonly be maximally heard in the left upper sternal border. This rules out choice A, making choice B (aortic stenosis) the best answer to this question. Often, there is more than one clue in the question stem that can help you to get to the right answer. Taking many questions gives you the skill on honing into them and picking those things out.
- BOOKS: My favorite book study book is PANCE PREP PEARLS on amazon.com not only because I wrote it, but also I really believe the format of it maximizes learning. The other two books that my students say are great are the DAVIS BOOK and the COMPREHENSIVE GUIDE (which is endorsed by the AAPA).
- WEBSITES there are many good websites out there. One that I have found particularly useful (and also gives you much more details on the available sources) is the PALIFE In addition they have practice questions and other great advice for both the student and the practitioner as well as awesome resource information on all the tools available to you.
- Review courses: The RUTGERS review course is one that many of my students have said has been a big help to them. My personal favorite review course is CME4Life because of their philosophy of gaining an UNDERSTANDING of medicine and MAXIMIZING your mind. CME4LIFE
- Exam Questions: the NCCPA has great questions, the link above to the palife, exam master and Kaplan just to name a few.
(Please note, I do not have any affiliations with the above organizations but just mentioning the ones that I get the most positive feedback from my students).
“Don’t be afraid of the lions, tigers, bears and ZEBRAS"
The PANCE/PANRE exam is not an exam based on clinical experience. It is based on the exam content and standards of practice. I think this is one of the hardest concepts for already practicing PA’s like myself because we get tested on diseases we don't see like smallpox (despite the fact the last case of smallpox in the United States as in 1949). So for practicing PA’s, don’t use the strategy that the Zebras (the diseases that are rare in compared to the horses) are not important to study. There are certain high-yield topics that come up a lot on exams and you will begin to notice the pattern once you start doing questions.
“Just because your friends do it doesn’t mean you can do it too!"
Although it infuriated me when my mom would tell me that (I really wanted a unicorn at my party after seeing Johnny had one at his). What we see and do in clinical practice can be different than what is on the PANCE/PANRE. The PANCE/PANRE is based on standards of medicine. In clinical practice, I rarely ever tell someone to come back in 3 days for suture removal on the face but the guidelines say that suture removal in the face is done in 3-5 days, so know the standards that will be tested. It is also hard for practicing PA’s because our drug of choice that we use for a disease based on our personal experience, hospital policy etc. may not be the standard drug of choice.
A caveat to that concept is to remember that the boards are also behind when it comes to changes in standards, so any new standard changes used in clinical practice that occur this year (for example) will not show up on the boards for at least a couple of years. The take home point is to know the standards of what will be on the exam. Again very important for the practicing clinician taking the PANCE/PANRE.
“Learn those books like you learn those songs."
My mother refused to accept that I couldn’t master trigonometry since I knew all the words to the every single one of the top 100 songs on the countdown. Learn the buzz words because they are often the deciding factor when you are left with two choices with a relatively similar presentation or similar exam findings. Also when learning them, know all the different disorders that buzz word is related to so you can look for the differences to help find the right answer.
Ex: A 22-year-old female with no prior medical history presents with diplopia and generalized muscle weakness that worsens with repeated use of the muscles. There is no history of night sweats or weight loss. There is no crepitus on palpation of the chest wall. A chest radiograph shows mediastinal widening. Which of the following is the most likely diagnosis?
A. Inhalation anthrax
B. Thoracic aortic aneurysm
C. Cardiac tamponade
E. Small cell lung carcinoma
So you highlight widened mediastinum as a buzz word, only to your chagrin when you read the choices and realize all of the choices can cause a widened mediastinum. Since all of the following disorders can potentially cause a widened mediastinum and many can cause fatigue or weakness, you have to use the additional “buzz words" to help you to figure out the answer.
Choice A (inhalation anthrax) is a rare disease and may be associated with a cutaneous presentation so a buzz word for that would have been a “painless black eschar on the skin" or exposure to cattle, sheep swine etc.
Choice B (thoracic aortic aneurysm) buzz words would include a “history of uncontrolled hypertension" “severe chest pain that radiates to the back or neck". The omission of those in the vignette would make this choice less likely.
Choice C (cardiac tamponade) buzz words would often include one or more of Beck’s triad (muffled heart sounds, systemic hypotension, increased jugular venous pressure)
Choice D (thymoma) buzz words would include an “anterior mass" or may present with Myasthenia Gravis (which is due to antibodies against POSTsynaptic acetylcholine receptors at the neuromuscular junction). This leads to generalized “weakness that WORSENS" with repeated use.
Choice E (small cell lung carcinoma) can cause Eaton-Lambert syndrome (which is the development of antibodies against the PREsynaptic calcium-gated channels responsible for acetylcholine release. The buzz words would include “generalized weakness that IMPROVES with repeated use."
Based on the buzz words given or “denied" in the vignette, choice D would be the best answer.
“Six of one, half a dozen of the other"
When I would try to delay doing a chore until later, she would tell me “ If you do it now or later, you are still going to have to do it before the day is done. Six of one, half dozen of the other". Many people remember the buzz words but often will forget what it means or don’t take time to understand the meaning of it. For example, may people remember whenever “Bamboo spine" like a Pavlovian dog, we are trained to say ankylosing spondylitis. Sometimes on the boards, they may put down Bamboo spine, but be aware of the fact that they may describe it in words such as “vertebral body fusion of marginal syndesmophytes" or more commonly “squaring of the vertebral bodies" which all allude to the “Bamboo spine." Another way they may describe the pulse of aortic stenosis besides the pulsus parvus et tardus is a “weak delayed carotid upstroke" so don’t just memorize the buzz words, but to be able to recognize them in all of their forms.
“Drugs are good for you"
In Panama, for every change of season, we would have to take a laxative or what she would call a “purge" of Castor Oil to clean out our systems. Besides Buckley’s cough syrup, that was the worse thing I ever tasted. I tried to get out of it by saying “Mom you told me to never take drugs" and she would tell me some drugs are good for me. Remember, pharmacology is 18% of the boards and many students and practitioners alike tend not to do well on this topic. They stress this on the PANCE/PANRE because one of the benefits of being a PA is our ability to prescribe medications. We have to understand how the drug is working for the disease we are using it for, side effects to warn the patients about (which often are related to the mechanism of action), contraindications and drug interactions so that we don’t cause harm to our patients unknowingly. She loved Willie Nelson so she would often sing:
- “You gotta know when to hold them." Know generics! Some medications have multiple brand names but there is only one generic name of a medication, and often times (not always) the ending of generic drugs can help you with the class of the drugs. Such as “pril" ending for ace inhibitors, “artan" for angiotensin receptor antagonists, “tidine" endings for the H2 blockers etc.
- “You gotta know when to fold them." You also need to know when the endings may mislead you. For example metronidazole is an antibiotic that is not in the same class as fluconazole (an antifungal) or that because many antibiotics were derived from Streptomyces, some drugs can have similar endings but are in different classes, such as streptomycin, vancomycin, clindamycin, erythromycin.
- “Know when to walk away." You need to know what are some of the precautions when using certain drugs, such as beta blockers can mask hypoglycemia.
- “Know when to run" - you need to know absolute contraindications of medications.
“Eat all of your veggies"
In doing exam questions, never leave any questions unanswered. Answer all of your questions. Because the PANCE/PANRE is a timed exam, you should practice doing questions in a certain amount of time, leaving yourself about a minute for each questions to assure that you answer questions sufficiently. If you think you have an answer but you spend 10 minutes perseverating on which one is right, then you have lost valuable time to answer other questions for that one question, forcing you to rush your thought process in answering the remaining questions. So put an answer down and flag it so that you can come back to it at the end of the exam and then have all the remaining time to spend on the flagged questions now that you have given an answer to all of the other ones. I have also found that, if I am lucky, some other similar question in that question block may have given me the clue or jarred my memory enough to remember the answer to a flagged question.
“When in a rut, trust your gut"
This is also crucial in time management tool when you are stuck on a difficult question. Many people will have a right answer and then change it to a wrong one because they falsely doubted their choice. Changing it may work if you were initially unsure of the choice you made and, through further reading, you now feel there is a better answer. But if you strongly believe an answer is right based on material that you feel you understand, then chances are your gut was right. Although this method doesn’t work for everyone, I am a firm believer in reading the stem and the question and then predicting what the answer would be before even reading the choices. If I am fairly confident in it based on the stem buzz words, inclusion and exclusion factors, then that will be my default answer when I am not sure which of the two to pick. I may still flag it and then come back to it later if I have time left over to make sure I am not missing anything. If there isn’t anything compelling when I re-read it to make me change my answer, then I will stick with it. And by compelling, I will give you this example. Let’s say I didn’t follow my own advice and I spent 5 minutes on one question and now I have 5 questions left and 6 minutes so I fly through the last few questions and flag them. Now with the last 2 minutes, I go back to the question that states:
A 42-year-old male presents with right leg swelling, pleuritic chest pain, tachypnea and shortness of breath after a 10 hour drive from Georgia to Connecticut. Labs show a Creatinine of 1.8, Sodium of 140, with a negative troponin and creatine kinase levels. ECG shows an S1Q3T3 pattern. Which of the following is the next most appropriate diagnostic test in the management of this patient?
A. D-dimer levels
B. Pulmonary angiography
C. Helical CT scan
D. Ventilation-Perfusion Scan
E. Coronary angiography
My choice when I read this was choice C but I admittedly read this fast. I used all the stuff from above. I used my “buzz words’ to know that this sounds like a classic pulmonary embolism presentation and that the ECG shows a classic (not common) ECG finding of S1Q3T3, making my best initial test in this vignette Choice C (Helical CT scan). But now rereading the question with more time, I realized the patient has an elevated creatinine, so the administration of IV contrast may worsen the kidney function in this patient. That qualifier now makes choice D (ventilation perfusion scan) the better option. Had it not been for that, I would have kept my answer as C. So if I reread it and I knew my answer was C and there were no factors to change it, I would have kept C but that qualifier does change the answer in this specific instance. Here, the test writer wanted to see if you knew how the person’s medical history would change your management.
This brings me to another important point. My mother would often say:
“If I ask you about the moon, don’t answer me the sun"
She would always say that to me when she asked me a question and I was stalling to find the answer I thought she was looking for by replying about something else. Always answer what the question is asking you.
Giving those same choices, if the vignette said or alluded to a low suspicion of PE and there were no compelling findings for DVT or PE, then D-dimer would have been correct. If the question asked “Gold standard" or “Definitive diagnosis" then the answer would be Pulmonary Angiography. This becomes important in questions that say “NEXT appropriate" etc. because sometimes you know the disease but you answer wrong because you didn’t answer what the question was asking. Remember that gold standard tests are often (not always) invasive and so are usually done to definitively diagnose someone with a high suspicion and a negative (often less invasive) test. Or if they specifically want to know what is the definitive diagnosis, don’t answer what you think you would be the next step. Many students tell me well isn’t the “the most appropriate" test the gold standard and in question form that usually does not equal to “six of one, a half dozen the other".
Remember that classic doesn’t necessarily mean common. For example the “classic migraine" is with an aura but most patients with migraine “common migraine" present without an aura. Or the classic chest radiograph finding in pulmonary embolism is Hampton’s hump or Westermark sign but the most common chest radiograph finding is a normal chest X ray. So read the question carefully to make sure you are answering what they are asking of you.
“Sometimes you avoid choking when you realize you have bitten off more than you can chew."
Be honest with yourself. If you are not ready to take the exam, don’t go into it “hoping for the best". This is different than being nervous or apprehensive about the exam. Deep inside, you know when you are not ready and you have an objective way of telling if you are not consistently falling above that 80-85% range on the “Fabulous 5" organ systems. Again “Failing to prepare is preparing to fail". So if you are not doing well in your studies, then delay the exam until you are ready. You won’t magically pass if you are not ready. Many students just hope for the best and end up with the worst.
“Hope for the best, plan for the worst"
Make sure if your certification is up soon, don’t wait until the last minute to take the exam. In the worst case scenario that you fail, you have to wait 3 months to take it again, which can put your career in jeopardy if you are a practicing PA. Give yourself enough time cushion so that you can retake it, take another course, study more etc. to ensure you pass the second time around.
Speaking of knowing when to fold them, I hope that these tips or techniques in terms of studying and approaching exam questions are helpful. Good luck, and make sure to thank my mother when you pass! :-)
Dwayne A Williams is a clinical professor at two PA programs and the author of Pance Prep Pearls, a study guide for the PANCE and PANRE available on amazon.com. He is also the author of the Medical Mnemonic Comic Book as well as the FlipMed medical app.
Winifred Williams is the author of Dwayne A. Williams :-)