Maximising the Practice Exam Experience
Past exams and practice exams are not simply a way to assess your progress knowledge-wise, but, if used correctly, are also a holistic study method. We can use them to consolidate concepts we understand through positive reinforcement, as well as learn new ideas and facts. Gliding through a resource of this nature and simply marking it to get an arbitrary score does not even scratch the surface of what these resources have to offer. They can specifically train our knowledge and skills to better suit what is required of us in an exam scenario, and also act as a brilliant opportunity to get inside the examiner’s mind and understand how it is that they assess us.
When being used correctly every wrong answer in a past or practice paper is an opportunity. It will offer us the chance to read around the relevant literature, study in a more precise way and ultimately enhance our understanding of medicine. This guide is directed at the traditional EMQ medical exam, but the methods are of course transferable to epidemiology, community health, evidence based clinical practice, health services and other fields of the course.
Choosing Resources
There are masses of potential questions to sharpen the blade of one’s medical knowledge. Over the course of your travels, you are sure to uncover past exams officially released by your faculty or another university, practice exams written by a company or student society, commercial question banks, or those infamous student recall exams. Let’s discuss which resources should be prioritised and why.
Past Exams
In short, these are the crème de la crème. Provided they are written by your faculty, for your year, they replicate the scenario you are actually going to face when it comes to your actual assessment as close as possible. In style, content, structure, focus and difficulty they are the best guide for your study.
The fact that they are officially released by your faculty makes it almost a certainty that they will not contain questions that will be repeated on your actual exam. But, of course, we’re not here looking for an easy mark, (for those of us that are, refer to “Student Recalled Exams”) we’re here to build real knowledge. The way these resources help direct your study is far more valuable (refer to “Studying with Questions”).
If you have access to other medical schools’ past exams, they can still aid your study, but of course their focus will vary slightly from how you will be assessed. For example, it seems that assessing the field of cardiology, Griffith University’s medical school seems to have little interest in assessing the different types of heart block while Monash University obsesses over it. Understanding this variance will ensure you don’t panic when encountering such content, and help you focus your attention where it is required.
It is not a given that official solutions will be provided with the release of a past exam. If there is, it will provide a degree of certainty about those select complex questions where the answer could be debated. When this is not available, there may be a student collaboration generated set of solutions available. These may not always be completely reliable but are a good medium for discussion and learning. Always take unofficial solutions with a grain of salt and conduct your own research where necessary.
Student Recalled Exams
These exams are generally created by students attempting to recall as much of the exams they recently sat and collaborating to recreate the exam as faithfully as possible. But try as they might, these recreations always leave something to be desired in terms of accuracy and completeness. You and your colleagues will inevitably encounter some of these over the course of your studies, and may be perturbed to find entire sections, option lists, or stems incomplete or missing. This may seem irrelevant but can become frustrating, as inaccuracies and deficiencies can be misleading and shift your focus away from where it is required. On the other hand, the perceived benefit is the potential for repeat questions to crop up in the actual exam - as these papers are generally based on more recent assessments.
However, it is important to recognise that the gathering of assessment material by students without faculty endorsement is generally against academic standards and may carry severe repercussions, for both those that create or are in possession of such resources. You must check the rules of your faculty and be aware of the potential consequences if you choose to engage with this material. Some faculties may enforce repeating of units or removal from the course for utilisation of such materials. A note about the use of unsanctioned materials may also make an appearance on the academic record.
Such resources carry severe repercussions and harbour significant shortfalls. Engaging in their creation, distribution, or application is not advised.
Practice Exams
These resources are written by commercial companies, specialist interest societies, medical student societies, and sometimes your faculty. They were never used in an actual assessment scenario. They tend to vary in quality and focus, so compare the content, style and structure with official past exams where possible.
Student specialist interest societies have a tendency of releasing sections of practice exams relating to their specialty that hugely depart from the difficulty level that your university would assess at. They do this to extend those that excel at their field, but we must ensure such resources don’t cause panic for the rest of us. Use them to learn, as they will build your experience in said field, if you don’t let yourself become too disheartened by their Herculean difficulty.
Question Banks
These resources may not actually appear in a traditional exam format, but rather present themselves as a stream of questions you can click through. Some of the larger resources may allow you to specify the specialty, level and difficulty of questions it presents to you (i.e., Pass Medicine, PastTest). This can provide a streamlined method of workshopping weak points in your knowledge. One of the greatest benefits of question banks is that they will often provide you with an explanation of their solutions, meaning your further reading and study is well guided and structured.
These are generally a paid resource when used online, so price may become a prohibitive factor. If the quality and mass of questions provided here is a must-have for you, consider organising having the members of your study group chip into a subscription that you can share.
Question banks in book form are also available for numerous specialties, subjects and levels of study. They provide similar benefits, including worked solutions and categorisation, and allow for the cost factor to be circumnavigated by borrowing them from your university library or acquiring an electronic copy.
Studying with Questions
The jumping off point for this style of study is of course to read the question thoroughly, analyse the key terms, and attempt to answer it. Your level of understanding of a question when you first encounter it will guide how you harvest every possible morsel of knowledge from it. As we will learn, knowing the answer to a question is only the beginning of what can be gained from it.
Questions you Understand
Through previous reading, study, clinical experience, tutorials, or lectures, you may well know the answers to some of the questions you encounter. But do not be hasty to discard such questions, as there is much more to be gained from them than a pat on the back. They can be reworked, repurposed, and reviewed to extend your knowledge of the field they assess.
Even if your instincts were right, and your selection from the option list was found to be correct, ensure that you understand each option, and research where necessary to fill in any gaps (refer to “Questions you Don’t Understand”). You should know precisely what it is about each of the other options that makes them incorrect. This will allow you to tackle more exercises based on this question.
Try writing your own question based on the same option list, but with a different solution. If time permits, write several, one for each option. This will fortify your understanding of how the solutions differ, and the quintessential factors that define and differentiate each option.
Explain to a colleague the question, and how you arrived at the conclusion. Explaining your solution takes a far more in depth understanding than simply selecting it. This exercise will make plain any gaps in your knowledge and provide a jumping off point for further discussion.
And finally, consider what details could have been included in the stem to make the answer more obvious. This is especially helpful for presentation and diagnosis-based questions levelled at the clinical student, as this exercise helps us understand what the characteristic features of a condition are, and how they appear in a history, exam or investigation, and precisely what terminology is linked to it.
Gaps in Knowledge
When you encounter a question you get wrong, you are often closer to the answer than you know. Sometimes, while your concept of a certain idea may be clear, your recall of all the details may fail you, and lead you to an inaccurate answer. These are often the questions where you have enough of an understanding to exclude all but two options, but chance fails you and you select the wrong one. For example:
After a thyroidectomy, a 43-year-old female reports paresthesia in her feet and hands. Examination reveals a positive Chvostek’s and Trousseau’s sign. This problem is most likely caused by which of the following phenomena?
A. Low systemic T3 and T4 levels
B. Increased TSH secretion
C. Hypothyroidism related iodide and chloride electrolyte channel disturbances
D. Hypothyroidism related changes to neural thresholds
E. Decreased PTH levels
You may have enough of an understanding of the endocrine function of the thyroid to rule out most options: you may know A is not likely as none of the symptoms are typical of low thyroxine levels (which are traditionally lethargy, sensitivity to cold, weight gain, constipation etc), that B is unlikely as there is no thyroid left for the TSH to stimulate, that D is unlikely as there is no recorded “neural threshold” change associated with hypothyroidism. This leaves you uncertain about whether the solution is C or E but has demonstrated you have an understanding of the function of the thyroid and the classical symptomology of thyroid pathology. Regardless of which of these two you choose; a learning opportunity has presented itself here.
In such a scenario, you need not re-engineer your understanding of the concept at hand, but rather fortify your comprehension and acquire more detail. To see this concept at a higher resolution specific research must take place. This pursuit of the details will require a search of your lectures, lecture notes, textbooks, and online databases. Here the key term that needs to be researched further is the “thyroidectomy” operation, and specifically its complications.
A close reading of the “Comparison of treatments of the thyrotoxicosis” on page 746 of Davidson’s Practice and Principles of Medicine (21st Edition) informs us that transient hypocalcaemia is a common complication of the procedure, while UpToDate’s page on Thyroidectomy clarifies that this is due to “transient hypoparathyroidism” and that “symptoms of hypocalcaemia range from mild (e.g. paraesthesia around the lips, mouth, hands, and feet) or moderate (e.g. muscle twitches or frank cramps) to severe (e.g. trismus or tetany)”. Further reading of their page on “Clinical manifestations of hypocalcaemia” explains that both the Trousseau’s and Chvostek’s signs are indicative of this phenomena, and the pathophysiology behind them.
This all leads us to the correct answer, E, and so deepens our understanding of the thyroidectomy operation, its complications, the situation and function of the parathyroid glands and the symptoms that result from their pathology. All questions where your understanding is significant but not complete can be further utilised for deepening your understanding in this manner.
Questions you Don’t Understand
If you find yourself in a situation that is completely foreign and you cannot find your bearings, it can be overwhelming. But we’re here to learn, and we should be glad we’re exposing ourselves to these unfamiliar situations in this setting rather than our actual exam. Initiate your research in unknown territory with something you are vaguely familiar with to help orientate yourself. For example:
Pre-surgery a patient has contents of the upper gastro-intestinal tract aspirated. Post surgery an arterial blood sample yields the following results:
pH 7.56
PCO2 53 mm Hg
HCO3- 41 mmol/l.
What is the most likely underlying pathology?
A.Mixed respiratory and metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Compensated respiratory alkalosis
E. Compensated metabolic alkalosis
If we had no understanding of compensated and uncompensated pH imbalances or the difference between a metabolic and respiratory alkalosis the similarity of the options here may seem vexing but let us use our understanding of high school chemistry as a jumping off point. Upon casting your mind back, you will recall that a neutral pH is 7, and anything above this is alkaline or basic. This understanding can serve as the foundation upon which we build a deeper understanding of this topic.
The next port of call would be to appropriate this understanding to a more medical context: what is the normal pH range for an ABG? And compared to this range how severely is this reading departing from that? To gather such general information can be found in the core medical textbooks (Davidson’s or Kumar and Clark’s).
From this point it is easy to relapse into the pattern of reading the entire chapter on water, electrolytes, and acid base balance from said textbook, but consumption of giant slabs of information is difficult to digest and recall, and the reason for using the medium of questions to study is help structure and contextualise our learning so that it may stand the test of time. Now that we have a grounding, the next step is to generate the handful of questions we have about the scenario at hand, and then go about researching them. For this example, they may be:
- How does the aspiration of the upper gastrointestinal tract affect pH?
- How would said pH change be categorised in terms of “compensated” versus “uncompensated” and “respiratory” versus “metabolic”?
For a very physiology-centric question such as our first one, we must know where to look textbook-wise. The gold standard textbooks by subject are generally well understood (Guyton for physiology, Grey’s or Last’s for Anatomy, Katzung for pharmacology, Davidson’s and Kumar and Clark’s for clinical medicine etc.). There are numerous lists published online, as well as an official booklist published by your medical faculty to guide you to the most appropriate texts. Textbooks can be prohibitively expensive, so it may be worth looking into what your university library stocks or procuring an electronic copy. For more clinical based questions medical databases and guidelines may be more helpful (refer to “Guidelines and Databases” from “How to Study from Clinical Cases”.
Gaps in Knowledge
When you encounter a question you get wrong, you are often closer to the answer than you know. Sometimes, while your concept of a certain idea may be clear, your recall of all the details may fail you, and lead you to an inaccurate answer. These are often the questions where you have enough of an understanding to exclude all but two options, but chance fails you and you select the wrong one. For example:
After a thyroidectomy, a 43-year-old female reports paresthesia in her feet and hands. Examination reveals a positive Chvostek’s and Trousseau’s sign. This problem is most likely caused by which of the following phenomena?
A. Low systemic T3 and T4 levels
B. Increased TSH secretion
C. Hypothyroidism related iodide and chloride electrolyte channel disturbances
D. Hypothyroidism related changes to neural thresholds
E. Decreased PTH levels
You may have enough of an understanding of the endocrine function of the thyroid to rule out most options: you may know A is not likely as none of the symptoms are typical of low thyroxine levels (which are traditionally lethargy, sensitivity to cold, weight gain, constipation etc), that B is unlikely as there is no thyroid left for the TSH to stimulate, that D is unlikely as there is no recorded “neural threshold” change associated with hypothyroidism. This leaves you uncertain about whether the solution is C or E but has demonstrated you have an understanding of the function of the thyroid and the classical symptomology of thyroid pathology. Regardless of which of these two you choose; a learning opportunity has presented itself here.
In such a scenario, you need not re-engineer your understanding of the concept at hand, but rather fortify your comprehension and acquire more detail. To see this concept at a higher resolution specific research must take place. This pursuit of the details will require a search of your lectures, lecture notes, textbooks, and online databases. Here the key term that needs to be researched further is the “thyroidectomy” operation, and specifically its complications.
A close reading of the “Comparison of treatments of the thyrotoxicosis” on page 746 of Davidson’s Practice and Principles of Medicine (21st Edition) informs us that transient hypocalcaemia is a common complication of the procedure, while UpToDate’s page on Thyroidectomy clarifies that this is due to “transient hypoparathyroidism” and that “symptoms of hypocalcaemia range from mild (e.g. paraesthesia around the lips, mouth, hands, and feet) or moderate (e.g. muscle twitches or frank cramps) to severe (e.g. trismus or tetany)”. Further reading of their page on “Clinical manifestations of hypocalcaemia” explains that both the Trousseau’s and Chvostek’s signs are indicative of this phenomena, and the pathophysiology behind them.
This all leads us to the correct answer, E, and so deepens our understanding of the thyroidectomy operation, its complications, the situation and function of the parathyroid glands and the symptoms that result from their pathology. All questions where your understanding is significant but not complete can be further utilised for deepening your understanding in this manner.
Questions You Don't Understand
If you find yourself in a situation that is completely foreign and you cannot find your bearings, it can be overwhelming. But we’re here to learn, and we should be glad we’re exposing ourselves to these unfamiliar situations in this setting rather than our actual exam. Initiate your research in unknown territory with something you are vaguely familiar with to help orientate yourself. For example:
Pre-surgery a patient has contents of the upper gastro-intestinal tract aspirated. Post surgery an arterial blood sample yields the following results:
pH 7.56
PCO2 53 mm Hg
HCO3- 41 mmol/l.
What is the most likely underlying pathology?
A.Mixed respiratory and metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic alkalosis
D. Compensated respiratory alkalosis
E. Compensated metabolic alkalosis
If we had no understanding of compensated and uncompensated pH imbalances or the difference between a metabolic and respiratory alkalosis the similarity of the options here may seem vexing but let us use our understanding of high school chemistry as a jumping off point. Upon casting your mind back, you will recall that a neutral pH is 7, and anything above this is alkaline or basic. This understanding can serve as the foundation upon which we build a deeper understanding of this topic.
The next port of call would be to appropriate this understanding to a more medical context: what is the normal pH range for an ABG? And compared to this range how severely is this reading departing from that? To gather such general information can be found in the core medical textbooks (Davidson’s or Kumar and Clark’s).
From this point it is easy to relapse into the pattern of reading the entire chapter on water, electrolytes, and acid base balance from said textbook, but consumption of giant slabs of information is difficult to digest and recall, and the reason for using the medium of questions to study is help structure and contextualise our learning so that it may stand the test of time. Now that we have a grounding, the next step is to generate the handful of questions we have about the scenario at hand, and then go about researching them. For this example, they may be:
- How does the aspiration of the upper gastrointestinal tract affect pH?
- How would said pH change be categorised in terms of “compensated” versus “uncompensated” and “respiratory” versus “metabolic”?
For a very physiology-centric question such as our first one, we must know where to look textbook-wise. The gold standard textbooks by subject are generally well understood (Guyton for physiology, Grey’s or Last’s for Anatomy, Katzung for pharmacology, Davidson’s and Kumar and Clark’s for clinical medicine etc.). There are numerous lists published online, as well as an official booklist published by your medical faculty to guide you to the most appropriate texts. Textbooks can be prohibitively expensive, so it may be worth looking into what your university library stocks or procuring an electronic copy. For more clinical based questions medical databases and guidelines may be more helpful (refer to “Guidelines and Databases” from “How to Study from Clinical Cases”.
In a section on “Metabolic Alkalosis” on page 666 of Kumar and Clark’s Clinical Practice of Medicine (8th Edition) it is clarified that the link between “nasogastric suction” and “metabolic alkalosis is substantial” and explains the exact mechanism of electrotype disturbance that takes place, allowing us to build knowledge regarding our first question.
Earlier in the same chapter elements of an explanation to our second question are also present: page 660 includes details of the precise pH range, and an a section on “Normal acid-base physiology” while a table on 638 clarifies the ranges of the relevant electrolytes (HCO3- should fall between 22 and 26 mmol/L and PCO2 between 35 and 45 mmHg), and that this patient indeed has “compensated” for their metabolic alkalosis with a elevated PCO2, guiding us to the correct answer, E.
The explanation that ensues is complex, and to ensure we don’t fall into the cycle of reading gargantuan slabs of information, we should attempt to create our own diagrams, tables and mnemonics from the information presented. Many questions have a “main idea” or “key” that, once understood, will make future questions of this type infinitely simpler. A good example of this is table 13.20 on page 663, on its own this table could actually serve to answer all questions of this type.
