How to Study for Your Physician Assistant Boards

PANCE/PANRE Test Taking Strategy

Here are the top ten bits of advice I'll have for you to pass your board. So this is the test-taking strategies that I recommend. This, again, is based on my experiences working with lots and lots of people who've taken this test. This is based on my experience working with test writers, people who wrote questions for the PANCE and PANRE. The one guy who I'm close with, his name's Robert Bay ... He is a really, really smart guy. He was director of the pack rat for four years. He came through my course, he helped my develop questions, he helped me develop the psychology. Again, this is based on me taking my boards, talking to hundreds and thousands of people who've come through my course. This is my test-taking strategy advice for you to take your boards.

Here we go. Number one is don't skip any questions. Ladies and gentlemen, when it comes to the boards, you're gonna get 60-minute blocks and 60 questions. I do not recommend the strategy of skip a question if it seems a little bit overbearing and I'll come back to it. Time can catch up with you, okay? Every single question, you leave an answer to, okay? There's no skipping questions. There's no advantage, it's just a huge disadvantage. Next, if you ... What if you don't know? Okay, clearly, ladies and gentlemen, there are gonna be a lot of questions that you viscerally know. I'm telling you, you won't know how valuable this course is until after you take your test. You won't know how many questions pop into your head because you remember something silly I said or I repeat it a couple times. Or you'll see the image of the erythema rashes and you'll know exactly where they were going with this.

You'll hear questions and you'll go, "Wait, this is one of those similar questions. John talked to me about this." But now, you read a question, and you just don't know the answer to it. There will be lots of them, okay? But now, I'm gonna challenge you to put it into two sub-categories. Is it a coin toss question or a Hail Mary question? Well, what's a coin ... Bottom line is, let's talk about the Hail Mary question. If it's a Hail Mary question, that means you read the question and you go, "I have no idea." It's like you're on the 50-yard line and you just throw the ball up at the end zone, three seconds left in the end of the game. Hail Mary is you read the question once and you have no idea of the answer. You just don't know where they're going. It's like it's a different language or you weren't in class that day. You have no clue. So then you read it a second time. And if you look at the distractors and you have no idea of what the answer is, here's what I recommend you do: drop an answer down and move on and you never look back. Just you're done. You're done. It's done.

Now please listen: there are questions on the boards that you're not designed to know the answer to. There are test questions that the NCCPA put out because they're testing something that is outside of what you're supposed to know. I don't know what they're testing, but they do it. How many questions? I don't know. It's absolutely confirmed that they do it. They ask questions that you're not supposed to know. Okay, yes ma'am?

Are those thrown out, then?

Yes, absolutely. They mean nothing. They don't even count, okay? Now, how do I know this? Well, I knew it from some high-end test writers telling me. But you know what cinched it for me? I'm teaching my board review class and Dawn Morton-Rias, the president and CEO of the NCCPA ... She came to my class in Orlando and she was sitting over here. And as I voiced this, I could see her head go ... okay? So, bottom line is, ladies and gentlemen, if you read a question and you just have no clue, it's one of those stupid test questions. Drop an answer, move on. Don't come back to it. Here's my concern: if you're a little emotionally fragile about this test and you get one of those questions, or maybe a couple of 'em in a row, it could be like a punch in the face. And it could hurt your whole day. Throw an answer down and move on. It doesn't mean anything. Don't carry any emotional burden forward. It's done. It's like a hockey goal. Like you get scored on, it's done. Okay?

It's like a firing squad, a military tribunal firing squad. You'll have eight guys on line. They do not load their own weapons. Someone loads it for 'em and gives it to them. One of the weapons has a blank in it. So they all fire (explosive sound). The guy dies. They go back to their rooms and they're like, "Man, did I just kill somebody? Wait a second. I could have had the blank." If you read a question and you're just clueless about it, it's just a test question. Just drop an answer down and move on. Don't come back to it. Now, ladies and gentlemen, that's different than a coin toss question.

A coin toss question is one of them where you can eliminate all but two. It's either A or B. And I don't know so much, it's either A or B. It's definitely not an alkalotic state, it's acidic. The pH is 7.1, so alkalosis is gone. It's acidic, I just don't know which one it is. Here's what I recommend you do: you answer it, and now you can flag it to return. So there's a button; it'll show you. You mark it, and then, "I wanna come back to this one if I have time." I think that's a good idea. Never come back to your Hail Mary questions, but your coin tosses: it's okay to revisit them. Now I'm gonna say something to you and I'm gonna ask you a question and you're gonna answer me with enthusiasm and I'm gonna tell you you're wrong. Just like when I ask which bites get infected more often, cat bites or dog bites. I didn't tell you that, did I? Holy cow, I skipped that with you guys. I'll come back to that.

You come back and look at a question that's a coin toss question and you change your answer. Do you change it to the wrong answer more often or you do change it to the right answer more often? What do you think?

Wrong.

That is incorrect, okay? Let me explain. Guys, we do computer-based testing, so we know when people changes their answers. So it's been documented. You more often change it to the right answer than the wrong answer. That's against conventional wisdom. Now, here's what I want you to know: I just want you, if you have a coin toss answer, give it a second look. Give it a second look. That's all. Now, what can happen is, after you hit a coin toss question and you finish the test, you come back and re-look at it. There is a chance that you're smarter now because you did more questions. Maybe the question opened up something. I'm not saying change your answer. I'm saying give it a fresh look. That's my advice. If it's a Hail Mary, no, no, no. Don't go back. Don't open yourself up to a punch in the face. It's done. It's a test question. It's a test question for the NCCPA. It means nothing.

Next, I love my gut. I love my gut. I love my gut. Something, again, that you guys can't know about this course: my absolute passion and obsession, my why. Why do I do what I do, okay? I'm not saying this lightly; I've thought a lot about this. I have put hours and hours into why do I get up out of bed in the morning? Why do I come into class and lecture for 10, 11 hours a day? Why do I do what I do? And I'll tell you exactly my why statement. My why statement is: to ignite empowerment in others so they can create extraordinary lives. That's why I get out of bed in the morning. That's why God put me on this planet: to ignite empowerment. Empowerment means a process of growth in strength and confidence, especially in finding one's own best will.

So my whole goal is to ignite you. To ignite you to be a better person. To be a better clinician. So you know what I do is? How do I do that? Well, I do it with trying to impregnate these thoughts in your head. I studied learning techniques. So everything I'm doing has meaning. I'm not doing it because I think it's cute. I'm not giving you a tacky pneumonic because I think it's tacky. No, if it works, it works. I've taught you so much stuff that's gone deep into your brain, that you're conscious might not pick it up, but your gut's gonna go, "Wait a second, I feel like I wanna pick this one, but something's drawing me to this one. I don't know what it is. Something makes me wanna go with this one." I'm saying go with your gut. Okay?

I'm telling you, your conscious mind is maybe 1 or 2%. Your subconscious mind is 98%. You have so much stored you can't even know. You can't even know. If your gut tells you an answer, my advice is go with that one. Is that a perfect strategy? No it's not, but that's my advice. When you take your pretests, practice that strategy. I'm telling you, go with your gut. Will you get every question right? No. I think you'll get more right than wrong. Question for you: if you play the game of blackjack and you have a 15 and the dealer's showing a king. What do you do? Do you hit or stay? What do you do?

Stay.

No, you hit. You don't know shit about blackjack! You hit! You always hit. The basic strategy says you will win more hands if you hit, okay? It's still a bad circumstance, but you will win more hands if you hit than if you stay. Okay? So, bottom line is, that's what I believe about this strategy. I believe you get more right than wrong if you go with the strategy.

Next, if there's a ... Guys, when you write a test question ... It's easy to write a test question. You know what's hard is writing plausible distractors. Writing answers that could fool you. So that's what's hard. That's why instructors love the similars so much, because I can write a plausible distractor with Crohn's and ulcerative colitis in the answer, because it could be either one. You're just looking for which one has fistulas. Oh, okay, that's this one. Okay? If you read an answer and you're like, "I don't think I've ever heard of that before," that's not right. That's not the answer. You were taught very ... bless you ... very well at this program. You guys are very well-prepared for your boards. So if you read an answer, something like a renin plasma level, and you're like, "What the hell is that? Did I miss that? Did I not study that? Was I ..." No, it's not the right answer. They're making something up. Okay?

Next: take the passive path. Take the passive path. Take the passive path. Take the passive path. Take the passive path. If there is a conservative distractor ... Now time out for a second. When I say a distractor, that means the answers. There could be four answers or five answers, just depends on the question. In an academic term, we call them distractors, because we're trying to distract you from the real answer. There's only one answer, but there are four or five distractors. If there's a very passive answer, take it. Let that bubble weigh high in your mind. If there is a passive distractor and the sequelae of the disease is not catastrophic, you need to take it, okay?

I could tell you in detail why I know this to be true. I'll spare you from it. I can't make a stronger recommendation than this. I would love to do this with you guys. I would love to take 50 NCCPA questions. This is what I would love to do with you: I'd like to take 50 of their questions from their pretest and do this. Put up on the board not the question, just the distractors. Just the answers. And we put it up there and I'd say, "As a class, you tell me which one up there is most conservative." You just tell me. So you all decided as a group, you all will go, "C. C is clearly the most conservative. It ends with the base question." Then say, "Is it right?" You'd read the question and go, "Well, yeah, it is." Okay, let's try another one. You put this one up here, and you'd go, "Which one's most conservative?" Well, paremyd is. Not Ciprol, metronidazole, not any of those antibiotics. Well, paremyd's most conservative. Let's look at the answer. Oh, that one's right, too.

Okay, I cannot stress that enough. I think that could be a 30-40 point swing on your boards, if you embrace this philosophy. Ladies and gentlemen, erectile dysfunction. What's the first thing you do? Is it testosterone levels? Put 'em on testosterone? Is it Viagra? No, it's couples counseling, okay? That's the passive path. Okay? I can't stress that strong enough. Pam needs you to go conservative. That's unless the sequelae of the disease is catastrophic and there's two that I wanna bring to your attention. What are the sequelae of disease that are catastrophic? GERD isn't GERD until you allow cardiac. Okay? You should not go passive on GERD. GERD is really cardiac ischemia until proven otherwise. That's the first thing.

Second thing is this: if you have a patient who's hallucinating, we don't send them to counseling. They need to be put on antipsychotic, okay? So those are two times that I wanna make you aware that you need to be a little more aggressive. Ladies and gentlemen: go passive. I'm saying this with the same degree of conviction that I'm saying to you when you get into clinical practice, be very, very mindful of diabetics. They're gonna burn you. I'm saying, you want an extra 30, 40 points in the boards? Get your psychology to go, "I'm not gonna be an aggressive PA. Pam won't tolerate it." Okay? Cool.

Next is what's called the Bestowa technique. This is my term. The Bestowa technique: it's the best way to bestow information from a test question. The Bestowa technique: let me tell you where this came from. This is kind of important that you understand how strongly I recommend this one as well. First off, you have the NCCPA and the AAPA. The NCCPA writes your tests. Now you have the AAPA. They have a concordant body called the PAEA, Physician Assistant Education Association. They have a concordant body called the PACKRAT committee. They write your PACKRAT. So who's on the PACKRAT committee? Same people that writes your PANCE. Academics. They're younger academics; they're not as senior as these, but they try to mimic this test. I know these test writers, and Robert Bay was the director of that committee for four years. So he went through thousands of questions, and he was on my payroll for a while. So after he left that position and it was unethical for him to do that, I hired him. He helped me with questions, helped me with the thinking process.

He said, "John, when you have people ... When you're working with students and there's a long, base question, like three or four lines, four or five lines, have them read the last line of the question, then the distractors, and then the base question." He said, "John, it'll make them really focus their thinking well." Now, he stressed it very highly. I didn't know if I believed it as strongly as he believed it, so I will not tell you guys stuff unless I believe it, too. I think he's incredibly credible and he tried to say, "John, teach 'em to do this." I didn't know if I felt that way until I took my boards, until I did my pretest and boards, and I'm like, "This is super effective." But that still ... It's a little too subjective that I wanted to push heavily.

Then something happened that I almost think was a little bit divine. You tell me what you think. I'm teaching a course in Nashville, Tennessee, and every single class, this class included ... There's a couple people I get to know a little more than other people, for whatever unique circumstance. Like someone who, all day, is just going, "Oh." I just get to know some people a little bit more. Okay." I'm kidding. So, bottom line is there are a couple people I just get to know more than others. That just happens. Every single class, there's a couple people I just had some sidebar conversations with. So right up in the front of the class was this young lady, this young lady, and this gentleman. I really liked them a lot. I just talked to them a lot during the course, and I just got to know them very well.

So I just like them, okay? And this guy was a super nice guy, kind of a spiritual guy. Thank you so much, I really appreciate that. So at the end of the course, he's like, "You know, I don't think I'm a super spiritual guy." He said, "Can I pray with you before you go?" And I'm like, "Yeah, please! Please, I can use that." Just super kind people, right? I liked them very much. So I said goodbye, I jump in my car, we drive two hours to Memphis. So I got another course in Memphis, I'm off on Wednesday, it starts Thursday, Friday, Saturday. I drive two hours to Memphis, I get in about 11:00, 1:00. So it's ... I get there and I got a two-hour conference call. So I get on the conference call, it's now 3:00 in Memphis, I'm two hours away from this other college. And I'm like, "Okay, what am I gonna do now? Like, well, let's go to the gym." Fine.

So I go and get ready to go to the gym and I go through my clothes and I realize, I hadn't packed enough clothes. Like, I under-packed gym clothes. So I pick up this shirt and I'm a sweaty dude, okay? And I wore it in Nashville. So I'm picking up this sweaty shirt going, "Ah, I just wore it." It's still a little damp, you know? Like, kinda ... and I'm like, "Am I gonna wear ... Come on." And I'm thinking, "I don't have enough clothes," and all of the sudden I'm like, "screw it. I'm gonna wear my stinky, sweaty shirt." Like, I got defiant about it. Who cares about a sweaty, stinky guy in Memphis? No one cares, okay? Like the song Walking in Memphis? And I go, "So I'm stinky in Memphis." I didn't even care.

So bottom line is I put on this shirt, and I'm like, "I don't care. I'm just going to the gym." So I go get on the elevator. I go down, the elevator opens. Who's standing right there?

The guy?

Her. She's standing there. And I'm like, first thought, "What are you doing, you freaky stalker chick?" First thought, right? Second thought is, "I'm in a stinky shirt." So I do this. "How you doin'?" So I give her knuckles from afar. "What the hell are you doing here?" She says, "Oh, we're doing our OSCEs tomorrow at this medical school in Memphis and we thought we'd come stay the night so we could go early in the morning." And I'm like, "Are you kidding me?" Where do you think she was right now? She was in the gym. So the one was right there when I got off the elevator, the other one was in the gym. And I'm like, "Okay, what do you got for me? This is crazy!" So bottom line is, I talked to them, I said, "Can I take you guys to dinner?" Okay, fine. So we go to dinner that night, and take 'em out and start talkin' about where they are. Because they're taking their boards like you guys in a couple weeks, and as I'm talking to them, the one girl's super smart. She's super good. The other one was in huge trouble. She had a nice front; she's in trouble.

And as I talked to her, she knew how much trouble she was in. And I'm like, "all right, well let's meet. Let's work, let's do some questions." So I met her in the lobby that night, we got a laptop out, let's do some questions. So bottom line is, we go for about a half an hour, and I said, "I want you to read the question and talk out loud. Tell me what you're thinking as you go." And all of a sudden, as she's thinking, (shooting sound) she is all over the place. She's cognitively trying to herd cats. She got nothing. She is like, clueless. And i finally had to say, "You've gotta stop. You're not thinking right. You're so broken. And her knowledge wasn't a big problem; she couldn't form structured thinking. So finally I said, "Read the last line of the question, read the distractors, then tell me about the distractors. Tell me what you know about 'em, and then read your base question."

So she started doing that, and all of a sudden, she started nailing it. all of a sudden, her thinking was very, "Well, it can't be that one because of this." That's beautiful. All of a sudden, she'd eliminate it down to two distractors and that's still a huge ... So all of a sudden, we worked on it for an hour, and at the end of it, I'm like, "she's now thinking right. She's so structured. There was an a-ha moment like, 'Oh, I get it now.'" Every once in a while, she'd get some momentum and some confidence and then we'd have a big base question. She'd start reading it at the top, I'd have to smack her. Like, no, read it our way. Do the Bestowa technique. And all of a sudden, it was so effective. I highly recommend it.

Let me show you an example of it. Here's an example of the Bestowa technique. So the last line of the question is: What's the best transportation option to the site? Is it an SUV, motorcycle, boat, walking, or airplane? So bottom line is, right now, I would say, "You tell me how would the question have to be written that SUV would be the best answer?" Well, I mean, maybe if you're going up a hill, 4-wheel-drive, you need 6 people in the vehicle. Motorcycle: well, maybe if you're going through narrow streets, or again, going up a mountain with a bunch of trees. Maybe if you're going super fast. Boat: well, that speaks for itself, water. Walking: when is that the best? If you said ... because I parked over in parking garage 2. What's the best way to get from here to the parking garage? Well, walking, of course. I'm not taking a boat or a motorcycle. It's best for me to walk. It's so close.

Airplane: okay. So bottom line is, right now, you think about what does the question have to say for those to be right? Now to go to the question. You were on vacation with your friends in Belize. It's a wonderful vacation spot. The resort is 32 miles from the airport; which various transportation options are available? You coordinate with your travel agent and decided that a private car was the best option. The resort is two miles from the paved road, so the driver drops you off at the base of the trail to the resort where you walk to registration. The bugs are plentiful, but good thing you put on bug spray. An iguana crawls in front of you and startles you. You are excited, as tomorrow, you will be doing your first open-water dive to finish your scuba certification. The dive site is 20 minutes from the resort dock. What is the best transportation to this site?

Okay, clearly this is a little ridiculous. It's the same concept. Same concept. Here's what happens, ladies and gentlemen. Let's just say you're reading about a 49-year-old guy with pain right here. So you're reading the question: 49 comes in with right upper quadrant, right lower chest pain. So immediately you go, "(gasp) This could be a PE. It could be a PE! This could be a PE." Your subconscious is saying it. Your conscious mind's not saying it. You're subconscious is going, "This could be a PE." So you tell your subconscious, "Psst. Go pull a PE file. Could be PE." So your subconscious is going through papers trying to find PE. And then you're reading and go, "Psst! Oh! This could be pneumothorax! Pull the pneumothorax file!" So your subconscious starts pulling these files, getting really nervous. Then you're like, "Wait, could be biliary colic. Psst, pull biliary colic! Pull pancreatitis!"

So all of a sudden, you're telling your subconscious to start pulling all these files as you're reading this long base question. So you got a bunch of files out, "Okay." Then you read the distractors. The distractors are biliary colic, cholecystitis, choledocholithiasis, pancreatitis. And you're like, "I don't need PE file or pneumothorax, put those away!" But your subconscious invested energy there. But if you read the distractors, they say biliary colic, choledocholithiasis, cholangitis, and pancreatitis. Then you read the question. Your brain will not waste any energy thinking about those because they can't be PE or pneumothorax. Because it can't be true. I highly recommend this.

Now, here's what I'm telling you. I don't think you're gonna be able to implement this on your own without you having a lot of discipline practicing it, because you are very well-conditioned. You are very good at test taking or you wouldn't be here. You're academically, ridiculously sound. This is just a strategy. When I was training for a triathlon, one of the times I trained I was in a waveless pool. So you're sitting in a pool and the waves are coming at you. So I'm swimming, but I'm not moving. And I have a coach on the side and he's got a noodle in his hand. So every time my hand isn't entering the water right, he'll wack my hand with a noodle. Until I get it right, and then he'll stop whacking my hand. Okay, fine. So he's giving me real-time feedback that, "Hey, you better change your body position," right? Very effective.

When you take your NCCPA pretest, pretend I'm sitting behind you with a noodle. And if you read a long base question from the top, just picture the noodle whacking you over the head. Guys, just try it. Try it, it'll focus your thinking. Now you're gonna say, "Wait a second, John, that's kind of slow and I'm really concerned about time." It's not slow. It's very effective. It's not slow if you're getting the right answers more often. I highly recommend it, okay?

Set a disciplined study plan. Ladies and gentlemen, I am telling you. What got you here may not put you in a position to be successful on the boards. Now let me explain. It's a different strategy now. The stakes are so high. This is arguably going to be the most heavy test you've ever taken in your life. Bless you. It's an endurance event. So a couple things: first and foremost, before a big sporting event, you never eat anything different the morning before. Like, okay, if you've got something big going on, you eat what you've always eaten. You do what you've always done. If you have a glass of wine at night, have a glass of wine the day before your boards. If you don't, don't have a glass of wine before your boards. Okay? Or the morning before your boards. Okay?

I'm saying, first off, you don't change your socks in the middle of the world series. If you've got something that's working for you, don't do anything. If you have two cups of coffee, have two cups of coffee. Don't have something ... Don't take a ... I'm gonna drink a Red Bull. You might get diarrhea during your test and that ain't a good thing, okay? I am not kidding. I think I told you about the girl ... I think I might have told you the girl that I'm talking to now, coaching ... She fell asleep during round one because she was so jacked up and she had to drive and she couldn't sleep. I don't know how to help with that right now, but I'm just saying don't do anything different now.

I've communicated to you guys that I'm an entrepreneur now. I'm a PA, I'm a speaker, but I'm an entrepreneur. I love being a business owner and I love growing businesses. I'm addicted to it. I love that personality type, I love being around other entrepreneurs. Now, I get to go to these really high-end business conferences. Super smart people. Global speakers. It's super humbling to be there. One of the things they said is that one hour of uninterrupted study time ... One hour of uninterrupted time is equal to 2.6 hours of interrupted study time. You get the same amount of work done if you have 1 hour, uninterrupted, than 2.6 hours of minor interruptions. That's what they found. Here's how I know that ... bless you. Here's how I feel this communicates medically.

Let me give you a metaphor. When it comes to CPR, you have to do 20 compressions to get enough profusion pressure up that each compression then ejects blood. So I gotta do 20 compressions that are just for profusion pressure. Those 20 compressions don't eject blood, but I have to get to a point that now each compression ejects blood. So 20 compressions just builds me up, then it works. I believe it's the same thing with studying. I believe that when you start studying, the first few minutes are kind of ... Your brain isn't ready yet. You have to build up profusion pressure. My best understanding is it takes about 16-17 minutes to get your mind optimal, so now you're gettin' it. Okay? That dissolves with every distraction. So all of a sudden, you're studying, you're gettin' it. You're gettin' it, now you're processing it, you're making some connections. There's global, "Okay, now I'm gettin' it, okay. I see how that's gonna present, okay fine."

All of a sudden, "Oh my gosh, he is so cute, I love him." You may have lost 16 minutes." My advice: what got you this far in PA school and your study tactics, I'm recommending you revisit them and take my advice when you study. I am not against studying in groups, I think it's a hugely effective way to study. I think you can study for four or five hours in a group that may have exhausted you if you studied by yourself. I'm not saying you shouldn't do that. I think you should, as long as you are in a good group. It's not social hour; it's time to get to work. This is a time to get away from your boyfriend, your husband, your wife. This is the time to get away from your kids. This is the time to say, "I've got a four-hour study block. I'm gettin' away from everybody. I'm going to put my headphones on; I got work to do."

Because I'm telling you, I had an in-home office for a while. And I'd be working at home, and I'd walk upstairs to get a cup of coffee and I'd see dishes in the sink. I might have lost a half an hour. It was about a five-minute dishes thing, but I lost half an hour. I'm not kidding. I'd walk out, there's cat poop in the cat dish my daughter didn't clean up. "Shit!" Half an hour gone. I gotta get out of the house. The $10,000-per-year office may have made me $100,000 because I stopped getting distracted. I'll tell you one other thing about strategy. I know me. I can study for about 45 minutes at a time before I get squirrely. What's your squirrely time?

Guys, what is it? Can you study for two hours straight before you get squirrely? That's fantastic. Is it an hour? Here's my advice: whatever you know your squirrely time is, stop before you hit it and then take a little break. Go stretch out, do some jumping jacks, listen to a song, check your Facebook page. But now, hey, five minutes. Now you're back at it. I'm not ... I don't recommend checking your Facebook page, by the way. Like, that could suck you into something, but it could be ... You know what I'm saying? "Oh, puppy video, I love puppy video." Veteran coming home and seeing his dog. "Oh, okay." I'll be there for an hour, okay? I don't know what that is about that, okay? "Okay, shit, let's watch more." You like that video? Look at this one! "Okay!"

So have a disciplined plan for you. I don't know how to help you with your boards unless you do your NCP test. Once again, if the college said, "We'll give you $100,000 raise and bonus if there's a 100% pass rate," but you have absolute control over the class, the bottom line is you would not be released to take your boards until you take a pretest and show it to me and you're in the green. If you do that, I believe you get 100% pass rate on the boards. If you decide to take your boards without doing a pretest, good luck. This is predictable. I've already showed you that. The higher you are in the green, the better you are. If you got 170s in the PACKRAT, prove it. Because this is put out by the NCCPA. It is highly predictable.

And here's my advice after this course. Today, we are going to jam through GI musculoskeletal, that I taught you 65% of what you need on the boards. Then I wanna cover some final stuff that are very high-yield. I can help you a lot with personality disorders, diabetic medicines, and hyponatremia. I can make diabetic medicines as easy as the pediatric rashes. What I recommend after my course: study my stuff. My stuff is very high-yield. You can do whatever you wanna do, ladies and gentlemen. I promise you, my whole goal is to make your job easier, so I've made it super easy. Every time I hear something new that's on the boards, I alter my course. Every time. If something's on the boards that I didn't know it, it wasn't in my ... It's in now. This course will be different next week, because I'm lecturing in Philly. Anything I learned a little bit different, then I'm gonna tweak it.

Know my stuff really well, and then what I recommend you do is take a pretest. I don't recommend as soon as you're done with this course, take a pretest, because if you contact me and show me your scores, I'm gonna say, "Go study my stuff." Make sure you really ... I'm not saying know my stuff like the back of your hand, but you should know it 80% or greater. And then when you do, then you take a pretest. And then, you know what happens when you get a pretest score? Look at where you are generally, and then what topics are you weak at? Then go to work on those weak topics. Only pick one or two topics. Don't go crazy. Let's just say ... Bless you. You realize GI is a real weak area for you. You're to the left side of that passing grade. Well, go to work on GI. Make that your job. Make it until you love it. You go GI, that's your sole focus, and then you know what you do? When you feel like you've fixed that area, take another pretest and see if you climbed out of it.

And then when you did ... Let's say you're a finger breath to the left of GI, and then you bust your ass studying it. And then you take it again, now you're a finger breath to the right. You understand the confidence that'll come over you? I fixed that problem. I own that now. And then you'll see your big bar move over, and you're like, "Okay, that was effective." Now what else? Well, GI and derm. Those are two weak areas. Go to work there until you crush it. How do you study? The four questions. You use those four questions to guide your studies. Do I know pathophysiology, presentation, diagnosis, treatment? When you do, you own the disease. So then, you go after dermatology in your ENT and then you take your boards again, see those lines jump. Next thing you know, you're mid-green, you're like, "Holy crap!"

Then you take your boards, you crush it by 200 points. Study smartly. I've told you guys the strategies that I've had from you from day one. This is based on, again, working with lots of people. Number one is the four questions of mastery. I highly, highly recommend study with that paradigm. It gets you thinking right. I was just talking to my friend and we talked about Addison's disease, so let's just revisit that right now. Don't say anything, think it.

What's your pathophysiology of Addison's? What's your pathophysiology of Addison's disease? Think about it right now. Now, right now, if your brain's a little fuzzy on it, it means you don't know the disease. Don't pretend you know it. What's wrong with Addison's? Well, bottom line is, Addison's disease is not even called Addison's disease. It's called "Add some cortisol" disease. So Addison's disease is adrenal insufficiency. The adrenals shut off. So the adrenal gland ain't workin'. So that means all three of the adrenal hormones are down. So what's the pathophysiology? Well, the adrenal gland is broken, either because of an adrenal problem or a pituitary problem. But either way, the adrenal gland ain't producing any hormones.

That's fantastic. That's all you need to know. Then we could take it a little deeper, go, "Well, what are the three adrenal hormones?" Ace. Aldosterone, cortisol, epi. What do three hormones do? Well, we talked about this. Aldosterone holds onto sodium and water. What does cortisol do? Well, it's an anti-inflammatory and it raises blood sugar and gives you more white count. Okay, cool. What does epinephrine do? Well, that vasoconstricts. So guess what? If I don't have enough of my adrenal hormones ... If I don't have enough sodium ... Or if I don't have enough aldosterone, and aldosterone raises sodium, sodium's gonna be low. And if I don't have enough cortisol, blood sugar's gonna be low. And if I don't have enough epi, they're gonna be hypotensive. That is exactly how Addison's presents. Hyponatremic, hypoglycemic, and hypotensive.

One other thing there: because you know that the adrenal gland is shut down, ACTH is jacked up. ACTH is super jacked up. Not that that's a big key feature of the disease. It helps in the diagnosis, but listen: ACTH has a roommate. That roommate: they're super close. And ACTH is like, "I'll come and try to stimulate you, but I'm bringing my friend. I'm not coming by myself." It's like tandem skydiving. I'll jump out of the plane, but I want someone with me. So ACTH will come down, but I'm bringing this other hormone with me. What's the other hormone that they're bringing with 'em? Because that is the last of the four features of Addison's. What hormone is ACTH bringing with it?

It is MSH. That's why they get hyperpigmented skin. So Addison's is four things: hyponatremia, hypoglycemia, hypotension, and hyperpigmentation of the skin folds. Okay, so now you know. So bottom line is, now you've gotta go Addison's. Pathophysiology, presentation, how do I diagnose it? So you have to study the diagnostic tests, but it takes a high degree of clinical curiosity to say, "Hey, this could be Addison's, and how do I treat it?" Well, if they're adrenal insufficient, I gotta give them adrenal hormones. So study those four questions. If you can't answer the four questions, you don't know the disease. So don't pretend you do. Become very honest with your own knowledge. If you know those four diseases, you own the disease. Again, I know there's such a gap, that's why we came with a PA prep compass. You do not have to ... We have a couple compasses left. If you want one, please get it. It's a really clean study resource. You don't need it; use your own book. This just makes it really easy and efficient.

One of the things my friend said, and she's [inaudible 00:35:23] class and she said the same thing that I'm kindred spirits with. Sometimes I can be a little overwhelmed to study resources. And I get that. I was like that. I could not walk into the UV Medical bookstore without walking out spending $100. Every single time I walked in. It's like walking into a Cabela's. "Okay, I want this, okay." It's a very clean study resource if you didn't take a look at it. The people who buy it love it. It becomes a very ... It's the book you carry around to go to your coffee shop because it gives you the four things that you need. Number one, study your most commons. That's the flashcards. You have them for free. If you're like me, I can't use them. We have a couple boxes of flashcards left. 750 absolutely, must-know. They're very high-yield facts.

Demographics. Guys, every single disease, as part of those four questions, it should say who gets this. Who gets this? Who gets this? What's the basic demographics in the textbooks? Because Pam will live and die by that. Let me ask a question: walking pneumonia, who gets that disease? What's the age? College age. So if you see mycoplasma as an answer and it's a 55-year-old, that's gone. Demographics are incredibly important. Next, I wanna tell you this, that I thought this was really important. I'm de-emphasizing it now. I think there are some key triads that you absolutely have to know. For a while, I thought you needed to know all the triads. I really thought that was important, but the more I got away from that recommendation, the more I'm into this, you gotta know Beck's triad, Virchow's triad, you gotta know Charcot's triad. We'll talk about it today.

Key triads: I used to think knowing all of them was really important. Now I don't think so. There's some key ones, about a dozen you need to know. Samter's triad. Master the similars. The similars are wicked important. And again, I think we only have one left, but this ... The Janis book makes it very simple. When I said demographics, know your demographics, that's what this timeline book is. What we did is we took every disease and told you what age it happens and what sex, males or females. Okay, cool. Just revisit this and then I'm gonna finish this and we'll take a quick break, and then we'll start our session for today.

Pathophysiology, presentation, diagnosis, treatment. Let me give you an example of this. Just make sure we got this right. Let's say you have a dilated cardiomyopathy. We covered dilated cardiomyo pretty decently in day one. My hope is, "Yeah, I feel good about that one, John," so you tell me. What's the patho ... Don't say it, think it in your head. And you have a patient with dilated cardiomyopathy and you gotta go explain it to them. Or let's say it's a parent. You gotta explain this to someone in your family. Doc says I have dilated cardiomyopathy. What is it? Help me understand it. What are they gonna present like?

So if a patient presents with what chief complaint should your differential diagnosis include dilated cardiomyopathy? How do I diagnose it and how do I fix it? Holcomb. Let's talk about Holcomb now. Hypertrophic cardiomyopathy. What's the pathophysiology? How are they gonna present? How do I diagnose it? How do I fix it? Once again, I think these are masterful questions, because if you can answer them, you know it. If not ... Now don't get me wrong, guys, you can always go deeper with every single disease. Do you understand that you could probably go to a CHF conference that's 10 hours a day for a week where they could talk about CHF on the cellular level and all the research going on? Clearly, you can study on a pyramid. You need fundamental knowledge of these four questions and you'll crush your boards. You'll crush your boards.

You don't need to know all the super details, super teeny, tiny, how we best ... What's a candidate for heart transplant with class-four failure? Okay, that's not us. We need to know beta blockers, ace inhibitors, little bit of loops, acute treatments, that kind of stuff. Cool? Find one review book. The two review books that I recommend: I do recommend Dwayne's review book, the Pance Prep Pearls. Ladies and gentlemen, I know Dwayne and I have tremendous respect for him, but I endorsed his book before I even met him as a person, so I do not feel I am biased. I liked the book before I met him. I also highly recommend ... Does anybody in here have the USMLE step 2 clinical knowledge book? I know I recommended it. Does anybody have it right in here now?

Okay, just so you know, I think it's a very, very good book as well. A number of you guys have Certification/Re-certification for Physicians Assistants by Babcock. I think it's a good book. I'm not taking anything away from it. A lot of my course was initially structured from that book. If I was gonna grade it, I'd give it a B. I don't think it's an A, I think it's a B. It's a good book. It's clean, it's efficient, it's a good book. But I think it was really lacking OBGYN and really lacking in Psych. I just felt like ... I read those and I'm like, "You're not giving me anything here I can use." I couldn't put my arms around it, so I really recommend Dwayne's book.

But then again, hold on a second. No book is perfect. Dwayne's book: very good book. Very detailed. It's not perfect, just like I'm not perfect. Nobody's perfect. I'm telling you that book, at times, can pull you very deep into a topic that the test writers aren't taking you. Like, he is so good at endocrine, it's sick. And I almost think he can ... If you go ... I don't believe you need to know pituitary causes of endocrine problems. So if you have someone with adrenal insufficiency, Addison's, it could either be the adrenal gland or the pituitary. One or the other. I'm saying don't worry about the pituitary. There's only one pituitary problem you've gotta think about, that's prolactinoma. Everything else, think of the end organ.

So you could thyroid problem either because the thyroid's a problem or the pituitary's a problem. I'm saying, don't go to the pituitary. That's not primary care stuff. That's gotta be advanced endocrine stuff. I think it's outside of our wheelhouse. He'll take you there. My problem is, if you're a 170s PACKRATer, go for it. Good for you. If you're a 130s PACKRATer, that's gonna waste a lot of time. That's my advice. The USMLE step book has a lot of pneumonics in it, colors, pictures, and I'm kind of attracted to that. So bottom line is, which book should you study? I think they're both grade-A books. Cool? Cool. Let's go ahead and take about an 8-minute ... Oh, question, question.

What edition of Pance Prep Pearls, the first or the second edition?

I think it's irrelevant, okay? So the question is, what's the difference between the first one and the second one? I can tell you that I had the first one and I used it as a study resource. When his Pance Prep Pearls 2 came out, I got it before everybody else got it and I made a deal with Dwayne that I would convert that into an audiobook. So, basically, I took Pance Prep Pearls to the white cover and I dictated the whole book into an audiobook. We were selling [inaudible 00:42:12], the audio files with the book. He asked us to stop doing it because the board review trajectory changed. The culture, climate of our business changed, so he asked me to stop selling it, which I was glad to.

I know the book really well. When I looked at the differences, it's just like me and my course. I can change my course between now and next week because I have new insights. If you hear a singer sing a song here and then five years later, they're gonna find better ways to sing the song because it won't be the same song. They'll sing it different. My course is different, so is him. So is his teaching. So he'll find new insights. Like, he and I did a board review course in New York City, I don't know, a year ago, where it was a five-day course ... Have you ever seen a dueling piano bar? Two pianos? He and I were in front of the stage for the whole five days. So I would present the topic in my theatrical memory way, then he would fill in the blanks. It was the best course I've ever done. He is so smart.

I know he took some of my teaching techniques and they're using it because they're effective. So, bottom line is, if you do have a book, I think it's fine. I don't think it's a big deal. I don't think it's worth buying a new book. I don't think so. Cool? Any other questions I can answer for you? Again, I know you guys are a very smart group, very well-studied. I'm not saying if you've got a good thing going and you're 160s and 170s in the PACKRAT, fine. If you think you've got a good thing going but you're 130s, 140s, I kind of think you should listen to me. But once again, if you're not sure what to do, right here's my contact phone number. Or if you email me through my website. If you'd rather talk through email, if you go to info@CME4life, it'll get filtered through somebody, but I'll get 100% of those and I'll respond to them. Cool? Take an 8-minute break.