By Rachael Moffett MD and Alanna O'Connell DO
Every year the in training exam (ITE) brings extra stress to your life as a resident. And while there is no replacement for reading and learning the material, half of the battle is knowing how to approach test questions as applying what you know can often be the hardest part of taking this exam. In this article, we will teach you some strategies to outsmart the test takers and ace your in training exam.
After reading the question stem, do not go directly on to the answer choices. Stop and think about what you would predict the answer to be. Ideally, this would be something specific like acute MI, but sometimes it might need to be more general like something that causes a metabolic acidosis. Only then should you go on to the answer choices. The idea is to find the match to your prediction.
This helps in a number of ways. One, it’s actually far more efficient than considering each answer choice individually. Just skim them until you find your match, choose it, and move on. Two, it really does help keep you out of trap answer choices. No matter how tempting a choice is, if it’s not the one that matches your prediction, let it go.
My approach to this question would be stop after the question and predict what I think this patient’s disposition would be. She’s not San Francisco negative so I’m predicting she gets admitted. Then, I look at the choices. Okay, there are two that say admit. This happens at times, you need refine your prediction. So I go back: I predict she needs to be admitted because she’s at risk for arrhythmia and needs further monitoring, which corresponds best to choice C.
Very often on the ITE the question stem will describe some disease or condition and then end with the question of, not what is the diagnosis, but what is the next test or what is the definitive treatment. When encountering those questions, I find it beneficial to stop myself and answer the first unasked question of “what is the disease?” before attempting to answer the actual question of “what is the treatment?”.
For this question, I would stop myself and ask, “What does this patient have?” Abdominal pain out of proportion to exam with atrial fibrillation on the EKG is going to mesenteric ischemia. Only then, will I ask myself the question the question stem is asking me: “How do I diagnose mesenteric ischemia?” With CT angiography or A.
TAKING YOUR BEST GUESS
Sometimes you just can’t predict because you just don’t know the answer, but that’s okay. There are tricks to guessing well too! One of these is what I call reasoning backwards. This takes advantage of the fact that each answer choice is generally only going to correspond to one condition. If I can identify what the other choices correspond to and convince myself that that’s not the condition described in the question stem, I can sometimes narrow it down.
So this is actually a multistep question, so I would actually start this by identifying what the patient has: toxoplasmosis. Then I tackle what the treatment for toxoplasmosis is, which may be something I can’t remember. So I go to the answer choices and try to reason backwards. Antituberculosis therapy is obviously the treatment for tuberculosis, not toxoplasmosis, so I can eliminate that as the choice. Gancyclovir is the treatment for CMV, also not toxoplasmosis, so cross that off. Amphotericin is the treatment for multiple fungal infection but in the setting of HIV they’re probably hinting at Cryptococcus, so also not toxoplasmosis. So the only thing left is pyrimethamine and sulfadiazine plus folinic acid or D. I didn’t know the answer, but I still confidently arrived at the correct choice.
OBSCURE ANSWERS ARE WRONG
Obscure answers, and by that I mean disease you vaguely remember from medical school, are usually wrong. They are included by test makers in an attempt to trick you and make you doubt yourself. They want your reaction to be: “Well, I’m pretty sure it’s A but I have no idea what D is so I’m not sure it’s not D.” Resist this! If you think you know what the answer is, don’t let a choice you’ve barely heard of distract you.
Incidentally, this is an example of when predicting can be handy. If you’ve predicted the answer and found it in choice A, there’s no reason for you to be even reading choice D!
Note: Q fever is never the answer. I don’t know what Q fever is, you don’t know what Q fever is, no one knows what Q fever is. The test makers are counting on that.
For this question, there’s honestly only two answer choices I recognize – Jimsonweed and Oleander – so I’m going to feel confident narrowing it down to those two. Even if I still don’t know the answer (it’s Jimsonweed, B), I’ve still given myself a 50/50 shot at guessing, which is pretty decent odds.
SIMILAR ANSWER ARE WRONG
Sometimes you may look at two answers and think to yourself if A is true doesn’t B also have to be true? Trust this instinct, because it means both answer are wrong!
For this question, I might predict: something that causes a metabolic acidosis. Unfortunately, that only eliminates choice D. I could start applying Winter’s formula here, but there’s an easier way. Is there any difference on bloodgas between ethylene glycol and methanol? No. (There’s differences in symptoms, obviously, but that information is not given in the question stem.) So both must be wrong and the answer is salicylates, A.
By the way, I use processes like this to avoid using Winter’s all the time. For most questions that want you to do it, only two of the answer choices will even show a metabolic acidosis anyway. That’s 50/50 odds, if you just want to guess.
WATCH THE WORDING
NEXT IS NEXT
Many questions on the ITE will ask what the most appropriate next step is. Keep in mind that next means next. Often multiple or even all answer choices will be things you want to do, but only one will be the most appropriate thing to do next.
For next questions look out of emergent interventions, things like intubation or needle decompression, or immediate action towards definitive management, calling the emergent consult. Rarely, will this is be testing, with the exception of quick, bedside tests like EKG and fingerstick.
In this question, the patient has shortness of breath and chest wall pain and crepitance indicating he has rib fractures with a pneumothorax. Once he becomes tachycardic and hypotensive, he know has a tension pneumothorax. What is the very next thing you want/need to do when a patient has a tension pneumothorax? Needle decompress them, B. Could he use fluids, sure. Will he need a chest tube eventually, yes. But those aren’t what you need to do next.
NEXT VERSUS BEST
Another trick the ITE will like to play is the idea of the next test versus the best test. The next test is usually something quick – blood glucose, EKG, maybe chest x-ray. The best test is the gold standard and may even be something you can’t get in the ER – angiography, MRI. Keep an eye out for which one the question stem is really asking for.
This question is asking for the next test. All of these are actually things you’ll want to get/do, but the next test is the fast, bedside test of a fingerstick blood glucose, D.
Compare to this question. In this question, you have a neonate with failure to thrive, cardiac gallop, and a liver that is down, all of which point to a diagnosis of heart failure likely secondary to a congenital cardiac abnormality. What test provides the specific diagnosis of heart failure (from any cause)? Echocardiography, C. If it had asked for the next test, the answer would have likely being chest x-ray, but it doesn’t. It asks for the best, the gold standard.
MOST SPECIFIC VERSUS MOST COMMON
Yet another fun game the ITE likes to play is the difference between the most specific symptom of or risk factor for some disease and the most common. The most specific symptom is the one that’s, well, specific. Only really people with that disease have. The common symptom is something that essentially all people with that disease have, but lots of people who don’t also have. For instance, the most common symptom in cauda equine is back pain, but it’s far from the most specific symptom.
This question asks for the strongest risk factors. This is another way of asking for the most specific. Which of these choices most greatly raises any given individual’s risk of having an ectopic pregnancy? Previous ectopic pregnancy, C.
Compare that with this question. This is no longer asking for the strongest or most specific risk factor, it’s asking for the most common. The most common risk factor or symptom is always going to be the one that is most widespread on a population scale. While, yes, being a pre-eclampic, cocaine user who drove her car into a tree would most raise your risk of abruption, very few women in the world are pre-eclampic, cocaine-using, bad drivers. Far more women are just hypertensives, which is the answer D.
COMMON IS COMMON
Common things are common, even under uncommon circumstances. For instance, the following is a common trap on ITEs and the like:
Yes, alcoholic patients are more predisposed to Klebsiella pneumonia. However, the most common cause of pneumonia in alcoholics is still the widely prevalent Streptococcus. Similar questions will be poses with HIV patients. Yes, they’re predisposed to PCP, but Streptococcus is still the most common cause of pneumonia in AIDS.
SPECIFIC TIPS AND TRICKS
WHEN TO CONSULT
The secret to knowing when to consult on the ITE is twofold.
1. All consults are eminently reasonable attending physicians who will respond appropriately to be called with a high clinical suspicion for something truly emergent even without imaging. If a history and exam is suggestive of testicular torsion, your urology consult will happily get out of bed and take the patient to the OR even without an ultrasound.
2. On the flip side, on the ITE, assume that any consult you call is an attending physician you are waking up in the middle of the night. So many things that in the real world we’ll call “the surgery night float intern to come by and look at” for are not things you’d be willing to wake an attending up at night for. I call it my “middle of the night” test and it’s fairly accurate.
This is patient with a cold, pulseless foot. What does she have? An acutely ischemic limb. What does she need? Vascular surgery, B. Even in the middle of the night? Yes! Sure, if you call a surgery resident, they’ll want labs and some kind of imaging. Not on the ITE. On the ITE, a vascular attending will roll out of bed and take the patient to the OR immediately.
Compare with this question. This is a pregnant patient with an IUP but an open cervix. What does she have? An inevitable abortion. At your residency, this is someone we’d likely have the OB/GYN residents come by and see, maybe place Cytotec. But is an inevitable abortion something you need to wake an OB/GYN attending up for in the middle of the night? No, not actually. This can be managed expectantly, B, and that will be the answer on the ITE.
ALL INFORMATION IS RELEVENT
One of the truly beautiful things about the ITE is that the question stems always include just enough information to answer the question. Never less and crucially, never more. There are no red herrings. All information in the question stem is relevant. Race, job, hobby… if they take the time to mention it, it’s helping point you at the answer. Sometimes this is obvious: if they mention camping, they’re angling at a tick-borne illness. Sometimes it’s more subtle.
In this question for instance, the patient has clearly suffered some adverse complication of the lumbar puncture. Based on that, it’s unlikely to be diabetic neuropathy, but all the others may still be on the table. If I’m stuck on something like that, I’ll often scour the question stem for the piece of information that they included but they didn’t have to. The seemingly extraneous piece of information that the question writer put there to lead me to the diagnosis.
Here, I find it in atrial fibrillation. This is not something that the writers would need to include unless it was relevant to arriving at the answer, because otherwise atrial fibrillation is not super relevant to a patient presenting with apparent bacterial meningitis. But they do include it, so what are they hinting at? Atrial fibrillation in patients hints at either embolic problems or the converse: problems associated with the anticoagulation. Is one of the answer choices related to either of these? Yes, epidural hematoma, B, is a bleeding complication.
There is a degree of pure word association on the ITE. Conditions and disease that you need to know nothing about except one single association. The question stem will always give you that key word and if they give you that key word the associated condition will always be the answer. These range from slightly un-politically correct to straight up offensive, but that’s how the ITE rolls.