How To Increase Your Emergency Medicine Board Exam Score By 10 Points

There are many tactics you can use when preparing to take a standardized exam such as the In-Training Exam (ITE) or Certification Exam. But there is one I found to be the most useful. 

As you begin to study for your exam there are areas you know well and are comfortable with. Maybe you have a special interest in toxicology and feel confident with any question that might be asked on interpreting the Rumack-Matthew Nomogram.

Because you are confident in toxicology, you spend less time reviewing it. Lets call this your known knowns. There is very little utility in spending too much time on your known knowns in preparing for your exam.

“There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don’t know. But there are also unknown unknowns. There are things we don’t know we don’t know.”

– Donald Rumsfeld

When I was a PGY1 resident, I realized my understanding of liver disease was poor. Hepatic encephalopathy was just a term to me. I did not understand how or why it occurred and I had a poor grasp on managing the condition. Liver disease was a known unknown. Because I recognized this specific deficiency, I was able to target my learning to diseases of the liver. 

Once I started to focus my learning I came across many concepts and ideas that I knew nothing about…never even heard about some of them. These were the unknown unknowns, a concept created by psychologists Joseph Luft and Harrington Ingham. It is part of their “Johari window,” a tool that helps users identify blind spots about themselves and others.

Known unknowns are things you’re aware that you don’t know—you can recognize that you don’t understand them. Unknown unknowns, however, are unexpected because you don’t know they exist.

The way to supercharge your In-training or Certification exam score is to identify your unknown unknowns. It takes a little effort, but it is rather easy. All you need are two things:


The system works like this.

Step 1: You answer a question from a question bank. If you get the answer wrong, read the explanation. Then write down in your notebook the part of the explanation that describes why the correct answer is correct. This process helps to identify your unknown unknowns. Subsequently, if there is any other information that you did not know or somewhat knew, record it as well in your notebook under the same topic.

You must do this for every question you get incorrect. I also encourage it for questions you may answer correctly but discovered new information in the explanation that you previously did not know. 

Step 2: Start each study session by reviewing your notebook which contains the key knowledge that was previously unknown or weakly known by you. As you do more questions you are going to get questions wrong on topics already recorded in your notebook. For example, if you answer a question incorrectly on which age group most commonly gets de Quervain tendinopathy you’ll record in your notebook something like de Quervain tendinopathy: Epidemiology includes women between 30-50 yrs old and postpartum. Two weeks later you can’t name the diagnostic test characterized by thumb flexion and ulnar deviation of the wrist, you should go back through your notebook to find your first entry on de Quervain tendinopathy and add the Finkelstein test as the way to diagnose the condition. While we are on the topic, here is a cheat sheet for de Quervain tendinopathy.

After a month or two of recording your incorrect answer explanations you will have a filled notebook of your unknown unknowns and maybe many of your known unknowns. If you do this on a consistent basis and get through 1,000 to 2,000 question bank questions for a 300-question standardized exam, you’ll have identified most of your blind spots that questions can be asked about. You end up converting your unknown unknowns to known knowns

Here is a page taken out of my notebook from 2004 (intern year)!


This is a Mead Composition notebook. All 100 pages (front and back) are filled with explanations from question bank questions I answered incorrectly.  

I used the same system and process to prepare for my MCAT, USMLE Step, In-Training, Initial Certification and Continuous Certification (ConCert) exams. And even used it to learn how to read EKGs better than a cardiologist.


By the end of residency, after taking four In-Training exams, my bookshelf looked like this


With the emergency medicine In-training and certification exams being around the corner, now is the perfect time to begin this system. It leaves time for adjustment and plenty of time to accumulate your unknown unknowns. Earlier in this post I mentioned that to supercharge your standardized exam score you’ll need two things: a notebook and time. The notebook you can buy any time. However, time disappears.

Identifying your unknown unknowns is how you can prepare to the lead up to your exams. But what can you do to improve your score simply by showing up to your exam?

How can you use the errors made by question writers to boost your score? 

The Anatomy of a Question

First, let’s understand the anatomy of a question.

A question is made up of the stem and the lead in. The stem is where you find all the details of the question such as the clinical presentation, past medical history, and laboratory results.  But, the critical part of the question is looking closely at the lead in. The question writer uses the lead in find out what you know or don’t know about the topic in the stem. But it is also the place where question writers make errors. By applying basic grammatical analysis, you will be able to identify the correct answer or at least narrow down the answer choices without knowing anything about the topic.

Here is an example of using grammatical cues.

Here is another technique that focuses on logical cues.

Let’s now focus on answer choices to identify a few more areas we can gain an edge.

The Anatomy of Answer Choices

Once you understand the goal of the question writer to create answer choices that are supposed to discriminate knowledge, it is easier to exploit technical flaws and improve the odds of getting a question correct.

Taking the time to identify your unknown unknowns will not only help you prepare for and excel on your exam, you’ll expand your core knowledge. Then, on test day, use the simple techniques to identify common flaws in questions which will increase your chances of getting a question correct.

Give this method a try and let me know how it goes. And if you are looking for an emergency medicine question bank to use…you know where to find one.

Adam Rosh, MD

P.S. If you have not listened to our latest podcast hosted by Nachi Gupta and Jeff Nusbaum, residents from the Mt. Sinai emergency medicine residency, I urge you to take 10 minutes and check them out. Pure educational gold.

Comments (11)
  1. michelle
    May 5, 2017

    Dr. Rosh,

    Thank you so much for my free trial review. I really ace my Panre.
    Do you have any review for MCAT also??

    • Adam Rosh
      May 5, 2017

      Dear Michelle,
      Glad to hear you did well on your board exam/PANRE.
      As of now, we do not provide content for the MCAT. Are you planning on going to medical school?

  2. Lateefa
    August 22, 2017

    Thank you so much for the tips.
    Wish If read your tips earlier.

    • Adam Rosh
      August 22, 2017

      You bet Lateefa. Is there a topic you’d like us to work on next?

  3. Olsheath
    November 3, 2017

    Thank you. I will definitely apply these tips for my upcoming UWI EM DM1 exam. Only is I had seen them before.

  4. Chris
    December 28, 2017

    How did you organize your notes when starting to go through questions? You mention that you would go back to previous topics in your note book and continue to add more information as you come across it. Do you usually leave several blank lines under topics you expect to see more often?

    • Adam Rosh
      December 28, 2017

      Thanks for the question Chris. I used multiple lines with taking the initial note. Sentences were rare – it was more about capturing the concept. Yes, I would leave lines between topics. At most, there would be 3 to 4 topics per page, closer to 3. So use the front and back of each page.

  5. Stephanie Joseph
    January 28, 2018

    Good morning,
    I am a FNP student, what strategies can I use to eliminate the wrong answers to appropriately get to the right answers?

  6. max
    February 24, 2019

    Hi, I have been using your qbank to prepare for my em recert. I have been having trouble with what we do in “our shop” vs the text book answers. In general when two choices seem correct and one is a test and the other an action, ie a trauma pt with borderline vitals and a choice of CT imaging (what the surgeons at my hospital always seems to want) vs strait to laparotomy, is the answer typically the procedure.

    • Adam Rosh
      February 24, 2019

      This is a common challenge. How we practice in our own “shops” should be set aside. The exam wants to know what should be done at “ABEM General”. Textbook answers.


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