How to Increase Your PANCE or PANRE Score by 100 Points

“If at first the idea is not absurd, then there is no hope for it”

-Albert Einstein
Let’s dive into two easy ways to help increase your PANCE or PANRE score by 100 points. There is no magic wand that will increase your score, but these two techniques are useful, easy to implement, and only require a little of your time.

The first strategy is to identify what you don’t know. Sounds easy, right? The key is to go through a curriculum and identify what you don’t know—not what you are weak at, but what you don’t know. The second strategy is to take advantage of human error. Tests are written by humans, and humans make errors. By paying attention to five types of flaws that question writers make, you can narrow down an answer choice to either the correct answer or to a 50/50 probability, even without knowing anything about the topic. When you combine these two strategies, you’ll be able to increase your PANCE or PANRE score by 100 points, which could be the difference between passing or failing. Let’s get started.


Determining your unknown unknowns 

As you begin to study for your exam, there are areas you are comfortable with. Maybe you have a special interest in orthopedics and feel confident with any question that might be asked on interpreting the X-ray of a child with slipped capital femoral epiphysis (SCFE). Therefore, you spend less time reviewing it. This is one of your known knowns. There is little utility in spending too much time on your known knowns when preparing for your exam.

During medical training, 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, such as hepatic encephalopathy—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 PANCE or PANRE exam score is to identify your unknown unknowns. It takes a little effort, but it is rather easy. All you need are two things:

Notebook and time

The system works like this:

Step 1: 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 that contains the key knowledge that you previously did not know or weakly knew. As you do more questions, you will 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, if 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 identify most of your blind spots that questions can be asked about. You will convert your unknown unknowns to known knowns

Here is an example of what your notebook might look like:

notebook

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

I use the same system and process to prepare for all standardized exams. You can even use it to learn how to read EKGs better than a cardiologist.

Study schedule

With the PANCE/PANRE and rotation exams 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 you’ll need two things to supercharge your standardized exam score: a notebook and time. The notebook you can buy anytime. However, time disappears.

Taking the time to identify your unknown unknowns will prepare you for the exam. However, we know five ways you can improve your score simply by showing up to your exam. You can 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.

Question, stem, lead in

Question
A 67-year-old woman who was recently diagnosed with breast cancer presents with increasing confusion over the past three days. Additionally, over the past week she has been complaining of fatigue, diffuse body aches, poorly localized abdominal pain, and constipation. 
Which of the following electrolyte abnormalities is the most likely explanation for her symptoms?

A question is made up of the stem and the lead in. The stem contains the details of the question such as the clinical presentation, past medical history, and laboratory results. But, the critical part of the question is the lead in. The question writer uses the lead in to find out what you know or don’t know about the topic in the stem, and it is also 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 are the first two tips:

1. Pay attention to grammatical cues.

Grammatical cues: one or more answer choices (distractors) don’t follow grammatically from the lead in.

A 60-year-old man is brought to the emergency department by the police, who found him lying unconscious on the sidewalk. After ascertaining that his airway is patent, the first step in management should be intravenous administration of which of the following?

A. CT scan of the head
B. Diazepam
C. Examination of CSF
D. Glucose with thiamine

A and C do not follow grammatically from the lead in. A good test taker can eliminate these.


2. Focus on logical cues.

Logical cues: one or more answer choices don’t logically fit in with the other choices.

A 22-year-old man is concerned he has appendicitis. Which of the following signs is most sensitive for the diagnosis of appendicitis?

A. Nausea
B. Pain with extension of the hip joint
C. Rebound tenderness
D. Right lower quadrant tenderness

Nausea is not a “sign” and can be eliminated by a good test taker.


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

The Anatomy of Answer Choices

QUESTION: A 67-year-old woman who was recently diagnosed with breast cancer presents with increasing confusion over the past three days. Additionally, over the past week she has been complaining of fatigue, diffuse body aches, poorly localized abdominal pain, and constipation. Which of the following electrolyte abnormalities is the most likely explanation for her symptoms?

A. Hypercalcemia
B. Hyperkalemia
C. Hypocalcemia
D. Hypokalemia

The lead in asks about the most likely explanation, so think carefully through each answer option. Here are the distractors:

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. The following three pointers round out our five tips that can help you answer a question correctly:


3. Look for answer choices containing absolute terms.

Absolute terms: terms such as “always” or “never.” When used in the answer options, these terms usually indicate an incorrect answer because they cannot hold up to scrutiny in all situations.

In patients with advanced Alzheimer disease, which of the following best characterizes the memory defect?

A. Can be treated adequately with phosphatidylcholine
B. Could be a sequela of early parkinsonism
C. Is always severe
D. Is never seen in patients with neurofibrillary tangles at autopsy

C and D contain absolute terms “always” and “never.” These should be avoided in answer choices because they are less likely to be true statements.


4. Keep an eye out for a long correct answer.

Long correct answer: the correct answer is longer, more specific, or more complete than the other options.

Secondary gain is which of the following?

A. A complication of a variety of illnesses and tends to prolong many of them
B. A frequent problem in obsessive-compulsive disorder
C. Never seen in organic brain damage
D. Synonymous with malingering

Option A is longer than the other options, and it is also the only double option. Item writers tend to pay more attention to the correct answer than to the distractors and write long correct answers that include additional instructional material, parenthetical information, and caveats.


5. Notice when a word repeats.

Word repeats: a word or phrase is included in the stem and in the correct answer.

A 58-year-old man with a history of major depression and post-traumatic stress disorder is hospitalized in the context of increased difficulty caring for himself. He speaks of experiencing the world as unreal. What is the term for this symptom?

A. Depersonalization
B. Derailment
C. Derealization
D. Focal memory deficit

This question uses the term “unreal” in the question stem, and “derealization” is the correct answer.


Whether you are taking your rotation exam, PANCE, or PANRE, there is so much at stake. 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 five simple techniques to identify common flaws in questions, which will increase your chances of getting a question correct.

Give these methods a try and let me know how it goes. Moreover, I’d love to hear about techniques you use that I did not write about.

And if you are looking for a PANCE review Qbank or PANRE review Qbank…you know where to find one.

Best,
Dawn Miller, PA-C



Comments (12)
  1. Cecilia Cannon
    March 5, 2017

    Really enjoyed and appreciated the free Review you gave to us loyal AAPA members. Test is in 18 days; am anticipating an easy “Pass.” Thanks!

    Reply
    • Adam Rosh
      March 6, 2017

      Dear Cecilia,
      We are privileged to be able to help.
      Best,
      Adam

      Reply
  2. Felix
    March 5, 2017

    This is very insightful. Thanks

    Reply
    • Adam Rosh
      March 6, 2017

      Dear Felix,
      Thank you. I hope you can benefit from it.
      Best,
      Adam

      Reply
  3. Nicole
    March 9, 2017

    I’ve actually been using the notebook trick- but I found it hard to maintain because once I had filled out pages of topics, I couldn’t quickly locate the topic when I wanted to add in a small detail. It almost became more of a hassle to flip through my notes and remember where my page on a certain topic was. How did you get around this with multiple notebooks? In theory it’s good, but almost too time consuming.

    Reply
    • Adam Rosh
      March 9, 2017

      Great questions Nicole. The key is not to write too much at first for each topic. Keep it to the most important. Try and return to review the notebook almost daily and you should become more familiar with locating the content. Another idea is to number the pages in top right – this provides another “marker” to remember content by. You can also create a color code system (e.g. by system) on the side of each page. These are some ideas. If you are spending more than a minute looking for a page, I’d recommend one of these additional techniques.

      Reply
  4. Diane Bairas
    April 13, 2017

    I just took my boards 2 weeks ago and passed. Used the Rutgers course and the review book, and studied for 3 months, daily. I took notes in a similar way, but had 17 headings in my notebook, one for each organ system. When I got a question wrong, I flipped to that section, made my notes, and studied them daily or while waiting in a line, etc. Also printed out flash cards – very helpful.

    Reply
    • Adam Rosh
      April 13, 2017

      Congratulations Diane and thank you for sharing your experience.

      Reply
  5. Luke
    January 13, 2018

    I feel like this practice has greatly helped me in the past month or two, but I’m curious at what point you cut yourself off from reviewing prior study sessions. 45 minutes? an hour? Based on your total notebook count, you might be reading for HOURS before you begin new questions.

    What was your timeline per study session while using this method?

    Thanks!

    Reply
    • Adam Rosh
      January 13, 2018

      Great question Luke. There should be a time that you become familiar with much of the content in the notebook that all you need is a glance. But you are correct in that the notebook review can take 30-60 minutes. It should not go more than that. Also, you do not have to do the full notebook; sometimes just start with the middle to the end.

      Reply
  6. Remonia
    March 2, 2018

    Thanks, just started this method for PANRE review, used similar method with index/flash card when studying for my PANCE exam to pass. Keeping those I missed in a separate stack. I enjoy your website especially the new board review questions. Thanks for your help.

    Reply
    • Adam Rosh
      March 2, 2018

      Thanks for your feedback Remonia.
      Best,
      Adam

      Reply

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