04-03-2007, 02:20 PM
I save this post exaclty last year when I joined the forum, it was posted in prep 4 usmle by an excellent Doctor, it is too long but read when you take a break for your study.
I took the exam on april 24,2006 and as per OASIS
trick last May 17, I have passed it. Just tweedling my
fingers waiting for the postman. I went into this exam
with the following statistic.
NBME form 1: 740 (3 weeks before exam) (1 hour timed
per block)
Kaplan QBank: 84% (all random, timed blocks no repeat.
Answered 1250 questions in groups of 2 to 4 blocks/day
over 9 days.)
USMLE CD : 46, 44, 48 (2 months before exam)
I reviewed for 7 months ( 4 months seriously) for this
exam. I am an IMG. A very, very old IMG. so that
you'll have an IDEA, when I was studying
1. DOC for Typhoid Fever was Chloramphenicol.
2. when I first encountered the word 'p53' all I could
think of was that he was senior member of this forum.
3. There was no treatment for AIDS.
4. 50% of our graduating class who went to the US
after graduation are now practicing physicians in the
US and most have already finished their J1 Waivers and
some are already citizens.
I've used this framework for analyzing my weak points
throughout my review.
We can divide our whole preparation into 3 parts,
1. Knowledge Acquisition(KA) - This is where you put
information into your Knowledge Bank(KB) Most new
graduates are extremely fine here (Except if you're
one of those who barely made it. Crammed for every
test and promptly forgot everything afterwards. Most
Old graduates and some IMG graduates usually have
problems here. If your deficiency is primarily here
(like me both old and IMG), I'm sorry, I don't think
there can be any successful prescription but to hit
the books.
2. Knowledge Recall or Review(KR) - This is how well
you extract information from your KB. Most new
graduates have some problem only here. FA and the
QBank makes a fantastic tool for improving Recall. So
people with problems here usually give fantastic
ratings to FA and Qbank.
3. Test Preparedness (TestPrep) - If you are not
familiar with CBT, MCQ or clinical slant to questions,
this is where your problem is. Problems with sitting
for 8 hour exam is also classified here. Difficulty in
answereing 2 to 3 step thinking questions also fall
here. This is where QBanks are the most effective.
If the problem is primarily in KA, answering 100
thousand Q's will not help, IF your KB is full and you
have problems only with KR and TP, hitting the books
will be a waste of time. QBank, FA, HY and Flashcards
should be the way to go.
How do I know where my primary problem is?
Well a quick way to know is to use an evaluation
examination, preferably one that's very near like to
the actual exam. (The Kaplan CD examination comes to
mind)
If you find while answering the questions that either
the choices, the question itself or the pictures makes
you think out loud "What the Heck is this?" You have a
KA problem.
If most of the time it is, "I know this, but I can't
recall how you differentiate between drug A and drug B
(or symptoms, presentation, treatment,
mechanisms,etc.)" You're having a KR problem.
If you thought you had the answer, then find out it's
wrong, but after reading the explanation, you are
surprised that you had misunderstood the question,
It's a TP problem. Running out of time answering
questions is also a TP problem.
As the medical adage goes, from the Diagnosis all
things flow. After you've correctly diagnosed your
problem, then the treatment is routine.
I'll discuss the solution to each identified problems
in my next post and particular strategies you can use
to improve your TestPrep ability.
As we all know, Medicine is a very broad subject, so
broad that we are divided into specialties. However,
for the purpose of the board we are required to know a
little of everything. So for the purpose of the board,
What you need to know is divided into 3 parts.
1. Knowledge that need to be mastered. - The so called
HY materials that are almost always tested.
2. Knowledge that need to be known. - you must know
enough so that they are taken into consideration in
your decision making.
3. Knowledge that you need only to be familiar - aware
that it exists.
Subsequently our own knowledge bank is divided into 3
parts
1. What we have mastered -we can recall this
information at any time in whatever way it is twisted
in whatever condition we are in.
2. What we know - we can recall this information only
when condition is optimum. We may need some time to
think about it.
3. what is familiar- we can recall this information
only with some clues and enough time to think about
them.
The more closely the component of our knowledge bank
conforms to what is expected of us by the board, the
higher the probability of acing the exam.
Why is this important? Because of the way the
examination is structured. The concepts that you are
required to master are usually presented in 2 to 3
step thinking format. Physio and Pharma concepts
requiring calculations usually include not only
irrelevant numbers but also may need multiple
calculations to come up with the answer. The exam is
extremely fair in this regard. I'll give 2 examples in
my exams (without giving away the actual question
since this is prohibited)
I had a question involving p21 Cyclin D and Cyclin E2.
Now I had mastered the p53 and Rb concept since I had
expected this to be one of those that should be
mastered. As you all know p21 and cyclin D are two
components that mediate between p53 and Rb. I had also
read about cyclin E2, which is the component that
normally initiate the process that pushes cyclin D and
Rb into allowing the cell to proceed to the S Phase.
The function of p53 if you would recall is merely to
act as a gatekeeper and does not initiate the process.
However, I did not memorize in detail the whole
process, ie. I was familiar with the role of cyclin E2
but did not master it. (Good thing the question popped
up in the 4th block when my mind was still
functioning). Any way they were good enough to give
details in the question stem on cyclin E2 (instead of
presuming you know it) Giving me a reasonably good
chance of answering the question.
Another example is on transcription factors. They gave
a drawing of the chemical formula of a transcription
factor (believe me it was fairly obvious which
transcription factor it was if you are even just
vaguely familiar with it) and asked its function. If
you know it, you can answer it. If you are familiar
with it, it gives you a reasonable chance to get the
answer.
So if you mastered what needs to be mastered and so
on, you'll probably ace the exam. Except that that is
impossible. Kaplan and all those in the prep-review
business will give an arm and a leg to be able to do
that. If you mastered what they want you to master,
you'll say that was fair. If you mastered what they
expected you to know, you'll say that's easy. If you
know what they expect you to master, you'll say that's
hard, If you are only familiar with or don't know what
they expect you to master, you'll probably curse and
call it experimental questions.
In reality experimental questions can be easy or hard.
They're called experimental questions since not enough
statistics have been gathered on the question to rate
them as hard or easy for the purpose of grading the
block.
Now going back to the quick and dirty method of
analyzing your weak point. If the QBank you used does
not reflect the emphasis of the board (Master what
needs to be mastered, etc.) What you thought is a KR
problem may be a KA problem after all. The Qbank may
have presented that concept in a straightforward
manner (ie, you know the concept) and you readily got
it, but the Board will present it in a 2 to 3 step
thinking manner (expecting you to have mastered it
which you didn't) Another disconnect, hence the danger
of relying only on Qbanks for review.
So what concepts should I master? Well, that maybe
impossible to answer for certain, but there can be
reasonable ways to arrive at what are the most
probable ones. You may think FA. But FA includes all
concepts tested on the exam, whether you are expected
to master it, know it or be familiar with it. If you
have the time to master all the concepts in FA fine,
but that would probably be more time-consuming than
reading entire texts. Remember memorizing is not
mastering. Mastering for example the Brachial Plexus
requires not only knowing the anatomy, but also what
they innervate, pattern of denervation or injury, etc.
Reading one line in FA should bring back a dozen or so
paragraphs that represent the concept that that one
line in FA represents.
A more reasonable way is to use HY books like HY and
BRS. For example, you've decided to use Big Robbins as
your main text for pathology because like me you've
forgotten half of what you know about pathology and
the other half is obsolete. You need BRS Patho because
it is practically impossible to master everything in
big Robbin's. A reasonable strategy is to master and
know most information in Big Robbin's that are also
found in BRS and just be familiar with the rest. If
you are a more recent graduate, you could start with
BRS and reference to Big Robbin's for concepts to
master.
Another good example is Micro and Immuno by Levinson
and Jawetz. Master all Organisms contained in its
"Brief Summaries of Medically important organism".
Know what is discussed in the text and be familiar
with organisms in the minor pathogen sections.
Exception is of course Immunology which you should
probably master.
I think this is a reasonable place to end this post.
I'll continue with the rest next time.
Just like any diagnostic exam, our quick and dirty
evaluation has its share of false positives.
While most people who have a KA, KR or TP problem
really have a KA, KR or TP problem. A minority have a
mixed problem, combination KA,KR or KA, KR, TP
problem. They often evaluate themselves to having a KR
or TP problem and so missed out that they also have a
partial KA problem.
I had thought of discussing this when we reach the KR
portion of the discussion, but judging from gigiMD's
post, I felt I should address this immediately. One
symptom is inability to raise your grade even with
repeated qBank drills. A pure KR problem should be
remedied promptly by answering huge number of Q's.
Failure to raise grade,or extremely small increments
of grade increase in relation to number of Q's done
points to a KA deficit.
There are a few more concepts we need to understand in
order to know why this is the case. I'll discuss this
here before we go back to discussing KA further.
In order to understand this we need to go back to the
concept of mastery, know and familiar. We can divide
our Knowledge Level (KL) of particular concepts as
Mastery level, know level and familiar level.(In
reality, there is more than 3 levels, but limiting to
3 levels make for easier discussion.) We can also
divide question difficulty(QD) to 3 levels, Mastery,
know and familiar. A question is easy, fair, hard or
impossible(experimental questions!!) for you depending
on the QD level of the question in relation to your KL
level of the particular concept being tested.
A table follows:
-------------------------QD
Level-------------------------
KL Level -------- Mastery---------
Know---------Familiar
Mastery------------ Fair ------------Easy------- Very
Easy
Know -------------- Hard------------ Fair---------
Easy
Familiar --------Impossible -------Hard--------- Fair
To further illustrate: let's take the drug Valproic
Acid.
All information available on it is as follows:
Broad Spectrum Antiepileptic that acts by Enhancing
GABA accumulation, Inhibiting repeated neuronal firng
by actions at Na channel, and inhibition of low
threshold (T-Type) Ca channel. DOC for Myoclonic sz.
Alternative for Partial and Generalized Tonic Clonic
sz, Absence sz. Tx for Mania Side Effects, dose
related anorexia, nausea, vomiting and idiopathic
hepatotoxicity. Teratogenic (Spina Bifida) Hepatic
Metabolism.
At KL of Mastery, you know and can easily recall all
the above facts when presented with a question. (Of
course, you need to know more than what's presented
above incl. mechanisms, clinical presentation, etc. to
be considered as having mastered the above concept,
but for the purpose of illustration, I've kept it
simple.)
A question presented at QD level of Mastery would need
most or all of the above information to be answered
quickly and your KL is at the right level to answer
it. Questions presented at Know or Familiar QD levels
would be a walk in the park for you.
At KL of know, the following information is easily
recalled by you:
Antiepileptic that acts on GABA, Na and Ca Channel.
DOC for Myoclonic Sz. Alternative for other sz. Side
Effects, Gi, hepatotoxicity, teratogen.
You probably can recall this subset of information
either because:
a) You read all the data as presented on the first
case but decided to remember only the above facts. You
mastered it at the KA Phase but only know it at the KR
phase. You have the potential to raise your Level to
mastery at the KR phase by doing lots of questions.
b) You can recall the above topics, because you used a
source that presented only the above facts. You know
this topic both at the KA and KR phase.
You may be able to answer questions presented at the
know and familiar QD level but you can only answer
questions presented at the mastery level under the ff.
circumstances.
a) Given enough time, you may be able to recall having
read some of the information before that will enable
you to choose one answer over another. You may need to
find some clues in the question stem, but you
eventually arrive at an answer that have a fairly
reasonable chance of being correct.
b) You need even more time because you had used an
abbreviated source as your main review and the only
way you can remember any of the more obscure
information is because a couple of years ago you had
the opportunity to use the drug and did some minor
reading.
Nonetheless, the common denominator you need is time,
which is a precious commodity indeed in USMLE.
At the familiar level all you know is Valproic Acid is
an antiepileptic.
At QD level of Familiar this is fine, since they
usually give enough information and clues in the stem
to help you (as illustrated earlier in my exam) or the
other choices are so obviously wrong(because your KL
level for all the other choices is obviously higher)
that you can clearly pick the right choice. At other
QD levels, it will obviously be extremely difficult
and you will need lots and lots more time and lots
more clue in the stem to get the answer right.
If you had KA this in mastery level, you can remedy
this in the KR phase by doing lots of questions. But
if you KA this at familiar level, questions are of no
help.
So why is it important to have a KL level higher than
the qd level the question was presented at the exam?
You could imagine the situation in the last 3 or 4
blocks of the examination, when fatigue makes
concentration and recall a little harder. You need to
read the questions twice because you don't get it the
first time. It takes longer to recall the answer even
if you've mastered it. So if your KL level for a lot
of the question is at a lower level then the QD level
it's presented, not only will you get a lot of it
wrong, you'll run out of time.
The situation when you are answering the Qbank at home
or in the library is more like the situation when you
are doing the first 3 or 4 blocks of the actual exam.
And if you are only getting 65% of the questions
right, you can extrapolate what is happening in the
last 3 or 4 blocks and understand why the end result
is what it is.
The problem of KL levels is a combination KA and KR
problem. You may have mastered the concept at the KA
phase but only know or are familiar about it in the KR
phase, in which case its a KR problem. But if you did
not master it at the KA phase, you cannot master it at
the KR phase. which makes it a KA and KR problem.
So it is possible for you to think you only have KR
problem because all the questions are familiar to you,
but you can still fail because you do not know and
have not mastered enough concepts to pass the exam at
the qd level presented in the actual exam although you
are familiar with almost all of them.
To remedy an inappropriate KL level problem, you may
need to go back to KA not just KR.
I took the exam on april 24,2006 and as per OASIS
trick last May 17, I have passed it. Just tweedling my
fingers waiting for the postman. I went into this exam
with the following statistic.
NBME form 1: 740 (3 weeks before exam) (1 hour timed
per block)
Kaplan QBank: 84% (all random, timed blocks no repeat.
Answered 1250 questions in groups of 2 to 4 blocks/day
over 9 days.)
USMLE CD : 46, 44, 48 (2 months before exam)
I reviewed for 7 months ( 4 months seriously) for this
exam. I am an IMG. A very, very old IMG. so that
you'll have an IDEA, when I was studying
1. DOC for Typhoid Fever was Chloramphenicol.
2. when I first encountered the word 'p53' all I could
think of was that he was senior member of this forum.
3. There was no treatment for AIDS.
4. 50% of our graduating class who went to the US
after graduation are now practicing physicians in the
US and most have already finished their J1 Waivers and
some are already citizens.
I've used this framework for analyzing my weak points
throughout my review.
We can divide our whole preparation into 3 parts,
1. Knowledge Acquisition(KA) - This is where you put
information into your Knowledge Bank(KB) Most new
graduates are extremely fine here (Except if you're
one of those who barely made it. Crammed for every
test and promptly forgot everything afterwards. Most
Old graduates and some IMG graduates usually have
problems here. If your deficiency is primarily here
(like me both old and IMG), I'm sorry, I don't think
there can be any successful prescription but to hit
the books.
2. Knowledge Recall or Review(KR) - This is how well
you extract information from your KB. Most new
graduates have some problem only here. FA and the
QBank makes a fantastic tool for improving Recall. So
people with problems here usually give fantastic
ratings to FA and Qbank.
3. Test Preparedness (TestPrep) - If you are not
familiar with CBT, MCQ or clinical slant to questions,
this is where your problem is. Problems with sitting
for 8 hour exam is also classified here. Difficulty in
answereing 2 to 3 step thinking questions also fall
here. This is where QBanks are the most effective.
If the problem is primarily in KA, answering 100
thousand Q's will not help, IF your KB is full and you
have problems only with KR and TP, hitting the books
will be a waste of time. QBank, FA, HY and Flashcards
should be the way to go.
How do I know where my primary problem is?
Well a quick way to know is to use an evaluation
examination, preferably one that's very near like to
the actual exam. (The Kaplan CD examination comes to
mind)
If you find while answering the questions that either
the choices, the question itself or the pictures makes
you think out loud "What the Heck is this?" You have a
KA problem.
If most of the time it is, "I know this, but I can't
recall how you differentiate between drug A and drug B
(or symptoms, presentation, treatment,
mechanisms,etc.)" You're having a KR problem.
If you thought you had the answer, then find out it's
wrong, but after reading the explanation, you are
surprised that you had misunderstood the question,
It's a TP problem. Running out of time answering
questions is also a TP problem.
As the medical adage goes, from the Diagnosis all
things flow. After you've correctly diagnosed your
problem, then the treatment is routine.
I'll discuss the solution to each identified problems
in my next post and particular strategies you can use
to improve your TestPrep ability.
As we all know, Medicine is a very broad subject, so
broad that we are divided into specialties. However,
for the purpose of the board we are required to know a
little of everything. So for the purpose of the board,
What you need to know is divided into 3 parts.
1. Knowledge that need to be mastered. - The so called
HY materials that are almost always tested.
2. Knowledge that need to be known. - you must know
enough so that they are taken into consideration in
your decision making.
3. Knowledge that you need only to be familiar - aware
that it exists.
Subsequently our own knowledge bank is divided into 3
parts
1. What we have mastered -we can recall this
information at any time in whatever way it is twisted
in whatever condition we are in.
2. What we know - we can recall this information only
when condition is optimum. We may need some time to
think about it.
3. what is familiar- we can recall this information
only with some clues and enough time to think about
them.
The more closely the component of our knowledge bank
conforms to what is expected of us by the board, the
higher the probability of acing the exam.
Why is this important? Because of the way the
examination is structured. The concepts that you are
required to master are usually presented in 2 to 3
step thinking format. Physio and Pharma concepts
requiring calculations usually include not only
irrelevant numbers but also may need multiple
calculations to come up with the answer. The exam is
extremely fair in this regard. I'll give 2 examples in
my exams (without giving away the actual question
since this is prohibited)
I had a question involving p21 Cyclin D and Cyclin E2.
Now I had mastered the p53 and Rb concept since I had
expected this to be one of those that should be
mastered. As you all know p21 and cyclin D are two
components that mediate between p53 and Rb. I had also
read about cyclin E2, which is the component that
normally initiate the process that pushes cyclin D and
Rb into allowing the cell to proceed to the S Phase.
The function of p53 if you would recall is merely to
act as a gatekeeper and does not initiate the process.
However, I did not memorize in detail the whole
process, ie. I was familiar with the role of cyclin E2
but did not master it. (Good thing the question popped
up in the 4th block when my mind was still
functioning). Any way they were good enough to give
details in the question stem on cyclin E2 (instead of
presuming you know it) Giving me a reasonably good
chance of answering the question.
Another example is on transcription factors. They gave
a drawing of the chemical formula of a transcription
factor (believe me it was fairly obvious which
transcription factor it was if you are even just
vaguely familiar with it) and asked its function. If
you know it, you can answer it. If you are familiar
with it, it gives you a reasonable chance to get the
answer.
So if you mastered what needs to be mastered and so
on, you'll probably ace the exam. Except that that is
impossible. Kaplan and all those in the prep-review
business will give an arm and a leg to be able to do
that. If you mastered what they want you to master,
you'll say that was fair. If you mastered what they
expected you to know, you'll say that's easy. If you
know what they expect you to master, you'll say that's
hard, If you are only familiar with or don't know what
they expect you to master, you'll probably curse and
call it experimental questions.
In reality experimental questions can be easy or hard.
They're called experimental questions since not enough
statistics have been gathered on the question to rate
them as hard or easy for the purpose of grading the
block.
Now going back to the quick and dirty method of
analyzing your weak point. If the QBank you used does
not reflect the emphasis of the board (Master what
needs to be mastered, etc.) What you thought is a KR
problem may be a KA problem after all. The Qbank may
have presented that concept in a straightforward
manner (ie, you know the concept) and you readily got
it, but the Board will present it in a 2 to 3 step
thinking manner (expecting you to have mastered it
which you didn't) Another disconnect, hence the danger
of relying only on Qbanks for review.
So what concepts should I master? Well, that maybe
impossible to answer for certain, but there can be
reasonable ways to arrive at what are the most
probable ones. You may think FA. But FA includes all
concepts tested on the exam, whether you are expected
to master it, know it or be familiar with it. If you
have the time to master all the concepts in FA fine,
but that would probably be more time-consuming than
reading entire texts. Remember memorizing is not
mastering. Mastering for example the Brachial Plexus
requires not only knowing the anatomy, but also what
they innervate, pattern of denervation or injury, etc.
Reading one line in FA should bring back a dozen or so
paragraphs that represent the concept that that one
line in FA represents.
A more reasonable way is to use HY books like HY and
BRS. For example, you've decided to use Big Robbins as
your main text for pathology because like me you've
forgotten half of what you know about pathology and
the other half is obsolete. You need BRS Patho because
it is practically impossible to master everything in
big Robbin's. A reasonable strategy is to master and
know most information in Big Robbin's that are also
found in BRS and just be familiar with the rest. If
you are a more recent graduate, you could start with
BRS and reference to Big Robbin's for concepts to
master.
Another good example is Micro and Immuno by Levinson
and Jawetz. Master all Organisms contained in its
"Brief Summaries of Medically important organism".
Know what is discussed in the text and be familiar
with organisms in the minor pathogen sections.
Exception is of course Immunology which you should
probably master.
I think this is a reasonable place to end this post.
I'll continue with the rest next time.
Just like any diagnostic exam, our quick and dirty
evaluation has its share of false positives.
While most people who have a KA, KR or TP problem
really have a KA, KR or TP problem. A minority have a
mixed problem, combination KA,KR or KA, KR, TP
problem. They often evaluate themselves to having a KR
or TP problem and so missed out that they also have a
partial KA problem.
I had thought of discussing this when we reach the KR
portion of the discussion, but judging from gigiMD's
post, I felt I should address this immediately. One
symptom is inability to raise your grade even with
repeated qBank drills. A pure KR problem should be
remedied promptly by answering huge number of Q's.
Failure to raise grade,or extremely small increments
of grade increase in relation to number of Q's done
points to a KA deficit.
There are a few more concepts we need to understand in
order to know why this is the case. I'll discuss this
here before we go back to discussing KA further.
In order to understand this we need to go back to the
concept of mastery, know and familiar. We can divide
our Knowledge Level (KL) of particular concepts as
Mastery level, know level and familiar level.(In
reality, there is more than 3 levels, but limiting to
3 levels make for easier discussion.) We can also
divide question difficulty(QD) to 3 levels, Mastery,
know and familiar. A question is easy, fair, hard or
impossible(experimental questions!!) for you depending
on the QD level of the question in relation to your KL
level of the particular concept being tested.
A table follows:
-------------------------QD
Level-------------------------
KL Level -------- Mastery---------
Know---------Familiar
Mastery------------ Fair ------------Easy------- Very
Easy
Know -------------- Hard------------ Fair---------
Easy
Familiar --------Impossible -------Hard--------- Fair
To further illustrate: let's take the drug Valproic
Acid.
All information available on it is as follows:
Broad Spectrum Antiepileptic that acts by Enhancing
GABA accumulation, Inhibiting repeated neuronal firng
by actions at Na channel, and inhibition of low
threshold (T-Type) Ca channel. DOC for Myoclonic sz.
Alternative for Partial and Generalized Tonic Clonic
sz, Absence sz. Tx for Mania Side Effects, dose
related anorexia, nausea, vomiting and idiopathic
hepatotoxicity. Teratogenic (Spina Bifida) Hepatic
Metabolism.
At KL of Mastery, you know and can easily recall all
the above facts when presented with a question. (Of
course, you need to know more than what's presented
above incl. mechanisms, clinical presentation, etc. to
be considered as having mastered the above concept,
but for the purpose of illustration, I've kept it
simple.)
A question presented at QD level of Mastery would need
most or all of the above information to be answered
quickly and your KL is at the right level to answer
it. Questions presented at Know or Familiar QD levels
would be a walk in the park for you.
At KL of know, the following information is easily
recalled by you:
Antiepileptic that acts on GABA, Na and Ca Channel.
DOC for Myoclonic Sz. Alternative for other sz. Side
Effects, Gi, hepatotoxicity, teratogen.
You probably can recall this subset of information
either because:
a) You read all the data as presented on the first
case but decided to remember only the above facts. You
mastered it at the KA Phase but only know it at the KR
phase. You have the potential to raise your Level to
mastery at the KR phase by doing lots of questions.
b) You can recall the above topics, because you used a
source that presented only the above facts. You know
this topic both at the KA and KR phase.
You may be able to answer questions presented at the
know and familiar QD level but you can only answer
questions presented at the mastery level under the ff.
circumstances.
a) Given enough time, you may be able to recall having
read some of the information before that will enable
you to choose one answer over another. You may need to
find some clues in the question stem, but you
eventually arrive at an answer that have a fairly
reasonable chance of being correct.
b) You need even more time because you had used an
abbreviated source as your main review and the only
way you can remember any of the more obscure
information is because a couple of years ago you had
the opportunity to use the drug and did some minor
reading.
Nonetheless, the common denominator you need is time,
which is a precious commodity indeed in USMLE.
At the familiar level all you know is Valproic Acid is
an antiepileptic.
At QD level of Familiar this is fine, since they
usually give enough information and clues in the stem
to help you (as illustrated earlier in my exam) or the
other choices are so obviously wrong(because your KL
level for all the other choices is obviously higher)
that you can clearly pick the right choice. At other
QD levels, it will obviously be extremely difficult
and you will need lots and lots more time and lots
more clue in the stem to get the answer right.
If you had KA this in mastery level, you can remedy
this in the KR phase by doing lots of questions. But
if you KA this at familiar level, questions are of no
help.
So why is it important to have a KL level higher than
the qd level the question was presented at the exam?
You could imagine the situation in the last 3 or 4
blocks of the examination, when fatigue makes
concentration and recall a little harder. You need to
read the questions twice because you don't get it the
first time. It takes longer to recall the answer even
if you've mastered it. So if your KL level for a lot
of the question is at a lower level then the QD level
it's presented, not only will you get a lot of it
wrong, you'll run out of time.
The situation when you are answering the Qbank at home
or in the library is more like the situation when you
are doing the first 3 or 4 blocks of the actual exam.
And if you are only getting 65% of the questions
right, you can extrapolate what is happening in the
last 3 or 4 blocks and understand why the end result
is what it is.
The problem of KL levels is a combination KA and KR
problem. You may have mastered the concept at the KA
phase but only know or are familiar about it in the KR
phase, in which case its a KR problem. But if you did
not master it at the KA phase, you cannot master it at
the KR phase. which makes it a KA and KR problem.
So it is possible for you to think you only have KR
problem because all the questions are familiar to you,
but you can still fail because you do not know and
have not mastered enough concepts to pass the exam at
the qd level presented in the actual exam although you
are familiar with almost all of them.
To remedy an inappropriate KL level problem, you may
need to go back to KA not just KR.