The Step 2 test is 9 hours long.  My study days would sometimes be even longer. Especially toward the end of a long study day, I would sometimes get to the end of a question only to realize that I hadn’t processed what I had read and couldn’t remember the details. Then, I would have to read it again, and, sometimes, again.

I developed a game to help myself pay attention, reduce memorization, and have fun!

Basically, the idea is to create a mini-differential, and then actively update it according to new information.  Then, you do not have to memorize the information in the question stem, you just remember your mini-differential. The differential serves as a filter for information, because it only changes when information is important. Because one is actively committing to a differential after each bit of new information— part of the game is to actually state a top differential with each line— one is engaged.  Finally, because one is updating a differential, one improves one’s clinical reasoning.

I will now show an example question, and then I will show how to play the game. The question is from the freely available samples on the national board of medical examiners (NBME) website.

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A hospitalized, 57-year-old man has had severe progressive pain in his left knee since awakening 2 hours ago. He was admitted to the hospital 2 days ago for an acute myocardial infarction. Cardiac catheterization showed occlusion of the left anterior descending artery, and he underwent placement of a stent. Current medications include aspirin, metoprolol, lisinopril, simvastatin, clopidogrel, and heparin. Vital signs are within normal limits. Examination of the knee shows a large effusion. The knee is hot to touch and erythematous. He holds the knee in 30 degrees of flexion; the pain is exacerbated with further flexion or extension. Laboratory studies show:

Hematocrit	40%
Leukocyte count	13,000/mm3
Serum
Ca2+	9.2 mg/dL
Urea nitrogen	15 mg/dL
Creatinine	1.0 mg/dL
Albumin	3.6 g/dL

An x-ray of the left knee shows calcification of the synovium. Which of the following is the most likely diagnosis?

(A) Deep venous thrombosis

(B) Gonorrhea

(C) Gout

(D) Hemarthrosis

(E) Pseudogout

(F) Septic arthritis

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So much information! So many choices! 

This is how to play the game.

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A hospitalized 57-year-old man has had severe progressive pain in his left knee since awakening 2 hours ago. 

Trauma due to sleeping position!

He was admitted to the hospital 2 days ago for an acute myocardial infarction. 

Vascular issue!

Cardiac catheterization showed occlusion of the left anterior descending artery, and he underwent placement of a stent. 

Plaque embolism!

Current medications include aspirin, metoprolol, lisinopril, simvastatin, clopidogrel, and heparin. 

Trauma due to sleeping position!

Vital signs are within normal limits. Examination of the knee shows a large effusion. 

Infection!

The knee is hot to touch and erythematous. 

Infection!!!

He holds the knee in 30 degrees of flexion; the pain is exacerbated with further flexion or extension. 

Infection!

Laboratory studies show:

Hematocrit	40%
Leukocyte count	13,000/mm3

Mild infection?

Serum
Ca2+	9.2 mg/dL
Urea nitrogen	15 mg/dL
Creatinine	1.0 mg/dL
Albumin	3.6 g/dL

Calcium issue!

An x-ray of the left knee shows calcification of the synovium. 

Some kind of gout!?

Which of the following is the most likely diagnosis?

(A) Deep venous thrombosis

(B) Gonorrhea

(C) Gout (?)

(D) Hemarthrosis

(E) Pseudogout (?)

(F) Septic arthritis

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The answer is E.

Here, I only end up with a 50-50 chance. I rarely ended up getting the right answer directly (but it felt great when I did), but even when I did not, after playing the game, I found it easier to look at the answer choices and then determine the most likely answer. Nonetheless, it is not so much about getting to the right answer as about staying engaged and thinking critically about how new information helps one refine a differential. This is not only an important test taking skill, it is an important clinical skill. 

If you are smarter than me, you might have multiple items floating around your differential at a time. Or, you might take the question in chunks rather than sentence by sentence.