Tips on how to pass the PANCE

Hello!  I just recently took the Physician Assistant National Certification Exam (PANCE), and I'm so thankful to say that I passed!  Friends have asked for tips and what books are best to prepare for the  PANCE.  Honestly, I'm not sure if I'm the best person to ask but I can share the resources some of my classmates and I used to prepare for it and information about the PANCE that will hopefully help you too!

The Exam:

• The exam has a total of 300 questions.  
• There are 5 sections of 60 questions.  
• You get 60 mins to complete each section
• You get an optional break in between each section, but the addition of those breaks cannot be more than 45 minutes.  
• Each question has 5 multiple choice answers. They're not easy choices.  Many times I'd narrow it down to 2-3 answers and had to make my best educated guess.
• Questions are usually short paragraphs of 3-4 sentences.  They aren't very specific either.  For example, they rarely provide key words such as "projectile vomiting" or "worst headache of her life."  You know, all of those good key words we learned to recognize during PA school :P 
• There are a lot of tertiary questions on the exam.  For example, a tertiary question would ask, "12yo presents with shortness of breath and wheezing after exercise.  What medication do you most likely need to caution use of?"  So, you not only have to know that the most likely diagnosis is asthma, but you also have to know that they cannot take aspirin or any non selective beta blockers.  
• My exam had a bunch of pharmacology on it, so I'd recommend reviewing your medications and contraindications to each of those medications.  
• Here is a breakdown of the PANCE by organ system (taken from the NCCPA website):

Organ System % of Exam Content Cardiovascular 16 Dermatologic 5 EENT(Eyes, Ears, Nose and Throat) 9 Endocrine 6 Gastrointestinal/Nutritional 10 Genitourinary 6 Hematologic 3 Infectious Diseases 3 Musculoskeletal 10 Neurologic System 6 Psychiatry/Behavioral 6 Pulmonary 12 Reproductive 8 Total: 100% Tasks % of Exam Content History Taking & Performing Physical Examinations 16 Using Laboratory & Diagnostic Studies 14 Formulating Most Likely Diagnosis 18 Health Maintenance 10 Clinical Intervention 14 Pharmaceutical Therapeutics 18 Applying Basic Science Concepts 10 Total: 100%

• Cardiovascular and pulmonary systems were definitely a huge portion of my exam.  It seemed like every patient I encountered had shortness of breath, chest pain or both!

Resources:

Here are the books and online resources I used:

Van Rhee PA Board Review	I find this one to be the most organized and concise. If you were to purchase one book, I'd recommend this one.  It's my favorite out of all of them. At the end of the book, there are appendices that layout things clearly such as Poisoning Antidotes.  If I had not looked at this before taking the PANCE, I would have missed that question on the exam on what to give a patient with opiate overdose: Naloxone.
A Comprehensive Review for the Certification and Recertification Examinations for Physician Assistants	2nd favorite. This book is great during clinical rotations and has up to date treatments and diagnostic tools.  I've pretty much butchered this book with tags, highlights, pen marks everywhere, drawings, coffee stains, abuse.  I think the more you abuse a book, the more you know it inside and out.  I read this book throughout clinical year and again after graduation.  It has great online practice questions.
Exam Master Packrats	Exam Master was the best study tool for me.  I started these questions AFTER I went through all of the PA review books, though, because I knew they were hard.  The Exam Master practice questions are long and very challenging. Many of my classmates and I were scoring 45% on each section!  This was a real downer.  That's why I recommend doing a mixture of easy and hard practice questions.  Although they were tough, they gave scenarios and asked questions that are similar to the ones on the PANCE.  Additionally, what's even more great is that each question provided explanations for why each answer was either right or wrong.  It was my favorite study tool for the PANCE.  Packrats are practice questions that were given by our program. They are very similar to the PANCE.  Surprisingly, I didn't use them during my preparation, and I kind of regret that.  But, I did fine with the Exam Master questions, so if you only have access to one or the other, you should be fine.
Physician Assistant Review 3rd edition Aka “Pat Auth” book	I believe this book was recommended by our school.  I didn't think the book was as good as the comprehesive review one, but it still provided some pretty good online practice questions.
PANCE Kaplan	I mainly used the online practice questions.  I didn't really use the actual book.
Davis’ PA Exam Review	Many classmates and 2 preceptors recommended this book.  “The questions in the book and on the CD were very similar to the ones on the PANCE. It’s full of questions, and friends basically did them until they could know the answer to the questions after reading the first and second sentence.”  Unfortunately, I didn't have enough time to go through this book, but from what I hear, it's a great resource.
Lange Q&A Physician Assistant Examination	Many of my classmates who did well on the exam recommended this book, but I didn’t get my hands on it in time.

Tips for the Day of:

• Try to visit the testing center the day before or much earlier than your testing time just so you know the area and won't get lost the day of.  You don't get your money back if you're late, and last I heard, money don't grow on trees.
• Also, get there at least 30 mins before your actual testing time.  I got there a whole hour and 15 mins earlier because I was just so nervous lol!  I ended up chillin' in the car with my Mom at 6:30am.  She gave me lots of encouragement and eased my anxiety.  They'll usually let you in 30 mins before your testing time.  Mine was at 8am in Atlanta (Dunwoody), and they started to let us in at 7:15am. But I'm sure every testing center is different.
• Bring lots of snacks and water. I brought a sandwich, some fruit and a bottle of water.  At each break, I pretty much forced myself to eat something even though I was so nervous I didn't have an appetite to eat.  I guess it's better to be filled than emptied and growling.
• Try to go to the bathroom at every break even if you don't have to.  Not good if you gotta go but you're on question #10 out of 60.  

What helped me the most:

• I had bad anxiety one week before the exam. I'd get palpitations and had to get up and stretch or do 100 jumping jacks.  What helped me out with the anxiety was going to the track afterwards with a friend and taking a brisk walk for about 45 mins.  I also discovered relaxing in a whirlpool for 15 mins in the evening made a world of difference and calmed me down instantly.  I also couldn't sleep at night, so I'd take my notes and study them to sleep.  Studying usually gets me to sleep very easily so I was knocked out in 15 mins or less. :P
• Every day, I'd go to the public library from 9am until they closed which was about 8pm. I'd pack a lunch and get a small private room to study, and I did this for about 2.5 weeks straight.  
• Having a support system. I was really grouchy during those 2.5 weeks. It was probably a good thing my husband was an ocean away from me at the time, otherwise, I'd make a fuss over stupid little things.  My mom was incredibly supportive and encouraging throughout the whole preparation for the exam.  My dad was too by telling me, "it's okay if you don't pass the first time.  You'll know how the test goes and will be prepared 2nd time around."  This put me a little more at ease after I realized that he was true and it wouldn't be the end of the world if I didn't pass.
• Practice tests.  Take a mixture of both easy ones and hard ones so you don't get bogged down with all the ones you missed with the hard tests.  
• Make notes or flashcards of the questions you got wrong.  Quiz yourself constantly.
• During my last semester as a PA student, I served as a TA for Anatomy.  This helped me out tremendously as there were about four questions on my PANCE that dealt with anatomy so review your anatomy!  For example, know the bones in the wrist and their location, review over radiographs, CTs and MRIs, know the different types of fractures like colles, the 5 types of salter harris fractures, and so on.  
• Surprisingly, a lot of questions on the exam weren't from lectures or text books.  They were from the experiences I gained in the clinical setting.  For example, prior to my dermatology clinical rotation, I didn't know anything about moles, lesions, or anything skin. I knew textbook material only.  But after starting the rotation, I discovered that a lot of it has to be felt with your own touch.  Soon into the rotation, I was able to fully understand textbook's descriptions of lesions.  This experience at this Dermatology clinic gained me 100% for derm on the exam.

What I recommend most:

• Allow yourself enough time to study. I did 2.5 weeks, and I wish I had more time.  I didn't feel prepared prior to the exam; however, somehow I still managed to pass the exam.
• Create a game plan.  Layout all the things you want to accomplish during the amount of time you have and create a day by day schedule.
• Try to go over all of the study books, take each of the exams, practice those Exam Master questions and do those packrats.  
• Make flashcards or notes and quiz yourself all the time, even on the John.
• Get plenty of rest each night because you're going to need it every day.  It's mentally exhausting!
• If you're still a student, take advantage of your clinical rotations and don't be so eager to go home.  Staying at the practice might give you opportunities to learn something that may be on the PANCE or more importantly of course, for someone's life.
• A classmate of mine made great charts and divided them up into systems like musculoskeletal, OB-GYN, Infectious Disease, etc.  She provided columns that described the symptoms, clinical picture, diagnostic test needed to be ordered and treatment options for each disease.  I reviewed over all of her charts, and it helped me out a lot.  If you are a student still, I'd recommend starting these charts early on.  They will help you during didactic, clinical and board review times.
• Sign up to take the PANCE on a Monday.  The NCCPA site will tell you it takes them 2 weeks for exam results to get in, but if you take it on Monday, you'll get results by Thursday.  Unfortunately, I took mine on a Tuesday, and didn't get results until a week and two days later which seemed like torture for me.

If anyone else has tips they liked to share as well, please leave share in the comment section!  Thank you and good luck to everyone!

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Overall PA School Experience

Well, I guess I should revisit my blog I started 5 years ago and intended to write on daily but never touched it once through PA school.  Five years ago, I started this blog in hopes of recording my failures, triumphs, and ultimately memories while becoming a Physician Assistant.  I had no idea PA school would be so hard.

They say the first year of PA school is like trying to drink water from an open fire hydrant.  A lot of information is being thrown at you, but your job is to catch and absorb as much of it as possible.  It was the didactic year, and this was my most stressful year of all.  I broke out in really horrible acne, seborrheic dermatitis, and of course, tears many times due to the overwhelming stress.  Luckily, Benji was there for me emotionally being the supportive and caring boyfriend who he is through each of those times.  Though we were long distance (he being in St. Maarten and me being in Miami), Skype helped make it seem like we were sitting right in front of each other.   

This is an illustration of one of the many confusing
diagrams for Neuroanatomy. "WHAT THE?!" I
know, right?!

I digress...  during the first semester with Barry's PA program, we had 7 classes:  Anatomy, Microbiology, Neuroanatomy, PA Role, Physical Diagnosis, Pharmacology, and Physiology.  My favorite two classes were Microbiology and Physiology. My least favorite was Neuro. I loved the professor, but didn't like the video lectures.  Everyday it seemed like there was a huge dark cloud over our heads...the dark clouds were exams after exams after exams.  

Second semester was better and more interesting because we were finally diving into more clinical material.  There were 10 classes total including:  Genetics, Geriatrics, Medical Spanish, OB-GYN, Pathophysiology, Physical Diagnosis, Pediatrics, Pharmacology, Psychiatry and Surgery.  My most favorite were OB-GYN and pathophysiology.  Least favorite was Genetics.  I believe the professor teaching the class plays a huge role in my learning. Our professor for OB-GYN was Professor Whitney Lester, and I was able to retain most everything I learned in her lectures just because of the way she taught the material.  She was very clear and shared her clinical experiences with the class.  She was a fantastic professor and one of my favorites in PA school.  My favorite professor was Professor Charity Ramsey who had a way with describing anything at all and making it fun to learn.

Third semester was even better than the previous semester.  Although we felt like we gained much more knowledge in the past two semesters about medicine, none of us felt like we were ready for clinical rotations.  This was our last shot at trying to learn as much as possible before being tossed out there in practice.  Third semester was during the Summer time -- the warm, sunny Miami beaches were such a tease.  We had 8 classes:  Pathophysiology II, Physical Diagnosis III, Radiology, Pharmacology, Emergency Medicine, Epidemiology, Research Methods, Health Prevention, PA Role, and a little more Medical Spanish II.  My favorite classes were Radiology and Pathophysiology.  Least favorite was PA role. Gotta say, I didn't really like that PA role class too much =/.  

My roomies and me during the first year of PA school

I don't think I would have been able to survive that first year without my awesome roommates, Bon Bon and 5arah.  They were like my family there in Miami.  We'd quiz each other during our carpools to and from school, vent with each other, cry to each other, go work out together, share foods with one another, and even do some retail therapy together at the mall conveniently located 10 mins walking distance away together.  We even got sick together.  Now that's family there!    

Now for the clinical rotations.  My rotations started off easy with my first one being Psychiatry at the Miami VA hospital.  Most of the experience was inpatient which I preferred more than outpatient.  Honestly, this rotation provided the best hours (7:30 am - 3:00 pm).  I'd get into the psychiatry unit at 7:30 for the morning report of patients, have round table discussions with my attending and resident, a pharmacy student, social worker, and the patient's nurse.  Then we'd see the patients one by one asking them how they were progressing or not. We'd also switch over to the hospital side and check on some patients just out of surgery to make sure they weren't experiencing any delirium.  I loved this experience a lot.  However, one thing I didn't like was the field.  Being an extrovert, I soak in my surrounding environment's energy.  I found that the field was sometimes depressing which depressed me often times when I came home from work.  Although I got off of work no later than 3pm daily, I was depressed and just wanted to curl up into my bed and take a nap.  

Internal medicine was my next rotation and that one was fun!  Surprisingly, it was more outpatient than inpatient, but I didn't mind because my Preceptor (Dr. Abassi)  was awesome.  Since I was her only student, we traveled together to hospitals, nursing homes, and even to patient's houses as she made house calls.  It was here where I finally mastered my physical exam in under 5 minutes.  We had to do it daily to each patient, so there was lots of opportunities for practice.  It seemed as if every patient had diabetes, hypertension and/or hypercholesterolemia.  Every now and then there will be an extraordinary case like neurosyphyllis or unsuspected colon cancer.  I would have loved to do another rotation with Dr. Abassi, but time just did not allow it.  I learned a lot during this rotation.

Then came Family Medicine with Dr. Wollschlaeger.  He was AWESOME.  Dr. W's office does not take insurance, so he can practice as freely as he wants to.  He's not regulated to order certain tests or give certain drugs just because an insurance company will pay for it or not, which makes his practice great. In addition, he is a one man show meaning he runs his family clinic all by himself.  He occasionally has students from the University of Miami School of Medicine, though they usually just sit in for one day.  My classmate Ali and I were pretty much the only students coming in daily.  We drew so much blood and gave so many injections during that rotation.  Although I would have like to have done more, it was a good experience.  Oh, and he always had house calls at the most luxurious places in Miami.  How he gets his connections, I have no idea...

Some other students were goofing around.  Being the good student that I
am, my head was always in my books.  Btw, that's not me on the left. That's
my evil twin sister.

Fourth rotation was Emergency Medicine at Westchester Hospital.  This is an all Spanish speaking hospital.  In fact, every four hours, a nurse would come around with a tray of small cups of colada (cuban espresso) for all of the Physicians, nurses and sometimes if we're buddy buddy with them, the students as well =D  It was here where I had lots of opportunities to practice my medical Spanish. I'd interview each patient in Spanish. Often times, I wouldn't know the word, so I'd have to act it out.  Let's just say, my acting skills were awesome. lol.  I noticed each patient arriving to the emergency room would get an IV.  So, on the first day of rotation, I practiced my IVs.  Second day, I practiced doing ABGs.  Third day, I inserted an NG tube for a woman with bowel obstruction. Fourth day, I did a couple of foley catheters....then the very last day of the week, I wanted to do something really cool!  I was thinking something like a chest tube for a pneumothorax or a pleural effusion, or something like that!  Nope, just changed an adult diaper packed with stool.  

Sometimes I'd get off of work at 5:30pm which was a perfect
time to get stuck in Miami traffic, so I'd stop at the nearby
McDonald's and talk to Benji via skype since it was 10:30pm
where he was in the UK then.

Fifth rotation was my least favorite, but surprisingly I gained a lot from it both medicinally and emotionally.  This rotation was during the time Benji and I had our wedding celebration in Miami, so it was a lot to manage.  It didn't help that this rotation site was 1.5 hours away making my total commute for the day to 3 hours.  Luckily, I was able to do a lot of wedding planning during the commutes, so it all worked out great.  Oh yes, this rotation was OB-GYN with Dr. C.  He was the meanest Dr I'd ever worked with.  During the first week, he yelled at me in front of his patient and then yelled at me some more once we were outside of the patient's room.  I broke down and cried right in front of him and then excused myself to cry some more in his office alone.  This was probably not the most professional thing to do, but I didn't care.  He didn't have to yell at a student like that for asking questions.  The MAs and office staff were very nice, understanding and comforting, which made me feel much better.  I spoke to my school's clinical director during that day's lunch break, and she helped me get through that obstacle.  I talked to Dr. C afterwards about the incident and tried to understand why he was so upset. At the end of the discussion, we were able to see eye to eye on a lot of things.  Afterwards, he allowed me to first assist him in hysterectomies, cancer staging, cervical cerclages, and delivering babies.  As a student, this was big stuff for me.  All in all, I started this rotation with fear of my attending, but later left with a friend.  As he wrote my overall evaluation at the end, he read it to me with tears in his eyes.  It was the most humbling rotation I'd ever had.  

Next rotation was Surgery with Dr. Legaspi.  Surgeons have it bad and are known to be the meanest people in the world.  They work long hours, have unconscious patients' lives in their hands, could easily nick a vein or artery, and so they yell at everyone around them and are known to be cocky and rude.  However, Dr. Legaspi was far from this and probably the nicest surgeon I'd ever met.  During each surgery, he'd hook up his laptop in the OR to some Mana tunes playing from Pandora and jam to them during cholecystectomies, liver resections, ablations, and more.  I got to experience and assist in my first whipple procedure which is a huge six hour surgery.  We removed a 15lb liposarcoma from one gentleman, then took out his right kidney because it necrosed due to the compression of the liposarcoma, removed his appendix, and also noticed his inflamed gall bladder so we removed that as well.  I'd say the patient lost a good 20 lbs instantly from that surgery. During this rotation, I got to work with other surgeons as well during the down times.  We amputated legs which easily seemed like a scene from Saw III.  Overall, this rotation with Dr. Legaspi at Mt. Sinai Hospital was a fantastic experience.

Dr. Quereshi and the Immunization Schedule he made for me

Seventh rotation was much less stressful:  Pediatrics!  The kids were so cute, and I'd often catch myself goo-ing and gah-ing over the cute kids and babies.  In the beginning, the kids didn't allow me look inside their ears, but with the help of fellow classmates and their tips, I managed to say "choo choo" as I checked their ears, and asked them if they had just had some chicken nuggest from McD's while checking their abdomen.  They were much more cooperative after that.  Dr. Q was my attending and an awesome one.  In between patients, he'd allow us to do our readings and studying in his office.  Every now and then, he'd make a quirky joke or share his excitement over some new techy gadget he wanted to get. lol. It was cute.  

Last but certainly not least was my rotation with Dr. Horwitz in Dermatology.  Stepping into this rotation without any experience at all was challenging.  The staff there probably expected me to know more, but my clinical experiences were poor while my knowledge of the material was adequate.  I was able to give treatment options but was not able to even recognize the diagnosis.  By the second week of this rotation, I was able to put 2 and 2 together.  The MAs there were extremely helpful and in the end, I was able to learn so much from this rotation that I scored a perfect 100% on the PANCE for the derm section.  

This was me introducing the keynote speaker for
Barry's 2013 graduating class!

Now, a lot of PA programs such as the University of Florida end their program after just two years.  Our program extended it to one more semester as 'Advanced Didactic.'  We prepared for the Physician Assistant National Certification Exam (PANCE), had the option of doing a 6 week supplemental rotation in any field of your choice, and took the following classes:  Clinical Therapeutics, Thanatology, Ethics, Board Review and we had to write a thesis paper.  I did my thesis paper on the efficacy of vaccinations and why individuals do not comply with their schedules.  I also spent my advanced didactic semester serving as an anatomy TA and tutor for physiology and anatomy.  Surprisingly, there were some questions on the board exam that made me so thankful I signed up to be an Anatomy TA.  After taking our exit examination out of PA school, it was all celebration from there.  Our class threw a huge graduation party on a boat drifting down the Miami intercoastal and it was magnificent!  Afterwards, it was tears after tears as we all graduated after suffering and struggling 2.5 years together.  

Did I suffer during PA school?  Yes.  Did I ever have a break down and cry?  Oh yes.  Would I do it all over again?  As my buddy Ryanadine would say, "Yeaaaaaaahhh buddy!"  It was the hardest period of my life, and I'm not sure if it was because I was away from home, my family, my significant other, and/or the stress of the program, but I'm so glad I did it.  I may not have invented the toaster strudal, or designed the Eiffel Tower, but this is far greater than I would have expected myself to do, and I am darn proud of myself.  I owe a huge appreciation to my friends and family who supported me all the way through and for their constant encouragement.  I'm so thankful to them!

Sincerely, 

Irene Gung Ho, MsCS, PA-C