The failure rate on this question is around 50% for first time encounters with the question. When we see these rates, we re-evaluate the question - is it confusing, incorrect, a trick question? Or does it make the point the question’s learning objective calls for?
This week, we’ll call it ‘Ovarian Torsion Bias’, OTB, because it’s not medicine if you can’t make an acronym out of it. But it’s really just plain old familiarity bias:
Our #1 missed question in our Emergency Medicine ABEM Initial Certification preparation this week is:
The most common answer is (c), and there’s a few reasons for that, and thus a reason questions like this exist on the exam.
First, does the student interpret rapidly life-threatening correctly? Do they distinguish correctly between urgent and lethal? In only one of the answers do the conditions all carry a high risk of quick decompensation.
Second, residents are frequently taught about common and memorable emergency conditions. Tubo-ovarian torsion, while failing to meet the lethality criteria, is something most residents know. They’re biased towards what’s common, and what they know.
Third, missing nuances in question phrasing (or chart phrasing). The ovarian cyst has continued bleeding, meaning a high hemodynamic risk. Some may also call a tubo-ovarian abscess just a complication of pelvic inflammatory disease - failing to recognize the septic shock risk when the abscess ruptures. Arguable, but implies that you know it isn’t severe, that you can drain it, or that you have time for antibiotics.
This question, apparently simple, is really about the extent to which the student understands the underlying pathophysiology. Someone that has memorized lists of emergencies without that understanding will pick option (c). Someone that cued in on rapidly life-threatening and continued bleeding will pick the correct answer, (b).
For an emergency physician studying for the initial boards, focus on how and why each condition can lead to rapid decompensation - in this example hemorrhagic shock and septic shock from ectopic pregnancy, ovarian cysts, and ruptured TOA. For the exam, teach yourself to spot phrases such as “life-threatening” and “continued” - look for modifiers to the condition that will cue you in.
And last, be aware of the tendency to choose familiar conditions just because they are more frequently encountered or discussed. Shifting the focus to consider how quickly a patient might decompensate with each condition will alter your focus from quickly answering the question, to what are the most important issues with the conditions or treatment named in the answers.
This question appears in Med-Challenger Emergency Medicine Review with CME
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