Secondary Logo

Journal Logo

Medically Clear: What I Learned Re-learned Studying for ConCert

Ballard, Dustin MD

doi: 10.1097/01.EEM.0000508293.66998.b0
Medically Clear

Dr. Ballardis an emergency physician at San Rafael Kaiser, co-chair of the KP CREST (Clinical Research on Emergency Services and Treatments) Network, and the medical director for Marin County Emergency Medical Services. He is also the creator of the Medically Clear podcast on iTunes or at Follow him on Twitter @dballard30.





This summer I have had the pleasure chore of studying for the Continuing Certification examination (ConCert). Remarkably, 10 years after my last go, my brain is nimbly haltingly recovering details it carefully stored in my youth: neglected formulas, minutiae, and zebras of many hues. With excitement annoyance, I have launched into the review material, cognizant that several months' worth of appraisal are likely to bring a lasting temporary upgrade in my emergency medicine knowledge base. Not wanting to forfeit a week of vacation for this opportunity toil, I've embarked on a slow and steady self-study algorithm:

Step 1: Use continuing education funds to purchase the deluxe package of the National Emergency Board Review Self-Study.

Step 2: Revel in the massive package that arrives in the mail: a binder bigger than my head, 225 image-laden “BizzBuzz!” flashcards, 28 audio CDs, 14 DVDs, and a flash drive (the contents of which remain a mystery.) I think I also received a pocket-sized DSM-V, just in case this caused a psychotic break.

Step 3: To complete the self-flagellation, I cued up the PEER VIII on my tablet, replete with 450 questions and detailed answers.

Step 4: Oh, months of endless enlightment, poorly deployed hippocampal effort!

My summer is nearly wasted over, and my brain is a lean, mean diagnostic medical trivia machine. Before I shut the cognitive door on this experience, I jotted down some tips to help those who will take the ConCert in the next few years. After all of my cramming efforts, here's my big takeaway. The ConCert actually stands for:

Back to Top | Article Outline

C=Calculating Formulas

I did not realize how much I missed calculating formulas on my own. If the Y2K glitch finally strikes and I am without access to the internet, a smartphone, or EHR-based calculators, I will not have struggle to remember the Parkland, the Winters, or the osmolal gaps.

Is it just me, or is it a waste of precious brain space to know that in a hyperglycemic patient the sodium is actually the measured sodium + 1.6 * (glucose-100)/100)? Isn't it enough to recognize that the sodium level in hyperglycemia is artificially low and the potassium level artificially high?

Back to Top | Article Outline

O=OMG, Rashes

There is nothing an EP loves more than a well patient visiting the ED for a nonspecific rash. If I had wanted to be a dermatologist, I would have done a pimple-popping residency. Unfortunately, ABEM takes a different approach to rashes. Jodie Craig, MD, a residency colleague of mine who recertified last year, pointed out that the exam does not allow access to Google images or the derm teleservice. I guess I'll be on the lookout for the Christmas tree appearance of Pityriasis rosea and the distinctive gray-white appearance of disseminated gonococcal infection.

Back to Top | Article Outline

N=Negative Reinforcement

EM Board Review pictorial flashcards are a great way to scare your children out of any interest in medical school. Here's what happened when my 7-year-old picked up my cards.

7-year-old: “Aaargh. Dad, what happened to his wiener?”

Me: “Chancre, son. Not painful but still not good. Needs some penicillin.”

7-year old looking at another card: “Gross!”

Me: “Fournier's gangrene. Bad news. Smells bad, too.”

7-year-old throwing cards across room: “You're weird, Dad.”

Back to Top | Article Outline

C=Cold Calorics

Amal Mattu, MD, is fond of advising his board review students what things are like at ABEM General and which rare conditions and tests we're expected to know, despite the fact that we may never encounter or use them in our day-to-day practice. Cold calorics are a perfect example. I have never performed this test, not even in the ICU.

I have to think that the only relevant aspect of the exam is to remind us not to use cold water when performing earwax irrigation. And what about the perimortem C-section? I am unlikely to ever perform it in real life, but I can guarantee that I will encounter it on the ConCert. As for the DPL, Dr. Craig wonders, “Seriously?”

Back to Top | Article Outline

E=Esteemed Eponyms

What is it with eponyms? Let's see, which name is more helpful? Slipped capital femoral epiphysis or Legg-Calve-Perthes? What about ulnar styloid fracture or Smith fracture? Clinically, isn't it enough to recognize a fracture of the posterior-lateral humerus associated with a shoulder dislocation without needing to know that in some yesteryear, Drs. Hill and Sachs decided to immortalize themselves by attaching their names to an avulsed piece of humerus?

Back to Top | Article Outline

R=Ruling Out Wrong Answers

My friend Jason Willis-Shore, MD, also studying for the exam, sums up the test-taking strategy as read the prompt first, and, if in doubt, choose B or D.

The biggest disappointment for me is that I cannot strike through wrong answers the way I used to at the testing center. What a drag! One of the only enjoyable moments of test-taking is the self-satisfaction that comes with aggressively crossing out an answer choice that I'm absolutely sure is wrong. Apparently, the computer has some means of recreating the process, but like going to the “beach” at a resort in Las Vegas, I suspect this just won't be the same either.

Back to Top | Article Outline


Those studying for ConCert are certain to pick up an odd fact or two along the way. Did you know that belonging to the Goth subculture increases risk of suicide? Or that the term “well hung” comes from the erection caused by proper execution by hanging? Turns out there would be no erection if a prisoner died by asphyxiation (poorly hung!) rather than spinal cord transection.

OK, all complaining aside, my studying has not been for naught. I am quite confident that I am now better equipped to diagnose a rare disease that I will never see — anthrax or the plague, for example — than I was before studying. Luckily for my patients, I will remain vigilant, I suspect, for at least three to four months before my diagnostic artery constricts back to its baseline diameter. And I'll remember that all prisoners have tuberculosis, and everyone between 12 and 35 is pregnant or has an STD.

My friend Dr. Willis-Shore (clearly someone more academically minded than me) said he has rather enjoyed the “excuse” to refresh his base of knowledge, and I suppose I grudgingly agree. I will freely admit, however, that I have greatly appreciated the “excuse” to listen to Billy Mallon's sound-effect-enhanced lectures on trauma and orthopedics.

Whoooooosh, that's the sound of all that relearned minutiae leaving my head.

Back to Top | Article Outline


Dr. Ballard's August column, “Separating the ‘Mercury Cure’ from ‘Germ Theory,’” incorrectly identified the medical schools of two students who conducted research about gender bias and resident evaluations. Daniel O'Connor is a medical student at the University of Pennsylvania, and Vineet Arora is a medical student at the University of Chicago. EMN apologizes for the errors.

Share this article on Twitter and Facebook.

Access the links in EMN by reading this on our website or in our free iPad app, both available at

Comments? Write to us at

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.