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Two articles in a row here (Previous articles have been moved to blog archive)

Now What?

Picture yourself sitting in from of the computer screen taking your exam. You read the paragraph setting up the question, the question “stem”. You read the question line at the end of the paragraph. Then, you look down over the options. And, you realize that you do not know the answer. Now what?

This moment, sitting there, not knowing the answer, is the most crucial moment in your exam. How you respond in this moment determines everything about your outcome. You will not get a top score because you know everything. Bluntly, you can not know everything. You get a top score because of what you do next in this moment. You do not know the answer—now what?

Most people in this moment do one of three wrong processes:

1.     Re-read the question stem. You will discover this does not help you. The question stem will be just as it was the first time you read it. You are not re-reading because it will help you, but because you do not know what else to do. And, because you are hoping (against hope) that somehow it will change into a different question, one that you can answer. In short, you are in denial, and denial will not get you to the reality of the correct answer.

     Sit and wait for an answer to occur to you. Waiting is an act of hope. You hope that if you just give it time, an answer will appear. But, you will notice, waiting does not move the process forward.  During you exam, no one can save you. No one will ride to your rescue. You are singly and utterly on your own. You will only be saved by your own actions.

     Tell yourself everything that you can remember on the topic. This is at least active, but usually does not generate the answer you need. Mentally reviewing general information does not generate the answer to the specific question before you. You need to think, yes, but not about what you know, rather about what you need to know.

So, if these processes will not help you, what do you need to do instead?

The USMLE is an exam where thinking, rather than knowing gets you that higher score. If you do not know the answer, you must have a process to generate one. How do you generate an answer? Begin by asking yourself:

       What is the central concept tested in this question? USMLE questions are all about making sure you have mastered important concepts. Questions asking about useless details or trick questions are do not make it into the question pool. For Step 1 ask, “What is the key mechanism?” For Step 2 CK and Step 3 ask, “What is the key clinical issue?”

       What are the possibilities for answers? Once you have summarized the problem, it’s time to reflect on possible solutions. Note that at this point, you are not looking for an answer, but simply laying out the possibilities. Laying out the possible protects you from jumping to an answer too soon, and engages the process of thinking.

       What evidence is presented to let me choose among these possibilities? Having laid out the possible, you need to weigh their relative probability based on the information the question presents. The facts presented in the question determine what will be the best answer. Change the facts, and you change the answer. You are not looking for certainty here, but doing a process that will generate a best guess response.

       So, given the options here, which is the best choice? USMLE options often do not give you the perfect answer that you are looking for. Instead of the classic drug you remember, you may see a different drug, but one with similar mechanism. Instead of the perfect words to say to the patient, you may see something which is OK, but not as good as another answer you can imagine. But, you have to pick from the options they give you. Make a choice. And then move to the next question.

The process of generating an answer when you do not know initially is straight forward-- a simple series of questions to allow a decision. The hard part about responding to “Now What?” moment is emotional. Do you have the mental resolve to keep going? When you do not know, do you feel rising panic? Do you feel a sense of helpless ness?

Or, are you able to rise to the challenge? Are you willing to take on the task? Are you willing to do something in order to gain everything?

Medicine is not about always being right. You will make mistakes. You will commit errors. Rather, successful medicine is about managing the risks each decision brings. And your exam is the same. Do you have what it takes to move forward? Do you have the confidence to see it through?

You have examined your patient. You have run the pertinent tests. And you do not yet know what is wrong with the patient. Now what? If that moment motivates and energizes you, then you have chosen the right field. The thrill of medicine comes not from the knowing, but from the ability to get to the answer when you do not know.

Steven R. Daugherty, Ph.D.

Second article:

Choose Not to Be Overwhelmed

Success on the USMLE depends on making the proper choices. The most obvious choices you must make involve selecting the proper letters to answer the presented questions. But, the most obvious choices are not the most important.

When you walk into the testing center on exam day, your score has already been determined by all the choices you have made up to that point. Your exam choices will be simply the sum of those preparation choices. Preparation defines outcome. Focus on making the right preparation choices and the exam choices will take care of themselves.

Of all the choices you will make in your exam preparation, none is as important as the decision about what you should study and the amount of time you should dedicate to each topic. The amount of material to be reviewed and mastered is so large as to seem overwhelming, if not impossible. Sitting with the stack of your books, notes, and other study materials before you, the pile can feel insurmountable. The size of the task can cause you to feel helpless, and even hopeless. What should you do to avoid feeling overwhelmed?

You begin by making choices, an making them early. You cannot learn everything, so stop trying to do so. 

Trying to learn everything is about avoiding making choices. You do not want to make a wrong decision, so you abandon decision making altogether. You hope that with a monumental effort you can master everything. The cold, hard reality is that even with infinite time and assistance you simply can not master the breadth and depth of material required by the USMLE. Realize that you are human and that there are limits to what you can do. You have to make some choices. Some subjects require your extended attention. Others can be ignored. Some concepts will require concentrated effort. Others you will masters with just a simple reading. Your main job, as you prepare for your exam, is to decide which is which.

Once you accept the principle that you can not learn everything, you are then ready to make specific choices as to how your preparation should succeed. Here are a few time-tested suggestions:

  1. Focus on your areas of greatest weakness

As you begin your exam preparation, it is so tempting to start with the subjects you like the best. You are probably pretty good at what you like and this experience can help boost your confidence. But, this initial confidence boost soon fades. Doing the easy stuff first does not make the difficult material any easier. Rather, putting it off can increase anxiety and make the already troublesome concepts even harder.

Start with your worst subjects. They will never be your best, but focus on at least raising your mastery to the level where these subjects will not hurt your score and hold you back. And once you realize you have gained ground on the most difficult material, you know you can master the easier content that remains.

  1. Get something, even if you do not get everything

Within each subject, you can not remember every detail. Get something out of each section you study, even if you do not get everything. Stop saying you don’t know anything when you just don’t know everything. Get rid of all or none thinking. Study is about making progress and is never ever really complete. Move ahead. Make your progress, and be glad for each step taken.

When learning a biochemical process, focus on getting some of the steps even if you can not remember them all. For each class of drugs, be able to recall some of them, the most important even if you can not name every option. Learn some essential disorders in the diagnostic differential even if you can not call an exhaustive list to mind. Each additional exposure to the material will expand the level and number of details you retain. Trying to get every detail all at once risks that you will retain none. Focus on making progress and you will be amazed how much you can learn in a day.

Then, at the end of each day’s work, stop worrying about all that lies ahead. Instead, look back in satisfaction at what you have accomplished, and what you know at day’s end that you did not know when the day began.

  1. Do something active with the material

Reading is not enough. You are expected to be able to mentally use the material you have studies to solve the problems presented in the USMLE questions. To get good at using the material you have do something with it. Make an outline. Write out notes. Draw diagrams. Talk with colleagues. Do practice questions. These exercises will help you uncover where your understanding is incomplete and also help give you the confidence to apply what you know when the exam requires it of you.

Preparation choices determine exam outcomes. By making choices, you assert your control over both the preparation process and the material you are seeking to master. Preparing for the USMLE can seem overwhelming, unless you take charge and make the choices required. Choose not to be overwhelmed, and you are really choosing to succeed.

Steven R. Daugherty, Ph.D.

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