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General Exam Issues

"Think and Know" vs. "Grab and Go"

The USMLE requires you to be able to think on your feet. The exam is not testing your knowledge, as such. Rather, each question is designed to assess your ability to sort out what is important, integrate the relevant concepts and solve the problem presented. You do not master this type of question by memorizing a lot of facts and spitting them out.  USMLE questions require you to decide early what is relevant, ignore what is not and pick the option that offers the most optimal solution. Grabbing for the first answer you see will not get you the score you want. You need to learn to think with what you know and come up with the very best choice.

Mastering this thought process for the USMLE is difficult for two reasons. First, much of medical school education is oriented towards strict memorization. Testing in medical school, whether by oral or written exams, often focuses on the subtle details and minute distinctions which demonstrate an in-depth exposure to the material of interest. When you show that you know these details on an exam, the faculty member feels confident that you have spent adequate time and attention on the content of most concern to them. But, being good at memorization and being good at thinking are two separate things. Even if you can think clearly and efficiently, medical school often rewards you for memory, not thought. And after spending time getting good at the processes of memorization, you may have lost the impulse for and habits of thinking well.

Second, the time pressure of the exam forces even those students who have retained the skill of thinking to abandon this higher intelligence and hope for salvation by reaching for the first option that looks familiar. Time pressure degrades our willingness to spend the moment thinking requires and induces us to value speed over effectiveness. We short circuit our thinking processes by using what cognitive psychologists call “heuristics”. Heuristics are ways of generating an approximate answer without fully considering all of the information presented. The two most common heuristics are: Availability, where what comes to mind first is given most credibility, and Representativeness, where things with similar features are deemed as being the same in all respects. Both of these heuristics serve you well in medical school. What is most available mentally is likely to be what you just studied as you crammed for an exam. What you have just learned is what will most likely be on the test (Availability). When you crammed for your exam, you were required to know a finite set of information. All you had to do on the exam was know a relevant detail that let you discriminate within this finite set of material (Representativeness).

But, the Availability and Representativeness heuristics, so valuable in medical school, interfere with the core thought processes essential to do well on the USMLE. The breadth and depth of the content covered by the exam you will face on the USMLE convert these mental heuristics from valuable short-cuts to disastrous dead-ends.

Most medical school exams are about “grab and go.” You see an answer that looks familiar and reminds you somewhat of the issue presented in the question, so you grab for it and go on to the next question. A good USMLE score, by contrast, depends on “think and know.” You must think about what is presented, compare this with your knowledge base, and reason through to the best possible answer. Sometimes the answer is something you have already seen and already thought about. These are the easy questions. However, increasingly, students say that USMLE questions present material in unique ways, from a perspective they never really considered before. These questions are harder, but are becoming the backbone of the exam. You must answer these integrative questions by applying your knowledge in new ways to situations that are distinct.

The key issue is this: the knowledge needed for the USMLE is the same as that you learned in medical school. What sets the USMLE apart is its insistence that you learn to combine the different threads of the knowledge you have learned and weave it into a new pattern. Doing well depends not on grabbing all the right treads, but learning the art of weaving. On the USMLE you will be asked to use your knowledge in ways that you may never have been asked to use it before. Not grab and go, but think and know.

The exam is not a quiz show where you get points for spouting off esoteric facts. The USMLE is a screening test to see if you have mastered the perspectives and thought processes essential for medical practice. A physician, a good physician, makes a living by thinking and reasoning. Take the time to relearn and practice this art of reasoning and you will reap the reward of a higher score.

Steven R. Daugherty, Ph.D.

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