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Handling USMLE Questions
(Three Articles in a Row!)

 #1: How a Clinician Thinks Through a USMLE Question
(With Dr. Philip Tisdall, M.D.)

  1. To answer a USMLE question correctly, you must focus on what the question-writer wants you to be thinking about. The underlying logic of the USMLE is clinical thinking. Understanding how a good clinician thinks will help you understand what you are supposed to be thinking as you read what is presented in the question.
  2. The key to seeing what the question-writer wants you to see is picturing the patient in your mind's eye and following a clinical "train of thought". This is how every clinical approaches problems in practice and the person who wrote the test question will be expecting you to do the same.
You can think about this clinical thought process as a series of steps.
  1. First collect the basics: Age, gender, time frame. Now STOP! Picture the patient and the setting in your mind’s eye.
  2. Next, do we have a “chief complaint”? By this I mean a standard  or clear clinical problem (e.g. hematemesis, fatigue etc.) with a known approach.
  3. From here, you must engage that clinical “train of thought”. As you read through the rest of the question stem, imagine you and a senior physician are in the room with the patient. Consider what is in the question stem as information conveyed to you by the physician was talking to you about the patient. 
  4. The idea here is to move you away from looking for a simple association or "hook" in the question to considering the full set of information which is presented. 
  5. Do not read the question line, yet. First, come to a conclusion about the disease in question. Next ask yourself, “Are they asking me  about presentation, pathophysiology or natural history?” 
  6. Only now do you read the question line, which at this point should seem like the logical conclusion of your clinical thought process. Given all that has been presented, what is it that the physician whom you have been talking with wants you to know? You pause before tackling the question line to help you to see the question being asked and not the question you wish you were being asked.
  7. Finally, decide on the answer. 
  8. Then, and only then, look at the choices.
  9. If you can not think of a good answer, try excluding the ones you know are not correct and pick from what is left.
  10. Move on to the next clinical case.
That's it. As you practice this process, you will develop a rhythm and an appreciation for what are the important details and how the question-writer has laid them out for you. When you get really good, you will begin to anticipate what information the question-writer will give you to solve the problem presented. Learning to think like a clinician is the key to understanding what each question expects from you and how to find the "train of thought" that leads you the solution waiting at the end.

 #2: It's Not How Many Questions You Do, 
Its How You Review the Questions That Counts

Many people believe that what score they will get on their exam is directly related to how many practice questions they do. This faith is misplaced. Yes, you need to do practice questions, but the benefit of doing questions lies not in the number of questions you do, but the learning you do as you review the questions you have answered.

This one of those areas of life where quantity does not equal quality. Racing though 1,000 questions will not increase you score nearly as much as a careful, guided review based on 100 questions. Practice questions are not about getting a score. Rather, practice questions give you a chance to test your application of knowledge and identify problem areas which you can them fix by reviewing specific content. 

Always do your practice questions in clusters and under time-pressure to simulate a real exam experience. Redoing questions is generally a waste of time. The second time you do a question it is a memory exercise, not the thought exercise that the real USMLE requires.

After you complete your set of practice questions, it's time for review. You should spend a lot more time reviewing questions than you spend doing questions. Expect to spend roughly 5 times longer in review than you spend doing a question, and sometimes even longer. This means that is you spend one hour answering questions, your review time can be 5 to 6 hours, depending on the percentage you got correct.

The image embedded below laysout the algorythm to follow for you question review process.

For each question: Did you get it right or wrong?
1. If right, then did you know it or was it just a lucky guess?
a. If you knew it, then move one to the next question
b. If you guessed it, then you need to review the content of the question
- read the annotated answer and explanation
- then, go back to your primary study materials and look at the section relevant to the question. If you missed this concept, there must be others in the same section you need to review.
- when done this review, go on to the next question
2. If wrong, then figure out why: a knowledge or a process problem?
a. If a knowledge problem, then you need to review the knowledge
- read the annotated answer and explanation
- then, go back to your primary study materials and look at the section relevant to the question. If you missed this concept, there must be others in the same section you need to review. 
b. If a process problem (e.g.: you focused on the wrong thing, you had the correct information by had faulty reasoning), then you need to re-examine your thought process
- Read the process explanation in the annotated answer
- Decide if this is a good or a bad question
> if bad, then ignore the question and move on to the next. (All Qbanks have bad questions. Do not get hung up on them!)
> If good, then stay with the question and look at your process again. What were you thinking about? What did the question writer want you to be thinking about? Move on to the next question only after you are satisfied that you have mastered  the thought process.

Review of questions, not simply answering questions is the essence of exam preparation. Take the time to learn from the questions that you do and your score can not help but improve. Questions find problems you have. Content study and review fixes the problems.

Steven R. Daugherty, Ph.D.

Article #3: Making Yourself Choose 

In the face of uncertainty we do not want to choose. Our rational side wants to postpone the decision until we know more. Our emotional side wants to avoid the decision all together to escape anxiety that uncertainly inevitably brings.

Decision-making on the USMLE is different than medical decision making in the real world. Medical practice demands you to be as certain as you can be. If you need more information, get it. If you need a consult, seek one out. If you make a bad decision in medial practice, you could kill someone, or at least cause avoidable pain and suffering. “Be sure,” your professors and mentors have told you from the first day of medical school. Being sure is the right way to practice medicine. Being sure is the wrong way to take the USMLE. You simply do not have the time to gain the level of certainty you would like to have. The clock is ticking continually and decisions must be made.

To make it through the exam, you have to be able to select an option in spite of the uncertainty you feel. Spending a lot of time on one question until you are certain as to the answer, means that you will not have time to even consider other questions down the road. Your choice is clear: either spending the time to achieve certainty on some questions, but never getting to others, or, learning to make your choices quicker, with less certainty on all questions.

Getting to all the questions is your best strategy. We decide before we are comfortable with our choice. You learn to make quicker decisions by giving up the search for comfort and moving ahead. Part of the time you spend selecting an answer involves cognitive processing of the presented information. At some point in this process, a decision is made. The time you spend on the question after that will not help you make a better decision, but will simply make you more comfortable with the decision you have already made. Although at first blush, simply deciding faster may seem a terrible approach, the reality is that giving up the search for comfort saves a lot of time on each question. Learn to force a choice even when you are not sure.

Answering questions on the USMLE requires that you keep making choices even when you are uncertain. In fact, USMLE questions usually require not one, but a series of choices. You must not merely decide on the answer to be chosen, but must make a sequence of small choices that will lead you to that final answer. The USMLE requires you to choose, and then keep choosing until you have solved the presented problem.

Expect, on average, that three correct decisions will be required to get you to the point where you can select the best answer. This means that USMLE questions require you to not only choose in the face of uncertainty, but to keep on choosing, piling one uncertain decision on top of the next. Acclimation to this mental headset takes time and practice. Of all the mental hurdles that need to be overcome to excel on the USMLE, none are as daunting as changing the way you make decisions.

You must learn to change the very way you make decisions. Learn to choose even when you are not sure. Learn to decide, and then keep making decisions even in the face of uncertainty. Doing practice questions is not just a way to test your knowledge.

Practice questions also provide a way for you to learn this new decision process. So, always do your practice questions with a clock. Only use fresh questions you have not seen before. Yes, taking time will give you a better practice score, but will not get you ready for the real exam. Getting good at deciding in the face of uncertainty is an essential skill for mastering the USMLE.

 Steven R. Daugherty, Ph.D.

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