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Handling Questions Step by Step


Knowing the material for the USMLE is one thing. Being able to demonstrate that knowledge on the actual exam is something else.

Over the years I have worked personally with a hundreds of students who seem to have mastered the essential medical knowledge required for the USMLE, yet still do poorly on the exams. All of this has led me to a simple conclusion: there a many, many ways to do a question incorrectly, but really only one way to do it right. Having the right method when doing a question will not guarantee that you will get the right answer, but it does help you leverage what you know to the maximum advantage.

Some people have internalized these steps and do them intuitively, without any conscious awareness. Others need to spend time learning these steps and use them consciously, until they are an internalized habit. Remember that test taking is not a genetic endowment, but consists of entirely learned behaviors. If you have not yet mastered the basic steps of answering USMLE questions, now is the time to learn.

Think of each USLE item, not as a single question to be answered, but as a clinical problem to be solved. The pathway to that solution is found by completing a series of 8 simple tasks. Each of these tasks solves one of the cognitive problems inherent in a USMLE question. Completing each of the 8 tasks in sequence leads you from uncertainty to your best possible effort on each question. The goal of these steps it to ensure that you gather the clues provided by the questions stem, think about them in a meaningful way, and then make a choice before moving on to the next question.

These 8 steps can be briefly described as:

1.  Read the Question!

Each question stem contains essential information that is vital to arriving at the best possible answer. Skimming the questions quickly, or ignoring it all together means that these clues will be missed. You have to gather all the clues provided. It is hard to assemble a puzzle if you do not have all of the pieces. Only reading the questions will give you access to these vital clues. Without careful reading, you are hunting for an answer in the dark.

2.  Understand the meaning

The information presented in the question stem means something. The words you read should trigger associations and help you to call to mind important concepts. Each sentence you read should be sorted mentally as significant or trivial. Does it matter? And if yes, why is it important? Reading the words without reaping the meaning is like walking past someone without having a conversation. Seeing the words is not enough. You have to grab hold of why they matter.

3.  Order of Importance

Some things matter more than others. Most questions will present you with, not one, but several points of significance. Your task is to sort out: What is the most important issue? If several medical problems are described, which one should be the main focus of your attention? If several facts are detailed, which one should carry the most weight as you sift though the different answer choices in you mind? Sorting what is primary and what is secondary will help you focus on the core medical issue being tested.

4.  Note the actual Question

The question you must answer is the exact question that is asked. One of the most common mistakes on the USMLE occurs when students answer the question they hope or expect to see rather then the one they are actually asked. The USMLE seems to pride itself in asking important but unusual questions that get you to look at the material you have mastered in new and unique ways. Be prepared for things a bit out of the ordinary, and never lose sight of the actual question.

5.  Compare with what you know

The clues in the question stem are only half of what you need. You must now combine those clues with the fund of knowledge you bring into the exam. With the item stem read, and with the actual line of the question firmly in mind, now is the time to pause and reflect on other pertinent information that comes to mind. In short, what can you add to what is presented? The best answer will be found by combining the clues in the question with the facts in your head.

6.  Anticipate the Answer

And then, before looking at the options, answer the question. Think about what makes a reasonable answer before even looking at the answer choices given. By rule, every USMLE question should be answerable by someone with the appropriate knowledge without any answer choices provided. Try it. You will be surprised how often you can anticipate the intended answer. Remember that each set of options contains a correct answer and a set of distractors. Distractors are supposed to look good and fool you. If you have a good bead on the right answer before encountering the options, you are simply less likely to be fooled.

7.  Look at all the Options

The correct answer is not simply one that is good, but the one that is the BEST. USMLE options are not either correct or wrong. Each option has a grain of truth in it. All of the options are “sort of” right. Your task is to pick the one that is “most right.” Sometimes this will be exactly the answer you thought of when you anticipated the answer. Sometimes the answer you want to see will not be presented. In this case forget looking for the optimal answer. Rather, pick the best of the set provided. The key issue here is to not simply stop with an answer that looks good, but to check though what is presented to be sure you have registered all the available option choices.

8.  Lock in your Choice

And lastly, MAKE A CHOICE! Having processed the questions stem, reflected on relevant content, and reviewed the options-- it is time to choose. The biggest time waster in the exam occurs right here as students hesitate and vacillate. Make that choice, lock it in and leave it. It’s time to move on to the next question. Forget second-guessing yourself. A question once answered is over. Move on.

If you take the first letter of each step they create the useful mnemonic “R-U-ON-CALL”. The mnemonic is meant as a useful tool to help you remember the sequence. But, do not simply memorize the 8 steps. Practice them, use them, make them part of your question answering habit.

One final comment, although at first glance it might seem that these 8 steps take more time then you have, once you get used to the sequence you will find that it makes you more efficient and will actually reduce the time you spend on each question. The trick is to use the time you have most efficiently; to get rid of those thoughts and behaviors that waste time and keep those which move you step by step towards the best answer.

Steven R. Daugherty, Ph.D.

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