Four Rules for Interviewing for Residency

So, you got the call (or email) to come in for an interview for a residency position. Congratulations! That means you have made it through the first two big steps in the screening process: the USMLE® score hurdle and the Application hurdle. You should be thrilled!

The places you interview are the places you get to rank for the Match. Handling your interviews well is key to getting ranked well by the Program Directors at the residency program you are targeting. As you prepare for your interviews, here are four core suggestions for how to present yourself in the best possible light during your interview.

1. Be You

We all seem to have an idea in our heads of what the best doctor (or person) looks like. The problem is, none of us really match this idealized image. No two people are alike. No two program directors are alike.

One of the biggest mistakes in the interview process is trying to act like the person you think the program director wants to see rather than the person you are. When you put on a mask and try to present yourself as someone you are not, you are making two mistakes: 1) you risk coming off as phony and 2) the people who would like the person you are will not get to see it because you are hiding.

You should have a sense of who you are. You should be able to talk with clarity and maturity about essential experience in your past and be able to convey a vision of what you want your future to be. The hard work of preparing for you interviews comes not from crafting the fictional self you think people want, but in learning to show and be comfortable with who you are.

2. Avoid scripted answers

You should think about questions interviewers might ask you and work out what your answers might be, but refrain from memorizing verbatim responses. Giving answers that you have memorized usually feels phony or odd to the interviewer. You come off as stiff and unnatural.

Rather than write out full scripted answers, make a list of key bullet points and work them into your answers. In other words, have a sense of what points you want to make, but be flexible in how you use them. Different program directors will ask different questions and you cannot fully anticipate everything you will be asked. By having some basic themes in mind, you will have a mental store of things to say without coming off as rehearsed or robotic.

During the interview, listen carefully to what you are asked and address the questions directly, but make the points about yourself you want to make in your answers. All of this takes some practice which brings us to…

3. Practice before hand

Getting used to putting answers together, and getting accustomed to the interview setting, requires practice. No one is born knowing how to interview well; you have to give yourself a chance to learn. Pair up with a colleague and do an interview where they role-play a Program Director and you be you. Video tape the interview and then watch the video. You will notice that you have certain quirks when you are nervous. If you think these are distracting, then work on not doing these in the future. Most of us are not aware how we look to others, and it can be eye-opening to observe yourself.

After the first practice interview, switch roles: now you play the program directors and let your partner plays themselves. Getting a sense of what it feels like from the interviewer’s point-of-view can give you a new perspective and better insight to what the process is about. Remember that the interviewer is not some strange person. They are basically you, but further along in your career. Taking on the interviewer’s role will help the whole encounter feel less foreign.

Keep doing practice interviews until the process seems normal. When you walk in for the first real interview, you want to feel poised and ready to talk about who you are and what you have to offer. Professionals always prepare. Practicing and getting comfortable with the interview experience is part of your professional training.

4. You should be excited to be asked for an interview. Show it!

An interview is an important and exciting event. Don’t be afraid to show your enthusiasm. Sitting face-to-face with someone is not just a time to tell them details about yourself, but to connect on a personal level. Remember, the Program Director is not just going to be working with you, but more-or-less living with you for the next three to five years. They need to see your intelligence and professionalism, yes, but also get a sense of who you are as a person.

The enthusiasm you bring gives the interviewer a sense of your energy and dedication. You need to show them that you want this job and help them to see how effective you can be while doing it. Medicine is not just about your brainpower, but, increasingly, about how you interact with and work with others. Teamwork requires engagement and a willingness to go the extra mile. You need to leave the interviewer with a sense that you are that kind of person.

Energy and emotional resonance are what makes us memorable. The emotional connection you make during the interview will keep you in their mind when all the other candidates have faded into a mass of nameless faces. Getting remembered means a greater chance of getting a higher ranking when the time comes. And getting a higher ranking is what this whole process is about.

Be you. Avoid sounding scripted. Practice before your interviews. Show your enthusiasm. Four simple rules to guide you through a successful interview season.

Learning for the USMLE: 4 Steps to Success

Learning at the level required by the USMLE involves doing a set of processes in sequence. You must be made aware of, and then, work though this process. This is important so I’ll repeat it. Effective study is not about doing a lot of one thing, but doing a set of thing in the right sequence.

• Highlight: Selecting the material to be mastered

Study begins by a series of decisions. First, what material to study? Second, what to focus on within that material? If, for example, you select Becker (Disclosure: I work with Becker) to help with your exam preparation, you have already made your first choice–Becker provides the study materials. I want to caution you about overloading yourself and trying to study the Becker material and another source simultaneously. More sources are NOT better. Find a single source you can believe in and then, master that sources. Using multiple sources usually leaves students feeling overwhelmed. Having a reference book on the side for detailed explanations makes sense, but the your selected study material should be your sole focus.

Teachers who help you prepare for your USMLE can help you make the next choice about what to focus on within the study material you have selected. Some students obsess about mastering each and every little detail without regard for relevance. Others, skim the surface, picking up a stray fact here and a fact there. Your teachers are your guides and can help you find the middle ground by telling you what is worthy of more attention and what is not. As you listen to lectures, as you talk with your teachers, the material they emphasize provides you direction as to what is most essential content AND what can be safely ignored. The role of your teachers is not just to cover material, but make you more efficient by underlining what matters more.

We call this step “Highlight” because this is when you may you highlighter pens. As you lecture listen to lectures by your faculty you should be underlining key material, making marginal notes, and marking annotations about what you need to return to for additional review.

• Repetition: Getting content into memory

Once you have highlighted the content  must you learn, you need to commit this content to memory. The human brain, although complex, has a simple functional imperative—it remembers content that recurs. Getting content into memory is, thus, a simple process of repetitive exposure.

Part of this exposure occurs during the lectures and discussion you have with our teachers and fellow students. I encourage students to look over the content to be covered each day prior to the lecture (Preview), attend lectures and listen to the teacher’s illustrations and guidance (Participate),  and then go back over the essential materials in the evening after each day‘s lectures are completed (Process). These multiple exposures provide the needed repetition to get your brain to pay attention and remember.

Most students will need to review core material one or two times outside of lecture. The number of repetitions required, of course depends of the student’s previous preparation and learning capacity. Two passes over most material (Lecture and then Review) are all that is required for most students. For more complex material, three repetitions may occasionally be necessary.

Refrain from mindless, rote reading of content more over and over again. Simply reading content again, without thinking about what you are reading is unlikely to be successful. Effective repetition for retention requires thinking, processing what they are reading, not merely reading the words just to read them. The difference, as one student once described it, is between “ingesting” and “digesting” the material. Ingesting is just reading for the sake of reading.  Digesting means reading with real comprehension.

• Recall: Accessing memory as needed

Repetition gets the content into your head. But to do well on their exam, you need to be able to access the content when you need it. Getting the content into your head is not enough.  You also need to be able to get it out again!

This is the key part of the study process many students neglect. As a consequence, they often report sitting in the exam, knowing that they studied the content be presented in an exam question, but being unable to call the needed content to mind.

Recall is fostered by creating an internal index that tells the brain where to find the desired material. Part of this process happens when we sleep. (So, it is essential that you get enough sleep as you study!) Part of this indexing happens whenever the student actually does something with the content they have learned. Talk to yourself and to fellow students about what you are learning. These discussions, mental and actual, are readily recalled on exam day.

Students sometimes think that if they do not have their nose in a book they are not learning. Recall is not about reading the book again, but about doing something with the content. Talk to yourself while walking or driving. Make outlines, draw pictures and construct graphs. The more of this you do, the more readily available will be the content on the day of the exam when you need it the most.

A nice rhythm for study is: read a page once looking for the key idea, read it again to fill in details, and then the third time, put your hand over the page and tell yourself what are the essential issues on that page. This last recall step is the essential element that separates the students who study hard, from the students who study hard and have good score to show for it.

• Practice: Behavioral habits for handling the exam. Knowing does not equal showing.

Once you have committed key content to memory and once you have spent some preliminary time facilitating recall of that material, you are ready to practice on questions. Questions are NOT the best way to learn content, but they are the ONLY way to learn and practice the questions answering behaviors and strategies that students will need the day of their exam. You must learn correct behaviors and practice them so that they become routine. Only then can you show what you have learned under the time pressure imposed by the USMLE format.

Here is a quick summary of good question processing behaviors:

1. Read the case presented in each question only once.
2. Predict what the correct answer will be before looking at the options.
3. Make a choice and live with it. Move on to the next question.
4. Do not change answers once they are selected.
5. When reviewing results, look at why you got a question wrong.
6. If questions reveal deficiencies in the recall or understanding of essential content, return to your core study materials to review that content once again.

Remember, you do not do questions to get a score, but to 1) learn and hone question answering behaviors and to 2) get guidance as to material you need to go back and review again.

What you do when you study should change as your exam becomes closer and you gain more familiarity with the material. You job is not just to stuff your brain with facts, but to understand the content you study, know why it matters, be able to access it quickly on exam day and become adept at the process of delivering the information to the questions you will face on exam day.

The days of being a student are over. The time to become a physician has come. Learn to think like a physician and you are well on your way to being able to prove on the USMLE that you are one.

Steven R. Daugherty, Ph.D.

 

 

 

Understanding versus Knowing

A truckload of bricks and a stack of lumber may contain everything you need to construct a house, but you will never have a house you can live in until they are all assembled in the right order. In the same vein, a pile of books may contain everything you need to prepare for your USMLE, but you are not ready to take your exam unless the material is organized it a way that makes it useful. Collecting the essential pieces is not enough. You must assemble the pieces in a way that allows you to see the fundamental patterns which are the key to successful problem-solving. Beyond simply having the knowledge, you must make sense of it.

Exams in medical school are often about having the right pieces of knowledge. You are faced with questions that ask you to regurgitate the knowledge you have memorized explicitly for that test. In a sense, medical school exams are a checklist, and the professor simply seeks assurance that you have learned each of the facts that they consider most essential. In medical school, if you have the knowledge, you have the answer.

The USMLE is asking for something different out of you than your medical school exams. Top scores on any USMLE Step depend not on knowing, but on using the knowledge you have learned. USMLE questions ask you to think and apply, not recognize and tell. On the USMLE, application of knowledge is key; when you understand the issues involved, you can more clearly see what makes the best answer.

Fortunately, your USMLE preparation time provides a unique opportunity for the type of reflective overview these types of questions require. Medical school or clinical practice with their pressing daily demands and vast amount of detail do not give you much chance to get this perspective. Details are not only overwhelming, but they can distract you from your real goal of understanding. As someone once said, “When you are up to your ass in alligators, it is difficult to remember that your initial objective was to drain the swamp.”

USMLE preparation is a time to move from collecting the pieces to assembling the puzzle picture that organizes and brings clarity. Remember that your goal at the end of this process is not to simply know things, but to understand how they all fit together. Only from that perspective can you respond to the sort of problems that you will encounter in each exam question. The key to effective study is not the accumulation of individual pieces of knowledge, but grasping the essential patterns that tie together the pieces and give them significance. In short, the core task is not to learn about things, but to learn the relationships among things.

These patterns and core concepts elevate you a higher level of understanding, but they also offer a framework which makes the task of rote memorization easier and more efficient.  Trying to recall individual facts is a difficult, thankless, and ultimately unprofitable task. Understanding how things fit together not only gives you the big picture, but also helps you retain the little details. With the right organization, the general patterns built from what you are able to remember help you figure out what specifics facts you may have forgotten.

So, how do you gain this larger understanding? How do you get attuned to the relationships so you are not blinded by the multitude of facts? Learning relationships occurs by three basic methods: Examples, Metaphors, and Contrasts.

Examples show you concrete instances of the thing under discussion. The abstract issue is grounded in the concrete referent. By the concrete example you come to see context and even how things change over time. Examples let you grasp core principles by inductive reasoning, that is, picking out what are the most essential features that bring things into focus. When I talk about an autoimmune disorder, you hear all of the defining features. But when I describe the process and progression of HIV/AIDS, you have a picture of something specific that anchors your retention of these essential features.

Metaphors highlight essential relationships by carrying over a known relationship to another context. A metaphor focuses on the essential relationship by virtue of the specified comparison; not an example of a thing, but an example of a relationship. To say e coli has a propulsion mechanism is one thing, but to say it propels the pathogen like a propeller on a submarine gives a more vivid picture of the possibilities for mobility. To say one of the signs of Lupus is a red facial rash is correct information, but to say it looks like a butterfly gives a picture of a cluster of essential details which are otherwise difficult to convey verbally.

Contrasts highlight features by comparison. This comparison serves first a positive function, focusing our attention on certain features by virtue of the referent chosen for the contrast. Each thing in the world has a large number of characteristics or properties. Contrasts among things help us to see which characteristics are more worthy of our attention. Secondly, contrasts also help us understand what something is in a negative sense; helping us see what something is by showing us what it is not. Describing Parkinson’s symptoms is one level of understanding. But, comparing the similarities and differences between Parkinson’s symptoms and the symptoms of Tardive Dyskinesia elevates our understanding of both disorders. Contrasts focus us on what is unique and, thus, what is most essential. Trying to recall all the features of an elephant is too hard. But, being able to say how an elephant is different from a hippopotamus clarifies our understanding of the unique features of each animal.

Examples, metaphors and contrast are the key techniques for elevating you from simple rote memorization to systematic understanding. As you do your studies, take time to think about: “What would this look like?” “What else is like this?” and, “How is this different from something else?”

Knowing things is not enough. The most essential insights of medicine are not what things are but how things relate to each other. You build up your USMLE score as you build this understanding of how things fit together. Focus not on the accumulation of facts, but in fitting the facts together in a way that makes sense. Once these relationships are clear, the knowledge will never leave you. And from the building blocks you will have constructed a “house” you can live in for life.

Steven R. Daugherty, Ph.D.

The Answer You Like vs. The Best Answer

The Emotion of Choices

All choices involve emotion. The inner sense you have that one option is better than another is the result of the emotional coloration, or valence, you give to each option. Options which trigger our most positive reactions are the ones we end up choosing. A strong positive valance makes us comfortable with our choice. A negative valence tells us what to avoid.

Emotion is the voice of experience, whispering in our ear and pushing us towards a particular option. Our emotional responses both frame our choices and guide us what action to take within that frame. This means that emotions are the essential guide helping you to a better USMLE result if properly attuned. They are also the culprit that holds you back if they are out of tune.

Not just Test Anxiety

When first thinking about emotion and the USMLE or any other standardized exam, most people think about “test anxiety”. Certainly test anxiety hurts your score. If you have high anxiety it is hard to concentrate and cognitive processing is disrupted. When you can’t focus and can’t think straight, it is almost impossible to apply all of the knowledge you have learned.

For people who suffer from test anxiety, the entire exam has a strong negative valance. This global negative overwhelms and positive or negative reaction to individual options. The entire exam is a negative. The push is to simply leave the exam, not to engage the presented options in a way that facilitates choice. The details of options may not even be seen and any positive valences they carry are swept away in the test anxiety flood.

But even for those without inhibiting test anxiety, emotion still controls your exam result. Because the valence of an option controls our choices, understanding the process by which these valences are established is critical to understanding why we make the choices we make. And understanding the process is the first step to learning to do it better.

Sources of our Choices

The valences we give options presented on an exam can come from a number of different sources.

Familiarity: We feel more positive about something we have seen before. If you look down over a set of presented options and recognize something you have studied, that recognition provides a positive valence inducing a desire to select that option.

In medical school where you are presented with or directed to a defined set of knowledge, familiarity can be a useful exam aid. On option which you recognize is likely to be one in the body of material you just studied for the exam you are taking and, therefore, has an increased probability of being the correct answer.

Availability: Associations which come quickly to mind require less effort, simplify our world, and give us a more positive feeling. Everything we encounter triggers association within us. Those associations which come most readily to mind are those which are likely to be more dominant, and to carry the most positive valences.

In medical school, where you have reviewed a finite body of knowledge just prior to your exam, availability is likely to help you grab onto the right answer. If you have studied well, then the content you have most recently studied will come to mind most readily.

Medical School vs. the USMLE

However, what works in medical school does not work very well on the USMLE. When the teachers are the testers, the valence of familiarity helps select the right option. When a test covers a defined, finite set of knowledge, such as a single subject or one organ system, availability, primed by what is most recently studied provides the critical valence.

The USMLE is both more comprehensive and more integrated than most, if not all, of the exams you faced in medical school. The set of material to be tested is vast and taken from a variety of sources. The presentation of that material is often unique to the test-takers experience. Because of these differences familiarity and availability are not likely to provide the proper valences.

Instead, the emotional valence of each option must be assigned by the assessment of the data presented in the stem of the test question. Each USMLE question presents a set of information scattered through the question stem like the pieces of a puzzle. The student’s cognitive task is to gather these pieces, assemble them to solve the puzzle, and then, in a flash of insight, recognize the picture provided. To select the best answer, the valances of the options must come from the clues provided in the question stem.

Analysis, not recognition is, therefore, the key. Unlike many medical school exams where the emotional response to the options guides the student to the answer, on the USMLE, the question stem, not the options themselves must be the focus. The question sets the frame, both cognitively and emotionally. The value of each presented option is determined by the context of the question stem, not the student’s sense of familiarity or availability.

This means that if you are used to answering questions on medical school exams, you will have to modify your process for assessing and answering USMLE questions. The valences you carry into the exam will not provide sufficient direction. You will have to adapt to getting the value of each option from the information provided in each question.

You learn this new process by practice. Doing practice questions helps to assess your knowledge level, but also offers an arena for you to develop an approach to questions that is more likely to lead to the best USMLE answers. Take the time to get the process right. Getting the right source of emotional valence on your USMLE questions will lead you to the ultimate emotional valence we call success.

Steven R Daugherty, Ph.D.

Answering from Fear vs. Answering from Confidence

Emotions are the motive force that guides our actions. What we feel has an awful lot to do with what we do. And in few places is this as true as when answering questions on the USMLE.

For some people the looming exam evokes fear. “How will I be judged?” “Am I up to the task?” “What if I fail?” For others the coming of the USMLE is a challenge that energizes. “Here is the chance to show what I have learned.” “This is the forum in which I will show myself and the world that I deserve to be a physician.”

Many people preach that the goal of the student during the exam should be to be calm and as emotionless as possible. Many people will tell you that during the exam, emotions are a stumbling block. Nothing could be further from the truth. The fact is that the exam will evoke strong emotions. Making the best use of your emotional reactions to the exam has a great deal to do with your final outcome.

Strong emotions are not bad. Emotions serve as the gateway to the cognitive processes demanded by the exam. The right emotional set lays the foundation for optimal cognitive processes. Emotions are the physiological backdrop within which our thoughts and mental processing occur. To do your best you do not want to be emotion free. Rather, make it your goal to harness those emotions you feel. Emotions provide the energy to keep you going when you are tired and to maintain your focus when you are distracted.

All decisions are emotional. Without emotion no decision would ever get made. The key to successful decisions is not a lack of passion, but having the right emotional basis by which cognitive decision-making can proceed. Doing well on the exam is not just about knowing, but more fundamentally, about being able to act, to make decisions. Answering the each presented question requires you to break free from the mere facts to the level where you understand what is being presented, what is most important and, therefore, what must be done.

Think about your preparation for the USMLE as essentially a contest between fear and confidence.

Fear is aversive. We don’t like fear and usually act to get rid of the feeling as quickly as we can. Because fear is aversive, it leads to thoughts of escape. In the face of fear we do not want to engage and solve, but disengage and run. Fear causes us to make impulsive choices to feel better, not thoughtful decisions which stand the test of time. Fear drives us to act, but drive out rational cognitive analysis at the same time. Driven by fear, we seek to get an answer in order to get rid of the question. And our whole motive changes from getting the great score to simply getting rid of the bad feeling.

Confidence is positive. Confidence has us jumping into the problem with the anticipation that we can handle whatever is presented. When we are confident a problem is not a burden, but something which energizes us as we seek to understand and to master. From this perspective, each question becomes a challenge. And our goal is transformed from avoidance to one of mastery. Confidence gives us a solid emotional platform on which we can build with our recollections and thoughts. Confidence takes the first step to success by assuming that we will succeed.

The difference between fear and confidence rests with a simple thought. If you think you can handle the exam, you are confident. If you think you can not, you will be afraid. Please note that which ever stance you take is not based on rationality, but on what you assess reality to be.

Can you handle this exam? The fact is that of course you can. You would not have made it this far in your career if you lacked the capacity. Perhaps you have not done everything right or perfectly you entire career. That does not matter. No one expects perfection. All anyone expect is for you to be the physician you are. A physician does not walk into the examination room with fear and trepidation, but with confidence. Each patient is not a problem. The patient is your job. Tending to the patient is you calling.

How do you get to confidence? What makes the difference between the disruption of fear and the energy surge of confidence?  It’s all about preparation. Confidence does not come from simply reading the content, but from doing things with it. Confidence is born in the flash of insight, in the ability to face something new and figure it out.

When you are well prepared, you are confident. When you are not well prepared, you fear. It’s really as simple as that. Put in the time learning to think and not just memorize and you will no longer fear the outcome, but rise to the challenge. That is the confidence that leads to success.

Steven R. Daugherty, Ph.D.

Timing IS Everything…

“If only I had more time,” is a common lament of students as they walk out of the USMLE. The simple fact is the USMLE is a timed test. And time matters. No, time by itself does not determine your score. But the time limits that govern each exam provides a constraint that restricts your potential and lowers your score. Having the knowledge is not enough. You have to able to show what you know. And you can only show that which time allows.

Time provides a palpable physical constraint. You have only one hour for each block of questions. When time runs out, the question block is over and you are not allowed to finish it. If you do not get to a question, you will not gain the potential point that question would provide. A question that you never get to is one you will never get right. With more time to think, with more time to reflect, with more time to be sure you get to each and every question, your total score would certainly improve. But you do not have more time. Therefore, it is imperative that you learn to make efficient use of the time that you do have.

Making the most of every minute requires efficiency. Here are three tips to help you get the most out of your limited time:

• Practice a question routine. Learn and practice a question answering routine before you take your exam. Develop a set behavioral routine in which you do the same steps with each and every question you encounter to reduce wasted effort. A practiced habit for answering questions will free you from focusing process and allow you more time to mentally absorb the question and think though the content issues you encounter. A practiced question routine means more questions covered in less time.
• Spend the bulk of your time on the question stem. As you consider each question, spend the most time on the question stem where it will do you the most good. Each question can be seen as having two parts. The question stem, which presents material in a clinical case format, and the options, which list the available answer choices along with a corresponding letter. A good rule of thumb is that 75% of your time on any question should be spent reading and thinking about the question stem, and only 25% should be spent on the options. The key to each question in the question stem. Read it carefully, but only read it once. You do not have time to read the long question stems on the USMLE twice. Then, when you turn to the options, be decisive and make your choice.
• Make yourself choose faster. If you find yourself chronically short of time, the best solution is to train yourself to choose faster. Do not short change your time reading the question stem. You need time to take in the information provided and to gather the clues provided. The way to gain more time for yourself is to make yourself pull the trigger, force yourself to make a choice as soon as you can. Research suggests that the time we spend on the question options can be divided into two parts. The first part we spend considering our choices and actually making our decision. The second part of the time we spend reconsidering, double checking, and doing other things to try to make ourselves more comfortable with the choice that we have really already made. This search for comfort does not improve answer, but simply wastes time. At this stage we are not seeking a better decision, rather we are feverishly trying to feel good about the decision we have already made. Train yourself to give up this search for comfort. Make your decision, live with it and move on!

Along with these physical constraints, time also provides a psychological distraction.  Just knowing that time is limited increases your anxiety and causes you to lose focus on the task at hand.  Every moment you spend thinking about the clock is a moment where you are not considering the questions before you on your exam. As the end of the block nears and the time grows ever shorter, actual panic can erupt.

How do you learn to deal with the distraction that time limits induce? The most basic solution is to make sure you do all of your practice questions under time constrains so you can become accustomed to the feeling of the seconds slipping away. The clock is always running. You can’t stop it. But you can get used to the feel of the time limits and learn to pace yourself accordingly. Time limits are most distracting when you as not used to them. Use your practice experiences to train yourself to see time limits not as an additional thing to worry about, but as a basic fact of life.

Time limits can not be discarded on the USMLE. They are real, and they matter. But, adequate preparation and practice can convert the terror of time into a simply part of your question answering routine. You can not slay the beast of time, but you can tame it. The question is simply, who will be the master? Will you learn to control your time, or will time control you? The right choice to this question is clear. By learning to control your time on your exam, you are learning to control your own destiny. And if you do that, then nothing, not even the pressure of time will keep you for achieving the success that you deserve.

The Right Motives Give the Best Results

Preparation for the USMLE requires persistent effort over time. Success depends on your ability to sustain that effort. So, as you prepare for your exam: What motivates you?  What keeps you going when thing seem hard? What sustains your effort over weeks and months?

The answer, in all likelihood, is that you are motivated by more than one thing. Some simply want to move through the process as quickly as possible. Others want the bragging rights which come from getting the highest possible score. Others want to show family and friends that they have the “right stuff”. Still others just want to avoid the embarrassment of failure.

Motives are what move us. What get us out of bed in the morning and keep us going through the long day. Motives are the driving forces that make it possible for us to put in the day, weeks, and months of efforts required for USMLE preparation.

Stripped of all jargon, there are two basic types of motives: Motives to get something and motives to avoid something. Both can be powerful forces that get us started and keep us going. But, while both can be useful, each carries with it a hidden danger.

Common USMLE Preparation Motives

Motive #1 Getting the Score

For some people, the USMLE score is everything. Getting a top score is the brass ring, the key and ultimate reward at the end of all the effort. Getting a top USMLE score is a solid, empirical measure of achievement that certainly makes getting a coveted residency position easier.

The danger here, however, is that a focus on the score will blind you to what you need to do to get there. Like someone single-mindedly concentrating on a destination, you are in danger of missing the twists and turns that make up the journey. Too obsessive a focus on the ends may lead you to not complete the process which gets you there. At the end of the day, it is the score which matters most, but having the right preparation process is what carries you to that ultimate success.

Getting a top score is a good dream. Just make sure you make the right moves to get you there. Wishing alone does not make it so.

Motive #2 Getting the Knowledge

Knowledge is the foundation of medical practice. Without the proper insight and understanding about the human body, disease processes, and the body’s responses to those diseases, a physician confronted with illness is simply guessing. Knowledge is what separates the physician from the non-physician, and the expert physician from the neophyte.

One of the great benefits of USMLE preparation is the chance to go back over previously learned material and come to a fresh understanding. Done correctly, you emerge from the process with an understanding beyond simple memorization. Done correctly, you walk into your exam with a clear sense, not only of what makes a good answer, but why it must be so. The flash of insight, the rush of comprehension, the thrill of understanding what was unclear before, can be a powerful motivator to keep pushing onward with exam preparation.

However, students driven by their own quest for knowledge and their own excitement at emerging insights is in danger of losing sight of the specific requirements of the USMLE. At the end of the day you will take and exam. You will not be judged by your knowledge and insights alone, but by your capacity to offer correct answers to the presented exam questions. Knowledge and insights give you the raw materials for this task, but to not carry you directly to the essential goal of getting that exam score.

In short, focusing on getting the knowledge, while it gives you the means to succeed, may cause you to lose sight of the essential endpoint of the process: getting that higher exam score. The danger is that you will become enamored with the journey itself and become lost on a journey without end, never to arrive at the final goal you must be seeking.

Motive #3 Avoiding Failure

Nobody wants to fail. The experience of failure is singularly unpleasant and calls in to question all of our past successes. Maybe failure is the reality and all of our past successes are the illusion. Maybe, as we have always feared, we are indeed, not ready for the tasks we face.

The fear of failure can be a powerful motive. When we are tired, it causes us to reach inward and give that extra effort. When we get distracted, it serves like a rudder to guide our attention back to the task at hand.

Fear is, however, a force that tells us what to avoid, not what to do. Fear, without direction quickly devolves into anxiety. Fear of failure grabs our attention, but risks paralyzing us at the same time. At its worst, the fear of failure becomes so great that we give up and do not even try. Better to fail because we did not try than to give it all we have and still fail!

In my experience, trying simply to avoid failure is a recipe for disaster on the USMLE. Fear is a good way to get started in your process. But if you are to succeed, you have to know what you are seeking, not just what you are hopping to avoid. To get to success, you have to face you fear and leave it behind.

Motive #4 Avoiding looking or feeling stupid

Who wants to looks stupid in front of friends or colleagues? Don’t we want our teachers and our parents to regard us as intelligent? What if, the spotlight of the USMLE shows this to not be true? What if we just are not smart enough and do not have what it takes?

And it is not only others. We want to see ourselves as smart. We want the face in the mirror that looks back at us each day to be intelligent, savvy, and successful.

So, we work hard to show that we have what it takes. We spend long hours with our books so that we will have the answers when our professors ask. We stay up late into the night so we will never have to face our parents and tell them we just did not know. Wanting to avoid looking and feeling, stupid and inadequate can be a strong, driving motive in our lives.

It can also encourage us to lie, to others and to ourselves.  To avoid the appearance of being stupid, we do not talk in class. We avoid discussions with colleague who we think know more than we do. We repeatedly re-read what we already know and avoid what confuses us so we can feel the sense of, “I have this.” We avoid practice exams that may result in scores below our and others expectations. We do practice questions we have looked at before to get that better practice score.

Seeking to avoid looking stupid encourages us to focus on how we look, not on what is real. Our study becomes driven by managing impressions, not by getting results. We hide from the light of reality as long as possible.

But we can not hide forever. Sooner or later, we have to face the harsh spotlight offered by the USMLE. In that light, the shadows of perception disappear, and we are left with the reality of a clear empirical result. Playing for image is no more than playing for time. Sooner or later reality always catches up with us.

To get to success, you have to accept the reality that you do not know things and then take action to change that. Image management is easy, but short term and fleeting. Let yourself look stupid. It is the first step to making a new reality where that is no longer true. You do not know everything. Your time and effort preparing for the USMLE are your commitment to changing that.

Seek to Win, Don’t Just Avoid.

The bottom line is that no one motive gets you where you want to be. In general, positive motives, seeking something (a score or knowledge) are better than negative motives (avoiding shame or failure). Positive motives tell you where you are going while negative motives merely tell you where you do not want to go. Avoiding pitfalls is critical, but having a goal and a vision that will sustain you throughout the preparation process is the more likely road to success.

Steven R. Daugherty, Ph.D.

Combining Content in Context: USMLE thinking

The thought processes required on the USMLE are different than those required on most medical school exams. The content you need to know is the same. But the way you need to think about that content, and how you will use that content in your exam, requires some mental reprogramming.

On medical school exams, recognition and paired association are the keys. A typical exam item presents a concept in the question stem and asks you to select the proper association from the presented choices. If you have studied sufficiently so that seeing a particular symptom reminds you of a disease diagnosis, or seeing a particular disease reminds you of the commonly used pharmacology, you will get the question correct. When you see “butterfly rash: you think “Lupus”.

You train yourself for these association questions by repeated exposure and memorization—going over the pairs and patterns over and over until you are programmed with the appropriate responses. In essence, questions on medical school exams are mostly are free association exercises. You get them right when you have trained yourself to have the associations your professors want you to have. As long as your associations are those of the faculty, you will do very, very well. You prove to the professor that you have mastered the required content by giving the required responses.

The USMLE wants more out of you. For the most part USMLE questions writers assume that you already possess the basic mental associations. They assume that the medical school has done its job. Their task is to see if you are ready for the next level. USMLE questions are not aimed at what you know, but are framed to see if you can apply what you know in a series of presented problem scenarios. Knowing is not enough, you have to be able to DO SOMETHING with your knowledge.

Few physicians would argue with this goal. The job of the medical practitioner is not to serve as a human reference book, but to make decisions, to take actions based on what they observe combined with what they know. This is what the USMLE tests: how you take in information and how you are able to reason with the information you collect.

Context is the key to understanding the information presented to you in a USMLE question. Particular facts mean different things in different circumstances. Meaning comes as much from surrounding data as from the presented detail itself. Fatigue, reported by a patient, may be an important symptom or merely the result of too little sleep. The meaning rests with the full set of symptoms and life circumstances presented. Single symptoms are ambiguous. Context provides the pieces to let you see the essential presented patterns.

Combination is the key process for the problem-solving required on USMLE questions. You must combine the information presented in the question with the information in your own head. The patterns you see plus the patterns you remember give you the insight to reason though to the best answer. If the question presents a symptom constellation, you must have the knowledge in you head to recognize the disease that this signifies. Recognizing a pattern in the question, but not remembering what it signifies means that you will not get the question correct.

Answer each USMLE question by first deciding, “What is given in the question?” and the deciding, “How does that relate to what you know?” This process, not simple association is the solution you seek. Content and combination result in the clarity you need to pick the best answer.

A detailed walk thought this process can be found in an article I posted in cooperation with Dr. Philip Tisdall on www.usmlethought.com. Look under the heading “Handling USMLE Questions.” Learning the mental steps to understanding USMLE questions is as important as mastering content details.

Steven R. Daugherty, Ph.D.

Judgment and Choices: On Becoming a Physician

Students excel by memorizing information and being able to recall that information in the right circumstance. The best students are the ones who can remember the most facts. On a multiple-choice exam, students make their choices based on what they can remember.

Physicians excel based on their judgment and their capacity to make the right choices in complex situations. Although physicians must have a solid knowledge base, the best physicians are those that can apply that knowledge in appropriate ways and circumstances. On a multiple-choice exam, physicians make their choices based on the application of their best judgment.

This capacity for judgment is what separates a student from a physician. This capacity for judgment is also what separates high USMLE scores from low ones. Seen simplistically, USMLE questions are actually different based on whether you read them with the expectations of a student or the perspective of a physician. For students, the essential theme for each question is, “What do I remember?” For a physician, the essential theme for each question is, “What is going on here?” The student, above all, seeks an answer. The physician, at his best, seeks a clear understanding of the presented problem. A student knows because he remembers; a physician knows because he reaches a conclusion.

Getting that top USMLE score depends on changing your thinking from that of a student, to that of a physician. The sooner you make this mental transition, the easier your USMLE experience will be and the better your results. So how does one make this transition?

Every physician begins as a student. You must first master the core content knowledge. But while students stop there, physicians go one step further. The transition to being a physician comes at the point where knowledge is, for the most part assumed, and the challenge shifts to the understanding of how to use that knowledge in the situation at hand. This means an ever more critical focus on the details of the situation and the application of judgment to determine the best course of action. The question, not the answer choices becomes the main focus. By carefully digesting the key elements of the question, the problem to be solved becomes clear and the right answer, obvious.

If you find your scores on practice questions stuck in the 50% to 60% range, then you are stuck thinking like a student and need to master the art of clinical reasoning. Clinical reasoning begins by recognizing that not everything matters, but some things are critical. You need to make the transition from trying to grab on to every detail to the point where you have the judgment to know the details which make the difference.

Here are some simple techniques you may find useful to help you with this transition:

1. Practice honing your judgment by being clear why something matters. When studying, tell yourself why each fact is relevant and in what circumstances it might be of value. Keep asking yourself, “So what?” or “Why does this matter?” If you can’t answer the question, then the content is likely too esoteric to matter for the USMLE.
2. Put together a short lecture on some content with which you are struggling. Nothing organizes your understanding better then having to talk about it.
3. Write some questions. Not the simple recall questions, but the longer USMLE clinical case items. By thinking about what to include, or leave out of your questions, you are helping yourself focus on the details that matter.
4. After answering a question, go back over the content and tell yourself how you would need to change the question to make every one of the options correct.

Judgment is not the same as memorization. There is a big difference between knowing what a hammer is, and knowing the right occasions for using one. Work on your knowledge base, and then, work on using that knowledge. The transition from student to physician is one of the most important moments of your career. Remember, the USMLE is not testing if you are a good student, but if you will be a good physician.

Steven R. Daugherty, Ph.D.

Who is in Charge on Your Exam?

Who is in charge when you take you exam?  Do you control you exam, or does the exam control you?

The USMLE is not only testing your content knowledge, but also your ability to problem-solve on your feet. In spite of distractions, are you able to contain your anxiety and focus on the pertinent issues before you? Do you approach each question with a confident curiosity? Or are you hoping that things will be easy; that you have seen the problem before; that you will get lucky and see a question focused on content you recently studied? Do you approach each question with quiet confidence or uneasy hope?

Success on the USMLE depends on identifying issues and thinking clearly. Yes, you must have memorized essential content. But, the exam wants more from you than a demonstration of what you have memorized. The exam wants you to show that you know how to use what you have learned.

To accomplish this you must be more than a recoding and playback device. You must be more than a machine. You must be a person who can assess, think and decide. In short, you are being tested on who you are as much as what you know. The USMLE expects you to be in control of yourself and to demonstrate that by your control of the exam.

Gaining the control you need for the exam begins with your preparation strategy. In the long process of exam preparation it is easy to lose perspective. Over the course of weeks and months it is easy to feel overwhelmed and buried under the material you must master. Once lost, you feel like you are playing catch-up, and you never quite catch up. To avoid playing continual catch-up, take charge of your USMLE preparation from the very beginning.

Begin by making decisions and taking action based on those decisions. Decide what is essential and what is lower yield. Decide what study material resonates with you and helps the content to make coherent sense. And then, plan your study to cover the material you have selected. Avoid the temptation of asking everybody else what you should do. Yes, listen to advice, but then make your own decisions as to what works for you. Be especially skeptical of advice from parents and family members who do not have first-hand knowledge of the USMLE. Family usually advises you to work hard and spend long hours at study, but they rarely can give you the critical insight about what to do with that study time.

You have to live with your exam results, so you need to take responsibility for deciding how you should proceed. Make a study plan that maps our how much time you will study each day, and then follow it! Avoid studying “every waking minute.” Treat study time like a job. Put in your time, mentally clock out at the end of the day and give yourself a chance to rest each evening. Tomorrow you must get up and do it all again. Make sure your strategy is one you can maintain long term, not just over a couple of days.

When your study turns to questions, stay in charge by avoiding excessive focus on you percentage correct. Each question is a chance to test what you know and how you think. If you get a question right, congratulate yourself on your progress. But never forget that it is the questions you get wrong that will really improve your performance on the actual USMLE. When you get a question wrong you have uncovered a deficit. Use this knowledge by taking direct action to resolve the deficit. Diagnose why you missed the question. Was it because you missed something when reading the question or because you did not know the content? If you missed something when reading, pay attention to what you miss and you will discover patterns of errors you can correct. If you did not know the content, go back to your study material and go over it again.

Don’t just react to questions, act on them. Don’t simply feel good or bad about your question results. Make use of the information you have gained and do something about it!

By making decisions all the way though your study preparation, you are not only going to do a better job of learning, you will also be teaching yourself the mental set and the self control the USMLE requires. You know how to take charge because you have learned to take change of yourself. We want doctors who have the self-control and the aplomb to handle whatever patient care issues with which they are confronted. Your final USMLE score is a much a reflection of you control of the exam as it is your memorized knowledge. Take charge of your preparation and you will take charge of your exam.

Steven R. Daugherty, Ph.D.