Hope Is Not a Strategy!

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Believing that you will succeed is the first step in making it so. You need to believe that you can do something if you are ever going to give it your best effort. The power of positive thinking gives you the momentum to deal with the most difficult challenges in life. Hope keeps us going, and gives us the confidence to see a task through.

But a positive attitude, by itself, is not enough. Simply wanting something does not make it happen. Success comes from using that confidence in the plans we make and the actions we take. Success does not come to those who wish for it, but to those who work for it.

No where is this more true that as you prepare for your USMLE. Confidence, by itself, will not carry you through and can even be a dangerous trap. When you feel confident, you are less motivated to focus on details and to do the kind of new learning which optimum performance demands. Confidence that gives you the energy and stamina to face the hard task and do the job is good. Confidence that makes you decide that you do not have to do much to get ready is bad. Some students wrap themselves in a positive attitude as a way of warding off the anxiety that actually engaging the study material can bring. “I don’t really need to study,” they say, and so they never actually review core material to find out that they have deficiencies. The question is simple: Is confidence a motivator that pushes you to achieve or a shelter where you will hide from your fears?

Success requires more than a positive attitude. Hope is not a strategy. Wishing is not a plan. Most of the people who take the USMLE are as smart and intelligent as you are. Preparation and effort are the only things that will give you an edge in this competition. Confidence only matters when it is based on a realistic foundation of learning, study, and practice.

Realistic preparation depends on facing your fears and targeting your deficiencies. The best exam preparation does not treat all material as the same, but allows you to focus on the topics and concepts on which you need the most help. Yes, you have to review everything, but some things, the things you are weakest in, will require more time and other things, the things you know better, will require proportionally less time.

Although it is tempting to simply study a certain number of pages, or do a set number of practice questions each day, this rote routine is inefficient. You must allow variation in your process. Some days you will find the material harder and need to spend more time on content study. Other days you will find the material easier and may spend more time answering and reviewing questions. A positive attitude gives you the confidence to make these day to day choices. Sometimes in the midst of your study you talk to a friend who is using a different set of study resources or a different study technique. Confidence in your own process allows you to maintain a focus on your own process and not be distracted by what others are doing.

 The power of positive thinking is the power to succeed. By making a clear study plan and sticking to it, you can harness that power to propel you to your goal. Believe that you will succeed, but also believe that your own efforts are a key part of that eventual success. Confidence, by itself does not win, but does help those who help themselves.

Making the Most of your Worst Subject

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We all enjoy spending time with the people we like, and try to avoid even seeing the people who make us uncomfortable. Good friends, the people who make us feel good, are one of the prime joys of life. And who needs anxiety? Is not avoiding those people who make us feel bad a sign of good mental health?

Unfortunately, this good, even instinctive, strategy for enjoying life is a disaster when applied to how you allocate your time when preparing for the USMLE. The pleasure you get from USMLE preparation is not from the experience itself. Preparation is hard work. Rather, your real satisfaction will come from the score you achieve at the end of the process. Let me repeat, the process is not fun (at least for most people), but the feeling you will get when you are told about your superior score will more than make up for the deprivation you put up with.

Successful preparation for the USMLE, therefore, begins with answering a simple question, “Can you endure short-term discomfort in order to achieve ultimate success?” Are you able to defer your gratification? Can you live with the anxiety and uncertainty of facing up to what you do not know and correcting the deficits you find? If the answer to these questions is a resounding “Yes”, then you are ready to begin the labor of study which will bring you ultimate prize. If your answer is “No”, then no amount of resolve or commitment will see you though to the end.

So, if you are ready, where do you begin? Many people think that USMLE preparation requires simply doing more and more practice questions. As I have pointed out in previous postings, practice questions test you and tell you where you are, but they do not teach you and make you better. Learning comes from study, not from questions. We tend to like questions because they are, well, more fun than studying. The mental challenge of deriving an answer is simply more engaging to most people than the routines of rote study. In addition, questions are “bite-sized”, presenting us with a defined cognitive task and freeing us from the vertigo we feel when confronted with the mass of information the USMLE requires. A question just feels more manageable than the bulky weight of study material.

Study is the core of your preparation and the foundation of your eventual success. Only by concentrated effort of reading and understanding can you absorb the basic facts at the core of the USMLE questions. Without this knowledge in you head, no amount of question expertise will help you. Faculty can help you by explaining what is unclear and indicating what is most important, but the actual work of making the knowledge your own must be done on your own.

You get the most out of this study time by focusing on the subject matter where you are weakest. If we are honest, all of us have some subject, or at least some subject area where our mastery is less than complete. We know we are not good in this subject. This sense of not measuring up makes us feel uncomfortable. To avoid the bad feelings, we often simply avoid the subject. And so, the weak area continues to be weak. Some people even take on a subject are weakness as a self-defining characteristic. It becomes a part of the label of who we are, “I’m just not good in…”

The point to USMLE preparation is not just to perpetuate these weaknesses, but to fix them. Rather than accept that you are not “good” in a certain subject, now is the time to change that. USMLE preparation grants you the unique opportunity to elevate yourself, to take a step up from the knowledge you acquired in medical school to a broader, more integrated comprehension of basic science and clinical knowledge.

So, organize your study time to give extra attention to those weak subject areas. You will not like it. You will feel anxiety as you face your deficits. But, this is simply the best way to reap the rewards of a superior score at the end of the process. Start your study time with your worst subject, and then look at it again just before the exam as added reinforcement. Or to really master the subject, spend ½ an hour every day on it in addition to whatever else you are studying. Don’t run away from your weak areas, embrace them. Meet your weaknesses head on.

USMLE is about problem-solving. But, if you can not call the basic facts to mind, is you do not have the knowledge you need to apply to answer the question, even the mostly finely-honed reasoning skills will be to no avail. Without a usable grasp of the basic knowledge, you will fail. Organize your time so you can focus most on the area where you are the weakest, and you will discover during the exam that you have the facts you need to solve the UMSLE questions you encounter. Rather than your worst enemy, you fill find that you have converted the subject you hate into your best friend.

Steven R. Daugherty, Ph.D.

How long should I study?: It’s What You Do with the Time That Counts

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Does extending your study time add points to your USMLE score, or does it actually hurt because you will start to forget what you already learned?

If you believe that USMLE preparation as a brute memory exercise, then you probably think that at some point the new stuff you learn will be negated by the old stuff you forget. When that balance point is reached, further study would not provide any real benefit. Once your memory is saturated, additional study would gain you nothing.

But, the focus on the USMLE as a pure memory exercise is misplaced. USMLE test items are not questions to be answered, but problems to be solved. You get the top score, not by regurgitating what you have taken in, but by being able to use that information and apply it to the situations each question presents. In short, doing well requires thought, not brute memory. Shear memorization does not get you that high score. Something more is required.

You get to this problem-solving level by changing what you do with the material you are studying. If you fell that you are studying hard but not progressing, it is time to change your approach to the material. As you learn more, you can do more with the material you have learned. Figure 1 (below) illustrates the essential point.

Initially, study is about memorization, but after a while you will find that you have gone as far as memory can carry you. To solve this impasse you need to shift to a focus on how things fit together within each subject you are seeking to master. Gaining a sense of connections and linkages among the things you have learned will help you see things in another light and make it easier to retain the things that you have already memorized. At this level you focus on learning patterns, that is, no longer learning things, but the relationships among things. Every medical subject area is defined by a set of essential patterns and templates which give a context to all the details and help them to make sense. Pattern recognition helps you focus on these most essential elements and moves you up to the next level of USMLE scores.

To get to the highest level you must move beyond pattern recognition within subjects to an integrated understanding of the connections between basic subject areas. All medical knowledge is about the same human body. All clinical issues can be approached from a variety of medical disciplines. Gaining an understanding that multiple approaches are possible to solving a presented problem, and acquiring the ability to select the must useful of the available approaches in any circumstance is the mental habit of mind required to achieve the highest level of performance.

Memorization only lifts you so high. Pattern recognition within subjects gets you higher. Understanding of how content is integrated between subjects moves you to the highest level. If you use added study time to shift to the next level, you will find clear improvement in your score. If you use added study time to simply focus on more and more memorization, you will fins you improvement has stalled. The key to progressing is not how long you study, but in shifting what you do as you study across time.

So, how long should you study for the USMLE?

The length of time you will need to study for the USMLE differs from person to person and depends where you are in your study process. If you are still at the level of memorization, longer time will be required. If you have advanced to pattern recognition, then somewhat less is needed. When you have achieved the level of integrated understanding, you are ready to take you exam.

In short, the optimum study time varies widely depending on the strengths and weaknesses of each individual. We can, however, offer some general guidelines to guide your planning.

As a rule of thumb, it takes about 2 to 3 months to prepare for each USMLE Step. Additional time may be required if you:

  1. Have been out of medical school for more than 1 year. Information fades over time. The longer you have been out of school, the more time is required to boost your knowledge base back up to where it needs to be. In addition, the thought processes required for USMLE questions are a bit different than those of actual clinical practice. Most people find they need time to get back to thinking in the appropriate ways.
  2. Had any academic failures in medical school (or barely passed two or more courses). Academic difficulty is clear evidence that you have some gaps in your knowledge base that will damage your USMLE score.
  3. Learned English after age 10. PET scan studies have shown that language learned prior to age 10 goes into Boca’s and Wernicke’s areas, whereas language learned at a later age goes into contiguous areas. This means that language learned later in life comes with slower processing speeds which can slow you down measurably on the USMLE. Everything you do to become more proficient in English will improve your score. Make sure you spend time increasing English comprehension and reading speed by taking time to practice reading in addition to you USMLE study time.
  4. Have a history of difficulty with focus and concentration. If you have actually been diagnosed with ADHD, or just have difficulty with maintaining your attention for prolonged periods of time, you will likely require more time to cover the mass of material required for the USMLE.
  5. Have other responsibilities during the time you are studying. If you have family or work responsibilities, you will not be able to give you full attention to your USMLE preparation. Part-time study simply means that you more months will be required for you to review and master the required material.

On the other hand, you should be able to shave time off of your preparation if you: 

  1. Are still in medical school
  2. Excelled in you courses
  3. Have a past history of performing well on standardized exams
  4. Enjoy puzzles and thought exercises

The good news is that you can take whatever time you need to get ready for the USMLE. Don’t let friends, family, or your school push you into taking the exam when they think you should. To be master of your own fate, you need to decide if you are ready or not. If you decide you need six months, take the six months. Remember that once you pass, you can not try again to improve your score! My own experience with students suggests that if you think you need more time to study, you probably do.

Take the time that you need. Force your self to move beyond memorization to pattern recognition and subject integration. Change how you learn as you learn more. Shifting how you learn is the key to stepping up to that higher USMLE score.

Steven R.. Daugherty, Ph.D.

MAKING YOURSELF CHOOSE

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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.

KEYS TO USMLE THINKING

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The USMLE exams are designed to test two things: 1) your knowledge base and 2) your capacity to reason with and apply that knowledge. Most students understand what is required to master the essential core knowledge: a careful review of high-yield topics. However, many students neglect to prepare for the application issue. In these cases, the student knows the content but cannot adequately represent that knowledge on the presented questions, and their score suffers accordingly.

Try these three techniques to train yourself to think with the material you know:

1. Study by contrasts.

The dominant cognitive process required by multiple-choice questions is not recall of knowledge, but differentiation among options. Therefore, your study strategy should focus on this issue. For example, when learning microbiology, do not imply memorize the properties of each pathogen. Instead, concentrate on what features make this particular pathogen stand out from the others. Ask yourself what other pathogens you might you easily confuse it with and then, how you will distinguish among them. When selecting among clinical intervention, the same logic apples. You must know more than what are common interventions. You must know when a particular one makes most sense. The key study question is what are the circumstances when I would select this intervention and not a different one? Kaplan Medical study materials are explicitly constructed to help you learn these important contrasts.

  1.  Making all the options correct.

When doing practice questions, the important issue is not how many you got correct, but learning from reviewing the questions after you answer them. You must know why you got a question right or wrong. After you answer a question, review the answer and read any provided annotations. Then, return to look at the question again. Taking each option one at a time, how would you change the question asked to make each of the options correct in turn. If “C” were the correct answer, how would you need to change the question so “A” is the correct answer? So that “B” is correct? This process focuses you on the key elements that determine what the proper answer will be on any given question. Repeat this process until it becomes second nature. If you really understand a question, you can say why one answer is correct, and why all the others are wrong.

  1.  Checking your perspective.

Not everyone who witnesses the same scene sees the same thing. By past experience or current habit, we all have mindsets that focus on some features in a situation and overlook others. In real life, these are simply the differences among people that make life interesting. On the USMLE, these differences can spell disaster. You see, it is not enough to read the question your way. You must learn to read every question the way the examiners intend you to read it. Some questions can be interpreted in a number of ways. When ambiguities exist, one way of seeing the question is right (the way the examiners intend), and all other perspectives are wrong. Your Becker USMLE faculty will help you understand how you should be approaching and reading questions, but you can also work on this issue in a group of your friends.

Sit and read through a question together with your friends. When you have all finished, everyone should pick and answer and jot down the corresponding letter. Then, reveal your choices. Take a moment and each person justify why they made the choice they did. This process not only allows you to review the content, but also allows you to pay attention to the way that each person reads the question, and the process by which they arrived at an answer. Experience suggest that if there is more than one way to read a question, and most people read it a certain way, that that is very likely the way that the examiners intend.

Success is a one-two punch: mastering content and being able to apply the content as needed. Remember, exam items are not so much questions to be answered as problems to be solved. Using these three preparation strategies to practice your problem solving processes will pay off in the end with the higher score you are seeking.

HOW TO READ A USMLE QUESTION

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Along with expanding your knowledge as you prepare for your exam, you should also take some time to improve you question-answering skills. The basic skills for answering multiple-choice questions are not difficult to describe, but require practice to master.  When confronting an exam question your main tasks are: read the question accurately, think as you are reading the question, and force yourself to make a choice among the options provided.  Of these tasks, learning to think as you read the question requires the most practice.

Each test question is composed of two parts: the Question Stem and the Answer Options.  Most students feel the urge to get to the answer options as soon as possible.  This is understandable. Questions are “aversive stimuli.” They invoke negative emotional reactions such as uncertainty and anxiety.  To avoid these emotions most people want to get rid of each question as soon as possible.  Answer options represent escape, and thus the route to feeling better.  The problem is, in your haste to get rid of the question, you may settle for any option rather than searching for the best option.

The answer to each question is to be found in the question stem, not in the options.  For the USMLE, every option seems reasonable.  Looking at the options is often more a source of confusion than clarity.  There are few clues in the options to help you choose among them.  The information you need to make a choice is in the question stem, and that is where the majority of your time and attention should be spent.

Every question on any USMLE is answerable by an expert in the field with no options presented.  So first, try answering the question without reference to the options at all.  To train yourself to do this, take a piece of paper and cover the options so you cannot see them.  Then read through the question.  Start at the first line, paying careful attention to the important demographic information it will often contain.  When you come to the end of the first sentence, stop briefly, and tell yourself what you think is going on. Call to mind pertinent knowledge.  Tell yourself where you think the question is going.  And then, with these thoughts in hand, read the next sentence of the question.  Continue this process until you have read the whole question stem, stopping at every period to tell yourself what is happening in the question.

This technique prods you to think and not merely to read without comprehension.  When you get to the end of the question stem you will find the actual question you are to answer.  If you have read the information provided for you in the question stem, you should now have a reasonable guess as to what the answer should be.  Now, and only now, take a look at the options provided.  By first focusing on the question stem, you should now be fully equipped to select an option that has a high probability of being the best of those presented.

USMLE items are not so much questions to be answered as problems to be solved.  The correct process for handling each question is not Read, then Answer, but Read, Think, Answer.  Training yourself to focus on the question is really a process of training yourself to think.  Your best score will come from practicing this simple sequence until your cognitive desire for the best answer can overcome your emotion desire to escape.

Steven R. Daugherty, Ph.D.

CHOOSING ACTION OVER REACTION

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We all like to know and feel confident that we know. We load our brains with facts and details to be sure that we have the ones we need when we need them. Learning begins with exposure to important details and sets before us the task of making these details our own. On exams, we prove to ourselves and others what we have learned by being able to state the relevant fact when it is called for. In short, we see; we respond. And having the right response gives us the feeling of competence and satisfaction of mastery.

But this kind of learning, this sort of knowing, has one strong limitation. We are only able to respond to what we have already seen. When confronted with something novel, we are unlikely to have the required response. In the face of uniqueness, we search our responses and find ourselves deficient. The sense of deficit leads to uncertainty, uncertainty to frustration, and frustration to paralysis. In this situation we see, but do not know how to respond, and our sense of mastery dissolves to leave us with a growing fear of incompetence.

At its best, the USMLE confronts you with things you may have never encountered and asks you to look at things in ways you may not have anticipated. Even those students who have studied well and taken in a host of details often find themselves surprised, and consequently frustrated. Many students try to overcome this by seeking to find out as much as they can about what has been tested and how it have been presented on previous exams. But this strategy inevitably comes up short. New questions are constantly being developed and novel presentations are continually being invented. Students who focus on what has been tested in the past will find themselves behind what is being tested in the present.

Doing well on the USMLE, therefore, depends not so much on having the right responses memorized, but being able to reorganize those acquired responses and refashion them to solve a new, unanticipated problem. Knowledge is the springboard for answering USMLE questions. But being able to reconstitute and think with that knowledge is the actual leap that carries you to success. Success depends not so much on having a pre-programmed reaction, but on being able to stop, think, and select the right action to respond to the novel situation presented. Mastering the exam rests not on programming your reactions to the questions you encounter, but on learning the right mental actions you take to arrive at the best solution. Thinking, not knowing, is the key.

The mental processes here are far more complex than the simple stimulus-response of a reaction. USMLE requires us to make new responses on the spot to cope with fresh, unanticipated scenarios. This is not mere temporal lobe recall, but frontal lobe problem-solving. The central issue is not do you know the right facts, but can you do the thought processes required to find the best answer.

But, having the right cognitive processes is just half the battle. Optimal performance also requires the proper emotional state. The question is, can you maintain your confidence long enough to let this essential problem-solving cognitive processes happen before uncertainty opens the door to anxiety and emotional escalation? The virtue of a pre-wired response is that it fixes emotionality. A pre-wired reaction means that little time is available for self-doubt, and that emotions remain in contained. Thinking takes time and doing the thinking that action requires allows time for emotions to run free elevate to a level of performance interfering anxiety.

As always, the secret to mastering the thought processes required by the USMLE is practice. Not practice in memorizing content, but practice at using that content in exam-parallel problem-solving situations. Mastering these thought processes means that you will have the essential skill the exam requires, but also that you will have the confidence that you can handle whatever the exam may throw at you. In the end confidence comes not from a sense of knowing everything (something that is not humanly possible), but in a practiced ability to think on your feet and arrive at a best solution to a any presented problem. The solution comes from thinking, not from knowing. And self-confidence arises from the ability to act to solve any problem, not merely from having the right pre-programmed reaction.

Remember that the USMLE is not only testing to see is you have the knowledge required to be a physician, but whether or not you can make use of that knowledge the way a physician’s have to use it. Knowing facts, but not knowing how to solve the problems that patient’s present makes you smart, but ineffective. What separates physicians from simple technicians, what makes you a professional, is that you know more than how to react to set scenarios, but that you can think and derive the right course of action to whatever situations you encounter. Knowledge is the foundation, but being able to think and apply that knowledge is what truly makes you a physician.

Steven R. Daugherty, Ph.D.