Most people think about learning as cognitive exercise in which acquiring knowledge means mastering and remembering facts, figures, and concepts. From this point of view, the chief task in preparing for the USMLE is to take in the necessary material and organize it in a way that makes sense. Once this task is accomplished, most people assume that they are prepared and will do well on their exam.

But cognitive preparation is only half the battle. Without parallel emotional preparation you have only the potential for good performance, but will not be able to make use of all that you know. Emotional preparation makes all the difference between knowing the content and actually being able to show what you know within the format of the multiple choice exam.

To most people, the word “emotion” in the context of an exam calls to mind visions of “test-anxiety”, an uncontrolled emotional arousal that can be debilitating and frustrate even the best prepared student. Certainly test-anxiety is a critical issue for some students, but for the vast majority, this arousal is under control and does not significantly interfere with exam performance. Yet, even without the interference of test anxiety, emotion plays an important role in the exam performance of everyone.

The role of emotions in this process is subtle and linked to the way our brain operates when placed in situations in which decisions are required. Without emotions, we are apparently incapable of making decisions at all. Patients with intact frontal lobe regions, but who are have sustained damage to critical brain regions linked with emotional response, are incapable or shutting down their analytic process and arriving at a conclusion. The breakthrough work of Antonio Damasio and others at the University of Iowa using MRIs to map the neurological activities involved in making decisions shows this process in graphic relief. Without emotion, we are trapped in an endless loop of analysis. Without emotion to guide us we pour over details, but are unable to come to a resolution.

Cognition tells you content and context, but emotion tells you what specific content or what features of the context matter the most. Cognition tells us what is real. Emotion is the source of how you determine value within that reality. And the value we attach to the options among which we choose is that makes it possible for us to decide.

Emotion determines your exam performance in three distinct ways.

1.) Emotion controls attentional focus.

When you are reading the details presented in the question, emotion tells you where to direct your attention. The words on the screen convey meaning your response to that meaning helps you sift out what is essential from what is irrelevant. Without emotion, everything seems to matter and the simple process of deciding what is “figure” and that is “ground” that allow pattern detection can not occur.

To prepare for this part of your exam task, you must not just learn the details, but learn which detail matter most. This sense of what matters provides the emotional valance to understand the point of the question and gives you a perspective from which to evaluate the presented options.

2.) Emotion controls thought processes.

USMLE questions require you to make a series of decisions on your way to selecting the option for your answer. You either have to reason from information given or collect the clues presented to solve the puzzle which the question provides. Your emotional certainty regarding each sequential decision has a lot to do with your capacity to keep going until you have resolution rather than giving up in frustration.

Part of your preparation for the USMLE must be to face and solve problems of the type and complexity you will see on the actual exam. This practice helps you understand the value of following though on the thought processes required and gives you the emotional toughness to keep going in the face of frustration.

3.) Emotion allows decision closure.

Analysis is a cognitive function, but decisions rest on emotion. Emotion values the options from which you will chose your answer and lets you rule out some while it directs you to focus on others. Emotion is the feeling that tells you that you have an answer. This feeling is what shuts down your decision process and allows you to select and options and then move on to the next question. Remember, your choice of an answer is always an emotional one based on the relative affective weight you give each of the options. Learning the values that govern what will be considered the best answer is as important a part of your preparation process and mastering the required content.

One of the reasons why some international medical graduates find the USMLE more difficult that US medical students due to the different emotional values they give to presented options. US medical students, schooled by the pool of faculty who write the exam questions are simply more likely to value the options in the way the question writers intend and thus are more likely to arrive at the keyed answer. International students, although schooled well cognitively, may have a different sense of the value of the options and so may pick one that feels right to them, but is not what the question writer intended.

Doing your best on the USMLE means learning the content, but also learning how to make decisions with that content. Cognition helps you hold on the content you learn, but it is emotion by which you make your actual decision. Your final exam score is the result of both processes working in a coordinated fashion.

Steven R. Daugherty, Ph.D.

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