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

Decision-making on the USMLE is different than medical decision making in the real world. Medical practice demands you to be as certain as you can be. If you need more information, get it. If you need a consult, seek one out. If you make a bad decision in medial practice, you could kill someone, or at least cause avoidable pain and suffering. “Be sure,” your professors and mentors have told you from the first day of medical school. Being sure is the right way to practice medicine.

Being sure is the wrong way to take the USMLE. You simply do not have the time to gain the level of certainty you would like to have. The clock is ticking continually and decisions must be made. To make it through the exam, you have to be able to select an option in spite of the uncertainty you feel. Spending a lot of time on one question until you are certain as to the answer, means that you will not have time to even consider other questions down the road. Your choice is clear: either spending the time to achieve certainty on some questions, but never getting to others, or, learning to make your choices quicker, with less certainty on all questions. Getting to all the questions is your best strategy.

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

Learn to force a choice even when you are not sure. Answering questions on the USMLE requires that you keep making choices even when you are uncertain. In fact, USMLE questions usually require not one, but a series of choices. You must not merely decide on the answer to be chosen, but must make a sequence of small choices that will lead you to that final answer.

The USMLE requires you to choose, and then keep choosing until you have solved the presented problem. Expect, on average, that three correct decisions will be required to get you to the point where you can select the best answer. This means that USMLE questions require you to not only choose in the face of uncertainty, but to keep on choosing, piling one uncertain decision on top of the next.

Acclimation to this mental headset takes time and practice. Of all the mental hurdles that need to be overcome to excel on the USMLE, none are as daunting as changing the way you make decisions. You must learn to change the very way you make decisions. Learn to choose even when you are not sure. Learn to decide, and then keep making decisions even in the face of uncertainty.

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

Steven R. Daugherty, Ph.D.


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