BEATING ISOLATION: HOW HELP FROM OTHERS CAN SPEED UP THE LEARNING PROCESS

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Medical education is often a solitary enterprise. In order to master the mountain of material required for the USMLE and medical practice, many students habitually lock themselves away with only books, flashcards, and personal notes for company. This solitude gives the time and mental space for learning, but does not guarantee that the learning will be either efficient or effective.

When you study on your own, you can easily to get bogged down in non-essential details or become distracted by one particularly difficult section of material and lose your focus on the core themes and content. When you study on your own, mistakes often go undiscovered and frustration builds as certain topics just seem to not make sense. Few of us have a perfect approach to studying. Without the corrective assistance of others, these imperfections are magnified over time.

Solitude is great for the simple task of memorization.  But other people improve our study process by:

  1. Helping us to decide where our focus should be. With so much to learn and master, it is essential that you focus on what is most important. Two (or more) heads are better than one in making these decisions.
  1. Helping us learn how to think. Exam questions must be read as the writer intended if you are to give the keyed answer. Working with other people helps us to avoid idiosyncratic approaches that miss the question writer’s intention.
  1. Stopping us from reverberating. Sometimes we read the same content over and over without it making any sense. Other people can give us a fresh perspective and a fresh approach to help move us beyond our mental blocks.
  1. Making us explain what we know. How do you know when you know something? If you can explain it to someone else, then you do. Other people are sounding board for us to say what we know, and in that saying, to see that we know it.
  1. Providing examples to illustrate the material. Theory sounds good, but having a practical sense of what the concept will look like concretely is the key to real understanding. It is hard to apply content to questions if you do not have a good concrete example in mind.
  1. Keeping our spirits up. The exam preparation process can be long and frustrating.  Most people get discouraged at some point. Working with others lets you know that you are not in this all by yourself.

Other people give us perspective. When we are off course, they can tell us. But most importantly, they can make us aware of why we do what we do, and get us to think about doing it better.

Don’t give up your time studying on your own.  It is still the core of the study process. But, spend some of your study time with other people. Your improvement will be marked by your results.

Steven R. Daugherty, Ph.D.

MEMORIZATION IS NOT ENOUGH

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One of the most common questions I hear when advising people preparing for the USMLE is how to memorize and remember all the details required for their exam.  The short answer is that if you are at the level of memorizing, you are simply not ready to take any of the Steps of the USMLE. Yes, the USMLE requires you to know essential medical knowledge. But, doing well on the exam comes from being able to apply that knowledge, not from the mastery of rote memorization.

Let me repeat, the USMLE is not about memorization. The examiners assume that you already know the required medical content. Your medical school success certifies that you have the basic knowledge already. The USMLE is not testing you on what you know, but problem-solving, whether you know what to do with what you know.

Focused repetition is the key to memorization. Anything that you read two or three time, if you are really paying attention, is recorded in the cortical regions of your brain. Your brain functions to retain what recurs. But, the USMLE requires more than this. You have to be able to recall and use the information within the time constraints of the exam. Remember, the USMLE is not seeing if you are a good student and able to digest all of the necessary information. Rather, the exams are checking whether you have a practical grasp of that information and understand the implication it has for medical practice.

You do not get to this level of mastery required for medical practice all at once, but by increasing levels of involvement and understanding over time. These levels can be conceptualized as pyramid in which one learning task supports the next. Figure 1 displays these levels of learning in graphic form. Recognition, being familiar enough with material to know it when you see it, is the bottom level of the pyramid. Next comes Memorization, being able to call content to mind when needed. Problem-solving, the third level, is achieved when you can combine remembered content and apply it to find the best response to presented situations. At the top of the pyramid comes Innovation, being able to create a new knowledge, new understanding, and new responses.

In medical school you are tested primarily on Recognition and Memorization. The USMLE test you primarily on Problem-solving. The amount of problem-solving required increases as you move from Step 1 to Step 3. The Clinical Case Simulations of Step 3 push problem-solving right up to the border of Innovative thought.

All of which means that at some point your preparation for the USMLE must move beyond brute memory and accelerate to the level of application and problem-solving. Sitting by yourself, reading and re-reading your study material simply will not get you to this higher level. You need to do something with the material. Outlines help. So does making diagrams. But, nothing speeds up the process like talking about the material. Interacting with peers and professors is the quickest way to boost your mastery beyond the level to recall, to being able to use the material you have learned.

The bottom line is that there are a lot of good sources of study material out there, but none of it will get you where you need to be unless you use it the right way.  Before you take your USMLE, you must move beyond memorization to application and problem-solving. The USMLE does not want to see what you know, but whether you can use that knowledge like a physician.

Steven R. Daugherty, Ph.D.

DECIDING WHAT TO LEAVE OUT

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The most difficult part of studying for your USMLE is not deciding what to study, but deciding what to ignore. There are a wide variety of resources available to help you prepare for your exam. Each of these resources has surveyed the knowledge of a given field and extracted the content that seems most relevant to the authors. Faced with this range of choices, you have two key decisions to make. First, what material will you choose to study? Second, what will you focus on within that selected material?

When selecting what material you will study, we recommend the “Goldilocks Rule”. You may recall the fairytale about Goldilocks and the three Bears. One bowl of porridge was too hot, one was too cold, and one was just right. When you select your study materials, those offering too much detail are not likely to help you focus. On the other hand, those offering the most distilled version of knowledge (all of the USMLE in one book) are likely to give you inadequate coverage. Your job is to select material that is “just right”; that give you enough detail without becoming overwhelming.

Whatever you select, pick one primary study source. The vast majority of students tell us that the Kaplan Live Lecture Notes give them everything they need for their exam. If you don’t think so, then pick another source.  But whatever you do, pick ONE source. “Double tracking”, that is, trying to digest two sources at once is a losing strategy for most people. Students with two or more sources quickly feel overwhelmed and lose focus on what is essential with in the double mass of material presented. Pick one source and learn it well.

With your study resources selected, you have a second choice to make. What will you focus on within the set of materials you have selected? The simple fact is that even within a set of content that distills the knowledge you must know to the essentials, you cannot learn and remember everything. If you try to, you will not succeed.  You will end up with gaps in your knowledge, and these gaps will be, essentially, random. A better strategy is to use your native intelligence and CHOOSE. That hard part about study is not deciding what to focus on, but deciding what to ignore. As you study, classify the material you encounter in to three groups. That which is Essential, that which is Important and that which is Secondary. What is it that you must know; what should you know; what would be nice to know?

If you have a hard time making this distinction, pretend you are going to give a lecture based on the material that you are reading. If your lecture time is short, what are the key aspects that you must mention, what would be nice to mention and what can you leave out because you just do not have enough time.

Making these kinds of choices, if you are not used to it, can be emotionally unsettling. Trying to learn everything gives you the emotional comfort that whatever is tested you till know. Making choices to not study certain things will cause you to not look at details you may well need during your exam. But wait; don’t feel bad about what you do not know. You are forgetting all the things you will know because of what your choices did give you time to study. You cannot know everything. The feeling that you can know everything is comforting, but it is the comfort of a false reality. Choose where to put your efforts. Make decisions about what you will focus on early. Success comes, not from trying to travel all roads, but from picking the right route to get you where you want to go.

Steven R. Daugherty, Ph.D.

TRAINING YOUR BRAIN UNDER STRAIN: GETTING THE MOST OUT OF PRACTICE QUESTIONS

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Doing practice questions is essential in your preparation for taking a multiple-choice exam. However, your goal should is not to “test” yourself, but to learn good question answering habits. As you do questions, yes, check whether you got them right, but more importantly, look at why you got the question right or wrong. Did you not know the content? Then that’s your cue that more study is needed. Did you misread the question? Then evaluate how you misread it and learn how the question writer wants you to read it.

When you do your practice questions, do them under a time limit similar to the actual exam. In general, your practice rule should be one minute per question. This is a little less time than you will have during the real exam. But a tighter interval will get you used to the time constraint. The ticking clock is one of the unchangeable realities of the USMLE.

To identify specific question answering bad habits, try this exercise. Select a set of 50 questions from a good questions source. These should be questions that you have never looked at before. Then, set a clock for 1 hour, and do the questions. Read them and answer them, but stay within the 1 hour time limit.  When the hour is up, do not score the questions. Instead, without a clock, go through and do them again. This second time, take as much time as you need — linger and reflect. When you have completed all 50 questions the second time, now look at the answers and score yourself. You probably got more questions correct from the second, untimed pass than you did the first, timed pass. With this data in front of you, you can now identify particular question answering problems that you have.

If you got a question correct on the untimed pass, but incorrect under time pressure, the issue can not be a lack of knowledge, rather you must have processed the question incorrectly. By examining these questions, the ones you got right the second pass, but missed the first time, you should be able to identify certain mistakes you are prone to making when answering questions under time pressure. Note what these mistakes are, and then think about what to do so you can correct this problem. If you know the content, but can not demonstrate it on the exam question, you get the same score as if you do not know the content at all! Spend time learning your most common mistakes, and then with this awareness, set up an approach to questions that avoids these common mistakes.

In addition to this self-diagnostic exercise, avoid these common mistakes when doing practice questions:

a.) Do not just do questions without preparatory studying. Review material first until you feel you know it, and then use questions to test yourself. Learning the answers to hundreds of questions that you may not see on the exam will not help you prepare. If you study by doing questions before you are ready, you will erode your self-confidence and fail to develop key linkages within the material.

b.) Do not get into the habit of lingering over a question or thinking about it for an extended period of time. You do not have this luxury on the real exam. Remember that you have just over one minute per question. You should spend about 75% of that time reading and analyzing the question stem, and the other 25% selecting an answer. Be honest when you do not know an answer; move on, and look it up when you are finished.

c.) So-called “retired questions” and many published questions in review books are not representative of questions featured on the current USMLE Step 1. They are a reasonable way to review content, but often do not reflect the length or form of the questions on the current exam. Kaplan Medical practice exams are your best sample of true USMLE-type questions.

d.) Do not do questions individually. Do them in clusters under time pressure, with 5 to 10 as a minimum. This will get you used to moving from question to question. Do not look up answers after each question. Instead, check yourself after you have done the full set of questions.

e.) When you start working on questions, do not panic if you do not get the correct answers. Learn from your mistakes. Questions are a part of the study process; they help you see what else you need to learn. You will get better at questions as your studying continues.

Answering questions is a game. To do well at this game you must identify needed skills and then practice those skills. Time spent learning to do question correctly allows you to demonstrate the level of knowledge you have and avoid the frustration of a score that is below your abilities.

Steven R. Daugherty, Ph.D.

RE-READING AGAIN AND AGAIN IS REDUNDANT AGAIN AND AGAIN.

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So, you have completely read through all of your study material to get yourself ready for the USMLE. Now what?

The most common advice I hear students giving each other about what to do after they have completed reading their study material is, “Read over the material again.” But, is this really the best way to get ready for the USMLE? What is the added benefit of going over the same material repeatedly? Once the farmer has plowed the field, is there really much benefit in plowing it again, and again, and again?

The fact is, students re-read and re-read study material because they want to put the effort in to get ready for their exams and they do not know what else to do. The effort is admirable. The results, however, do not justify the efforts. Most of you will have noticed that no matter how many times you re-read the material, you still find you cannot remember crucial information when you need it on an exam. Each re-reading does refresh your memory, but then the memory gets lost again as you move on to other things.

Getting ready for your exam is not about doing the same things over and over. Rather, you need to change what you do as you gain more familiarity with the material and your level of understanding increases. Think about this as a two step process:

Step 1: Getting the information into your head. Reading the material gives you familiarity. You know you have seen it before; you can recognize it. At this stage you need to read over the content and think about what you are reading. The key here is attention, to actually focus on what you are reading rather than simply going through the motions.

Step 2: Being able to recall, and use the material when you need it. Getting the material into your head is one thing. Being able to get it out when you need it is another. The key here is to do something active with the material, and doing practice questions seems to provide an excellent means making this happen.

The difference between re-reading and following up reading with practice questions has been convincingly demonstrated by the  work of the psychologists Henry Roediger, Mark McDaniel and Kathleen McDermott. In a series of research studies they had some students spend extra study time re-reading material over again. At the same time they had other students spent their extra study time doing practice questions and getting feedback on how well they performed on those questions. When both groups of student given exams to test their retention days and weeks later, the student who spent time on practice questions after their initial time studying did significantly better. This trend of better retention, if anything, increased over time.

This important research confirms what the best students already know from personal experience. Re-reading the same material over and over produces nothing but diminishing returns for the time invested. Adding practice questions to your study routine after initial concentrated study over the material helps to increase both comprehension and retention. Questions are not magic, but they do guide you to move beyond rote re-reading to the focus on recall which is essential to produce top exam scores. Questions should make you THINK and move you beyond the rut of memorization.

Steven R. Daugherty, Ph.D.

ARE YOU SMART ENOUGH FOR THE USMLE?

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The USMLE is more than an exam. It is a test – a test of your ability, a test of your confidence, and test of your will. The exam is long. The knowledge to be mastered is vast. The chances for error are profound.

By sitting for the UMSLE, you confront reality. You may tell yourself how good you are, but without come external validation, how do you really know? In your dreams, you may see yourself as a great physician, but how real are those dreams? People you know may tell you that you have what it takes, but are they telling you the truth or just being kind?

Hope, dreams and confirmation from others all fade in the face of the cold, hard reality of your USMLE score. Your score is a fact, a clear detail that can not be changed or avoided.

The USMLE offers the promise of validation. If all works out well, your score is a credential you will carry with you all of your life. Once you get the score you are seeking, no one can take it away from you. When you doubt yourself, your USMLE score will remind you that in the face of a difficult challenge, you were able to face it and succeed. When you question your ability, your score gives you a firm fact on which to stand.

But, how do you know you are good enough before you take your exam? How do you know you have what it takes? How do you know you are smart enough for the task ahead? How do you know what is true?

The short answer is that before you face your exam, you do not know. Before events unfold, you simply do not know how they will turn out. The desire for assurance may be strong, but reality has a way of surprising us. Reality will emerge only within the exam itself.

This truth is hard for many students to accept. The wish to know your result before you take the exam is strong. Some students spend as much time assessing how they are doing as they do in actual study and preparation. Many become obsessed with their scores on practice questions. Increasing numbers of students take the full series of NBME exams. All of these efforts are attempts to glimpse the future, to seek certainty, to answer the question am I really good enough?

The danger here is that all of your efforts will be dissipated trying to find out how you are doing, and not enough will be left for the actual task of preparing for the exam. The obsession with your score on practice questions, endless comparisons of how you are doing compared with peers, the overwhelming desire for reassurance, all of these distract you from the main job at hand. Exam preparation is a process. Too much focus on the outcome and you fail to learn the fundamental concepts and techniques that are required for success.

Self-assessment if fine, but the hard work and struggle of study are what really move you toward your goal. Exam preparation is not about helping you feel good, but about facing up to what you do not know and taking concrete steps to fix those deficits. Acknowledging personal deficits can be hard. But, that hard reality offers a wonderful foundation on which to build real world success.

Are you good enough? The exam preparation process does not answer that question for you. You must know before you begin. Preparation for the USMLE exam will not, in general, help you feel better. If you are like most students, you will be shaken. You will look doubt squarely in the face. Preparation will chip away at your confidence, not bolster it. Every practice question you get wrong, every fact you can not recall makes you feel less confident and less secure. Getting ready for your exam will not tell you if you are good enough. You have to have sufficient confidence to begin the process in the first place.

Are you good enough? You must begin your exam preparation process with a resounding, “Yes!” Look at the facts. If you have made it this far, if you have completed all of the hurdles to just get to the place where you are allowed to take the USMLE, then of course you are good enough! Reflect for a moment how many people wish they could make it to the level you have already achieved. The medical education system does not let you get to the place where you are even able to register for the exam unless the evidence is overwhelming that you will succeed.

Start with the assumption of confidence. That confidence will give you the grit and endurance to do the preparation you need to do. Then, spend your preparation time doing the things that will get you your higher score.

As you prepare for the USMLE, you have a simple choice. You can act to bolster your confidence, or act to boost your score. Begin with confidence and focus on the learning that will move you to success.

  1. Study subjects where you are the weakest to make them better. Resist the temptation to read over what you like but already know.
  2. Questions you get right help you feel great, but do not help you improve. Forget your practice score and focus on going back and learning the content that the questions you miss tell you that you still need to master.
  3. Talk about what you are studying with others even if you do not know it well and are afraid that they will think you are stupid. Discovering those deficits by talking with others will motivate you to go back to your study material and be sure they are deficits no more.
  4. Organize the material you study in a way that makes sense to you. Rote memorization of what is in your review books may seem the obvious method of preparation, but it will not give you the sort of in-depth understanding to handle the problem-solving required on USMLE questions. The exam rewards thinking, not memorization.

The USMLE exists for you to show the world that you have what it takes. This is where you stand up to be counted. This is where you struggle with your doubts and win. This is where you show all the critics that they are wrong. This is where you silence the whispers in your head with an assertion of simple, quiet resolve. Are you good enough? Are you smart enough? Of course you are. This is your chance to show it. The USMLE is the moment when you convert your confidence into the reality of achievement. Because doing that, converting confidence into finding solutions, is what Doctors do.

Steven R. Daugherty, Ph.D.

EMOTION SETS YOU IN MOTION

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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.