Questions are the heart and soul of the USMLE. Getting ready for the exam means doing questions as practice to prepare for the questions that count on exam day. Although questions are the target at the end of your preparation process, doing practice questions will not, by itself, get you ready for that big day of the exam.

Doing well on these exam questions requires two things: 1) a sufficient fund of knowledge and 2) a well-honed technique for dealing efficiently with the presented questions of the exam. Just doing as many practice questions as possible will not give you either of these two. Successful preparation depends on the adept blending of activities, not simply doing a lot of one thing. And doing each stage of preparation well, matters much more than how much time you spend preparing.

Doing questions will not give you the fund of knowledge that you need. But using the insight you gain while doing questions can guide you to the knowledge that you need to learn. Questions do not teach you. Questions test you. Questions tell you what you know and do not know. Your job is to take this insight and act on it.

Most practice questions of any merit come with annotated answers. In the best instances, these annotated answers tell you both why the right answer is best, and also why the other options are inferior. Reviewing the annotated answers should help you to grasp the key features and essential logic of the question. This is truly valuable information. But your exam preparation requires more than the nuggets of knowledge embedded in these annotations.

Question annotations give you little bits, atoms, of knowledge. The problem is that each little piece of knowledge floats around free, without any linkage to other important content. Annotations help you learn the knowledge important to the questions, but not how to use that knowledge in a broader context.

To achieve the level of understanding the USMLE demands, your knowledge must not be in atoms, but molecules. Facts must have context. Details must be associated with key ideas. Each individual piece must fit together to reveal the larger patterns. Questions annotations give you the pieces, but do not help you see how the pieces fit together into the frame of a larger puzzle.

To gain this larger perspective, after reading the annotated answer you must open you content study material to the topic featured in the questions and review the content in context once more. If you do not know the content, go back and look at it again. By going back to your basic study material, you will have the chance, not only to learn the specific points tested in the questions, but also related issues which will embed the question in your larger framework of knowledge.

Doing large numbers of questions will not teach you do to questions well. The trick is to learn to do questions well, before you do a lot of questions. If your technique for reading and answering questions is flawed, then doing a lot of questions will simply reinforce these bad habits. You will become highly skilled at bad question answering behavior.

Start doing practice questions slowly. Initially, work on having the right process, and don’t worry so much about whether you get the questions right or wrong. At the start, it is more important that you learn to do the questions the right way than if you select the right answer. When the proper questions answering technique has become a comfortable habit, then, and only then, should you ratchet up the number of questions that you do each day. Once you have the proper technique, practicing it more and more questions will make this good habit second nature. And when you questions habits are second nature, then your mind is free to focus on the content issues of the question.

Doing practice questions is essential and annotated answers are great. But, successful USMLE preparation requires more than these simple resources. Do not neglect the hard work of content study, and learn to do questions right before you do them in volume.

Steven R. Daugherty, Ph.D.

You Can’t Know Everything!


The key to successful exam preparation lies not in what you study, but in what you choose to ignore.

 Ever approach a faculty member in medical school with a thick book in your hand and ask them what are the most important things to know in the book?  Often the response from the faculty is that you must know, “Everything!” No only is that answer not very helpful, it is not true. 

 If you try to learn everything—every little detail, every little fact, you will not succeed, there is simply too much material to master in too short an amount of time.  The fact is if you try to learn everything, you will not succeed.  Instead, you will end up with gaps in your knowledge. The problem is that these gaps will be essentially random.  A better system is to use the guidance of your faculty and your own native intelligence to decide what is most important and what is not and to concentrate your efforts accordingly.  This way the gaps in your knowledge are of your own choosing, based on your assessment of what is more or less important.

Divide all material that you study into three categories:  1) What you must know, 2) What you ought to know, and 3) What it would be nice if you knew.  Then, orient your study accordingly.  Spend the most time on the “must”, then move on to the “ought”, and finally time on the “nice to know” if you have the time.  Your goal is not to learn all the trees in the forest, but to come to an understanding of how the forest fits together. 

 If you have difficulty deciding what is more or less essential, try this:  Give yourself 15 to 20 minutes to study a section of content.  At the end of that time, but you notes away, stand up and give a short lecture on what you just read.  You will find that in order to give a lecture, you will have to make some decisions.  What is essential and you must mention and what, although important, is less essential.

 If you have trouble making these decisions on your own, that is what faculty are for.  In live lecture courses or on the internet, faculty will guide you through the peaks and valleys of the material, helping you to separate the essential from the merely interesting.  Remember, no one cares what you know if it is not on the test.  Doing well is not about knowing everything, but rest on knowing the right things.

Steven R. Daugherty, Ph.D.

The Answer You Like vs. The Answer that is “Best”


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 hold 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.