Memorization Is Not Enough

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. 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.

Combining Content in Context

The thought processes required on the USMLE are different than those required on most medical school exams. The content you need to know is the same. But the way you need to think about that content, and how you will use that content in your exam, requires some mental reprogramming.

On medical school exams, recognition and paired association are the keys. A typical exam item presents a concept in the question stem and asks you to select the proper association from the presented choices. If you have studied sufficiently so that seeing a particular symptom reminds you of a disease diagnosis, or seeing a particular disease reminds you of the commonly used pharmacology, you will get the question correct. When you see “butterfly rash: you think “Lupus”.

You train yourself for these association questions by repeated exposure and memorization—going over the pairs and patterns over and over until you are programmed with the appropriate responses. In essence, questions on medical school exams are mostly are free association exercises. You get them right when you have trained yourself to have the associations your professors want you to have. As long as your associations are those of the faculty, you will do very, very well. You prove to the professor that you have mastered the required content by giving the required responses.

The USMLE wants more out of you. For the most part USMLE questions writers assume that you already possess the basic mental associations. They assume that the medical school has done its job. Their task is to see if you are ready for the next level. USMLE questions are not aimed at what you know, but are framed to see if you can apply what you know in a series of presented problem scenarios. Knowing is not enough, you have to be able to DO SOMETHING with your knowledge.

Few physicians would argue with this goal. The job of the medical practitioner is not to serve as a human reference book, but to make decisions, to take actions based on what they observe combined with what they know. This is what the USMLE tests: how you take in information and how you are able to reason with the information you collect.

Context is the key to understanding the information presented to you in a USMLE question. Particular facts mean different things in different circumstances. Meaning comes as much from surrounding data as from the presented detail itself. Fatigue, reported by a patient, may be an important symptom or merely the result of too little sleep. The meaning rests with the full set of symptoms and life circumstances presented. Single symptoms are ambiguous. Context provides the pieces to let you see the essential presented patterns. 

Start with the characteristics of the presented patient. What is the age? Gender? Region of the country? Occupation? All of these things make certain answers more or less likely. Putting this information together with other facts in the question stem along with your own medical knowledge will give you a better shot at the best answer than focusing on some special detail which catches your eye.

Combination is the key process for the problem-solving required on USMLE questions. You must combine the context and the information presented in the question with the knowlwdge in your own head. The patterns you see plus the patterns you remember give you the insight to reason though to the best answer. If the question presents a symptom constellation, you must have the knowledge in you head to recognize the disease that this signifies. Recognizing a pattern in the question, but not remembering what it signifies means that you will not get the question correct.

Answer each USMLE question by first deciding, “What is given in the question?” and the deciding, “How does that relate to what you know?” This process, not simple association is the solution you seek. Content and combination result in the clarity you need to pick the best answer.

Steven R. Daugherty, Ph.D.