Combining Content in Context: USMLE thinking


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.

Combination is the key process for the problem-solving required on USMLE questions. You must combine the information presented in the question with the information 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.

A detailed walk thought this process can be found in an article I posted in cooperation with Dr. Philip Tisdall on Look under the heading “Handling USMLE Questions.” Learning the mental steps to understanding USMLE questions is as important as mastering content details.

Steven R. Daugherty, Ph.D.

Judgment and Choices: On Becoming a Physician


Students excel by memorizing information and being able to recall that information in the right circumstance. The best students are the ones who can remember the most facts. On a multiple-choice exam, students make their choices based on what they can remember.

Physicians excel based on their judgment and their capacity to make the right choices in complex situations. Although physicians must have a solid knowledge base, the best physicians are those that can apply that knowledge in appropriate ways and circumstances. On a multiple-choice exam, physicians make their choices based on the application of their best judgment.

This capacity for judgment is what separates a student from a physician. This capacity for judgment is also what separates high USMLE scores from low ones. Seen simplistically, USMLE questions are actually different based on whether you read them with the expectations of a student or the perspective of a physician. For students, the essential theme for each question is, “What do I remember?” For a physician, the essential theme for each question is, “What is going on here?” The student, above all, seeks an answer. The physician, at his best, seeks a clear understanding of the presented problem. A student knows because he remembers; a physician knows because he reaches a conclusion.

Getting that top USMLE score depends on changing your thinking from that of a student, to that of a physician. The sooner you make this mental transition, the easier your USMLE experience will be and the better your results. So how does one make this transition?

Every physician begins as a student. You must first master the core content knowledge. But while students stop there, physicians go one step further. The transition to being a physician comes at the point where knowledge is, for the most part assumed, and the challenge shifts to the understanding of how to use that knowledge in the situation at hand. This means an ever more critical focus on the details of the situation and the application of judgment to determine the best course of action. The question, not the answer choices becomes the main focus. By carefully digesting the key elements of the question, the problem to be solved becomes clear and the right answer, obvious.

If you find your scores on practice questions stuck in the 50% to 60% range, then you are stuck thinking like a student and need to master the art of clinical reasoning. Clinical reasoning begins by recognizing that not everything matters, but some things are critical. You need to make the transition from trying to grab on to every detail to the point where you have the judgment to know the details which make the difference.

Here are some simple techniques you may find useful to help you with this transition:

  1. Practice honing your judgment by being clear why something matters. When studying, tell yourself why each fact is relevant and in what circumstances it might be of value. Keep asking yourself, “So what?” or “Why does this matter?” If you can’t answer the question, then the content is likely too esoteric to matter for the USMLE.
  2. Put together a short lecture on some content with which you are struggling. Nothing organizes your understanding better then having to talk about it.
  3. Write some questions. Not the simple recall questions, but the longer USMLE clinical case items. By thinking about what to include, or leave out of your questions, you are helping yourself focus on the details that matter.
  4. After answering a question, go back over the content and tell yourself how you would need to change the question to make every one of the options correct.

Judgment is not the same as memorization. There is a big difference between knowing what a hammer is, and knowing the right occasions for using one. Work on your knowledge base, and then, work on using that knowledge. The transition from student to physician is one of the most important moments of your career. Remember, the USMLE is not testing if you are a good student, but if you will be a good physician.

Steven R. Daugherty, Ph.D.