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.