The Answer You Like vs. The Best Answer


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 holds 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.

Answering from Fear vs. Answering from Confidence


Emotions are the motive force that guides our actions. What we feel has an awful lot to do with what we do. And in few places is this as true as when answering questions on the USMLE.

For some people the looming exam evokes fear. “How will I be judged?” “Am I up to the task?” “What if I fail?” For others the coming of the USMLE is a challenge that energizes. “Here is the chance to show what I have learned.” “This is the forum in which I will show myself and the world that I deserve to be a physician.”

Many people preach that the goal of the student during the exam should be to be calm and as emotionless as possible. Many people will tell you that during the exam, emotions are a stumbling block. Nothing could be further from the truth. The fact is that the exam will evoke strong emotions. Making the best use of your emotional reactions to the exam has a great deal to do with your final outcome.

Strong emotions are not bad. Emotions serve as the gateway to the cognitive processes demanded by the exam. The right emotional set lays the foundation for optimal cognitive processes. Emotions are the physiological backdrop within which our thoughts and mental processing occur. To do your best you do not want to be emotion free. Rather, make it your goal to harness those emotions you feel. Emotions provide the energy to keep you going when you are tired and to maintain your focus when you are distracted.

All decisions are emotional. Without emotion no decision would ever get made. The key to successful decisions is not a lack of passion, but having the right emotional basis by which cognitive decision-making can proceed. Doing well on the exam is not just about knowing, but more fundamentally, about being able to act, to make decisions. Answering the each presented question requires you to break free from the mere facts to the level where you understand what is being presented, what is most important and, therefore, what must be done.

Think about your preparation for the USMLE as essentially a contest between fear and confidence.

Fear is aversive. We don’t like fear and usually act to get rid of the feeling as quickly as we can. Because fear is aversive, it leads to thoughts of escape. In the face of fear we do not want to engage and solve, but disengage and run. Fear causes us to make impulsive choices to feel better, not thoughtful decisions which stand the test of time. Fear drives us to act, but drive out rational cognitive analysis at the same time. Driven by fear, we seek to get an answer in order to get rid of the question. And our whole motive changes from getting the great score to simply getting rid of the bad feeling.

Confidence is positive. Confidence has us jumping into the problem with the anticipation that we can handle whatever is presented. When we are confident a problem is not a burden, but something which energizes us as we seek to understand and to master. From this perspective, each question becomes a challenge. And our goal is transformed from avoidance to one of mastery. Confidence gives us a solid emotional platform on which we can build with our recollections and thoughts. Confidence takes the first step to success by assuming that we will succeed.

The difference between fear and confidence rests with a simple thought. If you think you can handle the exam, you are confident. If you think you can not, you will be afraid. Please note that which ever stance you take is not based on rationality, but on what you assess reality to be.

Can you handle this exam? The fact is that of course you can. You would not have made it this far in your career if you lacked the capacity. Perhaps you have not done everything right or perfectly you entire career. That does not matter. No one expects perfection. All anyone expect is for you to be the physician you are. A physician does not walk into the examination room with fear and trepidation, but with confidence. Each patient is not a problem. The patient is your job. Tending to the patient is you calling.

How do you get to confidence? What makes the difference between the disruption of fear and the energy surge of confidence?  It’s all about preparation. Confidence does not come from simply reading the content, but from doing things with it. Confidence is born in the flash of insight, in the ability to face something new and figure it out.

When you are well prepared, you are confident. When you are not well prepared, you fear. It’s really as simple as that. Put in the time learning to think and not just memorize and you will no longer fear the outcome, but rise to the challenge. That is the confidence that leads to success.

Steven R. Daugherty, Ph.D.

The Right Motives Give the Best Results


Preparation for the USMLE requires persistent effort over time. Success depends on your ability to sustain that effort. So, as you prepare for your exam: What motivates you?  What keeps you going when thing seem hard? What sustains your effort over weeks and months?

The answer, in all likelihood, is that you are motivated by more than one thing. Some simply want to move through the process as quickly as possible. Others want the bragging rights which come from getting the highest possible score. Others want to show family and friends that they have the “right stuff”. Still others just want to avoid the embarrassment of failure.

Motives are what move us. What get us out of bed in the morning and keep us going through the long day. Motives are the driving forces that make it possible for us to put in the day, weeks, and months of efforts required for USMLE preparation.

Stripped of all jargon, there are two basic types of motives: Motives to get something and motives to avoid something. Both can be powerful forces that get us started and keep us going. But, while both can be useful, each carries with it a hidden danger.

Common USMLE Preparation Motives

Motive #1 Getting the Score

For some people, the USMLE score is everything. Getting a top score is the brass ring, the key and ultimate reward at the end of all the effort. Getting a top USMLE score is a solid, empirical measure of achievement that certainly makes getting a coveted residency position easier.

The danger here, however, is that a focus on the score will blind you to what you need to do to get there. Like someone single-mindedly concentrating on a destination, you are in danger of missing the twists and turns that make up the journey. Too obsessive a focus on the ends may lead you to not complete the process which gets you there. At the end of the day, it is the score which matters most, but having the right preparation process is what carries you to that ultimate success.

Getting a top score is a good dream. Just make sure you make the right moves to get you there. Wishing alone does not make it so.

Motive #2 Getting the Knowledge

Knowledge is the foundation of medical practice. Without the proper insight and understanding about the human body, disease processes, and the body’s responses to those diseases, a physician confronted with illness is simply guessing. Knowledge is what separates the physician from the non-physician, and the expert physician from the neophyte.

One of the great benefits of USMLE preparation is the chance to go back over previously learned material and come to a fresh understanding. Done correctly, you emerge from the process with an understanding beyond simple memorization. Done correctly, you walk into your exam with a clear sense, not only of what makes a good answer, but why it must be so. The flash of insight, the rush of comprehension, the thrill of understanding what was unclear before, can be a powerful motivator to keep pushing onward with exam preparation.

However, students driven by their own quest for knowledge and their own excitement at emerging insights is in danger of losing sight of the specific requirements of the USMLE. At the end of the day you will take and exam. You will not be judged by your knowledge and insights alone, but by your capacity to offer correct answers to the presented exam questions. Knowledge and insights give you the raw materials for this task, but to not carry you directly to the essential goal of getting that exam score.

In short, focusing on getting the knowledge, while it gives you the means to succeed, may cause you to lose sight of the essential endpoint of the process: getting that higher exam score. The danger is that you will become enamored with the journey itself and become lost on a journey without end, never to arrive at the final goal you must be seeking.

Motive #3 Avoiding Failure

Nobody wants to fail. The experience of failure is singularly unpleasant and calls in to question all of our past successes. Maybe failure is the reality and all of our past successes are the illusion. Maybe, as we have always feared, we are indeed, not ready for the tasks we face.

The fear of failure can be a powerful motive. When we are tired, it causes us to reach inward and give that extra effort. When we get distracted, it serves like a rudder to guide our attention back to the task at hand.

Fear is, however, a force that tells us what to avoid, not what to do. Fear, without direction quickly devolves into anxiety. Fear of failure grabs our attention, but risks paralyzing us at the same time. At its worst, the fear of failure becomes so great that we give up and do not even try. Better to fail because we did not try than to give it all we have and still fail!

In my experience, trying simply to avoid failure is a recipe for disaster on the USMLE. Fear is a good way to get started in your process. But if you are to succeed, you have to know what you are seeking, not just what you are hopping to avoid. To get to success, you have to face you fear and leave it behind.

Motive #4 Avoiding looking or feeling stupid

Who wants to looks stupid in front of friends or colleagues? Don’t we want our teachers and our parents to regard us as intelligent? What if, the spotlight of the USMLE shows this to not be true? What if we just are not smart enough and do not have what it takes?

And it is not only others. We want to see ourselves as smart. We want the face in the mirror that looks back at us each day to be intelligent, savvy, and successful.

So, we work hard to show that we have what it takes. We spend long hours with our books so that we will have the answers when our professors ask. We stay up late into the night so we will never have to face our parents and tell them we just did not know. Wanting to avoid looking and feeling, stupid and inadequate can be a strong, driving motive in our lives.

It can also encourage us to lie, to others and to ourselves.  To avoid the appearance of being stupid, we do not talk in class. We avoid discussions with colleague who we think know more than we do. We repeatedly re-read what we already know and avoid what confuses us so we can feel the sense of, “I have this.” We avoid practice exams that may result in scores below our and others expectations. We do practice questions we have looked at before to get that better practice score.

Seeking to avoid looking stupid encourages us to focus on how we look, not on what is real. Our study becomes driven by managing impressions, not by getting results. We hide from the light of reality as long as possible.

But we can not hide forever. Sooner or later, we have to face the harsh spotlight offered by the USMLE. In that light, the shadows of perception disappear, and we are left with the reality of a clear empirical result. Playing for image is no more than playing for time. Sooner or later reality always catches up with us.

To get to success, you have to accept the reality that you do not know things and then take action to change that. Image management is easy, but short term and fleeting. Let yourself look stupid. It is the first step to making a new reality where that is no longer true. You do not know everything. Your time and effort preparing for the USMLE are your commitment to changing that.

Seek to Win, Don’t Just Avoid.

The bottom line is that no one motive gets you where you want to be. In general, positive motives, seeking something (a score or knowledge) are better than negative motives (avoiding shame or failure). Positive motives tell you where you are going while negative motives merely tell you where you do not want to go. Avoiding pitfalls is critical, but having a goal and a vision that will sustain you throughout the preparation process is the more likely road to success.

Steven R. Daugherty, Ph.D.

Who is in Charge on Your Exam?


Who is in charge when you take you exam?  Do you control you exam, or does the exam control you?

The USMLE is not only testing your content knowledge, but also your ability to problem-solve on your feet. In spite of distractions, are you able to contain your anxiety and focus on the pertinent issues before you? Do you approach each question with a confident curiosity? Or are you hoping that things will be easy; that you have seen the problem before; that you will get lucky and see a question focused on content you recently studied? Do you approach each question with quiet confidence or uneasy hope?

Success on the USMLE depends on identifying issues and thinking clearly. Yes, you must have memorized essential content. But, the exam wants more from you than a demonstration of what you have memorized. The exam wants you to show that you know how to use what you have learned.

To accomplish this you must be more than a recoding and playback device. You must be more than a machine. You must be a person who can assess, think and decide. In short, you are being tested on who you are as much as what you know. The USMLE expects you to be in control of yourself and to demonstrate that by your control of the exam.

Gaining the control you need for the exam begins with your preparation strategy. In the long process of exam preparation it is easy to lose perspective. Over the course of weeks and months it is easy to feel overwhelmed and buried under the material you must master. Once lost, you feel like you are playing catch-up, and you never quite catch up. To avoid playing continual catch-up, take charge of your USMLE preparation from the very beginning.

Begin by making decisions and taking action based on those decisions. Decide what is essential and what is lower yield. Decide what study material resonates with you and helps the content to make coherent sense. And then, plan your study to cover the material you have selected. Avoid the temptation of asking everybody else what you should do. Yes, listen to advice, but then make your own decisions as to what works for you. Be especially skeptical of advice from parents and family members who do not have first-hand knowledge of the USMLE. Family usually advises you to work hard and spend long hours at study, but they rarely can give you the critical insight about what to do with that study time.

You have to live with your exam results, so you need to take responsibility for deciding how you should proceed. Make a study plan that maps our how much time you will study each day, and then follow it! Avoid studying “every waking minute.” Treat study time like a job. Put in your time, mentally clock out at the end of the day and give yourself a chance to rest each evening. Tomorrow you must get up and do it all again. Make sure your strategy is one you can maintain long term, not just over a couple of days.

When your study turns to questions, stay in charge by avoiding excessive focus on you percentage correct. Each question is a chance to test what you know and how you think. If you get a question right, congratulate yourself on your progress. But never forget that it is the questions you get wrong that will really improve your performance on the actual USMLE. When you get a question wrong you have uncovered a deficit. Use this knowledge by taking direct action to resolve the deficit. Diagnose why you missed the question. Was it because you missed something when reading the question or because you did not know the content? If you missed something when reading, pay attention to what you miss and you will discover patterns of errors you can correct. If you did not know the content, go back to your study material and go over it again.

Don’t just react to questions, act on them. Don’t simply feel good or bad about your question results. Make use of the information you have gained and do something about it!

By making decisions all the way though your study preparation, you are not only going to do a better job of learning, you will also be teaching yourself the mental set and the self control the USMLE requires. You know how to take charge because you have learned to take change of yourself. We want doctors who have the self-control and the aplomb to handle whatever patient care issues with which they are confronted. Your final USMLE score is a much a reflection of you control of the exam as it is your memorized knowledge. Take charge of your preparation and you will take charge of your exam.

Steven R. Daugherty, Ph.D.

Hope Is Not a Strategy!


Believing that you will succeed is the first step in making it so. You need to believe that you can do something if you are ever going to give it your best effort. The power of positive thinking gives you the momentum to deal with the most difficult challenges in life. Hope keeps us going, and gives us the confidence to see a task through.

But a positive attitude, by itself, is not enough. Simply wanting something does not make it happen. Success comes from using that confidence in the plans we make and the actions we take. Success does not come to those who wish for it, but to those who work for it.

No where is this more true that as you prepare for your USMLE. Confidence, by itself, will not carry you through and can even be a dangerous trap. When you feel confident, you are less motivated to focus on details and to do the kind of new learning which optimum performance demands. Confidence that gives you the energy and stamina to face the hard task and do the job is good. Confidence that makes you decide that you do not have to do much to get ready is bad. Some students wrap themselves in a positive attitude as a way of warding off the anxiety that actually engaging the study material can bring. “I don’t really need to study,” they say, and so they never actually review core material to find out that they have deficiencies. The question is simple: Is confidence a motivator that pushes you to achieve or a shelter where you will hide from your fears?

Success requires more than a positive attitude. Hope is not a strategy. Wishing is not a plan. Most of the people who take the USMLE are as smart and intelligent as you are. Preparation and effort are the only things that will give you an edge in this competition. Confidence only matters when it is based on a realistic foundation of learning, study, and practice.

Realistic preparation depends on facing your fears and targeting your deficiencies. The best exam preparation does not treat all material as the same, but allows you to focus on the topics and concepts on which you need the most help. Yes, you have to review everything, but some things, the things you are weakest in, will require more time and other things, the things you know better, will require proportionally less time.

Although it is tempting to simply study a certain number of pages, or do a set number of practice questions each day, this rote routine is inefficient. You must allow variation in your process. Some days you will find the material harder and need to spend more time on content study. Other days you will find the material easier and may spend more time answering and reviewing questions. A positive attitude gives you the confidence to make these day to day choices. Sometimes in the midst of your study you talk to a friend who is using a different set of study resources or a different study technique. Confidence in your own process allows you to maintain a focus on your own process and not be distracted by what others are doing.

 The power of positive thinking is the power to succeed. By making a clear study plan and sticking to it, you can harness that power to propel you to your goal. Believe that you will succeed, but also believe that your own efforts are a key part of that eventual success. Confidence, by itself does not win, but does help those who help themselves.

Making the Most of your Worst Subject


We all enjoy spending time with the people we like, and try to avoid even seeing the people who make us uncomfortable. Good friends, the people who make us feel good, are one of the prime joys of life. And who needs anxiety? Is not avoiding those people who make us feel bad a sign of good mental health?

Unfortunately, this good, even instinctive, strategy for enjoying life is a disaster when applied to how you allocate your time when preparing for the USMLE. The pleasure you get from USMLE preparation is not from the experience itself. Preparation is hard work. Rather, your real satisfaction will come from the score you achieve at the end of the process. Let me repeat, the process is not fun (at least for most people), but the feeling you will get when you are told about your superior score will more than make up for the deprivation you put up with.

Successful preparation for the USMLE, therefore, begins with answering a simple question, “Can you endure short-term discomfort in order to achieve ultimate success?” Are you able to defer your gratification? Can you live with the anxiety and uncertainty of facing up to what you do not know and correcting the deficits you find? If the answer to these questions is a resounding “Yes”, then you are ready to begin the labor of study which will bring you ultimate prize. If your answer is “No”, then no amount of resolve or commitment will see you though to the end.

So, if you are ready, where do you begin? Many people think that USMLE preparation requires simply doing more and more practice questions. As I have pointed out in previous postings, practice questions test you and tell you where you are, but they do not teach you and make you better. Learning comes from study, not from questions. We tend to like questions because they are, well, more fun than studying. The mental challenge of deriving an answer is simply more engaging to most people than the routines of rote study. In addition, questions are “bite-sized”, presenting us with a defined cognitive task and freeing us from the vertigo we feel when confronted with the mass of information the USMLE requires. A question just feels more manageable than the bulky weight of study material.

Study is the core of your preparation and the foundation of your eventual success. Only by concentrated effort of reading and understanding can you absorb the basic facts at the core of the USMLE questions. Without this knowledge in you head, no amount of question expertise will help you. Faculty can help you by explaining what is unclear and indicating what is most important, but the actual work of making the knowledge your own must be done on your own.

You get the most out of this study time by focusing on the subject matter where you are weakest. If we are honest, all of us have some subject, or at least some subject area where our mastery is less than complete. We know we are not good in this subject. This sense of not measuring up makes us feel uncomfortable. To avoid the bad feelings, we often simply avoid the subject. And so, the weak area continues to be weak. Some people even take on a subject are weakness as a self-defining characteristic. It becomes a part of the label of who we are, “I’m just not good in…”

The point to USMLE preparation is not just to perpetuate these weaknesses, but to fix them. Rather than accept that you are not “good” in a certain subject, now is the time to change that. USMLE preparation grants you the unique opportunity to elevate yourself, to take a step up from the knowledge you acquired in medical school to a broader, more integrated comprehension of basic science and clinical knowledge.

So, organize your study time to give extra attention to those weak subject areas. You will not like it. You will feel anxiety as you face your deficits. But, this is simply the best way to reap the rewards of a superior score at the end of the process. Start your study time with your worst subject, and then look at it again just before the exam as added reinforcement. Or to really master the subject, spend ½ an hour every day on it in addition to whatever else you are studying. Don’t run away from your weak areas, embrace them. Meet your weaknesses head on.

USMLE is about problem-solving. But, if you can not call the basic facts to mind, is you do not have the knowledge you need to apply to answer the question, even the mostly finely-honed reasoning skills will be to no avail. Without a usable grasp of the basic knowledge, you will fail. Organize your time so you can focus most on the area where you are the weakest, and you will discover during the exam that you have the facts you need to solve the UMSLE questions you encounter. Rather than your worst enemy, you fill find that you have converted the subject you hate into your best friend.

Steven R. Daugherty, Ph.D.



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.



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.



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.



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.