The Answer You Like vs. The Best Answer

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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.

Timing IS Everything…

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“If only I had more time,” is a common lament of students as they walk out of the USMLE. The simple fact is the USMLE is a timed test. And time matters. No, time by itself does not determine your score. But the time limits that govern each exam provides a constraint that restricts your potential and lowers your score. Having the knowledge is not enough. You have to able to show what you know. And you can only show that which time allows.

Time provides a palpable physical constraint. You have only one hour for each block of questions. When time runs out, the question block is over and you are not allowed to finish it. If you do not get to a question, you will not gain the potential point that question would provide. A question that you never get to is one you will never get right. With more time to think, with more time to reflect, with more time to be sure you get to each and every question, your total score would certainly improve. But you do not have more time. Therefore, it is imperative that you learn to make efficient use of the time that you do have.

Making the most of every minute requires efficiency. Here are three tips to help you get the most out of your limited time:

  • Practice a question routine. Learn and practice a question answering routine before you take your exam. Develop a set behavioral routine in which you do the same steps with each and every question you encounter to reduce wasted effort. A practiced habit for answering questions will free you from focusing process and allow you more time to mentally absorb the question and think though the content issues you encounter. A practiced question routine means more questions covered in less time.
  • Spend the bulk of your time on the question stem. As you consider each question, spend the most time on the question stem where it will do you the most good. Each question can be seen as having two parts. The question stem, which presents material in a clinical case format, and the options, which list the available answer choices along with a corresponding letter. A good rule of thumb is that 75% of your time on any question should be spent reading and thinking about the question stem, and only 25% should be spent on the options. The key to each question in the question stem. Read it carefully, but only read it once. You do not have time to read the long question stems on the USMLE twice. Then, when you turn to the options, be decisive and make your choice.
  • Make yourself choose faster. If you find yourself chronically short of time, the best solution is to train yourself to choose faster. Do not short change your time reading the question stem. You need time to take in the information provided and to gather the clues provided. The way to gain more time for yourself is to make yourself pull the trigger, force yourself to make a choice as soon as you can. Research suggests that the time we spend on the question options can be divided into two parts. The first part we spend considering our choices and actually making our decision. The second part of the time we spend reconsidering, double checking, and doing other things to try to make ourselves more comfortable with the choice that we have really already made. This search for comfort does not improve answer, but simply wastes time. At this stage we are not seeking a better decision, rather we are feverishly trying to feel good about the decision we have already made. Train yourself to give up this search for comfort. Make your decision, live with it and move on!

Along with these physical constraints, time also provides a psychological distraction.  Just knowing that time is limited increases your anxiety and causes you to lose focus on the task at hand.  Every moment you spend thinking about the clock is a moment where you are not considering the questions before you on your exam. As the end of the block nears and the time grows ever shorter, actual panic can erupt.

How do you learn to deal with the distraction that time limits induce? The most basic solution is to make sure you do all of your practice questions under time constrains so you can become accustomed to the feeling of the seconds slipping away. The clock is always running. You can’t stop it. But you can get used to the feel of the time limits and learn to pace yourself accordingly. Time limits are most distracting when you as not used to them. Use your practice experiences to train yourself to see time limits not as an additional thing to worry about, but as a basic fact of life.

Time limits can not be discarded on the USMLE. They are real, and they matter. But, adequate preparation and practice can convert the terror of time into a simply part of your question answering routine. You can not slay the beast of time, but you can tame it. The question is simply, who will be the master? Will you learn to control your time, or will time control you? The right choice to this question is clear. By learning to control your time on your exam, you are learning to control your own destiny. And if you do that, then nothing, not even the pressure of time will keep you for achieving the success that you deserve.

The Question is the Problem

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What we find in life depends on what we are looking for. What we are looking for determines what will grab our attention. Nowhere is this more true than when taking the USMLE.

Many of those who have trouble with the USMLE are obsessed with “getting the right answer”. This focus is misplaced. An excessive focus on the answer misses an essential point. The key to getting the right answer is to be found in the question. The question stem presents the essential problem that you are called upon to solve, and gives you all the necessary information to solve that problem. In short, the question stem, not the options are the key to the exam.

Think of each item on the exam, not as a question to be answered, but as a problem to be solved. You are looking, not so much for an answer, as a solution. The correct mental headset for the exam is not a student trying to please an imagined professor by giving the correct answer, but a physician trying to resolve the problem presented by a patient. Sometimes you can solve the patient’s problem because you have seen it before. More commonly, you will need to think though the information presented to derive a solution that you may never have considered before.

You can look at every option and understand every detail they provide, but unless you have gathered the appropriate clues from the question stem, you will not get the question correct. Trying to answer the question without first collecting the available clues is like shooting at a target without first taking aim.

Learn to recognize your true friends and allies during the exam. The options are the enemy. The question is your friend. The purpose of the options is to fool you, to con you, to trick you into picking the wrong answer. The question stem is your ally. Only the question stem offers the key details you need to separate the wheat from the chaff and bring the best answer into clear focus.

The source of our obsession with the answers stems from our emotional response to the exam situation. Questions are aversive stimuli. We do not like questions and want to get past each one as soon as we can. In our heads our emotions scream for us to pick an answer, to get out, to escape the pain of the question. The problem is that our emotional instincts urging escape cause us to pick an option simply to exit the question, rather than have the patience to figure out the right answer. Questions are pain. Preparing for the USMLE is in part about learning to tolerate the pain of the question long enough to do the mental processes required sort out the best of the presented options.

Success comes from learning to love the question. Dive in and revel in the presented case. Read carefully. Collect the clues. Think about the problem before you. And then select the option that offers the best chance of providing a solution. Mastering this sequence is the ladder that leads to a great score and a successful exam performance.

The real challenge on the USMLE is not coming up with the correct answer, but understanding what the issues presented in the question. USMLE questions do not just ask you something, they also give you the clues you need to come converge on the best answer. Success goes, not to those who can guess the best, but to those who have the patience and mental discipline to collect the presented clues, identify the essential problem, and then reason though to the best possible solution. Look to the question and the answer will come to you. Once you fully understand the problem presented by the question stem, choosing the best answer is the easy part.

Steven R. Daugherty, Ph.D.

Combining Content in Context

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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.

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

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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.

MAKING YOURSELF CHOOSE

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In the face of uncertainty we do not want to choose. Our rational side wants to postpone the decision until we know more. Our emotional side wants to avoid the decision all together to escape anxiety that uncertainly inevitably brings.

Decision-making on the USMLE is different than medical decision making in the real world. Medical practice demands you to be as certain as you can be. If you need more information, get it. If you need a consult, seek one out. If you make a bad decision in medial practice, you could kill someone, or at least cause avoidable pain and suffering. “Be sure,” your professors and mentors have told you from the first day of medical school. Being sure is the right way to practice medicine.

Being sure is the wrong way to take the USMLE. You simply do not have the time to gain the level of certainty you would like to have. The clock is ticking continually and decisions must be made. To make it through the exam, you have to be able to select an option in spite of the uncertainty you feel. Spending a lot of time on one question until you are certain as to the answer, means that you will not have time to even consider other questions down the road. Your choice is clear: either spending the time to achieve certainty on some questions, but never getting to others, or, learning to make your choices quicker, with less certainty on all questions. Getting to all the questions is your best strategy.

We decide before we are comfortable with our choice. You learn to make quicker decisions by giving up the search for comfort and moving ahead. Part of the time you spend selecting an answer involves cognitive processing of the presented information. At some point in this process, a decision is made. The time you spend on the question after that will not help you make a better decision, but will simply make you more comfortable with the decision you have already made. Although at first blush, simply deciding faster may seem a terrible approach, the reality is that giving up the search for comfort saves a lot of time on each question.

Learn to force a choice even when you are not sure. Answering questions on the USMLE requires that you keep making choices even when you are uncertain. In fact, USMLE questions usually require not one, but a series of choices. You must not merely decide on the answer to be chosen, but must make a sequence of small choices that will lead you to that final answer.

The USMLE requires you to choose, and then keep choosing until you have solved the presented problem. Expect, on average, that three correct decisions will be required to get you to the point where you can select the best answer. This means that USMLE questions require you to not only choose in the face of uncertainty, but to keep on choosing, piling one uncertain decision on top of the next.

Acclimation to this mental headset takes time and practice. Of all the mental hurdles that need to be overcome to excel on the USMLE, none are as daunting as changing the way you make decisions. You must learn to change the very way you make decisions. Learn to choose even when you are not sure. Learn to decide, and then keep making decisions even in the face of uncertainty.

Doing practice questions is not just a way to test your knowledge. Practice questions also provide a way for you to learn this new decision process. So, always do your practice questions with a clock. Only use fresh questions you have not seen before. Yes, taking time will give you a better practice score, but will not get you ready for the real exam. Getting good at deciding in the face of uncertainty is an essential skill for mastering the USMLE.

Steven R. Daugherty, Ph.D.

HOW TO READ A USMLE QUESTION

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Along with expanding your knowledge as you prepare for your exam, you should also take some time to improve you question-answering skills. The basic skills for answering multiple-choice questions are not difficult to describe, but require practice to master.  When confronting an exam question your main tasks are: read the question accurately, think as you are reading the question, and force yourself to make a choice among the options provided.  Of these tasks, learning to think as you read the question requires the most practice.

Each test question is composed of two parts: the Question Stem and the Answer Options.  Most students feel the urge to get to the answer options as soon as possible.  This is understandable. Questions are “aversive stimuli.” They invoke negative emotional reactions such as uncertainty and anxiety.  To avoid these emotions most people want to get rid of each question as soon as possible.  Answer options represent escape, and thus the route to feeling better.  The problem is, in your haste to get rid of the question, you may settle for any option rather than searching for the best option.

The answer to each question is to be found in the question stem, not in the options.  For the USMLE, every option seems reasonable.  Looking at the options is often more a source of confusion than clarity.  There are few clues in the options to help you choose among them.  The information you need to make a choice is in the question stem, and that is where the majority of your time and attention should be spent.

Every question on any USMLE is answerable by an expert in the field with no options presented.  So first, try answering the question without reference to the options at all.  To train yourself to do this, take a piece of paper and cover the options so you cannot see them.  Then read through the question.  Start at the first line, paying careful attention to the important demographic information it will often contain.  When you come to the end of the first sentence, stop briefly, and tell yourself what you think is going on. Call to mind pertinent knowledge.  Tell yourself where you think the question is going.  And then, with these thoughts in hand, read the next sentence of the question.  Continue this process until you have read the whole question stem, stopping at every period to tell yourself what is happening in the question.

This technique prods you to think and not merely to read without comprehension.  When you get to the end of the question stem you will find the actual question you are to answer.  If you have read the information provided for you in the question stem, you should now have a reasonable guess as to what the answer should be.  Now, and only now, take a look at the options provided.  By first focusing on the question stem, you should now be fully equipped to select an option that has a high probability of being the best of those presented.

USMLE items are not so much questions to be answered as problems to be solved.  The correct process for handling each question is not Read, then Answer, but Read, Think, Answer.  Training yourself to focus on the question is really a process of training yourself to think.  Your best score will come from practicing this simple sequence until your cognitive desire for the best answer can overcome your emotion desire to escape.

Steven R. Daugherty, Ph.D.