BEYOND ANNOTATED ANSWERS: GETTING THE BIGGER PICTURE

Questions are the heart and soul of the USMLE. Getting ready for the exam means doing questions as practice to prepare for the questions that count on exam day. Although questions are the target at the end of your preparation process, doing practice questions will not, by itself, get you ready for that big day of the exam.

Doing well on these exam questions requires two things: 1) a sufficient fund of knowledge and 2) a well-honed technique for dealing efficiently with the presented questions of the exam. Just doing as many practice questions as possible will not give you either of these two. Successful preparation depends on the adept blending of activities, not simply doing a lot of one thing. And doing each stage of preparation well, matters much more than how much time you spend preparing.

Doing questions will not give you the fund of knowledge that you need. But using the insight you gain while doing questions can guide you to the knowledge that you need to learn. Questions do not teach you. Questions test you. Questions tell you what you know and do not know. Your job is to take this insight and act on it.

Most practice questions of any merit come with annotated answers. In the best instances, these annotated answers tell you both why the right answer is best, and also why the other options are inferior. Reviewing the annotated answers should help you to grasp the key features and essential logic of the question. This is truly valuable information. But your exam preparation requires more than the nuggets of knowledge embedded in these annotations.

Question annotations give you little bits, atoms, of knowledge. The problem is that each little piece of knowledge floats around free, without any linkage to other important content. Annotations help you learn the knowledge important to the questions, but not how to use that knowledge in a broader context.

To achieve the level of understanding the USMLE demands, your knowledge must not be in atoms, but molecules. Facts must have context. Details must be associated with key ideas. Each individual piece must fit together to reveal the larger patterns. Questions annotations give you the pieces, but do not help you see how the pieces fit together into the frame of a larger puzzle.

To gain this larger perspective, after reading the annotated answer you must open you content study material to the topic featured in the questions and review the content in context once more. If you do not know the content, go back and look at it again. By going back to your basic study material, you will have the chance, not only to learn the specific points tested in the questions, but also related issues which will embed the question in your larger framework of knowledge.

Doing large numbers of questions will not teach you do to questions well. The trick is to learn to do questions well, before you do a lot of questions. If your technique for reading and answering questions is flawed, then doing a lot of questions will simply reinforce these bad habits. You will become highly skilled at bad question answering behavior.

Start doing practice questions slowly. Initially, work on having the right process, and don’t worry so much about whether you get the questions right or wrong. At the start, it is more important that you learn to do the questions the right way than if you select the right answer. When the proper questions answering technique has become a comfortable habit, then, and only then, should you ratchet up the number of questions that you do each day. Once you have the proper technique, practicing it more and more questions will make this good habit second nature. And when you questions habits are second nature, then your mind is free to focus on the content issues of the question.

Doing practice questions is essential and annotated answers are great. But, successful USMLE preparation requires more than these simple resources. Do not neglect the hard work of content study, and learn to do questions right before you do them in volume.

Steven R. Daugherty, Ph.D.

You Can’t Know Everything!

The key to successful exam preparation lies not in what you study, but in what you choose to ignore.

 Ever approach a faculty member in medical school with a thick book in your hand and ask them what are the most important things to know in the book?  Often the response from the faculty is that you must know, “Everything!” No only is that answer not very helpful, it is not true. 

 If you try to learn everything—every little detail, every little fact, you will not succeed, there is simply too much material to master in too short an amount of time.  The fact is if you try to learn everything, you will not succeed.  Instead, you will end up with gaps in your knowledge. The problem is that these gaps will be essentially random.  A better system is to use the guidance of your faculty and your own native intelligence to decide what is most important and what is not and to concentrate your efforts accordingly.  This way the gaps in your knowledge are of your own choosing, based on your assessment of what is more or less important.

Divide all material that you study into three categories:  1) What you must know, 2) What you ought to know, and 3) What it would be nice if you knew.  Then, orient your study accordingly.  Spend the most time on the “must”, then move on to the “ought”, and finally time on the “nice to know” if you have the time.  Your goal is not to learn all the trees in the forest, but to come to an understanding of how the forest fits together. 

 If you have difficulty deciding what is more or less essential, try this:  Give yourself 15 to 20 minutes to study a section of content.  At the end of that time, but you notes away, stand up and give a short lecture on what you just read.  You will find that in order to give a lecture, you will have to make some decisions.  What is essential and you must mention and what, although important, is less essential.

 If you have trouble making these decisions on your own, that is what faculty are for.  In live lecture courses or on the internet, faculty will guide you through the peaks and valleys of the material, helping you to separate the essential from the merely interesting.  Remember, no one cares what you know if it is not on the test.  Doing well is not about knowing everything, but rest on knowing the right things.

Steven R. Daugherty, Ph.D.

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.

How long should I study?: It’s What You Do with the Time That Counts

Does extending your study time add points to your USMLE score, or does it actually hurt because you will start to forget what you already learned?

If you believe that USMLE preparation as a brute memory exercise, then you probably think that at some point the new stuff you learn will be negated by the old stuff you forget. When that balance point is reached, further study would not provide any real benefit. Once your memory is saturated, additional study would gain you nothing.

But, the focus on the USMLE as a pure memory exercise is misplaced. USMLE test items are not questions to be answered, but problems to be solved. You get the top score, not by regurgitating what you have taken in, but by being able to use that information and apply it to the situations each question presents. In short, doing well requires thought, not brute memory. Shear memorization does not get you that high score. Something more is required.

You get to this problem-solving level by changing what you do with the material you are studying. If you fell that you are studying hard but not progressing, it is time to change your approach to the material. As you learn more, you can do more with the material you have learned. Figure 1 (below) illustrates the essential point.

Initially, study is about memorization, but after a while you will find that you have gone as far as memory can carry you. To solve this impasse you need to shift to a focus on how things fit together within each subject you are seeking to master. Gaining a sense of connections and linkages among the things you have learned will help you see things in another light and make it easier to retain the things that you have already memorized. At this level you focus on learning patterns, that is, no longer learning things, but the relationships among things. Every medical subject area is defined by a set of essential patterns and templates which give a context to all the details and help them to make sense. Pattern recognition helps you focus on these most essential elements and moves you up to the next level of USMLE scores.

To get to the highest level you must move beyond pattern recognition within subjects to an integrated understanding of the connections between basic subject areas. All medical knowledge is about the same human body. All clinical issues can be approached from a variety of medical disciplines. Gaining an understanding that multiple approaches are possible to solving a presented problem, and acquiring the ability to select the must useful of the available approaches in any circumstance is the mental habit of mind required to achieve the highest level of performance.

Memorization only lifts you so high. Pattern recognition within subjects gets you higher. Understanding of how content is integrated between subjects moves you to the highest level. If you use added study time to shift to the next level, you will find clear improvement in your score. If you use added study time to simply focus on more and more memorization, you will fins you improvement has stalled. The key to progressing is not how long you study, but in shifting what you do as you study across time.

So, how long should you study for the USMLE?

The length of time you will need to study for the USMLE differs from person to person and depends where you are in your study process. If you are still at the level of memorization, longer time will be required. If you have advanced to pattern recognition, then somewhat less is needed. When you have achieved the level of integrated understanding, you are ready to take you exam.

In short, the optimum study time varies widely depending on the strengths and weaknesses of each individual. We can, however, offer some general guidelines to guide your planning.

As a rule of thumb, it takes about 2 to 3 months to prepare for each USMLE Step. Additional time may be required if you:

1. Have been out of medical school for more than 1 year. Information fades over time. The longer you have been out of school, the more time is required to boost your knowledge base back up to where it needs to be. In addition, the thought processes required for USMLE questions are a bit different than those of actual clinical practice. Most people find they need time to get back to thinking in the appropriate ways.
2. Had any academic failures in medical school (or barely passed two or more courses). Academic difficulty is clear evidence that you have some gaps in your knowledge base that will damage your USMLE score.
3. Learned English after age 10. PET scan studies have shown that language learned prior to age 10 goes into Boca’s and Wernicke’s areas, whereas language learned at a later age goes into contiguous areas. This means that language learned later in life comes with slower processing speeds which can slow you down measurably on the USMLE. Everything you do to become more proficient in English will improve your score. Make sure you spend time increasing English comprehension and reading speed by taking time to practice reading in addition to you USMLE study time.
4. Have a history of difficulty with focus and concentration. If you have actually been diagnosed with ADHD, or just have difficulty with maintaining your attention for prolonged periods of time, you will likely require more time to cover the mass of material required for the USMLE.
5. Have other responsibilities during the time you are studying. If you have family or work responsibilities, you will not be able to give you full attention to your USMLE preparation. Part-time study simply means that you more months will be required for you to review and master the required material.

On the other hand, you should be able to shave time off of your preparation if you: 

1. Are still in medical school
2. Excelled in you courses
3. Have a past history of performing well on standardized exams
4. Enjoy puzzles and thought exercises

The good news is that you can take whatever time you need to get ready for the USMLE. Don’t let friends, family, or your school push you into taking the exam when they think you should. To be master of your own fate, you need to decide if you are ready or not. If you decide you need six months, take the six months. Remember that once you pass, you can not try again to improve your score! My own experience with students suggests that if you think you need more time to study, you probably do.

Take the time that you need. Force your self to move beyond memorization to pattern recognition and subject integration. Change how you learn as you learn more. Shifting how you learn is the key to stepping up to that higher USMLE score.

Steven R.. Daugherty, Ph.D.

DECIDING WHAT TO LEAVE OUT

The most difficult part of studying for your USMLE is not deciding what to study, but deciding what to ignore. There are a wide variety of resources available to help you prepare for your exam. Each of these resources has surveyed the knowledge of a given field and extracted the content that seems most relevant to the authors. Faced with this range of choices, you have two key decisions to make. First, what material will you choose to study? Second, what will you focus on within that selected material?

When selecting what material you will study, we recommend the “Goldilocks Rule”. You may recall the fairytale about Goldilocks and the three Bears. One bowl of porridge was too hot, one was too cold, and one was just right. When you select your study materials, those offering too much detail are not likely to help you focus. On the other hand, those offering the most distilled version of knowledge (all of the USMLE in one book) are likely to give you inadequate coverage. Your job is to select material that is “just right”; that give you enough detail without becoming overwhelming.

Whatever you select, pick one primary study source. The vast majority of students tell us that the Kaplan Live Lecture Notes give them everything they need for their exam. If you don’t think so, then pick another source.  But whatever you do, pick ONE source. “Double tracking”, that is, trying to digest two sources at once is a losing strategy for most people. Students with two or more sources quickly feel overwhelmed and lose focus on what is essential with in the double mass of material presented. Pick one source and learn it well.

With your study resources selected, you have a second choice to make. What will you focus on within the set of materials you have selected? The simple fact is that even within a set of content that distills the knowledge you must know to the essentials, you cannot learn and remember everything. If you try to, you will not succeed.  You will end up with gaps in your knowledge, and these gaps will be, essentially, random. A better strategy is to use your native intelligence and CHOOSE. That hard part about study is not deciding what to focus on, but deciding what to ignore. As you study, classify the material you encounter in to three groups. That which is Essential, that which is Important and that which is Secondary. What is it that you must know; what should you know; what would be nice to know?

If you have a hard time making this distinction, pretend you are going to give a lecture based on the material that you are reading. If your lecture time is short, what are the key aspects that you must mention, what would be nice to mention and what can you leave out because you just do not have enough time.

Making these kinds of choices, if you are not used to it, can be emotionally unsettling. Trying to learn everything gives you the emotional comfort that whatever is tested you till know. Making choices to not study certain things will cause you to not look at details you may well need during your exam. But wait; don’t feel bad about what you do not know. You are forgetting all the things you will know because of what your choices did give you time to study. You cannot know everything. The feeling that you can know everything is comforting, but it is the comfort of a false reality. Choose where to put your efforts. Make decisions about what you will focus on early. Success comes, not from trying to travel all roads, but from picking the right route to get you where you want to go.

Steven R. Daugherty, Ph.D.

TRAINING YOUR BRAIN UNDER STRAIN: GETTING THE MOST OUT OF PRACTICE QUESTIONS

Doing practice questions is essential in your preparation for taking a multiple-choice exam. However, your goal should is not to “test” yourself, but to learn good question answering habits. As you do questions, yes, check whether you got them right, but more importantly, look at why you got the question right or wrong. Did you not know the content? Then that’s your cue that more study is needed. Did you misread the question? Then evaluate how you misread it and learn how the question writer wants you to read it.

When you do your practice questions, do them under a time limit similar to the actual exam. In general, your practice rule should be one minute per question. This is a little less time than you will have during the real exam. But a tighter interval will get you used to the time constraint. The ticking clock is one of the unchangeable realities of the USMLE.

To identify specific question answering bad habits, try this exercise. Select a set of 50 questions from a good questions source. These should be questions that you have never looked at before. Then, set a clock for 1 hour, and do the questions. Read them and answer them, but stay within the 1 hour time limit.  When the hour is up, do not score the questions. Instead, without a clock, go through and do them again. This second time, take as much time as you need — linger and reflect. When you have completed all 50 questions the second time, now look at the answers and score yourself. You probably got more questions correct from the second, untimed pass than you did the first, timed pass. With this data in front of you, you can now identify particular question answering problems that you have.

If you got a question correct on the untimed pass, but incorrect under time pressure, the issue can not be a lack of knowledge, rather you must have processed the question incorrectly. By examining these questions, the ones you got right the second pass, but missed the first time, you should be able to identify certain mistakes you are prone to making when answering questions under time pressure. Note what these mistakes are, and then think about what to do so you can correct this problem. If you know the content, but can not demonstrate it on the exam question, you get the same score as if you do not know the content at all! Spend time learning your most common mistakes, and then with this awareness, set up an approach to questions that avoids these common mistakes.

In addition to this self-diagnostic exercise, avoid these common mistakes when doing practice questions:

a.) Do not just do questions without preparatory studying. Review material first until you feel you know it, and then use questions to test yourself. Learning the answers to hundreds of questions that you may not see on the exam will not help you prepare. If you study by doing questions before you are ready, you will erode your self-confidence and fail to develop key linkages within the material.

b.) Do not get into the habit of lingering over a question or thinking about it for an extended period of time. You do not have this luxury on the real exam. Remember that you have just over one minute per question. You should spend about 75% of that time reading and analyzing the question stem, and the other 25% selecting an answer. Be honest when you do not know an answer; move on, and look it up when you are finished.

c.) So-called “retired questions” and many published questions in review books are not representative of questions featured on the current USMLE Step 1. They are a reasonable way to review content, but often do not reflect the length or form of the questions on the current exam. Kaplan Medical practice exams are your best sample of true USMLE-type questions.

d.) Do not do questions individually. Do them in clusters under time pressure, with 5 to 10 as a minimum. This will get you used to moving from question to question. Do not look up answers after each question. Instead, check yourself after you have done the full set of questions.

e.) When you start working on questions, do not panic if you do not get the correct answers. Learn from your mistakes. Questions are a part of the study process; they help you see what else you need to learn. You will get better at questions as your studying continues.

Answering questions is a game. To do well at this game you must identify needed skills and then practice those skills. Time spent learning to do question correctly allows you to demonstrate the level of knowledge you have and avoid the frustration of a score that is below your abilities.

Steven R. Daugherty, Ph.D.

EMOTION SETS YOU IN MOTION

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.