Understanding versus Knowing

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A truckload of bricks and a stack of lumber may contain everything you need to construct a house, but you will never have a house you can live in until they are all assembled in the right order. In the same vein, a pile of books may contain everything you need to prepare for your USMLE, but you are not ready to take your exam unless the material is organized it a way that makes it useful. Collecting the essential pieces is not enough. You must assemble the pieces in a way that allows you to see the fundamental patterns which are the key to successful problem-solving. Beyond simply having the knowledge, you must make sense of it.

Exams in medical school are often about having the right pieces of knowledge. You are faced with questions that ask you to regurgitate the knowledge you have memorized explicitly for that test. In a sense, medical school exams are a checklist, and the professor simply seeks assurance that you have learned each of the facts that they consider most essential. In medical school, if you have the knowledge, you have the answer.

The USMLE is asking for something different out of you than your medical school exams. Top scores on any USMLE Step depend not on knowing, but on using the knowledge you have learned. USMLE questions ask you to think and apply, not recognize and tell. On the USMLE, application of knowledge is key; when you understand the issues involved, you can more clearly see what makes the best answer.

Fortunately, your USMLE preparation time provides a unique opportunity for the type of reflective overview these types of questions require. Medical school or clinical practice with their pressing daily demands and vast amount of detail do not give you much chance to get this perspective. Details are not only overwhelming, but they can distract you from your real goal of understanding. As someone once said, “When you are up to your ass in alligators, it is difficult to remember that your initial objective was to drain the swamp.”

USMLE preparation is a time to move from collecting the pieces to assembling the puzzle picture that organizes and brings clarity. Remember that your goal at the end of this process is not to simply know things, but to understand how they all fit together. Only from that perspective can you respond to the sort of problems that you will encounter in each exam question. The key to effective study is not the accumulation of individual pieces of knowledge, but grasping the essential patterns that tie together the pieces and give them significance. In short, the core task is not to learn about things, but to learn the relationships among things.

These patterns and core concepts elevate you a higher level of understanding, but they also offer a framework which makes the task of rote memorization easier and more efficient.  Trying to recall individual facts is a difficult, thankless, and ultimately unprofitable task. Understanding how things fit together not only gives you the big picture, but also helps you retain the little details. With the right organization, the general patterns built from what you are able to remember help you figure out what specifics facts you may have forgotten.

So, how do you gain this larger understanding? How do you get attuned to the relationships so you are not blinded by the multitude of facts? Learning relationships occurs by three basic methods: Examples, Metaphors, and Contrasts.

Examples show you concrete instances of the thing under discussion. The abstract issue is grounded in the concrete referent. By the concrete example you come to see context and even how things change over time. Examples let you grasp core principles by inductive reasoning, that is, picking out what are the most essential features that bring things into focus. When I talk about an autoimmune disorder, you hear all of the defining features. But when I describe the process and progression of HIV/AIDS, you have a picture of something specific that anchors your retention of these essential features.

Metaphors highlight essential relationships by carrying over a known relationship to another context. A metaphor focuses on the essential relationship by virtue of the specified comparison; not an example of a thing, but an example of a relationship. To say e coli has a propulsion mechanism is one thing, but to say it propels the pathogen like a propeller on a submarine gives a more vivid picture of the possibilities for mobility. To say one of the signs of Lupus is a red facial rash is correct information, but to say it looks like a butterfly gives a picture of a cluster of essential details which are otherwise difficult to convey verbally.

Contrasts highlight features by comparison. This comparison serves first a positive function, focusing our attention on certain features by virtue of the referent chosen for the contrast. Each thing in the world has a large number of characteristics or properties. Contrasts among things help us to see which characteristics are more worthy of our attention. Secondly, contrasts also help us understand what something is in a negative sense; helping us see what something is by showing us what it is not. Describing Parkinson’s symptoms is one level of understanding. But, comparing the similarities and differences between Parkinson’s symptoms and the symptoms of Tardive Dyskinesia elevates our understanding of both disorders. Contrasts focus us on what is unique and, thus, what is most essential. Trying to recall all the features of an elephant is too hard. But, being able to say how an elephant is different from a hippopotamus clarifies our understanding of the unique features of each animal.

Examples, metaphors and contrast are the key techniques for elevating you from simple rote memorization to systematic understanding. As you do your studies, take time to think about: “What would this look like?” “What else is like this?” and, “How is this different from something else?”

Knowing things is not enough. The most essential insights of medicine are not what things are but how things relate to each other. You build up your USMLE score as you build this understanding of how things fit together. Focus not on the accumulation of facts, but in fitting the facts together in a way that makes sense. Once these relationships are clear, the knowledge will never leave you. And from the building blocks you will have constructed a “house” you can live in for life.

Steven R. Daugherty, Ph.D.

Judgment and Choices: On Becoming a Physician

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

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

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

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

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

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

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

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

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

Steven R. Daugherty, Ph.D.

Memorization Is Not Enough

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One of the most common questions I hear when advising people preparing for the USMLE is how to memorize and remember all the details required for their exam.  The short answer is that if you are at the level of memorizing, you are simply not ready to take any of the Steps of the USMLE. Yes, the USMLE requires you to know essential medical knowledge. But, doing well on the exam comes from being able to apply that knowledge, not from the mastery of rote memorization.

Let me repeat, the USMLE is not about memorization. The examiners assume that you already know the required medical content. Your medical school success certifies that you have the basic knowledge already. The USMLE is not testing you on what you know, but problem-solving, whether you know what to do with what you know.

Focused repetition is the key to memorization. Anything that you read two or three time, if you are really paying attention, is recorded in the cortical regions of your brain. Your brain functions to retain what recurs. But, the USMLE requires more than this. You have to be able to recall and use the information within the time constraints of the exam. Remember, the USMLE is not seeing if you are a good student and able to digest all of the necessary information. Rather, the exams are checking whether you have a practical grasp of that information and understand the implication it has for medical practice.

You do not get to this level of mastery required for medical practice all at once, but by increasing levels of involvement and understanding over time. These levels can be conceptualized as pyramid in which one learning task supports the next. Recognition, being familiar enough with material to know it when you see it, is the bottom level of the pyramid. Next comes Memorization, being able to call content to mind when needed. Problem-solving, the third level, is achieved when you can combine remembered content and apply it to find the best response to presented situations. At the top of the pyramid comes Innovation, being able to create a new knowledge, new understanding, and new responses.

In medical school you are tested primarily on Recognition and Memorization. The USMLE test you primarily on Problem-solving. The amount of problem-solving required increases as you move from Step 1 to Step 3. The Clinical Case Simulations of Step 3 push problem-solving right up to the border of Innovative thought.

All of which means that at some point your preparation for the USMLE must move beyond brute memory and accelerate to the level of application and problem-solving. Sitting by yourself, reading and re-reading your study material simply will not get you to this higher level. You need to do something with the material. Outlines help. So does making diagrams. But, nothing speeds up the process like talking about the material. Interacting with peers and professors is the quickest way to boost your mastery beyond the level to recall, to being able to use the material you have learned.

The bottom line is that there are a lot of good sources of study material out there, but none of it will get you where you need to be unless you use it the right way.  Before you take your USMLE, you must move beyond memorization to application and problem-solving. The USMLE does not want to see what you know, but whether you can use that knowledge like a physician.

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.

KEYS TO USMLE THINKING

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The USMLE exams are designed to test two things: 1) your knowledge base and 2) your capacity to reason with and apply that knowledge. Most students understand what is required to master the essential core knowledge: a careful review of high-yield topics. However, many students neglect to prepare for the application issue. In these cases, the student knows the content but cannot adequately represent that knowledge on the presented questions, and their score suffers accordingly.

Try these three techniques to train yourself to think with the material you know:

1. Study by contrasts.

The dominant cognitive process required by multiple-choice questions is not recall of knowledge, but differentiation among options. Therefore, your study strategy should focus on this issue. For example, when learning microbiology, do not imply memorize the properties of each pathogen. Instead, concentrate on what features make this particular pathogen stand out from the others. Ask yourself what other pathogens you might you easily confuse it with and then, how you will distinguish among them. When selecting among clinical intervention, the same logic apples. You must know more than what are common interventions. You must know when a particular one makes most sense. The key study question is what are the circumstances when I would select this intervention and not a different one? Kaplan Medical study materials are explicitly constructed to help you learn these important contrasts.

  1.  Making all the options correct.

When doing practice questions, the important issue is not how many you got correct, but learning from reviewing the questions after you answer them. You must know why you got a question right or wrong. After you answer a question, review the answer and read any provided annotations. Then, return to look at the question again. Taking each option one at a time, how would you change the question asked to make each of the options correct in turn. If “C” were the correct answer, how would you need to change the question so “A” is the correct answer? So that “B” is correct? This process focuses you on the key elements that determine what the proper answer will be on any given question. Repeat this process until it becomes second nature. If you really understand a question, you can say why one answer is correct, and why all the others are wrong.

  1.  Checking your perspective.

Not everyone who witnesses the same scene sees the same thing. By past experience or current habit, we all have mindsets that focus on some features in a situation and overlook others. In real life, these are simply the differences among people that make life interesting. On the USMLE, these differences can spell disaster. You see, it is not enough to read the question your way. You must learn to read every question the way the examiners intend you to read it. Some questions can be interpreted in a number of ways. When ambiguities exist, one way of seeing the question is right (the way the examiners intend), and all other perspectives are wrong. Your Becker USMLE faculty will help you understand how you should be approaching and reading questions, but you can also work on this issue in a group of your friends.

Sit and read through a question together with your friends. When you have all finished, everyone should pick and answer and jot down the corresponding letter. Then, reveal your choices. Take a moment and each person justify why they made the choice they did. This process not only allows you to review the content, but also allows you to pay attention to the way that each person reads the question, and the process by which they arrived at an answer. Experience suggest that if there is more than one way to read a question, and most people read it a certain way, that that is very likely the way that the examiners intend.

Success is a one-two punch: mastering content and being able to apply the content as needed. Remember, exam items are not so much questions to be answered as problems to be solved. Using these three preparation strategies to practice your problem solving processes will pay off in the end with the higher score you are seeking.

CHOOSING ACTION OVER REACTION

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We all like to know and feel confident that we know. We load our brains with facts and details to be sure that we have the ones we need when we need them. Learning begins with exposure to important details and sets before us the task of making these details our own. On exams, we prove to ourselves and others what we have learned by being able to state the relevant fact when it is called for. In short, we see; we respond. And having the right response gives us the feeling of competence and satisfaction of mastery.

But this kind of learning, this sort of knowing, has one strong limitation. We are only able to respond to what we have already seen. When confronted with something novel, we are unlikely to have the required response. In the face of uniqueness, we search our responses and find ourselves deficient. The sense of deficit leads to uncertainty, uncertainty to frustration, and frustration to paralysis. In this situation we see, but do not know how to respond, and our sense of mastery dissolves to leave us with a growing fear of incompetence.

At its best, the USMLE confronts you with things you may have never encountered and asks you to look at things in ways you may not have anticipated. Even those students who have studied well and taken in a host of details often find themselves surprised, and consequently frustrated. Many students try to overcome this by seeking to find out as much as they can about what has been tested and how it have been presented on previous exams. But this strategy inevitably comes up short. New questions are constantly being developed and novel presentations are continually being invented. Students who focus on what has been tested in the past will find themselves behind what is being tested in the present.

Doing well on the USMLE, therefore, depends not so much on having the right responses memorized, but being able to reorganize those acquired responses and refashion them to solve a new, unanticipated problem. Knowledge is the springboard for answering USMLE questions. But being able to reconstitute and think with that knowledge is the actual leap that carries you to success. Success depends not so much on having a pre-programmed reaction, but on being able to stop, think, and select the right action to respond to the novel situation presented. Mastering the exam rests not on programming your reactions to the questions you encounter, but on learning the right mental actions you take to arrive at the best solution. Thinking, not knowing, is the key.

The mental processes here are far more complex than the simple stimulus-response of a reaction. USMLE requires us to make new responses on the spot to cope with fresh, unanticipated scenarios. This is not mere temporal lobe recall, but frontal lobe problem-solving. The central issue is not do you know the right facts, but can you do the thought processes required to find the best answer.

But, having the right cognitive processes is just half the battle. Optimal performance also requires the proper emotional state. The question is, can you maintain your confidence long enough to let this essential problem-solving cognitive processes happen before uncertainty opens the door to anxiety and emotional escalation? The virtue of a pre-wired response is that it fixes emotionality. A pre-wired reaction means that little time is available for self-doubt, and that emotions remain in contained. Thinking takes time and doing the thinking that action requires allows time for emotions to run free elevate to a level of performance interfering anxiety.

As always, the secret to mastering the thought processes required by the USMLE is practice. Not practice in memorizing content, but practice at using that content in exam-parallel problem-solving situations. Mastering these thought processes means that you will have the essential skill the exam requires, but also that you will have the confidence that you can handle whatever the exam may throw at you. In the end confidence comes not from a sense of knowing everything (something that is not humanly possible), but in a practiced ability to think on your feet and arrive at a best solution to a any presented problem. The solution comes from thinking, not from knowing. And self-confidence arises from the ability to act to solve any problem, not merely from having the right pre-programmed reaction.

Remember that the USMLE is not only testing to see is you have the knowledge required to be a physician, but whether or not you can make use of that knowledge the way a physician’s have to use it. Knowing facts, but not knowing how to solve the problems that patient’s present makes you smart, but ineffective. What separates physicians from simple technicians, what makes you a professional, is that you know more than how to react to set scenarios, but that you can think and derive the right course of action to whatever situations you encounter. Knowledge is the foundation, but being able to think and apply that knowledge is what truly makes you a physician.

Steven R. Daugherty, Ph.D.