The Question is the Problem

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.

Memorization Is Not Enough

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

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.

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.

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

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.

Hope Is Not a Strategy!

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

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

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

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

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

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

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

Making the Most of your Worst Subject

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

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

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

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

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

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

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

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

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

Steven R. Daugherty, Ph.D.

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.

MAKING YOURSELF CHOOSE

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.