Answering from Fear vs. Answering from Confidence


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

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

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

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

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

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

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

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

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

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

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

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

Steven R. Daugherty, Ph.D.

The Right Motives Give the Best Results


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

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

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

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

Common USMLE Preparation Motives

Motive #1 Getting the Score

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

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

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

Motive #2 Getting the Knowledge

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

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

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

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

Motive #3 Avoiding Failure

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

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

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

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

Motive #4 Avoiding looking or feeling stupid

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

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

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

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

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

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

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

Seek to Win, Don’t Just Avoid.

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

Steven R. Daugherty, Ph.D.



So, you have completely read through all of your study material to get yourself ready for the USMLE. Now what?

The most common advice I hear students giving each other about what to do after they have completed reading their study material is, “Read over the material again.” But, is this really the best way to get ready for the USMLE? What is the added benefit of going over the same material repeatedly? Once the farmer has plowed the field, is there really much benefit in plowing it again, and again, and again?

The fact is, students re-read and re-read study material because they want to put the effort in to get ready for their exams and they do not know what else to do. The effort is admirable. The results, however, do not justify the efforts. Most of you will have noticed that no matter how many times you re-read the material, you still find you cannot remember crucial information when you need it on an exam. Each re-reading does refresh your memory, but then the memory gets lost again as you move on to other things.

Getting ready for your exam is not about doing the same things over and over. Rather, you need to change what you do as you gain more familiarity with the material and your level of understanding increases. Think about this as a two step process:

Step 1: Getting the information into your head. Reading the material gives you familiarity. You know you have seen it before; you can recognize it. At this stage you need to read over the content and think about what you are reading. The key here is attention, to actually focus on what you are reading rather than simply going through the motions.

Step 2: Being able to recall, and use the material when you need it. Getting the material into your head is one thing. Being able to get it out when you need it is another. The key here is to do something active with the material, and doing practice questions seems to provide an excellent means making this happen.

The difference between re-reading and following up reading with practice questions has been convincingly demonstrated by the  work of the psychologists Henry Roediger, Mark McDaniel and Kathleen McDermott. In a series of research studies they had some students spend extra study time re-reading material over again. At the same time they had other students spent their extra study time doing practice questions and getting feedback on how well they performed on those questions. When both groups of student given exams to test their retention days and weeks later, the student who spent time on practice questions after their initial time studying did significantly better. This trend of better retention, if anything, increased over time.

This important research confirms what the best students already know from personal experience. Re-reading the same material over and over produces nothing but diminishing returns for the time invested. Adding practice questions to your study routine after initial concentrated study over the material helps to increase both comprehension and retention. Questions are not magic, but they do guide you to move beyond rote re-reading to the focus on recall which is essential to produce top exam scores. Questions should make you THINK and move you beyond the rut of memorization.

Steven R. Daugherty, Ph.D.