The Answer You Like vs. The Best Answer

The Emotion of Choices

All choices involve emotion. The inner sense you have that one option is better than another is the result of the emotional coloration, or valence, you give to each option. Options which trigger our most positive reactions are the ones we end up choosing. A strong positive valance makes us comfortable with our choice. A negative valence tells us what to avoid.

Emotion is the voice of experience, whispering in our ear and pushing us towards a particular option. Our emotional responses both frame our choices and guide us what action to take within that frame. This means that emotions are the essential guide helping you to a better USMLE result if properly attuned. They are also the culprit that holds you back if they are out of tune.

Not just Test Anxiety

When first thinking about emotion and the USMLE or any other standardized exam, most people think about “test anxiety”. Certainly test anxiety hurts your score. If you have high anxiety it is hard to concentrate and cognitive processing is disrupted. When you can’t focus and can’t think straight, it is almost impossible to apply all of the knowledge you have learned.

For people who suffer from test anxiety, the entire exam has a strong negative valance. This global negative overwhelms and positive or negative reaction to individual options. The entire exam is a negative. The push is to simply leave the exam, not to engage the presented options in a way that facilitates choice. The details of options may not even be seen and any positive valences they carry are swept away in the test anxiety flood.

But even for those without inhibiting test anxiety, emotion still controls your exam result. Because the valence of an option controls our choices, understanding the process by which these valences are established is critical to understanding why we make the choices we make. And understanding the process is the first step to learning to do it better.

Sources of our Choices

The valences we give options presented on an exam can come from a number of different sources.

Familiarity: We feel more positive about something we have seen before. If you look down over a set of presented options and recognize something you have studied, that recognition provides a positive valence inducing a desire to select that option.

In medical school where you are presented with or directed to a defined set of knowledge, familiarity can be a useful exam aid. On option which you recognize is likely to be one in the body of material you just studied for the exam you are taking and, therefore, has an increased probability of being the correct answer.

Availability: Associations which come quickly to mind require less effort, simplify our world, and give us a more positive feeling. Everything we encounter triggers association within us. Those associations which come most readily to mind are those which are likely to be more dominant, and to carry the most positive valences.

In medical school, where you have reviewed a finite body of knowledge just prior to your exam, availability is likely to help you grab onto the right answer. If you have studied well, then the content you have most recently studied will come to mind most readily.

Medical School vs. the USMLE

However, what works in medical school does not work very well on the USMLE. When the teachers are the testers, the valence of familiarity helps select the right option. When a test covers a defined, finite set of knowledge, such as a single subject or one organ system, availability, primed by what is most recently studied provides the critical valence.

The USMLE is both more comprehensive and more integrated than most, if not all, of the exams you faced in medical school. The set of material to be tested is vast and taken from a variety of sources. The presentation of that material is often unique to the test-takers experience. Because of these differences familiarity and availability are not likely to provide the proper valences.

Instead, the emotional valence of each option must be assigned by the assessment of the data presented in the stem of the test question. Each USMLE question presents a set of information scattered through the question stem like the pieces of a puzzle. The student’s cognitive task is to gather these pieces, assemble them to solve the puzzle, and then, in a flash of insight, recognize the picture provided. To select the best answer, the valances of the options must come from the clues provided in the question stem.

Analysis, not recognition is, therefore, the key. Unlike many medical school exams where the emotional response to the options guides the student to the answer, on the USMLE, the question stem, not the options themselves must be the focus. The question sets the frame, both cognitively and emotionally. The value of each presented option is determined by the context of the question stem, not the student’s sense of familiarity or availability.

This means that if you are used to answering questions on medical school exams, you will have to modify your process for assessing and answering USMLE questions. The valences you carry into the exam will not provide sufficient direction. You will have to adapt to getting the value of each option from the information provided in each question.

You learn this new process by practice. Doing practice questions helps to assess your knowledge level, but also offers an arena for you to develop an approach to questions that is more likely to lead to the best USMLE answers. Take the time to get the process right. Getting the right source of emotional valence on your USMLE questions will lead you to the ultimate emotional valence we call success.

Steven R Daugherty, Ph.D.

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.

Timing IS Everything…

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

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

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

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

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

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

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

Combining Content in Context: USMLE thinking

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.

Combination is the key process for the problem-solving required on USMLE questions. You must combine the information presented in the question with the information 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.

A detailed walk thought this process can be found in an article I posted in cooperation with Dr. Philip Tisdall on www.usmlethought.com. Look under the heading “Handling USMLE Questions.” Learning the mental steps to understanding USMLE questions is as important as mastering content details.

Steven R. Daugherty, Ph.D.

RE-READING AGAIN AND AGAIN IS REDUNDANT AGAIN AND AGAIN.

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.