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There is more to the USMLE than volume of knowledge, and you can take the test efficiently by

acknowledging outright the things your subconscious probably already knows. This is a somewhat
randomly chosen question from the official 2013 USMLE Step 1 information booklet:
A previously healthy 48-year-old man comes to the physician because of fever and cough for 2 days.
He attended a convention 10 days ago, and two of his friends who stayed in the same hotel have
similar symptoms. His temperature is 38.3C (101F), pulse is 76/min, respirations are 20/min, and
blood pressure is 130/70 mmHg. Crackles are heard over the right lung base. A chest x-ray shows a
patchy infiltrate in the right lower lobe. A Gram stain of sputum shows segmented neutrophils and
small gram-negative rods that stain poorly. A sputum culture grows opal-like colonies on yeast
extract. Which of the following is the most likely causal organism?
(A) Campylobacter jejuni
(B) Eikenella corrodens
(C) Legionella pneumophila
(D) Proteus mirabilis
(E) Pseudomonas aeruginosa
Once youve done enough Step questions, you will already know the most likely answer at the word
convention (its C). Not every question can come as a knee jerk reaction, but one key to
Step preparation is not just overall knowledge but rather pattern-recognition and memorization.
What separates the massive scores from the excellent scores boils down to intrinsic genius, testtaking voodoo, and tons of studying. The first you cant change; the third you have to do (and should
do efficiently). The second you need to be clever about (and doing questions is key). You can lay a
strong foundation by making questions like the one above comically easy. Knowing

the key
phrases and patterns can allow you to literally feel the right
answer even without having conscious knowledge. If you can get in the
head of the question writer and know the tip offs, you can often make a
reasonable guess even if you dont actually know the basic science details the
question is supposedly trying to test.

Rid Yourself of Your MCAT Bias


Start by acknowledging that the USMLE is different from the MCAT. Knowledge during the MCAT
is foundation that allows you to reason through a question in order to arrive at an answer. Knowledge
in the USMLE is frequently the answer itself. There is minimal critical thinking involved. The slight
exception is physiology, which requires knowing more complex relationships (this goes up; this and
that go down; the other thing stays the same), which can also be memorized (though it is more
cumbersome to memorize than to intuit). Most of the test however is the straightforward application

of memorization dressed in the clothing of painfully verbose question-writing and enough length to
exhaust your sympathetic reserves.
MCAT and USMLE scores do correlate (of course they do). Know, however, that there are people
who perform very poorly on the MCAT that end up with massive Step scores. This is because you
can brute force your way to a solid score with questions, while its very difficult to improve your
verbal subscore on the MCAT.

Use the Force


The test-taking skill itself comes into play only in knowing when theyre trying to play you for
a fool. Inexperienced test-takers will second-guess themselves out of the correct answer or
hinge their guesses on irrelevant clues. Good test-takers get in the head of the question
writer. Another official example:
A 24-year-old primigravid woman at 28 weeks gestation has had nagging headaches, a puffy
looking face, and swollen legs for the past week. Her blood pressure is 180/95 mm Hg; it was
within normal limits earlier in the pregnancy. Urinalysis shows a protein concentration of 0.6
g/dL. Which of the following is the most likely diagnosis?
(A) Acute glomerulonephritis
(B) Congestive heart failure
(C) Eclampsia
(D) Nephrotic syndrome
(E) Preeclampsia
The answer is E. This is classic preeclampsia, and the question goes out of its way to list an
almost comical number of criteria. That said, its a question about a pregnant patient with a
seemingly pregnancy-related problem. Only two of the five choices is specific to pregnancy.
Question writers very rarely include totally extraneous details, so you should be looking for a
pregnancy problem first and foremost before believing the voice on your shoulder telling
you that theyre trying to mislead you. So, ask yourself: if you didnt know anything at all
about the actual criteria, which answer would you guess? You should be guessing E (C
requires a seizure).
USMLE questions are single best answer. That doesnt mean the other answers are 100% wrong or
that they arent even reasonable. Theyre just not the best. People find elements in the stem that
support other choices, and these force them to reconsider their gut (and usually correct) feeling. Your
feelings (except for that miasma of anxiety) matter, so dont ignore them.

In the above question, edema supports CHF and nephrotic syndrome. Proteinuria supports GN, and if
it were of a larger amount, nephrotic syndrome. These answer choices having true elements doesnt
take away from the fact that preeclampsia explains all of them.
But even if you dont know anything, your goal when guessing is to narrow down answer
choices. Think about the body systems involved, the time courses, acquired versus congenital, viral
vs bacterial, drug reactions, any answer choices you do recognize that you know cant be it. Cross
stuff out.
One more from the official packet:
An 18-year-old female athlete reports easy fatigability and weakness. Physical examination shows
no abnormalities. Laboratory studies show:
Serum
Na+ 141 mEq/L
Cl
85 mEq/L
K+
2.1 mEq/L
HCO3 35 mEq/L
Urine
Na+
K+

80 mEq/24 h
170 mEq/24 h

Which of the following is the most likely diagnosis?


(A) Aldosterone deficiency
(B) Anxiety reaction with hyperventilation
(C) Diabetic ketoacidosis
(D) Ingestion of anabolic steroids
(E) Surreptitious use of diuretics
Female athlete is a code word for eating disorder (the answer is E). If the question mentioned
a boxer, wrestler, or other sport with weigh-ins, ditto. Board questions reflect an extremely
judgmental worldview with heavy-handed generalizations about race, sex, and a wide variety
of stereotypes. African-American females in their 30-40s have sarcoidosis. If a woman takes oral
contraceptive pills, the question is nearly always implying that she doesnt use barrier
protection and has contracted an STD. People who have recently immigrated from another country
with cough have tuberculosis. If its a child who has recently immigrated, then they have a vaccinepreventable illness.
Often, in order to allow you to reasonably pick an obscure or rare illness with a set of non-specific
symptoms, these giveaways make sense. Sometimes they just make the question easier. Other times,
its a second-order question and simply knowing the diagnosis isnt enough anyway. But always look

for a questions internal clues to help you guess, give you the answer, or boost your confidence. You
cant learn every fact, and sometimes you dont have to. When picking facts to learn from a long
list of tidbits, pick the ones that help distinguish a diagnosis from other likely/related answer
choices.

Dealing with irritating clinical science questions


Which of the following is the most appropriate next step in management?
Which of the following is the most appropriate next step in diagnosis?
These question styles can make you question yourself and frustrate you in times when you otherwise
could have sworn you knew the answer. Here are a couple of takeaways from the official Step 2 CK
information booklet:
In emergencies/unstable patients, your go to answer is whichever one prevents death or most
stabilizes the patient. So, in the trauma setting, follow your ABCs (where C essentially always
means fluid resuscitation). For example, if tension pneumothorax is a possibility, then needle
decompression must be performed without delay. Always follow an algorithmic approach with the
goal of stabilization and prevention of avoidable complications. The definitive management is
almost always available as an answer choice and usually must be avoided for this style of question.
In real life, many things happen simultaneously, but while studying, always think about which thing
is the most crucial to perform.
A 22-year-old man is brought to the emergency department 30 minutes after he sustained a gunshot
wound to the abdomen. His pulse is 120/min, respirations are 28/min, and blood pressure is 70/40
mm Hg. Breath sounds are normal on the right and decreased on the left. Abdominal examination
shows an entrance wound in the left upper quadrant at the midclavicular line below the left costal
margin. There is an exit wound laterally in the left axillary line at the 4th rib. Intravenous fluid
resuscitation is begun. Which of the following is the most appropriate next step in management?
(A) Upright x-ray of the chest
(B) CT scan of the chest
(C) Intubation and mechanical ventilation
(D) Peritoneal lavage
(E) Left tube thoracostomy
This gentleman has a GSW to the abdomen extending to the thorax with ipsilateral respiratory
compromise from a hemothorax. You may remember from your studying that all GSWs to the
abdomen will go for exploratory laparotomy. But first things first, he has earned himself a chest tube
(choice E). After all, B comes before C in ABC. Now, if he were stable after the tube is in, he might
get a CT before going to the OR (B). He will certainly be intubated for surgery (C). But never forget

your ABCs. Dont get excited. Even if exploratory laparotomy or thoracotomy were answer
choices, they would also be wrong.
When patients are stable, the next best step/most appropriate test is that which is most likely to
make the diagnosis (always know the test of choice, especially for imaging studies) or rule out a lesslikely but potentially life-threatening diagnosis. If the diagnosis is already made, treat the problem
(there may be two treatments, but one is more important). Other tests may be reasonable and
performed concurrently in real life, but there is typically one test that is geared towards the most
likely diagnosis based on presentation. Thats the one you want. You should have some knee-jerk
associations for complaints (e.g. LLQ pain and fever diverticulitis CT scan of abdomen with
contrast; RUQ pain and fever cholecystitis RUQ abdominal sonogram). When given a classic but
non-acute disease presentation, always think about how to prevent catastrophic consequences.
42-year-old woman comes to the physician because of a 1-year history of vaginal bleeding for 2 to 5
days every 2 weeks. The flow varies from light to heavy with passage of clots. Menses previously
occurred at regular 25- to 29-day intervals and lasted for 5 days with normal flow. She has no history
of serious illness and takes no medications. She is sexually active with one male partner, and they use
condoms inconsistently. Her mother died of colon cancer, and her maternal grandmother died of
breast cancer. She is 163 cm (5 ft 4 in) tall and weighs 77 kg (170 lb); BMI is 29 kg/m2. Her
temperature is 36.6C (97.8F), pulse is 90/min, respirations are 12/min, and blood pressure is
100/60 mm Hg. The uterus is normal sized. The ovaries cannot be palpated. The remainder of the
examination shows no abnormalities. Test of the stool for occult blood is negative. Which of the
following is the most appropriate next step in diagnosis?
(A) Barium enema
(B) Progesterone challenge test
(C) Colposcopy
(D) Cystoscopy
(E) Endometrial biopsy
Now, there is a rule about abnormal vaginal bleeding in women over 35, but lets say you didnt
know that. Ask yourself, what would be the worst thing to cause non-acute bleeding? What
would you want to rule out? Cancer. Could it be that she has amenorrhea and that a progesterone
challenge test could answer our question? Yes. But we must rule out the life-threatening cause. The
answer is E.
So

Stabilize if necessary ABCs, even for non-trauma patients

Diagnose if necessary Test of choice to make the diagnosis or the test that will rule out a
potentially life-threatening cause

Treat If there are multiple appropriate options, which one is the most crucial?

Ultimately, most questions are fair. That said, every once in a while, the question is actually terrible.
If after all is said and done, it makes no sense, dont extrapolate too much from it for your general
test taking skills.

Managing Anxiety
There are always miserably hard questions on NBME Shelf and USMLE Step exams, and thats
okay. Its not realistically possible to get them all right. The nature of the test is such that a ball of
doubt will form deep in the core of you body, growing with each question you waver on. And, the
test is designed to make you waver over that second answer choice which doesnt feel right (but you
cant explain why its wrong). Allow yourself to approach the tests with an air of dispassion and
nonchalance. Your nerves dont help you. Your instincts do.
Stay awake. Stay focused. Use what they give you to make your life easier. When you dont know an
answer, try to narrow it down based on internal characteristics, guess, and move on. If you go back to
change an answer, you must know why and have a good reason. Never change an answer arbitrarily
because of feelings.

Even though the two questions are asking the same thing, the first question
is so much easier to answer than the second one. In fact this clinical
vignette is really a very straightforward one. To make this question tougher,
instead of telling you the patient had pneumonia, I would just give signs and
symptoms of pneumonia e.g. fever, rales, dyspnea and signs of lung
consolidation. I would give a low blood pressure reading instead of saying
she is hypotensive. I would give the results of BUN and creatinine tests as
well as protime, etc. instead of decreasing renal and hepatic function. I
would add a few unimportant findings like normal triglyceride, numerically.
This is how you get those kilometric questions that people are complaining
about.
If you cannot answer even the first question, it shows a lack of knowledge of
concepts being tested in the USMLE and there is no way you can answer the
second tougher question, which is basically asking the same question except
in a tougher way.

When I took my Step 1 in 2006, around half the questions were in the form
of clinical vignettes. As I understood it, the USMLE will continue to increase
the percentage of Step 1 questions in clinical vignette format. Therefore
difficulty with clinical vignettes can impact your score severely.
The solution really is to be able to diagnose quickly that the patient has DIC
and then to rephrase the question to: This patient died of DIC. What is the
most characteristic laboratory abnormality in DIC, which is exactly how the
first question is phrased. You would be surprised to know that many people
have trouble doing that or was too slow to figure that out and fail the exam
or get really low scores. There are various ways to remedy this and well
discuss it later.
Another common problem is the two to three-step thinking question. The
two to three step thinking questions arose directly from the fact that the
USMLE uses multiple choice questions. The weakness of multiple choice
questions has to do with the fact that the answer choices themselves gives
clues to the right answer. This is also the same reason for increasing use of
distractors in the answer choices, which is the third problem we will discuss.
I was fortunate that I graduated so long ago that exams then not only use
multiple choice questions but other formats as well. Fill in the blanks and
Enumeration require you to memorize the concepts since if you did not
memorize them you cannot answer those questions. The advent of multiple
choice question only examination made full memorization unnecessary. You
only have to be familiar with the concepts and you have a good chance of
answering a multiple choice question since the answer choices act as hints to
the right answer.
You could try this to see if you tend to do this. Whenever, you encounter a
question, can you answer it immediately without looking at the choices or do
you tend to look at the choice first before coming out with the answer. The
more often you need to see the choices first to come out with the answer,
the more chances you will fall victim to the two to three step thinking
questions and distractors. In my Step 1, I tend to know the answer 70% of
the time without looking at the answer choices. Which means I depend on
the answer choices 30% of the time. I am not immune to distractors and
two to three step questions so I got them right less than half the time.
Which me give me average scores of about 80%++ right.

Anyway, first step is understand most long form questions are usually clinical vignettes.
Therefore in those cases, you need to read enough to be able to diagnose the case. In fact in
Step 1, the actual question may have nothing to do with the details in the question stem. In

other words, most of the question is a clue for you to diagnose the case, but once diagnosed,
the details will not affect your final answer, since the only thing required is for you to know
what disease is involved to be able to answer the actual question. Another thing you should
do is try to practice faster reading and being able to pick out important details.
There is a component in my class where I teach people to do speedbuilding exercise in order to
be able to answer questions faster. In fact they are told to try to read the question, think of the
answer in 20 seconds or less. The reason for this is that the easy and short questions occupy
around half the exam. If you can finish those in 20 seconds or less, that gives you more time to
tackle both the longer questions and harder questions.