How I read NBME/USMLE questions

From a reader:

What’s your step by step process when answering questions on the NBME shelf exams? I have been reading the question first while highlighting the key words and then reading the answer choices (often glancing back at the words I highlighted to confirm that the answer choice I chose is correct.) With this method, I am sometimes pressed with time and tend to rush towards the end. Could you talk a little about your approach to questions on the shelf?

In the past, I’ve written about some of the ways I break down NBME and USMLE questions, but I haven’t actually written about how I really read one. That may be because the answer is relatively anticlimactic, but here I’ll talk a little bit about my focus on flexibility and speed over rigidity when it comes to approaching Step questions (with a few examples from the 2014 official sample questions). As always, this isn’t necessarily what you should do; it’s just my take. When I used to teach Kaplan MCAT, part of the “method” placed a lot of emphasis on using passage mapping as a consistent approach. If time management isn’t a problem for you, there’s no reason you can’t start/continue using these more involved strategies. But if you don’t have a big system and feel left out when you’re friends are fervently highlighting and using answer-choice first schemes etc, you’re not alone.

For me, willpower and emotional/physical endurance are scarcer than time, so I’d rather burn through quickly and not look back. When I took the various Steps, I always finished early, took my breaks between every section using my saved up test time, and finished the day early having never used my actual allotted break time. I also chugged diet mountain dew during breaks and had to pee constantly, so obviously, YMMV.

Top to bottom

I generally read through the question from top to bottom. I don’t bother highlighting key words because it just takes time. Many details are extraneous, distractors, or normal demographic information that may or may not be important, so it’s hard to highlight effectively. It’s difficult to prospectively know which portions are critical versus supportive versus useless. A patient being an African American female may be the big tip-off for sarcoidosis or it could be totally irrelevant. It’s easy to end up highlighting practically the whole passage. So I don’t bother. I get a gestalt and go back if I need certain data to help distinguish one of two reasonable choices. For me, I often find that questions build up toward one answer and that the facts as they come reinforce which parts are important from the preceding lines in a way that cannot be effectively done prospectively line by line. When certain facts make previous tidbits relevant/important, the “momentum” of the stem reinforces what matters. Highlighting for me distracts me from my actual goal: reading the question.

So let’s create a story:

3. A 4-year-old boy has delayed motor development and choreoathetosis. He had normal development at birth. He chews his fingers and lips, which has resulted in tissue loss. He has arthritis. Serum and urine uric acid concentrations are increased. Which of the following abnormalities is the most likely cause of these findings?

(A) Adenine phosphoribosyltransferase deficiency
(B) Hypoxanthine-guanine phosphoribosyltransferase deficiency
(C) Increased cellular turnover of nucleic acids
(D) Increased conversion of hypoxanthine to inosine monophosphate
(E) Phosphoribosylpyrophosphate synthetase deficiency

Lesch Nyhan syndrome is a deficiency in hypoxanthine-guanine phosphoribosyltransferase (HGPRT) (choice B). You could select the correct answer by either knowing the classic self-mutilating behaviors (chewing his fingers etc) or by knowing the associated elevated uric acid. Or both, which cinches this as an easy question. As you read, the story is: young boy with a degenerative condition associated with self-mutilating behaviors likely related to elevated uric acid. You could highlight every line of that question, but why bother? A lot of Step questions are actually easy once you know your stuff. If you highlight all of them, you may just be spending extra time you don’t need. Additionally, taking on the stem with a rapid more “gestalt” focus allows you to create a narrative of the question that can often jog your memory or elicit a knee-jerk neigh-unconscious Rain Man-like awareness of the correct answer. I always create a story as I go. If after reading through quickly, no story emerges, then I go back and look to pick out details that will help me think of the story. They’re called vignettes for a reason.

Caveat: If the whole stem looks really long, I will sometimes glance at the final line (question itself) and/or answer choices to help guide what I need to get out of it. I also occasionally do this if the question seems meandering or bizarre as I go through as a way to re-orient if I’m getting lost. Sometimes it’s clear from the question or answers what the diagnosis is and they’re really asking for what detail in the question would lean you toward a certain treatment, for example. In these cases, you then get to breeze by the things that are you giving you the diagnosis itself and look for what will help you for the actual question at hand (e.g. stability of the patient, allergies, age, etc). This can help you figure out when a question is physio, biochem, or other, which allows you to skim/ignore or not ignore certain details as being largely superfluous. An example:

8. A 62-year-old woman comes to the physician because of low back pain for 1 week. Menopause occurred 10 years ago. Physical examination shows localized tenderness over the lumbar spine after movement. X-rays of the spine show a compression fracture of L1-2. A DEXA scan shows decreased bone mineral density. Serum calcium and phosphorus concentrations and serum alkaline phosphatase activity are within the reference ranges. A bisphosphonate drug is prescribed. The expected beneficial effect of this drug is most likely due to which of the following actions?

(A) Decreased insulin-like growth factor-1 concentration
(B) Decreased osteoclast activity
(C) Decreased osteoprotegerin production
(D) Increased 1,25- dihydroxycholecalciferol concentration
(E) Increased osteoblast activity
(F) Increased receptor activator of NF-κB ligand (RANKL) production

This question is asking how bisphosphonates work, which they ask directly at the end. So the entire stem prior to the last two sentences is irrelevant. I don’t generally “read” the end of the question or answer choices in detail, I glance.

While you could screen the end routinely and truly skip the actual body of the question, I do still actually read the question anyway as a means of comfort. Over time, the number of questions written this way has gone down, since question writers are trained/told to avoid this pattern. So even though these questions make you want to slap your head when you get to the end because you’ve “wasted” your time, ultimately, this happens infrequently enough that it’s not worth worrying about.

Frequently ignore the hard data

I tend to ignore a lot of labs and vitals or look at them cursorily to see if something stands out as crazy unless from a 0.5-second glance at the answer choices it’s a physio question (physio questions often need the labs; most others don’t). I keep reading, and if I need them I go back to them once I have the story and I know what I’m looking for or how they’ll change my answer. If on a test, a guy comes to you with RLQ pain, fever, tenderness at McBurney’s point, nausea and vomiting, he has appendicitis. I don’t care that he’s also tachycardic and has a white count. Or vice versa. In many cases, this information is included for completeness, not because it’s necessary.

78. A 2-year-old boy is brought to the emergency department because of shortness of breath and left-sided abdominal pain for 3 hours. He appears pale. Physical examination shows hypotension and tachycardia. There is splenomegaly with the spleen tip palpated 8 cm below the left costal margin.

Laboratory studies show:
Hemoglobin 5.1 g/dL (N=12.1–14.9)
Hematocrit 16% (N=37%–44.4%)
Leukocyte count 4500/mm3 (N=4000–11,500) Platelet count 87,000/mm3 (N=150,000–400,000)

A photomicrograph of a Wright-stained peripheral blood smear is shown. Which of the following is the most likely cause of this patient’s current condition?
(A) Aplastic crisis
(B) Autoimmune hemolysis
(C) Congestive heart failure
(D) Salmonellal sepsis
(E) Splenic sequestration

The picture in the example shows sickled RBCs. Anyone reading this question with the picture should immediately know this patient has splenic sequestration (at least given the choices). The lab values are ultimately unnecessary.

Don’t Try not to agonize.

One key to my time management is that taking more time on tough questions leads to rapidly diminishing returns. Agonizing between what seem like reasonable choices isn’t worth it. Think about what information would help you distinguish between the two. If it’s not in the question stem or you’re not sure what would help, then go with your gut and move on. Epiphanies are rare and not worth holding out for.

For many students, test anxiety is a big component of people’s under-performance on game day compared with practice tests. The real deal isn’t necessarily harder. It’s that you care so much that not knowing what’s going on makes you miserable. Maintaining an air of nonchalance is I think a worthy goal. Yes, these tests are important. BUT:

  1. You can’t get all the questions right
  2. You will be dumbfounded and blindsided
  3. This will feel more frequent than it really is
  4. The harder the test is may be reflected in the curve etc

So your goal should be to move through the exam. Looking back the questions over and over to confirm your answer choice breeds anxiety. Leave the questions you’ve answered in the past where they belong, not shaking your rhythm as you progress. If you can help it, pretend you don’t care that much.

Don’t Try not to change answers

As a general rule, I almost never do it. Unless it occurs to you that you were absolutely wrong, fooled, or didn’t take a facet into account that definitely changes the correct answer, then don’t just change it. Test psychology dictates that your initial hunch is more likely to be correct than a “gut feeling” change. Uneasiness is natural and predisposes you to want to change. Doing so wastes your time and is unlikely to make a positive impact on your score. I believe that the more answers that you change without a strong indication, the less confidence you have in yourself and the worse you’ll do. So when you pick, even if you’re guessing, just pick. And once you’ve selected an answer, it’s done. Leave it and move on.

Be flexible

Overall, the problem with most systems is that they’re typically not flexible. To my mind, flexibility is particularly helpful because not all questions are framed the same way or looking for the same thing. So while using one rigid approach every time works, it also means that you aren’t likely being as efficient as possible. That’s why I start from the top and read through, adapting as necessary. For me, no system is the best system.

34 Comments

  1. Dear doctor,
    I finished my intership.I chanced upon your blog and found it quite useful.
    Could you please shed some light on IFOM CSE? At least the study materials.thank you

    Reply
  2. As far as I know, the IFOM CSE is similar to Step 2 CK and should be prepared for analogously. The main difference being that it’s shorter and available in several languages. I’m not particularly familiar with it, is there anything specific I can help with?

    Reply
  3. I’m a fourth year medical student, and I have Step 2 CK in two days – THANK YOU for writing this. So much wisdom imparted here. You’re doing a great, great, thing with this website!

    Reply
  4. I just wanted to take the time out to thank you for all of your advice. Every time I visit your page I always find useful information. I’m telling you, the page is worth more than gold. ;)
    Keep up the great work. It’s truly appreciated.

    Reply
  5. Hey Ben,
    your articles are really helpful! a lot of good stuff :). I’m definitely going to keep all of this in mind when I take my step 2 ck in 2 months! You’re doing a great job of helping alot of students get better at taking nbmes/steps. Thanks so much!

    Reply
  6. Thanks so much for writing this! I think it’s great advice. I have one question about test taking strategy, however, about classic cases and trick questions. I find that I do have the “gestalt” answer or “gut sense” to a question fairly often. But after I’ve chosen my answer, especially if it seems *too* classic – like a 35-year-old African American female with a cough and some skin findings, or a kid with polydipsia/polyuria/nausea/abdominal pain – I get paranoid that it’s a trick question, and they’re trying to get me to take the easy bait and miss a crucial finding that would change the diagnosis. Then I waste time by going back and poring over the question, looking for an indicator it’s something else. I’m sure this isn’t ideal, but the problem is that every once in a while I find it is a trick question. Is this a total waste of time? Should I just go with my gut, and assume that the few trick questions aren’t worth the time? Or should I try to hit every point?

    Thanks so much for any advice – your writing is super helpful, and much appreciated!!

    Reply
  7. What I would do hinges on a couple of things:
    1) How you’re doing with time management: If you struggle to finish, just don’t employ this habit. This happens infrequently enough that it’s not worth jeopardizing finishing the section. If you usually have time to spare (or want more convincing), then move to #2 and my thoughts below.

    2) How close are you achieving focused nonchalance: Stress and anxiety negatively impact performance. If looking for tricks constantly undermines your outlook/mojo, then it probably also isn’t worth it. Focused nonchalance is what I consider an ideal mental state for taking exams: You’re on your A game, but you take each question as they come and don’t let the ones you don’t know or struggle on get you down. Pick and move on; pick and move on.

    I think believing in yourself and the momentum it allows is an underappreciated part of test strategy and is doubly important for marathon tests like the Step exams. There is an internal mental distinction between being careful (positive) and doubting your ability (negative). If you think you’re being “fooled” and are double checking because you aren’t confident enough that you’ll pick it up on the first go around, you’re approaching the question from a position of weakness.

    As you noticed, most “trick” questions play off of otherwise absurdly easy classic questions. But, the majority of even easy classic questions are just easy questions. Furthermore, many trick questions aren’t so much tricks as corner cases (e.g. someone has syphilis, how do you treat? Oh but did you see in sentence 3 out of 7 that they have a penicillin allergy?). Ideally, all “tricks” can be caught prospectively (and sometimes they become apparent because of two otherwise seemingly correct answers). Retrospective review is okay, but not when it comes from paranoia. Consequently, when it’s game day, I’d personally just go with my gut unless I had a reason to go back (internal inconsistency, answer choices that don’t jive, etc–not just paranoia).

    As a final thought, this situation seems to happen less overall the more questions you do. I imagine it’s in part because some of the things that initially seemed like tricks eventually feel like thoughtful questions.

    Reply
  8. Thank you so very much for this! I will be writing my Step 1 in a few months and was wondering if there are any other advice you have regarding the new changes (May 2015) to the USMLE STEP 1. Thank you kindly!

    Reply
    • Nominal. Couple of fewer questions per section. Addition of “quality & safety” questions are likely to be trivial in number, mostly common sense, and shouldn’t require any significant additional effort.

      Reply
      • Thank you kindly for the prompt response. It is very much appreciated. Thanks again and keep being Awesome! Looking forward to reading more of your writings :)

  9. Hi, Ben you had shared some GREAT test taking strategies :
    “Think about the body system involved and drug reactions”.
    Can you please elaborate on both? I understand when you mention “Time courses aka sudden/gradual”, Acquired vs congenital (At birth or childhood/adult) and viral and bacteria “virus or bacteria” Thank you

    Reply
    • Body systems: Some disease processes are limited to one organ but others involve multiple organs. Being aware of which systems are affected helps you figure out what’s going on. Like the combination of hemoptysis (lungs) and renal failure (kidneys) can be seen in Goodpasture’s and Wegener’s. Throw in sinus disease too and it’s Wegener’s.

      Drug reactions: Look at the medication list when present to exclude a drug causing the clinical picture. Drug reactions (angioedema and ACE inhibitors, beta-blockers worsening asthma, lithium and diabetes insipidus, hydralazine and drug induced lupus, the list goes on and on) are important, commonly tested, and can often explain confusing clinical scenarios.

      Reply
  10. thank you very much for this helpful tips
    i have insomnia the day befor the exam so i can`t get enough sleep , even though i stop studying and get to bed early close all lights and doing sport early in the afternoon also i dont drink coffee or smoke , do you have any suggestion regarding my problem

    Reply
    • It’s an extremely common problem. Sleep hygiene is an every-night activity, not a one-time thing, so make changes at least a week or two prior to the test to give yourself a routine. The goal is to make the test day just another day. Melatonin could help. Other sleep aids are also available, some OTC, but you’d want to try any others way ahead of time to see if you wake up refreshed or not.

      Anti-blue glasses are a recent trend, something you could wear in the evening to help block the blue light common to electronics/screens that your body mistakes for daylight, which throws off your sleep-wake cycle and intrinsic melatonin production. Some people swear by these types of glasses for preserving a more “natural” night time devoid of the effects of artificial light.

      Reply
    • I would judge it as concordant and move on. When you start dropping 10 points or more it may raise questions about either your Step 1 performance (the “fluke”) or your clinical preparedness. Additionally, small changes at high score levels are even less meaningful as they are based on a small number of questions and more likely to reflect changes within the standard error. While Step 2 CK scores are higher on average than Step 1, a lot of people, including many PDs, don’t even seem to know that. So chances are you’re the only one who is likely to be upset if your score didn’t increase (assuming it was good to begin with).

      Reply
  11. Great article! Ben, I would like to hear (ready) your thoughts on the important of questions from Q banks (Kaplan, U-World etc) over the use of review books! I have often hear my colleagues state their focus is mainly on q-banks. Can you comment on that please?

    Reply
    • I largely agree with that premise, in that questions teach you both the facts and how they are presented/applied, whereas most books tend to do only the former. I discuss that some in this post.

      Reply
  12. Hello,
    thank you so much for your wonderful advice! They’re quite comforting to read and very informative. I take my step 1 in 1.5 weeks and unsurprisingly I am a bit anxious about the big day. My most recent problem is with my test taking skills with the NBME as I scored around 220 (however, my UW average and UWSA has me at a 240). Looking over my NBME questions, I notice that the trend isn’t that I don’t know the information but I make silly mistake or become fixated at one irrelevant fact while missing the ‘bigger picture’. I’m not sure if test taking anxiety has much to do with it but do you have any advice on how to approach the real test date? I’ve considered pushing the exam back because of my NBME performance but had to come to the realization that the problem isn’t my lack of content familiarity but rather exam taking skills. However, I’ve also heard that the NBMEs do predict your step scores quite accurately so I’m a bit confused on what I should do.

    Thanks!

    Reply
    • I don’t have too much to add to what I wrote above. You might also read the end of this post if you haven’t already. It’s time to get your habits in place. Good sleep, good eat, wake up on time, work diligently but not exhaustively, then go to bed at a good time. Ingrain your habits so the big day feels like another day.

      It’s pretty common for scores to shift around a fair bit on these practice exams and the real thing. Reacting to a practice exam by considering delaying is only going to psych you out.

      Reply
  13. Hi Ben,
    Not sure if it’s found elsewhere on your site, but do you mind sharing what your score was on Step 1? Just wanted to know how these test-taking strategies worked out for you personally.

    Thanks so much!

    Reply
    • You didn’t miss it, I have purposely avoided discussing that kind of personal anecdote on the site because of the problems of conflating the person and the method. I strongly disagree when people try to claim authority for the quality of approach based on their personal results.

      Obviously I wouldn’t be writing about any of this if my approaches didn’t work well for me personally and I didn’t think people could perform at the highest level doing similarly, but I’ve always done so in order to provide a foil from popular misconceptions, gunner methods, and flavor-of-the-day approaches.

      To make it a trust-me-I-got-a-270 thing just plays to authority bias. Sorry, I know that probably isn’t very satisfying.

      Reply
  14. Hey I have been studying for my CK for some time. And not doing well on NBMEs. I came across your blog and I believe you said a lot of the things I needed to hear. I have been so concentrated on having all the information in my head. I have noticed that when someone asked me about a topic I can explain it fairly well, but it has not been translating into the marks I get. I am actually lost in the study department. But I think honestly after reading your approach that maybe there may be some hope for me. Thanks so much for taking the time to write all this out. It really helped me.

    Reply
  15. Hello, Dr. White, I have been using your site for advice and to check my the answers to Free USMLE 120. The answers/explanations were much appreciated, as is the commentary on answering USMLE/NBME questions. However how would one remain in that focused nonchalant state during the board exams, given all the importance and anxiety attached to it?

    Reply
    • That is of course so so so much easier said than done. A couple brief points:

      One way that can make this easier is to simulate the environment at least sometimes in your studies by taking multiple sections, minimizing breaks, etc so that the big day feels more like just another day. Routines, including sleep and morning routines, are also helpful.

      Cognitively, one tries to develop a stoic mindset (as in stoic philosophy). In summary, you practice in all aspects of your life to be emotional only about the things under your control, and the only thing under your control is yourself. You don’t control the outcome of the test or even how it will be used in your future. You can only work hard and do your best. Knowing that, and you realize that you can’t control when you don’t know a question, so there’s no point feeling bad about it. You just answer to the best of your ability and move on. Again, very hard—but—not unique to Step 1. This is an approach to literally everything.

      Reply
  16. Ben, great stuff here. Any advice on how to prepare for step 3? I’m aiming high to help make up for other scores. Test anxiety is definitely a factor for me. Thanks!

    Reply

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