Explanations for the 2018 Official Step 1 Practice Questions

Here are my explanations for the new NBME 2018 USMLE Step 1 Sample Test Questions. This year there are 51 new ones (marked with asterisks).

Like in years past, the question order here is for the PDF version (not the FRED-simulated browser version). This facilitates using these explanations in future years when they change the available question set (because the old ones are always available via archive.org). The multimedia explanations are at the end.

Prior sets/explanations can be found here.
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More Perks of Flexible Duty Hours

You may recall the ACGME recently nixed its 2011 rule that mandated a 16-hour shift maximum for interns after “minimal” differences were noted in a study of surgical residents. I discussed those results here and the ACGME change here. Even in that study, the surgery trainees were basically less happy.

So, the ACGME didn’t wait for it, but now the results of a similar study in a cohort of presumably less self-flagellating medicine residents.

The study was designed to test the persistent leadership belief that the old days of infinite work were not only better for learning and patient care but also better tolerated by residents:

We prespecified four hypotheses regarding trainee education: that interns in flexible programs would spend more time involved in direct patient care and in education, that trainees and faculty in flexible programs would report greater satisfaction with their educational experience, and that interns in flexible programs would have noninferior standardized test scores to those in standard programs.

So, iCOMPARE randomized 63 internal medicine residency programs to flexible (read: long) or standard shifts. Both groups had the theoretical “80-hour” workweek cap. Standard programs adhered to 16-hour shift caps for interns and 24-hour caps for residents, while flexible programs “did not specify limits on shift length or mandatory time off between shifts.”

Contrary to the prevailing hypothesis, the flexible residents spent no more time on patient care.

However, the “flexible” (euphemism) program interns were “more likely to report dissatisfaction with multiple aspects of training, including educational quality (odds ratio, 1.67; 95% confidence interval [CI], 1.02 to 2.73) and overall well-being (odds ratio, 2.47; 95% CI, 1.67 to 3.65)”

One thing that was similar was the high-rate of burnout:

Reports of burnout were high in each group. The interns in each group had a similar likelihood of having high or moderate scores on the Maslach Burnout Inventory subscale for emotional exhaustion (79% in flexible programs and 72% in standard programs; odds ratio in mixed-effects logistic-regression model, 1.43; 95% CI, 0.96 to 2.13), high or moderate scores on the depersonalization subscale (75% and 72%, respectively; odds ratio, 1.18; 95% CI, 0.81 to 1.71), and low or moderate scores on the personal accomplishment subscale (71% and 69%, respectively; odds ratio, 1.12; 95% CI, 0.84 to 1.49)

3/4 are miserable. It’s hard to divide an 80+ hour pie into something that isn’t too many hours a week.

I think the conclusion sums up the state of medical training fantastically:

There was no significant difference in the proportion of time that medical interns spent on direct patient care and education between programs with standard duty-hour policies and programs with more flexible policies. Interns in flexible programs were less satisfied with their educational experience than were their peers in standard programs, but program directors were more satisfied.

So, whose happiness matters more?

Running from Depression

Scott Douglas, writing in Slate, on why doctors don’t prescribe the very effective treatment of moving for depression:

Why is the United States such an outlier? Structural barriers may be to blame. The U.S. health care system famously incentivizes procedures and pills over a holistic approach. That might be especially true with antidepressants, which the National Institute of Mental Health concedes are increasingly prescribed for “off-label” uses, meaning conditions like insomnia, pain, eating disorders, and migraines, rather than depression. This tendency to prescribe, and specifically to prescribe antidepressants, contributes to the aura of “they might help, and they probably won’t hurt,” despite warranted debate over their effectiveness for depression. A system that encourages such practices is at odds with a prescription of “get outside and move for half an hour most days” for depression.

Of course, the real answer is that doctors do tell patients to exercise.

What is this famous “incentivization” for pills over a holistic approach? A psychiatrist does not get paid for prescribing a medication. There are no kickbacks in the 21st century. Complexity in note-writing is a documentation burden, and certainly needing to evaluate labs etc might result in higher billing per visit, but the “incentivization” as such could better be framed: there isn’t much time in a 15-minute med check slot to do anything other than offer an Rx.

As the husband of a psychiatrist, the real story here is patient expectation: a lot of people don’t want to get a lecture on sleep hygiene; they want a sleeping pill.

Focused Nonchalance

Focused nonchalance is, I believe, the ideal attitude to cultivate when preparing for and taking a high-stakes exam.

While much much easier said than done, the goal of attitudinal preparation is to strive for a state of flow when answering multiple-choice questions: focused and potentially even joyful as you take an exam, marshaling all of your cognitive resources without falling prey to anxiety and self-doubt.

Flow, the now widely-phenomenon phenomena akin to being in “the zone,” was first described in the 90s by the prominent psychologist Mihaly Csikszentmihalyi in Flow: The Psychology of Optimal Experience:

In normal life, we keep interrupting what we do with doubts and questions. ‘Why am I doing this? Should I perhaps be doing something else?’ Repeatedly we question the necessity of our actions, and evaluate critically the reasons for carrying them out. But in flow there is no need to reflect, because the action carries us forward as if by magic.

While the optimal experience and apparent effortlessness of flow as it is most popularly described is probably out of the reach most students taking a multiple-choice test, my point in this discussion is to state firmly that achieving focused nonchalance or even a flow state is not dependent on your actual test-taking skills and prowess or the fraction of questions you get right easily, but is instead a reflection of your attitude and preparation. (Don’t get me wrong, if you always do well on exams and are a natural narcissist, this will likely all come easier). Csikszentmihalyi never argued that flow necessarily meant you were doing awesome; even in the title, he suggests that flow leads to an optimal experience. Nonetheless, that optimal experience goes a long way on a long and stressful examination.


Hitting the Wall

Many people who put in a considerable study effort eventually hit a score wall or plateau where more and more effort seems to yield minimal or even worsening score results.

Your specific goal, whatever it is, is awesome and I hope you get it, but you also need to realize that goals are only helpful as a means of motivation, not something to tie your entire self-worth into. Otherwise, the wall is crippling. A friend’s performance, peoples’ forum posts—absolutely none of that matters.

Putting aside the reality that people presumably do have a natural maximum performance range and the fact that the tendency to focus on learning fringe esoterica is unlikely to pay dividends test by test, I think a significant fraction of the mutable wall comes from two places: overthinking and fatigue.



Overthinking a question is a symptom of underconfidence. When you overthink and question yourself it’s because on some level you believe that you are insufficiently prepared to determine which facts are critical within the information provided to derive a correct answer. Therefore you start searching for hidden clues to avoid making a “silly” mistake.

The solution is to believe that at any point you are as prepared as you can reasonably be and that you should use the skills you have at that moment to answer to the best of your actual ability. Going hunting or dowsing for tricks isn’t going to help you if you don’t really know what it is you’re looking for.

The components of a question that matter to you only matter because you actually know what to do with them and what they signify. If you change your answer from what you would otherwise pick due to a hunch, you’re guessing. If you want or need to guess that’s fine, everyone does with some frequency, but then guess happily and move on. However, changing what you believe is the best answer just because you wonder if some detail might make a difference but aren’t sure is unlikely to consistently lead to better results.

Overthinking and dumb mistakes are actually two sides of the same coin: one tends to happen when you try to prevent the other. So you oscillate back and forth, even from question to question within a single block. When you check your answers, either in a tutor mode scenario or at the end of a block, the questions you get wrong are a head-slapping frustration-fest instead of learning opportunities.

This frustration is (naturally) compounded by being emotionally invested in your performance. This is why you need to believe that you’re going to do as well as you can. Agony helps no one.

When you’re stumped by a question, the answer isn’t to be sad or angry at yourself. The response should be, “Ah, here’s one of those irritating questions that I’m designed to get wrong. Time to narrow down as possible, guess, and move on.” Even if you know that you used to know the answer, you’re still human.

Your job isn’t to get the all the questions right; that’s an outcome you can’t control. Your actual job is to take each question individually, apply your knowledge and reasoning to it, and pick what you feel is the most likely answer.


Guess. Guess again. Guess better.

When you’re down to two choices, try to see if one answer might feel more right. Often, you will like one answer better but won’t be able to “rule out” a second choice. This second choice sometimes seems like it could be correct. Most high stakes exams including the USMLE use a “single best answer” format. This means that other answers don’t all have to be wrong, just that one of them stands out as better (i.e. “the best”). You don’t technically have to know the right answer, you just have to pick it.

Medical school sadly may not contribute very much to your 10,000 hours toward becoming a great doctor as Malcolm Gladwell popularized in Outliers. But it does give you a lot of mileage on the goal of being a great MCQ test taker.

So, the ability to instinctively and comfortably guess the correct choice is another reason to do tons and tons of practice questions from a reputable source. You can develop your innate question sense by practicing and practicing. Using low-budget or alternative questions can be a bit dangerous, as some of these resources over-test minutia or try to trick you in ways that are not typical of the real USMLE.


There’s wrong, and then there’s wrong

I remember that when I’d get questions wrong on UWorld, a lot of the time I would say, “oh wait, that doesn’t count, I knew that one.” But the fact is that there is more than one way to get a question wrong. Most people think of really being “wrong” when they’re totally clueless, but that typically makes up a minority of cases. Many times you will actually know (or tell yourself you “know”) the fact being tested even when you get it wrong in question format. Doing questions means continuing to pair up facts with answers, and it takes time.

One of the difficulties many of my former students had with studying through questions is that getting questions wrong is demoralizing. Again, the bottom line is that when you’re studying over the long term with UW or any qbank, your goal isn’t to get questions right; your goal is to learn. There’s almost as much to learn from the questions you answer correctly as the ones you get wrong.


Building the Routine

As you get closer to game day, however, the need for simulation outshines the learning benefit of savoring each question in a pressure-free study session between looking at Instagram stories. Taking several blocks in succession and not being able to check answers or take large breaks is mentally different than normal studying. The difficult questions wear on you, shake your confidence, and, psychologically, it’s hard to maintain peak performance and concentration. What you want is to achieve Flow but what you are is nervous and miserable (even on a practice NBME).

Athletes train in similar circumstances as their competitions so that they don’t get nervous on game day. Wholehearted simulation is key. I am generally a huge proponent of tutor mode, but this does mean that as you get closer to test day you want to fix your habits and strain your test muscles so that the big day is just another day:

2 weeks out at the minimum is when you want to get your sleep and other habits in line. But being mindful of your daily practices should start now. You’ll need to start doing test mode and doing two or three block chunks in a row so that you get used to working long stretches.

Never forget that the real thing can really feel terrible. It’s long and you never get any positive reinforcement. The questions you had to guess on will weigh heavily in your mind. This is all test psychology. How it feels doesn’t actually need to matter; chances are you are doing exactly as well as you normally do, and that’s what you need to tell yourself as you go through the day to make that true.

Remember, the goal is focused nonchalance. Don’t forget: “this test is a poorly constructed hurdle” is a better mindset than “this test determines my future.”