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

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.”

Amazon Enters

Amazon is now so dominant as a corporate force that even the announcement of a plan to someday enter a new industry is enough to crush stocks.

This happened to Blue Apron last summer after Amazon bought Whole Foods and filed a trademark for a possible meal-kit service a week after Blue Apron’s IPO, whose new stock proceeded to immediately tank.

Now it’s happening to healthcare, as Amazon, Berkshire, JPMorgan partner to cut U.S. healthcare costs:

Shares of UnitedHealth Group Inc (UNH.N), Cigna Corp and health insurer Anthem Inc (ANTM.N) were 4 percent to 7.2 percent lower at the close. Drugstore operators CVS and Walgreen Boots Alliance (WBA.O), as well as Express Scripts, closed between 3 percent and 5.2 percent lower. Drug distributors Cardinal Health (CAH.N), AmerisourceBergen Corp (ABC.N) and McKesson Corp (MCK.N) were off 1 percent to 3 percent. Amazon closed up 1.4 percent.

To be sure, the $69 billion loss in healthcare stock value should rapidly self-correct (unlike for Blue Apron, which does not enjoy a stranglehold on an entire segment of the economy).

But in the announcement, the new venture has zero stated plans outside of using “technology” to reduce costs for their own employees, but they do plan to “share the strategies and technology they ultimately develop to reduce costs for the economy and the government.” It doesn’t matter what Amazon does, just that they plan on doing something.

The fact that Bezos is joined by the biggest bank (JPMorgan) and the biggest non-healthcare insurer (Berkshire) just nicely rounds out the trifecta.

Who knows, maybe they could deign to start by developing a good EMR that also uses standards to make healthcare data completely portable in order to empower patients and reduce confusion, overuse, and duplication. If it’s just Amazon Prime Rx with cheaper mail order prescriptions, I’ll be a bit underwhelmed.

“The ballooning costs of healthcare act as a hungry tapeworm on the American economy,” said Berkshire Hathaway Chairman and CEO Buffett. “Our group does not come to this problem with answers. But we also do not accept it as inevitable.”

Buffet’s still got it.

The big industry of big pharma ads

From Harper’s January 2018 index:

Amount the US pharmaceutical industry spent in 2016 on ads for prescription drugs: $6,400,000,000

Number of countries in which direct-to-consumer pharmaceutical ads are legal: 2

$6.4 billion? Holy moly, what a depressing figure. Think about how much healthcare that would buy.

In case you’re curious, our partner in crime is New Zealand.

In case you’re still curious, permitting DTC advertising is a terrible idea that can only be satisfactorily explained by the power of lobbying.