An ad or two

For the past nearly 10 years of writing on this site, I have completely eschewed any form of display advertising. I’ve never wanted to jam the margins full of ugly banners that detract from the reading experience, and I definitely have no interest in being part of any of the usual industry practices of sneaky cookie-based endeavors, user tracking, gigantic data plan-choking scripts, or other things that make the internet worse.

My purposefully limited monetization has primarily been through Amazon affiliate links to things I write about anyway (see what I did there?). Over the years I’ve added relationships with student loan refinancing companies and a handful test-prep companies that I’m otherwise also interested in writing about, which is fine, but a big part of that has also always been to pass on discounts or bonuses to readers. This has always been a labor of love, which is why the vast majority of my writing doesn’t earn a cent and I keep giving away books for free.

This preamble is all to set up the news that the first ad I’ve ever run on the site is currently live. The reason you can’t see it is that it’s actually a time-limited sponsorship on a single popular (radiology) post. It’s from a company I respect with a relevant product and also includes a discount code. I’ve contemplated making the jump for a while now, and that’s the kind of ad I can get behind. If you’re a radiologist and happen to see it, cool. For the rest of you, it’s business as usual.

You may see eventually see an ad or two on a handful of posts or even maybe a single ad on the sidebar. Or you may not. I’d like to help justify (financially) the time it takes to maintain and grow this site, but it’s important to me to do so in a way that doesn’t jeopardize my editorial or the reader experience. That has and always comes first. There will never ever be any tracking of any kind, and I never collect any information from anyone ever.

If you’re a company–like the dozens that email every week asking me to publish your lame guest posts–and would like to reach a large unique audience of awesome medical students, residents, and other physicians, then get in touch.

The Hit Points

Starting in 2003, my secret work/study music has mostly been comprised of hundreds of wonderfully creative arrangements of video game music, largely thanks to a website called OverClocked Remix, which has been steadily curating a massive collection of high-quality pieces for almost 20 years.

Which brings me to this stellar bluegrass rendition of a theme from a Kirby game (that I haven’t played):

My son wants to listen to this song on repeat in the car on the way to school literally every day.

Check out The Hit Points’ complete new album CD for free on their bandcamp. Every piece isn’t a standout, but the overall effort is still just delightful. If you can recognize Guile’s theme from Street Fighter II from your childhood, you’ll immediately agree that it was meant to be played this way.

Workflowy redesign

This is some niche dorky stuff for a Saturday night, but I’m excited: My digital brain, Workflowy, just got a modern redesign.

For those who don’t know, Workflowy is a totally free (with very optional paid options) outliner/todolist/organizer that allows you to have infinitely nested arbitrarily large outlines/lists. If that doesn’t make sense, just try it. It’s ridiculously simple but very powerful. I even wrote the bulk of my last book in it.

The main downside for me has been that Workflowy’s design has been stuck in yesteryear. I’ve been spoiled by a number of elegant writing environments over the past few years, and I actually do think the extra zen makes a difference. This new design is, as expected, super simple, but the clean lines and font crispen up the experience just enough. Well done!

If you’ve already given Workflowy a try, you can activate the new beta design through the options page here. Now they just need to update the iPhone app!

Alto’s Odyssey

The sequel to my favorite iOS game came out last week. Alto’s Adventure, which came out in 2015, was a snow-boarding-themed endless runner that has remained the iPhone’s best meditation app for several years.

I’ve been playing the new sequel Alto’s Odyssey since it came out last week, and it builds on the original to deliver an outstanding sequel. It’s sandboarding instead of snowboarding, so the ambiance is freshened, and there are several new gameplay elements including bouncing hot air balloons and canyon wall-grinding. But most of all, there is still an incredible attention to detail with countless little design touches that are, frankly, delightful coupled with another fantastic relaxing soundtrack. It’s awesome.

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.”