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 keywords 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 synopsis: a 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:
- You can’t get all the questions right
- You will be dumbfounded and blindsided
- This will feel more frequent than it really is
- A harder test should be reflected in the scoring anyway
So your goal should be to move through the exam. Looking back at 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. (I also wrote a follow-up post about dealing with test anxiety.)
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.
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.