There are a couple of essentials to being able to master and excel at reasoning through questions on the USMLE Step 1 exam. Notice that we are specifying “reasoning through” and distinguishing it from “answering” questions.
- Prepare an excellent foundation on which to reason through the question and identify the distractors from the actually feasible answers for the variables set forth in the clinical or research scenario presented. A student cannot prepare for the Step 1 exam and learn information FOR RECOGNITION. Instead, try preparing and learning for RECALL AND APPLICATION. Hoping that a question will come up about a subject and you will recognize it if you see it will not work for Step 1. You must know the information to the level of being able to explain it to someone else. This is because you are being tested to see if you are capable of treating patients. What does this mean? At this level, it translates to thinking and processing the basic science of problems presented in the clinical situation… in other words, can you take your comprehensive knowledge base and reason through a problem to come up with a solution? You cannot do that if you learn for recognition. Nor can you do that if you learn isolated facts.
- Remain calm and do not let panic, frustration, or anger distract you during the exam. There will be a certain number of questions that you will miss: a) some are bad questions that are being ‘tested’ and do not count toward your score; b) there will be some questions where you will miss the essential piece in the scenario so you won’t be sure of the correct answer choice; c) there will be questions that present novel situations that you have never reasoned through and you may be unsure of your reasoning process on that subject. Research indicates that there are testing anxiety patterns that show that if a student becomes angry or frustrated with a question during timed exams, they can miss between 5-10 questions following the initial frustrating question while they deal with their emotions. Until they are able to calm themselves and regain a rhythm, their inability to adequately concentrate may cause them to answer several questions in a row incorrectly. To test for this, take several practice timed tests during your board preparations and when you feel yourself become frustrated, put a star next to the question. Go back and see if you have a pattern of missing 5 – 10 questions in a row on your practice tests. You may be dealing with this frustration problem.
- Read the entire question and reason through it to get the best answer. This is not the case of whether you know a fact or do not know a fact. It is, rather, can you be presented with a situation and reason through it to an answer? They are not going to ask you something that you might get asked in a classroom where a professor is trying to trick you to weed out the highest scorer. Instead, it is more like, what will the patient population present that a student will have to reason through to get an answer? The USMLE challenge is to use your vast knowledge base to combine and integrate across subjects to apply it to clinical situations. If you read the question with this challenge in mind, your perspective when looking at the answer choices changes. The USMLE questions’ main goal is to have as many clinically relevant, novel presentations as possible to challenge the student to test if they are ready to treat patients. They will present you with a patient (like in real life) that has several symptoms, and labs that cut across organ systems and subjects that you have studied. You must reason through all of the information and data presented to formulate the correct answer.
- Know that the question writers are not trying to trick you. All of the information you need to answer the question is provided in the scenario. You may be presented situations that you have not considered before and you may have to apply information in a way you never have, but the data needed to answer the question will be in the scenario. Therefore, you must be able to pick out what is essential to answer the question and discard or ignore what is not essential. To do so, think about each question as a case presentation and imagine that you are collecting clues as to the correct diagnosis. Also know that the USMLE will present questions using typical incidence data in their scenarios (such as an African American female with lupus, rather than a patient population where it would be much less common to see the condition). They are rarely looking for zebra conditions, but are looking for horses or more common conditions. However, these may be presented in novel ways that will challenge your reasoning skills.
Also see the article, “Cheat Sheet” for Answering Step 1 Questions.
If you have any suggestions for answering Step 1 questions, we would love to hear them. Please share them with us at your discretion.