Answering USMLE Type Questions – Part I

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I wrote this initially in response to someone who was really having a hard time answering tough USMLE type question. Most of the time, when people think their problem is answering tough USMLE type question. the reality is that they have a KA (Knowledge Acquisition) problem. In other words, they did not do their review properly and their problem is primarily with insufficient knowledge base rather than difficulty with USMLE type questions.

Therefore, I always make it a point to test their knowledge base first. This is usually done by testing them using straightforward questions that test knowledge and recall without the common tricks that accompany USMLE type questions.

Now as you may know, I have an online prep site at http://prep.askdoc-usmle.com.  The prep site contains all the courses available to course participants of my USMLE Step 1 prep course. There is a demo prep course for Review of Pathology which features the first chapter  out of 25 total chapters of Review of Pathology. It covers cell pathology. The online quiz is a straightforward quiz which directly tests recall and does not use USMLE type question. Do well there and it proves you do not have a knowledge base problem.

It is surprising though that out of almost 2 dozen people who had this problem and asked for help and was advised by me to take the test in order to evaluate their problem, only 4, yes 4 people actually took the test. That is quite bothersome and may explain why despite numerous articles I have written on how to prepare for the USMLE, too many people are still failing. It seems over 80% of people seek advice in order to confirm what they want to do rather than find out what they need to do to pass this exam. That is part of the reason that I prefer to just post articles rather than do one-on-ones as 80% of the time, people won’t follow my advise anyway and one-on-one advise is too time-consuming.

So how did the 4 who took the quiz go? Well if they had scored over 70% here, it means they have no problems with concepts or their knowledge base. between 60 to 70% means there are some problems with their knowledge although tough questions may be contributory to their low score. Anything below 60% means that they don’t know enough concepts to pass the USMLE.

Out of the 4, 3 got below 60%. The actual score was 2 with 50% and 1 51%. And these are people who have reviewed from 4 to 6 months already and was scheduled to take Step 1 in a month or so. The one who passed, scored a very high 80%, which means her main problem is really answering tough USMLE type questions rather than any knowledge deficit. It is for her that I started writing this answer which is now long enough to become an article.

I have yet to write an article dealing with Test Preparation or TP and answering USMLE type question is one of them. TP deals with all preparation to ready oneself for a specific type of examination. Preparing for essay or enumeration type questions is different from preparing for Multiple Choice Questions. Which is why Step 2 CS prep is so very different from the other Steps.

The most common reason for the increasing toughness of USMLE type question is the use of case-based questions or clinical vignettes. This is especially true for Step 1, primarily for those exam takers who lack clinical experience. These includes 2nd year medical students taking step 1 prior to going to third year and medical graduates of medical schools that provide little clinical training until internship or even residency.

To illustrate.

1. A patient was diagnosed with disseminated intravascular coagulopathy. The most characteristic laboratory abnormality for this condition is

A. increased bleeding time

B. elevated fibrin split products

C. deficiency of von Willebrand factor

D. increased plasma fibrinogen

E. thrombocytosis

Now instead if the question look like this,

1. A 45 year old female who was hospitalized for severe community acquired pneumonia, developed septicemia and hypotension on the fifth day of her confinement. Over the course of the next few days her condition worsened and was observed to have decreasing renal and hepatic function. She was bleeding from  the endotracheal tube, IV lines and foley catheter. She finally died of shock a few days later. At autopsy, microthrombi was found in the arterioles and capillaries of the brain, liver, adrenals and kidney. The most characteristic laboratory abnormality for this condition is

A. increased bleeding time

B. elevated fibrin split products

C. deficiency of von Willebrand factor

D. increased plasma fibrinogen

E. thrombocytosis

Even though the two questions are asking the same thing, the first question is so much easier to answer than the second one. In fact this clinical vignette is really a very straightforward one. To make this question tougher, instead of telling you the patient had pneumonia, I would just give signs and symptoms of pneumonia e.g. fever, rales, dyspnea and signs of lung consolidation. I would give a low blood pressure reading instead of saying she is hypotensive. I would give the results of BUN and creatinine tests as well as protime, etc. instead of decreasing renal and hepatic function. I would add a few  unimportant findings like normal triglyceride, numerically. This is how you get those kilometric questions that people are complaining about.

If you cannot answer even the first question, it shows a lack of knowledge of concepts being tested in the USMLE and there is no way you can answer the second tougher question, which is basically asking the same question except in a tougher way.

When I took my Step 1 in 2006, around half the questions were in the form of clinical vignettes. As I understood it, the USMLE will continue to increase the percentage of Step 1 questions in clinical vignette format. Therefore difficulty with clinical vignettes can impact your score severely.

The solution really is to be able to diagnose quickly that the patient has DIC and then to rephrase the question to: This patient died of DIC. What is the most characteristic laboratory abnormality in DIC, which is exactly how the first question is phrased. You would be surprised to know that many people have trouble doing that or was too slow to figure that out and fail the exam or get really low scores. There are various ways to remedy this and we’ll discuss it later.

Another common problem is the two to three-step thinking question. The two to three step thinking questions arose directly from the fact that the USMLE uses multiple choice questions. The weakness of multiple choice questions has to do with the fact that the answer choices themselves gives clues to the right answer. This is also the same reason for increasing use of distractors in the answer choices, which is the third problem we will discuss.

I was fortunate that I graduated so long ago that exams then not only use multiple choice questions but other formats as well. Fill in the blanks and Enumeration require you to memorize the concepts since if you did not memorize them you cannot answer those questions. The advent of multiple choice question only examination made full memorization unnecessary. You only have to be familiar with the concepts and you have a good chance of answering a multiple choice question since the answer choices act as hints to the right answer.

You could try this to see if you tend to do this. Whenever, you encounter a question, can you answer it immediately without looking at the choices or do you tend to look at the choice first before coming out with the answer. The more often you need to see the choices first to come out with the answer, the more chances you will fall victim to the two to three step thinking questions and distractors. In my Step 1, I tend to know the answer 70% of the time without looking at the answer choices. Which means I depend on the answer choices 30% of the time. I am not immune to distractors and two to three step questions so I got them right less than half the time. Which me give me average scores of about 80%++ right.

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28 thoughts on “Answering USMLE Type Questions – Part I

  • January 26, 2009 at 2:25 pm
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    hi there … does usmle requirement for the academic master study ?
    if so … which specialities need it for academic study ?
    thank u

  • January 28, 2009 at 5:17 am
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    Hi nadia,

    I’m not sure what you mean by your question? Do you mean usmle policy if you try to get a masters degree before taking the usmle? or do you mean if you need to take usmle if you want to take a master’s degree? please clarify,

    Thanks

    Askdoc

  • February 8, 2009 at 10:46 pm
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    hi there just wanted to ask how long u should study before giving the eaxam.wat should be the minimum time or the maximum time

  • February 12, 2009 at 12:57 pm
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    Hi foziaa,

    Actually the amount of time you need in order to prep for Step 1 is highly dependent on a lot of factors. Your year of graduation, your native talents. Please read my post on “How to Create a Study Plan for the USMLE” to know all the factors you need to consider in order to know how long you need to prep. For the average USMLE taker (Fresh grad, fairly good at school, fairly intelligent, AMG), 4 to 6 months prep averaging 6 to 8 hours 5.5 to 6 days a week is just about right. You need to adjust depending on your own circumstances.

    Askdoc

  • September 30, 2009 at 12:41 pm
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    HI Askdoc,
    I read your blogs on how to learn and I realized I have a problem mastering the concepts or problems retaining information. i took Step twice and I failed twice. I do not want to give up but I do not know how I can study better. I want to sign up for your class but I do not know which one i should sign up. Sept is already over and I just found my score today. I need your guidance where to begin. Should I sign up for November?

  • October 2, 2009 at 3:54 pm
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    Hi thuy,

    If you just recently took the USMLE and you got at least 160, then you can enroll in the November batch. But if you scored less than 160, big possibility you need to go through learning phase, so better go for January batch. If you need to go through learning phase, tell me and I’ll give you a few tips on how to proceed.

    Askdoc

  • November 10, 2009 at 1:53 pm
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    Hi Askdoc,

    I am an IMG. I realized it was very difficult to find a preparation materials or even a preparation class that will covers every tiny knowledges that may be tested in the USMLE test. Do you have any recommendation regarding this issue? Thanks.
    By the way, I read through your articles regarding how to prepare and answer USMLE type questions, I think you are the only person who fully understood how much difficulty and what kinds of difficulties many of our IMG faced so far, and thank you for your solution ideas.

  • November 11, 2009 at 11:16 am
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    Hi Frank,

    It is impossible to cover all the material tested in the USMLE. Neither is it needed to get a high score. In fact, I don’t think any normal person will ever be able to study everything. 🙂 What is needed is that you study the right material, in the right amount and be able to retain and recall them for the exam. You just missed the first lecture of the November batch of my prep course, which deals precisely with that problem. What to study, How to Study and How much to study to do well in the exam. Some people are good at that, while others just are not. If you are not good at it, then you need to rely on other people’s judgment. When you enroll into a prep course, or when you use a certain reviewer, you are relying on that person’s judgment on what you should study. For example, my students in my course, rely on my judgment on What they need to study, How they need to Study and more importantly how much they need to study in order to do well in the exam.

    Other people choose to read the forums, blogs and ask other people’s advise and decide for themselves what they need to study, etc. That is what I did in my case. But not everyone can do that. So depending on your own capability, you need to decide whether you can go it alone, or you need someone’s guidance.

    Askdoc.

  • November 11, 2009 at 5:41 pm
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    Hi Askdoc,
    Thanks for your reply, it is really helpful.
    I have difficulty in dealing with USMLE long question format, it made lose track of the key points. Could you please give me some suggestions in answering with those long questions? Thanks a lot.

  • November 19, 2009 at 11:20 am
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    Hi Frank,

    Sorry for the late reply. First, been really busy preparing the sixth and last lecture to September batch on Test Preparation Strategy, which deals with your question above. Then my site went down and I have been busy trying to get it back up again. Anyway, first long question format is at most between 25% to 40% of Step 1 unlike in Step 2 CK where they are more prevalent. Actually discussing in detail everything you need to do to cover the problem is too long to write. Hence, even in the course it is tackled through a lecture rather than written as notes. Anyway, first step is understand most long form questions are usually clinical vignettes. Therefore in those cases, you need to read enough to be able to diagnose the case. In fact in Step 1, the actual question may have nothing to do with the details in the question stem. In other words, most of the question is a clue for you to diagnose the case, but once diagnosed, the details will not affect your final answer, since the only thing required is for you to know what disease is involved to be able to answer the actual question. Another thing you should do is try to practice faster reading and being able to pick out important details.

    There is a component in my class where I teach people to do speedbuilding exercise in order to be able to answer questions faster. In fact they are told to try to read the question, think of the answer in 20 seconds or less. The reason for this is that the easy and short questions occupy around half the exam. If you can finish those in 20 seconds or less, that gives you more time to tackle both the longer questions and harder questions.

    Askdoc

  • February 19, 2010 at 3:23 am
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    I’ve spent a lot of time on this blog today…I was trying to find out my problem. Still I’m not sure about my solution but definitely I’ll think some differently after reading articles.
    Thank you

    regards,
    Ghosh

  • February 28, 2010 at 12:03 pm
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    sir could you give me your e mail

  • March 5, 2010 at 1:04 pm
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    sir i made an account and they said that an activation key is sent to my email but i did not get any activation in my email

  • March 28, 2010 at 7:41 am
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    hi,
    i’m an img with master’s degree(MD) but I’m planning to give usmle soon. I was trying to fill the form for step 1 but I got confused in the part where they had asked to fill the date of attendacne of medical school and graduation. Since, I’m a masters holder, should I refer to MBBS date of graduation or MD date of graduation . Pls help..thanks:)

  • March 28, 2010 at 11:52 am
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    Hi isha,

    As far as I know it should be MD date of graduation. But I suggest to be clearer you go the forums or the ECFMG itself. I am not really familiar with MBBS so do not know if that is an exception.

    Askdoc

  • March 30, 2010 at 4:19 am
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    thanks doc,

    I really appreciate ur help:) I called them up n they told me its mbbs grad date , so i guess i dont have mention my masters. thanks again

  • April 2, 2010 at 10:20 am
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    hi there,
    I’m here again with another query. During my final year I did elective in a clinical school’s hospital other than my graduate medical school. While filling the step 1 form,should I include this in item 20- Other Instituitions attended or in item no 21- clinical clerkship? thanks for your help.

  • April 10, 2010 at 8:09 pm
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    Hi isha,

    You are welcome

    Askdoc

  • July 20, 2010 at 8:32 am
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    hi ask doc iam medicine 4th yr.please tell me about usmle qualification to write exam

  • July 22, 2010 at 9:29 am
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    Hi bhavani,

    Best to consult ECFMG for the latest requirements to qualify for exam. It usually involves proving that you graduated from an accredited medical school and applying for the exam. But the exact requirements are different depending on your country of medical school. Go to http://ecfmg.org and search around.

    Askdoc

  • August 15, 2010 at 8:39 pm
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    sir,i did my mbbs 17 yrs back,md medicine 9 yrs back.i want to give USMLE part 1,please advise gave part 1 >10 yrs back i failed.got dissapointed and discontinued.i want to qualify USMLE ,before i retire.
    thanks

  • August 16, 2010 at 4:37 pm
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    Hi im sujeet,

    When I took my USMLE Steps in 2006, I was 17 years out of Medical School having graduated in 1989. So believe me I can sympathize in wanting to tackle this exam. However, you must realize that it will be expensive both in terms of time, effort and money in order to do so. Therefore, unless you do intend to proceed with a residency after you pass the steps, then I suggest you don’t even consider doing it. However, if you do dream of doing a residency in the US, then I encourage you to do so. But make no mistake, it is a very tough exam especially for old grads, so you must be determined if you really want to take this on.

    Askdoc

  • September 4, 2011 at 2:19 pm
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    hi there first off i’d like to say that i think you have an extremely amazing heart to devise this entire blog and take the time to answer everyone’s questions, you are truly. Having said that I myself have a question, I am a physician from canada currently doing a fellowship in the states—though i plan to return back to canada i need to write the USMLE’s to get my H1B visa. Being a surgical fellow you can imagine how far removed i am from step 1 material. I am about 65% of the way done with qworld questions (averaging about 50th percentile on them) and did the NBME form 6 today and received a score of 350. I’ve scheduled step1 for sep16th and wanted your thoughts on me writing it then and any helpful tips you can provide in terms of studying. i look forward to hearing from you, cheers!

  • September 4, 2011 at 6:06 pm
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    Hi darina,

    Sorry to be the bringer of bad news. Based on your q bank results and NBME you will be hard-pressed to pass Step 1 much less do well on it. You need a 400 in NBME to have a chance of passing and at least 450 if you want to be sure of passing. No way you can do that in 2 weeks. Using Q banks only to study for the USMLE may work for third year medical students and a few fresh grad. But if you are an IMG even a fresh grad, chances are that is not enough. Too many people have failed using that method. My suggestion is to evaluate how you prepped. You can read about how to properly prep for this exam in my blog. It’s long, not something that can be written in a short reply in the comments section.

    Askdoc

  • May 21, 2012 at 5:55 pm
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    I got very low scores in step1 and 2 and I think as you just wrote above I have a good knowledge base but I have the knowledge acquisition problem.

    I need to ask you if u have any course or video to explain for me how I can apply this medical knowledge to solve the Usmle style questions???

    Thanks

  • June 6, 2012 at 11:09 pm
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    Hi Marwa,

    There are two ways you can get more details on how to learn how to do this. First you can enroll and read my book on “How to Master the USMLE Step 1: Askdoc’s Method of USMLE Prep”. It discusses in more detail how to answer USMLE Type Questions and how to prep so you are ready to apply this medical knowledge to answering questions. Contrary to most opinion, you start preparing to answer tough questions during the Learning and Mastery phase, not just the Test Preparation Phase. There is a way to study so you are prepared for tough questions and this is detailed in the book. This is available at my prep site at http://prep.askdoc-usmle.com. Price is US$ 12.95. Or you can learn it through my step 1 prep course. The prep course includes live chat sessions and “how to answer a question” drills to teach you how to answer tough questions. It is more intensive than the book. This is done during Test Preparation Phase of the Prep Course proper.

    Askdoc

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