Answering USMLE Type Questions – Part I

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To illustrate; a one step thinking question using clinical vignette will look like this

A 40 year old male came back from a recent trip to Mexico 3 days ago. He presents to you with bloody diarrhea, abdominal cramps and fever. You admitted him to the hospital for workup. Sigmoidoscopic examination reveals ulceration in the cecum and ascending colon. Microscopic examination of the biopsy specimen showed flask-shaped mucosal ulcers with extensive necrosis and a modest nonspecific inflammatory response. The ulcers do not penetrate the muscularis propia. The patient admitted to self-medicating with antibiotics. The most likely organism that is responsible for this patients diarrhea is

  1. Giardia Lamblia
  2. Entamoeba histolytica
  3. Shigella
  4. Clostridium difficile
  5. Salmonella

This is actually already a two step thinking, albeit an easy one since one step thinking will ask the diagnosis, like ameobic colitis, pseudomembranous colitis, Giardiasis, Shigellosis or Salmonellosis. Three step thinking will give you choices about specific characteristic of the organisms like

  1. have two stages, trophozoite and cyst and positive string test
  2. have two stages, trophozoite and cyst and cause anchovy paste abscess of the liver
  3. nonlactose fermenting gram negative rods that do not produce H2S
  4. gram positive rods that produce exotoxin A and B.
  5. nonlactose fermenting gram negative rod that produce H2S

Another way is to ask you drug of choice or treatment of choice. Which in this case would be Metronidazole. To make it even harder, the question would say the patient was given the treatment of choice and ask what a common side effect would be or what the patient should avoid taking during treatment, or what pathogenic mechanism underlie the side effect. (Answers are severe nausea, vomiting, etc, then alcohol,  then disulfiram effect that blocks enzyme acetaldehyde dehydrogenase causing accumulation of acetaldehyde from alcohol metabolism)

Are there ways to do better in two to three step thinking question? You bet there are and we will talk about strategies and prep methods that will deal with this later. However, the best weapon is still solid grounding in the medical concepts tested by the USMLE.

The third common problem is the extensive use of distractors in the USMLE. The reason for this is as I said before, the habit most people have of not completely memorizing the concepts but relying on answer choices to help them remember the correct answer. In actual clinical practice with live patient, you are not presented with answer choices but more with fill in the blanks and enumeration. As in “The diagnosis is __________” or “the laboratory test I have to order is 1._____, 2._____, 3._______.” Obviously the USMLE do not want people to just be familiar with the concepts and pass the exam. Therefore the use of two to three step thinking questions and distractors are to ensure that students are forced to memorize rather than just familiarize themselves with the concepts.

One of the more common distractors used often is the “true statement that does not answer the question”. You will be surprise how often they use this type of distractor and how often they worked especially on concepts that the examinee has not solidly learned and still a bit hazy. They usually take their toll on the last few blocks when concentration is less and fatigue more.

Using the above example, the question on what pathogenetic mechanism underlie the side effect of the treatment of choice could have a distractor that goes like this. Antibiotics causes alteration of normal bacterial flora in the bowel with overproduction of bacteria that produces extoxins. The right answer could be stated like this. Antibiotics causes disuliram like effects, with alcohol causing nausea and vomiting on concomitant use. Both statements are true statements but only statement 2 answers the question. For example, one question in NBME on Postmenopausal Hirsutism relies on multiple true statements that does not answer the question. Only one statement answer the question.

Other types of distractors are used less often because they can only be used on specific conditions while the first type of distractor can be used almost anywhere. Other common type of distractors include the following

1.       Common misconceptions – for example most people know that AIDS are not transmitted by kissing so will presume that the HIV virus is not found in saliva, which is false

2.       Recent changes in medical concepts – a favorite is a change in drug of choice for various reasons. They will usually also give the old drug of choice or treatment of choice with the new one.

3.       Close sounding names and or diseases in the choice. Since most people memorize or familiarize themselves with concepts by reading aloud to themselves, they can get confused if they do not pay attention to the actual spelling or master the information i.e. Cushing disease vs. Cushing syndrome.

4.       Disease, drugs or other medical concepts that are similar in a lot of aspects except in some small crucial detail, to make sure you know the crucial detail.

Next time we will discuss the various ways you should prep for this and the strategies you can use when answering this type of questions. There are other characteristics of USMLE type questions you should be aware of, but this three are the major ones and the most common pitfalls for most people.

For those in the prep course who are wondering why I haven’t taught you these, they will actually be taught in the latter part of your prep when you start with q Banks and just before the actual examination. As I said the best way to prepare for the examination is to have a solid knowledge base to rely on. Relying on tips and tricks to pass the exam without a solid knowledge base of medical concepts is risky. Having a solid base and relying on the tips and tricks for those extra points to get higher scores is the best approach. So at this stage, you should be building a solid knowledge base. Plus, I am still in the process of building and making the necessary study tools you need for this part of your prep. Although you can build your own study tools, I would rather you study and let me make the tools, just to be sure it’s done right. High Yield Fast Facts is just one of the tools, more are coming.

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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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