I wrote part of this post in answer to questions from my readers and students. After 2 emails and one answer to comments, I have decided to elaborate and write in more detail as a post that I will share with everyone. So what do you do on the day of the USMLE Exam?
Be at Your Best on the Day of the USMLE Exam.
So what do you do on the day of the USMLE examination? The day you sit for the USMLE is the culmination of months of preparation. It may seem unfair that no matter how well your performance were in those countless q banks and test simulation, the only performance that really counts is the one you do on exam day. Therefore, it makes sense to maximize your chances of performing well for that date.
Your preparation should begin way before the date of your USMLE examination, when you schedule the examination. It is a known fact that during review, people do reach a plateau and the best time to sit for the USMLE exam is just before or just after you reach your peak. Earlier or later than that can result in lower scores. During review, immediately after learning and memorizing your lessons, you start forgetting right away. Normally, the amount of medical concepts you are memorizing and retaining is growing faster than you are forgetting them. However, there comes a time when you reach your peak and eventually plateaus. Afterwards you will go into decline and forget more than you are learning. Most people go into plateau in about 6 to 8 months, therefore the ideal review time for the USMLE is around that long. That is why my USMLE Step 1 prep course is around 6 months long.
Stop Studying for the USMLE Exam at the Right Time
The next question you have to ask yourself is when do you actually stop studying? Some make the mistake of studying right up to the night before they sit for the USMLE exam while others start relaxingtwo weeks before their scheduled USMLE exam.
What’s wrong with studying up to the last minute? Well to illustrate, imagine a marathon runner who the day before the marathon decides to do a marathon to see if he can win the marathon. The USMLE is an exhausting exam that will test your staminato the limit. Anyone who has taken the USMLE exam can tell you that their brains felt like mush and refuses to function properly in the last 2 blocks of the USMLE exam. I know, mine did. Therefore, it makes sense to rest as much as possible the day before the examination to regenerate your energy for the battle ahead. In fact I recommend to stop studying 2 days before the actual day of your USMLE examination.
Now if resting is good, why shouldn’t I rest 1 or two weeks before my scheduled USMLE exam. Again, let’s use a sports example to answer this question. Professional boxers usually arrive a week or 2 before the bout to the venue where the bout will be held. By this time they’ve already finished their training. Any boxer, who has not finished training for the bout by that time is bound to lose the fight. And yet instead of painting the town red, they spend their time in the gym, practicing and sparring. The reason is so that they can maintain focus on the bout itself. Losing focus this late may mean losing the bout. The same holds true with preparing for the USMLE. The problem most old grad have is to start their USMLE review. They usually go through lots of false starts before their review start going smoothly. The main reason is that it’s been too long since they’ve studied and there are lots of things going on in their life that its hard to focus on the prep. Getting distracted and losing focus too early before the exam can cause you to perform at less than peak condition in the actual USMLE examination. You need to block off everything until you’ve finished the exam.
What to Do 1 to 2 Weeks Before the Actual USMLE Exam.
So what should you be doing 1 to 2 weeks before the actual examination? Well definitely you should have finished the heavy lifting and not studying anything new. The reason is that your mind will tend to remember better the most recent things you have studied and if that is low yield new stuff (presuming you studied the higher yield stuff first), that is what you will remember better and unfortunately has less chances of appearing in the exam. Therefore the best thing to do at this point is try to cover the highest yield stuff. If you are in my course, you would be enrolled in the High Yield Fast Facts (HYFF) Course, a compilation of the highest yield test materials in electronic flashcard format. If you are reviewing on your own, you can use the Rapid Review section of First Aid at the back of the book. However, it is in table format which is less effective than in flashcard format. This way you remember the highest yield information best when you sit for the exam. (Did I mention that someone who got a 99/256 use my HYFF course two weeks before the exam? see here!)
What to Do the Last 2 Days Before the USMLE Exam
Another important thing to consider is how far you lived from the Prometric Center where you will be taking your USMLE exam. The exam is a high stress event. If you have to drive through traffic and you are 2 hours away, the stress can be tremendous. Worse, traffic may be unpredictable and you may get there late. In my case, I lived about 1 hour by car from the Prometric exam site. The route I have to travel is notorious for unpredictable traffic that could last for 2 to 3 hours. So instead of increasing my own stress. I booked myself into a hotel about 10 minute walk from the site the night before. I could take a cab (parking is also terrible) and be there in about 3 minutes including traffic light change. US$100, the price of one night in the hotel is small compared to the $800++ exam fees, $1000++ for books, qbanks, NBME, etc. and 7 months of prep time I had already invested so far. Cab fare is $5 plus tip.
You can spend the last 2 days before the examination on anything to relax you. I watched a movie before my exam. A comedy, Ice Age 2. Then on the night before the exam, the most important thing is to get a good night’s rest. That involves a regular meal, not too heavy. Maybe a nice warm bath. Sleep early so you can wake up early. But do not take tranquilizers as that can cause you not to be in peak form the next day. Make sure everything you need is prepared beforehand. (Clothes, food, water, medicine, ID, Exam permit, etc.) Preparing it early in the morning just increases your stress level. In fact if you can prepare everything 2 days before so much the better.
Remember, stress is additive. The USMLE examination itself is an extremely stressful event. Any other worries on the same day just adds to the stress. So prepare everything at least 2 to 3 days beforehand so that your only worry is the examination itself on that crucial day.
What to Do on the Day of the USMLE Exam Itself
Now a few things to remember on the day of the examination itself. The most important is to never leave a question blank. There is no penalty for a wrong answer. The USMLE is an MCQ exam and one answer is always correct. An unanswered question is a sure wrong, while a question answered even with a guess is a possible right. And just one additional right answer may mean the difference between a 74 and 75 or a 98 and 99. As sports great Wayne Gretzky said, “ You miss 100% of the shot you do not take.”
So what’s a method to make sure you do this. Well, you should allocate around 10 seconds per question to randomly pick the answer once your time runs out. At the two minute warning, it means you can randomly answer at least 12 questions. So if you have less than that to answer then you can start randomly answering the q’s that you have not finished. For example at the 2 minute warning, you have six questions unanswered. Continue answering as before, but at the one minute mark, just randomly guess an answer on the remaining unanswered questions.
Now for pacing in the actual examination. The best pacing schedule makes use of a couple of facts. One, you are more alert in the early morning than in the afternoon when the exam will have taken it’s toll. Therefore it makes sense to schedule more blocks before lunch. So for USMLE Step 1, 4, 3 would be good. For USMLE Step 2, no choice but 4, 4. Now you are sleepiest after lunch, because of the act of digestion, therefore schedule only 1 block after lunch then have a break afterward. Never take more than 2 blocks before you take a break with some food or sugared drink. Your sugar level starts falling after 2 hours (physiology of fasting) and sugar is the main fuel for your brain.
So best to schedule 2 blocks, 15 minute break, 2 blocks then 25 minute lunch, then 1 block, 10 minute break, then last 2 blocks.(or 3 blocks if Step 2) You can take a break between the last 2 blocks if you feel you need it. Notice that the total break is 50 minutes. Reason is that the actual break will usually be longer than the time you scheduled it. Just logging in and out of the room will take 1.5 to 2 minutes. The rest room is usually two doors out (both the exam center in my home country and the one in San Francisco where I took Step 3 have the same layout. So I presume all Prometric centers have the same general layout) So you have to walk. If you just need a short break between blocks, just sit on your cubicle and rest for a minute or two before starting the next block. As I said logging in and out is a time waster.
Scheduling Meals and Breaks on the Day of the USMLE Exam
Now we need to talk about scheduling meals and breaks and what to eat. Light breakfast in the morning preferably no meat but high energy carbohydrate. (High protein, high fat foods can make you sleepy, so no ham and eggs, sorry) Now coffee or tea to keep you awake, but limit to a cup since they increase urine formation.(increased heart rate, increased GFR = increased urine formation)
For the morning break, do not bring sandwich. It takes too long to finish eating it. Bring something sweet, high energy, high carbohydrate that can give you a sugar boost. (I ate a small high sugar cake that I finished in 4 to 5 bites.) You can opt to wash down with a cola (which can provide both sugar and caffeine boost) Do not skip the morning break. Remember your brain needs sugar to function properly. For the USMLE exam, you need your brain to function at peak condition.
For lunch break, do not eat full meal. A sandwich, preferably not high protein (egg sandwich or cheese sandwich comes to mind) is advisable. It’s actually basic physiology. A heavy meal will cause blood flow to be diverted to your GI tract longer therefore less blood flow to brain. Plus, proteins and fat will cause secretion of more HCl for digestion leading to Metabolic alkalosis. This leads to hypoventilation (to increase CO2) and therefore less oxygen to the brain. Longer digestive time causes longer time for HCl to be reabsorbed. This is the main reason why you are sleepiest after lunch.
For the afternoon break, a high sugary drink whether cola or juice will suffice. Limit total water intake as that can increase need for bathroom breaks.(600 t0 800 ml will be enough, max 2 breaks)
Medicines You might Need on the Day of the USMLE Exam
Now for the meds, you need the following.
1. Pain reliever – paracetamol, in case of headache or any other ache.
2. Loperamide – in case of gastrointestinal emergency eg. diarrhea
3. Antacid – in case of hyperacidity (anxiety can cause it)
4. Beta blocker – in case anxiety and palpitation become too distracting.
Don’t forget to bring any other meds you may need ( anti-histamine if you have allergies, salbutamol inhaler if you are asthmatic, etc.)
Now one last word of advise. Once you finish a block, forget about it. Concentrate on the block you are currently answering. Worrying about a block you have finished will not raise your score. Concentrating on the current block will help raise your score. Not paying attention to your current block because you are busy worrying about the previous block will even lower your score.
After you finish the exam. Go home. Stop thinking about the exam. Have dinner with your family, whom you probably haven’t spoken to in months. Then take on a week long vacation before even starting to worry about your USMLE score. In the meantime, prepare what you want to write on the exam experience page of your favorite forum.