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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