Make No Mistake: This USMLE MisSTEP is Totally Avoidable

  • /Reviewed by: Amy Rontal, MD
  • We are all guilty of it. In fact, it is the most common mistake I see as a student approaches a test question. It doesn’t matter if it’s a practice test, a shelf exam, or Steps 1, 2, or 3. In the fast-paced, high-energy test environment, it is a mistake that is just too easy to make. Thus, we all fall into the trap. I often do it myself and I am not proud of it. But what exactly is it that we’re all missing, despite our best intentions?

    We are quickly blowing through the first sentence of clinical vignettes and our question answering is suffering because of it.

    Why is it hurting us?

    The first sentence in your USMLE sample vignette is packed with some of the most useful information you need to find the right answer.

    There is loads of wildly important information to be found here! For example, in the first sentence, you will likely find out your basic demographic data. Are you dealing with a healthy 22-year old woman or a frail 67 year old man? The two experience very different sets of pathologies!

    Additionally, an often overlooked piece of information in this sentence is where and how the patient presents.

    Are they here for a routine wellness check-up? Were they brought in by EMS? Found by a caregiver? Is their pathology acute in nature, or has it been an indolent process? Patients with free air under their diaphragms don’t complain of 3 months of severe abdominal pain, and patients with slow GI bleeds secondary to colon cancer don’t just wake up one day with anemia-driven fatigue. The chronicity of the patient’s problem is crucial!

    Furthermore, is the question giving you the race of the patient?

    This is not done routinely and often hints at a particular pathology. There is a good chance that your Greek anemic man has beta-thalessemia while your African-American anemic man is suffering from G6PD deficiency.

    Most importantly, you get the patient’s chief complaint…

    What should I do with this information?

    If you haven’t noticed, most medical school curriculums focus on your ability to develop a broad differential diagnosis from the patient’s history, narrow it down from there with physical exam and specialized exam maneuvers, and only after all of that, use laboratory data and possibly imaging to settle on a diagnosis. The way you approach a real-life patient should be the way that you approach a vignette.

    Let’s say you are given a 62 year-old man with a cough. Somewhere in your mind, you have to build a differential diagnosis. Now, I’m not referring to the internal medicine case presentation where you wax poetic on the 32 possible diagnoses (including rare zoonoses and filarial infections) that might explain what’s going on. All you need to do is think of a few basic conditions that would make an older gentleman cough. A few things that come to mind are pneumonia, COPD, heart failure, upper respiratory infection, and GERD. Now this list is by no means comprehensive, but it will probably explain the cough of 85% of the patients in your USMLE clinical vignettes. It doesn’t have to be beautiful or complete, but you should at least take a breath and a moment to ask yourself the question “What might be making this patient cough?”

    It is nearly impossible to answer a USMLE question without making a diagnosis, so this is a necessary step. Only after you have formed a basic differential diagnosis should you proceed with the rest of the information in the question.

    This hard stop will ensure you don’t neglect the info in the first sentence.

    Why do we rush through this important information?

    There are a number of reasons.

    1. First of all, we are usually a bit “hungover” from the previous question.

    We devoted our entire minds to diagnosing and treating that poor middle-aged woman who was in a motor vehicle accident and now we have to address a 4-year old limping child. It is a difficult task to switch gears from trauma to peds within the click of a “NEXT” button. As we acquaint ourselves with this new patient, it often takes a sentence or two before we are actually focused on the new patient!

    2. Additionally, the first sentence is boring!

    It is the only sentence that is more or less the same throughout every question on the test. As such, we naturally get a little sick of reading them. How many times have you gotten to the end of a question and all you can remember is a “something year old man with such and such a problem?” The data has already been lost before you’ve even finished reading the question! And now you are expected to make an answer choice about a patient whom you have already forgotten? Impossible!

    3. Lastly, our minds crave the easily digestible things like lab work and imaging.

    It is a simple and satisfying thing to work your way through labs thinking “low, low, normal, high.” They are certain, finite, and easy to characterize. Imaging and EKGs call upon a different part of our brain that can get bored after working through hours and hours of incessant text. Thus, we fly through the question looking for an easy (likely non-existent!) crumb to pick up, a scent to follow to the correct answer.

    So please! Let this be a call to action and you will find your scores improving. Give the first sentence of all of your vignette-based questions the credence that they deserve. Come up with a brief but powerful differential before trying to interpret the rest of the question! You will find that there is only one way to approach a USMLE question – with patience and care.