Reasoning Through Multi-Step USMLE & Shelf Exam Questions

  • /Reviewed by: Amy Rontal, MD
  • USMLE and Shelf exam questions that involve two or three steps can be challenging. They often require reading a convoluted clinical anecdote before reasoning through several steps to arrive at the correct answer choice. While these questions may seem daunting, you can utilize a consistent approach that will simplify the process of answering these difficult questions.

    Step 1: Break it Down

    The first step to approaching a multi-level question is to break it down into its components. Trying to solve each component all at once often leaves you vulnerable to making silly mistakes. For example, a clinical anecdote might describe a patient who presents with recent weight loss, heat intolerance, sweating, and proptosis with a decreased TSH found on laboratory testing.

    A typical USMLE question following this anecdote might be “Antibodies to which of the following proteins underlies this patient’s clinical condition?” Questions like this one require you to answer at least one underlying problem before being able to address the actual question.

    So let’s break down each step of our first question. We can’t guess what the auto-antibody might be without knowing the condition and taking a look at all of the answer choices before thinking it over can be distracting. So, before moving on to selecting an answer we should address the underlying issue, which is “What is the clinical condition presented in this anecdote?” Grave’s disease seems like the most likely disease, especially given that the questions tells us an auto-antibody is involved in the pathogenesis.

    Step 2: Rephrase the Question

    After breaking down the question and answering the underlying problems, we can use them to tackle the actual question. I have found it most helpful to rephrase the question based on the answer from the previous step. For example, the question becomes “Antibodies to which of the following proteins underlies Grave’s disease?” — a much simpler problem that will lead us to look for “TSH receptor” among the given answer choices.

    Rephrasing becomes even more useful in the case of a three-step question, such as “The pathogenesis of this patient’s condition is most analogous to which condition?” Using the same clinical vignette of Grave’s disease, our second step will be to address “What is the etiology of this patient’s clinical condition?” — which in our case is a type II hypersensitivity reaction against the TSH receptor.

    Having addressed the first two steps, we can finally rephrase the question as “Which of the following conditions is a type II hypersensitivity reaction?” In this way, the problem is simplified into the single step of selecting a type II hypersensitivity reaction from the answer choices.

    Multi-step questions are difficult, not only because of the additional knowledge required to tackle the problem, but also because they necessitate a more extensive thought process. By utilizing a consistent approach of first breaking down and then rephrasing the question, you won’t get tripped up on the way to answering problems you know the answer to.

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