USMLE Strategy: Shrinking Questions Down to Manageable Size
- Sep 19, 2017
When I started medical school, I had a major problem — I was a very inefficient reader. While I could read through a passage or page very rapidly, I constantly found myself rereading that same material as many as four or five times before moving on. My logic was simple, yet flawed â€“ medical school is hard, every sentence I read could be tested, so I must memorize each sentence. It didn’t take long for me to realize that this strategy was unsustainable and that a better alternative needed to be found.
Over the next few UWorld blocks, I stopped re-reading material and instead focused on summarizing key details at the end of each passage or page.
Now, rather than forcing myself to memorize pages of minutiae, I was challenging myself to summarize text down to its’ most relevant details and conceptually understand each topic.
As I transitioned in to my USMLE Step I studying, I continued to utilize a similar strategy. However, despite my strong scores during preclinical courses, my UWorld scores were not where I expected them to be. While I could easily answer recall based questions (i.e. what is the mechanism of action of digoxin), I found myself struggling on the 2-step and 3-step questions that so often determine the difference between an average score and a 240+. As I analyzed my own performance, I noticed that I was frequently overlooking key details buried within the question stem. In doing so, I was choosing answers that addressed only a small part of the patient’s presentation or was struggling to decipher the overall objective of the question. Not being one to accept defeat, I began to devise new methods to approach the questions and ultimately settled on a summary technique that was like my reading style. Utilizing this method allowed me to master difficult questions, improved my speed, and built a foundation for test taking that I still use today.
My USMLE Question Summary Method:
As I read through questions, I routinely highlight the 4-8 most important details presented to me. These include things such as:
- Age â€“ a good test taker will ensure that the answer choice is in line with the patient’s age (i.e. you can probably rule out hypertrophic cardiomyopathy in an 89-year-old male with new onset cardiac symptoms)
- The acuity or chronicity of the presenting symptoms
- Pertinent positive and pertinent negative history and physical exam findings
- Key risk factors
- Key lab and imaging findings
Finally, once I have reached the end of a question I will make a summary statement that is 1-2 sentences long and serves to appropriately direct me towards the correct example.
Here is an example of my technique in action.
For practice, try to create your own summary statement of this UWorld-Style Question:
A 75-year-old male presents for evaluation of 3 months of worsening shortness of breath. His symptoms were initially present only with exertion but now occur at rest. He also notes shortness of breath that awakens him from sleep at night and has forced him to lie on 3 pillows. He denies any fever, chills, cough, or chest pain. His past medical history is remarkable for hypertension, type 2 diabetes, and a 45-pack year history of smoking. Seven years prior, he underwent stenting of a left anterior descending artery lesion after presenting with a myocardial infarction. His medications include amlodipine and metformin. On exam, his vital signs are: Temperature 98.9, Heart Rate 85/minute, Respiratory Rate 18/minute, and BP 145/85. O2 saturation is 92% on room air. His physical exam is remarkable for an early diastolic murmur best heard at the apex in the left lateral decubitus position and 2+ pitting lower extremity edema. Chest X-ray shows bilateral pulmonary edema and cardiomegaly. What is the next best step in management?
- Coronary angiography
- Inhaled Beta Agonist
- IV corticosteroids
As you can see, the above example is a 2-step question that requires you to both make a diagnosis and to know how to manage that condition. Additionally, based on the answer choices we can deduce that the diagnosis is either cardiac (answers A-C), infectious (answer D), or pulmonary (answers E-F). Thus, a good summary statement should serve to point towards one of those three options. As such, I try to focus on key details that would rule one of them in or out: being afebrile points away from infection, the presence of an S3 points towards cardiac, etc.
Sample Summary Statement #1:
This is a 75-year-old male with a past medical history of an MI and multiple cardiac risk factors presenting with worsening dyspnea. He is afebrile, has a low O2 saturation, lacks a cough, and has S3 and pitting edema on exam. His chest X-ray suggests a cardiac process. How should I treat him?
Sample Summary Statement #2:
How do you manage a patient with acute decompensated heart failure?
When creating a summary statement, I’ve found that there are generally two options depending on how well you know the material. The first statement that I created is made when you do not automatically reach the diagnosis by reading the question stem. Here, you are highlighting key details that should help you eliminate the non-cardiac answer choices (answers D-F) and thus focus your line of thinking.
As your knowledge base grows, you should begin to make summary statements like the latter option. These statements serve to focus your attention to the question at hand and can turn a complex 2-step or 3-step question in to a simple, 1-step problem.
Rules for Creating USMLE Summary Statements:
As with anything in medical school, success with this method requires practice. When I am working with students as a tutor and we are doing questions together, I will have them tell me their summary statement at the end of each question. In doing so, they can see what details they may have looked over and start to become masters of this technique early on. I can also give them several rules to follow. These include:
- Keep your summary statements short â€“ repeating the entire question stem is a waste of time and defeats the purpose.
- Learn from your mistakes â€“ if you miss a question, try to discover if it was because of a lack of knowledge (i.e. not knowing that the treatment of decompensated heart failure was diuresis in the example above) versus a failure of your process (i.e. not realizing that the question stem above was about decompensated heart failure in the first place). If the latter is occurring frequently, then you need to expand your summaries to include more key details.
- Don’t over extend yourself â€“ make a summary as to the best of your abilities and then start using other strategies to answer the question. You don’t want to waste time trying to craft the perfect summary or risk making an incorrect assumption because you are trying to answer the question ahead of the multiple-choice options.
One last example for practice â€¦
A 45-year-old female presents with 3-days of cough. She has a past medical history of HIV and is non-compliant with HAART. On review, she describes a cough with productive, purulent sputum. She also endorses fever, chills, and dyspnea on exertion. She was recently seen by her primary care physician and had a CD4 count of 175. Vital signs: Temperature 102.3, Heart Rate 105/minute, Respiratory Rate 18/minute, and BP 110/78. Physical exam is negative for murmurs. She has no lower extremity edema. Chest X-ray shows a bilateral infiltrate. What is the next best step in management?
Sample Summary Statement #1:
A 45-year-old female with HIV and a CD4 < 200 presenting with cough, fever, and a bilateral process on her chest x-ray. How should you treat her?
Sample Summary Statement #2:
How should you treat Pneumocystis pneumonia (PCP)?
Again, by looking at the answer choices I know that the objective of this question focuses on treatment of either a cardiac or infectious condition. Furthermore, I know that I need to distinguish of an infection is bacterial, viral, or fungal. Thus, when creating my summary statement I highlight her fever and HIV status to push myself in the infectious direction. From there, the bilateral chest x-ray findings point me away from community acquired pneumonia (answers A and E) and make me think of PCP.
In closing, I hope that you can utilize this strategy to help yourself master difficult questions on the USMLE. I believe that this method will help you address the important aspects of a question, ignore distractors, and improve your score. Good luck!