Learn to decipher what the USMLE and COMLEX are asking.
- Get to the root of what they are asking and lose the distractions
- Third-order questions
- Know what to look for in your review
Gather facts you didn’t know and critical thinking/reasoning
1.) Decipher what the USMLE is asking. This skill alone accounted for most of my mistakes on practice exams during my assessments. So I value this board prep learning JUST as highly as learning any knowledge from FA.
- A board question is a vignette and filled with distractors. Many vignettes discuss things you don’t know or DON’T need to know – things unnecessary to the question. I had questions discuss mice genetics on assays with detailed biochem that got me all up in arms trying to decipher if it was a genetic or biochem question only to figure out it was a biostatistics question at the very last sentence. Key here is ALWAYS read the question first before the vignette. The question is the last sentence before the answer choices. THEN go gather the info you need to answer that question from the vignette. YOU WILL NOT NEED ALL THE INFO! But don’t miss a few major data points in the vignette that will make one choice a better answer.
Third-order questions are full of dizzying distractors. Out of a clinical picture you are supposed to: First figure out what disease this is, then get the treatment right, then get the side effect and lastly remember the enzyme to blame for this side effect! And you know this is what you are looking for because a list of enzymes are the answer choices. See, in one question they are testing your entire understanding of what’s most important about a disease – not the disease name or the drug name…but; rather, the important target enzyme this disease highlighted which you can now identify as the culprit and treatment point to prevent serious side effects. Along the way of reading this vignette – should you get the disease or drug or side effect or enzyme wrong you would go down the wrong trail and get the question wrong. So while the specific names of each order in the question are simply distractors; the sequential line of recognition and knowledge must be in place. HARD right? But there is good news! When you lose your way and miss a single link in the chain of orders – all hope is NOT lost. Here’s a trick to make 3rd order questions work for you. Each disease or drug only has a few things highlighted by the USMLE that they think are important. (YOU WILL LEARN THESE by doing thousands of questions). Once you know these things you can skip a few chain links when you lose your way. Follow this example. You recognize TB in the vignette – good! But now they are talking about treatment and presenting a lot of special odd situations this patient is in and CRAP – you forgot the determinants of first-line treatment variations for TB. AND you forgot what RIPE stands for anyway! But WHOA now they are asking “what enzyme cofactor is depleted causing the most severe side effects of the first-line treatment”? How can you answer this without knowing the first-line treatment for this vignette? WELL, we know that the only TB treatment side effect that the USMLE loves is neuropathy and its the only one that can be fixed by vitamin B6 so that must be an enzyme cofactor. CORRECT! You didn’t need to know what’s the first line in this scenario or the drug name – you simply needed to recognize “1st – We are talking TB. 2nd – We are talking about treatment side effects that can be reversed. So this has to be the USMLE’s favorite “B6 fixes neuropathy – fact”. In short: Never waste time worrying about a link in the chain of multiple order questions. It will probably be a cliche board fact they are looking for in the end.
Doing these questions all day long you will learn what kind of things the boards think are important and only focus on those! For example, I have never ever been asked the name of a drug, I have never been asked to regurgitate a formula. But for each drug, there is a bigger physio topic they will chase down or they will use it to make you think about the pathology it is most commonly used for and go down that trail. Stop spending time on nomenclature and memorization as you see it is really a “connect the dots” game.
2.) If you don’t become skilled at Timing and Endurance you will lose big points for no reason. Its an absolute must. This is only learned by doing multiple blocks, timed, random. back to back. You have to. Make it second nature to pound out >150 questions a morning! See how I did it below.
3.) Practice questions have two categories of information you need. A.) Concepts and Critical thinking. B.) Facts and Memorization. You need both. As you review your practice tests categorize EVERY question into these categories. If you didn’t critically reason or conceptualize a topic correct then you need to review the topic and re-see it in the light of how the question can twist the interpretation and understanding of a medical concept. If you simply don’t know a fact (and it can’t but conceptualized) – then put it into a memorization bucket i.e. ANKI or a question journal.
For the first two months, I went through all of USMLE-RX FirstAid’s question bank in anatomical topical blocks of questions, timed but not randomized. I did these blocks in congruence with what I was going through my “in-depth topical block reviews”, which I was doing using FirstAid book and DIT videos. USMLE-RX Qbank follows FirstAid by referencing page numbers and images. Doing this congruently with my review cemented my FA and DIT lessons by turning the concepts/facts I was reviewing into application and clinical reasoning. When I got something wrong I could look into my print FA copy where I had just seen it earlier. I would see the fact again in the context of questions and for a repeat time to remember it.
IMPORTANTLY I staggered my questions so that if I reviewed a topic one day, I did questions on it 1-2 days later. This is a memory hack of science that we need to recall and relearn in order to remember something. So if you are renal today then tomorrow when you move to pulmonology you do renal questions so you recall and relearn renal and the next day you do pulm questions while you are learning another topic.
Last 3 months I did UWORLD. I did it randomized, timed in blocks of 45. 4 blocks back to back every morning. During this time I became a “question-whiz” learning all the skill of deciphering, getting to the true question, shortcuts/losing distractors, timing, and endurance. It was also a constant knowledge assessment. The most valuable knowledge assessment was what topics I couldn’t reason through, the 2nd assessment was where I was lacking in memorizable details e.g. bugs, enzymes, etc. By doing this I picked up thousands of facts and conceptual understandings that I hadn’t learned during my block study. I completed UWORLD 2x.