Test Taking Strategies for the USMLE

Hi everyone, I am making this new thread about test taking strategies.

A little bit about myself. I am an IMG from Indonesia. I graduated 2012, start studying
USMLE 2014. These are my scores:
step 1: 258
step 2 ck: 261
step 2 cs: first pass
step 3: 239

I have 2 years experience as a private USMLE tutor (all steps). All of my students
passed, some have good scores, some just barely pass, it really depends on their
baseline and effort. Since I usually post my ads in craiglist, the student that came to me
are the ones that very desperate and very difficult to teach. I need to explain in a very
basic, concrete way. This actually allows me to improve my ability to explain in dumbest
way possible lol. I used to cover all materials, but since I match, I don’t tutor that much
anymore… however, I can at least share my test taking strategies for you.

The reason why I am doing this is because I felt that test taking strategies are very
rarely discussed. you can always find good source for materials like Kaplan, UW, fa,
etc, but these will not improve your test taking skills per se. I know Kaplan/ Becker
discuss some test taking strategies, but as far as I know, they don’t go into very detail,
it’s more like helping you with the thought process rather than the actual techniques.

IMO, there are 3 things that you need to get great score:
1. understand the materials
2. memorize it
3. apply your knowledge, which is including test taking skill
I put these in order... you will have to understand first, then memorize it, then apply it.
you will have hard time to memorize something that you don’t understand, and it’s
impossible to apply a knowledge that you don’t even know.

This is my personal opinion: you can get 240 with perfect memorization, 250 if you
understand difficult concept really well, and 260 if you have great test taking skill. So,
materials make you pass or get a good score, while test taking skill gives you a great
score (of course if you lack knowledge and memorization, you can compensate with test
taking skill). People who has excellent score usually has great test taking skills, and my
personal belief is that they actually do these techniques naturally/instinctively without
realizing it. when you asked these people how they did that, most of the time they would
not be able to describe it to you. So, what I am trying to do here is to describe those
abstract mind, make it more concrete and understandable. Therefore, people who has
lack of test taking skills will able to do the same thing, and hopefully, achieve great
score.
these are going to be the topics that I would like to cover:
1. steps in doing questions in general
2. time management
3. test taking strategies of specific topic: ethics, calculation, biostat, physiology, pharm,
microbiology, pictures, fast ecg approach, journal/trial/ads question, etc (will add more
as we go)

These are the steps in general of how to do a question properly, this should
always be done in order
1. read the last line
2. read 2-3 lines before the last. if you got the big picture of the question, jump to
step no 5. if you have not got the big picture, then move to step no 3
3. read the first line, make sure you got the age, gender, and chief complaint. then
read the rest of the qs stem while paraphrasing it and highlight abnormal labs
4. combine the information you got and get the big picture
5. RECALL STEP. read the last line again, then recall information regarding what
the question is asking. think of an answer, then pick the answer that
closest/similar with what you want

1st step: Reading the Last Line

Why reading the last line is the first step to do? why not reading from the above and got
the story in a more chronological way? Let’s use this question as an example:

a 31 yo woman comes to the emergency department with palpitations and shortness of

breath. she had insomnia, increased anxiety, diarrhea, and weight loss since these past
couple months. Her past medical history is significant for asthma which is well controlled
with her albuterol inhaler, gestational diabetes, preeclampsia, atrial septal defect which
is not corrected since her birth, and chronic migraine. Physical exam reveals a pleasant
woman in no acute distress, lungs are clear to auscultation bilaterally, fixed splitting was
found. TSH and FT4 was sent with showed the following results:
TSH 0.02
T4 14
her b-hcg is negative. intravenous propranolol is given. in addition to its beta-receptor
blocking activity, propranolol is likely to benefit this patient by affecting which of the
following?
a. prevents the production of thyroid antibodies
b. synthesis of thyroxine
c. inhibits peripheral conversion
d. prevents t3 to bind to its receptor
Now, who cares if the patient is female, male, old, young? who cares if she has asthma
or migraine? I don’t care, and nor should you... the question is clear: what is another
propranolol mechanism of action related to thyroid condition? that is the only thing you
need to recall! so answer would be C

this question is a great example how reading the last line allow you to focus only at the
necessary information, recall only the important information, get you oriented
immediately, and SAVE A HUGE AMOUNT OF TIME.
A little note:
in step 1 you will have more chance to meet these types of questions where you can
read the last line and got the idea what the question is actually asking.
you will encounter less number of these questions in step 2 ck, and even less in step 3.
most of the question FORCE YOU to read everything. therefore, step 2 ck / 3 require
advanced test taking skills than step 1.

Question:
a 6 d old boy came to ED because can’t eat for 8 hours. he was unable to open his
mouth; his hands are clenched. mom is an immigrant and delivered at home. physical
exam reveals increase muscle tone, arching of the back, dorsiflex feet. umbilical cord is
dirty with soil on it. what is the most effective strategy to prevent this condition?

a. vaccination of pregnant women

b. antibiotics early
c. vaccination of the baby right after birth
d. immunoglobulin
e. breastfeeding early

if you read the last line, you can see that if you know what "this condition" is, then you
might know how to prevent it. this is another example how reading the last line make
you focus on what information is necessary to answer the question. the location of the
information that you need usually located at the 2-3 lines before the last, which is our
next step.

2nd step: Read 2-3 lines before the last to get the big picture

in above question, if you read 2-3 sentences before the last, you should be able to
figure out that "this condition" is tetanus. if you can’t figure that out, that means there is
a lack of knowledge.

now as you can see, once you know its tetanus, try to read the last line again, and now
the question changed: instead of how to prevent "this condition", it becomes: how do we
prevent tetanus in newborn babies? at this point, since you already got the big picture of
what the qs is asking, you jump to step no 5, the recall step.
The recall phase is purely a knowledge test. Try to think of an answer before looking at
the answer choices, and pick the answer that rephrase what you want. in this case, you
should recall that the best way to prevent tetanus in babies are vaccination to the
mother, therefore A is the best answer. (if you don’t know the answer, that is not the end
of the world. The next step is to rule out, which I will discuss later on)

Not all question can be done in 3 steps (last line, 2nd-3rd line before the last, recall and
answer)like above. sometimes you will need to start reading from above in order to get
the necessary information. Let’s use this question as an example:

A 66 yo M comes to the office with nausea, loss of appetite, fatique, and marked
weakness. his medical history is significant for hypertension, diabetes,
hypercholesterolemia, and CAD post CABG treated with lisinopril, amlodipine, statin,
and aspirin. the patient also has polymyalgia rheumatica, for which he was on
prednisone for 12 months, but he stopped taking the medication 7 days ago because he
was unhappy with the weight gain. temp afebrile, BP 110/65 mmHg, HR 100x/min, RR
20x/min. his face is round and plethoric, there is excess supraclavicular fat deposition.
labs as follows:
Na 132
K 4.1
CL 95
HCO3 25
BUN 18
cr 0.6
Ca 9.8
glucose 70
cxr is unremarkable. which of the following biochemical abnormalities is most likely to
be present in this patient?
a. low ACTH, low aldosterone, low cortisol
b. low ACTH low aldosterone
c. low ACTH and low cortisol
d. high ACTH and low cortisol
e. high ACTH and high cortisol

Lets use the steps I mentioned above to approach this qs:

step 1, reading the last line: which of the following biochemical abnormalities would
present in this patient?
step 2, read 2-3 lines before the last. face is plethoric, round, excess supraclavicular fat
deposition. cxr unremarkable

based on these 2 steps, the information that we got is: patient seems to have excess
cortisol level. the question is, would we know the answer just based on that? well,
actually no... because Cushing syndrome can be caused by lots of things: taking excess
exogenous cortisol, lung tumor secreting ACTH, pituitary tumor, adrenal tumor. So,
which one is it? we don’t know yet, and therefore, you need MORE INFORMATION.

Does this mean that it much better to read from above in the very beginning for this
particular qs? the answer is NO. if you read the first line, what you have is a middle age
man with vague symptoms (nausea, loss appetite, weakness). if you read the last line
and 2-3 line before the last, you oriented immediately that this is about Cushing
syndrome, and you just need to know what cause this patient to have Cushing, and then
you will be able to answer the question.

ok so this question forces us to move to the 3rd and 4th steps: read the first line, make
sure you got the age, gender, and chief complaint. then read the rest of the qs
stem while paraphrasing it, and highlight abnormal labs
First, focus on these 3 main information: age, gender, and chief complaint

for above qs it would be: 66 yo M with non-specific symptoms: nausea, loss appetite,
fatigue/weak.

then read the rest of the qs stem while paraphrasing, DONT READ WORD PER
WORD, but try to rephrase it using your own word in your head, and highlight abnormal
labs only. it will pretty much become like this:
66 yo M with nausea, loss of appetite, fatigue, and weakness, on multiple heart meds,
on prednisone for 12 months, stopped 7 days ago, round plethoric face, supraclavicular
fat deposition. now vital signs are ok. hyponatremia, hypochloremia.

now convert it into a single big picture: this is a case of pt taking steroid chronically, then
stopped suddenly!

now once the big picture is obtained, you go to the recall step. don’t forget to always
read the last line again and rephrase the qs, it will become something like this: in a pt
that taking chronic steroid then suddenly stopped for 7 days. what would be the
biochemical changes of this patient? (acth and cortisol)

now it’s time to recall and it’s just a matter of your knowledge. at this point, if you got it
wrong, it means that you have lack of knowledge (understanding or memorization) of
feedback mechanism. again, you have to think of an answer first and find the one that
closest to what you looking for a little note:

combining all information and converting it into one single big picture requires some
skill. there are some questions that you might not get the big picture at all, and usually
happened in step 2ck/step 3 where the question is so vague. one way to improve this
skill is to have better knowledge. for example, if I say there is a 16 yo M with infection of
lung three times last year, and UTI 2 times 2 years ago, and sinusitis 5 times, + platelet
of 56.000, and rash, what would be the big picture? yes, its Wiskott Aldrich. people who
does not know Wiskott Aldrich will never be able to put everything together. so again,
the skill to combine information into one big picture relies partly in your knowledge.

Now we have finished the general steps of doing a question, we will move to the next
section tomorrow, which probably what most of you are waiting for:
how to rule out answer choices and how to deal with 50:50.
Once you did your 3rd step, got the big picture and into the recall phase, there will be 3
possibilities:
1. you know the answer right away
2. you can’t rule in anything
3. you are in 50:50 situation

lets discuss possibility no 2 first: you can’t rule in anything. this means that you have a
lack of knowledge regarding the SPECIFIC topic being asked, but don’t give up yet, you
may still able to answer the question by ruling out.
THIS scenario takes more time so its suggested to mark the question, leave it blank and
comeback to it on the 2nd vuelta.
what you need to do is to read every single option and recall all information that you
know related to that options. let’s make a simple question:

Which of the following is the side effects of amiodarone?

a. livedo reticularis
b. bluish vision
c. red man syndrome
d. decrease FEV1

pretend that you don’t know what is the side effects of amiodarone, then you are going
to start ruling out:
1.what is the meds that cause livedo reticularis and what are the conditions that cause
it? you may recall it can be caused by amantadine, cholesterol embolism, and some
vasculitis
2.what cause bluish vision? its Viagra
3.what cause red man syndrome? its vancomycin

therefore only 1 options left, and that’s gotta be the answer: D

as you can see, its much faster if you know what are the side effects of amiodarone:
PFT, LFT, TFTs, and smurf skin. if you see decrease fev1, then you can just click it and
move on to the next qs rather recalling information for each option.

it’s always better to rule in then rule out. ruling out takes huge amount of time and effort.
usually a common mistake most people do is once they have the answer they like, they
still try to rule out the other options just to be sure. I personally think this is not a good
idea, here is why:
1. once you already think of an answer and it fits with one of the options, that is most
likely going to be the right answer.
2. there is a very small chance that you are going to change your answer if you already
think of an answer and find it among the options.
3. if you do change your answer, you will most likely to get it wrong.
so you see there is no point of try to rule out once you already rule in! 1. you will get it
right, 2.you will rarely change it, and if you change it, 3. you will get it wrong. so just
click the answer that you want and move on! if ever the habit of ruling out comes back,
always remind yourself with the 3 facts I mentioned above.

now, if you can’t rule out until you reach 50:50 situation, then it’s very unlikely to get the
qs right, pick something and move on. but most of the time you will at least reach 50:50
situation.
To be honest with all of you, 50% of the qs in the real test are 50:50(at least for me).
And for the other question, it’s not like I am 100% certain what the answer is, there
always gonna be some doubt. so this makes 60-70% of the time you are somewhat in
50:50 situation, which is HUGE! There are couple tips you can do when you are in this
situation:

1. never pick an answer that you never heard of

I think most of you have heard this before. if the correct answer is something that you
never heard of, then you will never get that qs right at your current state, don’t feel so
bad about it. learn from that qs and don’t make the same mistake again, your score will
definitely go up.

2. always pick an answer that you can reason better

instinct vs logic, it’s always a difficult thing. let me tell you what, always go with logic,
and you will have more consistent score. when your instinct gets you to the right
answer, that’s just luck. don’t click an answer just because you think it’s the right one,
you need to have a reason. this also important when you become a doctor, you don’t
want to prescribe medicine just because you feel that is right, but because it makes
sense. so, get used to train your brain to make decision. this also correlate with the next
tips

3. pick an answer that, even if you got it wrong, you will have the least regret
if you choose an answer by instinct, and you got it right you might feel good. but if you
got it wrong, you will feel very stupid. there is no reason to click on that answer, why
would you pick it? if you have good reason to pick an answer, and you got it wrong, then
most of the time there is some part of knowledge that is missing, that’s why you got it
wrong. there is no regret, since again, at your current state of knowledge, you would
never get that qs right. read, learn, and don’t make the same mistake again. this lead to
the next tips

4. always focus with what you know

there is no point dwelling in information that you cannot process. just focus with
information that you know and go with that. it’s somewhat difficult for me to really
explain it to you, hopeful these two examples would help you to understand:

I had a student once, we encounter this qs about herpes. history seems like herpes, for
me the pictures was obvious, but for him it wasn’t. And he picked non-herpes answers!!
this does not make sense at all. why would you change your answer based on a picture
that you are not even sure? you should just focus on what you know (the history), not
dwelling on the pictures you are not even sure, and even worse, make a decision based
on that! there is no point in processing information that you don’t even know. if that
particular information is a critical information to answer the qs, then you will never be
able to answer it with your current state of knowledge, accept it.
let me explain why my student (or some other people) did above mistake. this is
because of lack confidence in their knowledge. they were thinking subconsciously that
there is something they don’t know, so they pick the other options. so, the solution is
simple, have a good knowledge. how to make sure you have good knowledge? well, if a
certain topic never mentioned in UW or FA, then very low percentage of people will
know if. So, understand and memorize UW and FA really well! have confidence in your
knowledge, so you can apply the technique: focus with what you know.

5. if there is one thing that does not fit, ignore it.

this is actually a tip for getting a big picture rather than 50:50 although it can help with
the 50:50 as well. let’s make a simple qs:
44 yo F with shoulder pain, blurry vision, headache, and jaw pain. what is the most likely
diagnosis?

the most likely diagnosis in this case is temporal giant arteritis. but wait, she is 44 yo F!
isn’t temporal giant arteritis hit >50 yrs old? usually even 60 or 70... well, in this case, it’s
still giant temporal arteritis, because there is only one thing that does not fit: pt's age. so
just ignore it. however, if there are 2 things do not fit, the chance you miss something is
big, so reconsider your big picture.

6. recall further, then search more information in the question

this is actually what I called as a "lengthened recall phase" that usually happen in step 2
ck/3, but you will encounter some qs in step 1 that require this. let’s use below qs as
example:
A 57 yo F with past medical history of drug abuse, CKD not on dialysis, hypertension,
diabetes type 2, admitted to psych unit due to mania. she was found to be bipolar. her
BP is 140/78 mmHg, HR 95, afebrile, RR 20x. lab results showed wbc of 8000, hb of
9.8, platelet 160k, creatinine of 1.9, BUN 45, Na 143, Cl 101, K 4.3, Ca 7.8, Albumin
2.8, HbA1c of 7.8%. ECG showed Sinus rhythm with QTc of 500 msec. which of the
following is the best treatment for her bipolar disorder?

a. lithium
b. valproic acid
c. haloperidol
d. chlorpromazine
e. triamterene

1st step --> reading the last line. best treatment for bipolar disorder.
at this step actually the qs becomes very clear, it’s just tx for bipolar, so you don’t have
to go to the 2nd step, you should recall first. the treatment would be lithium, atypical
antipsychotic, or valproic acid. I strongly believe in step 1 you will only encounter one of
above drugs as the answer. so, I am using step 2 ck qs to make my point here. as you
can see at this point you are in 50:50 situation, because there are 2 drugs for bipolar
disease: lithium and valproic acid. both drugs definitely can be use in bipolar! so there
must be something in the qs that tell you which is better than the other. at this point you
should recall further what is the difference between lithium and valproic acid in terms of
MOA, clinical use, and side effects:
1. lithium MOA is not clear, we can’t use that. clinical use for bipolar only. you should
know that it has narrow therapeutic range, CKD may be a problem. side effects;
diabetes insipidus, tremor, neurotoxicity, Ebstein anomaly in pregnant woman.
2. valproic acid MOA is inhibiting Na channel in the brain, it has antiseizure activity as
well. side effects would be thrombocytopenia, alopecia, liver failure, teratogenic effect.
by recalling further, you can see that there is some information you need to look for in
the qs stem. this is the time to go to your 2nd and 3rd step to find those information,
here is some thought process in this qs:
if this patient has some neuro issues probably lithium is not a good thing, if she is
pregnant, probably is not good either. if she has hypernatremia it might not be a good
thing because lithium can cause diabetes insipidus. for valproic acid, if the pt has
seizure history as well this can be 2 birds in one stone, if patient has thrombocytopenia
or liver failure already it’s not good, and not good for pregnant woman either.

all the things that I mentioned above are all negative in this patient: she has normal Na
level, she is not pregnant, she has no seizure history, she has no thrombocytopenia or
liver failure. she got one thing though: renal failure. and lithium has narrow therapeutic
range. at least that one fits, so the better answer here is valproic acid.
I have to emphasize again that this is not a typical qs of step 1, but it’s one way to
approach a 50:50.

7. if it’s a 50:50 memorization thing, then the first thought is always correct. skip
the qs and come back.
for example, you forgot which chromosome cystic fibrosis gene is located. you are
between chromosome 17 and 7. the first thought you have most likely to be the correct
one. don’t stay in the question too long because your brain might play trick on you and
your first thought becomes blurry. one trick to make it clearer is to skip the question
altogether. when you come back, you will have less biased mind for a couple seconds,
get your first thought and click the answer.

8. if all above fails, then **** it, click whatever and move on. it is not the only qs in
the world, let it go.

TIME MANAGEMENT STRATEGIES

in a block of 40 qs and 1-hour time, you want to do 2 runs in 1 block. in the first run your
speed should be less than equal to 1 min/qs. NO EL CASO EN LA VIDA REAL
SIEMPRE. TOMEN Y DEJEN.. (as long as you have good knowledge, it should be <15
qs with 15 min left.) this is very possible to do, because in the first run your focus is to
find qs that only require a 2-step process: getting the big picture (by reading last line,
2nd-3rd line before the last, or reading and paraphrasing), then (easy) recall and
answer the qs. if the question requires you to do more than that, then SKIP IT!
another way to say this is to SKIP questions that:
1. hard to recall
2. force you to rule out
3. put you in 50:50 situation

Let me say this one more time, your goal in the first run is to:
1. hunt for easy questions and 2. getting the big picture for the difficult qs!

when I say SKIP, it means you LEFT IT BLANK. NEVER PICK AN ANSWER THEN
FLAG IT. the reason is to keep the qs unbiased. if you already pick an answer (based
on your half-made judgment/reasoning) and you come back, you will feel reluctant to
change it because the rule is not to change your first answer. Keep it unbiased by
keeping it blank!

Some of you may raise a question then: so, when should I flag a qs? well, basically
never... but I do flag questions when I accidentally click on something and realize that
the qs should be skipped from the first place. This just to give a sign that I should come
back to this qs later.

Now, if you have moderate- good knowledge, you should be left with <15 qs
unanswered. So mathematically:
there are 40 qs total, you do 1 min/qs, so in the first run you spent 40 min with 20 min
left. very rarely you can be perfect with 1 min/qs, so usually you will have 15 min left
with <15 qs unanswered.
if you end up having >15 qs unanswered, then either it’s a very difficult block, or you
definitely lack knowledge. please go study more.
during your first run, always check your time! for example, if you are in qs number 7,
then your time should show 53 min left! check your time especially after you felt that you
spend too much time on a question!

in the 2nd run, your job is to finish the rest of the qs by using the general steps I
mentioned in the previous post. since you already got the big picture, you only need
jump straight to the rule out or 50:50 techniques. during this 2nd run, you should not
spend more than 1 extra min per question. Have you ever heard the more time you
spend in a qs, the more likely you got it wrong? this is very true. if you encounter a qs
that you can’t figure out after 2 min, then accept it, you are most likely to get that qs
wrong. click whatever and move.

let me tell you this: most people with good test taking skills subconsciously do above
techniques (2 runs). they just skip a qs right away when they know it’s hard, they come
back and redo the qs. Nobody told them what the advantages are of doing that, they
just do. let me explain the advantage of 2 runs:

1. the idea of having 2 runs is to distribute the time correctly: you spend less time
in easy question and spend more time in the hard ones.
imagine if you have 7 min to do 5 questions. let’s say question no 1,4,5 are easy, while
qs no 2 and 3 are difficult. assume that you require 1 min to do easy questions, and 2
min to do the hard ones.
if you don’t skip the qs, what’s gonna happen is you are going to do qs no 5 with 1 min
left, which is anxiety provoking and increase the risk to get an easy question wrong
(imagine 80% of people got it right and you got it wrong. This will decrease your score
very significantly!). if you skip no 2 and 3, you will have 3 min left when you engage qs
no 5... after you answer qs no 5, you come back to qs no 2 and 3 with 2 min left. now
even if you got it wrong, it’s a hard qs which will not hurt your score that much. hope this
makes sense.

2. getting an epiphany. for some reason, you have more chance to get an epiphany
when you attempt a qs the 2nd time. This means you increase your chance of getting a
hard question right!

3. you actually do a question much faster by skipping it rather than dwelling with
it.
4. you have the peace of mind that you actually already saw all the qs, it gives you
less anxiety when you see the difficult qs the 2nd time. imagine if you have 1 min left
with 1 qs left that you have not encounter before. it’s much better to have 1 qs left with 1
min left but at least you have the big picture ready!

Now I have to discuss the last possible scenario: what if on the 1st run I got 18 qs
unanswered with 13 min left?!
if you are in this situation, guess 5 qs very quickly, so you will be in 13 min left with 13
qs. basically, just adjust the best you can so you left with 1min/qs for the 2nd run. I have
been in this situation many times, the key is just to have the mentality to get the job
done: answer all question with good judgment.
again its very rare you will be in this situation as long as you have good knowledge, it
should be <15 qs with 15 min left.

little tips: during the exam, you will definitely get this sense of losing focus. you don’t
know what you are reading, your mind moves to another place, or something like that.
These episodes are very hard to avoid but can be reduced. the trick is to not force
refocusing yourself, but to skip to the next qs. if you still not focusing on the next qs,
skip it again. just keep skipping until you regain your focus. once you regain your focus,
come back immediately to the qs you just skipped, and surprisingly, the previous qs
becomes very easy for you (if it’s truly easy).
another tip to keep focus during exam is to create a habit: like repositioning your
glasses, or rubbing your shoulder, or whatever. this is very commonly done by
professional athlete. for example, you can check how Rafael Nadal always touch his
nose and correcting his hair on both of his ears before serving. you can create your
own. do this when you lose focus or every time you go to the next question. it’s just a
mental trick to your brain.

ok, so in summary for time management strategies:

1.do 2 runs, 1min/qs
2.first run is to hunt for easy question or getting big picture for difficult qs
3.skip the difficult qs completely
4.2nd run is to apply rule out or 50:50 techniques. extra 1 min/qs
5.adjust your time as needed

alright everyone, basically we finished the main test taking strategies.

Please feel free to ask any questions!