How To Answer A USMLE/NBME Question

April 2, 2021
It’s common for students to feel overwhelmed or even panicked when put under the spotlight for a high-stakes, timed, multiple-choice test. Many questions can be tautological or filled with distractors, irrelevant information, and a slew of lab tests and diagnostics that obscure the case and the correct answer. However, having a systematic approach can demystify and organize the process, making these questions much easier. Remember: you’re taking a multiple-choice test, so you should use everything to your advantage to maximize your score.

Step 1: Start with the Question Being Asked

There are lots of strategies out there, but a tried and true approach is to first read the question stem and then quickly scan the answer choices. This generally takes less than 5 seconds and can give you a major edge. By reading the question first, you already know what you need to answer, and then you see which options are available. This is a fast, easy way of directing your thinking right from the beginning.

For example, if the question is “Which of the following is the most likely cause of this patient’s hypercalcemia?” you know you should scan the case for causes of hypercalcemia, and you can significantly filter all the information presented. 

But what about a broader question, such as “Which of the following is the most likely diagnosis?” In this case, quickly look at the answer choices. If you mostly see cardiac and pulmonary answers, you can pay closer attention to the cardiopulmonary risk factors, history, exam, and diagnostics.

Occasionally, the question stem will be broad, such as “Which of the following is the most appropriate next step in management?” and the answer choices will be too varied to direct you (that is, they might include a multitude of unrelated diagnostic tests and treatments). In this case, simply move on to step 2 and start reading the case from the beginning. 

Pro Tip

Frame your thinking by quickly reading the question stem and answer choices first.

Step 2: Read the Clinical Case

Now that you’ve directed your thinking by reading the question stem and looking at the answers first, you can enter the clinical scenario with a strict advantage of knowing what you’re looking for. One thing to always keep in mind is every question is written to test a concept. This may sound simple, but if the question writer wants you to answer correctly, they have to tell you something in the case to get you there.

Questions on the boards need to be consistent with the classic epidemiology and presentation of the disease in order to be tested. So whenever you’re in doubt or confused about a question, remember: the question is probably testing something classic and you just need to see the pattern of the disease that’s presented. This should quell many anxieties students have because generally, questions are meant to be straightforward, bread-and-butter medicine.

Pro Tip

Remind yourself that every question tests a basic concept. There’s enough information in the case to get every question correct.

With this in mind, you’re ready to read the case and interpret the information. When you read each question, there are two major pitfalls to avoid: 

Pitfall #1: Overanalyzing

The first one is overanalyzing and reading too slowly. The student who tries to interpret every single word and derive meaning from everything won’t be able to see the forest for the trees. They will get bogged down in the details and will never arrive at the correct answer because they can’t distill down the myriad of facts being presented. This bias exists more in anxious students who are afraid to miss anything. This is probably the worst habit to have and needs to be actively avoided.

Generally, students who overanlayze not only miss the question, but they don’t have time to finish their entire block. Avoid being an overanalyzer at all costs! If you ever find yourself spending too much time on a question and getting bogged down with the details, remind yourself that you have the information needed to get the question correct—all you have to do is find the pattern in the question to arrive at the correct answer

Take a deep breath, take a step back, and let the question flow and read the case, accepting that the entire picture may not make sense until you get to the end. Practice makes perfect: learn how to be comfortable reading questions at the needed pace by always practicing with timed blocks so you have real exam-day pressure on you at all times.

Pitfall #2: Focusing on Buzzwords

On the other hand, there’s the other pitfall—buzzwords. The buzzword medical student doesn’t really understand what’s going on but only looks for patterns. For example, this is someone who skims the entire case and sees “pain radiating to the back” and immediately picks aortic dissection but misses that the answer is actually pancreatitis.

You may get some questions correct with this approach, but you will find your scores to be remarkably below average. These students plateau early and have trouble progressing in their studies. Read the case and keep a steady pace, but if you’re just barely skimming it and trying to find an easy pattern without putting in thought and using your knowledge, you will likely miss every question that has even a slight trick, and you will certainly make lots of simple mistakes for diseases with similar presentations!

Pro Tip

Avoid buzzword learning! While pattern recognition is important, don’t simply solve cases with word association alone.

The Balanced and Focused Approach

The right approach is a balance of pace and focus. When going through the case, you need to go at a pace rapid enough that you can finish the question in an average of 90 seconds or less. This means you’re going to be reading pretty quickly, taking note of information relevant to the question stem, and synthesizing it into an understanding you can use to get the question correct. 

Finding the balance of not over- or underthinking takes practice, so practice, practice, practice with USMLE/NBME practice questions in a Qbank for the shelf exams/Step 2 CK! If you’re constantly running out of time, you’re overthinking things, but if you’re making tons of simple mistakes, you may be underthinking. Look at the big picture and pick the answer or step that comprehensively addresses the patient’s entire presentation.

Pro Tip

Practice, practice, practice with USMLE/NBME practice questions! Build intuition on how quickly to read and how “deep” to think by doing a ton of questions.

Step 3: Pick the Correct Answer—Deduce!

The final part of approaching a question is choosing the correct answer. Of course, this is easier said than done. One universal strategy that you want to use for every question is to cross off the incorrect answers and narrow the possibilities. This will drastically increase your likelihood of getting the answer correct! 

Begin by quickly crossing off the answers you know are wrong. This can make a challenging question far less intimidating. With the answers left, continue crossing off ones that you know are comparatively less correct. Finally, of the remaining answer choices, pick your best guess given the entire clinical picture, and move on. 

In most cases, ruminating, rereading the case, or “mentally pacing” is not going to help you but will instead eat into the time left for other questions, thus decreasing the probability of getting those questions correct. Pick the choice that best answers the question and move on. Remember, you’re not trying to get each individual question correct—rather, you’re trying to get the most questions correct in the block.

Pro Tip

Cross off the incorrect answers before picking your answer to increase your chances of getting the question correct.

Relax and Let Go

Some students have a hard time letting go and moving on or accepting that their best effort may be deducing down to two or three choices without 100% certainty. It takes practice, but it’s important to be comfortable being a little uncomfortable with your answer. Remember, every question is written in a way that makes every answer choice true or correct at some level. A really well-written question should have you thinking “all of these could be correct.” 

It’s natural for this to make you a little uncomfortable because, generally, questions will not have one answer that is definitively right and the others all absolutely wrong. For this reason, realize that crossing off the wrong answers, comparing the remaining answers, and picking the most correct answer is the entire purpose of this test. Once you’ve gone through this process, move on and try to rack up as many points as you can by getting to the other questions.

Pro Tip

You aren’t going to be 100% sure on most questions—this isn’t a problem! Pick your best guess, let it go, and move on.

Summary: Key Strategies to Answering a USMLE/NBME Question

These questions are meant to be challenging. Therefore, building and mastering a systematic approach is the best way to become efficient and maximize your score. Here’s the general strategy you’ll want to hone and master:

  1. Start with the question stem and look at the answer choices—this allows you to frame your thinking.
  2. Read the case with a balanced pace without overly focusing on every detail or underthinking and just relying on buzzwords. Build a comprehensive picture of the case at hand.
  3. Deduce! Cross off the incorrect answers to narrow your options and increase the chance of answering correctly.
  4. Pick the best answer. With the choices left, pick the answer that most holistically answers the question being asked. Don’t worry if you don’t feel 100% certain—you aren’t supposed to.
  5. Practice and hone this approach so it’s second nature to you on exam day!

Take this approach and apply it every day as you prepare. Not only will you increase your scores on standardized exams, but it will help you be a better, more confident doctor as well.

By Damian Apollo, MD

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