Combining Content in Context: USMLE thinking


The thought processes required on the USMLE are different than those required on most medical school exams. The content you need to know is the same. But the way you need to think about that content, and how you will use that content in your exam, requires some mental reprogramming.

On medical school exams, recognition and paired association are the keys. A typical exam item presents a concept in the question stem and asks you to select the proper association from the presented choices. If you have studied sufficiently so that seeing a particular symptom reminds you of a disease diagnosis, or seeing a particular disease reminds you of the commonly used pharmacology, you will get the question correct. When you see “butterfly rash: you think “Lupus”.

You train yourself for these association questions by repeated exposure and memorization—going over the pairs and patterns over and over until you are programmed with the appropriate responses. In essence, questions on medical school exams are mostly are free association exercises. You get them right when you have trained yourself to have the associations your professors want you to have. As long as your associations are those of the faculty, you will do very, very well. You prove to the professor that you have mastered the required content by giving the required responses.

The USMLE wants more out of you. For the most part USMLE questions writers assume that you already possess the basic mental associations. They assume that the medical school has done its job. Their task is to see if you are ready for the next level. USMLE questions are not aimed at what you know, but are framed to see if you can apply what you know in a series of presented problem scenarios. Knowing is not enough, you have to be able to DO SOMETHING with your knowledge.

Few physicians would argue with this goal. The job of the medical practitioner is not to serve as a human reference book, but to make decisions, to take actions based on what they observe combined with what they know. This is what the USMLE tests: how you take in information and how you are able to reason with the information you collect.

Context is the key to understanding the information presented to you in a USMLE question. Particular facts mean different things in different circumstances. Meaning comes as much from surrounding data as from the presented detail itself. Fatigue, reported by a patient, may be an important symptom or merely the result of too little sleep. The meaning rests with the full set of symptoms and life circumstances presented. Single symptoms are ambiguous. Context provides the pieces to let you see the essential presented patterns.

Combination is the key process for the problem-solving required on USMLE questions. You must combine the information presented in the question with the information in your own head. The patterns you see plus the patterns you remember give you the insight to reason though to the best answer. If the question presents a symptom constellation, you must have the knowledge in you head to recognize the disease that this signifies. Recognizing a pattern in the question, but not remembering what it signifies means that you will not get the question correct.

Answer each USMLE question by first deciding, “What is given in the question?” and the deciding, “How does that relate to what you know?” This process, not simple association is the solution you seek. Content and combination result in the clarity you need to pick the best answer.

A detailed walk thought this process can be found in an article I posted in cooperation with Dr. Philip Tisdall on Look under the heading “Handling USMLE Questions.” Learning the mental steps to understanding USMLE questions is as important as mastering content details.

Steven R. Daugherty, Ph.D.

Judgment and Choices: On Becoming a Physician











Steven R. Daugherty, Ph.D.