The Success-Limiting USMLE Skill Set

Top students master this career-altering USMLE skill set, and you can too.

Brilliant medical students fail the USMLE Step 1 exam—I see it regularly.

Average students pass the exam at a similarly surprising rate.

How can an average student outperform a brilliant one in an exam built to eliminate the weakest from the pack?

Is it a better understanding of the material?

No… Although content mastery is an important precursor to success.

Is it because some students know how to access a higher state of consciousness on exam day, tapping into the depths of their minds and magically remembering everything they’ve ever read or heard?

Of course not… But damn… Wouldn’t that be nice?

What’s the “one thing” that separates those who succeed on the USMLE exams from those who struggle to make progress or, worse yet, fail?

The answer is… Knowledge application + test-taking skills.

Knowledge, unfortunately, can only take you so far…

While test-taking skills, despite the misconception, can’t substitute for poor knowledge.

A metaphor, if you’ll indulge me…

Imagine the world’s most obsessed golf fan…

They watch golf all day, study the top professionals’ swings, and learn everything there is to know about the sport’s history… Will studying golf alone translate into being a great golfer? Probably not! If they’re not out on the course challenging themselves, turning their theoretical skills and knowledge into actual skills… Well, they’re not a golfer; they’re a student of the game.

The same concept holds true for success in the USMLE exams and throughout one’s medical career.

You can study ‘til your eyelids are heavy and your brain feels deep-fried, but until you can take what you know and use it effectively on the battlefield—meaning in questions or the hospital—it’s just theory. Until you can take what you know and apply it, you’re a student of medicine, not a practitioner. Understanding the difference greatly impacts how one performs on USMLE questions.

Developing your USMLE test-taking skills is tricky stuff…

Luckily, you don’t have to be in the top 0.01% of USMLE test-takers to pass Step 1 or score exceptionally well on Step 2 CK.

Mastering how to apply your knowledge to USMLE questions is a skill… One of the most important skills you can develop as a medical professional.

Believe it or not… It’s easier to accomplish than you might think.

Your medical school probably failed you in the USMLE preparation department—mine sure as f**k did 😤. That’s why I’m here to guide you to the promised land.

In the next few minutes, I’ll walk you through a series of steps I’ve battle-tested myself…

And it doesn’t matter if you’re what we’d traditionally call a “poor test-taker”… I’m the definition of a “poor test-taker”… Seriously, look it up. There’s nothing special about my academic abilities. I simply had an unwavering desire to overcome a lack of skills that became obvious when I couldn’t pass an NBME exam to save my life.

I worked hard to acquire the knowledge; hopefully, so did you! All that was lacking for me, and what’s lacking for most struggling students, is the right bridge to connect knowledge to correct answers.

When my school gave me the world’s worst advice—do at least ten thousand practice questions and memorize the First Aid—I had to figure things out on my own when it failed me.

So… If you’re ready to learn how I went from frustrated and lost to clear-minded and getting results, let’s get started.

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Quick aside… If you’d rather talk to me face-to-face and figure out how to overcome a specific issue you’re having in medical school, click the picture below—the one with the handsome fellow—and book a 60-minute call with me.

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Ok, here we go!

When my school told me to do “10,000 practice questions,” I started doing questions… Why wouldn’t I? They’re the experts—or so I thought!

No plan…

No strategy…

No actual knowledge of how to tackle USMLE questions…

And no actual skills… Just an arbitrary target of 10K questions 🤷

I plowed through question after question without stopping—this was a mistake.

If you want to pass Step 1 with ease and do exceptionally well on Step 2 CK, you’ll want to remember two things: Knowledge application + test-taking skills.

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Knowledge Application + Test-Taking Skills

To better understand where we’re going with these two elements, let’s define each:

KNOWLEDGE APPLICATION: This is the ability to take what you know—from your schooling and studying—and apply it to a given scenario. These scenarios include questions during test preparation and face-to-face patient interactions in the hospital or clinic. USMLE questions and patient encounters are different formats of the same thing. Think of USMLE questions as written encounters; they might be easier to navigate with this re-frame.

TEST-TAKING SKILLS: A student preparing for the USMLE exams should have tools that can be used at the question's start, middle, and end. For example, when seeing a patient, your starting strategy includes identifying the chief complaint and asking specific questions. As you get closer to identifying the problem, you’ll rely on specific tools to get the job done (blood work, imaging, etc). Questions should be thought of in the same way… Each starts out the same and then uses different tools to get the correct answer.

On the surface, both seem fairly obvious and straightforward, but they aren’t. I work with students every month who struggle immensely—through no fault of their own—to apply their knowledge and follow the test-taking strategies I’m going to share with you. It’s difficult to figure this out and stay consistent in applying the lessons. I’ll make things easy for you by giving you the steps, but it’s on you to stay mindful and disciplined as you begin applying them. The worst thing that can happen is seeing progress but falling back into bad habits that pull you in the wrong direction.

Now that we’ve established what needs fixing, let’s get specific.

Taking a step-by-step approach will be the easiest way to come away from this with usable skills and know-how. Below, I’ll outline the steps involved in the “test-taking strategy” and “knowledge application” processes and explain the what, why, and how.

By understanding a process's what, why, and how, you’ll gain the skills needed to excel while developing a deep understanding of the reasons behind the process. When you know the “what, why, and how” of a process or concept, you can act quickly to change direction if necessary.

Let’s use the following sample question to guide our strategy:

A 28-year-old male presents to the emergency department with a high fever, severe headache, and muscle aches. He reports that he has been feeling unwell for the past week. He recently returned from a trip to Southeast Asia, where he participated in outdoor adventure activities, including swimming in rivers and hiking through jungles. His vitals include a temperature of 101.9°F, blood pressure of 130/90 mmHg, pulse of 100/minute, and respirations of 16/minute. On examination, he appears jaundiced, and there is conjunctival suffusion. Laboratory results reveal elevated liver enzymes, thrombocytopenia, and acute kidney injury. Blood and urine cultures have been sent for further testing. Which of the following is the most likely underlying mechanism behind the cause of this patient's infection?

THE STEPS…

First, keep the following in mind: USMLE questions are written so that a competent test-taker can devise an answer—or be very close to one—without reading the answer choices. Therefore, a well-crafted strategy should revolve around this idea. It also hints that by sneaking a look at the answer choices before coming up with one of our own volition, we’re increasing the odds of being fooled, scammed, or hoodwinked by a well-written question.

With that out of the way, here we go…

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Step #1. Determine what the question is asking you to do.

What? The first step is to identify what we’re looking for. This could be a diagnosis, mechanism of action, etc. This specific example asks, “Which of the following is the most likely underlying mechanism behind the cause of the patient’s infection?”

Why? We want to review the chief complaint and history to solve a problem (i.e. The question). If we start reading the vignette from the top without first identifying the question in the last line, we don’t know what we’re searching for as we begin reading. When we understand what the question wants us to find, we can read the vignette with intention and direction toward the specific information that will help us solve the problem - while ignoring the rest. If we don’t follow this approach, we often have to re-read some or all of the vignette, which chews up time we could otherwise use for more challenging questions.

How? We do this by reading the very last line of the vignette. In this case, the last line asks, “Which of the following is the most likely underlying mechanism behind the cause of the patient’s infection?” By reading the last line first, we now know exactly what we have to do: Diagnose the problem, identify the causative organism, and figure out that organism’s mechanism of pathogenesis.

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Step #2. Devise a differential and narrow it down

What? Now that we know what we’re looking for—based on Step #1 above—we have to keep our eyes open and start figuring out what we’re looking for. In our practice vignette, we’re looking for the “mechanism underlying the patient’s infection.” Thus, our first goal is to determine what’s causing the infection. To do this, we begin formulating a general list of differentials while gathering data. Within the first few lines of a vignette, we should be able to list a few high-level differentials or, at the very least, have a direction in which we’re heading.

For example, in the sample vignette above, we’re given specific details that should move in a particular direction: 1) Exposure to freshwater, 2) Travel to SE Asia, and 3) Multiple systems affected.

Why? This gives us a path to follow as we progress through the vignette. There is no greater waste of time than reading a vignette without actively thinking. The goal isn’t to mindlessly read an entire vignette and then try to figure out what’s going on—that’s an absolute waste of time. Instead, we start thinking immediately so that by the time the entire vignette has been read, we’ve established an answer or are headed confidently in a particular direction.

How? By asking questions. When I go through USMLE practice questions with my students, I constantly ask them questions. The goal is to condition them to start doing it themselves. When you read the vignette’s first couple of lines, you should ask yourself the right questions to help solve the big question in the last line. Questions such as, “What’s my likely diagnosis?” are a great start, especially when your goal is to determine the underlying mechanism of infection.

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Step #3. Answer the question before looking at the answer choices

What? This is the toughest habit to break… for my students and probably for you, too. There’s a simple reason for devising an answer before looking at the answer choices: they’re designed to confuse you. Even if you think you know the answer, looking down before committing to it in your head will slow you down and give you headaches. Thus, you want to always… I repeat… Always… Answer the question before looking down at the answer choices. Sometimes, however, the correct answer choice is one of several possibilities. In this case, knowing which direction you’re heading before looking down will keep you moving down the right path. I’ll provide you with a specific example of this in a couple of minutes.

Why? USMLE questions are written with a few important goals in mind… One of which is to test your knowledge, duh! Another is to cause confusion and second-guessing. When you read a vignette and immediately look to the answer choices for guidance, you fall right into the test-writer’s trap. They will purposely include appealing distractors that line up with some of the vignette’s information. When you allow distractors to hijack your thoughts, you give up control and waste time… Not to mention, you’re more likely to answer incorrectly.

How? By strictly adhering to the principles of steps 1 and 2 above. Understand that you’re tasked with finding and devising a “most likely answer” based on your knowledge. If you follow those steps, by the time you’ve finished reading the vignette, you should have an answer—or an approximate answer—assuming your content knowledge is up to speed. If you’re regularly coming to the end of a vignette and unsure of the answer, your content’s not yet strong enough, so keep studying and learning from your questions. Returning to our sample question, we should have narrowed the diagnosis to leptospirosis (symptoms + travel history + exposure to freshwater activities in SE Asia). When prompted by the last line to identify the underlying mechanism, as we come to our diagnosis of leptospirosis, all we have to do is keep some of the key features of the leptospira organism in mind.

My thought process would look something like this: Leptospira is a spirochete that enters the host through mucosal surfaces or broken skin (supported by freshwater exposure), disseminates into the bloodstream, invades multiple organs (supported by the various systems affected in this patient), triggers a robust immune response. Armed with that knowledge, I simply look down at the answer choices and select the option that most closely fits my assessment of the situation:

Here are the answer choices for the vignette above:

A) Direct invasion of tissue by an intracellular parasite

B) Bacterial endotoxin release resulting in systemic inflammation

C) Binding of a bacterial exotoxin to host cell receptors

D) Invasion of the bloodstream by a spirochete bacterium

E) Disruption of the mucosal barrier by a fungal organism

Based on my thought process, I’d quickly select option D because it fits closely with my assessment of the situation.

Sidenote: Avoid going through and eliminating answer choices one by one; simply look for the option that aligns with your thesis. The elimination process should be reserved for when you find yourself lost and need to increase your odds of guessing correctly… Otherwise, you’re just wasting time unnecessarily.

If you’re in the habit of reading a vignette and immediately searching the answer choices, this strategy may seem difficult.

If it does, you’re likely not as solid or well-prepared as you should be. You don't know your stuff well enough if you can’t devise an answer without seeing the answer choices. The classic line, “I‘ll know it when I see it,” doesn’t work with USMLE exams. Test writers know that many students take this lazy approach and will punish you for it.

Don’t forget the following from earlier on:

What’s the “one thing” that separates those who succeed on the USMLE exams from those who struggle to make progress or, worse yet, fail the exam?

The answer is… Knowledge application + test-taking skills.

You can have the knowledge, but if you don’t apply it effectively and efficiently, you’ll be easily fooled by slick test writers.

Likewise, you can have outstanding test-taking skills—such as those outlined in steps 1-3—but that won’t do you much good without a strong foundation of knowledge.

Combining knowledge and knowing how to use it will take you to new heights.

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(Tactic Alert 🔔)

The Final Step: Answer vs. Direction

Sometimes, despite an obvious diagnosis, the last line asks you something like this:

“Further investigation will most likely reveal which of the following?”

When a question is posed like this, there could be one additional finding or a long list of possible findings.

What are we supposed to do in this scenario?

Based on the established diagnosis, we ask ourselves if there is one “most likely finding” or if there are many.

Here are two examples to illustrate this concept:

Scenario 1: A vignette has painted a thorough picture of Prader-Willi syndrome (PWS). It’s given us all the main signs and symptoms and a handful of additional findings, making this an obvious diagnosis. If we’ve been given nearly every feature of PWS, except for hyperphagia, then you’ll most likely see “hyperphagia” in the answer choices.

Scenario 2: A vignette paints a vague picture of SLE. You’re given the classic butterfly rash and a couple of additional signs and symptoms that support its diagnosis. We know, however, that SLE is a multi-systemic disorder that could present various findings. In this instance, it would be a waste of time to list ten additional findings that could be present. However, armed with a diagnosis of SLE, we can look down at the answer choices and find the one that fits best with SLE.

Thus, the last line is read first to determine what is being asked and how we should think about the answer.

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That’s it…

You’ve been empowered.

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