June 23, 2008

Cognition for the USMLE Step 1

I scribbled down a few notes when first thought of this blog entry. The thinking process for the USMLE Step 1 is interesting... and the more I realized what I was thinking about (meta-cognition), the more I learned from the process of learning. It was very strange. It's been about two months since I took the exam itself. My sharp dedication to this topic is rapidly fading since I started my third year orientation today. However, I also feel a sense of urgency to at least address this topic before I ponder my clinical years on this oft-ignored-blog-of-mine (but I'd like to do better!)

In regards to the USMLE Thinking Process, consider the 4 R's:
  1. Recognition/Resonance
  2. Recall
  3. Reword/Restate
  4. Reconnect
Recognition/Resonance refers to the first part of the question stem. When you're reading, a feeling will come up. Obvious clues related to risk factors (female, fat, forties, fertile for acute cholecystitis, for example) will act as triggers. However, you should watch out -- in real clinical practice, the heuristic of stereotyping may be misleading! Stereotyping in the USMLE is surprisingly effective... and amusing.

Once you've read through the stem, you ought to Recall some basic facts about the problem at hand. This is a great exercise during your tutorial sessions as you go through questions in USMLE World... it will eat up too much of your time if you systematically quiz yourself during a timed exam. Here are some example questions: What are some causes of acute cholecystitis? (Blocked duct by a stone, either pigment or cholesterol.) Why are pregnant women more likely to develop cholesterol stones? (Answer: estrogen increases the cholesterol in the gallbladder-->hypersaturation and progesterone decreases GI motility-->stasis in gallbladder)

Next, read the question. Sometimes, it won't make sense. Restate the question, in the context of the clues given in the stem. A lot of times, certain words will be disguised and you'll have to take the extra mental effort of rephrasing them so you'll readily recognize them. Example: During the physical examination, tenderness is elicited in the upper right hand quadrant of the abdomen. Convert this long sentence to the eponym "Murphy's sign" and voila! You've created a mental shortcut.

Restating the question and the stem in your own words often helps you Reconnect with the question-writer's intent, if you didn't recognize it right away. Sometimes questions will give you a "Bait-and-Switch" and ask you about something slightly different. Sometimes it will be so painfully obvious what the answer really is that you'll wonder 'is it really this easy?!?' I felt that way on the NBME and the USMLE enough times that I felt comfortable responding with a 'Yep!' Rarely, the USMLE will disguise the question and the answer choices to such an extent that you have to rephrase everything. However, USMLE World does an excellent job disguising questions that they are all imbued with high-yield topics. They are worthwhile branches to consider even if the answer is obvious.

Take the time to figure out why every other answer is WRONG! That's more important than knowing the right answer as you study. That's not my second opinion!

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