At some point in our lives, we will feel anxious. It's part of being human. The ability to prognosticate and think about the future gives us the power (or burden) to reflect upon what might happen. And, as survival instincts have led to our evolution over millions of years, we are always prepared for the worst of what might happen.
anx·i·e·ty: a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome.
Stress is designed to be a good thing. It’s the little extra something that allows for the upper echelons of human performance. We call this beneficial stress “eustress,” and juxtapose it against its antipode, distress — the feeling that something is wrong, that we are failing. And it spirals. And it sucks in any mental faculty we have. We wonder why we are worrying, and then this makes us worry more. And when 90% of our mind is dwelling on these negative feelings, there's not much more of it to focus on the task at hand: performing well on your test. What to do?
How to Manage USMLE Anxiety:
1. Remember that the USMLE is an opportunity, not a hurdle.
Let’s start with a general reframing of the entire situation. If you put in the dogged effort required to do well, if you prepare with every ounce of energy, and if you are confident that you couldn’t have worked any harder to succeed, then your exam will be a chance to excel. It's imperative to squelch the idea that the exam is a big, bad entity looking to destroy you. Replace this thought with the idea that the exam is an objective collection of questions, and it's your job (and has been your job ) to answer them, one by one.
Despite a rock-hard mindset, you might still find yourself in a jam. I remember sitting at the test-center computer, with ear plugs tickling my tympanic membranes and the Prometric leaf-blower style headphones on. A cardiology question involving heart sounds came up, and all of a sudden, there I was, with my own heartbeat reverberating in my head. This only made it louder. Valuable time was lost thinking about thinking, outcomes, scores, residencies, and about the time I was losing. I was able to rally and collect myself using some of the techniques below. Many are borrowed from cognitive-behavioral therapy, and can help you to disregard negative thought loops.
2. During your exam, remember the stop sign.
Close your eyes for a moment and visualize the word “STOP” taking up your entire field of view. Take a breath, think of something positive (success, puppies, the person you love the most beaming at you, etc.), smile, and when you're ready, get back to work with a newly centered mind.
3. Combat testing anxiety with deep breathing.
Pump the brakes on all thought and direct the entirety of your focus on your breath. Take two or three long, deep breaths, taking about 5 seconds to inhale, and 5 seconds to exhale. Even if this “costs” you 30 seconds, finding your center and going to the next question(s) with focus will be worth it.
4. Gather yourself.
It's so easy to let the mind wander during dark times at the test center. I need to not fail this test. I should have studied more. Why can't I do this?
Negative self-talk is the enemy. Do not try to answer questions with half of your mind on medicine and the other half on jabber. You have to stop and gather yourself.
Besides deep breathing, another technique involves putting all of these negative thoughts into a tiny cardboard box in your mind, and throwing it out of your mind’s eye. Not only will this visualization help you overcome the thoughts, but it will stop you from trying to answer questions with a compromised mind.
5. Use progressive muscle relaxation to focus your mind on your test.
This is another great way to bring things to a halt and de-stress your mind and body. Starting with your head and progressing inferiorly, violently tense every muscle in your body, then allow it to completely relax. Flex your forehead, jaw, chest, arms, lumbricals, abdomen, buttocks, thighs, calves, toes, etc. You will be much more relaxed after you channel some of that stress into muscular action, and release it all from your body.
What anxiety management techniques can I develop before exam day?
Sit in total focus and allow thoughts, both good and bad, to float through your mind like clouds in the sky. By relaxing your mind and strengthening your focus in non-testing situations, you will be in a better spot during the test as well. You needn’t be a reclusive yogi; sitting for 10 minutes per day in distraction-free silence is a great place to start.
7. Emulate the USMLE testing environment.
It is imperative to do enough practice tests—both NBME and full-length tests—to mimic the thoughts, feelings, and stress of important testing situations. Regular question blocks are too easy to coast through; you need something that you identify as important and different. How many is enough? While it is definitely a different number for everyone, Step 1 students should get through at least 2-3 NBMEs and one full-length practice test before the real deal. For Step 2, 1-2 NBMEs and the often forgotten full-length practice test should suffice.
For the real go-getter, you can purposely put yourself in a jam. Let 5-7 minutes tick off your UWorld block before beginning so that you're forced to work a little more quickly than usual and answer the last few questions with very limited time. That way, if it happens on the real test, you can have the positive thought, “I have been here before, and I know how to handle this situation.”
8. Be kind to your eyes and brain.
Taking a USMLE exam means staring intently at a computer screen for eight-plus hours and racking your brain to both recall trivial factoids you'll never use in real life, as well as synthesize answers based on complex physiology and pathology.
Any way you slice it, it is not an exam or day that you'll look back on fondly.
So be nice to your brain and eyes! Don't do a ton of studying the one or two days beforehand. Do some basic review work on your trivia factoid flashcards and then get out into the sun and exercise so that you're able to sleep the night before. Do something fun with your loved ones and take some stress off. Minimize your screen time so that when it's time to burn the USMLE software into your retinas, they've had a chance to rest. Feeling better will go a long way in helping to keep your anxiety at a manageable level on test day.
If you identify yourself as someone who definitely struggles with anxiety, there is tremendous value in seeing a professional to help you build a framework to approach and cope with your testing anxiety.
Many medical schools have expert mental health services to help you with situations just like this. They've seen anxiety before and know how to help students cope. Therapy exists for a reason, and while it's not something everyone is comfortable talking about, there is absolutely no shame in getting help when you need it.
If it means a better score, more residency opportunities, and an improvement of other areas of your life where you're feeling anxiety, then you should absolutely pursue this route. (Many of our students have done this and have seen tremendous improvements after getting their testing anxiety under control.)
To close, I want to remind you that you are not alone. A recent study found that 22% of second-year medical students experienced moderate to extremely high test anxiety! Everyone will experience anxiety; the difference comes in how you process it. Use some of the above techniques, make sure your preparation is as solid as possible, desire success more than you fear failure, and you will be on your way to your best score.
Green M, Angoff N, Encandela J. Test anxiety and United States Medical Licensing Examination scores. Clin Teach. 2015 Jun 3.