The day has finally come. You’re about to click start on your first question on the USMLE. Your breathing is rapid and your heart is fluttering, but you try to stay calm. The first question appears and you jump right in. It’s a long case, which you start reading from the top… but by the time you finish, you realize you were so nervous you don’t remember anything you just read! On the next question, you try to compensate by reading with extreme attention to detail. You focus on the vital signs and lab work of a sick infant girl, trying to diagnose her illness, only to get to the end of the case and realize it’s an ethics question and the diagnosis doesn’t even matter. Now you’ve wasted more time!

If this sounds familiar, it may be time to refine your question-taking strategy on the USMLE. The following steps provide some helpful tips for best tackling a case-based question on the boards or any medical school exam.

1. On the USMLE (or COMLEX), always read the question first!

The second scenario above is a perfect example of why it is always recommended that the very first thing you do when a question appears is read the question. By reading the question first, you immediately know what you’re being tested on. This can help you notice key details when you do read the case. Are you being asked the mechanism of drug? Or do you have to diagnose a patient’s disease? Sometimes the vital signs and CBC values aren’t even necessary for answering the ethics question that is tacked onto the end of a long case. Reading the question first is the best way to steer yourself in the right direction. Once you’ve got an idea of the question, don’t look at the answer choices just yet.  It’s time to look over the case.

2. Read through the case, creating a differential diagnosis in your mind and highlighting key points.

Next, read through the case.  At this point, you have an idea of what you’re being asked, so you can highlight key points related to the question as you read. It helps to create a differential diagnosis as you go. If there is a photograph attached to the case, look at it when you finish reading. On occasion, the question may seem so easy and straightforward that you’re tempted to answer it right away, without even reading through the case or looking at the image. In my years as a tutor, I’ve seen countless students lose points by working too quickly and missing things or making silly mistakes. Even if it is a recall question and you feel very confident you know the answer, at least skim the case and any provided images just to be certain. If you’re very confident you know the answer, this should take only a few seconds to do and will confirm your initial thoughts.  

3. Try to come up with the correct answer off the top of your head before looking at the answer choices.

After going over the question, the case, and any images, it’s time to come up with an answer! As tempting as it is, try not to look at the given answer choices yet. Instead, come up with your own best answer to the question. Then, see if your answer matches one of the answer choices. If the answer you come up with is incorrect, it’s highly unlikely to be one of the given choices, so if it shows up among the possible answers, you can usually be confident it is correct. Of course, it’s not always possible to come up with an answer off the top of your head. If the question is too confusing, or you can’t remember a particular piece of information, you can use process of elimination. However, process of elimination makes it easier to fall for a distractor, lose confidence, or pick a “zebra” answer choice. When using process of elimination, only cross out answer choices if you’re very sure they’re incorrect, and if you’re left with more than one possible answer, always go with the one that seems most obvious. Never pick an unfamiliar answer choice unless you are absolutely certain the other given choices are all incorrect.

4. Skim the remaining choices to double check.

Even if you’re able to come up with an answer choice that shows up among the given choices, always take a moment to skim the other choices and make sure there isn’t something better that you hadn’t thought of (hint: there usually isn’t). Only change your answer if you have a solid, concrete reason for doing so! Many students second guess themselves at the last minute and end up incorrectly answering the question because of it.

A few other test-taking reminders:

Be sure to pace yourself! Ideally finish each section with just a few minutes to spare. If you are finishing 20 minutes early, you a likely rushing through the questions the first time through and will make many silly mistakes. The best strategy is to give each question its due time when you get to it the first time and not expect that you will have time to go back to it.

So many students spend countless hours studying for the USMLE without realizing the wealth of points that can be gained by sharpening their question and test-taking strategy skills. When taking practice tests and NBMEs, begin to employ some of these strategies so that they start to come effortlessly, and you won’t lose valuable points on test day!

Good luck!