Whether you’re taking Step 1, Step 2 CK, or an NBME Shelf exam, follow me here—I advocate a standardized and repeatable approach to questions, which goes like this:
1. Read the last line, where the question for you to answer is stated.
This priming step is critical to effectively and purposefully reading the vignette. Radiologist don’t just dive into images cold, they confer with the medical or surgical team to ascertain what is suspected and what the utility of the read will be. Do the same, and get an idea of what you’ll eventually need to select: A drug? A diagnosis? A mechanism?
2. Glance at the answer choices (without reading them individually) to further your awareness of what type of answer you’ll need to select.
Are they cardiac drug names? Autoimmune diagnoses? Impossible-to-articulate biochemical molecules? I strongly advocate against reading each answer choice in detail at this point, so as to prevent premature activation of the associative recall you’ve labored so long to cement (more on this later).
3. Read the vignette at just-the-right unbroken pace to comprehend the information without skimming or unnecessary re-reading.
This just-right pace tends to be almost exactly the pace at which you can read the vignette out-loud to yourself without stopping. Seriously, though you may annoy that coquettish study buddy (she only liked you for your good books), reading vignettes out loud to yourself is an excellent way to find a quick but intelligible pace and to force your focus. Thoughts, associations, connections, insights—all will arise as you read and that is good (they’re what you’ve spent 6 weeks banking all day everyday)—though keep the vignette reading front-of-mind while the associations bubble up in the periphery.
4. Now here’s the big one: Look away from the computer screen!
Stare off into space (or the inside wall of your cubicle) and call those associations and insights to mind. Pull them from the periphery, think about how they may relate and try to draw some cohesion (bibasilar crackles, dyspnea, and displaced PMI... well that’s CHF). As a study exercise, I often have students use this pause-for-comprehension to summarize the vignette in no more than one sentence, in much the same way as you deliver a one-liner to your attending after spending 45 minutes on a history, physical, and chart review.
5. Use the linked associations and cohesive one-liner summary to predict an answer, or at least to get in the ballpark of an answer.
With relevant thoughts and associations congealing in your mind, and the confidence that your studying has delivered you these integrated ideas, now read through the answer choices and find the one most congruent with the ideas already in you mind.
The last line question asked me to select a drug; glancing at the answers revealed a bunch of cardiac drugs. After reading critically and pausing to comprehend, I deduced that the vignette patient has CHF, and I know what drugs are used to treat CHF (plus their MOA and toxicities because I studied like a beast!). All that’s left to do is look down at the answer choices and select the drug that’s already in my mind (look! a loop diuretic, boom!).
NB: 4 of 5 answer choices are incorrect (also known as WRONG) but that doesn’t prevent your well-trained brain from launching into a series of memorized associations and ideas upon reading those answer choices (Flecainide, well that’s a class 1C anti-arrhythmic, which blocks sodium channels and… wait, I gotta focus!). Therefore, if you dive straight into reading the answer choices without pausing to gather your thoughts and comprehend, 80% of the ideas blossoming in your mind will be misguided (read: WRONG) in the context of this question.
BIG TAKEAWAY HERE:
I find the experience of trying to retrofit 4 of 5 WRONG answers and their associated facts back into a hastily read and incompletely contemplated vignette to be the most stressful, most time consuming, and most confidence crushing experience of answering questions. Conversely, recognizing that Flecainide has little to do with this vignette patient—whom you’ve pegged as having a CHF exacerbation—is straightforward, streamlined, and FUN!
Now go save those fake patients, student-doctor!
P.S. As you prepare, be extra vigilant when you come across types of questions that have traditionally gotten the better of you. In other words...