Approaching Step 2 Questions, A Guide for Anxious Test Takers

I am a bad test-taker. No matter how hard I study, I will never do well on shelf examinations or the USMLE. I feel like I know the material, but I always pick the wrong answer.

Have you ever felt this way? Most people have, especially when preparing for Step 2. The challenge for Step 2 (and shelf examinations) is that you can no longer score well by simply memorizing an endless amount of flashcard decks. Instead, you need to memorize that information and learn how to apply it to clinical vignettes. 

And if that is not stressful enough, let’s not forget that your Step 2 score is more important than ever following the transition of Step 1 to pass/fail. 

Fortunately, there is an easy way to earn the score that will open the door to your dream residency … PRACTICE!!! Utilizing question banks to learn both the necessary information and critical thinking skills is the key to approaching Step 2 questions and crushing the exam.

Preparing for Step 2 Questions with Practice Questions

You cannot study for Step 2 by spending countless hours focused on memorization. You instead must use practice questions (e.g., question banks, NBME examinations) to learn how to work through the various question types and develop your test-taking skills. 

As you work through each practice question, you must also learn to focus on both the knowledge point being tested (which is usually something that needs to be memorized) and the critical thinking skills that were necessary to answer the question correctly. Additionally, when missing a question, you must learn to assess why you made that mistake. Sure, some mistakes will be knowledge based (e.g., you didn’t know the appropriate pharmacotherapy for the patient’s condition), but others will be the result of poor test-taking skills. 

While there is no way to guarantee success, students who complete at least one question bank (preferably two) and all of the NBME practice examinations usually end up doing very well.

What Are the Different Types of Step 2 Questions?

To simplify this as much as possible, Step 2 questions largely fall into one of the following three categories:

1. Diagnosis: These questions typically require you to select the most likely cause of a patient’s condition based on their clinical presentation (e.g., symptoms, examination findings, laboratory values, etc.). Answer choices here can vary between an actual diagnosis (e.g., Goodpasture syndrome) to more detailed information about the pathophysiology of that condition (e.g., anti-glomerular basement membrane antibodies)
   
2. Management: These questions are typically focusing on sequential care of a patient and can require you to differentiate between diagnostic evaluation and/or treatment (e.g., pharmacotherapy, surgery, etc.). Most of these questions are second- and third order questions that require you to assume the patient’s most likely diagnosis (or at least the differential diagnosis) based on their clinical presentation
   
3. Prediction: These questions typically require you to recognize the patient’s diagnosis and then answer an additional fact-based question on the condition (e.g., most likely cause of death, most likely complication)

In addition to these areas, there are ethics, biostatistics, and basic science questions that come up and can significantly impact your score.

Is Step 2 as Hard as Step 1?

The answer really varies for each person. Some might find it harder, others might not. You might find it harder if you struggle with any of the following test features.

• Step 2 questions are much longer than Step 1 questions, and this can cause some students to struggle. This is especially true for those who get distracted as they read, gloss over key details, and/or need to frequently read the question stem a second time.
  
• Step 2 questions require much more critical thinking than Step 1. Memorization and focusing on buzzwords will not be enough to do well. Instead, students need to work through distractors that may be pushing them towards a wrong answer choice.
  
• Step 2 will require you to manage patients. In addition to memorizing appropriate diagnostic evaluations and treatments, you will need to understand the appropriate sequence of management and be able to adjust this based on certain patient details (e.g., hemodynamic stability, medication allergies).

Even if you can memorize a lot of information, poor time management and critical thinking skills can certainly make Step 2 feel more challenging than Step 1. Taking practice questions will help you understand how to approach Step 2 questions and feel more confident going into test day.

Additionally, with Step 1 being a pass/fail examination, you have some ability to skip learning low-yield concepts. On the other hand, Step 2 being a scored assessment will require you to have a better understanding of a larger amount of content.

Are Shelf Examinations More Similar to Step 1 or Step 2?

Shelf examinations are more similar to Step 2. While these questions are typically of a similar length to Step 1, their overall focus is more in line with Step 2. With this in mind, doing well on your shelf examinations is a great way to jumpstart your journey to a successful Step 2 score. 

To ensure this, you should consider purchasing a question bank at the start of your third year and completing all of the relevant questions prior to each shelf examination. Don’t worry about using up these questions; you can always reset the bank or switch to a different one during dedicated studying for Step 2.

About the Author

Christopher Carrubba, MD, is an experienced medical education executive with over 12 years of experience in USMLE and COMLEX tutoring, question writing, and content development. During residency in Internal Medicine at the University of Colorado, he was hired to the position of medical director at MedSchool Tutors where, in addition to completing over 5,000 hours of personalized tutoring, he was responsible for hiring and training new tutors and establishing consulting relationships with medical schools and content providers. In 2017, he began his own tutoring and consulting firm where he is still active as a personal tutor and consultant for medical schools. He is also a medical director at TrueLearn and is responsible for item development in the USMLE and shelf banks. His focus is on creating content that mimics the tutor experience and provides students with multiple learning methods and an opportunity to improve their test-taking skills. He has taken several courses in learning theory and applies this to his work. In his free time, he enjoys spending time with his wife Aakriti and two sons, Donovan and Kairav.