USMLE Step 1 Test-Taking Strategies [Webinar Tutor Series: Part II]

Two of the major keys to success on USMLE Step 1 are building a strong foundation of knowledge and developing the test-taking skills that will allow you to maximize that knowledge base in most situations. While there are many steps to building that knowledge base (eg, reading, flashcards, question banks), working through practice USMLE questions will be the most effective for learning the necessary test-taking skills that will ensure you pass Step 1 and set you up for success on shelf examinations and Step 2.

The term ‘test-taking skills’ refers to an ability to apply your existing knowledge with critical thinking skills in order to work through USMLE questions. This can be used to both work through challenging questions that you may not feel confident about, as well as to double-check yourself when you do feel comfortable with the answer. 

For the purpose of Step 1, some of the most effective test-taking skills include:

1. Starting with the Last Sentence and Answer Choices First

Start each question by reading the question lead-in (last sentence) and answer choices first. This is the most effective way to approach each question because it:

• Provides you with some insight into the overall topic and direction of the question
• Allows you to take advantage of pseudo-stems (e.g., questions where the last sentence alone will be sufficient for answering)
• Allows you to more actively read the remainder of the question stem, with extra focus on what details will be important relative to the answer choices
• Minimizes the chance that you will gloss over a key detail for answering the question

2. Process of Elimination

Process of elimination allows you to use key question stem details to rule out answer choices. For questions that you feel confident on, this is a quick way to double check yourself and ensure that you are not making a mistake. For more challenging questions, this provides a starting point to allow you to more efficiently move through the answer choices and focus the majority of your thinking power on the answer choice(s) that are most likely to be correct.

With the process of elimination, the goal is to first go through the answer choices and remove any answers that are obviously wrong (e.g., would not cause the patient’s symptoms, could not account for the laboratory findings). From there, you can evaluate the remaining answer(s) to find the best fit.

3. Focusing on Question Wording

Slight changes in question lead-in wording can have a big impact on the question stem. For example, let’s say the question stem is presenting clinical features that point to a diagnosis of systemic lupus erythematosus:

• A lead-in asking for the most appropriate diagnostic study to screen for this condition would point to antinuclear antibodies as the correct answer choice
• A lead-in asking for a diagnostic study that would confirm this condition would point to anti-double stranded DNA or anti-Smith antibodies as the correct answer choice

Learning to recognize these subtle wording differences in order to answer appropriately will have a big impact on your score.

4. Working Backwards from the Answer Choices

USMLE questions are notorious for using second- and third-order questions that require you to work through multiple steps in order to arrive at the correct answer. An example of a second-order question is seen below:

______________

A 51-year-old man comes to the physician because of a 2-year history of worsening diffuse joint pain. He says the pain is minimally improved with use of over-the-counter pain relievers. He also has had fatigue, generalized weakness, and a loss of libido during this period. He was recently diagnosed with type 2 diabetes mellitus and started on  metformin. He also had anemia secondary to β-thalassemia minor. HIs father died of liver disease at age 60 years, and his older brother was recently diagnosed with cirrhosis. The patient does not smoke or drink alcoholic beverages. BMI is 22 kg/m2. Pulse is 65/min and regular, and blood pressure is 125/80 mm Hg. Abdominal examination shows hepatomegaly. Cardiopulmonary examination shows no abnormalities. Which of the following is the most likely underlying cause of this patient’s symptoms?

1. Accumulation of misfolded protein within hepatocytes
2. Decreased excretion of copper into bile
3. Decreased hepatic excretion of iron
4. Fatty infiltration of hepatocytes
5. Frequent blood transfusions
6. Increased intestinal absorption of iron

________________

With this question, answering correctly requires that you (1) recognize the presentation of hereditary hemochromatosis, and (2) match it to the correct pathophysiology (answer choice F: increased intestinal absorption of iron).

But what if you were reading through this question and could not make that diagnosis? Working backwards allows you to take advantage of the answer choices in order to determine what diagnoses are possible. To do this, you would convert each answer to the appropriate disease (e.g., answer A is alpha-1-antitrypsin deficiency, answer B is Wilson disease) and then read through the question details in order to determine which condition was most likely.

While there are many more test-taking skills that you can add to your tool bag to maximize success on Step 1, these are a great place to start. 

How Do I Improve My test-taking Skills for Step 1?

The simple answer: practice. Think about any great athlete; they don’t wait until the game to start playing one particular way. Instead, they practice the way that they want to play. 

When it comes to test-taking skills, the key is to start practicing immediately by doing as many Step 1 practice questions as possible. Additionally, when doing the questions, try to implement the following habits:

Don’t just guess. For questions that you don’t know, the temptation is often to just select an answer and then read the explanation to learn what you didn’t know. Instead, you should view this as a chance to work on your test-taking skills in an attempt to answer correctly.

When reviewing a missed question, don’t attribute every miss to a gap in knowledge. Instead, evaluate your test-taking strategy to see if there are any opportunities for improvement. Did you get too caught up by a distracting detail? Were you too focused on one part of the stem and missed something that was important? Could you have used the process of elimination to work towards the correct answer? By inspecting your test-taking process, you will be able to find opportunities for improvement.

If you are using the TrueLearn bank, you can take advantage of the insight sections that we have specifically made to cover test-taking skills and advise you on ways to approach certain question types.

How Long Does it Take to Develop test-taking skills?

This is highly variable, though most students will make some improvement fairly quickly by just starting to implement the skills reviewed above. Still, it is not some immediate fix and the best results come from sticking with it, practicing daily, and looking for new opportunities to improve. 

How Do You Deal with Step 1 Anxiety?

Above all, it is okay to be anxious, and whether they admit it or not, most people feel the same way — I know that I certainly did. In terms of managing that anxiety, there are several steps you can take. First and foremost, work hard to prepare for the test. The more that you study and build your foundation of knowledge and test-taking skills, the more confident you will feel. Additionally, take advantage of professionals that can help you deal with that anxiety; many students will benefit from talking to a therapist or psychiatrist about their anxiety. On top of that, having a good support group of friends and family will help. 

As for some Step 1 test-day tips:

• Remember that you are just answering questions, and if you’ve spent enough time studying, you’ve already answered thousands of questions. For the most part, if you have put in the work, you will have seen the majority of the content that is going to appear on your test.
• Thousands of people pass Step 1 every year. If they can do it, so can you.
• Try to break the test up into 2-block chunks (e.g., do 2 blocks, then take a break). However, if you felt rushed during a block and/or felt like a block was particularly difficult, there is nothing wrong with taking a break after that block to regain your composure. 
• Be prepared logistically for test day. Know how you are going to get to the test center, and maybe even have a backup route in case there is traffic. Have your food prepared and ready to go. Make sure you have multiple alarms set. You know, all of that good advice that you’ve been hearing since high school.
• Remember, you don’t need to answer every question correctly in order to pass. If (really, when) you encounter a difficult question that you do not know, just do your best to answer it, and then move on. You don’t need to dwell on it or waste time staring at it. It is okay to miss questions, and everyone will. 

Keep working hard to develop your knowledge and Step 1 test-taking strategies, and you will set yourself up to pass.

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.