NBME Shelf and USMLE Step Exam Strategy & Tips

Why Do You Need a Strategy?

Study hard for your shelf exams and USMLE Step exams as there is no better way to do well on the examination than to master the scientific knowledge available to you through review books and question banks. However, having experience, insight, and a carefully laid out plan on how to take the NMBE shelf and USMLE Step exams are almost as beneficial as your knowledge base on these challenges. The fast pace, length of the question vignettes, and sophistication of distracters in the answer choices make the exam extremely demanding.

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You will need a strategy to approach the questions to maximize your performance. It will also be necessary to remain calm and not panic as you face questions that will challenge your knowledge base. Remember that there are a certain number of questions on the exam that you will not know the answer to and several that are experimental questions that will not count against your score. Do not count the number of questions you believe you missed, as that will only work against your performance. Take each question as a single challenge to make the best educated choice possible. Then move on. Do not dwell on past questions. It is also very important to become familiar with the computer software being used on the exam, so you can be familiar with all of the underline, marking, and question features, such as videos, recently added pharmacology insert questions, and research abstract question formats.

Having a strategy for answering questions helps you maintain control of the testing experience. This in turn reduces stress and anxiety and prevents you from panicking when you face a question to which you do not know the answer. It also facilitates your goal of making the best educated choice or “guess” among the answers provided. After going through the following steps, mark your answer and move quickly on to the next question, placing the previous question out of your mind. If you are still uncertain about your choice, place a marker by the question so you can return to it at the end of the block and spend more time on it. However, always answer the question before moving on in case you run out of time on the block and cannot go back to your marked questions. Never mark more than 5-6 questions per block to return to as it will overwhelm you to backtrack to that extent. Returning to more than this number of questions will also lead you to second guessing yourself to the point where you will most likely be changing your answer to the wrong choice.

The Approach Step By Step

1. Read the Last Line of the Question Vignette First

Begin by reading the last line of the question. This will clue you in quickly as to what information in the vignette will be valuable to your answer formulation and what you can discard as irrelevant. This should make reading the vignette faster since you know what information to look for in answering your ultimate question.

2. Read the Question Vignette

Many research studies have found that students often consider the answers prior to reading or even scanning the question. Students read the answers first for a few different reasons. Sometimes they are eager to move on to the next question and subconsciously put off reading the long question vignettes, which can very long on clinical shelf exams and Step 2 CK examinations. Another reason is that they believe that if they read the answers first that they will not have to read the entire vignette to discover the correct answer and therefore save time. A third reason is that students are “result focused” so they are more comfortable with answers and more anxious with questions. However, experience with students and testing has shown us that the best approach is to carefully read the question vignette first.

How to read the vignette:

a. Read it once thoroughly

b. Look for diagnostic information, abnormal lab values, qualifying terms that refer to gender, race, age, etc.

c. Look for words of exception, limitation, and inclusion: always, only, never, except when, all except, none except. These words mean ALL of the time, not 99% of the time.

d. Underline or highlight only important key information using the provided software

3. Stop and Formulate the Answer to the Question in Your Head

Now that you have carefully read the question, try to formulate an answer from your knowledge base before looking at the answer choices. The questions on clinical shelf exams and the USMLE Step 2 are aimed at examining your knowledge of challenging scenarios that physicians face in the clinical setting on a regular basis. It is not an examination of obscure information, but the questions may present complicated cases. Similarly, the questions on USMLE Step 1 challenge you common but difficult clinical or research situations for which you will be asked to show your basic science mastery. With this in mind, formulating an answer prior to viewing the answer choices can act as a preventive tool for those who easily give into well written distracters.

4. Now View the Answer Options

a. Now scan the answer options to see if one either exactly matches or closely fits the answer you formulated before viewing the choices and mark it.

b. Next, carefully read the other answer choices to make sure that your formulated answer is the best choice.

c. Use the software to mark answers that you have eliminated, if you have the time. You might reserve using this feature of the software to difficult questions since it can eat up time. Practice using your practice questions to get faster and see when it can be useful for you.

d. Often there are two or more options that could be the correct answer. The question writers want you to choose the BEST answer. Compare the choices to each other to determine the differences between them, and then relate these differences with the stem to deduce which of the choices is the better one. Then, select the option that gives the most complete information.

NOTE: Remember that if only part of the answer is correct, then the entire answer is wrong. If you find yourself having to justify why an answer is correct in certain situations, then it is probably not the correct fit for the vignette.

If the answer seems easy, do not discount that you know this material well. You have learned a tremendous amount from your clinical experiences and exam preparation. It seems easy because of your level of clinical knowledge; it may prove difficult for others taking the exam without your particular experiences.

On NBME and USMLE exams, I do not agree with the assumption offered in some other literature that if two answers are almost the same, then most likely neither of them is correct. On examinations written at this level of sophistication, it is best to carefully consider both answers to determine the validity of each as independent choices.

5. Best Educated Guess Strategy

You have read the question and the answer choices, but are finding an answer elusive. It is time to eliminate answers you know to be incorrect. Look for answers that do not fit the vignette, if possible, and place an “X” by them. Also look for answers that are incorrect regardless of the vignette. This will assist you in narrowing down your choices. Remember what we mentioned earlier that the scenarios presented on NBME and USMLE are difficult, but generally refer to commonly occurring cases and disease processes seen in the hospital or research situations. You may also be tested on diseases processes that are of major interest in the scientific community, such as Alzheimer’s’, Parkinson’s, Type II Diabetes, etc. The questions are not typically looking for obscure diseases or treatment procedures.

Now that you have the five step strategy for approaching an NBME or USMLE question, please do not try this for the first time on the day of your exam. It is best if you practice this strategy while using your electronic question bank in timed, mixed mode to get used to the FRED software and the strategy outlined above. Test yourself a few times using your Question Bank without the strategy in blocks of 43- 45 questions and then using the strategy. Compare your performance with and without using the test taking strategy and keep track of difficult questions to see if this strategy helped you make more accurate decisions.

Melodee G. Mancuso, Ph.D., Chief Learning Specialist, ProMEDeus, LLC

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