How Do You Pick The Best Answers On The USMLE® and COMLEX®?

Consensus opinion provided by Jesse Cole, MD (AOA);  Nick Lorenzo, MD (AOA); S Huntly Plantz, MD (AOA), Scott Dulebohn, MD, Bill Gossman, MD; and Martin Huecker, MD (AOA)

While there are a lot of “tricks of the trade” to getting multiple choice questions correct, the old adage “practice makes perfect” is the rule to live by. In our experience, students we mentor that see a minimum of 10,000 unique practice questions prior to any USMLE® Step 1-3 or COMLEX® Step 1-3 board examination consistently achieve the highest scores. To do that, these students consistently report they started studying for USMLE Step 1 or COMLEX Step 1 in their M1 year, and made doing practice questions a daily habit throughout medical school.

In addition to regular question study, the following is a summary of techniques used by students that aced the boards.

Down Then Up

Board questions are usually long, complex, and often convoluted to simulate the challenge of sifting through information provided by patients to get to the correct answer. However, often the case presentation ends with a simple question such as “What is the most common cause of leg ulcers”? The question can often be quickly answered without wasting time on the history, physical, and laboratory values.

Come Up First

Read the question, then come up with the probable answer, and then scan the choices for the correct answer. By thinking of the answer first, you avoid getting distracted, and then focus quickly finding the correct answer.

Tick Tock Tick Tock

Watch your time. Prior to the test calculate the maximum amount of time you will devote to each question and then maintain that pace. You want to finish the test in time so that you have had an opportunity to answer every question that you do know the answer, correctly. If you run out of time on practice tests, you will on the real thing. During practice sessions, complete 10-20 questions in the desired time frame, to increase speed, just like a runner works on pacing. This point is crucial, you will throw away points on your score if you rush or don’t even see the last several questions in each block. Efforts to improve your pacing will pay off more than memorizing the brachial plexus. 

Too Many Questions, So Little Time

Board exams are marathons and those that finish the race, are more likely to be the top contenders. For most students, there are more questions than can be answered in the time allowed. If you can quickly get it down to two choices, and make a best guess quickly, you will have more time for those questions you know the correct answer. Ideally, you have some time at the end to review the ones you were uncertain about.

Don’t Dwell

USMLE, COMLEX, and most board exam questions are not in order of difficulty. As a result, if you are unsure of the answer, narrow it down, select the most probable answer, and move on to questions where you are more confident of the correct answer. Don't dwell on your lack of knowledge, if you don't know it, most of your peers will be in the same boat. You can also flag the questions you do not know and come back to them at the end. But do not leave any blank!

Bottoms Up

Read questions from top to bottom because USMLE and COMLEX question facts typically build sequentially. However, if the stem is long and complex, check the final sentence first, because sometimes you don’t need to actually read the entire question.

Just The Facts

For those of you who have ever seen a Dragnet reruns, Detective Joe Friday didn't beat around the bush. When given too much information he would say "Just the facts, ma'am." So, if the history is a heavy drinker and upper mid epigastric pain, you can skip the vitals, x-ray, and CT and quickly look for “elevated lipase” and then select “pancreatitis”.

Don’t Assume Facts

Lawyers commonly state, “do not assume facts not in the evidence”. This holds true for board questions. The only facts that you need to be concerned with are the facts given in the question. If the question tells you that a magic elixir exists, do not argue with the question.

Don’t Vacillate

Try not to agonize for precious minutes between two answer choices. Better to go with your gut and move on to a question you can more asuradely answer. You can always flag it and recheck it at the end.

Don’t Flip Flop

Your first thought will often be the right thought, but do change your answer if you feel very confident in your reasoning (don’t fall victim to the first instinct fallacy). Too much contemplation wastes precious time.

Foolish Distractors

Wrong answer choices, called distractors, are provided to send you down the wrong path. Understanding the rules for writing distractors helps you avoid being misled. Distractors must be:

• Homogeneous - example, they will all be drug choices
• Seem plausible
• Similar in construction
• Partially wrong
• Provide no clues as to the right answer

No Flaws

Board exams undergo rigorous review and testing, don’t waste your time looking as it is unlikely you will be able to reject any distractor due to any of the following flaws:

• Inconsistent grammar, punctuation, or spelling
• All inclusive such as “always”, “never”, “not”, “except”, etc.
• Different length and detail
• Word repeats where the same word is included in the stem and answer(s)
• Word association where question stem words are associated with the distractors
• Convergence where the correct answer includes elements common to other options

Go Long

The longest answer on multiple-choice tests is often correct because creating a truly accurate answer often requires the use of qualifying language.

Best Means Best

The format is multiple-choice with one best answer. Most questions have 4-5 choices but the total can be up to 11. The fact remains, you must look for the ONE best answer among the choices, even if it isn’t perfect.

Best Guess

• If A, B, C, D; B is slightly more common
• If A, B, C, D, E; E is slightly more common

High-Yield

Focus your study time on the topics that give the biggest bang for the buck. For example, the vast majority of USMLE® Step 1 and COMLEX® Step 1 questions are basic science or application of basic science to clinical situations. A few questions may be more clinical, but most will involve anatomy, neuroanatomy, histology, embryology, physiology, biochemistry, pathology, microbiology, and pharmacology. The strategy for USMLE® Step 1 and COMLEX® Step 1 is to focus more time on basic science principles and their application rather than signs, symptoms, and treatment issues.

Knowledge Deficits

Many exams, such as the USMLE® Step 1 and COMLEX® Step 1 include multiple epidemiology, genetic, and public health-based biostatistical questions covering hypothesis, sampling, experimental design, data collection, descriptive tools, inferential statistics, statistical error, p-value, misspecification and robustness checks, hazard ratios, mean, median, McNemar, and Mann-Whitney U tests, experimental study design and interpretation, accuracy, sensitivity, specificity, predictive values, and Kaplan-Meyer curves. Most students find it difficult to interpret complex research methodologies and statistical applications and apply them to clinical situations. 

Students that do well on these questions emphasize they spent a lot of time reviewing the concepts and then doing multiple practice questions, becoming comfortable with calculations, terminology, and application. Make sure your mechanism of action and pathways. While most of the preparatory systems offer a few questions, this is one subject area that www.statpearls.com is a tremendous resource. The database in Statistics and Healthcare Economics includes approximately 150 questions and over 35 short review articles. Students that complete these questions and review the articles are likely to perform well on this underappreciated portion of the exam.

Similar Is Similar

If two distractors are similar, one of them is more likely to be the correct answer.

Thoughtful Change

While it is generally true you should “never change an answer” if you have a strong feeling regarding changing an answer, that feeling is usually right. If you are sure you have marked an answer incorrectly, change it. 

Mindset

Believe in yourself. Students who ‘don’t do well on standardized tests’ often perform well above their historical scores on USMLE tests. Prior to the exam, visualize yourself in the room calmly taking the test. You will feel less stress on the day you take it. Practice visualizing yourself weeks later receiving a successful exam score.

Conclusion

Board exam questions generally will give you few breaks but smart-guessing is always better than random-guessing. During the week before the exam, take 2-3 full-length tests in the time you will be allotted on the real thing. This builds up your stamina and will prevent or at least reduce the mental fatigue students encounter on exam day.

Is there a way to improve your score on multiple-choice tests? The best answer is the hard work of preparing over time. But a few final things to remember:

• Develop a systematic long-term study strategy
• Exercise the night before the exam, and sleep well
• Embrace the "stress" you feel as the exam approaches, be "excited" not "anxious"
• Meditate, pray, or find something that will put you at ease before, during, and after the exam
• Know the material
• Practice practice practice
• Maintain confidence
• Remain calm
• Operate on logic rather than emotion