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5 Reasons Smart Students and Doctors Fail Medical Boards Exams — and What To Do About It

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Bad test-taking is a real thing in med school and on boards exams — and we know how to fix it! 

“I do great clinically, but I can’t translate what I know to exams.”

“I always narrow down to two and then pick the wrong one.”

“I miss or distort the key clues, and I don’t trust myself.”

“I am always rushing to catch up and making unforced errors.”

If any of these sound like you, you’re not alone. Bad test-taking, especially for something as daunting as medical boards, is more common than you think. But it’s also not the end of the road. 

Why Smart Students and Doctors Struggle with Boards Exams

There are typically five key issues “bad test-takers” encounter during medical boards exams: 

  1. Working memory overload
  2. A flawed sequence when it comes to reading board exam questions
  3. Binary test-taking mentality, 
  4. Abusing the prompt, and
  5. Twisting key clues 

In the video below, we help untangle these test-taking issues and get you moving in the right direction.

If you’re a self-identified bad test-taker, we can help. We work with you to identify and change your bad test-taking habits so that your testing reflects what you actually know. And we teach you how to read the question the right way every time.

Check out our STATMed Boards Workshop to learn more.

Transcript

Ryan Orwig: We often get asked, “Why am I a bad test taker? “And how do I fix it?” So today we’re gonna talk about how smart med students and physicians fail board exams and lay out some rules and guidelines that can maybe help fix that.

Bad test takers say things like, “I do great clinically, “but I can’t translate what I know to exams.” “I always narrow it down to two then pick the wrong one.” “I miss or distort key clues, and I don’t trust myself.” Or they may say, “I’m always rushing to catch up and making unforced errors.”

The common theme here for these bad test takers is they realize they could have gotten a missed question right after reading the answer and explanation. If this is an issue, you are indeed a bad test taker and we need to do things to fix this.

So today we’re gonna talk about what bad test-taking on medical board exams looks like. And we’re gonna lay out five key issues that we see over and over and over again.

The first one is working memory. So working memory is this sort of mental chalkboard where we solve problems. The duration can be anywhere from say 10 to 60 seconds. It’s fleeting. And there’s a capacity of seven plus or minus two. So maybe on the low end, someone could hold on to say five pieces of information. The average might be close to say seven. And then on the high end, say it’s nine. This is a little soft science, but it’s good enough for our purposes. And then on the robust end, maybe people can hold onto even more upwards of 10, 11. That’s just a guesstimation, right? But there’s a design flaw here. As new information comes in, it overwrites existing information. It’s just the nature of the beast. So how does this impact test-taking, this whole working memory thing? Simply put, losing key clues makes wrong answers appear to be correct.

So, cartoonishly, let’s look at this example here. Let’s just say, I ask you what’s 10 plus 10? And you say with confidence, well, that’s 20. And I’m like, no, it’s not 20, it’s 22. You’d be outraged. You’re like, that’s not true. You would say, but 10 plus 10 is 20. I say, I didn’t say 10 plus 10. I said 10 plus 10 plus two. Oh yeah, yeah, that’s 22. It’s really hard to get that right without the plus two. So how does this translate to medical board exams? Obviously our working memory can handle 10 plus 10 plus two, but once you get into dense, complex clinical vignettes, it’s relatively easy to lose a clue here and there.

Boards questions heavily burden working memory. And here is my pet theory as to why the role of working memory can be so problematic. So the old conventional thinking was the higher the IQ, the higher the working memory, the more robust the working memory. So if you’re really, really smart, you probably have nine, 10, whatever, working memory slots. There’s just been an undue blind expectation that if you’re smart enough to be in med school, smart enough to be a doctor, you could hold on to all these various bits and pieces. But what if you are indeed smart enough to be a doctor, smart enough to be a physician, whatever that means, and you have an average to below average working memory? It means that this test-taking format is gonna be much harder for you than for the person sitting next to you. When you know the exact same amount of information, the result is working memory issues can lead to boards test-taking issues. Now it just might be the way your brain is wired. If you have ADHD, you’re going to have a weaker working memory. You’re gonna have less slots. And I’m not saying that every bad test taker has poor working memory or average working memory. It’s just one of these key patterns that we see.

So what does this look like in an example? So let’s imagine that we’re reading a question, “which of the following is the most appropriate next step in management?” And as this med student starts to read the question, obviously the working memory starts to fill up. 36-year-old female, severe left leg and back pain, started two days ago, but has had back pain for years. Bilateral paraspinal muscle spasms are present. They note decreased sensation on her left shin and her foot. Left foot dorsiflexion three out of five. Now, as he’s reading this, the working memory is filling up. He’s starting to generate what he thinks diagnostically is going on, but he’s full. And I was gonna lose a clue as something else comes in. Ooh, straight leg test equals pain at 40 degrees. There’s no alert, there’s no safeguard, there’s no warning. And now the impact of this is he lost that this is an acute situation. And now he’s gonna choose the most appropriate next step in managing somebody with a chronic issue. Both of those answer options are gonna be down there. He’s gonna pick it, feel good about it and then miss it. So how’s he gonna feel about that? Well, he could feel like he just needs to study the concept more. And that’s really what most students and physicians who are bad at test-taking, they overcompensate with just ridiculously robust knowledge. They overcompensate. It’s the only way to get through it. Well, they could then maybe start to not trust his knowledge, which is just a slippery slope. And now everything starts to fall apart when you don’t trust what you know. That’s where you say like, well, I like A, but what if I’m wrong? Now, if you don’t trust what you know, the entire test-taking apparatus falls apart. Or he feels tricked by the test maker, which is extremely dangerous.

These test questions are certainly tricky but they’re not trick questions. A tricky question means you really need to pay attention and be diligent and look at all the clues. Whereas a trick question gives you clearance to not trust a given clue and dismiss a given clue. And when we start doing that, that takes that 10 plus 10 plus two. And you’re like, I’m not sure if that’s really says plus two. Or what if that plus is a minus? The whole thing falls apart. So the solution here, we wanna install a system that limits the burden on working memory. We wanna develop awareness of these negative patterns. If you are indeed a bad test taker, you’re probably engaging in the same three to five negative behaviors over and over and over. So the more aware you become of those behaviors, that can be the start to changing the test-taking issues because bad test-taking is bad behavior. Issue number two, the reading sequence.

We wanna think about the sequence we are using to read questions. This applies to our training and practice. And of course, how that translates to test day. I think you should re-read and train and practice as close as possible to how you wanna read and engage with questions on test day, especially if you’re a bad test taker. And there are many right ways to read questions. And it’s not that one way is right and other ways wrong. I just think we wanna use a process for us, for the bad test taker, that number one limits burden on working memory. We also wanna compartmentalize the reading sequence so that when we assess, we can see where we went wrong. The most common advice people are given, if they’re a bad test taker, is just do more questions. And if that works for somebody, again, great. That probably does work for the majority of med students. What does that majority mean? 60%, 80%, 85%, I don’t know. But if you’re on the other side of that and it’s not working for you, that’s where the true frustration comes in. And that’s where tactical intervention is required. Let’s tear down the system and install a new one. So the way I look at reading these questions, we wanna break it into multiple regions. So I wanna look at the last sentence, call it the prompt. I wanna give it new vocabulary to give us more control over the system that we wanna call everything above the prompt the passage. That can include labs and images as well. And then of course the answer options. So I wanna first break any question into these three zones. So to resolve these issues, we wanna talk about a very direct and simple system for reading each and every question. So we wanna always start by reading the prompt. So the last sentence that states the precise question being asked. This has gotten a lot of traction in the last 10 years. I think we know about this, but so many people either just don’t do it all the time or they do it but don’t profit from it. Then we wanna read the passage, keeping the prompt in mind on the one hand, and then identifying three key clues from the passage itself on the other. That’s not too burdensome for working memory. It gives us something actively to do as we read. And it will create a framework that we can build off of. You might say, yeah, but there’s more than three things I need to know. Of course, of course. But by at least getting that framework in place, it will prevent you from just grabbing onto a single clue, which is extremely damaging, or just sort of throwing your hands up and just saying, I can’t hold on to anything. And then we wanna read each option one by one, comparing it to the specific question being asked back to that prompt, turning each question into a set of many questions. This compartmentalization will free up working memory space.

So issue three. I think one of the most damaging things we see is this sort of limited binary mentality. So this binary test-taking mentality is the belief that you have, that you need to know everything to get a question right. It’s essentially fine when solving less robust, first order multiple choice questions. This is what you saw in undergrad. This is what you saw maybe in your grad program. Maybe even some first year classes.

Here’s an example of a simple first order question. “Which of the following is a first generation cephalosporin?” Here you’re probably better off even predicting the answer and then seeking it out. But when you get to second and third order questions that you’ll see in steps one, two, three, shelf exams, in services, specialty boards, these things are much more nuanced and it’s much more involved. And actually carrying this binary mentality, this idea that you need to know everything, can actually be damaging for a lot of these test takers. So instead we wanna use the opposite of the binary mentality and we can call that a partial knowledge test-taking mentality. This is where we go in and we have to learn to say, I’m gonna use the parts of what I know to rule out answer options and choose from the best of what’s left using the parts of what I know, connecting back to the question being asked. And we have to learn to really embrace that I don’t have to know everything because that’s where good test takers are truly profiting.

We also wanna learn how to avoid what I call the prediction trap. So many of us have been told, predict the answer. I hate this advice with a passion. How often at a step level, or especially at board level, can you confidently predict the answer without looking at the answer choices? Some people might say 50% of the time. I don’t believe that. 20%, maybe, maybe even more, maybe less. Let’s call it 50% just for the sake of argument. Then I ask people, how do you feel when you can’t predict the answer? But if you’re someone who says, oh, it makes me feel terrible. It makes me feel like game over. It makes me feel like I’m gonna miss the question. It stresses me out. That means you’re embracing a strategy. That’s gonna make you feel terrible 50% of the time. It could be as high as 80% of the time. That’s a bad strategy. Prediction is a key part of reading and thinking and comprehension and transaction. So I’m not saying don’t think in that regard. But this expectation that you’re supposed to be able to predict an answer at this level is extremely damaging. So let’s get rid of that. We wanna avoid the “rule in” traps. So many bad test takers are trying to rule answer options in. That’s taking the square peg and making it fit in the round hole. We can make a square peg fit in a round hole. You know how you do it? You hit it really, really hard. But we wanna flip the rule in and to rule out. Same equation as with partial true versus partial false. A little bit false is all false. A little bit wrong is all wrong. I want people who are bad test takers to learn to embrace that you can use the parts of what you know, to rule out wrong options, and choose from the safest of what’s left.

So issue four. Abusing the prompt. You would think that the prompt is the most innocuous thing that we can talk about. Again, the prompt is that that last sentence and the clinical vignette explicitly states the precise question being asked. It’s so easy to glaze over the prompt because there’s nothing really medical in it. But that’s dangerous. It is the most important sentence in any vignette. If you don’t precisely understand each aspect of the prompt and you don’t orient your way through the question and through the answer options, through choosing your answer by anchoring to the prompt, you’re putting yourself at great danger of missing the question. So it should always be read first, obviously. But you should also refresh and check it while working the question as well. Just because you read the prompt first does not guarantee you’re gonna know exactly what you’re looking for and answering 30 seconds later, 75 seconds later. So this is something that needs to be grown and developed, this idea of like, do I know what I’m looking for? Let me refresh and go back to it. That’s a nonlinear reading strategy. It’s a little bit of self monitoring. You have to keep that in mind. Do I know what I’m looking for? Let me check back to it. But just because people read the prompt first doesn’t mean they’re gonna accurately retain it 30 seconds, 70 seconds, 80 seconds later. We can’t treat it just like a box that we check off. So some of the problems we see with this, even when people are reading it first can be that they forget it within seconds. Imagine like Dory from “Finding Nemo” flittering across the screen, in one ear out the other. You will answer a question. You’re not gonna work into a vignette without answering some sort of question. Your brain will auto-correct. But think about the dangers of auto correcting. We don’t wanna rely on that. Or you could be answering one question with A and B and then a slightly different question on C and D. It’s very dangerous. So we wanna be aware, and that’s where this starts. Be aware that just because you read the prompt first doesn’t mean it’s gonna be accurately, concretely retained the entire way. You wanna grow a mechanism through self reflection. So looking back and say, how should I have done this to grow what’s called self-monitoring so you can monitor and regulate yourself in the run of play, where you’re sort of checking as you work through the question, “Do I know what I’m looking for?” Or you bounce back, check it, refresh and move on.

This might have to happen a few times within a question if you’re a bad test taker. It is a good skill to grow. It’s gonna be cumbersome and awkward at first. And that’s okay, it’s the price of getting better. Some people might experience will we call reducing the prompt. We have a desire in our reading system to take the least amount of information to then process. So we wanna compress information. And this can happen with complex prompts, obviously, but it can even happen with simple prompts. Look how simple this prompt is right here. What is the best initial treatment? How can you compress that? Well, you can compress it to what is the best treatment, which we then default think best overall, best broad spectrum. Both of those answer options can certainly be down there. They can both be down there, that’s not a trick. It’s not a booby trap. It’s asking do you know the sequence of treatments. It’s asking for specificity of your knowledge, not generic, fuzzy knowledge. And that’s fair. But what’s not fair is when you know the best initial treatment versus best broad spectrum treatment and you confuse it and answer the wrong one because you got tangled up in your thinking and reading and interpreting of the question. That’s what’s not fair. Prompts can also mutate. They can go from one thing to completely something else. And this might not happen in the first 15 to 30 seconds of reading, it could, but it might happen somewhere in that 45 second, 70, 85 second range. So let’s say you get some more weird nuancey prompt. A biopsy of the skin lesion would most likely reveal that they were what? So this means up in the clinical vignette above, you’ve got some woman coming in, she’s got all these symptoms and you’re supposed to figure out what the diagnosis is and then know that these lesions that are described, you know, go with that disease. That’s one way to get it if you know everything. But maybe you can’t tell what the diagnosis is, but there’s a description of the lesions and you can work through and eliminate the lesions that don’t fit. But what can happen in this kind of question? And I’ve seen this happen hundreds of times. Hundreds. Somebody turns a prompt like that into what’s wrong with this woman. What’s wrong with this lady, most likely diagnosis. And then they end up like manipulating square peg round hole, smash it make it fit, these lesion types and turning them into diagnoses, which you might think you can’t do, but you can, if you’re a bad test taker. So what I say is don’t throw stones in glass houses, right? You just don’t know, because this is a problem with the way we do practice questions.

It’s just the sort of brute force, head down, chug, chug, chug, doing volumes and volumes of practice questions. And then hoping that that untangles it and systems get built in the back of our consciousnesses. And again, if that works for someone, that’s great. But for the struggling test taker, the bad test taker, just doing a ton of questions and not getting proper feedback to show them the architecture of the questions, show them exactly where they are going right versus where they’re going wrong. This is where the problems really begin. The prompt is just one of multiple steps in a chain. They can’t see the code behind the computer program. And what we wanna do with people is we wanna be able to reveal the mystery. And it’s not that big of a mystery. If you add a system and a vocabulary, that’s very sequentialized. And that’s what we need to do. So again, this is, I think, understanding the nature of this thing is a really important first step. And I think for some people that can help. But if there are larger solutions that can be provided with the stat med boards workshop.

So binary and prompt issues. So here’s an example. So this was a med student that was sent to me. A third year med student, did amazing in his first two years, did fine on step one, but there was a gap in performance, but he was fine. But now he’s in rotations and he’s bombed three shelves in a row. When I say bombed I’m talking first, second, third percentiles. And they’re really confused in his med school. They’re like, what is wrong? What’s going on? We talked to this guy, we see him on rotations. You ask him questions he knows the answers. He’s performing clinically at a very high level, but we have a three strikes and you’re out policy. Now we’re trying to figure out a way around this. We’re gonna let him get one more chance, but zero tolerance. What’s going on with this guy? So he comes to me and he basically says, you know, I like to know everything. I’m used to knowing everything. And this is true, his entire life, he just knew everything. So he was the definition of the binary test taker. He just knew it all.

And as much as he had to learn, you know, going through this first two years, he kind of just had it all down. But once you get in, eventually there’s a threshold that gets crossed where that capacity just gets surpassed. Maybe that’s first block, first semester of med school. Maybe it’s not until step one. Maybe it’s not until rotations for him, right? So he comes in, he says, “I always narrow it down to two. “I always pick the wrong one. “I don’t trust anything anymore.”

So we sit down and do some questions and we look at a question that comes up. Here’s the prompt, which of the following. This is the best initial treatment for this patient. Dense clinical scenario. We’re not even gonna get into that, it’s too distracting. And he’s got, say, four answer options just to keep it lean, right? So he works through the question. He has a pretty good sense of what’s going on. And he narrows it down to two. He’s like, here we go again, just keep going. So he said this about B Indomethacin. “I’m pretty sure this is the first line.” I don’t know anything about medicine. My colleague, David and I, we’re reading and learning specialists. We don’t know about the medicine. We’re looking at the process. And then he says this. He says, but, you’re like, oh no. When you see people do this, when you hear this, you know that they’re probably getting themselves in trouble. “But I also know it’s not the best thing, “not as effective as D.” It’s like, well, that’s cool. You’re flexing on your knowledge, but now we’re starting to get off of what the question’s really asking. And then he goes to D. “Well, I know this is the better drug.” He knows more about it. He knows that it’s got more broad spectrum utility. “But is prednisone first line treatment?” Question mark. He’s saying, “I don’t know. “Well, I like prednisone better to treat this fake patient.” So he selects D and he finds out it’s wrong. He’s like, “Ah, there we go again.” And of course yes, B is right. I always narrow it down to two and pick the wrong one. Okay, so some of the things we’re seeing here. He tried to answer two prompts at the same time. He’s trying to answer the best overall treatment and best initial treatment. Chose the option he knew more about. “Oh, I know more about prednisone, I’m gonna pick it.”

He did not choose the thing that he knew that most closely connected back to the prompt. He narrows down to B and D. B fits, but he’s not 100% confident. He’s let’s say 70% confident. Since he’s not closer to a 100%, he’s gonna then bounce off B and pick D, which he knows more about, but doesn’t know how it connects back. That was his most significant pattern. And by fixing this, we fixed his career. Now he, you know, he went back, he’s succeeded. He’s a physician now. But I asked him in the moment. “Is this a knowledge or a test-taking miss?” Because this is the ultimate question. When you miss a question, we’re trying to sort them into one of two categories. Is that a knowledge miss or is it a test-taking miss? If it’s a knowledge miss, it’s fine. Like go study that. That’s like a learning side study-based, encode, retrieve type of process. But if it’s a test-taking miss, that’s where methodology for the test-taking process really comes into play.

So if someone comes to me and they say, “I’m a bad test taker because I study all the time “and I don’t do well on tests.” I’m like, “That doesn’t mean you’re a bad test taker.” I mean, maybe, but what’s happening when we study? That’s just as important, right? But when someone says, you know, out of 10 miss questions, that’s how I always frame it, if you look at 10 missed questions on average, representatively, how many would be knowledge miss? I just didn’t know enough to get it right. Versus test-taking. Oh, looking back after reading the answer explanation. I see how I could’ve maybe gotten it right. You know, five out of five, five knowledge, five test-taking. That’s bad test-taking, you know? If it’s like two test-taking, eight knowledge, one test-taking, nine knowledge, That’s probably not as, that’s more of a knowledge issue. But I meet people all the time. It’s four test-taking, five, six, seven test-taking. And of course you don’t know, but I tell people, you should definitely contact us. Contact us and let’s talk about it. That’s how we sort of operate. There’s not a great test for it other than that thin slice sort of response I just talked about. But I think it’s always worth if you’re one of these bad test takers, just talking to somebody, myself, or David. This is all we do every day. And sometimes that’s really helpful. So I asked him, you know. Is this a knowledge of test-taking miss? And he’s like, “This is definitely a knowledge miss.” And I was just like, no. I was like, “What do you mean?” He’s like, “Well, if I had known that “one thing about prednisone, “if I had known prednisone was not first line, “or if I had known that indomethacin was, “then I would have gotten it right. “So it’s a knowledge thing.” I say, no, those are knowledge gaps, absolutely. But you knew more than enough, 10 times out of 10, using proper process to get the right answer on this. And so for him, it was really breaking that pattern of thinking he needed to know everything and really learning how to lean into partial true, partial false, rule in rule out. And again, we had to sort of go through the workshop and really add the behavioral modifications to the training because this is bad behavior. This is really bad behavior. His default settings were bad. So we had to change that. And that’s something that I think for some people just having some rules laid out like in this video can absolutely help. But again, some people need more work.

So issue five, the last issue we’re gonna talk about is this idea of twisting key clues. So when we talk about any of these bad behaviors, it makes me think about this podcast I was listening to with Malcolm Gladwell. He writes about social phenomenon. And he was talking about some systems are called weak link systems. And some systems are called strong link systems. And he was talking about basketball and soccer. He said basketball is a strong link system. Strong link means if you have the best player on the court, you’re gonna win more championships. Michael Jordan, great example. You have Michael Jordan on the court. You’re gonna win more games. Whereas with soccer, soccer, it turns out the highest level is a weak link system. So you might have Cristiano Ronaldo. You might have Lionel Messi, doesn’t mean you’re gonna win the World Cup. So their respective countries had never won. Why? Some of the greatest players ever to play the game, why? Because soccer is about the weakest player on the field. And it’s all about finding and exploiting the weakness to score goals.

What is test-taking? Is test-taking a weak link system or a strong link system? I’m convinced it is absolutely, at this level, it is absolutely a weak link system. So I don’t care about whenever you nail a question here, you crush it over here. It’s about the bad things you’re doing. It’s not about the good things you’re doing. But we wanna think about test-taking as a weak link system. It’s not about, yes, I did a good job here, it’s fine. I mean, pat yourself on the back for sure. But it’s about identifying the bad behaviors and learning about why they’re happening. Because if you identify the pattern, you fix the pattern, that’s where we get exponential gains.

Back to the main topic here. One of the main patterns we see is this conflict between inferring and twisting. So inferences are good. It’s the lifeblood of good reading. In regard to test-taking, it’s when you draw logical conclusions from the clues presented in the vignette. And some people really have a tough time seeing that line, where is a good inference to be drawn and where is a bad one? And so when you cross that line, that’s where you’re twisting it. That’s where you’re making the square peg fit in the round hole. This is when you draw conclusions from the vignette that are not logical. They often require the insertion or deletion of words, ideas, or concepts. So a lot of times we’ll hear people say, what if, or maybe. And when you say, but what if this and maybe this, and you’re adding a clue at the end of that, that’s where you’re getting into trouble. It’s like adding a plus three to our 10 plus 10 equation. So there is a line where you’re where we say this clue equals this. If that’s really clear to you, that’s fine. But if this is murky, then this must be cleaned up. And again, I’m not saying all bad test takers engage in this type of thing, but this is one of the key patterns.

So here’s an extreme scenario and this is 100% true story. So we have this guy come onto the question. He’s a physician who’s a terrible test taker. And he proved it as soon as he did this question. So he sits down, he doesn’t read it using the proper system. You know, he’s top down, predicting, just slinging all over the place. 15-year-old female brought to your clinic, fathers said fainted twice during workouts with her personal trainer. What, she’s got a personal trainer? What’s going on? She’s fainted. Then he flies through it, denies using any medical, any medications or illegal drugs. And this is literally what he says. And more credit to him for articulating his thoughts. Denies using any medications or illegal drugs. But what about her sexual activity? She’s climbing out her window at night, running off to see her boyfriend, getting in the pickup truck. She’s pregnant. Ryan, I see it all the time. Teenage girls lie, she’s pregnant. So he zooms down, picks social history, clicks it and finds out he’s wrong. And then we find out the answer is indeed family history. He’s like, “Oh yeah, yeah. “I botched that.” Yes, you did. And he’s doing that when I’m watching him. What’s happening in the third hour of his test, right? So that’s a true story. This is an extreme scenario of twisting. Now, obviously he did a lot of things wrong.

How do we fix something like this? How do we go about re-engineering it? Well, first of all, you have to run out the play like he did. You have to track out exactly the steps taken to miss it and then take the steps you should have taken to get it right. This how you change test-taking behavior. So he goes through this. And how should he have worked it? Well, he’s like, “I should have started at the prompt.” It’s not asking what could be causing this. It’s a weird prompt. It’s asking what’s the thing you should find out first and foremost when you see these very limited symptoms. What are these symptoms? What should I find out first? What’s most pressing? Then you pick three clues. What would be the ideal clues to pick? And you can link and chunk ones together as well. So he’s like, okay, the female, her age, because she fainted twice during these new workouts with her trainer. So that’s the inference that we have to draw. If somebody drops during these intense workouts, what is that telling him? And she’s fainted multiple times during intense cardiovascular events. And she felt fine before and after. Okay, those are limited clues. What can we do with that? What would be the most concerning thing here? You can predict if you want, but don’t feel beholden to it. Now you go down the line, each one by one. Pulmonary function test, what would that do? Well, I’d be like for like an asthma type thing before and after, she felt fine after. Family history, okay, yeah. Like what if, now this is a what if, but do I need to be concerned about hypertrophic cardiomyopathy? Yeah, I mean I should be concerned about, I wanna rule that out. Family history would do that. Social history, of course you could go into all sorts of things with that, but not most concerned about first and foremost. Travel history, of course, you could have gone anywhere and got anything. Dietary could be anything. But given the limited clues, fainting multiple times during exertion, we have to rule out family history first.

Then you can explore all the other things. So by going through this analysis process, identifying the kinds of behaviors he’s susceptible to, that’s how he gets better. So assessment here since proper process would lead to the correct answer, this is a test-taking miss. He must meticulously trace out the steps he took to go wrong and then track out the steps he should have taken. This is how he has to get better. All right, now let’s do one last example. Now this is a much more subtle type of test-taking miss with some much more subtle twisting involved. So as she sits down to do this question, she’s engaging in proper process. Most likely diagnosis means she can read it a little faster, looking for key triangulations, working her way through the question. Chief complaint, muscle weakness in his right leg. Now here’s what happens. She’s gonna take that clue and she’s gonna reduce it to leg weakness. And now we’re default leg weakness equals bilateral. She reads the rest of the passage. She gets down here and she’s like Guillain-Barre syndrome. Yeah, like weird stuff going on, leg weakness. Maybe. Now in reality, she should have ruled that out because she actually knows that the Guillain-Barre is bilateral. But the clue has gotten, you know, reduced and then flipped in her head. And this is a critical error. Then she’s gonna say giardiasis. She’s gonna say, well, yeah, he’s like abroad and rivers and lakes. Like, yeah, maybe these are all partial trues. She’s ruling them in, not factoring in that these clues that she, from what she knows, don’t really fit that diagnosis, that presentation. Then she looks at MS, out. She looks at Addison’s, out. And then she’s like, those don’t fit symptomatically. But then with poliomyelitis. she’s like, you know, I don’t know much about poliomyelitis. I’m just gonna skirt cross it out. It’s not the right criteria to cross out. So then she’s down to two. And she’s like, well, okay, you know, symptoms, giardiasis don’t really fit. So boom, Guillain-Barre. Finds out she missed it. But this is the scenario where it’s not one or the other. It’s actually something she ruled out. Now this is called a bad slash. This is whenever you have definitively slashed out the right answer where it’s like, you’ve done something impulsive. You’ve smashed and grabbed, grabbed a few clues. You could do like she did here where she’s like weighing each option just on different single points of contact. It’s usually some of the lower hanging fruit that can be cleaned up the fastest. And it’s usually a hallmark of a really bad test taker if you’re often slashing out the right answer. And again, this is a different pattern than some of the things we talked about earlier. But it’s one of the key patterns. We don’t know if this is a knowledge or test-taking miss yet. You’re not gonna know until you do the analysis. There were some serious missteps taken here, I think. So she twisted or reduced the muscle in his right leg to leg weakness, and like I said, defaulted to that sort of bilateral instead of unilateral. She didn’t really triangulate to build that framework for her first phase. And she twisted rivers and lakes to make giardiasis fit when no sentence matched, so she could have ruled that out from the get go. It’s really dangerous to leave answer options in play as maybes when they could be slashed out. A little bit false is all false. So using proper reading of the passage. She could have weighed each option individually, emphasizing ruling out instead of ruling in. So again, a really good process is to practice going back and say, what would be my best triangulation? So here we’ve got the muscle weakness in right leg and be really deliberate and say that’s right leg. That is unilateral. And then as she’s reading through, she might also note muscle weakness has continued to worsen. Anytime you see a progression or timeline, those are pointy edges that you really must learn to grab onto. Then you’ve got the trip abroad, swim in various rivers and lakes. You might say, I don’t know what that means, but it’s so weird that it’s in there. That’s such a strange clue that I think it’s worth noting. And then of course, you’ve got some classic signs and symptoms, and then you’re gonna say, well, what am I gonna do with this? I don’t have a prediction, I don’t know what’s going on. That’s fine. So then you take each option one by one and say, GBS, bilateral, not unilateral, partial, false, all falls, out. Then you say, well, giardiasis, okay. I see the rivers and lakes and stuff. But the physical symptoms, the issues, this is not what happens, a little bit false, all false, definitively. And then C, D, they don’t fit. Those are more easy to wipe out. But then poliomyelitis, a lot of people are like, I don’t know anything about this. Like, we don’t study this. This is eradicated or whatever we say about it. But at the very worst you can say, I’ve never heard of this, question mark. but this person can certainly say, there’s not a single factoid that they can say, I know this goes against it. Therefore, it’s a question mark, it’s an unknown. Now, if you have some maybes, you pick the maybe over. So if this person had made GBS a maybe because they had turned the unilateral to bilateral, then they’re gonna pick GBS. If you know about GBS but you don’t know bilateral versus unilateral, you’re probably gonna pick it. And that’s a knowledge miss. But in this situation, this person knew enough to find a partial false with each of A, B, C, D. And therefore they should pick poliomyelitis 10 times out of 10. It’s gotta be the right answer.

Therefore, this is a test-taking miss, and they did not know it was a test-taking miss. They certainly thought all the way through working it up that this was a knowledge miss ’cause they didn’t know anything about poliomyelitis. Your job is to clean up your process so that you can systematically work each question the same way every time, eliminating the wrong answer options and choosing from the best of what’s left.

So in conclusion, if you identify as a bad test taker on medical board exams, there’s likely a reason why, and it’s usually mistake patterns. Bad test takers are usually engaging in the same two, three, four, five patterns over and over and over on an infinite mix. So we have to learn what those behaviors are, identify them, and then modify the behaviors so that we can control them. So this lecture may help entangle your issues. And if that’s so, that’s wonderful. I’m glad we can help get you going in the right direction.

But if this lecture only scratches the surface, feel free to check out our STATMed Boards Workshop, which is designed to address all the test-taking issues I just described in much greater depth and organization with rules and guidelines and personal training and feedback.

Or if your issue is more on the study and encoding side, if it’s nine of my misses, eight of my misses are because I can’t recall it in the moment, That’s where our STATMed class comes in, where we address study methodology. And we lay out the test-taking blueprint and develop time management strategies as well. I wanna thank you guys for watching. Please feel free to check out the website and our YouTube channel for more videos. Thanks a lot.