How to Mitigate ADHD’s Impact on Your Test-Taking Performance
In this video series, STATMed founder Ryan Orwig examines life as a doctor or medical student with ADHD. He outlines how ADHD affects your ability to study, take tests effectively, and manage your time. And he shares common patterns he’s observed with ADHD-affected medical students and physicians.
Test-taking for medical school and boards can be intimidating and nerve-wracking. A lot rides on your ability to accurately read and respond to these intense, complex questions and vignettes. For med students with ADHD, it can be even more daunting. But, there are ways to mitigate ADHD’s effects on your test-taking performance.
ADHD and Test-Taking in Med School
In this video, Ryan shares insights into how medical students or practicing physicians can successfully navigate ADHD and test-taking in med school and on boards. He outlines some of the ways smart students miss questions and explores specific strategies self-identified “bad test-takers” use.
“If you have ADHD along with a high miss rate (in testing), we likely understand why it’s happening and how to lay out steps to start to fix it.”
Ryan Orwig
Ryan outlines steps students with ADHD can take to help address bad test-taking habits. He explains the need for a structured process that limits the burden on working memory, contains impulsivity, and provides feedback.
In future videos, Ryan will dig into additional ways ADHD manifests for medical students and doctors and offer strategies to overcome these challenges. Be sure to subscribe to our email list for updates!
Transcript
Ryan Orwig: If you’re a med student or a physician and you have ADHD and you describe yourself as a terrible test-taker, I think you’re gonna find this video pretty interesting. My name is Ryan Orwig and I’m a Reading and Learning Specialist with STATMed Learning where we talk about the challenges of learning and test-taking in med school and on Boards. in this video I’m going to explain how I think ADHD leads to test-taking problems on medical board exams.
Let’s start by defining what I mean when I say “bad test-taking.” We start by taking any missed question and then we sort it into one of two categories after reading the explanation. The first is a knowledge miss, which means we just didn’t know enough to get it right in the moment. The other is a test taking miss. This is when you realize you could have gotten the question right if you would’ve use the parts you knew in the moment along with proper reading of the entire question and the use of proper test-taking methods.
So a bad test-taker is someone who consistently makes too many test-taking misses on a given exam. What does that mean? I usually say if you miss 10 questions, how many on average would be due to knowledge versus test-taking? If it is something like nine knowledge misses and one test taking miss then test-taking isn’t the issue, it’s your knowledge. But what if it’s more like a five knowledge and five test-taking? Yeah, that’s, that’s a pretty big issue. You’re probably a terrible test-taker. I’ve seen it be as bad as four knowledge to six test-taking, maybe even worse. Obviously this is a huge problem. Even seven knowledge to three test-taking misses can be a huge issue depending on your pass/fail margins. This is a very real pattern.
And if you have ADHD along with this high miss rate we likely understand why it’s happening and how to lay out steps to start to fix it. So what kinds of things do bad test-takers with ADHD at the medical boards level say about their experiences? Our first example is a med student with ADHD and she cites a combination of three different things. She might say “I either can’t tell what the question is asking,” or she might say “multiple answers seem right.” At a more macro level, she might also at times think ‘I’ll walk out of the test and have no idea what happened.’ Meaning it’s all a blur. And when she hears other people meticulously recalling the specific questions, she wonders how they can and she can’t. I attribute most of her situation as a bright med student with ADHD, to her working memory being in a constant state of overload during the test making her lose key clues along the way while working questions losing sight of the specific question being asked. And since she is churning so hard, not having a clear picture of what’s going on during and after the test.
Here’s another example. This is an emergency medicine doctor with ADHD, and he says, “I keep making dumb mistakes!” Which I hear a lot but it’s also so superficial that neither of us can really learn from it. And at the bigger more macro level, he may say “I walk out of the test thinking I nailed it then find out I was dead wrong.” This is all likely due to issues with impulsivity and med student or doctor like him is likely doing the same handful of impulsive mistakes over and over again on an infinite mix. And since they can’t see the pattern, he’s doomed to repeat it. The solution starts with naming the patterns underneath these impulsive “dumb mistakes.”
Then for a third example, we have a third-year med student with ADHD. She knows her stuff based on feedback on rotations but her scores are low and erratic on practice questions and shelves. So she’s worried about step two. Her main concern is one of the classics, she says, “I constantly narrowed down to two and pick the wrong one.” Let’s unpack this. First of all, missing a question after narrowing it down to two doesn’t necessarily mean it’s a test taking miss. Sometimes it is but sometimes it’s simply a matter of not knowing enough, your knowledge only going five layers deep and the question needs you to go seven layers deep.
But, that being said, one of the main things we hear from bad test-takers with ADHD is this phenomenon. Meaning, by and large they are tilting the scales against themselves while trying to break the tie, pushing it toward a miss. There are usually a few possible patterns at play here, for her it turned out to be she was what I call a binary test taker. She basically approached every question asking herself, ‘Do I know this or do I not know this?’ Thinking she had to know everything to get a question right because bad test takers compensate by over studying, powering through with over knowledge. Now I think a good test-taker narrows to two then use the parts of what they know to eliminate wrong answers that are partially wrong then choosing the remaining option that best connects with the vignette and the parts of what they do know. But bad test takers, like our med student here, she’s using her partial knowledge to kick away from the right answer. Let’s say she’s down to B and C and she likes B but she isn’t 100 percent sure. So, she kicks away from B clicks on C which it turns out she knows less about, but she never really weighed it and use the fact she knew so little about it to turn it into wild card. And that’s the wrong answer.
Once we identified this and gave her a very rigid process to follow in training and on test day, she was able to fix her test-taking issues and buffer herself against the bad behaviors induced by her ADHD. So why do med students and physicians with ADHD make the same kinds of predictable mistakes over and over again? I think there are a few reasons, but for me the number one issue is related to working memory. If you have ADHD, your working memory is likely on the low end. And I believe that makes a difference on board exams. Working memory is the mental chalkboard where we solve problems. It has a limited duration likely less than a minute. A weird design quirk is that once working memory is full new information will overwrite items you’re trying to hold on to with no alert or warning. Which is a pain because working memory has a limited capacity traditionally thought to be seven plus or minus two. The simple model for working memory says the average person can hold on to seven items. Those on the low end can maybe hold on to five items while those on the high end can hold a hold onto nine or more. So here’s my theory on working memory, ADHD and Boards.
The old conventional wisdom was the higher the IQ the higher the working memory. I think that as the testing mechanisms of medical boards evolved into the second and third order, multiple choice, clinical vignettes we know and love today or love to hate. And it’s probably more accurate, they evolved with the blind expectation that everyone taking these tests is obviously super smart so therefore they all have this incredibly robust working memory so they can hold on to nine, 10, 11 pieces of information. So here’s the thing. If you have ADHD then you likely have working memory issues.
You can be just as knowledgeable and smart as the person sitting next to you but the only difference is they can hold on to tenants items and you can only hold on to five. When working through Board’s questions, this makes a huge difference since losing key items is an easy way to make wrong answers look right, and that leads to all sorts of test-taking misses and can even grow other bad test-taking habits. Here’s an example of how an ADHD test-taker with impaired working memory might miss a board’s test question.
The question is asking, what’s the most appropriate next step in management? Then he starts reading the vignette which means his working memory starts to fill up as he goes. So it says the patient is a 36-year-old female. Her chief complaint is severe left leg pain and lower back pain. The pain started two days ago, but there’s a whole sentence on how she has had leg and low back pain for years. Some key findings include bilateral paraspinal muscle spasms, decreased sensation on her left shin and foot, left foot dorsiflexion is a three out of five. Now, the test-taker doesn’t know it but his working memory is full. There’s no alert. He just keeps moving through the vignette and finds another key clue but to fit it into his working memory something is going to get erased to make room for it. And here he loses the key clue that this is an acute situation over two days and replaces that with the straight leg test induces pain of 40 degrees further validating his suspected diagnosis but now he’s left thinking this is a chronic situation. So when he picks his answer he’s going to pick the most appropriate next step in managing a chronic disc side issue not an acute issue. So he’s technically right based on the clues he’s using but of course he’s wrong because those are not the clues in the literal black and white print on the computer screen. So he’s going to miss this question which will make him feel how?
Maybe he will feel like, ‘Oh that was a dumb mistake.’ Or ‘I thought I nailed that. What happened?’ Or maybe he’ll say, ‘I guess I thought I knew this topic but since I missed it, I guess I need to study it more.’ Or maybe it’ll even feel like, ‘Hey, I knew this. They tricked me.’ This makes him distrust the test makers, giving him license to not trust the clues and other questions, creating even worse test-taking habits. Look, here’s the deal. If we don’t understand the nature of the test taking miss, we perpetuate the pattern. That’s what we want to fix. All of this is bad. And the fact is this miss came from his working memory being so overloaded, he lost a key clue which happens way too often with ADHD on medical board exams. With bad test takers, we can expect impulsive issues to manifest in various ways due to ADHD on medical board exams.
One of the biggest test-taking issues I expect to see with an ADHD test taker is what I call twisting. Twisting is when you take a clue and distort it to make it play a desired role, to make the square peg fit in the round hole. It’s a weird way of using your own knowledge against yourself. If you hit it hard enough, it’ll fit. So for example, let’s say you’re trying to solve a most likely diagnosis question and one of the clues says, it’s confirmed that the patient contracted the disease from contaminated water. Good test takers are good at drawing inferences. The correct inference here is seemingly straightforward. This means the person ingested water and whatever was in that water gave him whatever illness, the most likely diagnosis we’re trying to figure out. In this example, let’s say the right answer is Giardia. So how could someone impulsively twist this clue? Oh, there are a lot of ways. So option A is Giardia the right answer and we’ll say option B is West Nile virus. Our ADHD test taker thinks you get Giardia by ingesting contaminated water but isn’t 100 percent sure and also doesn’t know a lot about it otherwise. On the other hand, she knows West Nile virus comes from mosquitoes and she gets fixated on the “acquired” through contaminated water clue.
Instead of ruling out West Nile virus based on this, thinking very fast and very impulsively, she twists the clue to rule West Nile in, saying something like, “If the water is contaminated with mosquitoes, then yeah, this person could get it from the water.” I know this sounds bad. And she was shocked she did this after the fact when I was sharing it with her. But this stuff happens. If you have to use “air quotes” or add hypothetical connector phrases, like what if, then it’s probably a twist, you’re making a square peg fit in a round hole. Twisting like this lets her use this one fact she knows to rule the wrong answer option in instead of using that one solid factoid to rule the wrong answer out.
If you are a twister, this can happen all the time in so many ways completely corrupting the way you are reading questions, narrowing your options and ultimately choosing your answer. And this is a classic way we see impulsive ADHD test takers destroy their test performance and then they wonder how they scored so much worse than they expected.
Another common issue is reducing key clues. Fundamentally our brains have a need to reduce information as we process it. Since clinical vignettes are so dense and precise, reducing clues can be problematic. Reducing the question from what is the most appropriate initial treatment down to what is the most appropriate treatment, can make multiple answers look right or worse, make the wrong answer appear to be right. That’s bad. Or let’s say the question sites, right arm muscle weakness buried amongst dozens of other clues. Then your brain reduces it to arm weakness. Then the weird thing, and I see this all the time and this is tied to working memory and impulsivity, I think. When the test-taker then unpacks that clue it defaults to thinking of it as bilateral arm weakness which is huge on the differential and we’ll definitely make a wrong answer appear to be right. We’ve identified a bunch of impulsive test taking issues over the years but the last one I’ll talk about here is the ever popular prediction trap. Look, predicting is a key part of dynamic, transactional reading. So I’m not saying don’t predict when you read. Some people use prediction as a great test-taking tool but predicting is a great example of how what works for one naturally gifted test taker can actually blow up in the face of others, especially our impulsive ADHD, board’s test-takers.
Here’s one way that can happen. Let’s say you skim over the answer choices and see an option that you like before you go up and read the passage. Maybe you know a lot about it. Then as you read the passage, you engage in some cognitive dissonance and maybe some twisting or reducing and you shape your reading to validate the desired predicted option making the wrong answer look also right in the moment. That’s bad impulsive test taking.
Here’s another way: you read the vignette hoping the answer jumps out at you but you get to the end of the passage and you can’t for the life of you predict the answer. Good test takers shrug that off but bad impulsive test-takers they either force a prediction or freak out because they can’t predict, greatly reducing their chances of getting the question right. My advice is this. You don’t have to predict the answer. If you can’t predict the answer, it’s okay. Just work with what you have and don’t get locked into any one prediction. Like if I’m working with say a group of pediatricians who are pretty knowledgeable and getting close to taking their boards, and I asked them, what percent of questions can you confidently predict the answer to before looking at the options? And the first thing they’ll do is ruefully laugh about it cause it’s a rough question, and then they’ll say, 50%. Then I say, “Really that high?” They say, “No, it’s way lower.”
The good test-takers are not affected by this. But the bad test-takers will say, “I try to predict the answer. And then when I can’t, I feel like, Oh no I’m a terrible doctor. Game over. I’m going to miss this question.” And then they keep spiraling. I point out that if your strategy in the case of predicting makes you feel like the sky is falling over 50% of the time, then it’s a bad strategy. Part of the work on rehabilitating the bad test-taker that we do is removing the weird expectation being built around the role of prediction. So you can imagine how merging impulsivity and prediction can very bad for some test takers. Anyone can experience any combination of the test-taking issues I’ve just described, but we expect to see them at a more detrimental clip when ADHD is present. Sometimes it’s really obvious. Sometimes we have to really dig into the system and find them.
The best way to address bad test-taking is to become aware of the bad patterns you’re engaging in and then grow self-monitoring skills to regulate yourself in all testing situations. I think there are lots of viable ways to read and work board style questions, but some processes are better or worse depending on your needs. I think med students and physicians who are bad test takers with ADHD need to use a very structured process to limit the burden on working memory, contain impulsivity, and provide feedback on test taking misses.
If you like this kind of stuff, I strongly recommend that you check out my talk on how smart physicians and med students fail medical board exams, linked below. And then if you want even more detailed help you should look into our boards workshop. That’s our one-on-one platform designed to turn bad test-takers at the medical board’s level into good test-takers. It’s not exclusively for those with ADHD but it is a perfect fit.
In our next video, I’ll share some feedback from med students and physicians with ADHD and how certain changes to their study, time management and boards test taking methods have made a huge difference in their careers. Until then feel free to reach out anytime with questions or if you want to share your story with me since that is how we continue to gain insights into the world of medical education, especially regarding ADHD. Make sure you like and subscribe below to hear more of our insights into learning and test-taking in med school, the Boards and related medical fields. As always thanks for watching.