UWorld cramming isn't a quick fix for step one, step two, or step three scores. It's actually the reason you're stuck. We've all heard we need to do 100 plus questions a day, but I've helped numerous students improve their scores by 10, 20, or even 30 points doing 50 or fewer questions a day.
The difference between a 230 and a 260 on step two, or passing and failing on step one, isn't what you know, but how you approach each question. Today, I'll share the top nine ways to immediately boost your USML scores. [Music] Score boost method number one is what I call judge versus lawyer.
This is the single most valuable mental shift you can make. Becoming a judge, not a lawyer. What do I mean?
In a court case, a lawyer is someone who finds even just the tiniest flaw in the opposing argument and pulls on that thread until the whole thing comes undone. On a USML question, this can be the kiss of death. Whenever I go over questions with students, they often get stuck between two answer choices and choose the wrong one.
On the surface, it looks like a coin flip, but if you actually delve deeply into their thought process, they're leaning more towards a single answer, but something doesn't quite fit. They'll find one tiny detail that doesn't jive with their idealized picture of what it should be, and then that doubt causes them to throw out the entire diagnosis. A step two student I worked with recently was doing a question where the patient was in shock.
They had a fever, they had high heart rate and low blood pressure. Um, they were thinking, "Okay, so this must be sepsis. " Only issue was that on physical exam the extremities were cold which as you know is actually the opposite of the classic presentation.
Right? In sepsis you get warm extremities. In low output forms of shock like heart failure and hypoalmia you would have cold extremities.
Here they had information that clearly supported sepsis but something that didn't quite fit with the picture. They ended up getting this question wrong because even though they thought okay like this is probably sepsis because one fact didn't fit with their view they just threw it out. Then they ended up choosing something like tempernut.
Instead of being the lawyer, you want to adopt the mindset of a judge. A judge is someone who evaluates all evidence before making a decision. They also acknowledge that facts will not fit perfectly, which is exactly what the USMLs are going to give you, especially for step two, shelf exams, and step three.
Instead of looking for the perfect answer, they're making their decisions based on the preponderance of evidence. The judge in this case would have said something like, "Well, this presentation matches sepsis in most ways, even if the cool extremities is a little atypical. " What we find when we do deep dives on NBMES after students have taken their practice tests, is that 50% or more of the questions can be due to things that have nothing to do with their knowledge.
We've routinely seen students improve their scores by 10, 20, or even 30 points just by not being the lawyer. In fact, a couple weeks ago, we had a student who improved their score from 200 to 245 in just three weeks. Really, by just learning how to tolerate the fact that there's not going to be a perfect answer for most questions on step two or step three.
If you could use a boost of 20 or more points, let me show you the exact framework that turns you from a lawyer into a judge. Score boost method number two is the context, chronology, severity framework. Be sure to write this down because this framework will instantly transform how you read every question.
Let's start with context. There are very few symptoms in medicine that are truly pathommonic. Meaning if I read a sentence and I only see one sign or symptom, it's extremely rare that one sign or symptom will definitively confirm a diagnosis.
For example, let's take a heart attack. Chest pain definitely not specific. If I see troponins are elevated in the serum, there are other causes beyond MI that can be the reason why you have an increase in tropponins.
In addition, even SC elevations by itself doesn't mean that it's an MI. But if you ask the context question of how does this connect to what I've already seen and put together chest pain and troponins and SD elevations, now you can make the diagnosis. The wrong way to read a question is to panic and feel really time pressured and read the last sentence first and try to figure out like, oh my gosh, by scanning every single sentence.
Can I find the buzzword? What high scorers do instead is that they calmly read every sentence and they think, okay, how can I connect this information with the other information that I've already been given? The next step is chronology.
Now, remember, test writers are deliberately going to present the information out of order. Uh, for example, they might say, "A 25-year-old woman presents to the emergency department with 3 hours of acute chest pain. 7 days ago, she got on a long flight, and then 8 weeks ago, she started taking oral contraceptives.
" Now, you can figure out the answer to this question. A lot of you have already probably thought of the answer. However, I would argue that the likelihood of getting it correct goes up dramatically when we put it in chronological order.
Now, the easiest way to do this is to think of it in the present tense. A 25-year-old woman starts taking OCPS, right? Notice how it's in the present tense.
Seven weeks later, she gets on a long flight. Five days after that, she has three hours of chest pain. Now, just the simple act of mentally rearranging this makes it so it's so much easier to figure out, oh, okay, this is probably a DVT that became a PE.
Final step when reading through a vignette is severity. Remember that up to 40% of step 2 and shelf questions hinge on management. There are two ways of trying to answer management questions.
What most people do is they'll try to go to like management algorithms and first aid or things like that and try to just brute force memorize all of the possible scenarios and details for the different management scenarios. If you're doing hundreds or even thousands of ANI cards, you know what I mean? Instead, a much simpler way of going through this is to recognize that management questions really hinge on two things.
You need to understand first the diagnosis and then second the severity. The more severe something is, the more invasive the interventions are going to be. The less severe, the less invasive.
So for example, I was tutoring a student who was brilliant. He had gone to Princeton for undergrad and he was at Harvard for medical school. He came to me once and he said, "I don't understand.
I think UWorld is wrong. " I was like, "Oh, interesting. Tell me more.
" He brought out two questions, both of which were acute diverticulitis questions. In the first one, the answer for the acute diverticulitis patient was to do IV fluids and IV antibiotics and to leave them NPO. In the second case, also acute diverticulitis, the answer was take them immediately to the operating room.
He was beside himself. He was like, "I don't understand. I've memorized the management of all of these conditions and I keep getting them wrong.
I I'll I'll use the answer for one year old question to try to answer another one and you know some of the times I'm right but often times I'm getting them wrong. What he was missing was the severity of the patient in the first case where the management was less invasive. So IV fluids, IV antibiotics and NPO the patient it was much less severe.
Clues would be things like the heart rate isn't very high. if the patient presents in a less acute setting. So if they're not in the emergency department and especially if they're not brought to the emergency department, it's going to be less severe.
In contrast, for the other patient, they were presenting to the emergency department. They had clear signs of shock. So they had the heart rate of the patient was higher than the systolic blood pressure.
They were in really, really bad pain. And in addition to that, they had signs of endorgan dysfunction. So for example, the patient was drowsy, meaning that they weren't getting enough blood to their cerebral cortex.
So it was affecting their cognition. In addition to that, you might see signs like low urine output, which means that you're not getting enough blood to the kidneys to get adequate kidney function. Now that you know how to read the vignette, let's make sure that you understand exactly what the questions asking.
Score boost method number three is to create a standalone question. This is one of the key habits that top scorers do differently than everyone else. It's that they understand how to get into the brain of the test writer to know what's really being asked of them.
The standalone question is deceptively simple. What you want to ask yourself is if I had to answer this question without knowing anything about the vignette and if I didn't know any of the answer choices, what would the question be where I could unambiguously answer it? Let me give you an example.
Let's say that we had a patient who had rest pain and they had peripheral vascular disease and maybe they had signs of chronic eskeemia in their lower extremities like muscle atrophy or loss of hair. I could ask something like how do I manage rest pain in a peripheral vascular disease patient who also has decrease in hair and muscle atrophy. The problem with asking a question that way is that it's extremely difficult to actually answer.
Instead, let's try to simplify it into a more conceptual standalone question. I think a better way of asking this is what's the treatment for severe peripheral vascular disease. Now, I've simplified all of the signs of rest pain and muscle atrophy and decrease in hair into just saying severe peripheral vascular disease.
And just like we learned previously in the context chronology severity framework, if we know the diagnosis and we know the severity, the management is actually pretty straightforward. So in mild peripheral vascular disease, you're going to do less invasive options like maybe some sort of diagnostic. In more severe peripheral vascular disease or really severe of any conditions, you're much more likely to do more invasive things like a stent or a graft.
Let's go through one more example so that you can really hone this score boosting technique. Let's say that you had a 25-year-old with a fever of 102 Fahrenheit. They were also tacocartic.
They had warm skin and they had decrease in urine output. Instead of just repeating all those details for my standalone question, let's simplify this by just saying, "What's the treatment for sepsis with shock? " In this case, it's it's going to be more clear that I'm going to need more invasive management.
Now, let's talk about how to prevent unforced errors when evaluating answer choices. If you ever find yourself getting a question wrong on something that you just studied, this is a technique that can change everything, especially if you're kind of stuck in that 230 240 range and you want to get to a 260 or above, it's to rule in before ruling out. To rule something in is very simple.
For every answer choice, first ask yourself, what condition would this be the treatment for? What in the vignette would make this a somewhat reasonable answer? What this does is it forces you to consider alternative diagnoses.
And it helps you to to not anchor on that one thing. If you've ever gotten a diagnosis question wrong and thought like, oh my gosh, I didn't even consider that in my differential as one of the diagnoses that were possible. This technique can be a complete game changer.
Only after ruling it in should you then rule it out. In other words, you'd say, why would this not be an appropriate answer choice? and try to make an argument for why it would be wrong.
What this does is it prevents elimination based on one detail that doesn't fit and instead forces you to be the judge instead of the lawyer. Let's go through a real example. So, let's say you've got a 62-year-old woman who's 3 days posttop from a knee replacement.
She's been receiving prophylactic lowd dose hepins and surgery. Today, she complains of calf pain and swelling in her operated leg. Ultrasound confirms a deep vein thrombosis.
So, the question would be something like what's the most appropriate next step in management? The answer choices would be a clipil, b compression stockings, c therapeutic heperin, d increase prophylactic hepin dose, or e th theolytics. Let's go through each answer individually.
For a clip, the rule in would be yes, this would be appropriate for clots, especially arterial clots. So things like coronary artery disease or stroke prevention. The rule out is that this is a deep vein thrombosis.
Venus thromboses are more of a coagulation cascade problem and not a platelet problem, which is what clipigral acts on. for B compression stockings. The rule in would be yes, this is used for venus circulation issues and can prevent DVTs.
The rule out is is that it's not appropriate treatment for an established DVT and in fact could potentially dislodge the clot and so you would only use this for prevention, not for treatment. For C therapeutic hepin, the rule in is that this actually is the standard treatment for an acute DVD. So it's like great, this actually would provide for that immediate anti-coagulation.
The rule out is actually no, that sounds pretty reasonable. So I would keep this answer for D. Increase prophylactic heperin dose.
The rule in is well that might seem logical since the patient's already on prophylactic hepin. However, the rule out is that prophylactic dosing even if you increased it is going to be insufficient to treat the established DVD. And so therapeutic dosing has just completely different protocol.
For E thrombolytics, the rule in is that it can dissolve clots in severe cases. The rule out is is that that would be way too aggressive for an uncomplicated DVT. That would be reserved for something like a massive PE or some sort of limbthreatening DVT.
So, I know what you're probably thinking. It's if I do context, chronology, severity, and the standalone question, and if I do rule in and rule out, this is going to take me way too long. There's no way that I'm going to be able to do it in time, and I'm already getting questions right.
Why would I need to do anything extra? Now, let me start by acknowledging that you're probably getting a lot of questions right, and you're not using most, if not all of these things. But let's take it to the logical extreme.
I could also close my eyes and just choose answers at random, and I'd still get about 20% of the questions correct. In other words, it's not about can I get a question correct. The question that we should really be asking is what can I do to maximize the chances of getting questions correct.
Statistics and probability tell us that our overall score on step one, step two, shelf exams or step three is going to be determined by the sum of the probabilities of getting every single individual question correct on our exam. So in other words, ask yourself if I were to understand the context of every single sentence and put it together. If I were to rearrange things that were out of order chronologically so that my intuition had a better chance of putting it together and if I could understand the different signs of severity which impacts up to 40% of my step two exam.
In addition to that, if I were to simplify the question making a standalone question and if I ruled in before I ruled out, would I increase the likelihood of getting the questions correct? I can tell you from experience that it's almost inevitable that you would increase your score if you did even just half of these things. But what happens when you encounter a question that genuinely seems impossible?
That's where our next technique becomes crucial. Score boosting method number five is to stop seeing ghosts. The phenomenon I call seeing ghosts means the tendency to invent complexity that isn't there.
One of the paradoxes I've seen is that as our knowledge increases, step two scores can often plateau or even sometimes decrease. Having more knowledge in general is good. However, it also gives students the tendency to read more into questions for things that aren't there.
I can't tell you how many times I've worked with someone who's interested in dermatology who had an overall lower score in dermatology than they did for other sections like things like cardiology or GI or neuro. And the reason for this is that by having extra knowledge we often times attribute meanings that test writers never really intended. So I'll give you an example.
So in a vignette there was a 55-year-old patient. They had palpitations basically presenting with classic hypothyroidism. The answer choices were calcium supplementation, iodine administration, prennazone therapy, propanol treatment, and thyroid hormone replacement.
What was interesting is is that the student got this question wrong and they chose B. When I asked them afterwards like you just studied all of the thyroid conditions, you know this really, really well. So, how is it that you chose B?
Like, walk me through your thought process. They said, well, I was thinking iodine therapy must mean radioactive iodine therapy. And I knew that I had just studied this and I couldn't remember like ah is it radioactive iodine therapy first and then propranol or I I just couldn't I just was mixing up the details of the different conditions in my head.
This perfectly demonstrates the seeing ghost phenomenon. They were manufacturing a debate in their head based on knowledge that they just learned. B iodine administration doesn't say anything about radioactive iodine.
In fact, it probably means something like iodine supplementation where they meant for it to be a treatment of low thyroid hormone. And because this person was inventing things that was weren't there, they didn't see that and they chose the wrong answer. So, how do you fix this?
First, always rule in before rule out. Try to understand what that thing would be the treatment for. Right?
So, for example, in it probably meant that they just wanted to supplement iodine. The second thing you need to do is you need to read what's actually there, not what you think might be implied. Now that we know how not to read too much into each of the answer choices, now let's move to the mental game that can completely transform your performance.
Score boosting method number six is that they're paid to play to. One way to very quickly boost your overall score is to prevent one tough question from becoming a series of misses or in extreme cases derailing your entire test performance. Examples of this are that often times on tests like step two, we see that some people miss multiple questions in a row in a way that suggests that it's not just at random.
Often times when you talk to these students, they'll say that they got rattled by a question where it was something where they felt like, "Oh my gosh, I should know this. " and they were beating themselves up and then they just kept thinking about it question after question after question and they weren't really able to focus on the question that was in front of them. This is not dissimilar to what happens in sports when a bad point can cause someone to unravel.
Sports psychologists have observed elite athletes and they found that some of the top performers often times differ in the way that they talk to themselves in difficult situations. We in the test taking realm can also learn from this so that we don't go into that vicious cycle. One phrase that you hear a professional athlete say a lot is, you know, the other side is paid to play, too.
Meaning that these are all very highly paid, highly skilled, highly trained athletes. And even when you do your best, the other side is also doing their very best. So, you're not going to run the table.
You're not going to get every single point. You're not going to win every single game. That's just the nature of the beast.
In the same way, when you find that really difficult question, just remind yourself, you know, the test writers are just doing their job. What I would do when I would take tests is I would say, you know what, that was a really good shot. meaning that I would appreciate their cleverness in coming up with such a good question.
Instead of going into the self-criticism mode that I would often do when I was younger. Your ability to recover is more important than your ability to never make mistakes. To improve on this skill, practice with a specific ritual.
An easy place to start is to just take deep breaths between questions. When you get to a particularly difficult question, don't start blaming yourself and say, "Oh my gosh, like how did you not know that? Oh, I should have studied this.
" And get into the regret behaviors. Instead, just compliment the test writer and say, "Wow, that was a really good question. You got me on that one, but I'll get you next time.
Then afterwards, just maintain your objectivity and make sure that you prepare well so that the next time you face a similar question, you don't get flustered. Score boosting technique number seven is intentional noise. Elite performers don't just practice.
They deliberately train under more difficult conditions than the competition. An important difference between step one versus step two and shelf exams and step three is that for step one, they tend to have less noise and they tend to have stronger signal. In other words, the question writers are unlikely to give you too much things that are trying to distract and instead are going to give you relatively classic presentations or signal.
Uh, in shelf exam step two and beyond, the test writers are now deliberately going to include more noise and give you non-classic features or in other words, less strong signal. These might be things like giving you a patient who has sepsis but doesn't have warm extremities. This can often create anxiety in unprepared students.
One thing that we do in our program is that we use custom AI prompts to intentionally give students more noise in presentations and to give them less signal so that you get used to sifting through unimportant details and trying to figure out what the true signal is. For the students that are part of our program that are watching this, you can actually ask it to increase the amount of noise that it gives you in the questions so that you can practice this skill and become more comfortable with the discomfort of not knowing exactly what's going on. So you can get better at the discomfort of not always seeing the classic presentation that you're expecting.
No matter what you do, you want to train your brain to become more comfortable with ambiguity so that when you see those difficult questions on the test, you don't go into that panic mode. Score boosting technique number eight is to create unavoidable accountability. What you measure improves and what you track daily can completely transform.
There was research that was done on people that were trying to lose weight. There was the control group which was just trying to lose weight and then there was a group where they were told to weigh themselves daily. What they found is that the people that weigh themselves daily lost almost three times as much weight through these consistent tracking.
If 50% or more of the questions that you're missing are because of test taking errors and not knowledge, then what you want to do is you want to track every single one of those. Now, note that this is going to feel uncomfortable. Just like when I weigh myself daily and I find like, oh my gosh, I ate that cake yesterday and I see myself gain weight the next day.
When I find that I've been letting myself go and eating a lot of late night snacks and I can actually see my weight get worse, it can feel really uncomfortable and I want to just stop. However, comfort is the enemy of improvement. If the only thing that you do is start tracking the number of error types that you have, you'll find that those error types will naturally get better because the discomfort of constantly seeing yourself say, "Oh my gosh, like I missed another question where I was the lawyer and not the judge.
" Some of the errors that you're going to want to track are when you weren't doing context chronology or severity. So specifically you could say like okay how many times should I have done chronology when I didn't or how many times did I miss a management question where I didn't think about it in terms of diagnosis and severity instead thought of it as a bunch of details how many times was I the lawyer and not the judge other ones include rule in and rule out implementation seeing ghosts where you have extra knowledge about something and therefore attribute things that aren't actually there getting into emotional spirals or sometimes it really will just be knowledge gaps to make this even more powerful share this data with someone else one of my favorite ways of forcing ing myself to do something is to tell a friend or a family member, hey, if I don't do this by X time, I will have to buy you a coffee so that I'm giving them some incentive to check in on me. So, for example, if I don't send you the list of all of the errors that I made for today by 5:00 p.
m. tomorrow, then I will buy you Starbucks. Whatever system it is that you want to implement, the key is is that you want to just get started.
Now, let's create the systematic approach that eliminates interpretation errors altogether. The final key score boosting technique is just consistency. Every single 260 or 270 score that I've ever worked with or known isn't approaching every single question differently.
Instead, they're using a flexible approach that can be applied to every single situation. What this means in practice is that you want to use the question interpretation protocol every single time. So, every time you do a vignette, you want to ask context, chronology, and severity.
Chronology. If the sequence is out of order, put it in chronologic order using the present tense. severity.
Use the clues that they're giving you in the vignette to figure out how sick the patient is. Then use those clues especially to help you to figure out and simplify the management questions. Next, when you get to the question, ask what is the standalone question?
Or in other words, what are they actually asking me? How can I simplify this question so I can answer it with the knowledge that I have instead of backing myself into some corner where I'm asking myself for a lot of random details that is making a question that I can't answer. And then finally, when you get to the answer choices, rule in before you rule out, so that you can figure out what was the intent of the question writer.
Who were they trying to fool with each of these answer choices? One of the things that the test writers do for the people that write step one and shelf exams and step two and step three is that if the incorrect answer choices aren't fooling at least some of the people, they're trained to eliminate those answers. So, in other words, ask yourself why would someone else be fooled by this answer so that you can figure out what the intent was behind it for the question writer.
Most importantly, you want to apply this to every single question, not just the difficult ones. Steph Curry, one of the greatest shooters in NBA history, practices 500 three-point shots per day. Now, the crazy thing is in a game, he might be only taking 10 or 20 three-point shots total in the entire game, but he's practicing 500 shots just like he's going to take them in game day so that he can be prepared for those small number of shots when the stakes are highest.
When you approach your questions, you want to do the exact same thing. There's a huge difference between someone who just does a bunch of questions just to say that they do them and someone who approaches it and says, "Okay, I'm going to approach this question exactly like it's going to be on my test because I want to improve all of the little skills that go into making up that big skill of being an excellent test taker. " This is what elite performers do that separate them from everyone else.
Your brain needs consistency so that when you get under pressure, it just becomes routine and natural. These nine techniques can transform your step two performance immediately, but they're just the beginning of your journey to a top score. Check out my UWorld complete guide, the five levels of mastery to 260 plus, where I break down the exact settings for each stage of your preparation, and realistic milestones for every starting point, even if you're below passing.
Don't waste time with generic advice that everyone who scores high does lots of questions. Get a proven framework that works no matter where you're starting from. Remember, you're not bad at test taking.
You just need the right approach.
