Julie Hansen - Pastest user, high performing med student at St George's University and USMLE Step 1 tutor - presents her own expert guide on how to interrogate a USMLE Step 1 integrated vignette...and get the question right!

Step 1: Read the last sentence first

Use the last sentence as a clue to get your first attempt at anticipating what the question stem is about.

• i.e. if the last sentence reads “what is the likely etiology of this patient's hypothyroidism?” you have a great first look into what the stem will be about.
• i.e. if the last sentence reads “what is the mechanism of action of this newly added medication?” you have a pharmacology question that can save you tons of time.
• Read 1-2 sentences up from the last sentence, find the drug and answer the question, saving yourself a bunch of time.
• i.e. if the last sentence reads “what changes are most likely to be seen in this patient?” you know that most likely this is a physiology question and need to see what is going on further.

Step 2: Briefly look at your answer options

A lot of students don't do this step and it's something super important.

• This step tells you the depth to which you need to understand what is going on in the stem.
• It can also give you more clues into what the stem will be about if the last sentence is very vague.
• i.e. if all I knew from reading the last sentence (“what changes are most likely to be seen in this patient”) was that it is physiology-related. by looking at my answer options I can see if this is going to be cardiology, endocrine, renal etc. Most of these questions will be the pesky column questions.
  • And without going into too much detail on those questions my advice is start with a column you 100% know! Then move to your next most confident column and so on.

Step 3: Read the first sentence

Do not take this sentence for granted! Here you will see the age, biological sex and chief complaint.

• If I have a 83-year-old male patient coming in with chest palpitations well it’s most likely to be Afib and way less likely a congenital defect, but if my question started with a 6-month-old who turns blue when playing and squats to feel better, it’s most likely a congenital defect and way less likely to be Afib.

Don't forget to pay attention to the timeline.

• Was this acute? Was it chronic?
• Sudden onset of testicular pain in a middle-aged patient is most likely testicular torsion but a slow onset to the pain could be cancer.

Step 4: Read the rest of the stem

This is where you pretend to be an investigator for the FBI (or maybe I’m the only one who does this?).

• Read a sentence and try to ask yourself why they are saying this. And if you think it’s fluff, say that! There is definitely excess information in every question (this is less true for NBME exams but true 99% of the time for Qbanks).
• Look for things like medication changes or new symptoms - did they just tell me they have 10 parrots (pets)? - and travel history.
• Constantly be probing yourself for what does this mean, what is this trying to lead me to think of? What can I eliminate now that I have this information?

Step 5: Process of elimination

I’m going to say this first because it’s most important. USE THE PROCESS OF ELIMINATION EVERY SINGLE TIME.

• If you know the answer right off the bat that’s great! But don’t get cocky. Select your answer and then read each other answer option ensuring you can eliminate them.
• Sometimes it’s hard to eliminate everything especially if you are just going off a gut feeling, and that’s fine to do sometimes, but the point is: Slow down, you have the time, still read each option and make sure you didn’t select too quickly. This is a great way to eliminate silly mistakes.
  • Don’t be that person that selects increased preload, instead of decreased preload because you just selected the first option you saw with “preload”.

Another strategy I use for very difficult questions is, if I have gone through and selected what I think is correct having roughly eliminated the other options but I'm still feeling iffy, I will read my last sentence with my answer option.

• i.e. what is the likely effect of this new medication - nitrates = decreased preload.
• Obviously this is an easy one, but you see my point. It helps clarify things just a little bit more in your mind.

Step 6 (Bonus): Flag it or move on

I get quite a few messages from students asking how I approach flagging questions.

• Typically if I truly don’t know or I know I just need to think about it longer at the end, I will flag it. This doesn’t mean I’m flagging questions I’m 80% sure on (if I’m not going to have a better answer later I just move on and trust my process) it just means I’m flagging questions I literally have no idea on. it also helps me remain calm not seeing red flags everywhere because I’m taking my time on the questions I’ve already answered and using all the strategies I’ve been working tremendously hard on implementing.
• When I come back to it I will reread everything I’ve highlighted and quickly see if I’ve missed anything.
• If I cannot give myself three reasons why my initial gut answer is wrong then I will not switch my answer.

Finally, never underestimate what you’re capable of, because trust me - you can surprise yourself!

Julie

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