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Read the Last Line First on the USMLE? Here’s Why You Shouldn’t.

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by Alec Palmerton, MD in Test Taking

A butter knife has a clear purpose: spreading butter. Try to use it for something else – like cutting a steak – and you’ll find it woefully inadequate.

Everything has a purpose. Things are most useful when their mission matches their use. Unintended use of items leads to poor results.

I’m reminded of this analogy anytime anyone asks me: should I read the question (and/or the answers) first in a USMLE vignette?

It’s simple advice, and like the butter knife, there are times when it fits the task like a glove. During high school, I used it on my SATs whenever I had a long reading passage. Instead of trying to remember long paragraphs, I could zero in on the one thing they were asking. I could focus my attention, and the answer was simple.

While this may help you with your SATs or high school exams, it is terrible advice for the USMLEs or Shelf exams. In this article, you will learn:

  • Why so many people believe they should read the question first when they do vignettes;
  • Why the advice is wrong for the USMLEs (minus one small exception for Step 2 CK), and;
  • How you can prove to yourself which is the better method and settle the matter once and for all

Table of Contents

Reading the question first: the pros

Question-first proponents give two standard justifications:

  • It will help you understand what the question is about so you can focus on the essential things
  • Sometimes you don’t even need to read the vignette itself, because the question tells you everything

Let’s start with the first point.

Reading the question first makes you rush, leading to preventable errors

For many tests you may have taken, reading the question first is helpful. Knowing it in advance focuses your attention on the most important things.

However, USMLE questions are different. Most MCQs we’ve taken till now are “one-step” questions – they require us to make a single inference or jump. Examples like this would be, “what is the subject of this article?” or “what is the total distance traveled by the racecar?” If you know the question, you can cut through the fluff, and find the exact thing the question is asking.

USMLE problems are different. They are famous for being “two-step” questions. Not only do you need to make a “first step” (usually the diagnosis), but you will also have to make the second step, as well.

In the following example, try reading the question first:

A 56-year-old man comes into the emergency department with crushing substernal chest pain for the past 3 hours. He has been sweating profusely, has difficulty catching his breath, and reports that he is starting to feel light-headed. His medical history is significant for long-standing hypertension, for which he has only occasionally taken his medications. He has no allergies, no prior surgeries, and was adopted, so doesn’t know his biological family. On physical exam, he is diaphoretic and has cool extremities. His left radial pulse is weaker than his right. EKG demonstrates sinus tachycardia, and initial serum troponin is negative. X-ray shows a widened mediastinum. What is the next most appropriate step in the management of this patient?

Did you try reading the question first? If not, go back and re-read the passage, knowing this is a management problem.

Ask yourself the following:

  • How much does knowing the question in advance help you?
  • How much time would it take to read every single question for every single vignette on your exam?

To me, knowing the question first is next to useless. Knowing the next step in management is often the easy part. The hard part is to figure out what the diagnosis is, and what the severity is. (The diagnosis here would be aortic dissection. The next step management would be CT aortogram to determine the extent/what type it is).

When you consider the cost in time for reading the question first, it becomes worse than useless. It actually hurts your performance.

How many times have you gotten a question wrong you were certain you had right? Then you looked back to see that you had skipped over the critical sign/symptom?

Had you processed that one sentence, the question would have been another easy point on your test. But because you were rushing, you didn’t see it.

One of the worst things you can do when reading through a question is to speed through it. Reading a question first will cause you to rush and make bone-headed mistakes. This causes you to lose the most valuable points: topics you actually know but get wrong for other reasons.

If I get a question wrong because I didn’t know the topic, I’m ok with that. If I spend hours mastering something, only to get it wrong because I didn’t read a word, my soul burns.

Sometimes you don’t even need the vignette

I can hear your next question. “But Alec, sometimes the question itself is all you need.” This is true. The majority of USMLE questions are two-step, and require detailed vignette analysis. However, you CAN answer a handful of items without knowing the story at all.

Does this justify the question-first approach?

We’ve all read vignettes with lengthy descriptions of someone with a myocardial infarction. Then they end with “what is the likely pathophysiology in a person with an MI?”

When I read questions like that, a part of me wants to explode.

“What? I analyzed every single sentence, only to have them GIVE me the diagnosis?”

It’s natural to think you could save time by identifying these questions, but you’d be wrong.

How do I know? Because I’ve done the math, and it isn’t pretty.

Like our previous example, don’t ask “is there ANY benefit to reading the question first?”

Instead, ask “does the amount of time spent JUSTIFY reading the question first for EVERY SINGLE VIGNETTE?”

Calculate the costs and benefits for yourself

What if I told you that you were going to take a 40 question test, but I’d only give you enough time to answer 36 questions. Medical students would be in an uproar! But reading the question first takes away at least 4 questions’ worth of time.

Next time you do a block of 40 problems, count how many times the question gives the diagnosis away. You may find one, or at most two items like this. Many blocks will have zero problems like this.

Next, count the amount of time it takes to read a question and think about it. Then multiply that number by 40. That is the cost of reading the question first.

Now we can tally our results. Conservatively, it takes about 10 seconds to read/process the question. Multiply that by 40 items, and we get 400 seconds or roughly 6.5 minutes.

In a 1 hour, 40 question block, each question should take 1.5 minutes. In other words, we are giving up more than 4 question’s worth of time by reading the question first.

What if we are high-speed readers/thinkers, and did it in half the time? The question-first approach still takes more than two questions worth of time.

To break even with the question-first strategy, you’d have to find at least 2-4 items where the last sentence gave the diagnosis away. And that’s assuming that you actually feel confident on your actual test NOT to read the question.

The real exam is always more nerve-racking than a practice block. If you find one of those magic questions that gives everything away, will you follow through and not read the rest? Probably not. My guess is you will feel guilty about not reading the entire vignette, and still try to “skim” it. This negates the entire benefit of reading the question first, and will cause you to rush even more.

The ONLY exception where I would read the question first

I know I’ve just been telling you not to read the question first. However, there is ONE situation in which it is useful. This is relevant only for Step 2 CK, particularly internal medicine.

There are a few questions that ask you to interpret research abstracts/advertisements. It might show you an ad for a new drug, which can be very long. Often these questions ask a very specific question related to the passage. Rather than read through the entire ad/question, I would read the question first.

The reason? These problems are fundamentally different than other Step 2 questions. First, they are very few in number (some estimate fewer than 5 per Step 2 CK). Second, and most important, they are one-step questions.

In other words, these items are like those one-step SAT reading passages. By all means, read the question first on these, but don’t use that to justify the practice generally.

Concluding thoughts

Reading the question first isn’t always bad advice. Nor is it always good advice. Remember that like our butter knife, you need to match the advice with the proper task.

Reading the question first can help with one-step questions. For most USMLE/Shelf questions, doing so will take away valuable test-taking time. Rushing through the remaining questions causes preventable errors. Missing these easy questions will leave you as frustrated as cutting steak with a butter knife.

What do you think? Is there another reason you think reading questions first is good, or bad? Let us know in the comments!

1 Comment
  1. Hermilio Carvalho says:

    You’re the best, mate! All of your content is helping me immensely not only to study for the USMLE, but to help my own students improve on the art of learning. Thank you!

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Want FREE Cardiology Flashcards?

Cardiology is key for impressive USMLE scores. Master cardiology from a Harvard-trained anesthesiologist who scored USMLE 270 with these 130+ high-yield flash cards. You’ll be begging for cardio questions - even if vitals make you queasy.