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The Secret to Scoring 250/260+ You Can Learn Right Now: Question Interpretation

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by Alec Palmerton, MD in Question Interpretation
USMLE Question Interpretation

What are the most frustrating or demoralizing questions to miss? For most of us, they’re the ones we SHOULD be getting right, but yet still mess up. Where we had the knowledge, but still managed to get the question wrong.

You know what I’m talking about. You look back, and you see that you didn’t understand what the question was asking you. Or you didn’t understand why they were saying the patient was a smoker. Or you just studied heart failure, but yet you STILL got the next CHF question wrong.

If you’re like most med students, these questions bother you. And they should! What you may not realize is that these questions are a huge source of potential points. In my experience, they’re even the difference between scoring 220s/230s and scoring 240s/250s/260s.

But how can you stop making these “unforced errors”? By question interpretation.

In this article, you will learn:

  • What is question interpretation, and why it can improve your score at any stage
  • The basic steps to analyze any vignette so you stop making silly mistakes on tests
  • How to verify your “gut instinct” to know if you’re going down the right path
  • The two things you should do for EVERY question that can immediately boost your score (hint: you’re not doing either)
  • Much more

Table of Contents

What is Question Interpretation?

Question interpretation is applying your knowledge to understand every sentence in context. Each sentence in a vignette has a purpose. Question interpretation is figuring out what each sentence means. (It will be more clear with the example below).

When I started my Step 1 dedicated study, my knowledge was already good. I had been making integrated Anki cards since my second quarter at Stanford. The result? My first NBME was 236. However, when I looked at my wrong answers, I realized something important.

Only about 50% of the questions I missed were because I didn’t have the knowledge.

Sure, some of the time I didn’t know a particular fact or concept. But most of the time, I knew the facts, but was still getting the questions wrong.

USMLE Question Interpretation

Knowing the facts is only part of the puzzle. Question interpretation means you can put them together.

For years, I’ve tutored hundreds of students on the USMLEs and shelf exams. If you are like these students, roughly 50% of the questions you’re missing on your test are NOT because you lack factual knowledge.

The dirty secret to scoring 240+ or 250+ on your USMLEs is that knowledge is only part of the solution. Knowledge will only get you so far, probably to 220s or 230s.

In other words, what would your score be if you ONLY missed questions that you truly didn’t have the knowledge? Much, much higher than it is currently.

How does one go from 220s or 230s to 240s/250s/260s? You have to reduce your unforced errors by interpreting questions properly.


What Question Interpretation is NOT

In my experience, most students have no clue how to interpret a question. Why? Because we’re never taught how to do it.

Instead, we do what we think we’re supposed to do. We skim the vignette, looking for buzz-words. Or we read the question first, hoping to glean clues from the answer choices. Or we “listen to our gut” and go with the first thing that pops into our head.

Whatever we’re doing, it is almost never true interpretation. Interpreting a question means you can say exactly why they put a particular sentence in a vignette. It also means knowing exactly what the question is asking you.

Next, we’ll go over the basic steps to analyze questions properly.

The Basic Steps to Analyze Any Vignette

In the Yousmle Online Course, we have two goals. 1) Teach you material so you never forget it and can use it. 2) Teach you how to know precisely what every sentence is trying to tell you.

Below is a simplified version of the question interpretation process:

First, recognize that every sentence has a purpose. Gone are the days of buzz-words being the key to Step 1. Why has the test had fewer and fewer questions over the years? Because each item is longer and takes more time.

Second, ask what every sentence means in context. Every sentence has a meaning. However, if you only consider that sentence by itself, you’ll jumble your thoughts.

Finally, understand what they are asking you. The USMLEs often have convoluted questions. Know how to simplify what they are asking. In the Yousmle Online Course, we call this the “stand-alone question” (SAQ). You should re-phrase the question so that it “stands alone” without needing to use the vignette.

Question Interpretation Example

Here is an example of question interpretation. First, start by analyzing the question yourself. (Really, do this step. You’ll understand much better if you try it yourself first).

A 56-year-old man is brought to the emergency department with 3 hours of chest pain radiating to his left shoulder. He reports shoveling his driveway when he felt sudden chest pain and lightheadedness. The patient decided to rest, but when the pain didn’t subside, he came to the emergency department. He has a history of uncontrolled hypertension. He occasionally drinks on the weekend and smokes 1 pack of cigarettes daily. Vitals are HR 42/min, BP 90/50, RR 18/min, and O2 sat 98%. On exam, he is diaphoretic. He has jugular venous distension. Cardiac auscultation demonstrates no murmurs. His lungs are clear to auscultation. His EKG demonstrates sinus rhythm, with 1.5 mm ST-elevations in leads II, III, and aVF.

What is the most likely cause of this patient’s bradycardia?

A. Brugada syndrome
B. Ischemia to nodal tissue
C. Congenital heart disease
D. Inflammatory disease
E. Ventricular arrhythmia
F. Sick sinus syndrome
G. Electrolyte imbalance

My Interpretation (You Go First, So You Can Compare)

First, I’ll go through every sentence. With every sentence, I will not only ask what it means, but what it means in context.

  • Sentence 1: classic presentation of MI (middle-aged man, radiating chest pain). The 3 hours is significant because stable angina is < 15 minutes.
  • Sentence 2: classic precipitant for MI = physical exertion → coronary plaque rupture. However, we have to wonder WHY IS HE LIGHTHEADED? Remember, lightheadedness likely means presyncope. Syncope/presyncope is almost always from hypotension. So really, we should be asking: why is he hypotensive? There are two possibilities if this is an MI. First, a non-fatal arrhythmia (e.g., ventricular tachycardia) → cardiac output ↓ → hypotension. Second, this may be a right-sided MI → SA node dysfunction → bradycardia → CO ↓ → MAP ↓ → presyncope. At this stage, we don’t know which it could be.
  • Sentence 3: confirming this is an acute coronary syndrome (either unstable angina or an MI). Stable angina would improve with rest.
  • Sentence 4 + 5: smoking and hypertension = risk factors for atherosclerotic plaques
  • Sentence 6: Bradycardia and hypotension. These raise our suspicion for a right-sided MI affecting the SA node.
  • Sentence 7: ACS often leads to diaphoresis. This is likely from sympathetic tone ↑ → M3 activation → sweat.
  • Sentence 8: Jugular venous distension = right-sided heart failure. We had been thinking of a right-sided MI before, so that would make sense.
  • Sentence 9: an MI wouldn’t lead to murmurs.
  • Sentence 10: lungs clear to auscultation = no left-sided heart failure. In CONTEXT, this means that he has isolated right-heart failure. This means he most likely has a right-sided MI.
  • Sentence 11: EKG shows he has an inferior STEMI, which fits the picture of right-sided MI with bradycardia.

Pathophysiologic Chronologies Verify Your First Thoughts

A favorite saying among residents is, “Trust, but verify.” If you tell me the patient’s labs were fine, I trust you. However, I should still look at the labs myself to verify the claim.

The same thing should be done with our first impressions when analyzing questions.

In the Yousmle Online Course, we talk about creating a “pathophysiologic chronology” (PC). In a PC, we walk through their disease’s pathophysiology from birth. Why? Because our associative mind is lazy. Our first thoughts may have been MI or aortic dissection. However, our first impressions are often wrong. A pathophysiologic chronology pushes us to assess whether our first impression is false. (It also helps us identify our knowledge gaps).

In the above example, this would be:

Patient born healthy with right-heart dominant coronary circulation. Poor lifestyle factors/hypertension → unstable atheromatous plaques in coronaries → rupture of RCA plaque during exertion → RCA STEMI → SA node dysfunction → bradycardia → CO ↓ → MAP ↓ → cerebral perfusion ↓ → lightheadedness.

Finally, let’s figure out what the stand-alone question is. Basically, the question is asking, “what is the most likely cause of bradycardia in a right-sided MI?” (The correct answer is “B. Ischemia to nodal tissue.” Recall that the RCA feeds both the R ventricle, as well as the SA node. Nodal ischemia can lead to SA node dyfunction → bradycardia).

Note how simple this question is! Every single question on the USMLE can be this simple. But few students do this and miss critical points because of it.

Broad Reflections on Question Interpretation

I’ve been teaching question interpretation – via tutoring and the Online Course – for years. Here are some of my observations.

Question Interpretation May Be Your Fastest Path to Improvement.

I’ve seen students improve by considerable margins in short periods. One Step 1 student jumped from 175 to 247 in less than 2 months. A Step 2 CK student went from 202 to 262 in less than 3 months. Another Step 1 student jumped 207 to 241 in 4 weeks. Even more students have gone from below-average Step 1 scores to 260+ on Step 2 CK. And it makes sense why.

Improving question interpretation improves my ability to answer every question. If I master 20% more of First Aid, it will only affect a fraction of the items.

“But why is question interpretation so important? I’ve gotten questions right just by skipping to the last sentence! Or skimming for buzz-words!!’

Sure, you CAN get a question right by guessing or using any number of other half-cocked techniques. However, that’s not the question you should be asking.

Think about the statistical concept of “expected outcome” for a second. A poor strategy, at worst, should yield an outcome no better than chance. Thus, if there are 5 answer choices, you’d expect to be right 20% of the time. Will you get some of them right? Of course! Will you like your score? Absolutely not.

Instead, think about the best way to improve the chances of being right for every question. By understanding every sentence and what it means in context, could you eliminate 1-2 more answer choices? Absolutely, and that would be an extra 20-40% chance of being correct. Add that up over your exam, and you can see a dramatic score improvement.

The First Three Sentences Matter the Most

What do you usually think after reading the first sentence? Do you:

A) Zone out, and read the last part for the chief complaint
B) Think, “I need more information before I think of anything,” or
C) Try to piece together all of the presenting symptoms into a coherent narrative

If you’re like most people, you chose A) or B). However, that’s a mistake.

Let’s look at our question again, and my analysis. Notice that I wrote and thought a TON over the first three sentences. After that, because my thoughts were clear, analysis became much faster.

Contrast that with how most people read sentences. When I tutor students, I ask them to narrate their thought process. Most will say things like, “hmm…I need more information.” Or “let’s see what the next sentence says.” Few if any people naturally stop and try to put things together early.

So why is the early analysis so important? Because if you don’t know what is happening early, you have no chance to interpret what comes next. Let’s look at our question again. However, this time, I will bold the non-specific sentences.

A 56-year-old man is brought to the emergency department with 3 hours of chest pain radiating to his left shoulder. He reports shoveling his driveway when he felt sudden chest pain and lightheadedness. The patient decided to rest, but when the pain didn’t subside, he came to the emergency department. He has a history of uncontrolled hypertension. He occasionally drinks on the weekend and smokes 1 pack of cigarettes daily. Vitals are HR 42/min, BP 90/50, RR 18/min, and O2 sat 98%. On exam, he is diaphoretic. He has jugular venous distension. Cardiac auscultation demonstrates no murmurs. His lungs are clear to auscultation. His EKG demonstrates sinus rhythm, with 1.5 mm ST-elevations in leads II, III, and aVF.

Notice how important the first 3 sentences are? If I hadn’t stopped to think about an MI/ACS, the rest of the question would be jumbled nonsense.

Hypertension? Could mean any number of things. Same with smoking. His vitals are relatively clear, but we have no idea WHY he’s bradycardic. And his physical exam only tells us he has isolated right-sided heart failure, not the cause. We could EASILY explain many of these symptoms/signs with an alternative diagnosis (e.g., PE).

The Online Course members know this because we harp on it regularly. If they don’t have a reasonable diagnosis or two by the end of the third sentence, their scores often nosedive.

Question Interpretation Necessitates Understanding the Material

Notice anything about my question analysis? It was devoid of the kind of random regurgitation you hear from most med students.

Attending: Hey, walk me through the baroreceptor reflex.
Med student: Oh, yeah…um…so when the blood pressure changes, the receptors stretch. Then the brainstem medullary-something causes…does it cause the heart rate to go up or down? I’m not sure, can you just explain it to me?

We have been trained for so long to memorize that when we need to use knowledge, our mind freezes up. This is a problem.

The difference between a 220/230 and a 240/250/260+ is mainly question interpretation. However, to even get to a 220 or 230, you must have good knowledge.

But even if your score is < 220, question interpretation is a valuable tool. Ever wonder what exactly you should be studying? Doing a pathophysiologic chronology for every vignette will expose your gaps. It will make it clear what you should be focusing on.

For more tips on how to master material, see my articles on:

Question Interpretation Skills Improve with Dedicated Practice

Let’s say you are a triathlete. You are fantastic at running, good at biking, and suck at swimming. If you wanted to improve your triathlon time, what would you do? Would you:

1) Spend all your time trying to boost your running times, or
2) Work like heck to swim better

If you’re rational, you will choose 1). However, this isn’t the choice most of us make in real life.

What do I mean? Next time you do an NBME, check how many questions you missed because of a deficit in rote knowledge. Usually, it is less than 50%. Interpretation problems make up the rest of the items. (Again, usually around 50%).

But how much time you do you spend on question interpretation? Almost none of it! The inertia behind watching videos, doing questions, or even Anki cards is so strong. Focusing on question interpretation is tough.

I have a student who is brilliant. Valedictorian of his high school, top of his class in med school. He knows many facts that I didn’t know at his stage. (And some I still don’t).

But his NBMEs have been hovering around 240 for months. Why? Because over that time he’s averaged a few QBank questions a day. Most of his time is watching videos, looking things up, and reviewing Anki.

He even told me at our last meeting: “Alec, at least half of the questions I missed were interpretation problems.” (It was actually more). Yet he’s done almost nothing to improve his QI skills since his last NBME.

He’s not alone. On your next NBME, assess how many questions you missed because of knowledge. That should be the time you spend on fixing your knowledge gaps. The rest? Learn what every sentence is telling you.

Concluding Thoughts

The NBME is very clear. They want you to apply knowledge, NOT memorize it. However, understanding mechanisms isn’t enough.

For impressive USMLE scores, you will need to practice applying that knowledge. At a minimum, make a pathophysiologic chronology and stand-alone question for every vignette. You can write these out or do them in your head. (Generally, I recommend writing out the first 5-10 until you get the hang of it.)

Your ultimate goal should be to understand what every sentence’s purpose is. Why did the author write it? The more you can decode the vignette, the higher your chances of getting the question right. And the higher the probability of success on each item, the happier you will be with your score.

Read More

To read more about other students’ experiences with question interpretation, see their articles:

What are your experiences with interpreting questions? Let us know in the comments!

Photo by Bruno Martins

  1. Aaron says:

    Why not just look at the initial question as asking which ones of these an cause bradycardia?

    Then your down to two answers (B & E)

    1. Yousmle says:

      Great point. In fairness, this question was a bit too easy – you can too easily eliminate other answer choices that don’t give bradycardia; the NBME likely would not have been so careless as I was when I wrote this question quickly. I’ve updated it to reflect more causes of heart rate changes, since the question – as you point out – specifically asks about bradycardia.

  2. Aaron says:

    Did you use any reference books for step 2ck?

    Any experience/thoughts on Online Meded?

  3. 박진명 says:

    Its sounds plasauble.
    I applyed your method on my qbanks but the time matters.
    underlining and getting interpretation of it takes much more time than I used to

    how Should I Manage the time with this method?

    Is it only way to get used to lining and thinking simultaneously?

  4. Bronxbomma says:

    Hi Alec,

    Great site and thanks for all the advice on the site.

    (1) How many cards are there in the Step 1 Anki deck? Are they constantly updated or are they a static deck?

    (2) Could you send me a price list of group tutoring and individualized sessions? Thanks!!

    1. Yousmle says:


      Thanks for your message. The Step 1 Anki deck has ~1800 cards in it currently – it is regularly updated, both in number of cards, as well as in content when I find new/interesting/highly tested concepts.

      You can find the group tutoring and individual tutoring prices here:

      Hope this helps!

  5. Anon 144000 says:

    Hi Alec,

    Thank you so much for this article and your devotion to students’ success. At this point, I currently have a major deficit in foundational knowledge. That being said, should I try to build my foundational knowledge first before trying to master question interpretation?

  6. longshot1710 says:

    Hey Alec, first thank you for your blog and flashcards, as well as your perspective on this whole process. It truly is something special, and your willingness to share with all is deeply inspiring.

    I was wondering if you would be willing to share the settings you use in Anki with regards to new cards (steps, new cards/day, intervals, staring ease) as well as reviews (maximum/day, easy bonus, interval modifiers, maximum interval), and any other settings you feel are necessary for success.

    Certainly the relevance of this information is predicated on the fact that if we are making our own cards, they align closely in style and length with your own.
    -Jonathan G

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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.