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Test Taking Anxiety: Why It Happens (and How to Overcome It)

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by Alec Palmerton, MD in Uncategorized

Stress and anxiety take many forms. Sometimes it is the chest tightness we get whenever exams approach. Maybe it’s how we constantly second-guess ourselves and always seem to choose the wrong answer. Or the seeming eons it takes to fall asleep. That feeling that we never quite deserve to be where we’re at. The nagging doubts of our abilities or feelings that we’re a fraud.

This stress and anxiety have real consequences. For example, depression, burnout, and suicide are much higher in doctors than in the general population. Nor is this new. I read an article recently titled, “The Fate of Idealism in Medical School.” In it, they explore “the development of cynicism and the vicissitudes of that idealism in the course of the four years of medical training.” It was from 1958!

We will save our discussion of how we can improve medical training for a different time. Today, however, I want to discuss:

  • How our assumptions about ourselves feed our anxiety,
  • Why our best efforts don’t make us happier (or might even make it worse), and
  • What we can all do today to make it better

Table of Contents

Our Assumptions Make Us Miserable

A physicist, a chemist, and an economist were stranded on a desert island with no implements and a can of food. The physicist and the chemist each devised an ingenious mechanism for getting the can open. The economist merely said, “Assume we have a can opener”!

Economists get (often deserved) criticism for their simplistic assumptions However, what we often miss is that EVERY system or knowledge rests on certain core assumptions. More to the point, I’d argue every belief rests on an assumption.

What do I mean? An assumption is something that we accept to be true without proof. These assumptions take on different names in different circumstances.

In math, they are called axioms. Things as simple as a+b = b+a (Commutative law for addition) or the existence of negative numbers are assumptions.

Even the scientific method rests on the assumptions of empiricism. We can’t PROVE there are natural causes for things that happen in the world around us. We also must assume that evidence from the natural world can be used to learn about those causes. That said, we also can’t prove these premises are false, either.

Note that I am NOT saying that math and science are wrong to make assumptions. On the contrary, to live in the real world, we must act on imperfect information. But, at their core, you can’t prove or disprove assumptions.

Much of the time, that is ok, as some axioms are definitions or seem apparent. However, like in economics, the quality of the outcome depends on our premises.

Our Assumptions Feed Our Stress and Anxiety

Axioms, postulates, and assumptions are a fact of life. That said, the fact we need to make assumptions to live doesn’t tell us WHAT assumptions to make. And therein lies the problem.

Let’s take the classic case of the overachiever. You’ve been outwardly successful for much of your life. However, no matter what you’ve accomplished, it never seems to be enough. You get 96 questions right on a test, but all you can think of are the 4 you missed. You got into medical school, which to many, is a lifelong dream. But no sooner than you got your acceptance that you started to downplay its significance.

Whether you hit your target or not, nothing seems to overcome your confirmation bias. So either you succeed and downplay your success with reasons for why this was an exception. Or you fall short and now are faced with “proof” of your inadequacy.

But why does this happen? Assumptions. We all have basic premises about ourselves. For many (most) of us in medicine, the nagging insecurity driving our anxiety is that we are not good enough. We try desperately to feel at peace with ourselves and do everything we can to achieve that. But like the starving economist on the island, the quality of our assumptions creates more misery.

Our Assumptions Feed Med School Test Anxiety

For our personal beliefs, these assumptions have a name, “negative cognitions.” These are the things that underlie our thoughts and actions. Think of the things that you tell yourself. For example, “I’m not a good standardized test-taker” is rampant. Another is, when reading a question, “I just don’t know the answer.” Implicit in this is the assumption that you don’t know enough, which happens to all of us.

I’ll give you an example. Recently I was working with a student preparing for Step 1. She is scoring well but feels burdened by the feeling that she didn’t prepare well enough in her first two years. “If I’d only done more, I’d know more and could get more questions right,” she regretted. She referred to herself as “fatalistic.”

However, when reviewing the questions on her NBME practice test, something became apparent. She DID have enough knowledge. Her problem was that she wasn’t using it.

One item showed a CT of the heart, and she was essentially asked to identify the tricuspid valve. Her answer – and internal dialogue – was instructive. She immediately focused on what she DIDN’T know. “Is this in the arterial phase? Hmmm…I always get confused by knowing whether it is a CT angiogram,” she mused.

The irony is that the question had NOTHING TO DO with angiograms or arterial phases. Instead, all this student needed was a simple piece of commonly-tested knowledge: the right ventricle is the most anterior chamber of the heart. She knew this. Had she assumed she knew enough, it’s likely she would have retrieved that basic knowledge. But, instead, she sabotaged her chance by telling herself her preparations weren’t good enough.

I have done the same to myself. Stanford, for all of its strengths, taught bone diseases minimally. As such, I had only a vague understanding of Paget’s disease. What’s worse, I was insecure about my MSK depth because of this perceived lack of instruction.

I got nearly every bone disease question wrong. Why? Because whenever there was something I was unsure about, I assumed I didn’t know enough. “Gosh, alkaline phosphatase seems a little higher than I expected. Must not be (the right answer.” More often than not, if Paget’s disease was among the answers, I’d choose it. (And I was almost always wrong).

It took a deep dive into my self-assumptions – and mastering Paget’s – to get those questions right.

Negative cognitions are nearly impossible to disprove with facts. Why? Because they are assumptions we make. These assumptions underlie our beliefs, and our beliefs drive our actions.

Like the CT question above, the insecure assumption prevented recalling the relevant information. Or, in my Paget’s debacle, my false premise spurred my doubts to mushroom and my judgment to falter.

How do we overcome our own negative cognitions?

Assess Our Assumptions Critically + Accept That We Will Never Disprove Them

The first step to address our negative self-premises is to explore them honestly. Most of us want to get into a good residency. It seems so self-evident: of course, I want to get good training! Who wouldn’t want to keep more doors open with greater prestige?

Let’s follow the thread of desires a bit more. If we’re honest, what are we really seeking? Academic titles are excellent, yes, as is financial security. But to what extent are they primarily ways of trying to somehow PROVE we’re good enough to ourselves and others?

For myself and most of my students, our insecurities usually stem from one Big Insecurity. And that Big Insecurity usually is the belief that we’re somehow deficient. “I’m not good enough.”

The irony is that we’ve trained to spot false assumptions in other parts of our lives. For example, in the medical literature, we search for improper premises with aplomb. Similarly, we are quick to point out confirmation bias in clinical practice.

To help overcome stress and anxiety, search for the core premise underlying them.

Explore How Our Past Affects Our Present Assumptions

We have automatic thoughts. For example, consider the phrase “roses are red.” Most likely, you involuntarily thought, “violets are blue.”

It’s also evident these automatic thoughts may be untrue. Remember, violets aren’t actually blue – yet we still think it automatically! Similarly, every time you think, “I don’t know enough,” it may not be true either.

But where do these negative thoughts come from?

Imagine that you’re a 4th grader tasked with giving your first public presentation. You prepare diligently and spend extra time practicing in front of the mirror. However, on the big day, it falls flat. You fumble your words, forget everything, and even start to tear up. What’s worse, everyone – including your teacher and classmates – laugh at you.

Would you get over it? Yes, at least the initial pain and heartbreak. However, could that experience shape your beliefs about yourself? And could those beliefs cause future stress any time you were in front of a crowd? You bet. You’d eventually stop thinking about that horrible day. You might even stop recalling it before a big presentation. However, the negative cognition would remain.

To find where these negative, automatic assumptions come from, explore your past. This may take the form of self-reflection, like journaling. You may consider counseling, or my recent favorite, EMDR therapy. Whatever it is, remember that past experiences have a powerful impact on our self-assumptions. This is particularly true of childhood experiences.

For example, I was bullied when I was a child. Not dangerously, and certainly not in a way that you’d read about in the news. But enough that I felt uncomfortable around larger, athletic guys. It was something I lived with my entire life until I explored my past experiences using EMDR.

The effects were immediate and dramatic. Being in crowds suddenly felt safer. My anxiety decreased, and I started sleeping like a baby.

You can read more about EMDR in this fantastic book here. Alternatively, if you’re in the Online Course, you can read more about my experiences and recommendations here.

Address the (Actual) Deficiencies That Feed Our Negative Cognitions

Jeff Bezos said once that stress comes from not taking action over something I have control over.

Let me be clear: our anxiety is not solely a product of pernicious assumptions. If I failed an exam, my assumptions might have played a role. I’d be naive to think that assumptions were the sole cause, and all I need is positive thinking. However, anxiety can stem from negative premises as well as cause results that worsen them.

Instead, assumptions and reality each contribute a different amount depending on the circumstance.

Feeling like I don’t know a lot after failing Step 1 or Step 2 CK? Maybe 20% negative cognition and 80% a true knowledge/retention/skills gap.

Still feeling insecure after getting my dream (score, residency, school, etc.)? Maybe 99% negative cognition, and only 1% reality.

It can be difficult to tell where our negative self-talk ends, and our reality begins. Unfortunately, such is the nature of perception and reality. That said, to improve how we deal with our anxiety, the solution must be “and” and not “either/or.”

For help on improving your approach, read more here:

If you prefer personalized guidance to transform your approach and build mastery then, have a free consultation on how we can help you understand more and memorize less for better scores.

Concluding Thoughts

Our anxieties are often never-ending loops of confirmation bias. And how could they not be? Assumptions underlie our beliefs. Our beliefs drive our actions which then feed back into our results. However, our negative self-premises are often immune to proof. By their nature, assumptions are things we accept without evidence.

Let me be clear. I’m NOT saying that you should feed yourself empty praise and ignore your weaknesses. For me, with Paget’s disease, I had an actual deficit in my understanding of the disease I had to fix. However, even after addressing my weakness, my performance continued to suffer. Only after I managed the assumptions underlying my doubts did my scores improve.

My point is that often our stress and anxiety come more from our assumptions than reality. While striving to change, learn and grow, don’t forget to address your own assumptions.

Are you struggling with anxiety that you can never win against? Do you find you can never “win” with your self-doubt? Let us know in the comments!

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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.

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