Learning how questions like to trick you...not helpful?

[Frank Nutter]

I am wondering how frequently USMLE writers use little tricks, like UWorld and Kaplan, to keep too many people from answering questions correctly. I get the feeling these Qbank writers get frustrated when what should be difficult questions content-wise are too straight-forward and 80%+ get them correct...so they tweak the wording to get people to answer them wrong. Or they find distractors that are the most tempting.

Example: using similar looking answer choices- if the answer is amiloride, listing amlodipine along with it. Or if the answer is polycystic ovaries, disguise the name as "enlarged ovaries" and list polycystic kidneys as another option.

I'm not actually keeping track of these tricks, but can't help but be aware of them and they are helping me rule out answers. Wondering if it will backfire when the step does things differently. Thoughts?

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[Phloston]

Interestingly, I wouldn't even consider the examples you've given to be actual tricks.

"Tricks" are making you think the answer is one thing and then having that not at all be the case.

An example would be giving you a vignette of a patient with a classic atypical pneumonia. They might also briefly mention a notably bad sunburn the guy had because he was also on vacation.

Then they ask you which drug was prescribed.

I had encountered this question and lamely said the macrolide, since those are the 1st-line Tx for atypical pneumonia. As it turned out, chlamydia, a cause of atypical pneumonia, can also be treated with tetracyclines, which happen to cause photosensitivity. Only 9% got it right because they tried making you think the macrolide was the obvious answer.

That's just one example. Doing lots of questions will put you on the lookout for that stuff, which is why I think thousands and thousands of practice MCQs are anyone's ticket to a dream score, keeping in mind on the actual exam, most people wouldn't realize they had missed a question like that.

And if they tell you enlarged ovaries in a girl with PCOS, that's not really a trick because that should be a given anyway.

 

[ijn]

I am wondering how frequently USMLE writers use little tricks, like UWorld and Kaplan, to keep too many people from answering questions correctly. I get the feeling these Qbank writers get frustrated when what should be difficult questions content-wise are too straight-forward and 80%+ get them correct...so they tweak the wording to get people to answer them wrong. Or they find distractors that are the most tempting.

Example: using similar looking answer choices- if the answer is amiloride, listing amlodipine along with it. Or if the answer is polycystic ovaries, disguise the name as "enlarged ovaries" and list polycystic kidneys as another option.

I'm not actually keeping track of these tricks, but can't help but be aware of them and they are helping me rule out answers. Wondering if it will backfire when the step does things differently. Thoughts?

In general the NBME subject exams, CBSEs, and CBSSAs have all had extremely straight forward prompts. Definitely not like Kaplan or some USMLERx styles where they intentionally try to trick you for the sake of learning. I haven't taken the actual STEP 1 yet, but I presume it'll be more like the CBSEs than anything else since the NBME markets those to the schools as an exam that is representative of the STEP 1. I guess they're retired questions? Anyway. Some prompts may be cryptic as hell, but I think the difficulty in those comes more from being unfamiliar with the particular buzz word or presentation.

Now something they do do that's like USMLEWorld is use buzz word pathological descriptions of histology as a way to hide the answer choices. For example a girl has a diastolic plopping murmur, syncope, and a mass in the left atrium. The answer will be disguised as "stellate cells in a loose stroma" or something along those lines instead of saying myxoma.

 

[Azipropofol]

I am wondering how frequently USMLE writers use little tricks, like UWorld and Kaplan, to keep too many people from answering questions correctly. I get the feeling these Qbank writers get frustrated when what should be difficult questions content-wise are too straight-forward and 80%+ get them correct...so they tweak the wording to get people to answer them wrong. Or they find distractors that are the most tempting.

Example: using similar looking answer choices- if the answer is amiloride, listing amlodipine along with it. Or if the answer is polycystic ovaries, disguise the name as "enlarged ovaries" and list polycystic kidneys as another option.

I'm not actually keeping track of these tricks, but can't help but be aware of them and they are helping me rule out answers. Wondering if it will backfire when the step does things differently. Thoughts?

Frank thanks for bringing this up. I feel the same way and would like to hear what previous takers think. My first pass uworld pct is above average and I am also concerned it's more due to understanding the language of the authors than content knowledge.

 

[rocketbooster]

Interestingly, I wouldn't even consider the examples you've given to be actual tricks.

"Tricks" are making you think the answer is one thing and then having that not at all be the case.

An example would be giving you a vignette of a patient with a classic atypical pneumonia. They might also briefly mention a notably bad sunburn the guy had because he was also on vacation.

Then they ask you which drug was prescribed.

I had encountered this question and lamely said the macrolide, since those are the 1st-line Tx for atypical pneumonia. As it turned out, chlamydia, a cause of atypical pneumonia, can also be treated with tetracyclines, which happen to cause photosensitivity. Only 9% got it right because they tried making you think the macrolide was the obvious answer.

I consider this to be common knowledge and definitely not a trick answer. And I question your claim that only 9% got it right. Photosensitivity and Ca chelation are the well known and most basic side effects of tetracyclins. It's also well known that chlamydia is treated with different kinds of antibiotics, not just macrolides. Given the question, this was common sense and definitely a straightforward question on the Step 1.

 

[Phloston]

I consider this to be common knowledge and definitely not a trick answer. And I question your claim that only 9% got it right. Photosensitivity and Ca chelation are the well known and most basic side effects of tetracyclins. It's also well known that chlamydia is treated with different kinds of antibiotics, not just macrolides. Given the question, this was common sense and definitely a straightforward question on the Step 1.

Rocketbooster, I must say, it looks like you'll be shooting to the moon on Step1.

 

[ijn]

I mean, knowing phototoxicity for tetracyclines, sulfonamides, and fluoroquinolones is about 100x higher yield than knowing every single piece of innervation in the ear. The former is definitely in Kaplan, First Aid, etc.

I do think it's kind of a bitch question, but it's for the purposes of learning. It seems to me that STEP would be more likely to put doxycycline as an answer choice and make you sift through cell wall inhibitors or DNA inhibitors.

 

[Phloston]

Fortunately, once the mistake is made the first time, it becomes obvious the second time around.

I would just think they'd be upfront and say "blistering skin" etc., but to merely touch upon a sunburn while on vacation in Mexico is tricky because that would be expected for most people anyway. It's definitely beating around the bush, and for the sole purpose of tricking people who aren't reading between the lines. Regardless, USMLE Rx is good for learning to pick up on stuff like that, so on the real exam, particularly when we're rushed for time, there's a good 10-15 points gained right there.

 

[AndyRSC]

The answer choices in pathology questions are usually the differential diagnosis. In other words, all the things you'd think about given the chief complaint, which you will narrow down to one by the specifics. The answer choices in pharm are usually drugs in that group (e.g. other antivirals). Et cetera. I don't recall any similar-sounding answer choices being on my exams. I will admit, there are drugs and conditions that may sound similar - and FA seems to be aware of it, sometimes juxtaposing them ("tricky Ts") - but their use doesn't seem advertent. Still, I agree that it's helpful to keep track of things that confuse you or sound similar to you, to make sure they don't cost you a point on the real exam.

I do have a quick tip regarding biochem. They often like to spell out the full name of enzymes, and if you're looking at "3-hydroxy-3-methyl-glutaryl-CoA reductase" versus four other long-winded enzyme names as choices for a statin question, or "hypoxanthine-guanine phosphoribosyltransferase" in a question about Lesch-Nyhan, the initial thought may be "oh, ****," rather than "that's the one." Cut out the numbers, condense each part of the enzyme to just the first letter, and it should get a whole lot easier.

 

[rocketbooster]

Fortunately, once the mistake is made the first time, it becomes obvious the second time around.

I would just think they'd be upfront and say "blistering skin" etc., but to merely touch upon a sunburn while on vacation in Mexico is tricky because that would be expected for most people anyway. It's definitely beating around the bush, and for the sole purpose of tricking people who aren't reading between the lines. Regardless, USMLE Rx is good for learning to pick up on stuff like that, so on the real exam, particularly when we're rushed for time, there's a good 10-15 points gained right there.

No, it's not beating around the bush. That's the classic example, not just on a test but in real life. Have you never been around a doctor when they prescribe doxycycline to a pt? The first question they ask the patient is if they are going to have excess sun exposure in the coming weeks, such as from a beach vacation.

Silly, Phloston, just because First Aid doesn't bold "phototoxicity" doesn't mean it's not common/important knowledge. There, I just bolded it for you. And I thought First Aid was supposed to be perfect, too..

 

[AndyRSC]

What's with all the picking on Phloston lately?

Btw, Phloston, who's the douche in your avatar?

 

[Kaputt]

Fortunately, once the mistake is made the first time, it becomes obvious the second time around.

I would just think they'd be upfront and say "blistering skin" etc., but to merely touch upon a sunburn while on vacation in Mexico is tricky because that would be expected for most people anyway. It's definitely beating around the bush, and for the sole purpose of tricking people who aren't reading between the lines. Regardless, USMLE Rx is good for learning to pick up on stuff like that, so on the real exam, particularly when we're rushed for time, there's a good 10-15 points gained right there.

Here's a tip -- never assume any physical finding they give you in a question stem is incidental. Every finding is important until proven otherwise. Why else do you think it was part of the question?

 

[Phloston]

Here's a tip -- never assume any physical finding they give you in a question stem is incidental. Every finding is important until proven otherwise. Why else do you think it was part of the question?

I actually disagree with that, which is part of the trickery right there. Sometimes they'll tell you someone is alcoholic or has GERD when they're really trying to get at ulcerative colitis or a heart condition.

 

[Phloston]

What's with all the picking on Phloston lately?

Btw, Phloston, who's in your avatar?

Me. Thanks!

 

[Kaputt]

I actually disagree with that, which is part of the trickery right there. Sometimes they'll tell you someone is alcoholic or has GERD when they're really trying to get at ulcerative colitis or a heart condition.

Have you taken the test? Otherwise, how would you know how "tricky" the exam actually is? Rx may be tricky (who knows, I didn't do it), but I actually thought every question in World was fair, as well as most questions on my actual exam.

Alcoholism and GERD are not physical findings, but whatev. When someone is an alcoholic, 99% of the time, it is directly related to the diagnosis on a boards exam. GERD and heart conditions are in the differential for chest pain, so I can understand why you would need to differentiate between the two. But on the real exam, most of the time they're really not trying to trick you by giving you unrelated physical findings or risk factors.

 

[Phloston]

Have you taken the test? Otherwise, how would you know how "tricky" the exam actually is? Rx may be tricky (who knows, I didn't do it), but I actually thought every question in World was fair, as well as most questions on my actual exam.

Alcoholism and GERD are not physical findings, but whatev. When someone is an alcoholic, 99% of the time, it is directly related to the diagnosis on a boards exam. GERD and heart conditions are in the differential for chest pain, so I can understand why you would need to differentiate between the two. But on the real exam, most of the time they're really not trying to trick you by giving you unrelated physical findings or risk factors.

Once again, I'd actually disagree with that because I've encountered plenty of questions that present distractor-info. Also, based on what I've read from others' posts, UWorld and Rx are closer to the real exam-style than Kaplan is, so I'd absolutely advocate Rx as a valid tool for the sake of delving into its idiosyncrasies and tricks. I also believe that whether someone has sat the actual exam is irrelevant in most cases because each exam differs so heavily anyway; we're all very aware of that. I could sit the exam tomorrow, but that wouldn't particularly enlighten me.

 

[ijn]

You've encountered questions from writers that aren't STEP 1 question authors. I've seen 2600 retired STEP 1 questions between 3 CBSEs and 10 CBSSAs. Some questions may feel poorly written or cryptic, but they don't to try trick you like Kaplan or Rx. In general they are straight forward.

I'd think about it this way - what is the discriminator value of a trick question with 5 answer choices where 9% of students answer correctly? There isn't one. When people are guessing an answer at a percentage less than random chance, then you know it's a poorly written question. I doubt a question like that would get through the NBME question writing process or the experimental question phase. They only have 322 questions to test a student with, so they can't waste it on questions that don't provide a meaningful statistical distribution. UWorld, Kaplan, and Rx have 2000-3000 questions to throw at you. Their goal isn't to get meaningful data on which to base a license to practice medicine, they're trying to teach you something.

 

[lakerfan38]

Where do you get access to these old nbmes?

You've encountered questions from writers that aren't STEP 1 question authors. I've seen 2600 retired STEP 1 questions between 3 CBSEs and 10 CBSSAs. Some questions may feel poorly written or cryptic, but they don't to try trick you like Kaplan or Rx. In general they are straight forward.

I'd think about it this way - what is the discriminator value of a trick question with 5 answer choices where 9% of students answer correctly? There isn't one. When people are guessing an answer at a percentage less than random chance, then you know it's a poorly written question. I doubt a question like that would get through the NBME question writing process or the experimental question phase. They only have 322 questions to test a student with, so they can't waste it on questions that don't provide a meaningful statistical distribution. UWorld, Kaplan, and Rx have 2000-3000 questions to throw at you. Their goal isn't to get meaningful data on which to base a license to practice medicine, they're trying to teach you something.

 

[ijn]

You can buy CBSSAs numbers 3-7 and 11-13 on the NBME's website for $60.00 a pop. Soon 3 will be taken down. You can find copies of 1 and 2 on IMG websites but I don't know exactly how to obtain them.

CBSEs are bought by medical schools and administered under controlled conditions. You can't find them on the internet. I know there are at least 3 different versions. There may be more but my school didn't offer any more.

 

[Phloston]

You can buy CBSSAs numbers 3-7 and 11-13 on the NBME's website for $60.00 a pop. Soon 3 will be taken down. You can find copies of 1 and 2 on IMG websites but I don't know exactly how to obtain them.

CBSEs are bought by medical schools and administered under controlled conditions. You can't find them on the internet. I know there are at least 3 different versions. There may be more but my school didn't offer any more.

I've never heard of CBSSAs or CBSEs. What are those? And how do they compare/relate to the NBMEs for the sake of Step1 prep?

And btw, are you the person in your avatar?

 

[ijn]

Haha, no that's Lionel Raymon from Kaplan. He's the God of Pharmacology (and demigod of Biochemistry). I wish he taught more.

CBSSAs are what people refer to commonly as the NBME #s - computerized basic science self assessments. CBSEs are bought by institutions usually - computerized basic science exams. They're the same content wise, just different questions. Presumably they're all retired STEP 1 exam questions although you hear rumors of repeats so they are either repeating stems with different question twists at the end, or they just aren't that careful on actually retiring the questions.

 

[Kaputt]

Once again, I'd actually disagree with that because I've encountered plenty of questions that present distractor-info. Also, based on what I've read from others' posts, UWorld and Rx are closer to the real exam-style than Kaplan is, so I'd absolutely advocate Rx as a valid tool for the sake of delving into its idiosyncrasies and tricks. I also believe that whether someone has sat the actual exam is irrelevant in most cases because each exam differs so heavily anyway; we're all very aware of that. I could sit the exam tomorrow, but that wouldn't particularly enlighten me.

Once again, I disagree. You have not taken the exam, so your opinion on the actual exam is worthless. Question banks are there to teach content first and foremost, and they are not the most accurate as far as question style. My actual exam was very straight-forward. The question style was exactly like the NBMEs, in that it was very "you know it or you don't", not the World-style 5 step reasoning questions.

The easy questions were extremely easy. And the hard questions were simply obscure. We get tied up into this notion that Step 1 is this super-confusing mess where question-writers intentionally try to make students get the question wrong. This is certainly not the case. The exam is fair.

Also, I don't think World has many "tricky" questions to begin with. But if you think photosensitivity as a complication of treating an atypical pneumonia is tricky, you have a lower threshold for "tricky" than I

 

[Aclamity]

Once again, I disagree. You have not taken the exam, so your opinion on the actual exam is worthless. Question banks are there to teach content first and foremost, and they are not the most accurate as far as question style. My actual exam was very straight-forward. The question style was exactly like the NBMEs, in that it was very "you know it or you don't", not the World-style 5 step reasoning questions.

The easy questions were extremely easy. And the hard questions were simply obscure. We get tied up into this notion that Step 1 is this super-confusing mess where question-writers intentionally try to make students get the question wrong. This is certainly not the case. The exam is fair.

Also, I don't think World has many "tricky" questions to begin with. But if you think photosensitivity as a complication of treating an atypical pneumonia is tricky, you have a lower threshold for "tricky" than I

Dr. Sattar keeps saying that they'll give you "knee-jerk" questions with a subtle clue that actually changes the diagnosis. Idk about others, but to me that's a "tricky" question. Did you encounter many of those on your exam?

 

[Kaputt]

Dr. Sattar keeps saying that they'll give you "knee-jerk" questions with a subtle clue that actually changes the diagnosis. Idk about others, but to me that's a "tricky" question. Did you encounter many of those on your exam?

I'd say these sorts of questions exist (a few pop into mind from my exam), but the "clue" isn't that subtle if you know what you're looking for. You'll only think it's subtle if you're shaky on the material or the factors that differentiate two similar conditions. It's good to get that shakiness out of your system with a qbank like World--they have tons of questions where you need to meticulously take into account everything in the question stem before landing at your diagnosis. But I think that's fair. It's difficult, but fair.

For example, you could get someone with hypotension and distended neck veins, and you have to decide between tamponade and pneumothorax. It may be a tricky question if you don't have a firm enough grasp on the distinctions, but all the information you need is there.

 

[bigslick]

yeah i think it might be helpful to learn their tricks.. i just had a uworld question on a left sided heart failure w/ all the classic symptoms, and they asked what the mechanism was for the patient's pulmonary hypertension. i definitely knew there was blood backup into the heart, so i picked "increased volume of flow and pressure in the pulmonary arteries," of course thinking, more volume of blood causes increased pressure. but no, since the answer said volume of FLOW, flow means that blood is actually going through without any problems, and the correct answer was actually "reactive vasoconstriction due to venous congestion," which i eliminated when i saw the word "reactive" b/c i knew CHF wasn't inflammatory and didn't even see the word "venous congestion" in the latter half of the sentence. had they just said "increased flow" instead of "increased volume of flow" i probably would've eliminated everything and went back and re-read all the answers again.

also another one i picked up on (don't remember specific example), is that sometimes they ask what is the cause of the disease and other times they ask what is the direct cause of whatever they were describing, and what that really means is that in a series of steps in the pathogenesis of a disease, when they ask what is the cause of the disease, you gotta pick the 1st step, and if they ask what is the DIRECT cause, you gotta pick which individual step is responsible for that finding and NOT the first step which indirectly causes it.

i think if i were to go back in time, i'd probably try and write down ways that i've been tricked out of the right answer, because many times you actually know the answer if someone were to just ask you straight up, but if you had to pick between several answer choices, then you really have to decode the exact question they're asking and what they're really trying to say in the answer choices.

 

[Kaputt]

yeah i think it might be helpful to learn their tricks.. i just had a uworld question on a left sided heart failure w/ all the classic symptoms, and they asked what the mechanism was for the patient's pulmonary hypertension. i definitely knew there was blood backup into the heart, so i picked "increased volume of flow and pressure in the pulmonary arteries," of course thinking, more volume of blood causes increased pressure. but no, since the answer said volume of FLOW, flow means that blood is actually going through without any problems, and the correct answer was actually "reactive vasoconstriction due to venous congestion," which i eliminated when i saw the word "reactive" b/c i knew CHF wasn't inflammatory and didn't even see the word "venous congestion" in the latter half of the sentence. had they just said "increased flow" instead of "increased volume of flow" i probably would've eliminated everything and went back and re-read all the answers again.

also another one i picked up on (don't remember specific example), is that sometimes they ask what is the cause of the disease and other times they ask what is the direct cause of whatever they were describing, and what that really means is that in a series of steps in the pathogenesis of a disease, when they ask what is the cause of the disease, you gotta pick the 1st step, and if they ask what is the DIRECT cause, you gotta pick which individual step is responsible for that finding and NOT the first step which indirectly causes it.

i think if i were to go back in time, i'd probably try and write down ways that i've been tricked out of the right answer, because many times you actually know the answer if someone were to just ask you straight up, but if you had to pick between several answer choices, then you really have to decode the exact question they're asking and what they're really trying to say in the answer choices.

I think this is about as "tricky" as questions will get. In that it isn't that tricky if you slow down and read everything carefully. There will be a clearly correct answer choice.