The Hunch Reflex: the not so “Secret” to success on the USMLE, COMLEX, and shelf exams

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I promised you last time that I’d clue you in to the not-so-top-secret discovery I made about boards success. Two things (we’ll cover one this time around) stood out to me about my own success. Despite all the review books I had purchased, agonized over, and annotated, the one category of prep material that made the difference was the boards style question.

We’ve all had the experience of coming across an item on an exam, not being entirely sure of the answer, and then immediately picking an item based on a hunch.

Well, that hunch is part of the equation to success. Sorry. I don’t really have anything more earth-shattering.

The “hunch” can be honed and developed to the point where answering questions is like a reflex. Maybe some examples will help show what I mean. From the talk of friends after exams or in preparing for exams, a body of lore has grown surrounding useful associations. These used to be in the form of buzzwords.

Nowadays, question writers have caught on to the fact that buzzwords basically give away answers. Think about it. If we play a game of “tell me the first thing you think of when I say a given phrase”, then when I say “bag of worms,” you’re very likely to respond with “varicocele.” Because the powers that be do not want you to grant you the abilities to perform surgery, make life and death decisions about another person’s life, etc. just because you are gifted at trivia (makes sense, right?), buzzwords have gone the way of the wooly mammoth. Still their descendent remains. And that is the elephant in the room: not the buzz word, but the buzz-trope (or clinical archetype, buzz-description, boards leitmotif, whatever you’d like to call it).

Everyone knows that if a question stem talks about an athletic male with acne and aggression, there’s going to be something about the use of anabolic steroids in the answer choices.

Schwarzenegger Bodybuilding
If the patient in the vignette looks like this, he’s probably using anabolic steroids…

This Rorschach approach to medical education cannot be eliminated entirely. There are always going to be a limited number of ways to cover information and that is why the buzz word has evolved into the buzz trope. Except that the buzz trope/description involves pattern recognition, which is somewhat applicable to real-life medicine whereas buzzwords just involve reflexive, rote memorization. The ability to answer questions based on buzzwords is like a deep tendon reflex; the ability to answer questions based on formulaic descriptions is more like the muscle memory that develops from years of practicing a musical instrument. So even if they took out the words, the “buzz” reflex, the “hunch”. can still be trained.

So what’s the key to developing your hunch reflex so that choosing the correct answer comes automatically?

Actually there are three: 1) questions 2) questions and 3) questions. You have to do questions, think about questions, memorize questions, make questions the very air you breathe when you’re studying for a boards-style exam.

In the fallout after my Step 1 exam, I realized that of all the things that I did to prepare, answering questions was number one in importance. This is because the more you do, the more you will understand why one answer is the most correct and you’ll understand why the other answer choices are wrong and why you were tempted to pick them. I probably could have eliminated everything else, if only I had the questions.

The first key to boards success: develop a muscular “hunch” reflex by doing a ridiculous amount of questions.

Next time: the difference questions make, my own personal journey from crying alone in a corner after getting the results of an exam, to being able to click on the “view results here” link at the time scores are released without any antecedent GI distress. Please comment or ask a question below. Or head to one of our social media sites to join the conversation. Thanks for reading.


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Patrick C. Beeman, MD

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A disclaimer: I firmly believe that people who are very successful on the boards, you know, the people who make us throw up a little in our mouths when we see them, can be crappy doctors. Sure, some have got well-developed buzz reflexes, so they score in the 99th percentile on everything and garner top residencies, but they cannot think outside of patterns at all. You know, in the real world, with real patients and the real limitations of resources, facilities, and circumstances where it actually matters. More importantly, just as a matter of encouragement, even if you score only mediocrely on your boards or hail from a medical school that is “not that good” (sounds kind of arrogant when you say it out loud doesn’t it?), you can be a great doctor. In the real world of suffering patients, whose stories wouldn’t fit well into a clinical vignette, I am often jealous of the abilities of some of my colleagues who I know have not scored that well (or even failed one of their exams). Why? Because I see their ability to arrive at a diagnosis quickly (like ten times faster than I), think on their feet (a weakness for some “boards smart” but “real life dumb” doctors I know), and communicate information to their patients. After all, what good is a diagnosis and treatment plan, if it can’t be applied to a patient because the doctor can’t communicate worth a …