To deal most effectively with exam questions, you need to have some understanding of how the questions are constructed. Getting a question correct means selecting the best answer. Incorrect options are called "distracters." Their purpose is to distract, that is, to get you to pick them rather than the best answer. Each distracter will be selected by some examinees, or it would not be included as an option. Every option fools somebody. Your job is to not be misled.

In general, distracters will seem plausible and none of them will stand out as obviously incorrect. Distracters may be partially right answers, but not the best answer. Common misconceptions, incomplete knowledge, and faulty reasoning will lead you to select a distracter. The NBME tells its question writers that their distracters must follow these five rules:

1. They will be homogeneous. For example, they will be all laboratory tests, or all therapies, not a mix of the two.

2. They will be incorrect or definitely inferior to the correct answer. There will be enough of a difference between the right answer and the distracters to allow a distinction. For example, if estimating the percentage of a population with a disease, the options will differ by more than 5%.

3. They will not contain any hints as to the right answer. Distracters are meant to induce you to an incorrect choice, not give you clues as to the correct one.

4. They will seem plausible and attractive to the uninformed. If you are not sufficiently familiar with a topic, you may well find that all of the options look good.

5. They will be similar to the correct answer in construction and length. Trying to "psych-out" the question by looking for flaws in its construction is not a useful strategy.

Questions that do not adhere to these rules are not used on the exam. All options are meant to distract you, but often one of the distracters will seem better than the others, the so-called preferred distracter. While still incorrect, this is the wrong answer chosen most often. Preferred distracters are why you can often get yourself down to two choices: the correct answer versus the preferred distracter.

USMLE Primacy and Recency Effects

Primacy and Recency Effects—getting the right cognitive set
Information that appears early in a question stem and information that appears at the end of the question stem exert a strong influence on the student answering the question. Early and late information forms the student’s cognitive set, making finding the correct answer either easier or harder. Information at the start of the question stem has a primacy effect, controlling our thinking by determining what we start thinking about. Information at the end of the question stem has a recency effect, controlling our thinking by providing the jumping off point to select the correct answer.

If the key information for the question appears in the primacy or recency spots, the student will be led to the correct answer. The difficulty for the examinee comes when the key information lies some where in between. Primacy and recency information can blind students to other essential content. Students sometimes fixate on early or late information and in so doing, miss other important information given in the question stem.

For example, if a question begins by describing a patient as having a generalized anxiety disorder, all of the information which will tend to be seen in that context, even though the anxiety disorder diagnosis may not be directly pertinent to the correct answer for the question!

Primacy or recency effects seem most pronounced when the beginning or ending information in a question stem is something with which you are unfamiliar. We all have a special tendency to fixate on unknown content.

If you suspect that primacy or recency information is distorting your reading of a given question, try changing the order in which you read the question. Skip the initial content, read the rest of the question first, and see if this changes your perspective. Simply, if reading the question forward seems confusing, try reading it backwards. Remember, no one single piece of information is the key, you must deal with each question as a whole. Avoid fixating on one word or concept you do not know, and focus on the parts of the question you do know.

USMLE Tips & Trends Strategies for Best Exam Performance

Be cautious about changing answers. In general, your odds of changing a correct answer to a wrong one are so much higher than the reverse that it is simply not worth the risk. If you change an answer, you are most likely making it wrong! Your first impulse is usually the correct one. Stay with it unless some clear insight occurs to you. If you are not sure, leave your answer as you first marked it.

If you finish a question block with time left over, go back and "check" only those answers that you have previously marked. Checking almost always leads to changing and tends to reduce your score. If you have a spare moment, make sure that you have entered an answer for every question in the block and then, relax. Sit, take a break, and mentally prepare yourself for the next block of questions. Focus on the questions to come, not the ones that are past.

Segment your time so that you know how much you have left, and so that you do not find yourself hurried at the end. You have just over one minute per question (72 seconds). Some questions will take more time and some less. Work on your pacing from the beginning of the question block. Check your watch every 10 questions to make sure you are on the correct pace to finish. If you pace yourself throughout the block, you should not be squeezed by time at the end.

Do not spend a lot of time on individual questions. Research has shown that students spend the most time on questions that they get wrong. If you find yourself spending a lot of time on a question, this is your indication that you do not know the answer. How will you know if you are spending too long on any one question? If you find yourself thinking, "Gee, maybe I’m spending too long on this question," you are. As soon as you think this, stop, mark your best guess, and move on to the next question!

During the breaks between question blocks, try to relax and not think back over the exam. The desire to recall questions is strong, but not helpful. Those questions are in the past for you; you will never see them again. Focus on relaxing and making the most of your break. Remember, you will always tend to remember those questions you got wrong. Thinking back over these questions will just convince you that you do not know anything. This puts you in a bad frame of mind and leads to negative thoughts that only make the remainder of the exam more difficult. Be glad one set of questions are behind you. Forget about them, and think about something else more pleasant.

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USMLE is a joint program of The Federation of State Medical Boards of the United States, Inc. and the National Board of American Medical Examiners.