The MCQs of Medical School

Sara Corderman
Sep 3, 2018 · 3 min read

You’ve got your ABCs, your SIGECAPS, your NAVEL. Sometimes you have to write an (AE)IOU, and sometimes you’re just a FAILURE*. All of these out-of-place capitalizations are mnemonics, the favored memory device of medical students everywhere. Whether as acronyms or as funny phrases, mnemonics are created, traded, learned and studied with a seriousness that my professors undoubtedly wish we would instead direct at their lectures.

Select mnemonics have their role in clinical practice, but the majority of the time they’re created and memorized for a single purpose: MCQs. An acronym, MCQ stands for ‘multiple-choice question.’ These, some medical students might say, are the determinants of success in medical school. All three ‘Steps’ of the United States Medical Licensing Examination consist of 9-hour-plus computer-administered multiple-choice exams, with a cursory clinical component thrown in during Step 2 that there are good reasons to do away with. The ‘shelf exams’ taken at the end of each required clinical rotation in the third and fourth year are targeted 4-hour versions, and many schools use National Board of Medical Examiners (that’s NBME)-purchased MCQs to test the competency of students in the pre-clinical years.

Step 1, usually taken after the second year, is to residency applications what the SAT is to college, or the LSAT is to law school. Many residency programs won’t consider students below a certain Step 1 cutoff score, and it’s notoriously difficult to be considered by certain specialties with a low score. This provokes understandable student anxiety concerning Step 1 — do poorly, and you may be forced to reevaluate your dreams of becoming a certain type of doctor. Thought you could be the next Derek Shephard or pre-politics Ben Carson? Time to reconsider.

Sample practice questions for the USMLE Step 1 exam (https://www.usmle.org/practice-materials/)

There are widespread consequences of this emphasis on standardized testing in medical school. For one thing, lecture attendance is at an all-time low, with many students choosing to skip class to instead use resources that teach for the test instead of their school’s curriculum. A quick look at Med School Reddit will clue you in to the “big four” of Step 1 study aids — UWorld, Pathoma, Anki, and the true object of our desires, First Aid.

Beyond upsetting our professors though (and upset they are), there are more insidious effects of this trend. In a multiple-choice question, there is always a best answer. As the test-taker it’s your job to deduce that answer in less than a minute (ideally) and move on. There’s no time to get to know the patient in the preceding four-sentence clinical vignette or situate their clinical problems within a broader biopsychosocial framework. Instead, you’re forced to look for buzzwords or anchor on stereotypes.

The implications for perpetuating racism and implicit bias have been well-discussed elsewhere, notably in Jennifer Tsai’s piece for Stat earlier this year. What’s also concerning is how little room this leaves for uncertainty. Real-life medical decision-making does not always have a correct answer, and it’s hopefully never a one-sided decision. In a country plagued by an epidemic of chronic pain, few physicians are trained in how to work with patients who may never have a diagnosis. I would argue that this discomfort with uncertainty certainly contributed, at least in part, to the current American opioid crisis. When we’re trained to think in a way that elevates correct and incorrect answers over ambiguity, is it any surprise that we should want to offer our patients such clear answers as well?

Even as I myself study for these exams and tutor my peers, I can’t help but wonder — what could medical education accomplish if it acknowledged a world that wasn’t so black and white?


  • ABCs: Elements of a primary survey for a patient in distress (Airway, Breathing, Circulation)
  • SIGECAPS: Elements of DSM-5 major depressive disorder diagnosis (Sleep disturbances, Interest decreased (anhedonia), Guilt and/or feelings of worthlessness, Energy decreased, Concentration problems, Appetite/weight changes, Psychomotor agitation or retardation, Suicidal ideation)
  • NAVEL: The order of structures in the femoral triangle (Nerve, Artery, Vein, Empty Space and Lymphatics)
  • AEIOU: Indications for urgent dialysis (Acidosis, Electrolyte imbalances, Intoxication, Overload, Uremia)
  • FAILURE: Causes of congestive heart failure exacerbation (Forgot medication, Arrhythmia/ Anemia, Ischemia/ Infarction/ Infection, Lifestyle: taken too much salt, Upregulation of CO: pregnancy, hyperthyroidism, Renal failure, Embolism: pulmonary)

Sara Corderman

Written by

Medical student and more. I’m interested in the financial, emotional, psychological and physical costs of healthcare and medical education. Brooklyn, NY.

Welcome to a place where words matter. On Medium, smart voices and original ideas take center stage - with no ads in sight. Watch
Follow all the topics you care about, and we’ll deliver the best stories for you to your homepage and inbox. Explore
Get unlimited access to the best stories on Medium — and support writers while you’re at it. Just $5/month. Upgrade