Note: Students with generalized anxiety or severe anxiety issues should seek professional help.

Test Anxiety

Everyone gets anxious about USMLE exams. Anxiety is not a problem unless the physical symptoms make you miserable and/or your score drops significantly (more than 10-15 points) on your real exam compared to your practice exams. If you’ve had problems with this in the past, you need to address it head-on. Without intervention, test anxiety can snowball as you begin to fear both the content of the exam and the anxiety itself. 

Knowing you have control over your level of anxiety is very empowering. Think of your anxiety as the flame on a gas stove. When you find yourself slacking off, turn the flame up a few notches. When you have a USMLE exam fast approaching, begin to turn the flame down.

Manage Your Thoughts

Frame your expectations in a helpful way:  Don’t tell yourself that you have to earn a certain score on your test, tell yourself that you expect that score based on solid evidence (scores on NBME practice exams, etc.) This difference in language can help you feel in control. 

Let Go of Perfectionism: You may have been a perfectionist in the past and it’s great to have that approach towards medicine and patient care. But remind yourself that you can’t learn absolutely everything in med school. In addition, standardized exams are designed so that every student will miss quite a few questions. These two factors can create enormous stress for perfectionists. With this in mind, remember:

• When you’re running short on study time due to a heavy clinical load, learn the important concepts deeply and thoroughly and let some of the minor details go.

• Before starting an exam, write a note on your whiteboard: You will miss questions today; get over it! Remind yourself that a basketball player who expects to make every shot will not play well. They’ll get rattled every time they miss a shot. The same principle holds true on standardized exams.

Don’t give a test the power to define you. An exam won’t tell you whether you’re brilliant or not so brilliant. It’s simply a reflection of how well you prepared for that particular exam, coupled with your prior knowledge from Step 1.

Remind yourself of your past successes. It’s easy to lose perspective when you’re struggling. Remind yourself of courses in which you initially struggled but managed to do well by the end. 

Remind yourself that during a USMLE exam, everyone is incredibly anxious. It’s normal! As long as you’ve learned strategies for “turning down the flame” of your anxiety, the anxiety can enhance your performance rather than hurt it.

Practice Anxiety Control: Induce & Reduce

As you take practice tests, try to induce a greater level of anxiety by telling yourself something negative or stressful. Then use counted breathing and self-talk to lower your level of anxiety. Feeling the physical difference will help you believe that you can control your anxiety.

A counted breathing routine: Close your eyes and inhale through your nose to the count of seven; hold briefly and then exhale through your mouth to the count of seven. Do two or three sets of this breathing pattern until you notice a physiological change. End with positive self-talk or a mini-prayer. Repeat this exercise again and again during practice tests.

Test Week

• A week or two before your test, visit the test site and take a practice exam. Talk to the receptionist and ask questions. Voice any worries or concerns you might have.

• Sleep well and get up every day at the same time that you will be getting up on test day. Adequate sleep will help you stay healthy, think clearly, and manage stress.

• Limit or reduce various sources of caffeine. (Anxiety increases the effects of caffeine.)

• Limit contact with anyone who might increase your stress.

• The day before, get plenty of exercise so you will sleep well.

• The evening before, some students find it helpful to watch a familiar movie that’s either a comedy or a sappy tear-jerker. (The preference for tear-jerkers surprised me, but then I realized that crying can help you relax and it’s also a reality check: whatever happens tomorrow, you won’t be suffering as much as the characters in the movie.)

Test Day

• Eat a light breakfast with a good balance of protein and carbs.

• Visualize your day ahead and how you will complete the test successfully despite your anxiety. Play the entire tape in your mind.

• Bring plenty of food to the testing site.

• Arrive early for the test and take a walk. Avoid talking to other students. 

Be prepared to reframe anything negative in a positive way.

If you find yourself sitting next to someone who is taking a different exam and typing furiously… remind yourself that you can wear earphones. If you find yourself waiting in a long line to get back into the test room after a break, tell yourself that you’re in luck because you now have a chance to stretch and jog in place and do some deep breathing as you wait in line. Whatever happens, try to frame it in a more positive way. At this point, your studying is finished and the only thing you can control is your attitude and focus. 

Develop an Anchor: Write a Note on your Whiteboard

• Write an anchor for yourself: your latest scores on NBME practice tests, words of wisdom or comfort, a smiley face – whatever you think will work for you.

• A note about humor: It’s hard to feel anxious when you’re smiling. One student kept looking at a scar on his arm during his test. For some reason, this made him smile as he thought of what a klutz he was for burning his arm. Several students have told me that a smiley face made them smile each time they looked at it.

Think Right

• If you’ve had some bad tests in the past, think of how things are different now.

• Remind yourself of solid evidence that you will succeed (your NBME scores).

• Remind yourself that you’ve answered thousands of questions just like the ones you’re facing today.

• Each time a negative thought enters your head, talk back to it and glance at your anchor to center yourself. You’re worried about your racing heart? Remind yourself that you’ve practiced anxiety control and you know it works.

• Don’t obsess about running out of time. Check the time every 10 questions and take a mini-break at the same time (do a brief counted breathing exercise). Remind yourself that even high-scoring students sometimes have to rush toward the end of a block.

• Do NOT think about how well you’re doing. Trust me, you can’t know.

• Expect a few curve balls on the exam. Don’t let a few head-scratchers throw you off your game. Make an educated guess and move on

All the best,

Cecelia Downs, Clinical EED