Credit to @vanib for suggesting I make this post.
Disclaimer: Everyone approaches questions differently, and you need to find your most comfortable way of doing it.
1. Initial overview of the Q: Take in the question as a whole. Is it a short stem, or a long vignette? This will change the way you approach the question.
a. Short vignette: just read it from start to finish. No need to look at the answer choices beforehand as it won’t really save you any time in this situation
b. Long vignette: You’ll need to pay attention to the other steps that follow to help you get through it. If you’re the type to glance at the answer choices, this is the time to do it.
2. If you’re going to look at the answer choices, also look at the last 2 sentences of the vignette.
a. There’s NO point to just look at answer choices, as it will rarely tell you what is going on. The last sentence of the question is also useless, as it’ll just ask a simple question (ie, next step in management, diagnosis, mechanism, etc…)
b. The last couple sentences often contain the majority of the buzzwords, and it’ll help guide you through the long vignette
3. Pay attention to demographics
a. Not all questions will provide demographic info, so if they do, there might be a reason why (50yo AA female with SOBàyou’re already thinking sarcoidosis)
4. For step 2 – use the vitals to determine if the patient is stable or not. This is especially important for trauma questions, as you will need to emergently manage the patient. Obviously, always glance at the vitals (Temp for an infection; BP for HTN, etc), but vitals are key for trauma questions. Don't waste time looking at weight and height - just look at the BMI
5. Buzzwords are not as commonly included in vignettes anymore, so you need to use solid history and physical exam findings to differentiate diagnoses
a. This is where differentiating overlapping pathophysiology comes in. A great example is cardiopulmonary. COPD vs CHF is probably the most commonly tested question given the amount of overlap in history and physical. Subtle findings and your gut feeling will often lead you to the right answer
b. You need to still memorize all your buzzwords, because when it’s given, you MUST get that answer choice. These are the free-bees
6. NBME is never trying to trick you. They never have, and never will. If an answer is wrong, then cross it out. This is important, as it will make the right answer more obvious
a. Don’t waste your time trying to convince yourself why a wrong answer could be right.
7. Labs - You'll get comfortable with the common labs by doing many UW questions. You don't want to waste time looking up normal K or Ca levels - this should be committed to memory just by doing many questions. A weird lab value, though, is not something you should waste time memorizing. Just look that up.
a. Cardiac index and PCWP are fair game - know them.
8. Timing is an obvious issue for many, and coming up with a clear strategy on approaching questions will help you. Mark only those questions you feel you can figure out with more time. If you have zero idea what the answer to a question is, and no amount of time would allow you to figure it out, then just click an answer and move on. You won't have time to mark 20-25 questions in a block.
Hope this helps, and I hope others can contribute any other advice they may have!