What’s in a lead-in?

When it comes to Single Best Answer (SBA) questions, the lead-in—that final part of the question stem that asks you what to do or think—is your ultimate guide. Think of it as the GPS of the question: it tells you exactly where you need to go. Yet, many students overlook its importance, leading to confusion or wasted time. Let’s dive into why the lead-in is so crucial and how you can use it to ace your SBAs.

What is the Lead-In?

The lead-in is the question’s “ask.” It’s the short sentence at the end of the stem that directs you to the answer. Common examples include:

  • “Which is the most likely diagnosis?”
  • “Which is the best next step in management?”
  • “Which is the most appropriate investigation to confirm the diagnosis?”

While the clinical scenario in the stem provides context, the lead-in defines your task. Misinterpreting it can send you down the wrong path, even if you’ve read the stem correctly.

Why the Lead-In Matters

  1. Focus Your Thinking:
    The lead-in tells you what the examiners are testing—diagnosis, management, investigation, or something else entirely. Without it, you might end up solving the wrong problem.
  2. Clarifies Ambiguities:
    In SBAs, all the options might seem plausible at first glance. The lead-in ensures you prioritise the right type of answer based on what’s being asked.
  3. Saves Time:
    Knowing the task upfront allows you to filter the information in the stem and evaluate the options more efficiently, keeping you on track for the 72-second-per-question pace.

How to Approach the Lead-In

  1. Read It First:
    Before diving into the clinical stem, read the lead-in. Knowing the question upfront helps you focus on the relevant details in the stem. For instance:

    • If it asks for a diagnosis, you’ll focus on symptoms, history, and examination findings.
    • If it asks for the next step, you’ll look for clues about what’s already been done and what’s urgent.
  2. Rephrase It in Your Own Words:
    Make the lead-in clearer to yourself. For example:

    • Original: “Which is the most likely cause of this presentation?”
    • Rephrased: “Which condition explains these symptoms?”
  3. Stay Alert for Key Phrases:
    Certain words in the lead-in can drastically change how you approach the question:

    • “Most likely”: Focus on common conditions rather than rarities.
    • “First step” or “Initial investigation”: Think practical and urgent.
    • “Definitive treatment”: Look for the gold-standard intervention.
  4. Double-Check Before Choosing an Answer:
    After narrowing down your options, revisit the lead-in to ensure your choice aligns with the task. For instance, if the lead-in asks for the initial management, choosing a definitive treatment (like surgery) could be incorrect if stabilisation (e.g., IV fluids) is the first priority.

Examples of Focusing on the Lead-In

Scenario 1: Diagnosis

Stem: A 34-year-old woman presents with palpitations, weight loss, and tremors. On examination, she has a diffusely enlarged thyroid gland and exophthalmos.
Lead-In: “Which is the most likely diagnosis?”
Approach: Focus on symptoms and signs. The lead-in clearly asks for the diagnosis, not the next step or treatment. Answer: Graves’ disease.

Scenario 2: Management

Stem: A 68-year-old man arrives at the ED with chest pain and ST-elevation in leads II, III, and aVF.
Lead-In: “Which is the next best step in management?”
Approach: Prioritise immediate actions. The lead-in asks for the next step, so the focus is on acute management (e.g., PCI), not long-term care. Answer: Start aspirin and arrange for primary PCI.

Common Mistakes with Lead-Ins

  1. Answering Without Reading It Fully: Jumping straight to the options without understanding the lead-in can lead to errors, especially in nuanced questions.
  2. Overthinking It: The lead-in is designed to be straightforward. If it says “best next step,” don’t get distracted by thinking about second or third steps.
  3. Ignoring Context: While focusing on the lead-in is crucial, don’t ignore the stem—it provides the context needed to answer correctly.

Final Thought: The Lead-In Is Your Compass

In SBAs, the lead-in is your most powerful tool for staying focused and finding the right answer. By reading it first, understanding its nuances, and tailoring your approach to its demands, you can avoid common pitfalls and approach each question with clarity and confidence.

Practice this technique with platforms like Best Answers, where every SBA is designed to sharpen your skills and boost your accuracy. The better you get at decoding the lead-in, the closer you’ll be to exam-day success!

Signed,

Best