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How to Avoid Choking on the CPHQ Exam

Ivan Lendl was the World Number One tennis player in the mid to late 1980s and is considered one of the best tennis players of all time. However, for a few years before attaining the top ranking in men’s professional tennis, he was labelled with terms such as “choker” and “perennial bridesmaid” because he failed to win the first four Grand Slam singles Finals in which he played.

What is Choking?

“Choking” is a pejorative colloquial term used to describe acute performance failure under perceived stressful conditions in sports. Professional sports history abounds with stories of individuals and teams choking. No matter what sport you follow, I have no doubt you can recall a sports figure or team crack, apparently under the pressure of the situation.

CPHQ Examinees Who Choke

The rest of this article will discuss people who choke on the CPHQ exam.

These are individuals who apparently have everything to pass the exam comfortably:

  • Ample experience in healthcare quality management (or some related field),
  • Adequate preparation, which might include lots of reading, attempting mock questions, and perhaps even attending a revision course, and
  • Theoretical and practical knowledge in healthcare

At least on paper, these persons shouldn’t just pass, they ought to do extremely well.

But many fail to make the grade. They choke.

Chokers Are Usually Top Performers

Often the CPHQ exam score report belies the true abilities of these candidates. In fact, a large proportion of examinees who seek our assistance after failing the exam have all the necessary skills and knowledge (or even more) to pass.

Contrary to what some folk might expect, such individuals are not underachievers; they usually have an outstanding academic record and a very good work ethic in terms of exam preparation.

Like a diamond in the rough, these people merely need a little polishing of their exam technique.

Top performers who choke on the CPHQ exam should be distinguished from people who are inadequately prepared for the CPHQ exam, in terms of:

  • Experience in the field of healthcare quality management, or the like,
  • Preparatory work, such as completing the required reading and attempting properly-constructed CPHQ exam practice questions, and/or
  • Planning for the actual exam, e.g. logistics, leave from work, adequate rest and nutrition.

The latter group of individuals fail the exam because they:

  • Don’t have enough knowledge and/or skills,
  • Panic on the exam,
  • Guess too much on the exam,
  • Suffer delusions of grandeur (e.g. of one day becoming a CPHQ),
  • Underestimate the level of difficulty of the exam, or
  • Some other reason.

(By the way, these factors are not mutually exclusive.)

We won’t consider such persons here. A person who bought their first tennis racquet last week cannot “choke” if they find themselves playing in Center Court at Wimbledon in the first week of July.

Why People Choke

Psychologists have written tomes on this topic. But I’ll summarize the theory.

Simply put, chokers undergo analysis paralysis.

After months of preparation and anticipation, the big day (i.e. exam day) is finally here. You make your way to the Assessment Center and it finally dons upon you that you are three hours away from being a CPHQ!

And this is where the problem begins. People start to overthink everything they do and the consequences of their actions. Perfectionists are particularly prone to this type of introspection, but really, anyone under certain conditions will fall into this trap.

Using the analogy of a tennis player, the seasoned professional (such as Lendl) would, under normal circumstances, hit the ball without thinking about the specifics of their strokes, footwork, or other technicalities. (The latter are collectively called explicit learning.) Instead, they’d be subconsciously thinking about strategy and hitting the ball to win the point, the game, the set, and especially the match. (This is termed implicit learning.) I’ve watched tennis matches in which champions (e.g. Bjorn Borg, Pete Sampras, Roger Federer) get out of sticky situations by “playing their game”, not by thinking about whether their ball toss was a little too high, reminding themselves to follow through on their strokes, or constantly telling themselves to stay on the balls of their feet. And almost anyone who’s played tennis knows this fact: if you think too much about what you’re doing on your serve, you’ll double fault.

This is not to say that the basics—adequate knowledge, practical competence, good exam technique—are not important. To the contrary, having these attributes allows one to focus on implicit learning and on passing the exam. Champions don’t win merely by having good on-court strategy; they usually have very good technical skills that were developed through hours of training and hard work.

The Candle Problem

the candle problem

"The Candle Problem."

More than half a century ago, Sam Glucksberg, now a Princeton professor of psychology, conducted a fascinating study in motivation—the famous candle experiment.

He brought a group of people into a room, and in that room there was a table placed against a wall. On the table was a book of matches, a box of thumbtacks, and a candle. He asked the test subjects to attach the candle to the wall in such a way that when it was lit, the wax would not drip onto the table. He also told this group of subjects that he would be timing them, and would use their results to “establish averages and benchmarks.”

Glucksberg later brought another group of subjects into the same room, and showed them an identical set-up: table against the wall, matches, box of thumbtacks, and candle. He also gave them identical instructions as the first group of subjects but added that he would reward them with money based on their times. If they finished in the top quartile of all times, they would receive a certain amount of money, and if they had the fastest times, he would double the amount.

He repeated this process with other groups, some were offered money and some weren’t.

The results of the experiment might surprise you…

The groups of people who received the monetary reward were, on average, three-and-a-half minutes slower at finding the correct solution, compared to the groups who were not offered money as a reward.

This observation might seem counter-intuitive. You might have thought that the higher the reward, the better the performance. Certainly, many employers and managers have fallen into this mindset. Unfortunately for them, there is very little evidence to support this hypothesis.

Once money, an extrinsic motivator, was offered as a reward, the test subjects in Glucksberg’s experiment pushed themselves harder to achieve better results at the expense of creative problem-solving.

The results of this study have been replicated in similar experiments by others.

Often, trying too hard leads to failure, not success.

So what’s the point?

Answer: If you keep thinking about the end result (Pass = I become a CPHQ; Fail = I don’t become a CPHQ) during (or even before) the exam, your performance will likely suffer. The advanced processes of your brain will slow down, perhaps grind to a halt, if you think too much and become overwhelmed by the consequences of the exam result. Of course, for many people, it goes beyond just becoming a CPHQ. Their job, career, disposable income, and other things (e.g. pride, sense of self-worth, reputation) associated with the CPHQ credential are often at stake. Which only makes the effect of thinking excessively about them even more deleterious.

Practical Ideas to Avoid Choking

The following are some things that my students have found beneficial:

1. Alternate stressful scenarios with periods of (non-stressed) recovery

For many people, getting the CPHQ credential would be the pinnacle of their career. So, the stress of taking the exam can understandably be extreme.

Researchers have found that people, in general, can immunize themselves from performance failure by being repeatedly subjected to (productive) stressors.

To be clear, I did not say do more CPHQ exam practice quizzes (though many of our questions might qualify as being sufficiently challenging)—“toughening up” to one type of stress can carry over to other areas (i.e. sitting the CPHQ exam). For example, conscripts of Singapore’s National Service often find that military training (undoubtedly a universally stressful experience, especially when it is not voluntary) makes them better prepared for tertiary education and/or the workforce.

Conditioning to stressors could include: public speaking courses, training for a marathon, leading an improvement project at work or at a local school or church. As you face these challenges, your psychology (mind) and physiology (body) will learn to adapt to that particular stress as well as other types of stressors, including the CPHQ exam. Of course, taking (appropriate/realistic) CPHQ exam practice quizzes under exam conditions (no food, no books, no access to Google) is also helpful. There are other means to create additional but controlled stress but I’ll reserve this topic for a separate article.

Another important aspect of this process is recovery, i.e. a period of no stress. After being subjected to a stressor, the person should be allowed to recover and to become more resilient/stronger. Like building your body’s fitness or physique, stress (intense physical activity) needs to be interspersed with periods of rest to allow the body to recover and to improve endurance, strength, muscle definition, bulk, etc.

Some people make the mistake of pushing themselves too hard (e.g. in the two months leading up to the exam) without giving themselves sufficient periods of rest and recreation—this is poor exam technique: it doesn’t help retention, and may even increase the chance of burnout and/or choking on the exam.

2. Develop Realistic Expectations

In healthcare quality, we espouse excellence, not perfection. If you’re aiming to get full marks on the exam, you’ll be sorely disappointed because you won’t succeed.


The perfect is the enemy of the good.
The best is the enemy of the good.

– Voltaire, 1694–1778

However, more often, candidates expect to pass when, in reality, they are not ready to take the exam. All expectations, including the CPHQ exam score report, need to be managed properly for optimal performance.

People’s judgment may be clouded by many different things. Here is where an independent opinion might be useful—an experienced mentor/coach in this area can give you an assessment of your readiness to take the exam.

3. Eliminate the Mental Chatter

Many individuals replay in their minds entire episodes of bad experiences in great detail. They’d ruminate about what they could have done better, what they could have done more, what they should not have done, why/how other things or people affected their performance, etc. etc. They engage in (usually negative) never-ending self-talk in the belief that this might improve their performance. This cannot be further from the truth.

Consider your last episode of self-talk about something unpleasant which you experienced. How much did that help you anticipate problems, better handle difficulties or improve your condition or that of a loved one? Chances are the whole exercise just made you feel lousy without making a dent in improving things.

So stop rehashing your mistake(s), traumatic event, or embarrassing moment. It’s not likely to do you any good and may contribute to the probability of you choking.

Healthcare quality professionals should be about the future, not the past.


Ivan Lendl's first Grand Slam title came at the 1984 French Open, after defeating then world No. 1 John McEnroe in the Final. Lendl was 2 sets to love down against McEnroe but staged a remarkable comeback to take the match in five sets. He would go on to claim 7 more Grand Slam singles titles.

Choking on the CPHQ exam is quite common, especially among academic high achievers and those who have high expectations of themselves. CPHQ candidates should focus on obtaining the highest score possible during the exam (while blocking out the consequences of the exam result); they can train themselves to cope better with exam stress by using a variety of strategies. And, like Lendl, they may break the shackles of underperformance and start to shine.

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