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How To Study For USMLE Step 1

The reason I am writing this is because I have been in your shoes. I have known the feeling of being told the importance of an exam and having absolutely no idea where to start. Okay, that was a lie, everyone knows to start with First Aid, but it’s only one small but important piece of the puzzle. My journey was long, difficult, turbulent, but also challenging, rewarding, and undoubtedly one of the defining periods of my medical school career. However, it definitely could have been helped with some wise words, advice, and encouragement from someone who was formerly in my shoes as an MS2. As an MS3 now, I am here to offer my hand to the next class on how to study for USMLE Step 1.

Framework

Step 1 is an important test. You’ve heard it before a hundred times and you will hear it a hundred more times before MS3 begins. Advice from upperclassmen also says Step 2 is slightly less important and Step 3 even more so. What I was hearing was that Step 1 might be the last opportunity in my life where doing well on an exam has a profound impact on my future. Like how the SATs opened doors for colleges and the MCAT opened doors for medical school, Step 1 sounded like the last key to the last and most important door—residency.

Here is where I’d like to give you the right frame of mind. Know that I am not a student where concepts come naturally and facts linger for days in my mind. I’m of normal intelligence but try to work as hard as I can. I need repetition to retain information. I need the same information from multiple sources. I have also never been a gifted standardized test taker, but that was something I tried to change for Step 1. At first I wondered, could this be changed at all? After hearing advice from upperclassmen about doing lots of practice questions, I sought to do as many practice questions as possible. So many that by the time of my exam I would know there was nothing more I could have done to prepare myself.

For a moment, let’s appreciate the unique opportunity that is Step 1. Step 1 is truly the last time where you are given a very extended period of time to focus on a single thing. You have no other responsibilities except to study for this one test. In MS3 and MS4 and in residency, you’ll be pushed and pulled 10 different ways, keeping track of 20 patients, notes you haven’t written, putting together a presentation, etc. Right now in MS2 you have a single job and that is to study for this test. Not only that, you can pretty much decide your own schedule each and every day. You can wake up when you want, you can exercise when you want, eat when you want. Your entire life is in your control, and it is this way so that you can place yourself in optimum studying conditions for this exam. During these next several months you can ask any question you have and professors will be happy to answer them. You don’t have to be judged for not knowing an answer. In fact it is your job to ask as many questions as possible and not be afraid of any repercussions or implications. You are truly on a several month-long journey to pursue knowledge.

Here is the very first step of studying for Step 1. Setting a goal. It is not impossible to score well on Step 1 with a modest amount of work. Do your research into what fields you believe you have a chance of being interested in. Look at the Charting Outcomes for the Match results and see what median Step 1 scores are for those specialties. After that, think about your personal goals. How would you feel if you suddenly discovered a passion for a very competitive specialty during MS3 but didn’t know beforehand and so you didn’t study as hard during Step 1? It doesn’t happen to every student but it happens to some every year. I can honestly say I think somewhere between a 240 and 250 is a very achievable goal given a few months of hard work. You don’t have to drive yourself crazy for all of MS2. If that’s your goal, I cannot stress the importance of working hard during those few months but also taking the rest of your time to enjoy life as a second year. Things are much different in third year. Study hard for a few months, relax during the rest, and enjoy your life.

However, even if your goal is to only score in the 240-250, there is never a guarantee that with the appropriate amount of studying you will score in that range. The approach you must take is that even on your worst test-taking day, you will still score in your desired range. Believe me, there will be numerous factors (a few hours of sleep the night before, a lot of nerves, clumsy errors) that will prevent you from feeling like you performed your best. This guide is written to help you achieve the highest possible score you can achieve. Every additional single point requires exponentially more time and studying to achieve. There is a law of diminishing returns. However, if your goal is to score the highest possible score, you have to find a way to persevere through the hours of additional studying for each point that you want.

The second step is to find a group of friends. Find people who share your goal. During studying time there will be countless times you will want to rant to friends about being destroyed by a block of questions, or a poorly explained answer, or just how much information is falling out of your head. Your friends are absolutely crucial to this time. They help motivate you. You help motivate them. It is more than a pep talk in the morning; it’s staying up late and listening to them talk for weeks in a row, it’s dragging them out to the gym even when they feel terrible, it’s forcing them to come out to dinner and take a break with you to keep both of you sane. Your group of study friends does not have to be the same group as your best friends; branch out and learn about people you thought you knew before.

What is the test?

Read the introduction to First Aid. It’s essentially all there. Briefly, it’s an 8 hour exam. 7 hours of those 8 are spent answering questions. Each hour has a block of 44 questions. This means you have to answer at about a rate of just over a minute per question (which leaves several minutes to review some flagged questions). Never leave a question blank. If you have difficulty with an answer, pick an answer, flag it, and come back to it at the end of your block with your free time.

How do you study for the test?

Here is the third step. After many, many hours spent online reading different strategies and study plans, and implementing this myself, I can confidently say that these resources are components of the best study plan to achieving the best score possible, regardless of what type of learner you believe yourself to be (visual, flashcarder, lecture slides, etc.).

  1. First Aid + Qbanks
  2. Pathoma
  3. Misc items such as Anki, Firecracker, Goljan audio, etc.

First Aid and Qbanks are by far the most important. Almost everyone agrees First Aid is useful and they carry it around so that they can study from it, but most people aren’t utilizing it properly.

First Aid

First Aid is not a textbook, it doesn’t teach you much in concepts. What it does teach you, is how much you don’t know. For example, you will look up a drug in First Aid and see a side effect you had never known to be associated with it. First Aid is an accumulation of the highest yield facts believed to be tested by the USMLE because it is written by people (students) who have seen recent questions. The learning and understanding of each individual topic in first aid must be done outside of First Aid. Reading Wikipedia, your lecture slides, a textbook, getting an answer from a question bank. This is where the true learning is done. The type of learning that helps you retain information long after you read it. After you learn it from these sources, you look it up in First Aid and you read it there again. You can feel free to write notes in the margin so that when you read it 2 months later, you’ll have an idea of how to understand the topic rather than memorize it.

Understand that First Aid is a big book. It’s over 600 pages of dense content. It would take me 10 minutes or more to make my way through an entire page of details (and this was during study period when I already felt comfortable with most of the material), imagine the time it takes to go through the entire book. You will not make it through the entire book and memorize most of it if you open the book for the first time 1 month, or even 2 months, before your exam. Speaking for most students, I don’t think it is possible. Even if you think you’re exposing yourself to it by skimming it during the school year and reading relevant parts that match with your lecture, there is simply too much information outside of lecture in there to process in 4-5 weeks of free study time. Yes you may be able to make a couple solid passes through the book, but ask yourself what percentage you think you’ll be able to retain. You need repetition. And because the book is so thick, that repetition needs to start now. It cannot wait until later.

Each page in first aid is filled with details within details. You cannot begin to imagine the details hidden on each page that can become test questions. On my 3rd pass of FA during my study period I was still finding new words I missed before and had never seen. Read the small italicized font that you didn’t think was important. Read the captions to the images. Read the labels of diagrams. Every single word is important. This must be your approach to studying. There are no more high yield or low yield facts. Every single fact is high yield.

Don’t neglect the chapters that aren’t easily associated with lectures. Behavioral Science is extremely important but doesn’t quite fit into a systems based approach. I highly recommend it as a starting point, not just because it’s the first chapter of the book, but because it doesn’t require you to recall physiology from last year. You can dive right into it. The same is true of the pathology and pharmacology sections. Those sections pull topics from many different organ systems and they contain many, many factoids that could be easily translated into flashcards.

Lastly, purchase the newest edition of First Aid. It’s absolutely worth it. I studied with a friend who had the older edition and he regretted it.

Qbanks

If you want to do fairly well on the exam, you need to purchase Uworld Qbank (which your class will purchase as a group if you haven’t already) and you should save this for dedicated study time (5 weeks prior to your exam). I say this because Uworld offers the most difficult and thought provoking questions. It is by no means an assessment tool. Do not use it as a big practice test. Instead, it is a learning tool. It will teach you to become accustomed to the level of difficulty of the real exam. It will teach you that you have not been reading FA as closely as you think. It will teach you that knowing 80% of a topic is not enough. It will teach you that memorizing 4 out of the 5 side effects of a drug is not enough. It gets you in the proper state of mind before taking the test because the test will be difficult. Can you use Uworld as your 1st Qbank? You can, but I recommend not doing that for the reasons above. Step 1 is like the real race and Uworld Qbank is like an intense exercise program. You want your most strenuous regimen to be close to your performance. You don’t want to train hard months in advance and then take a break with something lighter just before you need to perform. Can you re-do Uworld prior to your exam? You absolutely can, but I argue there is very limited utility. You’ll remember a lot of answers to questions, and the sense of seeing new, strange questions won’t be the same. That feeling of truly new questions is exactly what you will feel on the exam.

If you want to do even better than well, you will likely need another qbank to practice with during the year. Your other 2 qbank options are Kaplan and USMLE Rx. My opinion is that Rx has shorter question stems and feels easier than Kaplan. Either is fine to use. Pick one qbank and finish it before study period starts.

If you truly want to do the best you can, you must purchase both Kaplan and USMLE Rx. The reason I say so is that my strongest belief about this exam is that your score is highly correlated to the number of practice questions you do. A research study from Albert Einstein demonstrated that the number of questions finished directly correlated with students’ step 1 performance. Yes FA is a big book of facts that you must memorize but when it comes to answering questions, the questions require processing information. It requires integrating different data and organ systems and coming up with a conclusion where you have to weigh certain answer choices. Some more than others and ultimately pick one and hope it’s right. Many times it comes down to a gut feeling. But remember, you have to move at a pace of slightly over 1 minute per question. And there are over 300 questions on Step 1 over 7 hours. What does this mean? This means you need to become a pattern-recognizing machine. Step 1 questions are all about patterns. Each disease process and pathology has a classic pattern it is associated with and Step 1 loves to ask questions that incorporate these patterns. In order for you to recognize patterns, you must build an intuition. This test-taking intuition can only be built upon hundreds and hundreds and thousands of questions. There are slightly over 2000 questions in an average question bank. Maybe 3 of these questions will touch upon a very rare disease that takes up about a paragraph or less in First Aid. 3 questions are not enough to build a strong enough intuition such that on the real exam in a slightly different scenario you would have the confidence to pick the right answer. This is why you absolutely must do more than 1 qbank. With 3 qbanks you now have at least 9-12 questions on this rare topic in your experience and can begin to form your intuition.

Here is where the study schedule comes into play. Decide for yourself what your goal is. Decide for yourself how many question banks before Uworld you will need to achieve that goal. Divide up the number of questions you have by the remaining number of weeks you have left to study. This is how many questions you must do per week. It’s very simple but it requires an incredible amount of time. Start by doing tutor mode. You can even start by doing one organ system at a time. Eventually (at least several weeks in advance of study period) you must do them timed (1 hour for 44 questions) and you must do them random. This is the environment you will be in during the test, and like a marathon or a competition you must absolutely practice during these same conditions so that you feel as comfortable as possible during the real exam. I absolutely promise you that the real exam will not feel like any practice exam and there will be numerous reasons why you will be made to feel uncomfortable as possible.

Take into consideration the amount of time you will need for each block you begin in your first qbank.

-For 44 questions, it will take you 1 hour to do the block. When you review the block, here is what I would do if I were you:

  • I would read the entire answer explanation.
  • I would open my pdf of FA and find the topic.
  • I would read what FA says on the topic
  • I would Wikipedia/google any topic I didn’t understand
  • I would jot down notes in the margin of FA if I found it appropriate or believe it might be high yield or improve my understanding and therefore retention in the future. I would also make a flashcard if I felt it needed memorizing.

As you can imagine, this process may take more than a few minutes, depending on how well you knew the topic asked. In the beginning stages of your studying, this will take many minutes per question. If it takes you even 5 minutes per question, this means you will end up spending 4-5 hours reviewing a block after already spending 1 hour to take the exam. This is a big chunk of time during your day or your weekend, you absolutely must plan accordingly. After several weeks of this, your pace will improve. As fewer topics are unfamiliar to you, you will spend closer to 3-4 hours reviewing a block.

When you consider it will take 4-6 hours per block and each Q bank has 2000-2200 questions each, you will find it takes a significant amount of time outside of regular school studying to do all of these questions. This is why you must plan your weeks accordingly.

Don’t be so concerned with moving through First Aid like a book, one chapter at a time. You absolutely can if you want to. Read one chapter of First aid while doing questions relevant to that section. But one piece of advice I strongly believe in, is to use the question banks as your tour guide through first aid. Let them show you the details you missed in just reading the sentences. Let them show you how a single word can be used to ask a question, how two topics in FA can be commonly used together to trick you. If a question from a Q bank demonstrates that you are weak on a certain topic, use that as a springboard to learn from First Aid and other resources. Make flashcards on that topic. Doing questions is not only much more interesting than reading words off a page in FA, but also helps you to build your test-taking intuition.

Pathoma

Where does it come in? I found the most utility in pathoma by using it during the year. It’s greatest strength is in teaching conceptual understanding of various topics, and therefore it is a great resource to use during the school year. However, there are many more obscure diseases that he calls “high-yield”. After having gone through studying for step 1, a good fraction of these obscure diseases may never appear on a question. However, I still believe it to be important to approach memorizing pathoma the same way you will approach first aid. It is a much shorter read and I found it useful to turn the whole book into flashcards as I was reading it (make a flashcard for every fact). This is not as practical for First Aid since the book is just too large; for First Aid you’ll have to pick which sections are just brute force memorization and make flashcards for those. My greatest recommendation for pathoma is to finish watching it once (while making flashcards) and then watching it one more time or reading the book yourself one more time. This will give you two solid passes through Pathoma before study period.

As if Question banks, First Aid, and Pathoma were not enough, if you want to know what you can do between all those resources, my advice is to use anything that gives you repetition. Reading answers to questions, reading pages from FA or pathoma, these are all passive ways of learning. With the vast amount of information present on the test, you need incredible amounts of repetition. Not only do you need repetition, but having multiple avenues of learning and digesting information will keep you from being bored and also help you to retain information. This is where flash cards come in.

Flashcards 

Flashcards are essential for repetition. However, they are important in helping you think critically but only if you use them right. The two best ways to do flashcards is either create them yourself (Anki) or use pre-made cards (Firecracker). Flashcards are electronic now so you can do them anywhere. Whether you are walking to class, waiting for the bus, sitting on the toilet, or during a commercial break of a football game, you can literally do flashcards any time. Flashcards can be the glue that helps keep all the information that you learn from Qbanks, First Aid, and Pathoma together.

Self-made flashcards:

While you grind through your Q bank, one of the best things you can do is make flash cards for questions that you got wrong. If you got a question wrong because you did not understand a certain concept, make a flashcard or a set of flashcards that will help you remember and understand this concept in the future. Then maybe a week or two after you missed that question, you will see that specific flashcard in your deck, helping you reinforce what you learned. This cannot be emphasized enough. You must learn from your mistakes. Using flashcards is one of the best ways to do so. Sometimes the best way to use a flash card is to screen shot a table from First Aid, paste it onto a flashcard, blot out of the text, and memorize the hell out of it.

Firecracker:

Firecracker is a premade flashcard program that attempts to integrate all important information for Step 1. Their flashcards connect well with First Aid, Pathoma and UWorld. The reason why Firecracker could be useful is because their flashcards tend to cover material from all three of these resources. You can use Firecracker starting day 1 of medical school because there are sections for physiology and anatomy as well. Firecracker is probably even more useful during second year (especially if your first year covers physiology while your second year covers pathophysiology). The following is great way to use Firecracker:

  • Whenever you learn a concept in class, watch the Pathoma videos that correlate to that covered subject.
  • While watching Pathoma, take notes on your First Aid to supplement anything that First Aid doesn’t cover or to help you understand First Aid material.
  • Then afterwards, find the correlating section in Firecracker and quickly read it (this shouldn’t take long because you just covered most of it in Pathoma and First Aid)
  • Do the flashcards for that section

This way, you not only study Pathoma/First Aid, you also get some immediate flashcards that will help you see whether you actually learned something or not.

Keep in mind that Firecracker is a tool that is meant to be used every day. It is for constant repetition. If you are going to use Firecracker, you should be dedicated. Attempt to do 50-100 review questions a day in addition to learning to material. It’s ok if you don’t meet your daily quota or if you skip a couple days but just make sure you are consistent most of the time.

Having a quick source of random flashcards (whether they’re self-made or from firecracker) serves a second purpose. In the week or two prior to your real exam, you will find that you will need to cram. Yes you spent several months memorizing, but the truth is that there is still too much information to learn. It is too difficult to make a pass through First Aid in just one week. In the 1-2 weeks before your exam, instead of skimming First Aid, you can flip through flashcards and get a truly randomized quick way to review all of the difficult topics

Putting It All Together

 After you’ve set your goal, found your group of friends, pulled together these resources and played around with them for a bit, there is a final and crucial step before beginning this long journey of studying and that is attitude. First, you absolutely cannot give up studying lectures. I distinctly remember two questions on my real step 1 that I learned from lectures in MS1 and MS2 that I never encountered again during my Step 1 studying. I know it seems impossible asking you to study all these sources but also continue to focus on lectures, but it’s the only way to score your best on step 1. Second, the approach you have to keep in mind for the next several months is curiosity. Be curious about every single thing you come across. If you hear a maneuver named after someone, or a drug you’ve never learned, or a gene name mentioned briefly—look it up. Google it, Wikipedia it, or Uptodate it if you’re brave enough. Read about it, even if it’s just for 1 minute. There is always a chance it could appear on Step 1. First Aid, the Qbanks, and Pathoma cover a vast majority of topics likely to be asked, but they will never be able to cover every single topic.

A final piece of the puzzle, which will not be discussed in detail here, are the practice exams. There are 6 NBME exams available for purchase, each 200 questions. There are 2 U world self-assessments available, each also 200 questions. That is an additional 1600 questions of experience in addition to your question banks. As I said before, your score is highly correlated to the number of questions you have done. Therefore, you must do all 8 of these exams. Not only for the purpose of assessing your score (many, many people end up getting the average of their practice scores on the real test), but also for refining your intuition.

Overall the journey seems daunting, but know that it is far from impossible. It is an incredible experience to bond with your classmates over; it is also a very big step in advancing your knowledge and clinical reasoning toward being a physician. Best of luck.

This article was a collaborative effort by students from the David Geffen School of Medicine.

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