USMLE Step 1: How to study in a pass/fail environment

You just started medical school and you’ve heard that USMLE Step 1 is becoming pass/fail. At this point, you’re likely wondering what you need to know about the test and how to prepare for it.  Well, you’re in the right place because I was once in your shoes and I’m going to break down everything you need to know for this beast of a test (which may not be so beastly anymore).  Here’s an overview of what we’ll be discussing:

• #1: Study as if it were not pass/fail
• #2: Don’t waste time
• #3: Focus on your coursework
• #4: Learn with an emphasis on understanding and remembering the material
• #5: Less resources equals more
• #6: Use spaced repetition 
• #7: Use memory palaces
• #8: Use question banks
• #9: Take NBME practice tests
• #10: If you’re going to skimp, choose wisely
• #11: Stay healthy

 

Tip #1: Study as USMLE Step is not pass/fail

You may be tempted to slack off during your pre-clinical years because, after all, USMLE Step 1 is only pass/fail, right? Wrong. This is a dangerous mindset. There is so much to learn in medical school - embryology, anatomy, biochemistry, physiology, and the list goes on.  As you study for your coursework and the exam, try to remember that you’re not just studying for quizzes, tests, and board licensure exams. You’re studying for your future patients. You’re studying to become a great doctor.  When the patient with a myocardial infarction presents to your emergency room in cardiogenic shock, you’ll be grateful you put in the hours to know your stuff backwards and forwards.  Another point to keep in mind is that with the pass/fail change, residency program directors may have to rely more on Step 2 CK scores as a standardization metric. As you finish your third year of medical school, you’ll likely have a narrow window of time to prepare for and take Step 2 CK.  Remember, during this time you’ll be flying halfway across the country to take Step 2 CS, squeezing in a few electives, preparing your residency application, getting letters of recommendation, AND taking Step 2 CK. The last thing you want to worry about during this chaotic time is circling back to learn information you should have mastered during your preparation for Step 1. After all, much of the information tested on Step 2 CK is similar to what is tested on Step 1.  If you study your butt off during your pre-clinical years you’ll be much better prepared to not only pass USMLE Step 1, but also to dominate Step 2 CK. So don’t slack off during this time, and make sure you put in the time to really learn the material. Study as if your patients' lives depend on it. Because they do. 

#2: Don’t waste time

You cannot afford to waste time during these years when you have more time. Use them to focus on learning this valuable information.  I still remember thinking as a first and second year medical student that I was so busy. I couldn’t possibly get any busier. However, when my third year came around, I was shocked at how much time I actually had during those pre-clinical years.  During the third year of medical school, you’re faced with constantly being in the hospital or clinic, oftentimes working 70-80 hours a week. Trying to find time to study information you should have learned during your pre-clinical years while simultaneously preparing for your surgery patients the following day, studying for the shelf exam, and trying to squeeze in a few hours of sleep is unlikely to happen. So be vigilant, and don’t waste your valuable time.

#3: Focus on your coursework

I heard this so many times during my pre-clinical years, and I thought upperclassmen didn’t know what the heck they were talking about. Looking back I recognize that, in a lot of ways, they were right. Focusing on your coursework is important because it forces you to learn the information in a well-organized way - kind of like taking baby steps.  So, for example, if August is your month to learn about embryology, become a master of embryology during that month. Don’t waste your time thinking about physiology or microbiology - focus on embryology. If the professor is great at teaching embryology concepts, go to the class and learn from him or her. If the professor is wasting your time, then learn embryology from a solid external resource such as Physeo.com. 

#4: Learn with an emphasis on understanding and remembering the material

As you’re going to classes and studying for quizzes or tests, make sure you are actually understanding the material. It’s so tempting to look at a page in First Aid, read one paragraph on an incredibly complicated topic, and think, “I’ve got this down.”    It wasn’t until much later when I created a video on the topic (https://physeo.com/pulmonology-section-4/) that I appreciated just how complicated this information is.  Don’t just rely on reading the information. You’ll likely need to see something multiple times before it sticks. Dig deeper and try to understand the processes or mechanisms behind the concept.  At times it may be helpful to look at UpToDate or - don’t judge - Wikipedia. Use multiple modes of learning including video, questions, and audio. Immerse yourself in the complicated topics, test yourself, test your friends, and make sure you truly understand the information.

#5: Less resources equals more

In an era when so many USMLE Step 1 prep resources are available, it’s critical that you limit yourself here. You may feel like a drug addict surrounded by offers of methamphetamine at a discount, but resist the urge to buy. You don’t need 10 resources to do well in your classes or on the exam. 3-4 at most will suffice.  The issue with using so many resources is that your attention is so heavily split that you’re unable to ever finish any single resource from start to finish, and end up missing important information.  Don’t just use a resource because your friend is using it or because you heard an upperclassmen recommended it. Try out a few resources with free trials and watch sample YouTube videos to get a sense of how the information is covered. See what fits best with your learning style, and stick with it. Look at the back of the latest edition of First Aid and see what resources have an “A” rating. Go to Reddit.com and read reviews on resources. If you like a resource that has a “C” rating from First Aid and poor reviews on Reddit, you may want to try out something else and compare.  With so much good information out there, don’t settle for anything less than amazing. If I could do it all over again I would supplement my coursework with First Aid, Physeo, Anki, and Uworld. 

#6: Use spaced repetition 

Studies have shown that spaced repetition improves retention and improves scores (AMA-ASSN). The indisputable number one resource for spaced repetition is Anki.    Anki is a flashcard system that has many pre-made decks created to help medical students succeed. If you’ve never heard of Anki or would like to learn more I’d suggest checking out the AnKing’s YouTube channel (Youtube).  In the beginning, it may not be the most user-friendly application, but the AnKing makes it much easier.  The most popular, and in my opinion, best, pre-made deck is currently Zanki, which I would highly recommend using.  The key to improving your score with Anki is using it every day. You may end up with several hundred cards per day towards the end, but sticking with it and being consistent will definitely help you master the information. 

#7: Use memory palaces

While I am a strong advocate for understanding information, some information in medical school must simply be memorized. For example, most of microbiology and pharmacology is rote memorization. Do you remember that Staphylococcus aureus is a gram-positive organism that is catalase positive? Or that methotrexate is hepatotoxic? These aren’t facts that can easily be understood by learning about an underlying process. You must simply memorize them. For these topics it is futile to read or listen to someone recite fact after fact, hoping it will stick.  I still remember seeing a table that contained approximately 1 billion facts during one of my pharmacology classes. It was a bit excessive, but then the tables just kept coming afterwards. Good luck memorizing that! No - don’t waste your time learning factual information that way. Instead, use memory palaces (also known as image mnemonics / picture mnemonics). 

A Physeo Example:

A good memory palace has a solid story with symbols that should help you remember difficult information. For example, Physeo’s memory palace on Clostridium tetani is shown below and is an epic story about a necromancer raising monsters from the dead.  The necromancer is tethered to the gates of hell and the word “tethered” should help you remember “tetani” in “Clostridium tetani.” Each element in the story has a meaning and will help you compartmentalize and retain all of the facts you need to memorize for USMLE Step 1.  I would recommend learning most of pharmacology and microbiology this way. There are some elements from biochemistry, immunology, embryology, anatomy, and pathology that I would also recommend learning this way. However, don’t get sucked into thinking you need a memory palace for everything. If you overload your brain with 900 memory palaces it may be just as hard to recall all of the details when you need them.  Whenever possible, try to understand the information and learn about underlying processes or mechanisms. This will help the information stick long-term without the need for a memory palace. 

#8: Use question banks

While there are many solid question banks for USMLE Step 1, I highly recommend Uworld (Uworld). This is the gold standard when it comes to Step 1 test prep. The other two question banks I would recommend are Amboss and USMLE-Rx.  There is an ongoing debate regarding saving Uworld for your dedicated prep period or diving into it beforehand. For those advocating saving it for dedicated, they recommend using other question banks leading up to your dedicated period. However, now that USMLE Step 1 is becoming pass/fail I think doing 2-3 full question banks may be a bit of an overkill.  You may get through all of Amboss or USMLE-Rx without enough time to finish Uworld, which is the biggest concern here. Uworld is pure gold, so prioritizing it is key. Let me be clear, though - the goal is not to finish Uworld. It’s to understand Uworld. Don’t just answer the questions and move onto another test. Read through the explanations. Read about why the correct answer is correct and why the wrong answers are wrong. 

#9: Take NBME practice tests

Most medical schools will require you to take an NBME practice test (Practice Tests) sometime during the start of the new year leading up to your exam (eg, January, February, March). This is a great starting point to assess how prepared you are for the exam.  If you pass the first time around, be sure to look at your overall performance. Did you barely pass or did you pass with flying colors? If you’re doing extremely well at this point, I would suggest taking a breather and focusing more on coursework and getting ready for your clerkships. If you’re struggling, it’s time to buckle down and improve your score so that you’re passing with flying colors.  Once you’re in your dedicated study period, be sure to use at least one or two more NBME practice tests to be confident you’re at a passing level. If you’re struggling, I would recommend doing one every week leading up to your exam. 

#10: If you’re going to skimp, choose wisely

Previous to USMLE Step 1 being pass/fail, you probably would have been mocked for considering the possibility of skimping on material. However, with this change, you may have some flexibility here. For example, biochemistry and embryology are notorious for having little clinical utility for practicing physicians. Ask any attending about the derivatives of the second pharyngeal cleft and they’re probably not going to know the answer. Simply put, some information that you’ll be tested on for USMLE Step 1 is not very clinically relevant. So if you know you don’t want to be a physician that studies embryology in a basic science lab, you may be able to skimp a bit in this department. Now I’m not advising you to ignore all information that isn’t clinically relevant. Definitely don’t do that! However, if you’ve put in the time and are still struggling with some of these slightly less clinically relevant topics, then perhaps it’s okay. So if you have to choose, focus on the material that will be most helpful for you as a practicing physician. 

#11: Stay healthy

It may be a bit cliché, but it’s so true: stay healthy. If you read all of First Aid, watch every Physeo video, do 1,000 Anki cards a day, finish Amboss, USMLE-Rx, and Uworld, and do all of the NBMEs, but lose your sanity, is it worth it? No! It’s definitely not worth it! You don’t need to kill yourself to pass this test or to succeed in medical school.  Make sure you take time to do the things you enjoy. Spend time with your friends and family. Pursue your hobbies. Exercise. Eat healthy. You know - all of the good stuff. As you take time to stay healthy your mental capacity will increase and you will be more successful. 

Conclusion

Volumes of text have been written on Reddit.com and elsewhere regarding how to study for USMLE Step 1. Up until recently, much of that information may have been relatively useful. However, in a pass/fail environment the rules have changed.  If you follow the above tips, I can guarantee you’ll not only pass the test, but you’ll become a competent doctor ready to face the challenges of clinical medicine and beyond.