Board Review: The Gunner “Methods to Success” Fallacy

Much of the entire self-help book market is predicated on the idea that copying the habits of successful people will make you successful. This is untrue.1The same can be said any other resource that purports to help you succeed by sharing the secrets of the elite. This isn’t to say that no one benefits from shared wisdom, but while someone else’s methods may work for you, the most important thing to know about other peoples’ success is that it is theirs.

If you were to read posts from high-performing students on studentdoctor.net, for example, you would have found the fastest way to experience survivorship bias: people who work insanely hard, do well, and then post their over-the-top methods (the SDN “average” is almost 250). These methods always seem to work. The failures (using the same methods or others) are rarely present. It causes a conflation of the individual student and the methods that they use.

So is it the hard work or the resources that define high-performance when it comes to board examinations? I argue that is hard work, innate test-taking skill, and a sufficient amount of dedicated study time that determines your step score—not the quantity of books or question banks you slog through.

If you are the kind of student who wants to run their eyes over every page of every relevant book so that they might not miss a fact that could potentially appear on an exam one day, this post is not for you. If you’re somewhere else on the spectrum, however, I hope this will assuage your anxiety.

I believe that a focused review of a limited number of resources with a heavy emphasis on questions is probably best for the majority of people. That’s not necessarily prescriptive. You’ll do whatever you want. But if that sounds like something you feel inclined towards and you’re nervous about missing out, then here are some reasons why you shouldn’t feel bad:

Review books are not textbooks. The goal of a review book is to teach or remind you of high-yield information, not to try to break you down with an extra layer of mind-numbing minutiae. You can and will learn from review books, but you will do so focused on testable concepts. Because review books generally contain the same information, you can pick one and go with it. And because these types of books contain the majority of commonly tested material, they are generally sufficient. When studying for the boards, additional resources exist to flesh out a terse description found in a review book, not for a cover to cover read. Likewise, there is very little no meaningful data that you’re missing out if you were to “only” do USMLEWorld twice instead of doing UW and then Kaplan or USMLERx.2And so on and so forth.

It’s a particularly gunner silliness that complains about the lack of complex detail and rare almost meaningless disease processes in review books. For most medical students, being concise and incomplete is a feature, not a shortcoming. A balance of detail and speed is critical. Since you’re unlikely to memorize every word of even a relatively broad and superficial review book, greater detail is not your friend. It simply confounds the take-home points and makes you weaker in the areas where knowledge really counts. The Step and Shelf exams, though very difficult, do not really reward that most granular level of esoterica in a predictable or consistent way. While there are always going to be extremely difficult almost arbitrary/random questions, extreme reading probably won’t help you. You may know an oddly tested fact by chance, but you cannot know every fact. Performing at the highest level does not really require mysterious factoids found only in the depths of the sickest and most arduous classic textbooks. It requires an unshakeable understanding of the things that are on every test every time. In medicine, we say that uncommon presentations of common diseases are more common than rare diseases. If you see hoofprints on the ground, you’re looking for a horse, not a zebra.3Unless you’re in Africa, in which case all bets are off. In your limited time, you’re better off truly mastering the things that show up over and over. Generally, the easiest way to accomplish that is to internalize some good written information and do lots of questions. USMLEWorld has the benefit of combining both. It takes a significant amount of time to truly memorize UW and First Aid to the point where you would get every question right if you saw it again.

I submit to you that the kind of people who typically have the stamina and dedication to get through multiple resources are simply more likely to perform at a high level, regardless of the resources they use. It is not that going through USMLERx and Kaplan after (or before) going through USMLEWorld will finally give you the factoids you need to do well on the Step. But putting in the hours it takes to do all of that almost certainly does correlate! So I would argue that it is better to know a single resource extremely well then to spread yourself thin over multiple sources. Are there minutia that are not present in these resources that you may stumble across during your exam? Absolutely. There are, and there always will be. But the small number of ridiculous questions may be ridiculous to you no matter which resources you use. They are ridiculous for everyone. And their difficulty and tendency to come out of left field gives them outsize importance in your memory. These questions (the ones that drive you crazy) will stay with you, even haunt you. It’s part of the psychology of test-taking. Everyone thinks their test is disproportionately full of the very subject they seemed to know the least of. Some of these questions are so absurd that they are essentially chance-based and merely exist to distinguish (by luck) the people who are scoring at the very highest performance level. If you know the higher yield material (that which is present in the majority of resources), then you will be prepared for the exam. At the very highest level, chance is almost certainly the most important factor. The difference between a 43 and 45 and MCAT is nominal (a couple of questions). The difference between a 270 and a 280 is obviously going to be truly slight.4But how else do you separate the 98th percentile from the 99th?

So, if you want to use Pathoma instead of reading Big Robbins, fine. If you’re doing First Aid and don’t want to supplement with Goljan, you do you. If you only have a few weeks of time for dedicated study and would rather just rock USMLEWorld as hard as you can until your eyes explode? YOLO.

Study how you want to study. But if you don’t understand how you could possibility get through DIT, First Aid, Goljan, Pathoma, UW and then USMLERx, it’s because you don’t have to. Someone else did it. Good for them.