How to Study for the USMLE Step 1

I’ve spent the majority of my “adult” life as a standardized test taker. As a resident physician, my skills are still developing. But as a student, as an aficionado of the multiple choice question, I’ve already reached (and probably lost) my peak abilities.

I am asked frequently about my thoughts on the Step exams, especially the USMLE Step 1. It is after all the single most important determining factor in what specialty a medical student can reasonably hope to enter and probably the easiest and most-used exclusion criteria used by program directors everywhere (with the likely addition of graduating year and US Allopathic schooling). I can hear your thoughts. They ask, how should I prepare? My answer is simple:

USMLE World.

Theoretically, any good question bank should do. In practice, UW is the best.

More so than First Aid, more so than Goljan, and absolutely more so than Doctors in Training, I believe the USMLE World question bank is far and away the most critical component of Step preparation (with a solid helping of Wikipedia). Here is why:

When you learn a fact in a book, you can congratulate yourself on adding a virtual index card into the Rolodex of your brain. However, you have not indexed this fact in a retrievable way. It isn’t necessary usable in a test-taking context. This is one of two reasons why many people who know things still do poorly on tests. They can talk about it, but they can’t apply it. You may know the right buzzwords but never seen them described in an exam question. When you do questions, you both learn facts and learn them in context. You learn them in a question format, instead of learning them in a paragraph and then struggling to integrate and apply it to a question. Your time is valuable, wouldn’t you rather kill two birds with one stone?

UW questions have extensive explanations and are essentially a textbook page unto themselves. You can learn what you need to know from UW. The only downside to UW is that is not “organized” like a book for those students without sufficient background in need of a stronger foundation (this is what a quick read-through of First Aid as fast as possible at the very beginning of your study process will give you: a reminder of what you’ve learned, a horrifying glimpse of how much you do not know). This can be is a strength for two reasons: 1) it’s [slightly] less boring 2) the USMLE is not divided into sections. You never know on what topic the next question will be. 3) Patchy random exposure to topics isn’t exactly “spaced repetition,” but it does work along those lines.

So read through First Aid in a week or less. Just get through it. Bring up all the hidden junk you memorized long ago, then go straight to questions. Questions, questions, questions. Use books only to memorize tables and diagrams or flesh out your knowledge when you find yourself stumped by concepts or totally out of your element. Many students spread themselves thin trying to get through multiple sources at the expense of not doing enough questions—this is a mistake. Focus and depth trump breadth, end stop. Go through UW and mark/flag all the questions you get wrong and all the questions you guess on. Then do the marked ones a second time. Unless you have a significant problem finishing exams on time, I believe in “tutor” mode: this mode allows you to learn the correct answer and read the explanation immediately after each question. The goal is here is to learn first (and simulate the test second). If you do NBME practice tests closer to test day, those will obviously be done in timed mode. Ultimately, this is a matter of preference.

UW also goes to the trouble of explaining not only why the right answer is right but also why the wrong answers are wrong. This is crucial. This means you learn how to answer similar questions correctly again as well as when the wrong choices would be correct. Several related facts in one caffeine-riddled swoop. These explanations are on the whole excellent. These exams no longer include the classic buzzwords found in review books; they describe those buzzwords and key phrases. UW employs this nuance well.

The second major reason people struggle with MCQ tests is the inability to “get in the head” of the question writer. There are individuals who seem to test better than they should. You could ask them to explain why they choose the correct answer and they typically cannot explain themselves. Or, if they know why, it often is not entirely based on their book-knowledge. They’re able to narrow it down to those same two choices as the next guy, but they pick the right one more regularly. These people are natural test-takers. Step 1 is a MCQ test, but its style is not identical to that of the SAT or MCAT. You need to do Step questions to know how to do Step questions. It’s like any other skill. Hone it.

Because you wouldn’t learn to play guitar by practicing the flute, would you? Sure, the flute is a musical instrument: your dexterity would improve, your knowledge of tempo, rhythm, and music itself would develop. But if you picked up a guitar, you would still suck. Don’t spend 10 hours a day for six weeks learning the flute, then pick up a guitar and hammer on a few chords for a week and call yourself a guitarist. Just play the damn guitar. Skip the middle man.

Here is my compilation of free USMLE questions, which can be helpful before you’re ready to shell out for a definitive resource. Here are some things to keep in mind while studying. And some more thoughts about how I read Step questions.