Thoughts on studying in medical school

Let’s start with this premise: In the 21st century, the medical school basic science curriculum is probably best learned through guided self-study and likely not whatever your school is trying to teach you (especially if that involves the blind leading the blind via TBL). How much you can fulfill this ideal will unfortunately depend on how cooperative your school is with reality.

Here’s our tour:

• Understanding Your Curriculum
• Considering Question-centric learning
• Spaced Repetition
• Resource Recommendations

Understanding Your Curriculum

Ultimately, while medicine is a large field and the basic sciences cover a lot of material, the first two years of medical school could essentially be a correspondence course. With the exception of gross anatomy dissection (which is being deemphasized across the nation), the basic science materials can easily if not better be learned on the one’s own with resources that are increasingly standardized across the country. The importance of Step 1 for residency selection success has increasingly shaped how courses are taught. The relatively recent trend of many schools to include various problem-based and team-based learning (PBL & TBL) activities is in many ways mostly a desperate attempt to make medical school relevant again in an age where classic classroom instruction has been supplanted by multimedia materials, online lectures, well-honed textbooks, and question banks, etc, which are frankly better than most schools can actually offer from their own. Sad but true.

The “basic science” material may be voluminous but generally speaking is not particularly complex (with rare exceptions), and success during the first two years (if it’s even graded and not simply pass/fail) is largely a matter of stamina and continual self-improvement to find a method that works well for you when learning a large volume of material within the confines of your school’s particular demands. It is what it is. For strictly pass/fail curricula, your success will essentially depend on how much Step 1 can motivate you to actually study for two years in a row.

So with that cynical introduction behind us, how you will study and especially the materials you will buy/focus on unfortunately will still vary greatly depending on the composition of your medical school curriculum. Several factors are at play:

• Is your school pass/fail or graded?
• Do your teachers provide extensive course syllabi (homebrewed textbooks) from which their test questions derive?
• Are test questions written in a clinical vignette format with an eye towards preparing you for your standardized examinations (NBME Shelf Exams and USMLE Step Exams) or are the questions mostly irrelevant bullshit derived from the professors’ idiosyncratic interests?

If your courses are truly pass/fail, then by all means, study what you believe seem to be the very best resources.1I’ve written about the basic science resources here. You can safely ignore any class lecture that doesn’t appear to be worth your time, or every class regardless. Unless you hear otherwise, any resources you study will almost certainly be enough to pass your local exams. You’ll have to ask your MS2 colleagues for some guidance on anything that is surprisingly worth it or for which you could possibly have the chance of failing.

If your classes are graded, that’s probably not a good idea. At the least, one shouldn’t exclude out of hand the materials that your teachers derive their questions from (whether their own syllabus, lecture slides, or a favored textbook). If—based on feedback from more senior students—the tests are analogous to NBME shelf exams, USMLE, etc, then again you can go with the “high-yield” resources.

That’s why there can be no truly specific advice for “how to study in medical school,” because everyone’s needs are at least partially dependent on the makeup of your curriculum. Online forum discussions and Amazon reviews stating that book X is too detailed or book Y is too superficial or anything of that nature are fraught with a specificity that may not apply to your circumstances. There will be plenty of “good” resources that you should never use.

Considering Question Centric Learning

Something that was less popular years ago when UWorld wasn’t quite as dominant and beloved but has become increasingly common is the use of a question bank as a de facto textbook. I think this is an overall an awesome idea (see my Step 1 advice).

I am sometimes asked whether “using up” UWorld is a good idea, and I’m not sure exactly how to respond to that. I think if you use UW for your various modules over the first 1.5-2 years of school and then reset it for your pre-Step dedicated review that it will have been so long that many of the questions will seem new. More importantly, if you really do know the question bank “cover to cover,” regardless of how you’ve achieved that, you will be in fantastic shape for Step 1. If you’re in a school that routinely uses shelf exams for tests, using a solid question source like UWorld will be an excellent resource to prepare for your tests. No amount of book reading will ever prepare you for doing questions quite the same way that doing questions will (which should seem self-evident, but you’d be surprised).

If you like the idea of using a question bank but still want to save UWorld for dedicated review, I think that’s ultimately fine. There are several reasonable alternatives/adjuncts: Kaplan, BoardVitals (code BW10 saves 10%), TrueLearn (formerly USMLEWeapon, $25 off with link), and USMLE-Rx. None of them are quite as good, but all contain the highest yield stuff/low hanging fruit as well as near-useless esoterica. Even when relying heavily on a qbank, it’s worth noting that you still want a foundation/framework prior to diving into questions so you have some context from which to learn.

Spaced Repetition

In addition to a smorgasbord of newer resources like Pathoma, SketchyMedical, Picmonic, FireCracker, etc., the biggest study change over the past few years has been the popularity of the spaced repetition technique. You’ve probably already heard of it or may even be a believer already. The concept is simple. You have a bunch of flashcards, and the ones you know well appear less often and the ones you don’t know show up more, and the spacing of the repetition is designed to maximize long-term retention. As in: study smart, not hard.

Anki is the most popular spaced repetition system with a cross-platform app and web interface and a system that supports text, images, and even video. This is where it’s at. There are a number of free “decks” available online for medical school, and you can definitely use these. There is something to be said for making your own decks, though, as picking the content you want to learn and displaying in a self-friendly format is definitely part of the battle. To be fast, consider taking photos of book pages and screenshotting things online and using that to make your cards instead of typing and typing and typing.

When using the software, you can choose how many new cards to train with each day, the maximum review cards, etc, so you can set aside rules for how much time to dedicate to this form of studying. The details of optimal deck creation and whatnot can feel overwhelming, and it takes some getting used to. A few resources to start with:

• SuperMemo on how to formulate knowledge (i.e. make good cards).
• Yousmle has a lot of email list sign pop-up requests and a pretty spammy I-got-a-270-learn-my-secrets writing style, but he talks a lot about how to use Anki for those so inclined (he’s also trying to sell you very expensive Anki decks).
• Terrance Wickman’s video tutorials

If you find yourself using Anki a lot and have an iOS device, it’s probably worth shelling out the $25 bucks for the AnkiMobile iOS app, which works well and has a robust sync across platforms. The Android app is made by other folks and is available for free. If you don’t want to spend the money but want mobile, you can use the web version for free on your phone or import Anki decks into the free AnkiApp (which despite the name is not official and is more of a competing platform that won’t sync with the original service).

David Larson, who wrote Medical School 2.0, really likes iFlash for Mac ($15, with a free iOS app). It’s a pretty app, but it looks like its functionality, particularly on mobile, has fallen behind. It also doesn’t have a true SRS algorithm, which may be a good thing if you want to CYOA but less good if you’ve bought the hype. I think Anki is probably a better default choice, especially in that you can use the web interface from any computer when needed (like the school library).

Another free cross-platform alternative is Mnemosyne. There are a few other apps and services, but nothing that is compelling enough to move past those two.

Do you need to use Anki? Absolutely not. And it’s very easy to blow way too much time making decks (just like it’s easy to spend way too much time writing handwritten notes or mountains of flashcards). But if you find learning and retaining material from books or lectures difficult, then Anki is something to seriously consider.

Maybe don’t trust the smart kid too much

Imagine you want to guess a coin flip correctly as many times as you can out of 10. The first guy says to do all heads: it’s chance, it doesn’t matter. The second guy says: all tails, saying the first guy has the right idea but that tails is simply better. The third gives you a complex algorithm, because he’s full of shit. On any given series, any of one of these methods could win.

The bottom line of that unnecessary analogy is that just because someone is successful doesn’t mean their advice will work for you. That may seem ironic given that I’ve spent years giving advice on this site, but that’s exactly the point. You shouldn’t listen to anything I say just because I did great in medical school; you should listen (if you want to) because my advice seems reasonable, reasonably likely to work for you, or just gets you thinking actively about your own approach. If advice you get—even from a good source—doesn’t work for your time needs or personality, then do something else. The issue is that people attribute specific success to certain books and methods so much that they lose the individual variability factor that is such a huge part of all test taking endeavors. You want to do your best, but not everyone’s best is the same.

Resource Recommendations

• I’ve reviewed resources for the basic sciences here and discussed several of the preclinical shelf exams here.
• The clinical years are typically graded and often depend significantly on your performance on standardized subject-based NBME shelf exams. I’ve covered studying for clerkships and clinical shelf exams here.
• Finally—only peripherally related—my equipment picks are here.

Final Thoughts

Note that none of this post actually tells you how to study. That’s because that would be really presumptuous. You need to figure out how you want to study. What I (or anyone else) can tell you are some general considerations, methods to choose from, and, perhaps most importantly, what you don’t have to do. You don’t have to follow the leader; you don’t have to copy the kid with the highest score on the anatomy practical; you don’t need to add more and more resources because other people like them.

If you don’t want to watch online video lectures, then don’t. If reading long textbooks makes you “understand” the material better, then if you can do it, do it. If you like mnemonics and memorable little pseudo-stories, use them. If you don’t, don’t. This is your life. Spaced repetition with rapidly made/curated decks coupled with a qbank may be the fastest way to learn the most salient material, but I’m not going to tell you that doing anything else is a mistake.

As a new MS1 or someone trying to start fresh, you need to make a plan with a coherent study style and a reasonable number of resources and then try it. Iterate and get better. Squeeze in a hobby or two, time to exercise, and time to unwind with friends. Rinse. Repeat. Good luck.