Get to Steppin’: Tips for USMLE Success

By Hasan Ali Kakli, MD

There are two types of USMLE® exam takers: those who want only to pass the exam and those who want to crush it.  If you want to pass a USMLE® Step, here is the simple formula (which has been touted by many successful examinees): 1) Get a First Aid Book and 2) a question bank.  If you want to crush the exam here is the slightly more complex formula: Repeat 1 and 2 multiple times.  There are no added steps or short-cuts.

If we were to perform a cohort study and follow examinees prospectively from test preparation to score results, we would undoubtedly discover differences in many variables such as an individual’s reading speed, memorization, and recall ability to name a few, but these variances would follow a simple Gaussian distribution.  We all know a couple of classmates who seem to get it while the rest of us peruse a chapter to achieve understanding but herein lies the main point:

The USMLE® exams are not designed for the scholastic over-achievers, outside the 5-95% confidence interval. They are designed for those of us in the middle portion of the distribution curve.

Whereas the MCAT is a test designed to select the top performers in a field of 70,000 each year (hence its acronym as an admission test), Steps 1 & 2 are designed to determine whether or not the 16,000 or so examinees have the necessary knowledge to function as competent physicians. It is NOT a residency admission test and should not be interpreted as such.

So if we have 16,000 similar students in terms of scholastic ability, what will separate their scores? The only independent variable is time spent in exam preparation.  Thus a USMLE® exam truly gauges one thing: How much one prepares for it.  The key to success in the USMLE® is repetition. Why do we need to review the same material before we actually comprehend it?  There are many theories about why we forget.  Each day our mind processes terabytes of sensory input but also dumps the vast majority of it, never encoding the information into our accessible memory.  From an evolutionary standpoint this helped us focus on matters pertinent to survival, and unfortunately our primitive ancestors did not need to answer obscure multiple choice questions in order to survive.  The only way to overcome this innate tendency to forget is repetition.  We must not allow ourselves to become frustrated by our forgetfulness but realize this is a natural human trait.  A lot of examinees recommend starting Step 1 prep early on during the first two years of medical school. I disagree.  The basic science years are difficult enough and most professors adhere to a rigid curriculum which is not tailored to Step 1. Lastly and most importantly, it is inevitable that one will forget most of the information if it is a few months before the test date.  I recommend remaining focused on your classes, using the textbook/syllabus provided by your instructors for the first two years. And when that second summer break comes, dig in because it is going to be an endurance challenge most of us have never faced before.

Each USMLE® exam tests a handful of subjects and each subject is represented differently.  For Step 1, physiology and biochemistry are the major players.  Do not try to memorize the brachial plexus (again) if you do not know the oxygen-hemoglobin disassociation curve cold.  And the best measure of one’s comprehension is doing practice questions.  A lot of them.  Practice questions expose weaknesses in our knowledge where we otherwise thought we were strong.  And practice questions are utterly useless without thorough explanations.  One major pitfall of USMLE® preparation is not allotting enough time for practice questions.  I used Qbank for Step 1 and it took a significant amount of time to cover, even the questions I answered correctly because I may have taken an educated (or blind) guess, or not know why certain answers were wrong.  It is not enough to just do questions. One must thoroughly understand their explanations.  Some test strategists recommend starting practice questions later in exam preparation or only doing questions on the subjects you have recently covered.  I disagree on both counts.  Start early and stay random.  For the first few weeks, I was literally scoring 25% on Qbank (slightly better than a monkey filling bubbles at random). And needless to say it was a confidence killer.  I felt that I retained nothing during my first two years of medical school and all that time was for naught.  But as I saw my average score increase merely a few percentage points each week I felt my understanding of the material increase.  Mid-way through my exam prep I was getting roughly 50% correct and a few weeks before test day I was at 75%.  The sooner you begin the sooner you can see yourself improve, and that is the ultimate confidence builder.

Just as important as starting early is to always do random questions, even if you have not yet studied particular subjects.  On exam day, you do not have the luxury of knowing which subject is pertinent to a particular question and you need to keep your mind ready to shift gears at a moment’s notice.  It is unlikely that on test day you will encounter a question that is completely foreign to you, but if you do, you will have been well-conditioned to handle such a situation.

Remember that the study of medicine is complicated by the fact that unlike other disciplines such as mathematics, medicine does not adhere to consistent principles. For example, in mathematics we can count on the fact that a negative number multiplied by another negative number will always be positive without exception.  But exceptions abound in medicine and while there may be reasons for the exceptions, they are not apparent and are often counter-intuitive.  Do not let yourself get discouraged by forgetting or not immediately grasping an abstract point.

If you are preparing for a Step exam, you are most likely only a few years into a lifelong journey. Do not make the mistake of believing your performance on a single test will dictate the path of this journey. Focus on the task at hand, remind friends and family that you are preparing for a national exam, expose yourself to as much as the material possible through high yield review books and practice questions with detailed explanations, and finally, go over the same material time and time again.  Go in to the test with confidence, and you will emerge satisfied with the result.

 

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All of the opinions expressed here are the author’s and his alone, and do not represent necessarily those of Kaplan or its employees.

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