1-2 Weeks Before Your USMLE? Read This

by Alec Palmerton, MD in Plan

20 comments

Preparing for the USMLEs is like running a marathon. The last two weeks are the final sprint. Your preparations may have started months, or even years ago. If test-day is fast approaching, you might be thinking: what’s the point? However, many things can boost your final score and prevent test-day disappointment.

But how can you maximize your limited time? With 1-2 weeks to go your goal should be to fine-tune your approach to the actual USMLE. In this article, you’ll learn how to:

• Decide whether you’re ready to take your USMLE
• Prevent anxiety-causing surprises on your test
• Deal with pre-test insomnia
• Schedule a practice test at the Prometric center
• Much more.

To that end, here are seven suggestions:

Table of Contents

1. Ask, “Am I Happy With My Score?”

We all have our goal score. Mine was 260. For others, it might be 240, 200, or a “pass.”

The beauty of the USMLEs is that the only requirement is that you pass. Your goal score will depend on your self-assessment, your temperament, and your career goals.

The best score predictors are the NBME (National Board of Medical Examiners) Self-Assessments. The NBME has correlated each form with students’ final scores. As such, the NBME Self-Assessments are the most accurate predictors of your final USMLE score.

(To read NBME Self Assessments: Ultimate Guide for the USMLEs and Shelf Exams, click here).

Note: I do NOT recommend using the bootlegged copies floating around online. Even though the NBME Self-Assessments are not perfect, the most valuable thing about these exams is their predictive value. Each NBME form has its own unique “curve.” (E.g., eight questions wrong on one test may predict a 250 3-digit score. On another NBME, eight wrong may predict a different score).

To my knowledge, no bootlegged copy has reproduced each NBME form’s unique curve. I have no idea how the bootlegged score predictor works. Use it at your peril.

Be Realistic About Your Final Score

What if your goal score is 240, but you score a 200? Be realistic and ask yourself three questions:

1. How important is it that I attain my goal score?
2. What score would be satisfactory?
3. When is the latest date I can take my exam, and would I consider pushing back my exam date?

The answers to these questions are highly personal. I cannot answer them for you.

Does Delaying Your Exam Delay Your Graduation?

But how long should you delay? To answer this, consider: will delaying force you to push back your graduation by a year?

(To read Are You Ready to Take Your USMLE or Need More Time?, click here).

For me, I would have taken the test if my predicted score was above 250. I might have pushed back my test date had I scored significantly below that.

At the time of Step 1, I was planning to apply to internal medicine. I didn’t need a killer score. As such, I probably wouldn’t have pushed back my graduation to score a 240.

If I had wanted to match in a super competitive field like dermatology? Different story.

(To read Get Into a Top Residency: 5 Things You Need to Know, click here).

Most people’s scores are not EXACTLY like their most recent NBME. However, most are in the ballpark, particularly for Step 1. It is rare to see someone score substantially higher (or lower) than their most recent NBME. NBMEs within a week or two of the final test are most predictive.

There is no shame in preparing to take the test until you’re ready. More than 1/3 of my Stanford class delayed taking their exam. Some Stanford students even spend several extra months studying. They spent the rest of their extra year doing research/other things to help improve their residency applications.

You only get one shot at this exam. Put your best foot forward.

2. Take 1-2 Full-Length Practice Tests

The USMLE Step 1 has 7 blocks total. Each block is 1 hour. Thus, with 1 hour of break/instruction time, the total test will take 8 hours. (Step 2 CK has 8 question blocks/1 hour of breaks. The total time is 9 hours!).

You likely have never taken such an extended test before. Fatigue can be a significant issue, particularly in the last couple of blocks.

To simulate this 8-hour gruel, I took 2 full-length practice tests. One of these practice tests was back-to-back UWorld Self-Assessments (UWSA). Each UWSA is 4 blocks. Thus, two UWSAs back-to-back is one block extra than the real exam.

Why was my practice test was even longer than the real thing? I wanted to train myself to answer questions beyond 7 blocks. The additional practice block helped me when the fatigue hit on the actual test day.

Take an NBME on the Back-End to Predict Your Final Score

Want to practice for the real exam AND predict your final score? Then consider taking an NBME right after a UWSA exam.

In the experience of many, UWSAs tend to overestimate your score. But why would you want to take the NBME after the UWSA? Won’t you be so exhausted that your NBME will be artificially low?

Yes! The point is to give you some margin-of-safety. If you take an NBME after a 4-block exam, it is more likely to underestimate your score rather than overestimate it due to fatigue. Tell me: would you rather be pleasantly or unpleasantly surprised by your final score?

Your practice exam(s) may look like this:

• UWSA #1, then NBME. (8 blocks total).

Or if you want extra practice:

• UWSA #1, then NBME. (8 blocks total).
• UWSA #2, then NBME. (8 blocks total).

7 blocks (8 blocks for Step 2 CK) is a lot of questions. It doesn’t help that we’re conditioned to feel like the USMLEs have do-or-die stakes. (Remember: it’s just a test! Take several deep breaths).

Practice a full-length test once or twice before the real exam. That final block on test day will be much more doable.

Practice Everything You’ll Do on Your Final Exam

You (and your classmates) probably feel like this right now:

How most med students feel before their USMLE

Your goal should be to walk into the exam like this:

How you will feel after completing the steps in this article

But how to ensure test-taking nirvana? Re-create as many of the conditions as possible for the real exam.

Things you should practice:

• The timing/duration of breaks. (See below).
• Snacks. (I recommend protein/fat > carbs).
• Sleep aids the night before. (I used diphenhydramine. Others use Ambien or melatonin. Remember: drowsiness can linger past their desired duration. Try it first in a low-stakes situation. Never use a sleep aid for the first time before your real exam.).
• Caffeine before/during the test. (I used a small bag of chocolate-covered espresso beans. I’d eat one between every block).

Familiarity breeds calm. Do a complete dry run before your test to work out any last kinks.

3. Practice at Your Prometric Test Site

To repeat: familiarity breeds calm. What better way to ensure familiarity than taking a practice exam at the place your real test will be?

You want to know how to:

• Find the test center (centers are often in an industrial park)
• Navigate rush-hour traffic
• Check-in/out
• Find the bathroom, and
• Navigate every other little variable you might experience on your test day

If you’re like most, you will already be pretty nervous for your exam. Stress from things you didn’t expect can affect your concentration and test-day performance.

Demystifying your test-day experience helps you be calmer when it matters most.

Note: as of this writing, the practice exam at the Prometric test center is only 3 blocks (120 questions) total. You can get the same questions for free. (These are known as the “Free 120” released by the USMLE). Translation: you may NOT be seeing new information. That’s not the point. Instead, use your practice session to get familiar with the test center layout and procedures.

Click here to schedule your practice exam at the Prometric test site.

4. Do As Many Questions As Possible

There is no substitute for practice. Try to do as many questions as possible. (At least 100-150/day). I recommend:

• All (mixed) subjects
• Test (timed) mode

Approach each item as if it were the real thing. I highly recommend using UWorld questions, since they best approximate the real thing.

(Read UWorld: Is Your Strategy Wrong? (I Scored 270 By Ignoring The Dogma), click here).

5. Map Out Your Test Day Break/Lunch Time Strategy

You have up to 60 minutes of break time on Step 1 and Step 2 CK. Having a plan for your break time will help you feel calmer. You also don’t want to waste precious energy stressing about when/how long to take a break.

First of all, skip the introductory tutorial. (You can take 30 seconds to check that your headset audio is working).

Why skip the instructions? Because if you skip the instructions, you can add the 15 minutes allotted for them to your 45 minutes of break time. Translation: instead of 45 minutes, you’ll have a total of 60 minutes for breaks. (That essentially adds 1/3 to your break time).

Note on breaks: At the end of each block, you can choose to move on to the next section or take a break. Important: you need to click on “Break” if you choose to take a break. If you choose nothing, it will choose to start your break time automatically. (This is to prevent you from missing an entire section because you forgot to click on “Break”).

How to Allot Break Time on Test Day

First, how much break time do you get? Both Step 1 and Step 2 CK give you 45 minutes of break time.

“But wait, I thought I get an hour!”

Yes! That is true. However, it comes because there is a 15-minute computer-based orientation at the beginning of each exam. If you SKIP the orientation (preferably after you’ve spent 30 seconds checking your headphones to make sure there isn’t a problem), you’ll get the 15 minutes added to your break time.

Now, how would I recommend you use your break time on your exam?

Here is my Step 1 break time strategy. (Note there are 7 blocks of Step 1 questions, and 60 minutes of break time if you skip the 15-minute tutorial):

• Tutorial: check that your headphones are working, then skip remaining 15 minutes of tutorial for use as extra break time
• Do 2 blocks back-to-back, then 10 min break (if necessary, 3-minute “sit-down” break in front of computer in-between first two blocks)
• 2 blocks, then 10 min break
• 1 block, then lunch break (20-30 minutes; variable, can choose to take lunch break at any time)
• 1 block, then 10 min break
• Final block, then done!

And here is my Step 2 CK break time strategy. (Note there are 8 blocks of questions, and 60 minutes of break time if you skip the 15-minute tutorial):

• Tutorial: check that your headphones are working, then skip remaining 15 minutes of tutorial for use as extra break time
• Do 2 blocks back-to-back, then 10 min break (if necessary, 3-minute “sit-down” break in front of computer in-between first two blocks)
• 2 blocks, then 10 min break
• 1 block, then 10 min break
• 1 block, then lunch break (20 minutes; variable, can choose to take lunch break at any time)
• 1 block, then 10 min break
• Final block, then done!

This is based on the observation from both myself and others that your attention will be much stronger in the beginning, and doing two blocks back-to-back is not much of a challenge.  However, as you move on, it becomes increasingly difficult to go over questions without a break in-between.

If you feel like you need a break early on, but don’t have one scheduled, you can give yourself a short, 2-3 minute “sit-down” break, by sitting at your computer and starting a break, but without taking the time to check out and in again.

6. Active > Passive Studying of Weaknesses

No test-taker feels 100% on every subject. You will have strengths and weaknesses.

Some people prefer passive learning. (E.g., listening to Goljan, watching Pathoma/Doctors in Training, etc.). These aren’t very useful, period. However, passive learning is even worse in the weeks leading up to your exam.

Why? Because the NBME writes questions that will force you to use knowledge. Cramming and memorizing are next to worthless if you want to improve your score.

(To read How Are USMLE Questions Written? 9 Open Secrets for Impressive Boards Scores, click here).

Instead, focus on active methods for testing yourself. These include:

1. Using the Yousmle Cheat Sheets. These include subjects ranging from Nernst potential to the coagulation cascade, to ion channel physiology and EKGs.  These are designed to test you actively on knowledge from First Aid/Qbanks, but in a way that is integrated and applied. (Exactly how you will be tested on for the USMLE).
2. Quizzing with a friend.  Ideally, find someone whose strengths/weaknesses are complementary. Go back and forth testing each other on things you’ve learned.
3. QBank questions. Mentioned previously – this is the best way to improve your application of knowledge on your test.

7. Embrace the Unexpected

No matter how well you prepare, something unexpected will happen. You might:

• Forget your lunch on the counter
• Make a wrong turn
• Be stuck next to someone who’s trying to cough up their lung

Embrace the unexpected. That’s part of the fun of test day. You’ve done your best to prepare. However, there will always be some little wrinkle that throws you for a loop. There’s even evidence suggesting how we think about stress affects whether it negatively affects our health.

“WTF” Questions Test Application of Principles

Even if you’re lucky and everything goes according to plan, you will see questions you’ve never seen before. You won’t have seen them from a lecture, your QBanks, or your NBME practice exams.

These “WTF” questions test your ability to reason and apply your knowledge. They do NOT test your ability to memorize.

I have the utmost respect for the NBME question-writers who make the USMLEs. They’re not stupid. They read the same resources we do. The NBME is excellent at making questions that we haven’t seen. They even have ways of identifying when students share answers with their friends.

Remember, 50% of all of the pathology questions are designed to be “General Principle” questions. (According to a USMLE Step 1 question-writer I spoke with). So when you ask yourself, “WHAT?? I DIDN’T KNOW THAT I NEEDED TO KNOW THE CAUSES OF HEART DISEASE IN GAMBIAN RATS!” Remember that you WEREN’T supposed to know the specific knowledge. So take a step back, and figure out what principle they want you to apply.

Concluding Thoughts: You’re Almost There!

If you’re wondering what to do 1-2 weeks before your exam, congratulations! You’re 1-2 weeks away from one of the best feelings in medical school: finishing your USMLE!

And if you decide to push back your test, don’t despair! The best anxiety-reliever is knowing you did your best to prepare. If it takes several weeks, or even months to reach that point, it’s worth it.

Either way, getting to this point takes immense work. You deserve a huge congratulations!

Finishing a USMLE is one of the greatest feelings in med school.

In summary:

1. Assess where you relative to your goals with an NBME self-assessment
2. Take 1-2 full-length (or 8-block) practice exams (may combine w/ Step #1 to for a score estimate)
3. Schedule a Prometric site practice exam (Link)
4. Do as many questions as possible
5. Map our your test break/lunch strategy
6. Shore up weak areas w/ active learning (Table of Contents)
7. Embrace the unexpected

What do you think? This list is by no means exhaustive. Please share in the comments section other tips/advice you’ve heard from others/have used yourself!

Photos by: Bernard Goldbach, jessicahtam, Ian Stauffer, Andreas Fidler